Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald's Heart Disease

Cover Page\r......Page 1
Copyright......Page 2
Dedication......Page 3
Foreword......Page 4
Preface......Page 5
BRAUNWALD’S HEART DISEASE COMPANIONS......Page 6
Pacemaker Mechanisms......Page 7
Autonomic and Other Influences......Page 8
Suppression of Normal and Abnormal Automatic Subsidiary Pacemakers......Page 10
Arrhythmias Caused by Automaticity......Page 11
TRIGGERED ACTIVITY......Page 12
Ionic Basis of Delayed Afterdepolarizations......Page 13
Properties of Delayed Afterdepolarizations......Page 14
Ionic Basis of Early Afterdepolarizations......Page 15
Requisites of Reentry......Page 16
Functional Reentry......Page 18
Excitable Gaps......Page 21
Reentrant Tachycardia Resetting......Page 22
Resetting Response Curves......Page 23
Resetting with Fusion......Page 24
Basic Principles of Entrainment......Page 25
Relationship of Pacing Site and Cycle Length to Entrainment......Page 26
Reduced Membrane Excitability......Page 27
Cellular Coupling: Gap Junctional Organization......Page 28
Uniform Versus Nonuniform Anisotropy......Page 29
Anisotropy and Unidirectional Block......Page 30
REFERENCES......Page 31
Risks and Complications......Page 33
Electrode Catheters......Page 35
Catheter Positioning......Page 36
His Bundle Catheter.......Page 37
Transaortic Approach......Page 38
Fluoroscopy-Guided Transseptal Catheterization......Page 39
Intracardiac Echocardiography–Guided Transseptal Catheterization......Page 41
Complications of Atrial Transseptal Puncture......Page 42
Epicardial Approach......Page 43
Unipolar Recordings......Page 44
Timing of Local Events......Page 45
His Bundle Electrogram.......Page 46
His Bundle–Ventricular Interval.......Page 48
S1, S2, S3,  .  .  .  SN.......Page 49
Cycle Length Responsiveness of Refractory Periods......Page 50
Technical Aspects of Atrial Stimulation......Page 51
Sinus Node Response to Atrial Extrastimula­tion.......Page 52
Type I Response.......Page 53
Atrial Response to Atrial Extrastimulation.......Page 54
Technical Aspects of Ventricular Stimulation......Page 55
Normal Response to Rate-Incremental Ventricular Pacing......Page 56
Normal Response to Ventricular Premature Stimulation......Page 57
Concealed Conduction......Page 59
Supernormality......Page 60
REFERENCES......Page 61
Unipolar Recordings......Page 63
Mapping Procedure......Page 65
Mapping Focal Tachycardias......Page 67
Mapping Macroreentrant Tachycardias......Page 68
Limitations......Page 69
Fundamental Concepts......Page 70
Fusion During Entrainment......Page 71
Post-Pacing Interval......Page 74
Mapping Procedure......Page 75
Limitations......Page 76
Interpretation of Pace Mapping......Page 77
Mapping Procedure......Page 78
Fundamental Concepts......Page 79
Clinical Implications......Page 80
Fundamental Concepts......Page 81
Clinical Implications......Page 83
Limitations......Page 84
Fundamental Concepts......Page 85
Mapping Procedure......Page 86
Clinical Implications......Page 89
Mapping Procedure......Page 90
Clinical Implications......Page 91
Clinical Implications......Page 92
Fundamental Concepts......Page 93
Mapping Procedure......Page 94
Fundamental Concepts......Page 95
Fundamental Concepts......Page 96
Clinical Implications......Page 97
Using the AcuNav Catheter......Page 98
Clinical Implications......Page 100
Fundamental Concepts......Page 101
Clinical Implications......Page 102
CONCLUSIONS......Page 103
References......Page 104
Radiofrequency Energy Delivery......Page 106
Convective Cooling......Page 107
Tissue Effects of Radiofrequency Ablation......Page 108
Electrode Length.......Page 109
Radiofrequency System Polarity.......Page 110
Temperature Monitoring......Page 111
Complications of Radiofrequency Ablation......Page 112
Mechanism......Page 113
Monitoring Radiofrequency Energy Delivery......Page 114
Clinical Applications of Cooled Radiofrequency Ablation......Page 115
Biophysics of Cryothermal Energy......Page 116
“Cryoablation”......Page 117
Pulmonary Vein Isolation.......Page 118
Clinical Applications of Microwave Ablation......Page 119
ULTRASOUND ENERGY......Page 120
Diode Laser.......Page 121
REFERENCES......Page 122
Anatomy and Physiology of the Sinus Node......Page 124
Electrocardiogram and Ambulatory Monitoring.......Page 125
Persistent Atrial Fibrillation.......Page 126
Sinus Node Recovery Time......Page 127
Sinus Node Recovery Time in Patients with Sinus Node Dysfunction......Page 128
Zone II: Zone of Reset.......Page 129
Sinoatrial Conduction Time in Patients with Sinus Node Dysfunction......Page 130
PRINCIPLES OF MANAGEMENT......Page 131
REFERENCES......Page 132
Atrioventricular Node......Page 133
Degenerative Diseases.......Page 134
Natural History of Atrioventricular Block......Page 135
Atrium.......Page 136
Type 1 Second-Degree Atrioventricular Block......Page 137
Type 2 Second-Degree Atrioventricular Block......Page 138
High-Grade Atrioventricular Block......Page 139
Third-Degree (Complete) Atrioventricular Block......Page 140
Atrioventricular Node.......Page 141
Localization of the Site of Atrioventricular Block......Page 142
Atrioventricular Node.......Page 143
Atrioventricular Dissociation......Page 144
PRINCIPLES OF MANAGEMENT......Page 146
REFERENCES......Page 147
Phase 3 Block......Page 149
Phase 4 Block......Page 151
Aberration Caused by Concealed Transseptal Conduction......Page 152
Site of Block......Page 153
Right Bundle Branch Block......Page 154
Left Bundle Branch Block......Page 155
Left Median Fascicular Block......Page 156
Intermittent Bundle Branch Block......Page 157
Localization of the Site of Block in Left Bundle Branch Block......Page 158
Diagnostic Maneuvers......Page 159
REFERENCES......Page 161
PATHOPHYSIOLOGY......Page 163
Clinical Presentation......Page 164
P Wave Morphology......Page 165
P/QRS Relationship ......Page 166
Left Atrial Tachycardias ......Page 167
Initiation by Atrial Extrastimulation or Atrial Pacing......Page 169
Termination and Response to Physiological and Pharmacological Maneuvers......Page 171
Concept of A-V Versus A-A-V Response After Ventricular Pacing During Supraventricular Tachycardia......Page 172
Activation Mapping......Page 174
Electroanatomical Mapping......Page 176
EnSite Noncontact Mapping System......Page 178
Multielectrode (Basket) Catheter Mapping......Page 179
Ablation Technique......Page 180
REFERENCES......Page 181
1. Clockwise and Counterclockwise “Typical” Atrial Flutter......Page 183
3. Lower Loop Reentry......Page 184
Typical Atrial Flutter......Page 185
Induction of Tachycardia......Page 187
Goals of Programmed Stimulation During Atrial Flutter......Page 188
Electroanatomical Mapping......Page 189
Target of Ablation......Page 190
Radiofrequency Ablation......Page 191
Endpoints of Ablation......Page 193
Confirmation of Bidirectional Cavotricuspid Isthmus Block......Page 194
REFERENCES......Page 196
Right Atrial Non–Isthmus-Dependent Flutter......Page 198
Left Atrial Macroreentrant Tachycardia......Page 200
ELECTROCARDIOGRAPHIC FEATURES......Page 201
Atrial Extrastimulation......Page 202
Localization of the Reentrant Circuit Chamber (Right Atrium Versus Left Atrium)......Page 203
Identification of the Complete Reentrant Circuit......Page 205
Electroanatomical Mapping......Page 206
Noncontact Mapping......Page 207
Left Atrial Flutter......Page 208
Ablation of the Mitral Isthmus......Page 209
Endpoints of Ablation......Page 210
Safety of Right Atrial Flutter Ablation......Page 211
REFERENCES......Page 213
Mechanism of Atrial Fibrillation......Page 214
Mechanism of Initiation of Atrial Fibrillation......Page 215
Mechanism of Maintenance of Atrial Fibrillation......Page 216
Interstitial Atrial Fibrosis......Page 217
“Atrial Fibrillation Begets Atrial Fibrillation”......Page 218
Pulmonary Vein Anatomy......Page 219
Epidemiology......Page 221
Prevention of Systemic Embolization......Page 222
Rhythm Control......Page 224
Atrial Activity......Page 225
Atrioventricular Conduction During Atrial Fibrillation......Page 226
Catheter Ablation of Atrial Fibrillation: Substrate Modification......Page 228
Catheter Ablation of Atrial Fibrillation: Elimination of Triggers......Page 229
Technical Aspects Common to Different Methods of Ablation......Page 230
Rationale......Page 232
Identification of Arrhythmogenic Pulmonary Veins......Page 233
Endocardial Activation Mapping......Page 235
Noncontact Mapping......Page 236
Which Pulmonary Veins to Isolate......Page 237
Lasso Catheter Mapping......Page 238
Mapping During Normal Sinus Rhythm......Page 239
Mapping During Atrial Fibrillation......Page 242
Basket Catheter Mapping......Page 243
Ablation Technique......Page 246
Endpoints of Ablation......Page 247
Rationale......Page 250
Electroanatomical Mapping......Page 251
Intracardiac Echocardiography–Guided Mapping......Page 252
Ablation Technique......Page 253
Intracardiac Echocardiography–Guided Ablation......Page 254
Ultrasound Ablation......Page 255
Rationale......Page 256
Target of Ablation......Page 257
Endpoints of Ablation......Page 258
Endpoints of Ablation......Page 260
Right Atrial Cavotricuspid Isthmus Line......Page 261
Mapping of Complex Fractionated Atrial Electrograms......Page 262
Target of Ablation......Page 263
Target of Ablation......Page 264
Rationale......Page 265
Clues to Ligament of Marshall Activation......Page 266
Mapping of the Ligament of Marshall......Page 267
Mapping of Superior Vena Cava Ectopy......Page 268
Ablation Technique......Page 269
Success Rates......Page 271
Recurrence of Atrial Fibrillation......Page 272
Pulmonary Vein Stenosis......Page 273
Cardiac Tamponade......Page 276
Atrioesophageal Fistula......Page 277
Left Atrial Tachyarrhythmias......Page 279
Thromboembolism......Page 280
Phrenic Nerve Injury......Page 282
RECOMMENDATIONS AND CONTROVERSIES......Page 283
Determination of Candidates for Catheter Ablation......Page 284
Determination of Necessity of Adding Left Atrial Linear Lesions......Page 285
Ablation Technique......Page 286
Outcome......Page 288
Ablation Technique......Page 289
REFERENCES......Page 290
Initial Evaluation......Page 293
ELECTROPHYSIOLOGICAL TESTING......Page 294
Target of Ablation......Page 295
Endpoints of Ablation......Page 296
Outcome......Page 297
REFERENCES......Page 298
Tachycardia Circuit......Page 299
Slow-Slow (Posterior-Type) Atrioventricular Nodal Reentrant Tachycardia......Page 301
Acute Management......Page 302
ELECTROCARDIOGRAPHIC FEATURES......Page 303
Atrial Extrastimulation and Atrial Pacing During Normal Sinus Rhythm......Page 305
Ventricular Extrastimulation and Ventricular Pacing During Normal Sinus Rhythm......Page 306
Initiation by Atrial Extrastimulation or Atrial Pacing......Page 308
Initiation by Ventricular Extrastimulation or Ventricular Pacing......Page 309
Typical (Slow-Fast) Atrioventricular Nodal Reentrant Tachycardia......Page 311
Atrial Extrastimulation and Atrial Pacing During Supraventricular Tachycardia......Page 312
Ventricular Extrastimulation and Ventricular Pacing During Supraventricular Tachycardia......Page 313
Para-Hisian Pacing......Page 316
Target of Ablation......Page 317
Ablation Technique......Page 319
Outcome......Page 321
Cryoablation Technique......Page 322
REFERENCES......Page 323
Wolff-Parkinson-White Syndrome......Page 325
Atrioventricular Reentry......Page 326
Atrioventricular Nodal Reentrant Tachycardia and Atrial Tachycardia.......Page 327
Wolff-Parkinson-White Pattern.......Page 328
Initial Evaluation......Page 329
Management of Asymptomatic Patient with Preexcitation......Page 330
Inapparent Preexcitation.......Page 331
Intermittent Preexcitation.......Page 332
Orthodromic Atrioventricular Reentrant Tachy­cardia.......Page 333
Atrial Fibrillation.......Page 334
Baseline Observations During Normal Sinus Rhythm......Page 335
Ventricular Pacing and Ventricular Extrastimulation During Normal Sinus Rhythm......Page 337
Orthodromic Atrioventricular Reentrant Tachycardia: Manifest Atrioventricular Bypass Tract.......Page 338
Orthodromic Atrioventricular Reentrant Tachycardia: Manifest or Concealed Atrioventricular Bypass Tract.......Page 339
Antidromic Atrioventricular Reentrant Tachy­cardia.......Page 340
Effects of Bundle Branch Block.......Page 341
QRS Alternans.......Page 342
Oscillations in the Tachycardia Cycle Length.......Page 343
Antidromic Atrioventricular Reentrant Tachy­cardia.......Page 344
Maneuvers to Prove Presence and Participation of Atrioventricular Bypass Tract in the Supraventricular Tachycardia.......Page 346
Antidromic Atrioventricular Reentrant Tachy­cardia.......Page 348
Response to Para-Hisian Pacing.......Page 349
Interpretation of Results of Para-Hisian Pacing.......Page 350
Limitations of Para-Hisian Pacing.......Page 351
Technique.......Page 352
Exclusion of Other Arrhythmia Mechanisms......Page 353
Effects of Bundle Branch Block During Orthodromic Atrioventricular Reentrant Tachycardia.......Page 355
Earliest Ventricular Activation Site During Preexcitation.......Page 356
Mapping Atrial Electrogram Polarity Reversal.......Page 357
Local Atrioventricular (or Ventricular) Interval.......Page 358
Target of Ablation......Page 359
Radiofrequency Delivery.......Page 360
Transseptal Approach.......Page 361
Technical Considerations......Page 362
Anatomical Considerations......Page 363
Technical Considerations......Page 364
Cryomapping......Page 365
Causes of Failed Bypass Tract Ablation......Page 366
REFERENCES......Page 367
Types of Atypical Bypass Tracts......Page 370
Baseline Observations During Normal Sinus Rhythm......Page 371
Induction of Tachycardia......Page 373
Diagnostic Maneuvers During Tachycardia......Page 374
Mapping the Atrial Insertion Site......Page 375
Mapping Sites of Mechanically Induced Loss of Preexcitation......Page 377
Outcome......Page 378
Supraventricular Tachycardias in Patients with Short PR Intervals......Page 379
Response to Pharmacological and Physiological Maneuvers......Page 381
REFERENCES......Page 382
Clinical Presentation......Page 383
Acute Management......Page 384
Assessment of Regularity of the Supraventricular Tachycardia......Page 385
ELECTROPHYSIOLOGICAL TESTING......Page 386
Atrioventricular Nodal Echo Beats.......Page 387
Inducibility.......Page 388
Oscillation in the Tachycardia Cycle Length.......Page 389
Effects of Bundle Branch Block......Page 390
Termination.......Page 391
Termination.......Page 392
Entrainment.......Page 393
Atrial Activation Sequence.......Page 394
Differential RV Pacing......Page 395
When the Ventricular Extrastimulus Advances the Next Atrial Activation.......Page 396
ΔHA (HAventricular pacing − HASVT).......Page 397
REFERENCES......Page 398
Medications.......Page 399
Ventricular Tachycardia Versus Aberrantly Conducted Supraventricular Tachycardia......Page 400
Dissociated P Waves.......Page 401
QRS Morphology.......Page 403
Algorithm 1.......Page 404
Algorithm 2.......Page 405
Algorithm 3.......Page 406
His Bundle–Right Bundle Branch Potential Sequence.......Page 407
Atrial Pacing.......Page 408
REFERENCES......Page 409
Mechanism of Postinfarction Ventricular Tachycardia......Page 410
Epidemiology......Page 411
ELECTROCARDIOGRAPHIC FEATURES......Page 412
General Principles in Localizing the Origin of Post–Myocardial Infarction Ventricular Tachycardias......Page 413
Anterior Myocardial Infarction Ventricular Tachycardias......Page 414
Recommended Stimulation Protocols......Page 416
Induction of Multiple Sustained Monomorphic Ventricular Tachycardias.......Page 417
Visible His Potential During Ventricular Tachy­cardia.......Page 418
Technique.......Page 419
Resetting.......Page 420
resetting with fusion.......Page 421
Technique.......Page 422
Entrainment.......Page 423
Termination.......Page 424
Supraventricular Tachycardia with Aberrancy.......Page 426
Bipolar Recordings.......Page 427
Mid-Diastolic Activity......Page 428
Entrainment Mapping......Page 430
Post-Pacing Interval......Page 431
QRS Morphology During Pacing Versus Ventricular Tachycardia......Page 433
S-QRS Interval During Pace Mapping......Page 434
Electrograms with Isolated Delayed Components.......Page 435
Principles.......Page 436
Limitations.......Page 437
Technique.......Page 438
First Step: Substrate Mapping During Normal Sinus Rhythm.......Page 439
Fourth Step: Pace Mapping During Normal Sinus Rhythm.......Page 440
Hemodynamically Stable Ventricular Tachycardia......Page 441
Ablation Technique......Page 442
Success and Recurrence.......Page 443
REFERENCES......Page 444
Types of Adenosine-Sensitive Ventricular Tachycardia......Page 446
Acute Management.......Page 447
Right Ventricular Outflow Tract Versus Left Ventricular Outflow Tract.......Page 448
Aortic Cusp Ventricular Tachycardias.......Page 450
Induction of Tachycardia......Page 451
Mapping......Page 452
Activation Mapping......Page 453
Interpretation.......Page 454
Electroanatomical Mapping......Page 455
Noncontact Mapping......Page 456
Basket Catheter Mapping......Page 457
Ventricular Tachycardias Originating in the Left Ventricular Outflow Tract and Aortic Cusps.......Page 458
Radiofrequency Delivery.......Page 459
Pathophysiology......Page 460
ECG During Ventricular Tachycardia.......Page 461
Purkinje Potential.......Page 462
Exclusion of Other Arrhythmia Mechanisms......Page 463
Ablation Technique......Page 464
Ablation of Noninducible Ventricular Tachycardia......Page 465
REFERENCES......Page 466
Clinical Presentation......Page 468
Baseline Observations During Normal Sinus Rhythm......Page 469
Tachycardia Features......Page 470
Antidromic Atrioventricular Reentrant Tachycardia Using an Atriofascicular Bypass Tract......Page 471
Ablation of the Left Bundle Branch......Page 472
INTERFASCICULAR REENTRANT VENTRICULAR TACHYCARDIA......Page 473
REFERENCES......Page 474
PATHOPHYSIOLOGY......Page 475
Clinical Presentation......Page 476
Pharmacological Therapy......Page 477
ELECTROCARDIOGRAPHIC FEATURES......Page 478
ELECTROPHYSIOLOGICAL FEATURES......Page 479
Electroanatomical Substrate Mapping......Page 480
ABLATION......Page 481
REFERENCES......Page 482
Electrophysiological Features......Page 484
Mapping......Page 485
Mapping......Page 486
Epicardial Mapping......Page 487
Mechanism......Page 488
Polymorphic Ventricular Tachycardia in the Presence of Normal QT Interval......Page 489
Activation Mapping......Page 490
REFERENCES......Page 491
Abbreviations......Page 493
Index......Page 494