Kamp O, DeCock CC, Visser CA. Free University Hosp, and the Interuniversity Cardiol Inst, Amsterdam. Echocardiography, Vol 12, Jan 1996. The combination of transesophageal atrial pacing and transesophageal echocardiography (TEE) provides an alternative stress echocardiographic technique capable of assessing pacing-induced wall-motion abnormalities and ischemia-induced mitral regurgitation. The rationale for combining pacing with TEE resulted from experiences with inadequate transthoracic stress studies in up to 15% of the patients and second, from failure of transesophageal atrial pacing with a single lead in another 15% of the patients. Simultaneous TEE and transesophageal atrial pacing was performed in 90 consecutive patients using continuous short-axis monitoring obtained at papillary muscle level. All but one patient had good image quality at rest and during pacing. No complications occurred, in three patients (6%) pacing had to be discontinued prematurely because of discomfort. Early atrioventricular Wenckebach block occurred in eight patients (9%). In 83 patients (92%) coronary artery angiography was performed Sensitivity for assessment of suspected coronary artery disease was 83%, and specificity 94%. Multivessel disease in patients with prior myocardial infarction was assessed with sensitivity of 77%, and specificity of 100%. In 6 of 25 patients (24%) new or increasing mitral regurgitation after induction of wall-motion abnormalities was observed. In conclusion, TEE in conjunction with atrial pacing is feasible, safe, and an alternative echocardiographic stress technique, capable of detecting wall-motion abnormalities and changes in mitral regurgitation. Because of its semi-invasive nature, only patients with a poor transthoracic window are candidates.