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Introduction to

Electrophysiology
Wm. W. Barrington, MD, FACC
University of Pittsburgh Medical
Center

Objectives

Indications for EP Study


How do we do the study
Normal recordings
Abnormal Recordings
Limitations of EP Study

Indications for EP Study


Characterization of an arrhythmia with the
intent of performing ablation therapy.
Characterization of the conduction system
to determine the need for permanent
pacing.
Stratify the patients risk of developing a
symptomatic or life threatening
arrhythmia.
Characterization of the effectiveness of
therapy.
"Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation
Procedures Circulation. 1995;92:673-691.)

Ablation is a large part of the current indications


for EP Study

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
Am J Cardiol (2009)104:671-77

Study examined reentrant SVTs

Atrial Flutter

AV Node Reentry
Accessory Pathways

Ablation site
Ablation Line
Ablation
Site

Am J Cardiol (2009)104:671-77

Meta-Analysis of Ablation of Atrial Flutter and SVTs


Atrial
Flutter

Accessory AV Node
Pathways Reentry

Single procedure success

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

Am J Cardiol (2009)104:671-77

Meta-Analysis of Ablation of Atrial Flutter and SVTs


The authors concluded:
studies of RFA for treatment of patients with atrial flutter
and SVT report high efficacy rates and low rates of
complications1.
Furthermore:
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.
1. Am J Cardiol (2009)104:671-77

2. J Am Coll Card (2003) also available at www.acc.org

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)

12 Lead ECG of patient with short HV interval

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.

Paced at 600 ms (100 bpm)


for > 30 sec

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.

Normal Decremental Function

AH = 160 ms

PCL = 600 ms

AH = 195 ms

PCL = 500 ms

AH Interval

AV Nodal Function Curve

Normal
Decremental
AV Nodal
Conduction
Faster Rate
S1 Interval

Wenkebach Block Mobitz type I


(above His bundle)
V
A
H
AH = 220 ms

No V
A

A
No H

Wenkebach CL = 410 ms
PCL = 410 ms

Mobitz type II block


(below the bundle of His)

AH V

A H

AH V

A H

Atrial PCL = 500 ms or 120 bpm

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

Drive Train of 8 beats at 500 ms (S1)


and one premature S2 310 ms after S1

S1
S2
300 ms

AH=280 ms

Drive Train of 8 beats at 500 ms (S1)


and one premature S2 300 ms after S1

AV Nodal Function Curve

AH Interval

AH Interval jumps suggest


conduction moved from one
conduction pathway to another.
A > 50 msec jump in AH
interval with a 10 msec
decrease in S1S2 interval is
called Dual AV Nodal

Physiology
More Premature
S1S2 Interval

Right Atrial Anatomy

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

SVT at 200 bpm

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.

Concentric retrograde conduction


V

PCL = 500 ms

His A is earliest

Earliest A
In His
Earliest A
In CS
(left side)

Concentric (AV nodal) retrograde Activation

Eccentric (AP) retrograde Activation

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

Single Ventricular extra stimuli

No ventricular
response
ERP of the RVA

S1 = 600 ms

S1S2 = 240 ms

Single Ventricular extra stimuli

Single
induced
beat

S1= 400 ms

S1S2 = 240 ms

Single Ventricular extra stimuli

No repetitive
response

S1 = 400 ms

S1S2 = 250 ms
S2S3 = 200 ms

Multiple Ventricular extra stimuli

400/260/230

Sustained Monomorphic VT

Multiple Ventricular extra stimuli

Sustained Monomorphic VT Rate = 220 bpm

Induced Ventricular Tachycardia

Limitations of the EP Study


EP Study has not been widely used in
patients with nonischemic
cardiomyopathy
Sensitivity and specificity is likely
decreased

Limitations of the EP Study


EP study may not be able to reproduce a
non-reentrant arrhythmia
The EP study tries to cause block in
one limb while exciting the other limb to
induce the arrhythmia
Pharmacologic maneuvers may help
induce non reentrant arrhythmias

How to do an EP Study
These techniques along with

Electro-anatomic mapping (CARTO)


Catheter mapping
Pacing maneuvers
Allow us to localize the arrhythmia circuit
to facilitate diagnosis and treatment with
ablation.

Ablation is a large part of the current indications


for EP Study
so lets look at a few examples

Baseline ECG for 17 year old with palpitations

Wide QRS
(130 ms)

Negative HV

AP Potential

Pacing from HRA

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

Post Ablation ECG

ECG of SVT in 67 year old

I
aVF
V1
V6

Why are these


different?

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

Termination of SVT with RF

Questions
or
Comments?