Basic Cardiac ElectrophysiologyBasic Cardiac Electrophysiology
and ECG Conceptsand ECG Concepts
胡瑜峰醫師胡瑜峰醫師
台北榮總心臟 科內台北榮總心臟...
OutlineOutline
• Ion current, action potential and cardiac
conduction
• Surface EKG
• Intracardiac mapping
• Mechanism and...
Electrical System of the HeartElectrical System of the Heart
Purkinje fibers
Bundle of His
Sinoatrial node
Atrioventricula...
Pacemaker ActivityPacemaker Activity
• Spontaneous time-dependent depolarization
leading to action potentials
• Pacemaker ...
INa+
rapid
depolarizing
(non-nodal)
IK+
repolarizing
(all myocytes)
ICa+
depolarizing
(nodal AP
and myocyte
contraction)
I...
Pacemaker Action PotentialPacemaker Action Potential
Cardiac Muscle DepolarizationCardiac Muscle Depolarization
Ventricular Action PotentialVentricular Action Potential
5 Phases
0 – upstroke of AP
ICa+ – slow
ICa+/INa+ - fast
1 – rapi...
Comparison of Slow Nodal andComparison of Slow Nodal and
Fast Non-nodal Cardiac Action PotentialsFast Non-nodal Cardiac Ac...
Velocity of Electrical ConductionVelocity of Electrical Conduction
Purkinje fibersPurkinje fibers
Bundle of HisBundle of H...
Fletcher G F et al. Circulation 2001;104:1694-1740Copyright © American Heart Association
12 Lead ECG Electrode Placement12...
Surface EKG MorphologySurface EKG Morphology
As the heart beats action
potentials on the heart cause an
electrical signal on the body
surface.
The larger the structure...
Atrial depolarization givesAtrial depolarization gives
rise to the P waverise to the P wave
Conduction throughConduction through
the small AV node isthe small AV node is
associated withassociated with
virtually no ...
Depolarization ofDepolarization of
the ventricle causesthe ventricle causes
the QRS complex.the QRS complex.
QRS is largeQ...
Repolarization of the
ventricle causes the T
wave
Dispersion causes it to be
smaller and last longer than
the QRS complex....
Conduction/ Surface EKG MorphologyConduction/ Surface EKG Morphology
12 Lead-12 Directions12 Lead-12 Directions
Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
Normal atrial depolarization
12 Lead-12 Directions12 Lead-12 Directions
Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
12 Lead-12 Directions12 Lead-12 Directions
Transition of Precordial LeadsTransition of Precordial Leads
12 Lead-12 Directions12 Lead-12 Directions
Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
Accessory PathwaysAccessory Pathways
Different Morpholgy indicatesDifferent Morpholgy indicates
different location-Atrial Tachycardiadifferent location-Atrial ...
12 Lead-12 Directions12 Lead-12 Directions
Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
Limb Leads
• 1. R1 + SIII > 25 mm
• 2. R wave in aVL > 11 mm
• 3. R wave in aVF > 20 mm
• 4. S wave in aVR > 14 mm
Precord...
12 Lead-12 Directions12 Lead-12 Directions
Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
Left Ventricular HypertrophyLeft Ventricular Hypertrophy
Intracardiac MappingIntracardiac Mapping
HRAHRA
HisHis
RVRV
CSCS
Example-Atrial TachycardiaExample-Atrial Tachycardia
Intracardiac MappingIntracardiac Mapping
Voltage imply the tissue electricalVoltage imply the tissue electrical
function o...
Aging Changes of Typical AFL
Huang JL, Heart rhythm 2008
Intracardiac MappingIntracardiac Mapping
The timing of signal indicate the activation timeThe timing of signal indicate th...
Isochronal Map (Activation map)Isochronal Map (Activation map)
Distribution of AF triggerDistribution of AF trigger
Haissagurre et al. NEJM 1998Haissagurre et al. NEJM 1998 Chen et al. ...
Circumferential PV Isolation and SegmentalCircumferential PV Isolation and Segmental
AblationAblation
Thank you for your attention!Thank you for your attention!
Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區
Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區
Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區
Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區
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Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區

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  • Figure 3. Placement of 12-lead ECG electrodes. RA indicates right arm; LA, left arm; RL, right leg; and LL, left leg.
  • Basic Cardiac Electrophysiology and ECG Concepts_20120902_北區

    1. 1. Basic Cardiac ElectrophysiologyBasic Cardiac Electrophysiology and ECG Conceptsand ECG Concepts 胡瑜峰醫師胡瑜峰醫師 台北榮總心臟 科內台北榮總心臟 科內
    2. 2. OutlineOutline • Ion current, action potential and cardiac conduction • Surface EKG • Intracardiac mapping • Mechanism and catheter ablation
    3. 3. Electrical System of the HeartElectrical System of the Heart Purkinje fibers Bundle of His Sinoatrial node Atrioventricular node Pacemakers – Sinoatrial node, Atrioventricular node, Purkinje fibers
    4. 4. Pacemaker ActivityPacemaker Activity • Spontaneous time-dependent depolarization leading to action potentials • Pacemaker with highest frequency sets the heart rate. – SA node – 60 beats/min – smallest electrical region in the heart, sum of 3 ion channels produces pacemaker (ca, k, f) – AV node – 40 beats/min – can take over for SA node, pacemaker determined by same three channels as SA node. – Purkinje fibers –20 beats/min – unreliable pacemaker, but great conducting system, pacemaker determined by ‘f’ channels only.
    5. 5. INa+ rapid depolarizing (non-nodal) IK+ repolarizing (all myocytes) ICa+ depolarizing (nodal AP and myocyte contraction) If “funny channel” or HCN Pacemaker current (activated during hyperpolarization) Hyperpolarization activated Cyclic Nucleotide gated channel Na+ /K+ (activated during depolarization) MAJOR MYOCYTE ION CHANNELS Which channel is absent in SA and AV node? Absent in ventricular myocytes? Read- Table 20-1
    6. 6. Pacemaker Action PotentialPacemaker Action Potential
    7. 7. Cardiac Muscle DepolarizationCardiac Muscle Depolarization
    8. 8. Ventricular Action PotentialVentricular Action Potential 5 Phases 0 – upstroke of AP ICa+ – slow ICa+/INa+ - fast 1 – rapid repolarization Ik+ – activation ICa+/INa+ - inactivation 2 – plateau phase ICa+/INa+ - activated 3 – repolarization Ik+ 4 – diastolic potential Ik+, ICa+, If Produce pacemaker activity SA/AV node, purkinje use If Phase 1 and 2 not present in SA/AV nodePhase 1 and 2 not present in SA/AV node
    9. 9. Comparison of Slow Nodal andComparison of Slow Nodal and Fast Non-nodal Cardiac Action PotentialsFast Non-nodal Cardiac Action Potentials
    10. 10. Velocity of Electrical ConductionVelocity of Electrical Conduction Purkinje fibersPurkinje fibers Bundle of HisBundle of His (0.05 m/s)(0.05 m/s) (0.05 m/s)(0.05 m/s) (1.0-2.0 m/s)(1.0-2.0 m/s) (1 m/s)(1 m/s) (2.0-4.0 m/s)(2.0-4.0 m/s) Functionally, how might the speeds be important? (0.3-1.0 m/s)(0.3-1.0 m/s) Ventricdular myocardiumVentricdular myocardium
    11. 11. Fletcher G F et al. Circulation 2001;104:1694-1740Copyright © American Heart Association 12 Lead ECG Electrode Placement12 Lead ECG Electrode Placement
    12. 12. Surface EKG MorphologySurface EKG Morphology
    13. 13. As the heart beats action potentials on the heart cause an electrical signal on the body surface. The larger the structure the greater the voltage it induces. This voltage pattern is called the electrocardiogram
    14. 14. Atrial depolarization givesAtrial depolarization gives rise to the P waverise to the P wave
    15. 15. Conduction throughConduction through the small AV node isthe small AV node is associated withassociated with virtually no electricalvirtually no electrical signal on the skin.signal on the skin.
    16. 16. Depolarization ofDepolarization of the ventricle causesthe ventricle causes the QRS complex.the QRS complex. QRS is largeQRS is large because thebecause the ventricularventricular mass is largemass is large QRS is shortQRS is short becausebecause conduction overconduction over the ventricles isthe ventricles is very fastvery fast
    17. 17. Repolarization of the ventricle causes the T wave Dispersion causes it to be smaller and last longer than the QRS complex. Repolarization is not a conducted wave.
    18. 18. Conduction/ Surface EKG MorphologyConduction/ Surface EKG Morphology
    19. 19. 12 Lead-12 Directions12 Lead-12 Directions Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
    20. 20. Normal atrial depolarization
    21. 21. 12 Lead-12 Directions12 Lead-12 Directions Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
    22. 22. 12 Lead-12 Directions12 Lead-12 Directions Transition of Precordial LeadsTransition of Precordial Leads
    23. 23. 12 Lead-12 Directions12 Lead-12 Directions Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
    24. 24. Accessory PathwaysAccessory Pathways
    25. 25. Different Morpholgy indicatesDifferent Morpholgy indicates different location-Atrial Tachycardiadifferent location-Atrial Tachycardia
    26. 26. 12 Lead-12 Directions12 Lead-12 Directions Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
    27. 27. Limb Leads • 1. R1 + SIII > 25 mm • 2. R wave in aVL > 11 mm • 3. R wave in aVF > 20 mm • 4. S wave in aVR > 14 mm Precordial Leads • 5. R wave in V5 or V6 > 26 mm • 6. R wave in V5 or V6 + S wave in V1 > 35 mm • 7. Largest R wave + largest S wave in the precodial leads > 45 min Voltage Indicates Ventricular MassVoltage Indicates Ventricular Mass -Left Ventricular Hypertrophy-Left Ventricular Hypertrophy
    28. 28. 12 Lead-12 Directions12 Lead-12 Directions Help to Analyze Gross Heart conductionHelp to Analyze Gross Heart conduction
    29. 29. Left Ventricular HypertrophyLeft Ventricular Hypertrophy
    30. 30. Intracardiac MappingIntracardiac Mapping
    31. 31. HRAHRA HisHis RVRV CSCS
    32. 32. Example-Atrial TachycardiaExample-Atrial Tachycardia
    33. 33. Intracardiac MappingIntracardiac Mapping Voltage imply the tissue electricalVoltage imply the tissue electrical function or viabilityfunction or viability
    34. 34. Aging Changes of Typical AFL Huang JL, Heart rhythm 2008
    35. 35. Intracardiac MappingIntracardiac Mapping The timing of signal indicate the activation timeThe timing of signal indicate the activation time
    36. 36. Isochronal Map (Activation map)Isochronal Map (Activation map)
    37. 37. Distribution of AF triggerDistribution of AF trigger Haissagurre et al. NEJM 1998Haissagurre et al. NEJM 1998 Chen et al. Circulation 1999Chen et al. Circulation 1999
    38. 38. Circumferential PV Isolation and SegmentalCircumferential PV Isolation and Segmental AblationAblation
    39. 39. Thank you for your attention!Thank you for your attention!
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