Post on 11-Apr-2017
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EP STUDYMINIMUM PROTOCOL
WEVE TALKED ABOUTEQUIPMENTPATIENT PREPARATIONRELEVANT ANATOMYCATHETERS and PLACEMENTBASIC INTERVALSTESTS OF SN FUNCTION
AND NOWEQUIPMENTPATIENT PREPARATIONRELEVANT ANATOMYCATHETERS and PLACEMENTBASIC INTERVALSTESTS OF SN FUNCTION
ATRIAL and VENTRICULAR EXTRASTIMULUS TESTINGREFRACTORY PERIODSGAP INCREMENTAL PACINGMINIMUM PROTOCOL FOR DIAGNOSTIC EPS
Extrastimulus testing
5Drive train with a single extra stimulus
8 paced beat drive train EP steady stateExtrastimulus(Coupling interval)
5Coupling interval
Extra stimuli
S1S1S1S1S1S1S1S1S2SensedDRIVETRAIN
S1S1S1S1S1S1S1S1S2SensedDRIVETRAIN
S3
SingleDoubleTriple
6Coupling interval: time between extra stimui (S2) after train pacing
Atrial Extrastimulus testing Dynamic properties of AVN and HPS conductionAVN and RA refractory periods
Atrial Extrastimulus testing Dynamic properties of AVN and HPS conductionAVN and RA refractory periods
Dual AVN physiology
Atrial Extrastimulus testing Dynamic properties of AVN and HPS conductionAVN and RA refractory periods
Dual AVN physiology
Arrhythmia induction
S2 with long coupling interval
Conduction at fairly constant velocity
A2H2 equal or slightly more than A1H1
A1H1 80 ms ~ A2H2 95 ms
S1A1 ~ S2A2 ~ 55 ms
H1V1 ~ H2V2 ~ 50 ms
S2 with short coupling interval
Slowing of Conduction
A1H1 < A2H2
A1H1 80 msA2H2 140 ms
S2 with shorter coupling interval
Blocked AES at AVN
Ventricular Extrastimulus testing Retrograde conduction over HPS and AVN
Accessory pathway conduction
Arrhythmia induction
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
S2 with long coupling interval
H buried in VV1A1 almost equal to V2A2
Earliest atrial activation in HBEAtleast 30 ms before HRAProximal-to-distal CS activationCONCENTRIC ATRIAL ACTIVATION
S2 with short coupling interval
S2 with shorter coupling interval
S2 with short coupling interval with short drive cycle length
Blocked VES at AVN
VA block
Differs with ES coupling interval Drive cycle length
S2 with short coupling interval
Tissue latency in local evoked response
Occurs just above the tissue refractory period
Even shorter coupling interval
Blocked VES locally at RV apex
Loss of ventricular capture
Ventricular Extrastimulus testing Other Normal responsesNo VA conduction at allAtropine, IsoprenalineNo VA conduction despite drugs
Ventricular Extrastimulus testing Other Normal responsesNo VA conduction at allAtropine, IsoprenalineNo VA conduction despite drugs
Retrograde exit site from AV node maybe near CS ostium rather than HBE earliest atrial activation at Proximal CS
Ventricular Extrastimulus testing Other Normal responsesNo VA conduction at allAtropine, IsoprenalineNo 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
Refractory periods
EFFECTIVE Refractory PeriodERP of a tissue
EFFECTIVE Refractory PeriodERP of a tissue (or a structure)
EFFECTIVE Refractory PeriodERP of a tissue (or a structure) is the LONGEST coupling interval that fails to capture the tissue
EFFECTIVE Refractory PeriodERP of a tissue (or a structure) is the LONGEST coupling interval that fails to capture the tissue (or be conducted over the structure)
FUNCTIONAL Refractory PeriodFRP 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
FUNCTIONAL Refractory PeriodFRP 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-V1S2-A2-H2-V2AVNHPSAV conduction system
RELATIVE Refractory PeriodRRP of a tissue (or a structure) is the input interval at which the output interval just begins to differ from input interval
RELATIVE Refractory PeriodRRP 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
In all tissues, ERP and FRP are length-dependentSo, measured using atleast 2 different drive cycle lengths
AVNERP
Longest A1A2 interval that fails to capture HB
A1A2 maybe longer than S1S2 due to tissue latency
AVNFRP
Shortest H1H2 in response to any A1A2 interval
AVNRRP
Longest A1A2 interval at which A2H2 exceeds A1H1
Normal range of refractory periods (ms)ERP AtriaERP AVNFRP AVNERP HPSERP V150-350 230-430330-530330-450190-290
*Denes, Akhtar, Durrer, Josephsen series
GAP phenomena
ES conducted as LBBB
INCREMENTAL ATRIAL PACING
INCREMENTAL VENTRICULAR PACING
MINIMUM PROTOCOLBasic intervalsSNRT and CSNRTAES AVNERP AV WCLVES VERPVA WCL
Arrhythmia induction
TO BE CONTINUED.
.NEXT presentationsAtrial arrhythmiasVentricular Pre-excitation and AVRTVentricular arrhythmiasCatheter ablation