Day - 2

EP lab setup, basics of IEGM and AVNRT

EP lab setup
diagnostic catheters

ablation catheters

long sheaths

trans-septal puncture set

drugs
Isoproterenol(used to
induce the tachycardia)

adenosine (to block the av

node
EP equipment
(workmate
Claris)
 Fluoroscopy is used to guide catheters into position.
• Vascular access sites:
•Superior approach:
•Internal or external jugular, subclavian or
brachial veins to access the CS or on
occasion the RV.

Superior and •Inferior approach:

•Right or left femoral veins to access the
inferior right atrium (RA), His region, coronary
sinus (CS) or right ventricle (RV). Multiple
catheters may be inserted into the same
approach femoral vein.
•Femoral artery is used for access to the
left ventricle (LV) via the retrograde aortic
approach.
•Transseptal approach to cross the septum
and introduce a catheter into the LA/ LV.
Catheter
type and
purpose
Basics of intracardiac EGM
• An Intracardiac Electrogram records the cardiac electrical activity or the depolarisation of a localized area of the heart.
• These signals are from the cardiac tissue in the immediate vicinity of electrode catheters placed in the heart.
• Ground View of Conduction System!
Baseline measurements
 • Measured in milliseconds
• Basic or Sinus Cycle Length - BCL or SCL
• A-A or V-V interval (range 600-1000 ms)
• Intra-atrial conduction time - Atrial Channel deflection to atrial deflection
on His Channel
• Atrial to His: A-H interval (range 50-120 ms)
• His to Ventricle: H-V interval (range 35-55 ms)

Baseline
measurements
IEGM Correlation with Conduction system
PA Interval (normal: 25–55 ms)
• It represents the time for activation to travel from the SA node region to the AVN region.
• The PA interval is measured from the earliest atrial activation in any channel (surface P wave or earliest atrial
EGM) to the rapid deflection of the atrial EGM on the His bundle catheter.
AH Interval (normal: 55–125 ms)
• It represents the time for the impulse to travel from the low RA through the AVN to the His bundle.
• The AH interval is measured on the His bundle catheter between the earliest rapid atrial deflection (low RA
depolarization) and the beginning of the His EGM.
HV Interval (normal: 35–55 ms)
• The HV interval is the time needed for conduction from the His bundle through the His-Purkinje system to
the ventricular myocardium.
• It is measured from the onset of the HBE to the earliest ventricular activation (surface QRS or V EGM).
 Drive train

Extra stimuli
Pacing
protocols
Burst and ramp pacing

Antegrade and retrograde pacing

maneuvers
Drive train
• A series of 6-10 fixed paced stimuli at a
constant rate separated from other paced beats
by a pause.
• Called S1
Extra stimuli
• Introduce one or more premature impulses
after an intrinsic impulse or a drive train
• Called S2, S3, S4
Extra stimuli
 Decremental Pacing

Ramp • Pacing at a progressively increasing

heart rate by decreasing the amount
of time between each paced beat
pacing and • Also called Ramp Pacing

burst Burst Pacing

pacing • Increase heart rate at a fix pacing rate

• Also called Overdrive Pacing- pacing
at a cycle length faster than sinus
Ramp pacing
and burst
pacing
Retrograde pacing What to see???
• Check Base CL • Capture or Not
• Start 500 ms and decremental • Concentric or Eccentric
20ms • Decrementing or not
• Until VA Wenckebach (VA ERP) • Dual AVN physiology –
or VA block (V ERP) or 200ms Jump or echo
• VA block (VA ERP) >>
recorded
• V ERP recorded
• Induce tachy or not
Capture or not? And
concentric or eccentric?
• Pacing from the RVA shows V spike and wide
• ECG QRS, followed by A spike-earliest A in
the HIS and latest A in the HRA
Decrementing or not???
• With shorter coupling interval (S1S2) the
node will start
• to slow down conduction- here, the VH
interval stretches
• from the 2nd to 3rd paced complex
VAERP or VA Block
• Pacing from RVA captures the ventricle (wide
QRS and
• V spike) but is not followed by A spike-
indicates VA ERP
VERP
• Pacing in RVA fails to capture ventricle- lack of
wide
• QRS and V spike indicates Ventricular ERP.
Antegrade pacing What to see???
• Start at 590 or faster than • Captured or Not
baseline
• Decremental by 10 or 20ms • Concentric or Eccentric
• Check for capture beat
• Decrementing or Not
• Check AV conduction
• Pace to see jump or tachycardia • Any AH Jump?
or AV block or AERP
• Cycle length (Value) of AV
Block

• Cycle length (Value) of AV

ERP, V ERP
Antegrade conduction
• Pacing from HRA results in P-wave on
• ECG, A spike followed by H and V spike on
IEGMs, as well as narrow QRS on ECG
Decrementing or not
• With shorter S1S2, node will delay the
impulse to
• the ventricle. Here, the AH stretches from
2nd to 3rd
• pacing complex
AVNERP
• Pacing from HRA captures atrium (we see an
A spike on
• HIS IEGM) but there is not resulting H or V
spike or QRS.
• This indicates we have hit the ERP of the AV
node.
AERP
• Pacing from HRA fails to capture the atrium,
as there is
• no resulting P wave on ECG or A spike on
IEGM,
• indicating atrial ERP.
AH jump
• A “jump” in the A-H interval of greater ≥50
msec
• During atrial extra-stimulus testing
As S2 is sequentially decremented by 10 msec
Wenckebach Point
• The Wenckebach interval is defined as the
longest cycle length that does not result in a
1:1 conduction during constant pacing

• This maneuver evaluates the functional

capacity of the AV node and can be used for
comparison before/ after an ablation
Entrainment
• Entrainment is a pacing maneuver that has
traditionally been applied during
macroreentrant tachyarrhythmias to
determine whether a pacing site is a part of
the circuit
AVNRT(Atrioventricular nodal re-entrant
tachycardia)
Anatomy
Koch’s triangle is an anatomical area located in the superficial
Para septal endocardium of the right atrium and its
boundaries are coronary sinus orifice, tendon of Todaro and
tricuspid valve
Mechanism of AVNRT
▪ The AV node behaves functionally as if
there were two separate pathways
through the node.

▪ Pathways are differentiated by their

characteristic properties:

1) Slow Pathway – has a relatively

short ERP and conducts
slowly
2) Fast Pathway – has a relatively
long ERP and conducts
more rapidly.
ECG features of AVNRT
• Regular tachycardia ~140-280 bpm.
• QRS complexes usually narrow (< 120 ms)
• P waves are often hidden – being embedded
in the QRS complexes.
• Pseudo R’ wave may be seen in V1 or V2.
• Pseudo S waves may be seen in leads II, III or
aVF.
• In most cases this results in a ‘typical’ SVT
appearance with absent P waves and
tachycardia
Initiation of Tachycardia
• AVNRT Sinus beat
• labeled S1

• Premature Atrial Contraction (PAC)

• labeled S2
• blocked in fast pathway
• the slow pathway may permit reentry
into the AV node
• short recovery time
• depolarizes both atria and ventricles
AH jump
Tachycardia
Entrainment from right
ventricle
• Measure TCL
• Paced from RVA 10-40ms faster than TCL
• Confirm entrainment by A accelerate to
pacing length
• Measure last pace V to V and compare A
to A.
• TCL must continue.
• Measure PPI-TCL
• PPI- TCL > 115 ms(AVNRT) and < 115
ms(AVRT)
VA interval
Check VA interval
• <70ms AVNRT
• >70 ms AVRT
SA-VA interval
• SA from last pacing interval to the
earliest A
• VA the earliest ventricle
electrocardiogram or surface ECG to
earliest A
• SA-VA > 85 ms(AVNRT)
< 85 ms(AVRT)
Treatment of AVNRT
▪ May be treated with beta blockers or Ca blockers

▪ Drug therapy can result in fatigue and bradycardia

▪ Another option is RF ablation (>95% efficacy) –no long term therapy

required
Treatment of AVNRT
Radiofrequency ablation
• In AVNRT ablations, the target site will be the area of
slow conduction with a 4 or 5mm tip ablation catheter.

• The ablation catheter position will exhibit a more

anterior approach to the HIS catheter on an RAO
projection
Treatment of AVNRT
• When ablating near the AVN, always be prepared to pace the ventricle. A good recommendation
is to have a quadripolar catheter in the RVA for pacing. There may be a probability of ablating and
permanently damaging the fast pathway which will require the implant of a pacemaker.

• When using RF energy during slow-pathway ablation, always look for an accelerated junction
rhythm.

• (May suggest thermal injury of the “slow pathway”)

• During accelerated JR, atrial pacing is often performed to assure maintenance of 1:1 antegrade
conduction
Now its time to see
one sample case of
AVNRT!!!!!!!!
 Patient Name : X
Age : 48y/M
Symptoms: Dyspnoea, Palpitations
History: Hypertensive And Diabetic
Baseline ECG
• Baseline EGM with AH
and HV intervals
• Pacing from RV
• concentric conduction
• VA Wenckebach at cycle
length 290ms
• Pacing from RV
• Tachycardia induction at
cycle length 300ms
• Tachycardia
• Tachycardia ECG
• P wave : retrograde p
waves in aVR lead
resolved
• QRS complex : Pseudo R’
wave may be seen in V2.
• Pseudo S waves may be
seen in inferior leads.
• Pacing from RV at 300ms
• RV Entrainment
• Differentiating avnrt from
avrt
• PPI – TCL ( 450-
300)=150(>115)
• Hence it is AVNRT
• Junctional beats during
RF ablation
• Post RFA
• Pacing from RV
• VA Wenckebach at 270ms
• Post RFA
• Pacing from CS 7,8
• AV Wenckebach at 240ms
• Post RFA
• AVNERP at 450/220ms
• Post RFA; AVNERP
• Patient on Iso
• Arrhythmia induction
• Pacing from CS 7,8
(S1=400,S2=200,S3=200)
• Conclusion:
• Successful ablation at slow pathway in patient
with dual AV nodal pathway physiology.
• The slow pathway can be located by mapping
along the posteromedial tricuspid annulus close
to the coronary sinus ostium
Thank you all
~ Vishnu Reddy