Karen Bain

James Cook University Hospital

Middlesbrough
Electrophysiology
Electrophysiology...
Is the study of the hearts electrical system
Assesses the function of each component of cardiac
conduction
Determines the potential for a patient to have an
arrhythmia
Determines the mechanism of an arrhythmia
Evaluates the need for treatment/ therapy
The role of EPS in the diagnosis and
treatment of cardiac arrhythmias
To characterise physiological and pathological properties of the
atria, ventricles and the atrioventricular conduction system, identify
accessory pathways, and determine the sites and mechanisms of
arrhythmias

To correlate patient symptoms with arrhythmias and evaluate risks

for life threatening events and/or differentiate arrhythmias.

To define arrhythmia induction and termination methods for EPS

guided interventions: i.e. Medications, anti-tachycardia pacing, anti-
arrhythmic surgery, ICDs, ablation or modification.
Indications
Class I an EP study is indicated

Class II an EP study may be indicated

Class III an EP study is not indicated

Indications class I
Patients not tolerating or not responding to medications
for narrow complex tachycardia in whom the study would
alter their therapy

Narrow QRS tachycardia preferring ablative therapy

Sustained wide QRS complex tachycardia

An accessory pathway tachycardia that is symptomatic

and may require ablative therapy
Indications class I
Unexplained syncope and known structural heart disease.

Palpitations and documented inappropriate rapid pulse rates

without apparent cause.

Survival of cardiac arrest with NQWMI or surviving cardiac

arrest occurring >48 hrs after AMI.

Candidates for implantation of an electrical device to treat

their arrhythmias or those who have an implanted device and
require therapy changes that may alter the safety or efficacy of
their device.
Indications class II
Sinus node dysfunction - to exclude other arrhythmic causes or
assess the severity or mechanism of dysfunction and drug
response to direct therapy.

Second or third degree AV block to determine the site or

mechanism of the block in order to direct therapy.

Symptomatic patients with bundle branch block to assess the

site and severity of the conduction delay in order to direct
therapy and evaluate prognosis.

Patients with premature ventricular complexes and

unexplained pre-syncope or syncope.
Indications class II
Asymptomatic patients with ECG evidence of WPW syndrome
to evaluate the accessory pathway in high-risk activities, a
family history of premature sudden death, or unexplained
syncope

Patients with clinically significant cardiac palpitations thought

to be of cardiac origin but not documented by non-invasive
testing in order to diagnose, treat, and assess prognosis

Risk stratify post MI patients with reduced LV function having

frequent PVCs, NSVT, or both, particularly if the signal
averaged ECG shows late potentials.
Indications class III
Symptomatic patients with sinus node dysfunction with
ECG documentation of a bradyarrhythmic cause

Asymptomatic patients with nocturnal bradycardia

Patients with congenital or acquired long QT syndrome

with symptoms related to an identifiable cause or
mechanism
Patients with a known cause of syncope

Patients with cardiac arrest occurring only within the first

48 hrs of AMI
Newer indications
AF
Paroxysmal
Persistent
Permanent?

Complex VT
Fascicular VT/Idiopathic LVVT
BB Re-entry
VT associated with RVD
Ischaemic VT
In other words...
Do it if... Dont do if...
Palpitations Known indications for
WPW pacemaker or ICD implant
Known or suspected Recent MI
arrhythmia Asymptomatic
Unexplained syncope
Medication intolerance
VPBs/APBs
National Service Framework chapter for arrhythmias
and sudden cardiac death Chapter 8; March 2005
Contraindications
Bleeding disorder
Unstable angina
Uncontrolled congestive heart failure
Uncooperative patient
Severe peripheral vascular disease
Valvular or sub valvular stenosis (LV access)
Thrombophlebitis (femoral access)
Groin infection
Bilateral amputee (femoral access)
Possible complications
Hypotension Systemic emboli

Haematoma Acute cardiac tamponade

Haemorrhage Pneumothorax

Vascular injury Death

Thrombophlebitis
Before we start...
Patient preparation
Informed consent
Drugs stopped
Bloods
INR if on warfarin
Results of investigations
ECG of tachycardia is very useful
What we need...
Equipment EP equipment
Fluoroscopy unit Programmable stimulator
Radiographic table Multichannel lead switching
Physiologic recorder and box (junction box)
oscilloscopes
Electrode catheters
Instrumentation for vascular
access Ablation system
Crash trolley Generator
Irrigation Pump
Personnel
Remote Panel
Electrophysiologist Cables
Cardiac physiologists Tubing
Nursing staff 3D Navigational Mapping
Radiographer System (optional)
Lab set up
Lab set up
Junction
Patient
box

Signal
amplifier

Oscillo-
Recorder Stimulator
scope
Catheters and sheaths
Electrodes
Tip and ring
99% Platinum
Good conductor of electricity
1% Iridium
Radio-opaque
Binds to copper connecting wire
Curves
Josephson
Dr Mark E Josephson
Cournand
Cournand, Andr Frdric 1895-1988.
French-born American physician. He shared a 1956 Nobel
Prize for developing cardiac catheterisation
DAmato
Anthony N. DAmato: 19302001
Curls and sweeps
Terminology
Quadripolar - Quad
Four poles
Decapolar - Dec
Ten poles
Duo Dec
Twenty poles
Spacing
Spacing indicates the space in mm between electrodes on
the catheter.

First number is spacing between electrodes 1 and 2

Second number is spacing between electrodes 2 and 3

etc

Only one number indicates that all inter electrode

spacings are equal
Spacing
Spacing
Smaller spacing to map complex or small localised
electrograms i.e. 2-2-2
His bundle
Para-Hisian
Bundle branch potentials
Larger spacing to map larger areas of myocardium or
cross chamber i.e. 2-8-2
CS (LA&LV)
H-Curve (or duo-dec, Halo) for RA whole chamber mapping
Catheter size
French gauge scale
Abbreviated to FR, Fr or F
Measurement of outer diameter of cylindrical objects
i.e. catheters
D (mm) = Fr/3
Fr = D (mm)x3
Catheter French
Advantages of 6F over 5F Advantages of 5F over 6F
More stability Smaller introducers
More Torque Reduced risk of
More Pushability complications, damage
and healing time due to
smaller size
Preserve vessel access in
younger patients
Less chance of
compromising circulation
Catheter uses
Visualise intracardiac electrograms
Fluoroscopy visualisation
Measurement of electrograms
Pacing
Geometry creation for navigational mapping
Ablation
Internal Cardioversion
Catheter placement
Access route is commonly
the femoral vein
Other routes include:
External jugular vein
Internal jugular vein
Subclavian vein
Catheter placement
Quad in HRA (e.g. JSN)
Dec in CS
HRA
Quad at His (e.g. CRD-2)
Quad in RV (e.g. CRD)

CS

His

RV
 E L E CTRODE P OS ITIONS
Electrode positions - RAO
(R AO P ROJ E CTION)

HRA

CS

HIS

R VA
Electrode positions - RAO
SVC

RA

RV
IVC
 E L E CTRODE P OS ITIONS
(L AO P R OJ E C TION)
Electrode positions - LAO
HRA
CS

HIS

R VA
Electrode positions - LAO
Anterior

TV MV

CS

Posterior
Sheaths
Short or long
Short cannulation of arteries or veins at access point i.e.
femoral vein
Lockable or standard
Long
for intracardiac use
Offer stability
Transseptal
Various curves for different chambers and locations
Sinus rhythm
Sinus rhythm
Sinus rhythm
Sinus rhythm
Basic intervals
AH interval
Time taken to travel over the AVN
Measured from the atrial EGM recorded at the HIS bundle
to the onset of the HIS EGM
Normal = 55 125ms
HV interval
Time taken to travel through the His-Purkinje system
Measured from the onset of the HIS EGM to the earliest
ventricular activation in any lead (inc. surface)
Normal = 35 55ms
Pacing in EP
Programmed electrical stimulation is used:
To assess refractory periods, conduction properties and
automaticity
To evaluate inducibility of those patients who have an
indication for EPS
To characterise arrhythmia and assist in choice of therapy
For the purpose of mapping and ablation
To evaluate efficacy of treatment
To evaluate success of treatment
Drive train with extrastimuli

S1 S1 S1 S1 S1 S1 S1 S1 S2
A H V A H V
A H VA
A H V
V A V A
V A V
V A
Initiation and termination of
tachycardia

Antegrade and retrograde curves

Burst atrial/ventricular pacing

His synchronous VPB

VT stim protocols
Programmed electrical stimulation (PES) of the RV
Usually two pacing sites: RVA and RVOT/RV septum
Drive train of eight paced impulses (S1) and a variable
number of extrastimuli (S2, S3 and S4)
Progressively shortened coupling intervals between the
drive and extrastimuli
Extrastimuli induce VT or cause ventricular refractoriness
Isoprenaline may be used during VT stimulation
Wellens protocol
Stage 1
SR with one extra stimulus (S2), decrease by 20ms until
refractory.
Stage 2
S2 refractory + 20ms plus S3, decrease by 20ms until
refractory
Stage 3
Drive train (S1) of 100bpm (600ms) + S2
Stage 4
As stage 3 + S3
Wellens protocol
Stage 5
As stage 3 with drive train of 120bpm (500ms)
Stage 6
As stage 5 + S3
Stage 7
As stage 3 with drive train of 140bpm (428ms)
Stage 8
As stage 7 + S3
Wellens protocol
Stage 9
SR with S2 refractory + 20ms and S3 refractory + 20ms plus
S4
Stage 10
As stage 9 with drive train at 100bpm (600ms)
Stage 11
As stage 9 with drive train at 120bpm (500ms)
Stage 12
As stage 9 with drive train at 140bpm (428ms)