A prospective study of the value of the oesophageal electrocardiogram in the differentiation of wide complex tachycardias.
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The accurate differentiation of a ventricular from a supraventricular origin of a wide QRS tachycardia (QRS > 120 milliseconds) is an important clinical problem. Misdiagnosis of this arrhythmia can lead to institution of inappropriate drug therapy acutely with potentially catastrophic consequences. Various diagnostic aids have been used to obtain electrocardiographic potentials to aid in the differentiation. This report assesses the clinical usefulness of oesophageal electrocardiography in the differentiation of wide complex tachycardias and describes a simple, safe technique to obtain oesophageal electrocardiograms. Eighteen consecutive patients between the ages of 27 and 71 years who were haemodynamically stable were selected for this study. The technique was performed in the following manner: A temporary pacing catheter was lubricated and passed nasally and advanced with the patient being instructed to swallow. Adjustments in catheter depth were made as necessary to obtain an optimal recording on a standard electrocardiograph recorder. Satisfactory placement with minimal patient discomfort was achieved within 6.5 minutes (average 4.5 minutes) in all cases. High quality tracings were obtained in every instance. In the 18 patients with tachyarrhythmia, AV dissociation consistent with ventricular tachycardia was demonstrated in 11 instances; in the remainder the diagnosis was supraventricular tachycardia. Of the 11 patients diagnosed as ventricular tachycardia, 9 were initially misdiagnosed as supraventricular tachycardia, whilst only 1 of 7 patients with supraventricular tachycardia was misdiagnosed. This study has demonstrated that oesophageal electrocardiography is useful in the differentiation of wide complex tachycardias. The technique outlined in this report is simple and offers the following advantages: the temporary pacing catheter is associated with minimal discomfort; the catheter allows easy manoeuverability within the oesophagus which allows proper depth to be easily obtained; the equipment used is routinely available. Therefore the technique offers a rapid, safe and simple method of obtaining an oesophageal electrocardiogram which is invaluable in the electrocardiographic differentiation of a wide complex tachycardia.