Basic cardiac and EP lab principles
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| How are EP catheters different from Cath-lab catheters? | Solid core with multiple electrodes
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| What is determined in EP lab? | Baseline intervals and effects of altering conduction initiation
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| What is assessed in the EP lab? | SA node, AV node, Bundle of His, and Purkinje Fibers
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| What is "mapping"? | Finding the location of arrhythmia foci for ablation therapy
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| Complications of EP testing are | ABC IT- Arrhythmias, Bleeding, Cardiac perforation, Infection (local or systemic), Thrombo-embolism (pulmonary)
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| What are the bleeding complications? | Bleeding HAPpens: Hematoma, A-V fistula, Pseudoaneurysm
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| What is withheld before the study in patient preparation? | Medications, ESPECIALLY anti-arrhythmics
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| What is least likely to occur in the EP lab? | Myocardial Infarcts
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| Which catheter is presented in profile in the LAO projection? | Coronary sinus
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| Are sheaths placed in the arterial or venous system in the EP lab? | Venous, 2 or more sheaths per vein.
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| Where do most v-tachs occur? | RVOT
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| Where are catheters placed? | HRA (high right atrium), BOH (Bundle of His), RV apex (or RVOT), Coronary Sinus (& RV apex)
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| If you were studying SVT's, where would you place the catheter? | Coronary sinus and RV apex
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| If pacing of the RV is required, where would you place the catheter? | RVOT, right ventricular outflow tract
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| What is achieved by inserting the catheter into the coronary sinus? | Pacing and recording of the LA
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| Where is the coronary sinus located? | Posterior and slighly inferior to the tricuspid valve.
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| What does the coronary sinus catheter evaluate? | LA depolarization
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| What three beats does the HIS catheter record? | Atria, BOH, right ventricle. A, AH, V
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| What does lead I show? | Provides visualization of right to left activation
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| What is seen using lead aVF? | High to low activation
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| Activation of what is seen in lead V1? | The Bundles of His
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| What do catheter hookups start with proximally? | High numbers
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| What numbers are found distally on the Coronary sinus catheter? | Low numbers, 1, 2, 3, etc
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| What is the sweep speed of EGMs? | 100mm/sec
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| Where does the coronary sinus catheter sit? | Between the LA and the LV
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| Which intra-cardiac tracing shows the initiation of atrial depolarization? | A
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| His Bundle activation is illustrated by what letter? | H
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| Ventricular deploarization is noted by what letter? | V
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| AH+HV=? | PR-Interval
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| What are the functions of the EP catheters? | Record activity & Pacing abilities
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| What do surface ECGs demonstrate? | Sum of all cardiac activity
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| EP catheters are filtered so that what phase of the action potential is seen at specific electrodes? | Zero
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| Premature impulses are introduced in order to ... | *Measure refractory periods * Assess conduction properties of tissue, * Assess automaticity * Study reentrant circuits
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| First premature beat following a pacing chain is labeled what? | S2
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| What landmarks surround the Triangle of Koch? | Eustachian valve, Oval fossa, Tendon of Todaro, Tricuspid valve
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| What is located within the Triangle of Koch? | The Coronary Sinus
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| Normal Range of Cycle Length (CL) | 1000-600 ms (60-100 bpm)
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| AV nodal conduction interval range (AH) | 50-120 ms
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| His-Purkinje conduction (HV) | 35-55 ms
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| Sinus node to ventricles interval range (AV) | 120-200 ms
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| Interval range for ventricular depolarization | 80-110
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| Ventricular repolarization (QT) | <500 ms
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| First Premature beat following a pacing chain is labeled? | S2
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| Escape rhythms are the result of? | Failure of impulse generation
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| Three areas of activity visualized by the HIS catheter? | A - Atria, H - His Bundle, V - Ventricle
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| Structure closest to the septum in the Triangle of Koch? | Tendon of Todaro
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| The two valves separated by the Triangle of Koch? | Eustachian valve and Tricuspid Valve
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| Where is the coronary sinus located? | Within the Triangle of Koch in the right atrium
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| The closed conduit in the right atrium near the Eustachian valve | Oval fossa
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| Conduction | Movement of impulse from structure to structure or cell to cell
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| Refractory Period | Period of time wen cell/structure is not able to produce or transmit impulse
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| Response of cardiac tissue to premature stimuli | Refractoriness
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| Refractory | Performed through pacing several beats followed by premature stimuli at progressively shorter intervals
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| Heart blocks are the result of what? | Failure of impulse propagation (conduction)
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| Many brady-arrhythmias are treated how? | Pacemaker insertion
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| Three causes of tachy-arrhythmias | Triggered activity
Re-entry beats/rhythm
Enhanced automaticity
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| Which cause of tachy-arrhythmias cannot be evaluated in the EP lab? | Enhanced automaticity
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| Example of enhanced automaticity | Inappropriate sinus tach (IST)
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| How are tachy-arrhythmias treated? | Pharmacology, ablation, over-ride pacing
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| What vessel if blocked, would disrupt the SA & AV nodes? | RCA
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| Automaticity disturbances are seen in which phase of the action potential | 4 - the resting phase due to leakage of ions across the membrane leading to gradual change in voltage.
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| Causes of Automaticity disturbances | Metabolic (kidneys), ischemia, electrolyte deficiency, acid-based disorders. Could be d/t blockage
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| Tachy-arrhythmia not inducible so unable to be evaluated in the EP lab? | Enhanced Automaticity
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| Has features of both automaticity and re-entry abnormalities making it hard to distinguish in the EP lab | Triggered activity
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| How is Triggered tach similar to Automaticity tach? | Leakage of ions creating rise in action potential
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| "Afterdepolarizations" are noted in what phase of the action potential? | Late 3 early 4
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| Likely cause of SVTs | Triggered tach
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| Triggered tach is thought to be the mechanism of action for what? | Torsades de Pointe
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| Introduce premature stimuli delivered in predetermined patterns and timed intervals | Fixed cycle lengths
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| Bidirectional conduction with unidirectional block | Re-entry Tach
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| Common cause of arrhythmias and extremely dangerous | Re-entry circuit disturbances
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| What kind of bypass tracts do re-entry tachs have | Dual SAN or AVN and AV
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| Results in reentrant VT | Scar tissue d/t MI or cardiomyopathy
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| Re-entrant tach can be acquired through the development of | Cardiac disease states
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| Alpha re-entry conduction | Slow conduction - short wake
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| Beta re-entry conduction | Fast conduction - long wake
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| Premature beats can follow a _______ conducted beat more closely than a ____________ conducted beat | Slowly - Rapidly. Just as slow boats can follow more closely
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| Normal atrial impulses reach AVN through | Beta pathway (Fast conduction/long refractory)
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| Slow conduction = | a longer PRI
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| Faster conduction = | a shorter PRI
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| If a premature atrial impulse finds the Beta pathway refractory and the Alpha pathway not, what will happen? | Impulse will take Alpha pathway and increase the PRI
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| Results in paroxysmal SVT | Impulse traveling retrograde up Beta and down Alpha
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| This often PRECEDES a P-SVT | Long PRI
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| Results in a long PRI | Alpha pathway
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| Results in a short PRI | Beta Pathway
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| Termination of Re-entry | Overdrive pacing, Pharmacology, Ablation
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| What does pharmacology do to the action potential? | Alters the "0" phase shape and/or refractory periods
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| Permanent termination of a re-entry stimuli | Ablation
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| Locations of Accessory Pathways | Anterior/Posterior/ Right Free-wall/ Left Free-wall
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| Pathway closest to Anteroseptal pathway | Right Freewall
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| Anteroseptal pathway is between which valves | MV & TV
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| Pathway separating Left and Right Freewalls | Posteroseptal pathway
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| Pathway below the non-dominate Aortic Valve cusp | Anteroseptal pathway
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| The septal pathway that is the largest | Posteroseptal
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| Non-conductive ridge along the lateral wall of the RA | Crista Terminalis
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| Bypass tract that conducts ANTEGRADE is said to be | Wolff-Parkinson-White (WPW)
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| Pre-excitation of the QRS is called ____ and seen in ____ | Delta wave / WPW
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| A delta wave is evidence that | ventricle was stimulated prematurely
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| Antegrade conduction that stimulates the ventricle prematurely is noted by | A delta wave on the QRS
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| An impulse traveling over a bypass tract does not experience ___ as a normal impulse traveling through the _____ | Delay / AV node
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| Pre-excitation is usually manifested by | Short PRI/ slurring of the QRS complex
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| The slower the AV nodal conduction | the larger the delta wave
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| Four types of bypass tracts | A - Kent's Atrial muscle to ventricular muscle
B - Low atrial tissue near AVN connecting to HIS-Purkinje
C- Mahaim AVN connected to Right Bundle Branch (AVN-RBB)
D- HIS-Purkinje fibers to ventricular myocardium
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| What is at the tip of the Triangle of Koch, closest to the septum? | The Bundle of His
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| Intra-Atrial Conduction Time (PA) | 20 - 30ms
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| Coupling Interval Time between LAST NORMAL impulse (S1) and first PREMATURE/PACED impulse at end of pacing chain (S2) | Coupling Interval
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| Introduction of PREMATURE beats into rhythm at PRECISELY TIMED intervals | Programmed stimulation
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| Programmed stimulation delivered in predetermined patterns at precisely timed intervals | Fixed Cycle Lengths
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| Introducing a train of paced beats at fixed cycle lengths | Incremental Pacing
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| Types of Programmed stimulation | Incremental pacing and extra stimulus pacing
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| Introducing extra-stimuli at a shorter length than the pacing chain (usually 8 beats long) or the patients intrinsic rhythm | Extra stimulus pacing. S1= Last intrinsic or paced beat
S2= first extra stimuli S3= next extra stimuli
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| The "P" wave is inverted when stimuli takes place in | The middle of the heart as in a Junctional waveform
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| In atrial pacing, the SAN is evaluated for | Automaticity and Conductivity
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| When pacing the atria, the AVN and HIS-Purkinje is evaluated for | Conductivity and refractoriness
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| When do we attempt to induce atrial arrhythmias? | Atrial Pacing
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| Retrograde conduction (ventricle to atria) is assessed during | Ventricular pacing
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| During ventricular pacing we attempt | To induce ventricular arrhythmias
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| When do we assess potential for drug effect? | During atrial or ventricular pacing
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| In the EP lab we cannot assess automaticity disturbances but we can evaluate SAN or AVN automaticity. How? | Paced at faster-than-normal rate
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| Pacing at faster than normal rate is called? | Overdrive suppression
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| What are you doing with overdrive suppression? | Trying to wear out the heart to measure how long it takes to recover
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| When overdrive suppression pacing is stopped, there is often a relatively _____ pause before node _____ and spontaneously ____ an impulse | long / recovers / generates
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| A longer than normal recovery time indicates | A disease process is present
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| Short recovery time after overdrive suppression pacing indicates | No disease is present
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| Potentially fatal bradycardic arrythmias, such as escape rhythms, heart block, etc is resultant to | Poor automaticity
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| Measurement of the period of time when no stimulus regardless of intensity will produce stimuli | Absolute Refractory Period
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| When is an action potential in absolute refractory period? | Time from onset of action potential until about midway down phase 3 of action potential.
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| The absolute refractory period is difficult to measure so what period is used? | Effective Refractory Period
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| Why would a premature impulse fails to propagate through tissue demonstrating the longest coupling interval? | The tissue is refractory
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| Long effective refractory period (ERP) is due to | Slow conduction time
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| Faster conduction time is due to a | Shorter effective refractory period (EFP)
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| Measurement of how rapidly a structure can conduct form itself to another (i.e. AVN to BOH) | Functional Refractory Period
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| Functional Refractory period is measured how | Pacing proximal structure at progressively faster rates until no signal reaches distal structure
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| Functional Refractory Period is shortest interval between successive impulses were impulse reached | distal structure
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| Functional RP | Conduction
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