2011 Barrington Electrophysiology
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Transcript of 2011 Barrington Electrophysiology
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Introduction to
Electrophysiology
Wm. W. Barrington, MD, FACC
University of Pittsburgh Medical
Center
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Objectives
• Indications for EP Study
• How do we do the study
• Normal recordings
• Abnormal Recordings
• Limitations of EP Study
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Indications for EP Study
• Characterization of an arrhythmia with theintent of performing ablation therapy.
• Characterization of the conduction system
to determine the need for permanentpacing.
• Stratify the patient’s risk of developing asymptomatic or life threatening
arrhythmia.• Characterization of the effectiveness of
therapy.
"Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation
Procedures“ Circulation. 1995;92:673-691.)
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Ablation is a large part of the current indications
for EP Study
Am J Cardiol (2009)104:671-77
The authors examined published results from
1990 to 2007 that were cited in Medline or
EMBASE:
• 18 Primary Studies of Atrial Flutter ablation
• 39 Primary Studies of SVT ablation
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Study examined reentrant SVT’s
Am J Cardiol (2009)104:671-77
Atrial Flutter
Ablation Line
Ablation site
AV Node Reentry
Accessory Pathways
AblationSite
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Meta-Analysis of Ablation of Atrial Flutter and SVT’s
AtrialFlutter
Single procedure success
Am J Cardiol (2009)104:671-77
AccessoryPathways
AV NodeReentry
91.7% 90.9% 94.3%
Multi-procedure success 97.0% 93.3% 96.0%
Repeat ablation procedure 8.0% 8.0% 5.6%
Procedure related mortality 0.0% 0.1% 0.0%
Hematoma 0.0% 0.3% 0.3%Cardiac Tamponade 0.0% 0.4 % 0.1%
Need for Pacemaker 0.2% 0.3 % 0.7%
Complications
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1. Am J Cardiol (2009)104:671-77
• “studies of RFA for treatment of patients with atrial flutter
and SVT report high efficacy rates and low rates of
complications1.”
• “the 2003 consensus guidelines for SVT management2
recommend radiofrequency ablation as a class I
intervention in all cases except:
• First episode of well tolerated atrial flutter• SVT patients who do not desire ablation or
• Asymptomatic patients with WPW.”
Meta-Analysis of Ablation of Atrial Flutter and SVT’s
2. J Am Coll Card (2003) also available at www.acc.org
The authors concluded:
Furthermore:
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• Electrophysiologist will place 1, 2, 3 ormore catheters into the heart.
• Access will be from femoral vein,
antecubital vein, subclavian vein orinternal 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
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How to do an EP Study
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High Right Atrial
Location
HRAHis Bundle
Location
His
Right Ventricular ApicalLocation
RVA
How to do an EP Study
Typical CatheterLocations
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How to do an EP Study
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• 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
• Screen display shows surface ECG andappropriate intracardiac channels
How to do an EP Study
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How to do an EP Study
P
QRS
A
H
V
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• 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)
How to do an EP Study
Baseline Measurements
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SCL (AA) = 830 ms
PR = 170 ms
QRS = 80 ms
QT = 380 ms
AH = 90 msHV = 40 ms
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AA = 880 ms
PR = 140 ms
QRS = 140 ms
AH = 100 ms HV = -30 ms
Ventricular Pre-excitation
(Wolff- Parkinson-White)
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12 Lead ECG of patient with short HV interval
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• 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.
How to do an EP Study
Atrial pacing – examining SA nodal function orSinus Node Recovery Time (SNRT)
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Last “paced” A
First “sinus” A
SNRT = 1320 ms
Paced at 600 ms (100 bpm)
for > 30 sec
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Sinus Node Recovery Times
(SNRT)
• Normal is < 1.3 x sinus cycle length
(
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• Pace the HRA at gradually increasing
rates.
• Look for gradual prolongation in the AH
interval (“decremental” conduction).
• Determine the AV nodal wenkebachcycle length.
How to do an EP Study
Incremental atrial pacing – examining AV nodalfunction
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PCL = 600 ms
AH = 160 ms
PCL = 500 ms
AH = 195 ms
Normal Decremental Function
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A H I
n t e r v a
l
S1 Interval
NormalDecremental AV NodalConduction
Faster Rate
AV Nodal Function Curve
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A A H
V
A
PCL = 410 ms
Wenkebach CL = 410 ms
AH = 220 ms
Wenkebach Block – Mobitz type I(above His bundle)
No V
No H
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Atrial PCL = 500 ms or 120 bpm
A H V A H
Mobitz type II block
(below the bundle of His)
A H V A H V A H V A H A H A H
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• 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
How to do an EP Study
Atrial extra stimulus techniques
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Drive Train of 8 beats at 500 ms (S1)
and one premature S2 310 ms after S1
S1 S2310 ms
A H V
Drive Train of 8 beats at 500 ms (S1)
and one premature S2 300 ms after S1
AH=160 ms
S1 S2
300 ms
A H V
AH=280 ms
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A H I
n t e r v a
l
S1S2 Interval
Dual AV Nodal
Physiology
• AH Interval “jumps” suggestconduction moved from one
conduction pathway to another.
• A > 50 msec jump in AH
interval with a 10 msec
decrease in S1S2 interval is
called
More Premature
AV Nodal Function Curve
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Right Atrial Anatomy
Superior Input Inferior
Input
Left Atrial
Input
Atrial depolarizationcan reach the AV
node by several
“paths.”
When activation
changes from the
“fast” conducting
Superior input tothe “slower” Inferior
input – we see an
AH interval jump.
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S1 S2240 ms
A H V
AH=250 ms SVT at 200 bpm
AV Node Reentry
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S1 S2
310 ms
A H V
QRS = 120 ms
PR = 210 ms
HV = 45 ms
Functional LBBB
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• 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.
How to do an EP Study
Incremental Ventricular pacing – examiningretrograde AV nodal function
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PCL = 500 ms
His A is earliest
Concentric retrograde conduction
V A
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Concentric (AV nodal) retrograde Activation
V A
Earliest A
In His
V A
Earliest AIn CS
(left side)
Eccentric (AP) retrograde Activation
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S1 = 600 ms
VA = 80 ms VA = 210 ms
Retrograde “Jump”
V V A V A A
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• 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
How to do an EP Study
Ventricular extra stimulus techniques
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S1 = 600 ms S1S2 = 260 ms
Single Ventricular extra stimuli
No retrograde conduction No repetitive
response
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S1 = 600 ms S1S2 = 240 ms
ERP of the RVA
Single Ventricular extra stimuli
No ventricular
response
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S1= 400 ms S1S2 = 240 ms
Single
inducedbeat
Single Ventricular extra stimuli
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S1 = 400 msS1S2 = 250 ms
S2S3 = 200 ms
Multiple Ventricular extra stimuli
No repetitive
response
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Multiple Ventricular extra stimuli
400/260/230 Sustained Monomorphic VT
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Induced Ventricular Tachycardia
Sustained Monomorphic VT Rate = 220 bpm
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• EP Study has not been widely used in
patients with nonischemic
cardiomyopathy
• Sensitivity and specificity is likely
decreased
Limitations of the EP Study
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• EP study may not be able to “reproduce” a
non-reentrant arrhythmia
• The EP study tries to cause “block” inone limb while exciting the other limb to
induce the arrhythmia
• Pharmacologic maneuvers may help
induce non reentrant arrhythmias
Limitations of the EP Study
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• Electro-anatomic mapping (CARTO)
• Catheter mapping
• Pacing maneuvers Allow us to localize the arrhythmia circuitto facilitate diagnosis and treatment withablation.
How to do an EP Study
These techniques along with
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Ablation is a large part of the current indications
for EP Study
so lets look at a few examples
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Baseline ECG for 17 year old with palpitations
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AP Potential
Pacing from HRA
Wide QRS
(130 ms)
Negative HV
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His “cloud”
Ablation
Location
4 cm
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Successful RF Ablation
Wide QRS
(130 ms)
AV = 50 ms AV = 180 ms
QRS = 80 ms
Loss of antegrade
AP function
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Post Ablation ECG
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ECG of SVT in 67 year old
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I
aVF
V1
V6
hRA
His p
His m
His d
Abl d
Abl p
Cs 4
Cs 3
Cs 2
Cs dRVa
Stim
Intracardiac in SVT
Eccentric Activation
Concentric Activation
Ventricular Pacing
Why are these
different?
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I
aVF
V1
V6
hRA
His p
His m
His d
Abl d
Abl p
Cs 4
Cs 3
Cs 2
Cs dRVa
Stim
Eccentric
Activation
In SVT
Concentric
Activation
RV pacing
I
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Termination of SVT with RF
aVF
V1
V6
hRA
His p
His m
His d
Abl d
Abl p
Cs 4
Cs 3
Cs 2
Cs d
RVa
Stim
Termination with
Block in AP
SVT
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Questions
or
Comments?