Clinical Handbook of Cardiac Electrophysiology

Preface
Contents
Editors and Contributors
Editors
Contributors
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)
		Atrio-Ventricular (AV) Junction
	His Bundle
	The CS
	LV Conduction System
	RV Conduction System
		Aberrant Ventricular Conduction
		ECG Signal Acquisition
	References
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
		Ionizing Radiation in Cardiac Electrophysiology
	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
		Freezing: Thawing Phase
		Hemorrhagic: Inflammatory Phase
		Replacement: Fibrosis Phase
	Electroporation
	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
		Transseptal Access
	Equipment
		Trans-septal Needles
		Transseptal Sheaths
		Guidewires
		Fluoroscopic Approach
	Echocardiographic Visualization
	References
3: Electroanatomic Mapping
	General Principles of EAM Mapping
	Reference Point
	Window of Interest
	Activation Mapping (Isochronal)
	Voltage Map (Isopotential)
	Entrainment Mapping
	Specific Mapping Systems
		Ensite Precision (Abbott Technologies, Minnesota, USA)
		CARTO Mapping System (© Biosense Webster, Inc.)
			Merging the Baseline CT/MRI onto the Anatomic Map
			Additional Features of Carto
	Reference
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
		Procedure
		Differentiation Between AVNRT and AVRT
		Differentiation of AVNRT from Atrial Tachycardia (AT)
	Ablation Techniques
		Ablation Endpoints
		Troubleshooting the Difficult Cases
	Risks of EP Study and RF Ablation of AVNRT
	References
5: Accessory Pathway (AP) Conduction
	Anatomy
	Mechanisms
	Classification
	Electrophysiological Evaluation
		Baseline ECG
		Algorithms
			ECG Features of Posteroseptal Accessory Pathways
			ECG Features of Anteroseptal Accessory Pathways
			ECG Features of Mid-Septal Accessory Pathways
			ECG Features of Left Lateral Accessory Pathways
			ECG Features of Right Free Wall Accessory Pathways
		Risk Stratification of Accessory Pathways
		Risks of EP Study and Ablation
	Diagnostic EP Study
	Differentiation Between AVRT, AVNRT and AT
	Mapping the Accessory Pathway
	Ablation of Accessory Pathways
		Posteroseptal Accessory Pathways
		Posteroseptal Accessory Pathway: Difficult Case
		Anteroseptal Accessory Pathway
		Midseptal Accessory Pathway
		Right Atriofascicular Accessory Pathways
			ECG Features
	EP Study and Mapping of a Right Atriofascicular Accessory Pathway
		Left Lateral Accessory Pathway
		Right Free Wall Accessory Pathway
		Accessory Pathway General: Difficult Case
	References
6: Atrial Tachycardias
	Introduction
		Procedural Planning
	Intracardiac Mapping and Ablation
	Focal Atrial Tachycardia
	Tachycardiomyopathy and Incessant Atrial Tachycardia
	Locations of Atrial Tachycardias
	Crista Terminalis
	Tricuspid Annulus
	Perinodal/Parahisian Region
	Coronary Sinus Os
	Pulmonary Vein Atrial Tachycardia
	Mitral Annular Atrial Tachycardia
	Atrial Appendage Tachycardias
	References
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
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
		Re-Entry Mapping
			Focal Impulse and Rotor Modulation of Atrial Fibrillation
		Non-Invasive Multi Electrode Mapping
	References
9: Ventricular Tachycardia
	Introduction
	Mechanism
	Diagnosis
	Surface ECG Features
		Localization
		Outflow Tract Anatomy and the ECG
		ECG Characteristics Suggestive of Epicardial Involvement
		Mapping and Ablation of Scar Related VT
	Macro-Reentrant VT Involving the Conduction System
		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
		Mapping and Ablation of Focal Ventricular Arrhythmias
		The Outflow Tracts
		The Atrioventricular Valve Annuli
		The Purkinje Fibers and Papillary Muscles
		The Left Ventricular Summit
		Challenging Ablation Sites
		Epicardial Access and Ablation
		Epicardial Access
	Epicardial Mapping and Ablation
	References
10: Anti-Arrhythmic Drugs
	Mechanisms of Action: An Overview
	Antiarrhythmics with Class IA Properties
	Antiarrhythmics with Class IB Properties
	Class IC 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: Vernakalant
		Sodium Channel Blockers: Ranolazine
	References
Index