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Electrophysiologic Study for Pacemaker Implantation

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Electrophysiologic Study for Pacemaker Implantation

  1. 1. Electrophysiological Study for Pacemaker Implantation 2013/03/23 Chun-Chieh Wang 王俊傑 醫師 台北 / 林口 長庚紀念醫院 第二心臟內科 Electrophysiological Study for Pacemaker Implantation1. Establish diagnosis g2. Assist in pacemaker parameter settings3. Confirm efficacy of ATP therapy (DDDRP)4. Assist in future troubleshooting5. ??? 1
  2. 2. Pacemaker / ICD Troubleshooting1. Rhythm strips / 12-lead ECG2. Initial PM/ICD parameters3 Stored i f3. d information i4. Underlying rhythm / event markers5. A/V sensing threshold tests6. A/V capture threshold tests7. Atrial pacing tests (AV relationship)8. Ventricular pacing tests (VA relationship)9. Final PM / ICD parameters10.Images Technique 1. Conventional EP study 2. Noninvasive EP study 2
  3. 3. Electrophysiological Study for Pacemaker Implantation 1. Establish diagnosis & confirm indication for permanent pacing 2. Assist in pacemaker parameter settings 3. Confirm efficacy of ATP therapy (DDDRP) 4. Assist in future troubleshooting 5. ??? Case Study 1-170 y/o female, ER visit for recurrent syncope recently with resultant blunt head trauma ECG rhythm monitoring at ER 3
  4. 4. Case study 1-2Baseline 12-lead ECG before EPS Case study 1-3 4
  5. 5. Case study 1-4 12-lead ECG after atropine 1mg i.v. Cardiac rhythm diagnosis of this patient? Before atropine 1mg i.v.After 5
  6. 6. Case study 1-512-lead ECG after atropine 1mg i.v. Case study 1-6 6
  7. 7. Case study 1-75 minutes after atropine 1mg i.v. Case study 1-8 Rapid atrial pacing 7
  8. 8. Case study 1-9 Rapid atrial pacing Case 2 History♥ 57 y/o Female♥ DCM, LVEF26%, mild MR, mod to severe TR, mod pulmonary H/T, NSR H/T♥ Admission for fluid overload and acute decompensated HF (ADHF)♥ Improved after i.v. Bumetanide, short course of Dobutamine i.v. infusion and OMT♥ Chronic HF NYHA Fc III~ ambulatory IV♥ Past history: TIA, hepatitis B carrier. history♥ Personal history: smoking (-), alcohol (-)♥ Laboratory exam: within normal limit including thyroid function and electrolytes. 8
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  10. 10. CRT? 10
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  13. 13. Primary Prevention of SCD with ICD LVEF ≤ 35% Optimal Medical Therapy COMPANION MADIT-CRT, RAFT , CRT D CRT-D NYHA Class III – IV YES NO CLBBB? NO Prior MI No Prior MIEF ≤40% EF ≤35% SyncopeEPS + EPS + EPS + Bundle branch VTMUSTT MADIT DEFINITE ICD RF ablation PA view LAO view 13
  14. 14. Electrophysiological Study before Pacemaker Implantation1. Establish diagnosis g2. Assist in pacemaker parameter settings • AV delay • PVARP • PVAB • Special algorithms: MVP algorithms3. Confirm efficacy of ATP therapy (DDDRP)4. Assist in future troubleshooting5. ??? Case study 4-1 14
  15. 15. Case study 4-2Case study 4-3 15
  16. 16. Case study 4-4Case study 4-5 16
  17. 17. Case study 4-6Case study 5-1 17
  18. 18. Case study 5-2Case study 5-3 18
  19. 19. Case study 5-4Case study 5-5 19
  20. 20. Case study 5-5Case study 5-6 40 20
  21. 21. Case study 5-8AP LAO Case study 5-7 PVARP 250ms 42 21
  22. 22. Case study 5-8 PVC Response 280ms Electrophysiological Study before Pacemaker Implantation1. Establish diagnosis g2. Assist pacemaker parameter settings3. Confirm efficacy of ATP therapy (DDDRP)4. Assist in future troubleshooting5. ??? 22
  23. 23. Atrial Antitachycardia Pace- termination (ATP) TherapiesA-Burst+ Burst train followed by 2 premature pulses Atrial Antitachycardia Pace- termination (ATP) Therapies A-Ramp Decrements between each pulse, and p adds one pulse to each sequence 23
  24. 24. Electrophysiological Study before Pacemaker Implantation 1. Establish diagnosis g 2. Assist in pacemaker parameter settings 3. Confirm efficacy of ATP therapy (DDDRP) 4. Assist in future troubleshooting 5. $$$ Case study 6-1• General Data – 64 y/o, male – Retired merchant – Taiwanese – Married• C.C. sudden and transient LOC < 10s at home• CAD, two vessel disease, post LCX stenting in 2008/10 , and type 2 DM• Propranolol, atorvastatin, and aspirin at CV clinic• Smoking: quitted 10+ years, alcohol (-) 24
  25. 25. ECG 2008/10/28ECG 2011/09/29 25
  26. 26. ECG 2011/09/29ECG 2011/10/01 26
  27. 27. TET 2011/10/04TET 2011/10/04 27
  28. 28. TET 2011/10/04TET 2011/10/04 28
  29. 29. Cath 2011/10/05Cath 2011/10/11 29
  30. 30. Cath 2011/10/11Cath 2011/10/11 30
  31. 31. Cath 2011/10/11Cath 2011/10/11 31
  32. 32. Cath 2011/10/11 ESC Guidelines for the Diagnosis and Management of Syncope Pacing in BBB & AV blockEur Heart J 2009;30:2631-71 64 32
  33. 33. Permanent Pacing in Chronic Bifascicular Block ACC/AHA/HRS 2008 Guidelines I IIa IIb III Permanent pacemaker implantation is p p indicated for advanced second-degree AV block or intermittent third-degree AV block. I IIa IIb III Permanent pacemaker implantation is indicated for type II second-degree AV block. I IIa IIb III Permanent pacemaker implantation is indicated for alternating bundle-branch block. Permanent Pacing in Chronic Bifascicular Block I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia. I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of a markedly prolonged HV interval (greater than or equal to 100 milliseconds) in asymptomatic patients. y p p I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological.ACC/AHA/HRS2008 Guidelines 33
  34. 34. Permanent Pacing in Chronic Bifascicular Block I IIa IIb III PM implantation may be considered in the setting of neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle dystrophy (limb girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms. I IIa IIb III Permanent pacemaker implantation is not indicated for fascicular block without AV block or symptoms. t I IIa IIb III Permanent pacemaker implantation is not indicated for fascicular block with first-degree AV block without symptoms.ACC/AHA/HRS 2008 Guidelines Technique 1. Conventional EP study 2. Noninvasive EP study 34
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  44. 44. Th k you f your attention!Thank for tt ti ! 87 44

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