Professional Documents
Culture Documents
Electrophysiology
Wm. W. Barrington, MD, FACC
University of Pittsburgh Medical
Center
Objectives
Atrial Flutter
AV Node Reentry
Accessory Pathways
Ablation site
Ablation Line
Ablation
Site
Am J Cardiol (2009)104:671-77
Accessory AV Node
Pathways Reentry
91.7%
90.9%
94.3%
Multi-procedure success
97.0%
93.3%
96.0%
8.0%
8.0%
5.6%
0.0%
0.1%
0.0%
Hematoma
0.0%
0.3%
0.3%
Cardiac Tamponade
0.0%
0.4 %
0.1%
0.2%
0.3 %
0.7%
Complications
Am J Cardiol (2009)104:671-77
How to do an EP Study
Electrophysiologist will place 1, 2, 3 or
more catheters into the heart.
Access will be from femoral vein,
antecubital vein, subclavian vein or
internal jugular vein.
Catheters generally at least quadrapolar
(4 electrodes) in configuration.
Pacing and recording usually done in
bipolar configuration (one electrode +
and the other -)
How to do an EP Study
How to do an EP Study
Typical Catheter
Locations
High Right Atrial
Location
HRA
His Bundle
Location
His
Right Ventricular Apical
Location
RVA
How to do an EP Study
How to do an EP Study
Screen display shows surface ECG and
appropriate intracardiac channels
Intracardiac recordings are filtered to
allow visualization of signals
Band pass filter from 30 or 40 Hz to
400 or 500 Hz
Gain settings to optimize viewing
Clipping as needed
How to do an EP Study
P
QRS
How to do an EP Study
Baseline Measurements
Sinus cycle length (SCL or AA
interval)
PR interval (120 200 ms)
QRS duration (< 100 ms)
QT interval (QTc < 440)
AH interval (60 125 ms)
HV interval (35 55 ms)
PR = 170 ms
QT = 380 ms
QRS = 80 ms
SCL (AA) = 830 ms
HV = 40 ms
AH = 90 ms
PR = 140 ms
QRS = 140 ms
AA = 880 ms
AH = 100 ms
HV = -30 ms
Ventricular Pre-excitation
(Wolff- Parkinson-White)
How to do an EP Study
Atrial pacing examining SA nodal function or
Sinus Node Recovery Time (SNRT)
Pace HRA at fixed rate for at least 30
seconds.
Measure interval from last paced atrial
signal to first sinus atrial signal this is
the sinus node recovery time (SNRT).
Generally this is repeated for a variety of
pacing cycle lengths.
Last paced A
First sinus A
SNRT = 1320 ms
How to do an EP Study
Sinus Node Recovery Times
(SNRT)
Normal is < 1.3 x sinus cycle length
(<1600 ms)
Can correct by several methods:
CSNRT = SNRT SCL
( Normal <525 ms)
Ratio of SNRT/SCL (Normal < 1.5)
Limitation of SNRT is that while it is very
specific it is not very sensitive!
How to do an EP Study
Incremental atrial pacing examining AV nodal
function
Pace the HRA at gradually increasing
rates.
Look for gradual prolongation in the AH
interval (decremental conduction).
Determine the AV nodal wenkebach
cycle length.
AH = 160 ms
PCL = 600 ms
AH = 195 ms
PCL = 500 ms
AH Interval
Normal
Decremental
AV Nodal
Conduction
Faster Rate
S1 Interval
No V
A
A
No H
Wenkebach CL = 410 ms
PCL = 410 ms
AH V
A H
AH V
A H
AH V
A H
AH V
A H
How to do an EP Study
Atrial extra stimulus techniques
Pace the atrium at a fixed CL (typically
600, 500, 400 ms) for 8 beats then
introduce 1,2 or 3 extrastimuli
Useful in determining:
Refractory periods
Change in conduction
Dual AV nodal physiology
Initiation of an arrhythmia
S1
S2
310 ms
A
H V
AH=160 ms
S1
S2
300 ms
AH=280 ms
AH Interval
Physiology
More Premature
S1S2 Interval
Superior Input
Inferior
Input
Left Atrial
Input
Atrial depolarization
can reach the AV
node by several
paths.
When activation
changes from the
fast conducting
Superior input to
the slower Inferior
input we see an
AH interval jump.
S1
S2
240 ms
A
H V
AH=250 ms
AV Node Reentry
S1
S2
310 ms
QRS = 120 ms
PR = 210 ms
HV = 45 ms
A
Functional LBBB
How to do an EP Study
Incremental Ventricular pacing examining
retrograde AV nodal function
Pace the RVA at gradually increasing
rates.
Look for gradual prolongation in the VA
interval (decremental conduction)
Concentric activation (via AV node)
Eccentric activation (via AP).
Determine the VA wenkebach cycle length.
PCL = 500 ms
His A is earliest
Earliest A
In His
Earliest A
In CS
(left side)
Retrograde Jump
VA = 210 ms
VA = 80 ms
S1 = 600 ms
How to do an EP Study
Ventricular extra stimulus techniques
Pace the ventricle at a fixed CL (typically
600, 500, 400 ms) for 8 beats then
introduce 1,2 or 3 extrastimuli
Useful in determining:
Refractory periods
Change in conduction
Dual retrograde AV nodal physiology
Initiation of an arrhythmia
No retrograde conduction
S1 = 600 ms
No repetitive
response
S1S2 = 260 ms
No ventricular
response
ERP of the RVA
S1 = 600 ms
S1S2 = 240 ms
Single
induced
beat
S1= 400 ms
S1S2 = 240 ms
No repetitive
response
S1 = 400 ms
S1S2 = 250 ms
S2S3 = 200 ms
400/260/230
Sustained Monomorphic VT
How to do an EP Study
These techniques along with
Wide QRS
(130 ms)
Negative HV
AP Potential
His cloud
4 cm
Ablation
Location
Wide QRS
(130 ms)
QRS = 80 ms
AV = 50 ms
AV = 180 ms
Loss of antegrade
AP function
Successful RF Ablation
I
aVF
V1
V6
hRA
His p
His m
His d
Abl d
Abl p
Cs 4
Concentric Activation
Cs 3
Cs 2
Cs d
Eccentric Activation
RVa
Stim
Intracardiac in SVT
Ventricular Pacing
I
aVF
V1
V6
hRA
His p
His m
His d
Abl d
Abl p
Cs 4
Cs 3
Cs 2
Cs d
RVa
Stim
Eccentric
Activation
In SVT
Concentric
Activation
RV pacing
I
aVF
V1
SVT
V6
hRA
His p
His m
His d
Abl d
Abl p
Termination with
Block in AP
Cs 4
Cs 3
Cs 2
Cs d
RVa
Stim
Questions
or
Comments?