Cardiac Electrophysiology
An Introduction
F.M.Leonelli M.D.
ELECTROPHYSIOLOGY STUDY
DIAGNOSTIC THERAPEUTIC
combined with RFA
PROGNOSTIC
EPS
Diagnostic indications:
• Non diagnostic initial evaluation of
palpitations or syncope
• Unclear mechanism of arrhythmia
(WCT)
• Sudden death risk stratification
EPS
Aims:
• Assess electrophysiological functions
of SN and conduction system
• Evaluate arrhythmia induction
Functions of the Cardiac Electrical System
Impulse formation
Impulse conduction
From cell to ECG
Cellular EP
EP Testing
ECG
EPS
Technique
• Potentials generated during cardiac
depolarization can be:
Recorded
Amplified
Interpreted
by intra-cardiac catheters placed during EPS
EPS
Technique
• Catheters are made of woven Dacron
• Inserted percutaneously Femoral, Jugular
vein/s or Femoral artery
• Recording from uni/bi-polar electrodes
• Under fluoroscopy positioned in stable
locations or
• Rowed in a cardiac chamber to “map”
electrical activation
Recording Catheters
Thermistor
Recording/Ablating
From Cell to EPS
CellularLevel
• As some cells depolarize while others are
still in the resting state, a difference in
voltage is created, and this generates a
current which will form the
electromagnetic force or vector recorded by
the ECGraph
Vector
Vector Recording
• Cardiac depolarization generates an infinitesimal
electromagnetic force (Vector) detected, filtered, recorded
and displayed.
• One of the assumptions of vector recording is:
• When an electromagnetic force is directed towards the
positive electrode of a bipolar lead will record a positive
(up-going) deflection, negative (down-going) if directed
towards the negative electrode
Intracardiac Catheters placement during EPS
DIGITAL ACQUISITION
DIGITAL DISPLAY
PRINTING
Electrophysiology study
Baseline recording
EPS
Technique
• Recordings and stimulation (rapid pacing and
introduction of extrastimuli) performed at EPS
• Stimulation protocols usually standardized but
frequent variations
• Aim is to assess physiological response of a
structure (RA,AVN, HPS) or to induce an
arrhythmia
S1 S2 S3 S4
S1
Shortening of APD at faster stimulation
ERP
Decremental, non decremental conduction
Rapid Atrial Stimulation
Rapid Ventricular Stimulation
R atrial programmed stimulation with induction of AVNRT
Diagnostic
82 yrs old female
Normal CV function
Multiple presyncopal spells
ELECTROPHYSIOLOGY STUDY
DIAGNOSTIC THERAPEUTIC
combined with RFA
PROGNOSTIC
EPS
Prognostic
• SCD incidence is 300.000/yr unchanged
over last 10 yrs
• In the great majority of cases due to fast
ventricular arrhythmias
• Strong association with pre-existing
ischemic heart disease
• Effective SCD resuscitation 1-3%
EPS
Prognostic
• Primary prevention by identification of
individual at risk
• Protection of patients by
Antiarrhytmic drugs
Implantable Cardioverter Defibrillator
SCD and CARDIAC DISEASE
Incidence and absolute numbers of SCD events in various populations
with progressively more severe cardiac disease Circulation 1998;97:1514
Triggers and Substrate
MUSTT
Patient Results Total Mortality
0.6
EP-Guided Rx, No ICD
No EP-Guided Rx
0.5 EP-Guided Rx, ICD
0.4 p < 0.001
Event Rate
0.3
0.2
0.1
0
0 1 2 3 4 5
Time after Enrollment (Years)
Buxton AE. N Engl J Med. 1999;341:1882-90.
EPS
Prognostic
• MADIT I, II, SCAT EF etc support ICD
implant in patient with EF<35%
• Prognostic EPS in selected pts with
intermediate EF and risk factors (MI, NSVT)
• Questionable role of EPS in LQTs or HOCM
EPS
Prognostic
• Monomorphic VT at EPS predicts high risk of
future VT/VF in pts with:
CAD (MI and or ischemic CMP)
structural HD and syncope
low EF, CAD and asymptomatic NSVT
• Non inducibility does not confer a benign
prognosis
• Negative and positive predictive value of EPS in
this setting is 88% and 49%
Monomorphic VT induction during RV stimulation
EPS
Prognostic
• Polymorphic VT /VF more commonly
induced than MVT but less specific
• Predictive value of EPS in DCMP very
limited
• Syncope, but not EPS, in this subgroup
predicts SD
• EPS can identify conduction disease and SVT
causing syncope
Ventricular fibrillation induced at EPS
ELECTROPHYSIOLOGY STUDY
DIAGNOSTIC THERAPEUTIC
combined with RFA
PROGNOSTIC
EPS
Therapeutic
• EPS identifies the mechanism of tachycardia and
pathological substrate
• Intracardiac location of substrate is identified
• With RFA (Crio/US) substrate can be destroyed
curing the arrhythmia
EPS
Therapeutic
• Any arrhythmic substrate can be eliminated
• Acute success rate close to 100% in AVNRT,
AVRT and Atrial Flutter
• Recurrence rate less than 5%
• Atrial tachycardias less predictably induced but
success rate close to 90% in induced arrhythmias
EPS
Therapeutic
• Any arrhythmic substrate can be eliminated
• Acute success rate close to 100% in AVNRT,
AVRT and Atrial Flutter
• Recurrence rate less than 5%
• Atrial tachycardias less predictably induced but
success rate close to 90% in induced arrhythmias
EPS
Therapeutic
• New insight into arrhythmic substrate of AF
• Fast discharging sites induce A Fib
• Areas of abnormal tissue maintain the arrhythmia
• Ablation of these targets is feasible and
successfully cures A Fib in up to 85% of cases
EPS
Therapeutic
• VT in normal CV systems can be successfully
and permanently ablated in >90%.
• Ablation for VT in CAD lower success (40-70%)
and higher recurrence rates
• Clinically significant VPCs permanently
eliminated in 80-90% of pts
EPS
Therapeutic
• Arrhythmic substrate localization often complex
based on:
Reconstruction of intracardiac activation during
the arrhythmia by recording of endocardial
activation using a rowing catheter (mapping)
Scar
Ablation line
Cardiac Electrophysiology Study
Radiofrequency ablation
• After mapping, the arrhythmic tissue is destroyed
• RF energy is unmodulated alternating current
between 300kHz and 2MHz
• Delivered by a catheter connected to a generator
• Heat at the point of contact destroys the targeted
tissue
Radiofrequency induced lesion
EPS
Complications
• Complications rate
Death 0.3 %
Stroke 0.2 %
AV block 1 %
Tamponade 0.6 %
MI 0.1 %
Pneumothorax 0.1 %
F artery laceration 0.1 %
EPS
Conclusions
• EPS gold standard in:
Diagnosis of any clinical arrhythmias
Assessment of cardiac EP properties
• EPS valuable in:
Stratification of patients at high risk of SD
EPS
Conclusions
• EPS and RFA:
Offer a permanent cure in the great
majority of arrhythmias
Should be considered first line therapy
in SVTs, AFL, AT some VTs
Will play a dominant role in the
management of Atrial Fibrillation
