Cardiac Electrophysiology

An Introduction

F.M.Leonelli M.D.
 ELECTROPHYSIOLOGY STUDY

DIAGNOSTIC THERAPEUTIC
combined with RFA

PROGNOSTIC
 EPS
Diagnostic indications:
• Non diagnostic initial evaluation of
palpitations or syncope
• Unclear mechanism of arrhythmia
(WCT)
• Sudden death risk stratification
 EPS
Aims:

• Assess electrophysiological functions

of SN and conduction system
• Evaluate arrhythmia induction
Functions of the Cardiac Electrical System

Impulse formation

Impulse conduction
From cell to ECG

Cellular EP

EP Testing

ECG
 EPS
Technique
• Potentials generated during cardiac
depolarization can be:
Recorded
Amplified
Interpreted
by intra-cardiac catheters placed during EPS
 EPS
Technique
• Catheters are made of woven Dacron
• Inserted percutaneously Femoral, Jugular
vein/s or Femoral artery
• Recording from uni/bi-polar electrodes
• Under fluoroscopy positioned in stable
locations or
• Rowed in a cardiac chamber to “map”
electrical activation
 Recording Catheters

Thermistor

Recording/Ablating
 From Cell to EPS
CellularLevel
• As some cells depolarize while others are
still in the resting state, a difference in
voltage is created, and this generates a
current which will form the
electromagnetic force or vector recorded by
the ECGraph

Vector
 Vector Recording
• Cardiac depolarization generates an infinitesimal
electromagnetic force (Vector) detected, filtered, recorded
and displayed.
• One of the assumptions of vector recording is:
• When an electromagnetic force is directed towards the
positive electrode of a bipolar lead will record a positive
(up-going) deflection, negative (down-going) if directed
towards the negative electrode
Intracardiac Catheters placement during EPS
DIGITAL ACQUISITION
DIGITAL DISPLAY
PRINTING
Electrophysiology study
Baseline recording
 EPS
Technique
• Recordings and stimulation (rapid pacing and
introduction of extrastimuli) performed at EPS
• Stimulation protocols usually standardized but
frequent variations
• Aim is to assess physiological response of a
structure (RA,AVN, HPS) or to induce an
arrhythmia
S1 S2 S3 S4

S1
Shortening of APD at faster stimulation
ERP
Decremental, non decremental conduction
Rapid Atrial Stimulation
Rapid Ventricular Stimulation
R atrial programmed stimulation with induction of AVNRT
 Diagnostic
82 yrs old female
Normal CV function
Multiple presyncopal spells
 ELECTROPHYSIOLOGY STUDY

DIAGNOSTIC THERAPEUTIC
combined with RFA

PROGNOSTIC
 EPS
Prognostic
• SCD incidence is 300.000/yr unchanged
over last 10 yrs
• In the great majority of cases due to fast
ventricular arrhythmias
• Strong association with pre-existing
ischemic heart disease
• Effective SCD resuscitation 1-3%
 EPS
Prognostic

• Primary prevention by identification of

individual at risk
• Protection of patients by

Antiarrhytmic drugs
Implantable Cardioverter Defibrillator
 SCD and CARDIAC DISEASE

Incidence and absolute numbers of SCD events in various populations

with progressively more severe cardiac disease Circulation 1998;97:1514
Triggers and Substrate
 MUSTT
Patient Results Total Mortality
0.6
EP-Guided Rx, No ICD
No EP-Guided Rx
0.5 EP-Guided Rx, ICD

0.4 p < 0.001

Event Rate

0.3

0.2

0.1

0
0 1 2 3 4 5
Time after Enrollment (Years)
Buxton AE. N Engl J Med. 1999;341:1882-90.
 EPS
Prognostic
• MADIT I, II, SCAT EF etc support ICD
implant in patient with EF<35%
• Prognostic EPS in selected pts with
intermediate EF and risk factors (MI, NSVT)
• Questionable role of EPS in LQTs or HOCM
 EPS
Prognostic
• Monomorphic VT at EPS predicts high risk of
future VT/VF in pts with:
CAD (MI and or ischemic CMP)
structural HD and syncope
low EF, CAD and asymptomatic NSVT

• Non inducibility does not confer a benign

prognosis
• Negative and positive predictive value of EPS in
this setting is 88% and 49%
Monomorphic VT induction during RV stimulation
 EPS
Prognostic
• Polymorphic VT /VF more commonly
induced than MVT but less specific
• Predictive value of EPS in DCMP very
limited
• Syncope, but not EPS, in this subgroup
predicts SD
• EPS can identify conduction disease and SVT
causing syncope
Ventricular fibrillation induced at EPS
 ELECTROPHYSIOLOGY STUDY

DIAGNOSTIC THERAPEUTIC
combined with RFA

PROGNOSTIC
 EPS
Therapeutic
• EPS identifies the mechanism of tachycardia and
pathological substrate
• Intracardiac location of substrate is identified
• With RFA (Crio/US) substrate can be destroyed
curing the arrhythmia
 EPS
Therapeutic
• Any arrhythmic substrate can be eliminated
• Acute success rate close to 100% in AVNRT,
AVRT and Atrial Flutter
• Recurrence rate less than 5%
• Atrial tachycardias less predictably induced but
success rate close to 90% in induced arrhythmias
 EPS
Therapeutic
• Any arrhythmic substrate can be eliminated
• Acute success rate close to 100% in AVNRT,
AVRT and Atrial Flutter
• Recurrence rate less than 5%
• Atrial tachycardias less predictably induced but
success rate close to 90% in induced arrhythmias
 EPS
Therapeutic

• New insight into arrhythmic substrate of AF

• Fast discharging sites induce A Fib
• Areas of abnormal tissue maintain the arrhythmia
• Ablation of these targets is feasible and
successfully cures A Fib in up to 85% of cases
 EPS
Therapeutic
• VT in normal CV systems can be successfully
and permanently ablated in >90%.
• Ablation for VT in CAD lower success (40-70%)
and higher recurrence rates
• Clinically significant VPCs permanently
eliminated in 80-90% of pts
 EPS
Therapeutic

• Arrhythmic substrate localization often complex

based on:
Reconstruction of intracardiac activation during
the arrhythmia by recording of endocardial
activation using a rowing catheter (mapping)
 Scar

Ablation line
 Cardiac Electrophysiology Study
Radiofrequency ablation
• After mapping, the arrhythmic tissue is destroyed

• RF energy is unmodulated alternating current

between 300kHz and 2MHz
• Delivered by a catheter connected to a generator
• Heat at the point of contact destroys the targeted
tissue
Radiofrequency induced lesion
 EPS
Complications
• Complications rate
Death 0.3 %
Stroke 0.2 %
AV block 1 %
Tamponade 0.6 %
MI 0.1 %
Pneumothorax 0.1 %
F artery laceration 0.1 %
 EPS
Conclusions
• EPS gold standard in:
Diagnosis of any clinical arrhythmias
Assessment of cardiac EP properties

• EPS valuable in:

Stratification of patients at high risk of SD
 EPS
Conclusions
• EPS and RFA:
Offer a permanent cure in the great
majority of arrhythmias

Should be considered first line therapy

in SVTs, AFL, AT some VTs

Will play a dominant role in the

management of Atrial Fibrillation