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EP equipment and setting
( EP 的基本設定 )
國立成功大學附設醫院
心肺室 劉明端組長
EP Lab Equipment
• Fluoroscopy unit
• EP recording system
• For viewing and
recording intracardiac
EGM and surface ECG
• C...
硬體設備
• X 光機 (Philips, Siemens, GE, Toshiba)( 單向或雙向 )
• 多頻道記 器錄 (Channels-32,64,96,128)
• 刺激器 ( 機械式、電腦式 )
• 電燒器 ( 控式或磁導式溫 3...
Integris Allura Bi-plane 10/10
Artis zee biplane
Innova 2100/2121 EP XRay
Fd10+stereotaxis to proof
existance of partnership
Polygraphy Equipment
Stimulator
• EP4
Commonly Used Ablation Generators
The radiofrequency generator is used to delivery radiofrequency energy from the distal
e...
Electro-Catheters
• Fixed Curve Diagnostic
• Coronary Sinus Catheters
• Deflectable Tip Diagnostic
• 20 Pole Catheters
• S...
bipolar (2 poles) for temporary
quadripolar (4 poles)
hexapolar (6 poles)
octapolar (8 poles)
decapolar (10 poles)
multipo...
Fixed catheters
• Diameter
• Length:
• N° poles:
• Spacing:
• Curves (colour):
• Connector:
• 5F
• 6F
• 7F
• 110cm
• 115cm...
Electrodes
• Quadripolar(4 poles)
• Hexapolar(6 poles)
• Octapolar(8 poles)
• Decapolar(10 poles)
• Mutipolar or
• Duo-Dec...
Deflectable Diagnostic Catheters
Design Considerations :
• Negotiate the sharp angles that result
when attempting access t...
Coronary Sinus
Catheters(10o
)
20 Pole and Specialty Catheters
HALOHALO™™ XPXP
TVA Mapping
ISMUS™ CATH
Atrial Isthmus
Mapping
Atrial Mapping;
Crista Term...
Specialty Catheters for atrium Mapping
AFocusII double loop(SJM)
200
PentaRay (Biosense Webster)
200
HD Mesh Mapper (Bard)...
LASSO™ Circular Mapping Catheter
AFib Opportunity
AFib – most common form
of all sustained arrhythmias
Atrial premature be...
銀鐸實業有限公司 20
Standard Ablation Catheters
•CELSIUS®
Livewire TCTM
EP study catheter setting (SVT)
• 靜脈 (Vein)
RA 、 His 、 RV 、 CS 、 Ablation
catheter
(for AVNRT)
• 動脈 (arterial)
Ablation ca...
驟步 : (for AVNRT or AVRT)
• 四極電導管於上腔靜脈與右心房交接處即 high
right atrium (HRA) 作為記 與刺激錄
• 四極電導管置於希氏束 (His Bundle) 作為記錄
• 四極電導管置於右心室...
Catheters used in SVT studies:Catheters used in SVT studies:
 Quadripolar in theQuadripolar in the HRAHRA (usually fixed ...
Catheters used in standard EP studies:Catheters used in standard EP studies:
Quadripolar in the HRA (usually fixed curve)...
Catheters used in a Conduction
System Study
• Quadripolar for HRA
• Quadripolar for HBE
• Quadripolar for RVA
Evaluate sin...
Basic 13-Channel Mapping for SVT
Catheter positioning
HRA
CS
His
RV
Catheter Positioning – Fluoroscopic
Imaging
HRAHRA
CSCS
HISHIS
RVRV
Electrogram (EGM)
Electrical System- Atrial conduction
Diagnostic catheter position with
signals
Electrical System- Automaticity
Diagnostic catheter position with
signals
Diagnostic catheter position with
signals
Electrical System- Ventricular
conduction
Diagnostic catheter position with
signals
Baseline EGM recording
Electrical System- Localized
difference in conduction
測量 (1)
• 心房間傳導時間:由表面心電極最早之 P
波
或 (HRA 之 A 波 ) 至 HBE 之 A 波間距
• 房室結傳導時間:由 HBE 之 A 波至 H 波的
間距
(50ms-120ms)
• His-Purkinje 纖維傳...
測量 (2)
• 右傳導束傳導時間從最早 V 波到 RV apex V 波
之間距
• PA 間距延長,表示心房室束傳導出問題,可
能心房擴大而傳導時間 加結果增
• AH 間距 (55-130msec) 若有延長,表示房室結
傳導有問題
• ...
記 與頻道設定錄
• 表面心電圖極
(I,aVF,V1) , HRA , HBE , ( 可分為近端
與遠端 ) , CS( 共 5 頻道 ) 以及 RV
• 於 HRA 所記 仍為竇房結錄 (SA node) 附近
心房去級化波通常可記 一較...
• CS 所記 仍是在二尖瓣膜環後面之左心房錄
及左心室去極化波 A 與 V 波
• RV 所記 主要為右心室頂之去級化波錄 V 波
• 記 紙速度通常為 秒錄 每 100mm or 200mm ,為
心電圖記 紙錄 4 倍快速 ( 間距變寬 ...
刺激方式
(Pacing Protocol)
Electrophysiology Study
• Measurement of baseline conduction
intervals
• Atrial Pacing
- Assessment of SA nodal automatici...
Electrophysiology Study con t
• Ventricular pacing
– Access retrograde conduction
– Access ventricular refractoriness
• Ar...
心房漸進式刺激
atrial incremental pacing (Antegrade)
通常採用比正常竇性節律稍快的刺激頻率,
給予 8 次稱之為 S1) ,緊接給予一比 S1 稍
短頻率之心房刺激 ( 稱之為 S2) ,此類似給
予一心房...
• 當 S2 刺激提早至有 A 波而沒有 H 及 V 波之最長的 S1
S2 間距,稱之為房室結疲乏期 (AV node ERP)
• 此時 S2 又提早至只有刺激 S2 波而無心房 A 波之最長
S1 S2 間距,稱之為心房疲乏期疲乏期 (A...
• SNRT
• SACT
• AV Decremental Properties
• AV Wenckebach cycle length
(Incremental pacing only)
• AVNERP
• AERP
Standard ...
心室漸進式刺激 (ventricular
incremental pacing)
• 與心房刺激相同方式,但是在右心室給予 8 次
之
S1 ,緊接給予一早期收縮 S2 ,重複進形直到心
室疲乏期發生。藉以了解房室結逆向傳導功能
,及 Kent...
• 測試竇房結 (SA node) 功能,會測量竇房結至心
房之傳導時間 ( 簡稱 sinoatrial
conduction time, 簡稱 SACT)
• 心房短期快速刺激,以測量竇房結恢復時間 (SN
recovery time)
• ...
 Evaluate sinus node function (Evaluate sinus node function (sinus nodesinus node
recovery time, sino-atrial conduction t...
Pacing – Incremental Pacing
• Incremental Pacing - is pacing the
heart at a fixed rate. The rate is
increased (pacing inte...
Pacing – Decremental Pacing
• Decremental Pacing – pacing at a
progressively increasing heart rate by
decreasing the amoun...
Pacing – Extra Stimulus Pacing
For the standard EP
study to test the
refractory periods, one
extrastimulus (S2) will
be us...
Standard EP Study Protocol Cont. –
Atrial Pacing
Atrial pacing is performed with the HRA catheter to determine the followi...
With Wenckebach there are grouped beats with gradual prolongation of the AH
interval until conduction to the ventricle eve...
The ERP of the AV node is reached when conduction from the atrium to the
ventricle is blocked due to reaching the refracto...
The ERP of the atrial tissue is reached when you pace at a rate
faster than the absolute refractory period of the atrial t...
AERP
No local atrial
electrogramPacing “spike”
Standard EP Study Protocol Cont. –
AV Node Conduction Curve – AERP
AERP = 2...
VERP
Pacing “spike”
No local ventricular
electrogram
VERP = 200 - 270 msecs
Standard EP Study Protocol Cont. –
Retrograde ...
V A V A V A V V A V
No “A” wave
Note that on the 4th and 6th beats no “A” wave follows
the “V” wave. This is called VA blo...
VA Conduction Patterns
Midline Right
eccentric
Left
eccentric
謝謝聆聽
EPS 的基本設定_20120916_南區
EPS 的基本設定_20120916_南區
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EPS 的基本設定_20120916_南區

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EPS 的基本設定_20120916_南區

  1. 1. EP equipment and setting ( EP 的基本設定 ) 國立成功大學附設醫院 心肺室 劉明端組長
  2. 2. EP Lab Equipment • Fluoroscopy unit • EP recording system • For viewing and recording intracardiac EGM and surface ECG • Cardiac stimulator… • essentially an enhanced temporary pacemaker… • used to introduce artificial stimuli for inducing and terminating arrhythmias • Ablation generator • 3-D mapping and navigation system • Intracardiac ultrasound unit
  3. 3. 硬體設備 • X 光機 (Philips, Siemens, GE, Toshiba)( 單向或雙向 ) • 多頻道記 器錄 (Channels-32,64,96,128) • 刺激器 ( 機械式、電腦式 ) • 電燒器 ( 控式或磁導式溫 3-D) • 注射式 浦幫 (Isuprel,Proternol-L)0.2mg(1amp)in 50ml N/S=4ug/ml,15ml/h(1ug/min)/3min 30ml/h by heart rate 100 bpm﹥ • 電極導管與電燒導管 • 去顫器 • 急救設備
  4. 4. Integris Allura Bi-plane 10/10
  5. 5. Artis zee biplane
  6. 6. Innova 2100/2121 EP XRay
  7. 7. Fd10+stereotaxis to proof existance of partnership
  8. 8. Polygraphy Equipment
  9. 9. Stimulator • EP4
  10. 10. Commonly Used Ablation Generators The radiofrequency generator is used to delivery radiofrequency energy from the distal electrode of the ablation catheter through the myocardial tissue and to the ground pad to ablate the arrhythmia. Medtronic Atakr IMedtronic Atakr I StockertStockert IBIIBI MedtronicMedtronic Atakr IIAtakr II EPT 1000 RadionicsRadionics EPTEPT OsypkaOsypka OsypkaOsypka EPT 1000XPEPT 1000XP
  11. 11. Electro-Catheters • Fixed Curve Diagnostic • Coronary Sinus Catheters • Deflectable Tip Diagnostic • 20 Pole Catheters • Specialty Catheters
  12. 12. bipolar (2 poles) for temporary quadripolar (4 poles) hexapolar (6 poles) octapolar (8 poles) decapolar (10 poles) multipolar (20 poles) FIXED CURVES quadripolar (4 poles) hexapolar (6 poles) octapolar (8 poles) decapolar (10 poles) multipolar (20 poles) DEFLECTABLE CURVES DIAGNOSTIC CATHETERS
  13. 13. Fixed catheters • Diameter • Length: • N° poles: • Spacing: • Curves (colour): • Connector: • 5F • 6F • 7F • 110cm • 115cm • 60cm (special curve) • 2, 4, 6, 8, 10, 20 • 2, 5, 10, 2-5-2, 2-8-2mm
  14. 14. Electrodes • Quadripolar(4 poles) • Hexapolar(6 poles) • Octapolar(8 poles) • Decapolar(10 poles) • Mutipolar or • Duo-Decapolar(20 poles) 1(-)2(+) 3 4 His(D) 1-2 His(M) 2-3 His(P) 3,4
  15. 15. Deflectable Diagnostic Catheters Design Considerations : • Negotiate the sharp angles that result when attempting access to the coronary sinus • Placement of the His catheter • Helps to minimize the excess procedure time often associated with manoeuvring and mapping in the coronary sinus
  16. 16. Coronary Sinus Catheters(10o )
  17. 17. 20 Pole and Specialty Catheters HALOHALO™™ XPXP TVA Mapping ISMUS™ CATH Atrial Isthmus Mapping Atrial Mapping; Crista Terminalis SANTORO™ Atrial Isthmus Mapping superior approach
  18. 18. Specialty Catheters for atrium Mapping AFocusII double loop(SJM) 200 PentaRay (Biosense Webster) 200 HD Mesh Mapper (Bard) 320
  19. 19. LASSO™ Circular Mapping Catheter AFib Opportunity AFib – most common form of all sustained arrhythmias Atrial premature beats initiate AFib from ectopic foci within the pulmonary veins Formerly: lack of effective method for mapping of the ectopic beats inside the veins
  20. 20. 銀鐸實業有限公司 20 Standard Ablation Catheters •CELSIUS® Livewire TCTM
  21. 21. EP study catheter setting (SVT) • 靜脈 (Vein) RA 、 His 、 RV 、 CS 、 Ablation catheter (for AVNRT) • 動脈 (arterial) Ablation catheter (for Lt side AVRT )
  22. 22. 驟步 : (for AVNRT or AVRT) • 四極電導管於上腔靜脈與右心房交接處即 high right atrium (HRA) 作為記 與刺激錄 • 四極電導管置於希氏束 (His Bundle) 作為記錄 • 四極電導管置於右心室頂 (RV apex) 作為記錄 與刺激 • 多極 (6-10) 電導管置於冠 靜脈竇狀 (coronary sinus, CS) 記 左心房與左心室之電訊號錄
  23. 23. Catheters used in SVT studies:Catheters used in SVT studies:  Quadripolar in theQuadripolar in the HRAHRA (usually fixed curve)(usually fixed curve)  Quadri, hexa, octa, or decapolar at theQuadri, hexa, octa, or decapolar at the HBEHBE (fixed curve or(fixed curve or steerable)steerable)  Quadripolar in theQuadripolar in the RVARVA (usually fixed curve)(usually fixed curve)  Hex, octa, or decapolar in theHex, octa, or decapolar in the CSCS (fixed curve or steerable)(fixed curve or steerable)  Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter Catheters used in VT studies:Catheters used in VT studies:  Quadripolar in theQuadripolar in the HRAHRA (sometimes omitted)(sometimes omitted)  Quadripolar (most common) at theQuadripolar (most common) at the HBEHBE (fixed or steerable)(fixed or steerable)  Quadripolar in theQuadripolar in the RVARVA (steerable is common so that it can be(steerable is common so that it can be moved to the RVOT)moved to the RVOT)  Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter Catheters used in SVT and VT Studies
  24. 24. Catheters used in standard EP studies:Catheters used in standard EP studies: Quadripolar in the HRA (usually fixed curve)Quadripolar in the HRA (usually fixed curve) Quadri, hexa, octa, or decapolar at the HBEQuadri, hexa, octa, or decapolar at the HBE (fixed curve or steerable)(fixed curve or steerable) Quadripolar in the RVA (usually fixed curve)Quadripolar in the RVA (usually fixed curve) Hex, octa, or decapolar in the CS (fixed curveHex, octa, or decapolar in the CS (fixed curve or steerable)or steerable) Catheters used in a EP Study
  25. 25. Catheters used in a Conduction System Study • Quadripolar for HRA • Quadripolar for HBE • Quadripolar for RVA Evaluate sinus node function Evaluate antegrade AV node conduction Evaluate retrograde AV node conduction
  26. 26. Basic 13-Channel Mapping for SVT
  27. 27. Catheter positioning HRA CS His RV
  28. 28. Catheter Positioning – Fluoroscopic Imaging HRAHRA CSCS HISHIS RVRV
  29. 29. Electrogram (EGM)
  30. 30. Electrical System- Atrial conduction
  31. 31. Diagnostic catheter position with signals
  32. 32. Electrical System- Automaticity
  33. 33. Diagnostic catheter position with signals
  34. 34. Diagnostic catheter position with signals
  35. 35. Electrical System- Ventricular conduction
  36. 36. Diagnostic catheter position with signals
  37. 37. Baseline EGM recording
  38. 38. Electrical System- Localized difference in conduction
  39. 39. 測量 (1) • 心房間傳導時間:由表面心電極最早之 P 波 或 (HRA 之 A 波 ) 至 HBE 之 A 波間距 • 房室結傳導時間:由 HBE 之 A 波至 H 波的 間距 (50ms-120ms) • His-Purkinje 纖維傳導時間:由 HBE 之 H 波 至最早出現 QRS 波或 V 波之間距 (35ms-
  40. 40. 測量 (2) • 右傳導束傳導時間從最早 V 波到 RV apex V 波 之間距 • PA 間距延長,表示心房室束傳導出問題,可 能心房擴大而傳導時間 加結果增 • AH 間距 (55-130msec) 若有延長,表示房室結 傳導有問題 • HV 間距 (30-55msec) 若有延長,表示 His-Purkinje 纖維傳導問題
  41. 41. 記 與頻道設定錄 • 表面心電圖極 (I,aVF,V1) , HRA , HBE , ( 可分為近端 與遠端 ) , CS( 共 5 頻道 ) 以及 RV • 於 HRA 所記 仍為竇房結錄 (SA node) 附近 心房去級化波通常可記 一較大的錄 A 波以 及遠端心室去級化之一小的 V 波 • HBE 所記 除了近房室結錄 (AV node) 心房 去級化波 A 波,更可直接記錄 His Bundle 去級化 H 波及心室去極化波 V 波
  42. 42. • CS 所記 仍是在二尖瓣膜環後面之左心房錄 及左心室去極化波 A 與 V 波 • RV 所記 主要為右心室頂之去級化波錄 V 波 • 記 紙速度通常為 秒錄 每 100mm or 200mm ,為 心電圖記 紙錄 4 倍快速 ( 間距變寬 ) • 測量單位為 60sec×1000 = 60,000msec
  43. 43. 刺激方式 (Pacing Protocol)
  44. 44. Electrophysiology Study • Measurement of baseline conduction intervals • Atrial Pacing - Assessment of SA nodal automaticity and conductivity - Assessment of AV nodal conductivity and refractoriness - Assessment His-Purkinjie system conductivity and refractoriness - Assessment of atrial refractoriness
  45. 45. Electrophysiology Study con t • Ventricular pacing – Access retrograde conduction – Access ventricular refractoriness • Arrhythmia Induction – Atrial extrastimulus testing – Atrial burst pacing – Ventricular extrastimulus testing – Ventricular burst pacing
  46. 46. 心房漸進式刺激 atrial incremental pacing (Antegrade) 通常採用比正常竇性節律稍快的刺激頻率, 給予 8 次稱之為 S1) ,緊接給予一比 S1 稍 短頻率之心房刺激 ( 稱之為 S2) ,此類似給 予一心房早期收縮,此種刺激模式重複進 行,但 次每 S2 刺激頻率比前次早 10ms , 由於 S2 愈早,其房室結傳導時間愈拉長 (AH 間距延長 ) ,重複刺激一直到心房疲乏 期 (atrial effective refractory period ,AERP) 發生。
  47. 47. • 當 S2 刺激提早至有 A 波而沒有 H 及 V 波之最長的 S1 S2 間距,稱之為房室結疲乏期 (AV node ERP) • 此時 S2 又提早至只有刺激 S2 波而無心房 A 波之最長 S1 S2 間距,稱之為心房疲乏期疲乏期 (AERP) • 利用此方式刺激不緊可以明瞭房室結的傳導功能 ( 尤其是否有雙套或多套傳導系統 ) • 測量房室結,心房及額外傳導束 (kent 纖維 ) 之疲 乏期 (ERP) ,更可誘出臨床表現之心博頻脈 (tachycardia)
  48. 48. • SNRT • SACT • AV Decremental Properties • AV Wenckebach cycle length (Incremental pacing only) • AVNERP • AERP Standard Conduction System Study - Antegrade Stimulation
  49. 49. 心室漸進式刺激 (ventricular incremental pacing) • 與心房刺激相同方式,但是在右心室給予 8 次 之 S1 ,緊接給予一早期收縮 S2 ,重複進形直到心 室疲乏期發生。藉以了解房室結逆向傳導功能 ,及 Kent 纖維之特性,或誘導心博頻脈。 • 正常逆傳導時,其逆向之 A 波最早應在 His 極 上或者是冠 靜脈竇開口處狀 (CS 之 os 極 ) 。 • 當 S2 提早至有 V 波而無逆向傳導之 A 波時之最 長 S1S2 間距稱之為 VAERP • S2 又提早至只有刺激 S2 波,而無心室之 V 波 之最長 S1S2 間距稱之為 VERP
  50. 50. • 測試竇房結 (SA node) 功能,會測量竇房結至心 房之傳導時間 ( 簡稱 sinoatrial conduction time, 簡稱 SACT) • 心房短期快速刺激,以測量竇房結恢復時間 (SN recovery time) • 竇房結恢復時間減去心房刺激前之正常竇性結 律時之 RR 間距,稱之為矯正後竇房結恢復時間 (Corrected SN recovery time) < 525ms 為正常
  51. 51.  Evaluate sinus node function (Evaluate sinus node function (sinus nodesinus node recovery time, sino-atrial conduction timerecovery time, sino-atrial conduction time))  Evaluate antegrade AV node conductionEvaluate antegrade AV node conduction ((AVNERP, AERP, AV Wenckebach cycleAVNERP, AERP, AV Wenckebach cycle lengthlength))  Evaluate retrograde AV node conductionEvaluate retrograde AV node conduction ((VAERP, VERP, VA Wenckebach cycleVAERP, VERP, VA Wenckebach cycle lengthlength)) Standard Conduction System Study
  52. 52. Pacing – Incremental Pacing • Incremental Pacing - is pacing the heart at a fixed rate. The rate is increased (pacing interval decreased) with each set of beats. S1-S1=400 S1-S1=390 S1-S1=380 S1-S1=370
  53. 53. Pacing – Decremental Pacing • Decremental Pacing – pacing at a progressively increasing heart rate by decreasing the amount of time between each paced beat. Used primarily to induce or terminate tachycardias. It is also called “ramp” pacing. Sns Sns Sns Sns TACHY.SENSE S 1 S 1S 1S 1S 1 SnsSnsSns RAMP
  54. 54. Pacing – Extra Stimulus Pacing For the standard EP study to test the refractory periods, one extrastimulus (S2) will be used. If a second extrastimulus is used, it is usually for arrhythmia induction and is called “S3”. Up to 3 (S4) extrastimuli (S2, S3, S4) can be given in a standard EPS. Any more than 3 extrastimuli would induce a non- clinical arrhythmia. That is, it could induce an arrhythmia in a normal subject. Exrastimulus Pacing DRIVETRAIN Sensed S1 S1 S1 S1 S1 S1 S1 S1 S2 Single extras
  55. 55. Standard EP Study Protocol Cont. – Atrial Pacing Atrial pacing is performed with the HRA catheter to determine the following: – AV decremental properties – AVNERP – AV Wenckebach cycle length – AERP Pacing spike A wave
  56. 56. With Wenckebach there are grouped beats with gradual prolongation of the AH interval until conduction to the ventricle eventually drops. Therefore only an occasional “A” wave will not conduct to produce a “V” (see the dropped “V” above). This occurs as pacing is hitting far into the relative refractory period. AH Intervals Dropped beat Standard EP Study Protocol Cont. – AV Node Conduction Curve – AV Wenckebach
  57. 57. The ERP of the AV node is reached when conduction from the atrium to the ventricle is blocked due to reaching the refractory period of the AV nodal tissue. This would be evidenced by an “A” wave after the pacing spike not followed by a His potential or a “V” wave. AVNERP = 280 - 450 msecs No His or “V” Pacing spike Standard EP Study Protocol Cont. – AV Node Conduction Curve – AVNERP A V
  58. 58. The ERP of the atrial tissue is reached when you pace at a rate faster than the absolute refractory period of the atrial tissue. This would be evidenced by a pacing spike not followed by an “A” wave. Consequently there would be no His potential or “V” wave. Pacing Spike V No “A” waves Standard EP Study Protocol Cont. – AV Node Conduction Curve – AERP
  59. 59. AERP No local atrial electrogramPacing “spike” Standard EP Study Protocol Cont. – AV Node Conduction Curve – AERP AERP = 200 - 270 msecs
  60. 60. VERP Pacing “spike” No local ventricular electrogram VERP = 200 - 270 msecs Standard EP Study Protocol Cont. – Retrograde Conduction Study – VERP
  61. 61. V A V A V A V V A V No “A” wave Note that on the 4th and 6th beats no “A” wave follows the “V” wave. This is called VA block. Standard EP Study Protocol Cont. – Retrograde Conduction Study – VA Block 4th 6th
  62. 62. VA Conduction Patterns Midline Right eccentric Left eccentric
  63. 63. 謝謝聆聽

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