Transesophageal atrial pacing for intraoperative sinus bradycardia or AV junctional rhythm: feasibility as prophylaxis in 200 anesthetized adults and hemodynamic effects of treatment

Sinus bradycardia (SB) or atrioventricular junctional rhythm (AVJR) may produce circulatory insufficiency in anesthetized surgical patients, especially those with cardiovascular disease. Chronotropic drugs have been the preferred initial treatment, except when epicardial pacing is available. Alternative methods include transvenous or transcutaneous pacing. Drugs may be ineffective or have undesirable effects. Transvenous pacing is time consuming and risky, and transcutaneous pacing is not universally applicable or effective. Transesophageal atrial pacing (TAP) lacks these disadvantages, but unavailability of equipment and unfamiliarity with the method has discouraged widespread use. Feasibility of TAP as prophylaxis for intraoperative SB or AVJR was tested with approved or investigational devices in 200 anesthetized surgical patients, not necessarily with cardiovascular disease or having cardiac surgery. Of these, 84 later had incidental SB ≤60 beats/min, and 23 of these 84 had SB ≤50 beats/min. Thirteen patients had AVJR (72 ± 4 beats/ min; mean ± SEM). TAP at 80 beats/min for SB, or at a rate sufficient to overdrive AVJR, was effective initial treatment in all patients. Respective average increases in systolic, diastolic, and mean arterial pressures for patients with SB ≤60 beats/ min were 14,12, and 14 mmHg ( P < .001); for SB ≤50 beats/min 22,17, and 19 mmHg ( P < .001); and for AVJR 23 ( P < .01), 9 (NS), and 15 mmHg ( P < .05), respectively. For patients with cardiac output measurements the average increase for SB ≤60 beats/min was 1.4 L/min (N = 13, P < .01); for SB ≤50 beats/min 1.8 L/min (N = 7, P < .05); and for AVJR was 2.6 L/mmin (N = 2). There were no apparent complications of TAP as prophylaxis or treatment for SB or AVJR. TAP has been shown to be a safe, simple, rapid, and effective method for prophylaxis and initial treatment of intraoperative SB or AVJR. Potential advantages of TAP over drugs are discussed.