Basics of

electrophysiological
study
Dr Mervat Aboulmaaty
Prof. of Cardiology, Ain Shams University

Dr Rehab Hamdy
Lecturer of Cardiology, Alazhar University
2014
The normal conductive system
of the heart

His
SAN

AVN
 Objectives
 General objectives of EP-study

 Assess the integrity or function of the

Conductive System

Sinus node function AVNN function

 Induce tachycardia & study its mechanism

 RF ablation
EPS procedure

 Vascular access (Venous – arterial)

 Electrode catheter (mapping – pacing)
 Catheter position (Cath Lab)
 Multichannel recording system +
programmable stimulator
 3D Electroanatomical Mapping
Electrode catheter Connecting port

4 312 1

Dist.
Prox.

Bipolar intracardiac recording

(localized electrical activity-
depolarization of tissue)
EP Lab = Cath Room + EPS machine + Ablato
+/- 3D mapping
Fluoroscopy

‫جهاز القسطرة‬ Stimulator

EPS Machine RF ablator & Infusion Pump

Display screen:
The first page is 12 lead surface ECG
second page :intracardiac ECG (local
electrograms)
 Femoral
sheaths
Ablation catheter

CS
catheter
Subclavian
venous sheath
Ablator

Temp:
time:
Impedence:

Ablation catheter

Indifferent electrode
Catheter position

 SVT VT
HRA SAN HRA
His AV cond His
RVA RVA +/- LVA
CS SCV/IVC

Recording from RA, RV, His , CS

Catheter Placement and recording

HRA

HIS

CS

RV
Catheter position
RAO LAO

His

ABL CS
CS
ABL
RV
Catheters projection in RAO and LAO views
Cs catheter (deflectable) inserted through IVC
LAO 20 Pole mapping catheter catheter
(HALO) and long sheaths for stability

Halo
catheter
mapping the
RA

ABL
CS
Long
Sheath His
Ablation Catheters
 Measurements

 Millisecond (msec) - The unit of time used in

measuring intervals. 0.001 of a second.

 Heart rate (HR)- The number of

depolarizations per minute.

 Cycle length (CL) - msec it takes from a

single point in one cardiac cycle to the
same point in the next cardiac cycle.
CL= 60000 / HR msec
HR= 60000 / CL bpm
BASIC DEFINITIONS:
Nomenclature
 S : Sinus activation
 A : Atrial activation
 H : His Bundle activation
 V : Ventricular activation
 S1: Regularly delivered stimulus in a series
 A1: Atrial activation resulting from S1
 H1: His bundle activation resulting from S1
 V1: Ventricular activation resulting from S1
 S2: First premature stimulus
 S3: Second premature stimulus
 A2: Atrial activation resulting from S2
 H3: His bundle activation resulting from S3
Refractory Period

 Effective refractory period (ERP) is the

longest S1-S2 that fails to depolarize the
chamber being paced or the AV node.

 Functional refractory period (FRP) is the

shortest S1-S2 that depolarizes the chamber
being paced or the AV node.
Catheter Placement – High Right Atrium (HRA)
Catheter Placement – Right Ventricular Apex (RVA)
Catheter Placement – His Bundle
Catheter Placement – Coronary Sinus
baseline cond. intervals

 SCL= interval bet. 2 successive A waves

 AH interval ( 50—120 msec) AVN
 HV interval (35 – 55 msec) His-RV/QRS
 His deflection (cond. Via His bundle)
Basic intracardiac recordings
Basic intracardiac measurements
SAN function

 Pacing (site- type- differentiation)

 Tests of SAN function:
-SNRT (assess SAN automaticity) (up to
1500 msec) - variable with HR
-cSNRT (SNRT-BSL) up to 525 msec
- SACT (50-125 msec) assess cond. of
impulse from SAN to adjacent atrial tiss
 Recovery interval
SAN function Time = 30 sec

550 A
HRA 400
S1

SCL= 450 msec SNRT= 550 msec CSNRT= 150 msec

 SAN function
Sino Atrial Conduction Time
Idea: reset the SAN – Narula method
8 paced beats

S1 580
A

Recovery interval= time of paced beat penetrates & resets SAN+SCL+time for spont.
Beat to exit SAN = SCL+ 2 SACT SACT=580-450/2 = 65 msec
Tests of AVN function

 Antegrade 1:1 AV conduction

 Antegrade WCL
 Retrograde 1:1 VA conduction
 Retrograde WCL
 AVN/ERP
Atrial pacing
1:1 AV cond.

AV
 Atrial pacing
Weckebach AV block

RA A A A A

HIS
H
HIS
V V V
RV
Basic intracardiac ECG
Atrial pacing, Wenckebach more yellow than purple
Atrial Extrastimulation
To measure AVN/ERP
Atrial Extrastimulation
to measure AVN/ERP
Atrial Extrastimulation
AVN/ERP 500/280 msec
V pacing
To measure retrograde AVN
or detect AP

AV VA
1:1 VA cond. Retrograde sequence of activation
Concentric

VA VA VA

PCL= 300 msec

Ventricular Pacing
VA dissociation

A A A A A

V V V

PCL=260 msec
Ventricular
Extrastimulation S1 S2

V1 V2

A1 A2
Ventricular
Extrastimulation
Decremental conduction

V1
V2

A2
A1
Ventricular Extrastimulation :
ERP of retrograde limb of AVN

V1 S2 No V

A1
Ventricular Tachycardia Study
Induction by Extra stimulus and
termination by Overdrive Pacing
 The CARTO XP System
Components
• Patient Interface Unit (PIU)

• Communication Unit (COM)

• PC Windows NT 4
Workstation

• Location Pad
(external, ultra-low magnetic
field emitter.)

47
 Location Pad
An External Ultra-Low
Magnetic Field Emitter

48
 Catheter Tip Location
The Fields possess
Temporal and spatial The Triangulation Principle
distinguishing
characteristics

D1 D3

D2

49
 Two Sensors: REF and
MAP
Mapping Catheter Mapping Catheter

Reference Reference
Patch Patch

Location Pad Location Pad

50
 Carto Concept:
Sequential Contact Mapping of
Endocardium

51
What is new ??!!
Patient with LVOT VT .CARTO 3 Mapping
THANK YOU FOR YOUR
LISTENING