Joseph Rizk

Electrophysiological study generally is negative in patients < 40 years suspected of supraventricular tachycardia but also complaining of chest pain and/or syncope

BACKGROUND The diagnosis of paroxysmal supraventricular tachycardia (SVT) frequently is a dilemma. Electrophysiological study (EPS) is the only means to evaluate the nature of symptoms when noninvasive studies remain negative. Our objectives were to determine the clinical factors of negativity or positivity of (EPS) in patients suspected of SVT. METHODS EPS was performed in 2650 patients complaining of tachycardia and suspected of SVT. Transesophageal EPS consisted of programmed atrial stimulation in control state and after isoproterenol. Patients were followed from 1 month to 18 years (2.93 ± 4 years). RESULTS SVT was induced in 1944 patients, age 48 ± 19.5. EPS remained negative in 706 patients, age 34 ± 17 (p<0.0001). Age <40 years, feeling of dizziness/syncope or chest pain associated with tachycardia, the absence of heart disease or short PR interval was more frequent in patients with negative EPS (respectively 64, 42, 26, 96, 88.5%) than in patients with induced SVT (34, 14, 4, 88, 59%) (p<0.0001).The positive predictive value for the prediction of a negative EPS of age <40, chest pain, syncope or their association was 63.5, 42, 26.5, 11% and negative predictive value was 66, 86, 94.5, 99.5%. At multivariate analysis, age <40 (0.000, OR 2.79), the presence of syncope associated with tachycardia (0.000, OR 5.075) or chest pain (0.000, OR 17.923) was an independent factor of negative EPS. CONCLUSIONS Among patients complaining of nondocumented tachycardia, suspected of SVT, the association of tachycardia with chest pain and/or syncope and age <40 years generally was correlated with a negative EPS and did not indicate initially invasive studies. In the remaining patients transesophageal EPS is indicated.

0018: Clinical interest of transesophageal electrophysiological study in patients with no documented tachycardia suspected of paroxysmal supraventricular tachycardia

Paroxysmal supraventricular tachycardia (SVT) documentation is not always easy and in some patients referred for SVT ablation, EPS sometimes remains negative. The purpose of study was to evaluate the follow-up after esophageal EPS for no documented tachycardia. Methods 1569 patients, mean age 42±19.5 years, 637 males, with normal ECG in sinus rhythm, were suspected of SVT. Exercise testing, 24 hour Holter monitoring were normal. Transesophageal EPS consisted of programmed stimulation with 1 and 2 extrastimuli in control state and after isoproterenol. Results EPS remained negative in 594 patients (group I). Atrial fibrillation/tachycardia (AF) was induced in 70 patients (group II), atrioventricular (AV) nodal reentrant tachycardia (AVNRT) or AVRT using a concealed accessory pathway in 887 patients (group III). Group I was younger (34±17 years) than group II (53±16), III (46±20)(p Conclusions Prognosis value esophageal EPS was excellent. A negative study noted in younger patients complaining frequently of dizziness/syncope/ chest pain predicted a favorable prognosis. None of the patients with induced AF had AVNRT/AVRT and this group (older, with HD) had frequently AF during follow-up (20%). Patients with induced AVNRT/AVRT benefit frequently from ablation of their tachycardia.

0019: Significance of atrial fibrillation/tachycardia induced by esophageal stimulation

Esophageal electrophysiological study (EPS) is an easy means to evaluate the cause of palpitations in patients with negative Holter monitoring or when cardiac event monitor is not interpretable. The purpose of study was to evaluate the clinical significance and the diagnosis value of inducible atrial tachycardia or fibrillation (AF) by esophageal EPS. Methods Esophageal EPS was performed in 159 patients, 72 males, 87 females, aged from 19 to 89 years (mean 56±16) with a normal ECG in sinus rhythm; 35 patients had presented one episode of documented sustained AF (group I). Remaining 124 patients had no documented AF (group II) and were studied for not documented tachycardia (n=70), not documented tachycardia associated with dizziness/syncope (n=23), unexplained stroke and salvos of AF (n=25), wide-QRS tachycardia suspected of atrial origin (n=6). Atrial pacing and programmed atrial stimulation with 1 and 2 extrastimuli were performed in control state (CS) and after infusion of isoproterenol. Patients were followed from 1 month to 13 years (mean 4±4 years). Results Among group I, AF was induced in 21 patients (60%). Sustained AF was induced in CS (n=50) or after isoproterenol (n= 64) in all group II patients. The follow-up indicated that 7 group I patients (21%) had recurrent AF/atrial flutter requiring ablation, 5 patients with induced AF and 2 with negative EPS (NS). Two group I patients (6%) with induced AF died from a cardiac cause. Among group II, 20 patients (16%) presented documented AF/atrial flutter and 14 of them required an ablation. Five group II patients (4%) died from a cardiac cause. The sensitivity of esophageal EPS to reproduce AF was 60%. Its positive predictive value to predict the occurrence of AF in symptomatic patients without documented AF was 16%. The positive value to predict AF and cardiac death was 24%. Conclusions Despite an average sensitivity for the induction of AF in patients with documented AF, the risk of subsequent AF and/or cardiac death was relatively high in these patients and in symptomatic patients without documented AF but with induced AF. These patients require a careful follow-up.

199: Prevalence and significance of stroke among patients with paroxysmal supraventricular tachycardia

The risk of atrial fibrillation (AF) in patients with paroxysmal supraventricular tachycardia (SVT) is well-known. AF is a cause of embolic event and a risk of stroke in patients with SVT can be expected. The purpose of the study was to assess the prevalence of unexplained stroke in patients presenting with SVT and to look for the risk factors. Methods Electrophysiological study (EPS) was performed in 1379 patients without anterograde conduction through accessory pathway (AP) for SVT. Clinical and electrophysiological data were collected. Results Stroke was noted in 38 patients (group I) (prevalence 2.8%). 1341 patients had no stroke (group II). 1) Clinical data: Group I was older than group II (62±13 vs 49±19 years) (p Conclusions Unexplained stroke was a rare event in patients with paroxysmal SVT (2.8%). Old age, and AF history were the only independent significant factors associated with the history of stroke in these patients. They had a risk of severe adverse events during the follow-up as spontaneous AF (21%) or death (8%). SVT ablation did not reduce the risk of new stroke, spontaneous AF or death.