Use of a modified, commercially available temporary pacemaker for R wave synchronized atrial pacing in postoperative junctional ectopic tachycardia

Abstract

Junctional ectopic tachycardia (JET) is a life-threatening arrhythmia frequently seen after surgical correction of congenital heart defects. This study evaluates the use of a modified, commercially available temporary dual chamber pacemaker used to reestablish AV synchrony by R wave synchronized atrial pacing, a technique not routinely applied because of a lack of appropriate equipment. Ten consecutive children with postoperative JET (median maximum heart rate 185, range 130-240 beats/min) age 0.3-45 (median 5.2) months were studied. R wave synchronized atrial pacing was performed using the VAT mode with inverse connection of the pacing wires (effectively AVT mode), short postventricular atrial refractory period (100 ms), and long AV (effectively VA) delay. AV delay was adjusted to achieve maximum increase in arterial pressure by optimal AV resynchronization. Pacing was successfully applied in all patients for a median period of 29 (range 10-96) hours until tachycardia cessation and led to an immediate increase in systolic, mean, and pulse pressure by 8.9 +/- 3.2 (P < 0.001), 8.1 +/- 4.0 (P < 0.001), and 11.9 +/- 7.8% (P < 0.005), respectively. Two patients developed pacemaker-mediated tachycardia, which could be easily stopped by AV (effectively VA) delay prolongation. Atrial flutter was induced in one patient by asynchronous atrial pacing during the VAT (effectively AVT) mode and managed by overdrive pacing. In conclusion, R wave synchronized atrial pacing could be easily performed using a modified, commercially available temporary dual chamber pacemaker. Significant hemodynamic benefit was achieved due to optimal AV resynchronization at intrinsic heart rate and spontaneous ventricular activation sequence. R wave synchronized atrial pacing should be included in the standard management protocol of postoperative JET.