Deglutition-induced atrial tachycardia: direct visualization by intracardiac echocardiography.

A 56-year-old man with gastroesophageal reflux disease had severe but transient palpitations during swallowing with every meal. He continued to have symptoms despite cessation of alcohol and caffeine consumption. Although he was occasionally able to reproduce his symptoms with dry swallowing, they were more prominent after swallowing solid food or carbonated beverages. He reported no palpitations unrelated to deglutition. A 24hour Holter monitor revealed numerous runs of atrial tachycardia (AT) during meals with varying atrial cycle lengths between 320 –500 ms (Figure 1). An echocardiogram was normal. He was initially placed on -blockers, which had minimal therapeutic effect and were not tolerated due to fatigue. He was then placed on flecainide, which reduced but did not abolish the arrhythmias. Because of his daily symptoms despite antiarrhythmic medications, he underwent an invasive electrophysiology study. During electrophysiology study, an AT with varying cycle lengths between 300 –510 ms was reproducibly induced with swallowing and was found to arise from the left atrium. A circular mapping catheter was placed in the right superior pulmonary vein (Figure 2). During direct intracardiac echocardiographic visualization of the esophagus, AT was induced during swallowing of a carbonated beverage and was coincident with early electric activation from the circular mapping catheter (online-only Data Supplement Video, Figure 3A and 3B, and Figure 4). The esophagus was noted to course close to the right pulmonary veins (Figure 5). The right superior pulmonary vein was circumferentially isolated with radiofrequency ablation (Figure 5), confirmed by pulmonary vein entrance and exit block. No vagal response was elicited during right superior pulmonary vein isolation. After ablation, the right superior pulmonary vein remained quiescent during deglutition and no atrial arrhythmias were inducible with swallowing or programmed stimulation. After more than 12 months of follow-up, the patient remains completely free of palpitations during swallowing. A follow-up 24-hour Holter monitor revealed sinus rhythm with no atrial premature contractions or AT.