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Electrophysiology study protocol

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Minimum protocol for Electrophysiology study of conduction in heart.

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Electrophysiology study protocol

  1. 1. EP STUDY MINIMUM PROTOCOL
  2. 2. WE’VE TALKED ABOUT… EQUIPMENT PATIENT PREPARATION RELEVANT ANATOMY CATHETERS and PLACEMENT BASIC INTERVALS TESTS OF SN FUNCTION
  3. 3. AND NOW… EQUIPMENT PATIENT PREPARATION RELEVANT ANATOMY CATHETERS and PLACEMENT BASIC INTERVALS TESTS OF SN FUNCTION ATRIAL and VENTRICULAR EXTRASTIMULUS TESTING REFRACTORY PERIODS ‘GAP’ INCREMENTAL PACING MINIMUM PROTOCOL FOR DIAGNOSTIC EPS
  4. 4. EXTRASTIMULUS TESTING
  5. 5. 5 Drive train with a single extra stimulus S1 S1 S1 S1 S1 S1 S1 S1 S2Sensed PAUSEDRIVETRAIN S1-S2 Interval Sense-S1 Interval 8 paced beat drive train – EP steady state Extrastimulus (Coupling interval)
  6. 6. Extra stimuli S 1 S 1 S 1 S 1 S 1 S 1 S 1 S 1 S 2Sensed DRIVETRAIN S 3 S 4 S1 S1 S1 S1 S1 S1 S1 S1 S2Sensed DRIVETRAIN S 1 S 1 S 1 S 1 S 1 S 1 S 1 S 1 S2Sensed DRIVETRAIN S3 Single Double Triple
  7. 7. Atrial Extrastimulus testing • Dynamic properties of AVN and HPS conduction • AVN and RA refractory periods
  8. 8. Atrial Extrastimulus testing • Dynamic properties of AVN and HPS conduction • AVN and RA refractory periods • Dual AVN physiology
  9. 9. Atrial Extrastimulus testing • Dynamic properties of AVN and HPS conduction • AVN and RA refractory periods • Dual AVN physiology • Arrhythmia induction
  10. 10. S2 with long coupling interval Conduction at fairly constant velocity A2H2 equal or slightly more than A1H1
  11. 11. A1H1 80 ms ~ A2H2 95 ms S1A1 ~ S2A2 ~ 55 ms H1V1 ~ H2V2 ~ 50 ms
  12. 12. S2 with short coupling interval Slowing of Conduction A1H1 < A2H2
  13. 13. A1H1 80 ms A2H2 140 ms
  14. 14. S2 with shorter coupling interval Blocked AES at AVN
  15. 15. Ventricular Extrastimulus testing • Retrograde conduction over HPS and AVN • Accessory pathway conduction • Arrhythmia induction
  16. 16. Ventricular Extrastimulus testing • Retrograde conduction over HPS and AVN • Accessory pathway conduction • Arrhythmia induction • Stimulation at RV apex conventionally – RV apex Stim – distal RBB – HPS – AVN – RA
  17. 17. S2 with long coupling interval
  18. 18. H buried in V V1A1 almost equal to V2A2 Earliest atrial activation in HBE Atleast 30 ms before HRA Proximal-to-distal CS activation CONCENTRIC ATRIAL ACTIVATION
  19. 19. S2 with short coupling interval
  20. 20. S2 with shorter coupling interval
  21. 21. S2 with short coupling interval with short drive cycle length Blocked VES at AVN VA block Differs with – ES coupling interval – Drive cycle length
  22. 22. S2 with short coupling interval Tissue latency in local evoked response Occurs just above the tissue refractory period
  23. 23. Even shorter coupling interval Blocked VES locally at RV apex Loss of ventricular capture
  24. 24. Ventricular Extrastimulus testing • Other ‘Normal’ responses – No VA conduction at all • Atropine, Isoprenaline • No VA conduction despite drugs
  25. 25. Ventricular Extrastimulus testing • Other ‘Normal’ responses – No VA conduction at all • Atropine, Isoprenaline • No VA conduction despite drugs – Retrograde exit site from AV node maybe near CS ostium rather than HBE – earliest atrial activation at Proximal CS
  26. 26. Ventricular Extrastimulus testing • Other ‘Normal’ responses – No VA conduction at all • Atropine, Isoprenaline • No VA conduction despite drugs – Retrograde exit site from AV node maybe near CS ostium rather than HBE – earliest atrial activation at Proximal CS • Maneuvers to prove accessory pathway
  27. 27. REFRACTORY PERIODS
  28. 28. EFFECTIVE Refractory Period • ERP of a tissue
  29. 29. EFFECTIVE Refractory Period • ERP of a tissue (or a structure)
  30. 30. EFFECTIVE Refractory Period • ERP of a tissue (or a structure) is the LONGEST coupling interval that fails to capture the tissue
  31. 31. EFFECTIVE Refractory Period • ERP of a tissue (or a structure) is the LONGEST coupling interval that fails to capture the tissue (or be conducted over the structure)
  32. 32. FUNCTIONAL Refractory Period • FRP of a tissue (or a structure) is the SHORTEST ‘output’ coupling interval that can be elicited from a tissue (or structure) by any ‘input’ interval
  33. 33. FUNCTIONAL Refractory Period • FRP of a tissue (or a structure) is the SHORTEST ‘output’ coupling interval that can be elicited from a tissue (or structure) by any ‘input’ interval S1-A1-H1-V1 S2-A2-H2-V2 AVN HPS AV conduction system
  34. 34. RELATIVE Refractory Period • RRP of a tissue (or a structure) is the ‘input’ interval at which the ‘output’ interval just begins to differ from ‘input’ interval
  35. 35. RELATIVE Refractory Period • RRP of a tissue (or a structure) is the ‘input’ interval at which the ‘output’ interval just begins to differ from ‘input’ interval • This is the point at which Latency or Decremental conduction begins to occur • Least commonly measured
  36. 36. • In all tissues, ERP and FRP are ‘length- dependent’ • So, measured using atleast 2 different drive cycle lengths
  37. 37. AVNERP Longest A1A2 interval that fails to capture HB A1A2 maybe longer than S1S2 due to tissue latency
  38. 38. AVNFRP Shortest H1H2 in response to any A1A2 interval
  39. 39. AVNRRP Longest A1A2 interval at which A2H2 exceeds A1H1
  40. 40. Normal range of refractory periods (ms) ERP Atria ERP AVN FRP AVN ERP HPS ERP V 150-350 230-430 330-530 330-450 190-290 *Denes, Akhtar, Durrer, Josephsen series
  41. 41. GAP phenomena ES conducted as LBBB
  42. 42. INCREMENTAL ATRIAL PACING
  43. 43. INCREMENTAL VENTRICULAR PACING
  44. 44. MINIMUM PROTOCOL • Basic intervals • SNRT and CSNRT • AES – AVNERP • AV WCL • VES – VERP • VA WCL
  45. 45. • Arrhythmia induction
  46. 46. TO BE CONTINUED….
  47. 47. ….NEXT presentations • Atrial arrhythmias • Ventricular Pre-excitation and AVRT • Ventricular arrhythmias • Catheter ablation

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