EPS presentationEPS presentation

Presented by Presented by Dr.Lamyaa Allam

Assisstant lecturer of cardiologyAin Shams universityAin Shams university

• 30 year old female she is an engineer married and30 year old female, she is an engineer, married and has two year old child who had CHD in form of VSD which was discovered after normal laborwhich was discovered after normal labor.

• She has suffered from attacks of palipations for four years which are regular of sudden onset and offestyears which are regular of sudden onset and offest related to stress and exercise but she thought that these attacks were related to life stressthese attacks were related to life stress.

• After her baby’s surgery, she asked for routine check ( h h b d di d t h lup(as her husband was discovered to have paroxysmal

AF), when she was discovered to have tachycardia at t f 180 brate of 180 bpm

Investigations for detection of cause of tachycardia ves ga o s o de ec o o cause o ac yca d awere done as CBC, thyroid profile and echocardiogram which all were normal.g

So Holter mointoring was recommended and then she was referred for EP evaluationshe was referred for EP evaluation

G. Examination :

BP120/70, HR100‐130 bpm. Peripheral pulse :well felt. JVP lJVP:normal

Cardiac examination:

N   b li    d dNo abnormality was detected

Chest/abdominal examination: 

b l d dNo abnormality was detected

I

II

IIIIIIaVR,

aVLaVL

aVF

V1

V2

V3

V4

V5

Tang et al,1995

So, EPS & ablation was plannedSo, EPS & ablation was planned

Kistler, P. M. et al. J Am Coll Cardiol 2006;48:1010-1017Kistler, P. M. et al. J Am Coll Cardiol 2006;48:1010 1017

AT with 2:1 AV block

HR 150bpm

CARTO mapping (LAT) for CSCARTO mapping (LAT) for CS

From RA the site of earliest activation isFrom RA the site of earliest activation is the CSO….. But still not early enough

Site of the earliest atrial activation

There’s a characteristic anatomic distribution for FAT.

In the RA:

these foci commonly originate from the CT, TA, CSO, and the para-hisian region, SVC (less common)p g , ( )

In the LA: In the LA:

these foci particularly tend to cluster around PVs representing ≈76% of LATs (ostial 93%or distal) MArepresenting ≈76% of LATs (ostial 93%or distal), MA

less commonly: LA septum, LAA, vein of Marshell

Vein/ligament of MarshallVein/ligament of MarshallVein/ligament of MarshallVein/ligament of Marshall

The ligament of Marshall is the embryological remnant of the left superior vena cava which as itremnant of the left superior vena cava, which, as it becomes atretic during development, may remain open as the so-called vein of Marshallopen as the so-called vein of Marshall.

This vein drains in the coronary sinus and runs posteriorly and superiorly in the epicardial surface ofposteriorly and superiorly in the epicardial surface of the left atrium, to join the LSPV.

Th   i   f M h ll i       f  i     f The vein of Marshall is a source of various types of atrial arrhythmias

Histology and Arrhythmogenecity

Myocardial tractsMyocardial tracts (Marshall bundles) with multiple insertions ( t b t t )(reentry substrate)

Sympathetic nerve fibersSympathetic nerve fibers (enhanced automaticity)

Fatty matrix (area of insulation doubleinsulation double potentials)

J Am Coll Cardiol, 2000; 36:1324-1327

CS approach: Disconnects insertion of Marshall CS pp o c : sco ec s se o o a s abundles into CS

LSPV approach: Ablation around the LSPV LSPV approach: Ablation around the LSPV interrupts the MB

Atrial approach: Disconnects the insertion of MB Atrial approach: Disconnects the insertion of MB into the LA free wall

1- Palpitations in young female should be investigated before considering it Psychological problem .

2-12 lead ECG should be done routinely during pregnancy.pregnancy.

3-Localization of FAT by P wave morpholgy in ECG is not always accurate (sensitivity 93%) JACC Vol 48 No 5is not always accurate (sensitivity 93%) JACC Vol. 48, No. 5, 2006

4- Compained 3 D electro-anatomical mapping and p pp gconventional mapping in the same procedure increases the sucess rate of FAT ablation