Electrophysiology of the Heart

ELECTROPHYSIOLOGY OF THE HEART

An electrophysiology study is a test performed to

assess your heart's electrical system or activity and is
used to diagnose abnormal heartbeats or arrhythmia.
The test is performed by inserting catheters and then
wire electrodes, which measure electrical activity,
through blood vessels that enter the heart.
BASIC PRINCIPLES OF ELECTROPHYSIOLOGY
• The muscle cells of the heart normally are stimulated and
paced by the electrical activity of the cardiac impulse-
conducting system
•The impulse-conducting system cells have the ability to
stimulate the heart without the influence of the nervous
system. However, the autonomic nervous system normally
plays a major role in controlling heart function.
• Cardiac muscle cells normally generate an electrical
imbalance across the cell membrane, with a positive charge
on the outside and a negative charge on the inside.
• This is the resting or polarized state in which there is no
electrical activity
Stimulation of the “polarized” cells causes an influx of Na+
into the interior portion of the cell; this is called
depolarization
• Depolarization causes the cardiac muscle cells to contract
momentarily. Depolarization is immediately followed by
repolarization , which is a rapid return of the cell to the
“polarized” position in which the electrical imbalance across the
membrane is reestablished
• The impulse-conducting system has three types of cardiac
cells capable of electrical excitation:
pacemaker cells (sinoatrial [SA] node, atrioventricular [AV]
node), specialized rapidly conducting tissue ( Purkinje fibers),
and atrial and ventricular muscle cells.
• The ability of these cells to depolarize without stimulation is
known as automaticity. Each of these cardiac cell groups varies
in degree of automaticity
 IMPULSE-CONDUCTING SYSTEM
• The impulse-conducting system is responsible for initiating the
heartbeat and controlling the heart rate. It also coordinates the
contraction of the heart chambers, which is essential to move
blood effectively
• A defect in the impulse-conducting system may lead to
inadequate cardiac output and decreased tissue perfusion.
• Normally, the SA node, which is located in the upper portion of
the right atrium, has the greatest degree of automaticity and paces
the heart
• Any heartbeat originating outside the SA node is considered an
ectopic beat.
• The SA node is innervated by the autonomic nervous system,
which allows the sympathetic and parasympathetic nervous systems
to influence heart rate.

• Stimulation of the sympathetic nervous system, such as occurs

with the administration of certain medications (adrenergic
bronchodilators), increases the heart rate,

• whereas activation of the parasympathetic nervous system slows

the heart rate by influencing the degree of automaticity within the
SA node

• The electrical impulse generated by the SA node travels rapidly

across the right atrium, through intraatrial pathways, to the left
atrium by way of the Bachmann bundle; this causes a wave of
depolarization to occur over the atria, producing atrial contraction.
• Next,the impulse moves to the AV node, located in
the intraventricular septum in the inferior aspect of
the right atrium
• The AV node is the “backup” pacemaker because it
has the second greatest degree of automaticity in
the healthy heart.
• In most cases, if the SA node fails to function
properly such as may occur with ischemia or in
response to certain medications, the AV node paces
ventricular activity at a lower heart rate of 40 to 60
beats/min,which is generally sufficient to maintain
adequate cardiac output.
• Theelectrical impulse is temporarily delayed at the
AV node to allow the ventricles time to fill with
blood. That brief delay also limits the rate of the
ventricular stimulation during excessively fast atrial
rhythms that, if passed to the ventricles, would lead
to a very rapid heart rate that would cause the
cardiac output to be inadequate
• The impulse exits the AV node, enters the bundle of His,
and rapidly moves to the bundle branches. The bundle
branches carry the impulse rapidly into the right and left
ventricles.

•The bundle branches terminate in the Purkinje fibers,

which are small, finger-like projections that penetrate the
myocardium

• These fibers stimulate contraction of the myocardium

from the apex of the heart upward toward the base of the
heart, causing a coordinated contraction of the ventricles,
which normally is effective in moving blood.
The impulse travels most rapidly in the Purkinje
fibers, which is essential if contraction of the
ventricles is to occur in a coordinated fashion.
Immediately after depolarization of the ventricles,
repolarization occurs in preparation for the next
impulse.
12 Lead Electrocardiogram
(ECG)
The Heart
All heart muscle is
capable of conducting an
electrical impulse and
initiating a spontaneous
electrical discharge.

The 12 lead ECG is a

graphical
representation of this
activity
 Main Structures
● Sino-atrial node (SAN)
● Atrio-ventricular node (AVN)
● Fibrous atrio-ventricular septum
● Bundle of His
❖ Right bundle
❖ branch Left bundle
branch
– anterior bundle
– posterior
Purkinje bundle
Fibres
 The electrical events of a single
cardiac cycle and how it is represented
on ECG paper.
R
 The Iso Electrical Line

This represents the resting potential of the heart.

The electrical events of the cardiac cycle will
be represented by deflections away from this
line.
SAN Depolarisation End of
Iso Electrical Line
● The events of the
cardiac cycle are
initiated by
depolarisation of the
sino- atrial node
Atrial Depolarsiation (P Wave)
● The wave of
electrical
depolarisation is
conducted through
the cardiac muscle
of both atria
Atrial Contraction (P Wave)
● The depolarising wave
causes contraction of
the atria pushing
blood into the
ventricles
AVN depolarisation (PR Interval)
● The wave of
depolarisation reaches the
atrio-venticular node
which depolarises and
conducts, but slows the
wave
Atrial Contraction (P Wave)
● The depolarising wave
causes contraction of
the atria pushing
blood into the
ventricles
AVN depolarisation (PR Interval)
● The wave of
depolarisation reaches the
atrio-venticular node
which depolarises and
conducts, but slows the
wave
Specialised conducting tissue
(QRS Complex)
● The AVN conducts the
depolarisation to the
Bundle of His
Ventriculardepolarisation
(QRS Complex)
● The wave of
depolarisation
quickly moves
through the
specialised
conducting tissue
Ventricular contraction (QRS
Complex)
● The co-ordinated,
synchronised
depolarisation
produces an effective
contraction of both
ventricles
Ventricular Repolarisation
(T Wave)
● After depolarisation and
contraction the ventricle
repolarise, returning to
the resting potential.
12 Lead ECG
● 12views of the
heart

● 6 chest leads

●6 limb leads

● Only 10 wires
 Lead Position - Chest

● V1 - 4th ICS RSE

● V2 - 4th ICS LSE
● V3 - midway between V2
& V4
● V4 - 5th ICS MCL
● V5 – Level with V4 AAL
● V6 - Level with V4 MAL

V1 V2 V3 V4 V5 V6
 Relationship of limb and chest
leads
● The chest leads look at the
heart across the horizontal
● plane
I
aVR aVL
The limb leads look at the heart
V6 ● in a vertical plane
Leads aVR, aVL and aVF look
V5
● from three separate directions
I II
V1
I I Leads I, II and III are
summation of potential
V4
V2
V3 differences between limb leads
aVF
 Positive / Negative Deflections
Positive deflections above Negative deflections below
the Iso Electrical line the Iso Electrical line
mean the electricity is mean the electricity is
flowing towards that lead flowing away from that
lead
 ECG Changes in Relation to
LEAD AVR Lead AVR

AVF

LEAD AVF