Severe esophageal burn after transesophageal pacing.

3−week history of fatigue and headaches was admitted with suspected myocardi− tis. Echocardiography showed a dilated left ventricle with a shortening fraction of 12%. Electrocardiography revealed ec− topic atrial tachycardia, with a heart rate of 200 beats per minute. Cardioversion was performed to terminate the tachycar− dia, but this was unsuccessful. Intrave− nous amiodarone was started, but within hours the girl had deteriorated. Verapa− mil and beta blockers were not suitable because of their negative inotropic ef− fects, and so a transesophageal electrode catheter was placed under fluoroscopic guidance. Rapid atrial pacing (320/min− ute, 20 mA) resulted in atrioventricular block and the ventricular rate fell to 160 beats per minte. The amiodarone treat− ment was continued and sinus rhythm was achieved after 18 hours, when atrial pacing was stopped. Esophagogastroduodenoscopy was per− formed 6 hours after the transesophageal pacing was stopped: areas of deep tissue necrosis, reaching into stomach, were found in the distal anterior and posterior esophageal wall (l" Fig. 1). Less severe but circumferential burns affecting the superficial mucosa were found in the en− tire distal part of the esophagus. Antibio− tic therapy and a 2−week course of pre− dnisolone were initiated. The girl recov− ered over the following weeks and was able to swallow clear liquids and then sol− ids without difficulty. Six weeks later, esophagogastroduodenoscopy showed no esophageal strictures, revealing only well−healed, scarred lesions, without nar− rowing of the lumen (l" Fig. 2). Her myo− cardial function had completely normal− ized. The distal esophagus lies in direct contact with the left atrium and it is therefore used for transesophageal pacing in severe arrhythmias. In adult studies only mini− mal esophageal injury was reported in a couple of patients after short−term stimu− lation [1]. In animal studies, transesopha− geal pacing of 30−minute duration, 2 msec, and 75± 100 mA produced minor lesions, but longer pacing times may cause lesions at currents of less than 40 mA [2]. Transesophageal pacing can be a life−sav− ing procedure but it has to be kept in mind that prolonged stimulation carries a risk of significant esophageal injury, and follow−up endoscopy should be con− sidered.