TUGAS EP

JERRY MARISI H MARBUN

 LADDER DIAGRAM

 A technique of graphically representing the electrical activation sequence of the heart

 For generations has helped students understand the mechanisms of cardiac arrhythmias and conduction disorders
 It helps clinicians and learners visualize and communicate mechanisms of arrhythmia

Johnson NP, et al. Am J Cardiol. 2008.

 Surface electrocardiography loses information due to superimposition and silence of the electrical signal
 Atrial and ventricular depolarization and repolarization sum to produce the standard 12-lead electrocardiogram,
while sinoatrial and atrioventricular (AV) nodes produce signals too faint to detect
 Important atrial electrical findings can hide behind the towering QRS complex
 Conduction into the AV node may be concealed

 Therefore, the ladder diagram remains a popular visual aid when graphically representing the mechanism of
arrhythmia
 For surface electrocardiography, a ladder diagram plays the role of disentangling atrial and ventricular electrical
activity and giving representation to the sinoatrial and AV nodes

Johnson NP, et al. Am J Cardiol. 2008.

 REQUIREMENTS FOR LADDER DIAGRAM

 A physician needs to have basic knowledge about cardiac conduction and electrophysiology
phenomenon, which include:
1. Effective refractory period: The longest interval of 2 repetitive impulse which cans still be conducted
2. Conduction velocities in cardiac tissues; the conduction velocity in the AV node is slower than in the atrium,
conduction velocity in the His-Purkinje system is slower than in the myocardium
3. Concealed conduction: Retrograde conduction from ventricle to atrium that goes through the AV node will
affect the next antegrade conduction
4. Autonomic and pharmacologic effects to the cardiac conduction
5. Waves identification and intervals

Raharjo SB, et al. Kapita Selekta Aritmia. 2018.

 SINUS RHYTHM

 ECG surface showing normal sinus rhythm. Ladder diagram revealed the conduction mechanism, impulse from
the SA node underwent fast propagation through the atrium (A), then through the Atrioventricular (AV) node with
slower conduction, and finally to the ventricle (V).

Chugh, et al. Textbook of Clinical Electrocardiography. 2006.

SINUS ARRHYTHMIA

 Ladder diagram depicting sinus arrhythmia

 The vertical lines in the A level line up with the
beginning of each P wave
 The vertical lines in the V level line up with the
beginning of each QRS complex
 The AV nodal conduction is represented by a slanted
line drawn to connect the bottom of each atrial line to
the top of each corresponding ventricular line

Summerfield N, et al. J Vet Cardiol. 2005.

 ATRIAL FLUTTER

 A single-circuit macro-reentrant atrial tachyarrhythmia

 Surface ECG  P waves are typically replaced by regular saw-tooth waves called flutter (F) waves and a clear
delineation of the baseline is not possible
 The latter can make the identification of the onset of the F waves difficult and potentially affect the preciseness of
the line representing atrial depolarization on the ladder diagram
 Ventricular rhythm and rate will depend on the atrial rate and state of AV conduction

Summerfield N, et al. J Vet Cardiol. 2005.

 ATRIAL FLUTTER

 Flutter waves (F waves) are depicted as originating

from one site in the atrium at a regular rate
 The F wave preceding the last fully inscribed F wave
immediately in front of the ventricular complex is
assumed to be the one that conducts to the ventricles
 The F wave that is thought to conduct through the AV
node is circled in red and showed in ladder diagram
with red line

Summerfield N, et al. J Vet Cardiol. 2005.

 ATRIAL FIBRILLATION

 A multiple circuit re-entrant atrial tachyarrhythmia

 Asynchronous conduction, concealed conduction, summation, cancellation of wavefronts and local re-entry may
all contribute in determining whether or not the His bundle will be excited
 When constructing a ladder diagram for AF, vertical lines in the A level represent theoretical fibrillation waves,
which are more rapid and indistinct than F waves
 Identification of specific fibrillation waves is not possible, so these lines serve merely as a representation
 These vertical lines will not be evenly spaced, unlike the usually regular F waves in atrial flutter
 Non-conducted fibrilation waves are depicted with parallel lines of varying length in the AV level, to show that
each impulse probably penetrates to a different depth within the AV junction depending on its state of
refractoriness

Summerfield N, et al. J Vet Cardiol. 2005.

ATRIAL FIBRILLATION

 Ladder diagram of atrial fibrillation

 Fibrillation waves (f waves) are represented by
arbitrarily positioned dots and lines in the A portion of
the ladder diagram
 Concealed conduction also is arbitrarily represented by
the varying lines and block in the AV portion
 Ventricular depolarization is shown as either a straight
(normal conduction) or bifurcated red (altered
conduction) line
 Note the repeated long-short coupling pattern that
results in varying degrees of right bundle branch block.

Summerfield N, et al. J Vet Cardiol. 2005.

Spectrum of supraventricular tachycardia illustrated in
the ladder diagram

Johnson NP, et al. Am J Cardiol. 2008.

 ATRIOVENTRICULAR NODE CONDUCTION

 AV node has a decremental characteristic

 It is marked by the slower conduction velocity when there is faster impulse that came to the AV node
 Prolonged PR interval in surface ECG
 There could also be dual AV node pathway

Raharjo SB, et al. Kapita Selekta Aritmia. 2018.

• Ladder diagrams showing normal sinus conduction pattern through AV node, conduction pattern with slow–fast atrioventricular
nodal reentrant tachycardia (AVNRT), and conduction pattern with fast–slow AVNRT
• Each panel shows the AV node (top), a ladder diagram (middle), and a surface ECG lead (bottom)
• Solid lines indicate anterograde AV nodal conduction, and broken lines retrograde conduction; straight lines indicate conduction
over the fast pathway, and wavy lines conduction over the slow pathway
• During sinus rhythm the impulse traveling over the fast pathway turns around after traversing the AV node and retrogradely
penetrates the slow pathway  the slow pathway is concealed
• The simultaneous registration of P’ waves and QRS complexes during common AVNRT, with RP’ < P’R
• During uncommon AVNRT, inverted P waves are visible, with RP < PR.

Mahadevan S V, et al. An introduction to clinical emergency medicine. 2012.

DUAL ATRIOVENTRICULAR NODAL PATHWAYS

 Rhythm strip from lead V1 of a surface ECG

 Ladder diagram demonstrated the proposed
mechanism for 1:2 AV conduction via dual AV nodal
pathways.
 Concealed retrograde conduction in both fast and
slow pathways led to a pseudo-Wenckebach pattern
 The Wenckebach cycle length of the fast pathway
during the electrophysiology study was 320 ms,
significantly shorter than the sinus cycle length here

Johnson NP, et al. Am J Cardiol. 2008.

 ATRIOVENTRICULAR NODE REENTRANT TACHYCARDIA (AVNRT)

 AVNRT with 3 AV nodal pathways (marked f, i, and

 Dual-pathway atrioventricular node reentrant
s) labeled explicitly
tachycardia (AVNRT) using explicit labels for fast
and slow pathways
 Alpha slow pathway; beta fast pathway

Johnson NP, et al. Am J Cardiol. 2008.

 AV BLOCK

 Ladder diagram of first degree atrioventricular (AV) block

 The blue arrows correspond to p waves originating in the atrium (A), conducting via the AV
node (AV) to the ventricle (V)
 Each p wave is associated with a QRS after a prolonged PR interval

Pellegrini CN, et al. Herzschr Elektrophys. 2015

 AV BLOCK
 Ladder diagram of atrioventricular (AV) Wenckebach
block (Mobitz I)
 Conduction through the AV node progressively
delays, shown by a shallower slope of the blue line in
the AV row, ultimately leading to a nonconducted p
wave due to block at the level of the AV node
 The PR of the beat immediately following the
dropped p wave shortens
Pellegrini CN, et al. Herzschr Elektrophys. 2015
 Ladder diagram of second degree Mobitz II
atrioventricular (AV) block
 Nonconducted p waves occur at irregular intervals
with no preceding PR prolongation or subsequent PR
shortening
 The block is generally below the level of the AV
node and pathologic, displayed here by the blue
arrow being stopped just after passing through the
AV node row
 AV BLOCK

 Ladder diagram of third degree atrioventricular (AV) block

 The p wave are marching through at a normal to fast rate, but are all being blocked
somewhere in the conduction system
 All ventricular beats are the result of an escape rhythm from the His bundle or ventricle
 The asterisks just above the ventricular row represent the junctional escape beats

Pellegrini CN, et al. Herzschr Elektrophys. 2015

 LIMITATIONS

 Ladder diagrams work best with reentry phenomenon

 Occurrences of abnormal automaticity such as after-depolarizations or triggered rhythms do not lend themselves
to simple ladder diagram depictions
 A long QT interval with R-on-T degenerating into Torsades de Pointes, which likely represents early after-
depolarizations, has not been shown on a ladder diagram,
 In general, the ladder diagram represents well abnormalities of impulse conduction but is less explicit with
abnormalities of impulse formation
 CONCLUSION

 Ladder diagram is a supportive tool to understand arrhythmia mechanism

 Basic knowledge about cardiac conduction and electrophysiology phenomenon is required to make and understand
the ladder diagram
 REFERENCES

1. Johnson NP, Denes P. The Ladder Diagram (A 100+ Year History). Am J Cardiol. 2008;101(12):1801–4.
2. Yuniadi Y. Diagram ladder: Alat bantu memahami mekanisme aritmia. In: Raharjo SB, editor. Kapita selekta aritmia.
Jakarta: Sagung Seto; 2018. p. 3–15.
3. Chugh S. Sinus rhythm and its manifestations. In: Textbook of clinical electrocardiography for postgraduates,
residents and practicing physicians. 3rd ed. Rohtak: Jaypee Brothers Medical; 2012.
4. Summerfield N, Estrada A. Ladder diagrams for atrial flutter and atrial fibrillation. J Vet Cardiol. 2005;7(2):131–5.
5. Gurudevan S V. Cardiac dysrhythmias Anatomic essentials. In: Mahadevan S V, Garmel GM, editors. An introduction
to clinical emergency medicine. 2nd ed. California: Cambridge University Press; 2012. p. 55–72.
6. Pellegrini CN, Scheinman MM. Bradycardia : sinus and AV node dysfunction. Herzschr Elektrophys. 2015;26:175–91.