Clinical utility and the predictors of outcome of overdrive transesophageal atrial pacing in the treatment of atrial flutter

Transesophageal atrial pacing (TEAR) using a pill electrode was performed in 49 patients with atrial flutter. The responses observed were (1) immediate sinus rhythm in 17 (35%), (2) delayed sinus rhythm in 13 (27%), (3) atrial fibrillation in 11 (22%), and (4) no success in 8 (16%) patients. Sinus rhythm was thus restored in 30 patients (61%). In group A, 12 of 17 patients (p < 0.05) had coronary artery disease. The patients in group D had echocardiographic evidence of right atrial enlargement (2.56 ± 0.29 cm, p = 0.007), left atrial enlargement (4.6 ± 0.12 cm, p < 0.0001), right ventricular dilatation (3.41 ± 0.45 cm, p < 0.05), left ventricular dilatation (6.39 ± 0.66 cm, p < 0.05), and depressed left ventricular ejection fraction (32 ± 7%, p < 0.05). Optimal pacing rate (375 ± 54 beats/min) was 41% higher than the mean atrial flutter rate (266 ± 37 beats/ min) for cardioversion to immediate sinus rhythm. Pacing current strength and the pulse width had no influence on the final outcome. On the basis of the result of the initial attempt, patients undergoing TEAP repetitively had an almost predictably similar outcome on the subsequent attempts. Thus, normal sinus rhythm could be resumed in most patients with atrial flutter by TEAP. It does not require general anesthesia and can be performed even in patients who have undergone digitalization, when a direct-current countershock may be of some concern.