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Pr inciples of E P (His bundle, Mapping techniques)

Pr inciples of E P (His bundle, Mapping techniques). Dr. Meenu. PA – 4 wire. Prep Routine EP study 2 kinds of pacing: ES < Incremental <. SNRT. SNRT. AES. Protocol Uses. AV node antegrade conduction. AVN – decremental conduction. VES. Uses : 1 2 3.

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Pr inciples of E P (His bundle, Mapping techniques)

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  1. Pr inciples of EP (His bundle, Mapping techniques) Dr. Meenu

  2. PA – 4 wire

  3. Prep • Routine EP study • 2 kinds of pacing: • ES < • Incremental <

  4. SNRT

  5. SNRT

  6. AES • Protocol • Uses

  7. AV node antegrade conduction

  8. AVN – decremental conduction

  9. VES • Uses : • 1 • 2 • 3

  10. Incremental A pacing – AV WCL

  11. Incremental V pacing – VA WCL

  12. Minimum protocol for diagnostic EP • Measurement of basic intervals • SNRT at BCLs of 800, 600, 500, 400, 350 ms • V ES testing down to v refractoriness at BCLs of 600 and 400 ms • Incremental V pacing from ~ > SR down to VA Wenkebach point or a min CL of 300 ms • A ES testing down to refractoriness at BCLs of 600 and 400 ms • Incremental A pacing from ~ > SR down to AV Wenkebach point or a min CL of 300 ms

  13. AT- site of origin

  14. AT - Mech • Microreentry • Focal: • Triggered activity • Abnormal automaticity

  15. Typical A Fl – Macroreentrant RA circuit

  16. Typical A Fl

  17. AF

  18. AVNRT – Dual AV N PathwaysFast Slow

  19. A-H JumpDefinition

  20. AV N ReentryTypical AV N echo Initiation of AVNRT

  21. AV N ReentryTypical AV N echo Initiation of AVNRT

  22. V pre excitation – EP diagn overview • Maneuvers to increase pre excitation • Normalizn of abnormal QRS • Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn • Initiation of AVRT by APC • To :manifest ( identify presence of) pre excitn + : aid localizn AP • Differential A pacing • Differential V pacing • Para Hisian pacing

  23. Degree of pre excitn • Rel time for atr impulse to reach : AV N / AP • Time taken to conduct over : AV N / AP • SR -- absent Delta • Concealed • Latent • To incr pre excitn • Delay AV N • Differential A pacing

  24. V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP Differential A pacing Differential V pacing Para Hisian pacing

  25. Normalizn with His ES

  26. V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP Differential A pacing Differential V pacing Para Hisian pacing

  27. Retrograde atr activn – Concentric Eccentric

  28. Ecc atr activn clearer (Other than VPCs) • Adenosine block AV N • Differential V pacing ( at site close to AP ) • Observe orthodromic AVRT (retrogr exclusive over AP)

  29. V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of orthodromic AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP ( Shortest s -∆ interval ) Differential A pacing V P His

  30. Differential pacing

  31. Unusual AP • Rate dependent • Concealed • Anterograde Mahaim

  32. VT • PVS

  33. Pace mapping

  34. Activation mapping

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