This book provides a detailed summary of all aspects of cardiac electrophysiology, presented in an easy to use handbook. For each arrhythmia the aetiology, classification, clinical presentation, mechanism, and electrophysiology is set up (including precise set up and ablation parameters) and trouble-shooting are presented and demonstrated using interesting images, fluoroscopy images, ECG’s and electrograms.
The overall aim of this book is to provide a logical and practical approach to cardiac arrhythmia management. It acts as a useful resource and, importantly, helps to promote this sub-specialty. This book is aimed at cardiac electrophysiologist’s, fellows, cardiologists, physicians, family practitioners, cardiology trainees, students, allied professionals and nurses. Given its succinct summary of electrophysiology is a useful reference guide for the electrophysiology laboratory. It is aimed at an international audience and provides an important guide for those studying for all heart rhythm exams..
Foreword
Preface
Contents
Contributors
Chapter 1: Cardiac Anatomy and Electrophysiology
The Cardiac Action Potential
Phase IV (Resting Phase)
Phase 0 (Depolarization)
Phase I (Early Repolarization)
Phase II (Plateau Phase)
Phase III (Repolarization)
Refractoriness
Arrhythmia Mechanisms
Re-entry
Automaticity
Afterdepolarizations and Triggered Activity
Anatomy of the Cardiac Chambers
The RA
The SN
Crista Terminalis (CT)
RA Conduction
Cavotricuspid Isthmus (CTI)
LA
Atrio-Ventricular (AV) Junction
His Bundle
The CS
LV Conduction System
RV Conduction System
Aberrant Ventricular Conduction
ECG Signal Acquisition
Autonomic Innervation of the Heart
References
Chapter 2: Cardiac Electrophysiology Study, Diagnostic Maneuvers and Ablation
Indications for an EP Study and Ablation
Supraventricular Arrhythmias (SVT)
Typical Atrial Flutter
Atrial Fibrillation (AF)
Ventricular Arrhythmias
EP Study and Ablation: Patient Preparation
EP Study and Ablation: Potential Risks
Collateral Damage During Ablation
Pericardial Effusion
Phrenic Nerve Injury
Esophageal Injury
Coronary Artery Injury
Important Note on Ionizing Radiation
Administration of Sedation and Anesthesia
Peri-procedural Anticoagulation
EP Laboratory Set-Up
How Electrograms Are Derived: Amplification and Filtering
Electrogram Signals: Unipolar and Bipolar
RF Generation and Ablation
Cryoablation
Ablation Catheters
Ablation Catheter Size
Irrigation
Contact Force Catheters
Vascular Access
Femoral Cannulation
Subclavian/Axillary Vein
Internal Jugular Vein
Electrophysiology Catheters and Positioning
Baseline Measurements
Sinus Node Recovery Time (SNRT)
Sinoatrial Conduction Time (SACT)
AV Conduction Times (AH and HV Intervals)
Refractory Periods (AERP, AVNERP, VERP, VANERP)
AV Wenckebach Point
Basic EP Study
VT Stimulation Protocol
SVT Diagnostic Maneuvers
Baseline Observations
Initiation and Termination
VA Relationship and Atrial Activation
Effect of Bundle Branch Block
RV Entrainment
PVC During Tachycardia
Para-Hisian Pacing
Stimulus: Atrial Interval (SA)
His: Atrial Interval (HA)
Atrial Activation Sequence (AAS)
Transseptal Access
Equipment
Trans-septal Needles
Transseptal Sheaths
Guidewires
Fluoroscopic Approach
Echocardiographic Visualization
References
Chapter 3: Electroanatomic Mapping
General Principles of EAM Mapping
Reference Point
Window of Interest
Activation Mapping (Isochronal)
Voltage Map (Isopotential)
Entrainment Mapping
Specific Mapping Systems
CARTO Mapping System (© Biosense Webster, Inc)
Merging the Baseline CT/MRI onto the Anatomic Map
Additional Features of Carto
Ensite Velocity System (St Jude Medical, Minnesota 55442, USA)
Rhythmia Mapping System (Rhythmia Mapping, Rhythmia Medical, Boston Scientific Inc., Marlborough, MA, USA)
References
Chapter 4: AV Nodal Re-entry Tachycardia (AVNRT)
Introduction
Anatomy
Mechanism
Classification
Slow/Fast AVNRT (Typical AVNRT)
Fast/Slow AVNRT (Atypical AVNRT)
Slow/Slow AVNRT
Electrophysiological Evaluation
Baseline Data
Risks of EP Study and Ablation
Procedure
Differentiation Between AVNRT and AVRT
Differentiation of AVNRT from Atrial Tachycardia
Ablation Techniques
Ablation Endpoints
Trouble Shooting the Difficult Cases
References
Chapter 5: Accessory Pathway (AP) Conduction
Anatomy
Mechanisms
Classification
Electrophysiological Evaluation
Baseline ECG
Algorithms
ECG Features of Posterospetal Accessory Pathway’s
Coronary Sinus Accessory Pathways
ECG Features of Anteroseptal Accessory Pathway’s
ECG Features of Mid-Septal Accessory Pathway’s
ECG Features of Left Lateral Accessory Pathway’s
ECG Features of Right Freewall Accessory Pathways
Risks of EP Study and Ablation
Diagnostic EP Study
Differentiation Between AVNRT and AT
Mapping the Accessory Pathway
Ablation of Accessory Pathway’s
Posteroseptal Accessory Pathway’s
Posteroseptal Accessory Pathway: Difficult Case
Anteroseptal Accessory Pathway
Midseptal Accessory Pathway
Mahaim Accessory Pathways
ECG Features
EP Study and Mapping of Mahaim
Left Lateral Accessory Pathway
Right Free Wall Accessory Pathway
Accessory Pathway General: Difficult Case
References
Chapter 6: Atrial Tachycardias
Focal Versus Macro Re-entry
Locations of Atrial Tachycardias
Crista Terminalis
Coronary Sinus os
Septal Atrial Tachycardias
Tricupid and Mitral Isthmus Atrial Tachycardia
Pulmonary Vein Atrial Tachycardia
Left Atrial Appendage Atrial Tachycardia
References
Chapter 7: Atrial Flutter
Cavotricuspid Isthmus Dependent Atrial Flutter
Anatomy
ECG Features
Ablation of the CTI for Typical Atrial Flutter
Decremental Pacing
Decremental His to Coronary Sinus Pacing
An Alternative Ablation Technique: Maximum Voltage Guided Ablation
Potential Complications of Cavotricuspid Isthmus Ablation
Difficult CTI Ablation
Success of Cavotricuspid Isthmus Ablation
Upper and Lower Loop Re-entry
Right Atrial Lateral and Postero-Lateral Wall Flutter
Left Atrial Flutter
Mitral Isthmus Dependent Atrial Flutter
References
Chapter 8: Atrial Fibrillation
Classification of AF
Etiology
Hypertension
Coronary Artery Disease
Valvular Heart Disease
Diabetes Mellitus
Obesity and Obstructive Sleep Apnea (OSA)
Autonomic AF
Familial AF
Oral Anticoagulation
Vitamin K Antagonist
Non-vitamin K Antagonist Oral Anticoagulation Therapy (OAC’s)
Direct Thrombin Inhibitors
Factor Xa Inhibitors
HAS-BLED Score
Catheter Ablation for AF
Risks of Catheter Ablation of AF
How to Perform a PVI
Patient Preparation
Transseptal Access
Anatomic Reconstruction of the Left Atrium
Ablation Technique
Pulmonary Vein Potentials and Farfield Signals
Confirming Pulmonary Vein Isolation
Assessing for Non PV Triggers
Cryoablation
Hybrid Ablation of AF
Ablation of Persistent AF
Linear Lesions
Roof Dependent Left Atrial Flutter
Mitral Isthmus Dependent Atrial Flutter
CFAE Mapping and Ablation
Rotor Mapping
Focal Impulse and Rotor Modulation of Atrial Fibrillation
Non-invasive Multi Electrode Mapping
References
Chapter 9: Ventricular Tachycardia
ECG Criteria
Scar Related VT
Mechanism
Mapping and Ablation of Scar Related VT
Epicardial Access and Ablation
ECG Characteristics Suggestive of Epicardial Involvement
Epicardial VT Ablation
Epicardial Access
Epicardial Mapping and Ablation
Epicardial Ablation: The Difficult Case
Idiopathic VT
Bundle Branch Re-entry
EP Study and Ablation for Bundle Branch Re-entry VT
Fascicular Re-entry VT
EP Study and Ablation for Fascicular VT
The Difficult Case
Outflow Tract VT
Anatomy and ECG Features
Outflow Tract Tachycardia: EP Study and Ablation
Indications
Risks
Procedure
Initiation and Catheter Positioning
Mapping
Ablation
Endpoints and Success
The Difficult Case
Lack of Spontaneous Ectopy
Lack of Early Sites
Continuation of the Arrhythmia Despite Ablation
Inability to Deliver Ablation in the Cardiac Venous System
Mitral Annular VT
References
Chapter 10: Anti-arrhythmic Drugs
Mechanisms of Action: An Overview
Class IA Antiarrhythmics
Class IB Antiarrhythmics
Class IC Action AAD’s
Class II Antiarrhythmics
Class III
Class IV
AAD’s Not in the Vaughan Williams Classification
The Future: Novel AAD’s
Atrial Repolarization Delaying Agents: Vernakalent
Sodium Channel Blockers: Ranolazine
References
Index
