The Clinical Cardiac Electrophysiology Handbook

381 Pages·2016·18.92 MB·English

by  Jason G. Andrade et al.

The
eBook
Included
CLINICAL CARDIAC
ELECTROPHYSIOLOGY
Handbook
Jason G. Andrade, MD
Matthew T. Bennett, MD Andrew D. Krahn, MD
Marc W. Deyell, MD Laurent Macle, MD cardiotext
Nathaniel Hawkins, MD Stanley Nattel, MD
PUBLISHING
The CliniCal CardiaC
eleCTrophysiology
handbook
Jason G. Andrade, MD
Matthew T. Bennett, MD
Marc W. Deyell, MD, MSc
Nathaniel Hawkins, MD
Andrew D. Krahn, MD
Laurent Macle, MD
Stanley Nattel, MD
Minneapolis, Minnesota
The Clinical Cardiac Electrophysiology Handbook.indb 1 01-02-2016 AM 10:11:26
© 2016 Jason Andrade
Cardiotext Publishing, LLC
3405 W. 44th Street
Minneapolis, Minnesota 55410
USA
www.cardiotextpublishing.com
Any updates to this book may be found at:
www.cardiotextpublishing.com/clinical-cardiac-electrophysiology-handbook
Comments, inquiries, and requests for bulk sales can be directed to the publisher at:
[email protected].
All rights reserved. No part of this book may be reproduced in any form or by any means
without the prior permission of the publisher.
All trademarks, service marks, and trade names used herein are the property of their
respective owners and are used only to identify the products or services of those owners.
This book is intended for educational purposes and to further general scientific and
medical knowledge, research, and understanding of the conditions and associated treat-
ments discussed herein. This book is not intended to serve as and should not be relied
upon as recommending or promoting any specific diagnosis or method of treatment for
a particular condition or a particular patient. It is the reader’s responsibility to determine
the proper steps for diagnosis and the proper course of treatment for any condition or
patient, including suitable and appropriate tests, medications, or medical devices to be
used for or in conjunction with any diagnosis or treatment.
Due to ongoing research, discoveries, modifications to medicines, equipment and devices,
and changes in government regulations, the information contained in this book may not
reflect the latest standards, developments, guidelines, regulations, products, or devices
in the field. Readers are responsible for keeping up to date with the latest developments
and are urged to review the latest instructions and warnings for any medicine, equipment,
or medical device. Readers should consult with a specialist or contact the vendor of any
medicine or medical device where appropriate.
Except for the publisher’s website associated with this work, the publisher is not affiliated
with and does not sponsor or endorse any websites, organizations, or other sources of
information referred to herein.
The publisher and the author specifically disclaim any damage, liability, or loss incurred,
directly or indirectly, from the use or application of any of the contents of this book.
Unless otherwise stated, all figures and tables in this book are used courtesy of the authors.
Library of Congress Control Number: 2015956425
ISBN: 978-1-942909-00-2
Printed in The United States of America
The Clinical Cardiac Electrophysiology Handbook.indb 2 01-02-2016 AM 10:11:26
We are extremely grateful to our colleagues and technical staff at the
Montreal Heart Institute and Vancouver General Hospital, without
whom this book would not have been possible.
For Becky, Amélie, and Noah
The Clinical Cardiac Electrophysiology Handbook.indb 3 01-02-2016 AM 10:11:26
ConTenTs
About the Authors ix
Preface xi
Abbreviations xiii
1. Fundamentals 1
The Cardiac Action Potential 1
Arrhythmia Mechanisms 4
Entrainment 9
Resetting 10
Fusion 10
Left-Sided Access: Transaortic and Transseptal Approach 11
Intracardiac Electrogram (EGM) 15
3D Cardiac Mapping 18
Arrhythmia Mapping 20
Ablation Energy 26
2. Electrophysiology Study and Maneuvers 29
The Electrophysiology Study 29
Standard Catheter Placement 30
Measurement of Basic Conduction Intervals 32
Refractory Periods 34
Anterograde Conduction 41
Retrograde Conduction 42
Arrhythmia Induction 45
Programmed Ventricular Stimulation 47
Observations in Tachycardia: Atrial Activation Sequence 49
Ventricular Pacing Maneuvers During Tachycardia 56
Atrial Pacing Maneuvers During Tachycardia 61
Pacing Maneuvers During Sinus Rhythm 64
Evaluation of Sinus Node Function 71
Evaluation of Atrioventricular (AV) Node Function 74
3. Electrophysiology Study: Specific Approaches 79
Approach to Narrow-Complex Tachycardia (NCT) 79
Approach to Wide-Complex Tachycardia (WCT) 88
Programmed Ventricular Stimulation 95
Pharmacologic Challenge for Inherited Arrhythmia Syndromes 97
v
The Clinical Cardiac Electrophysiology Handbook.indb 5 01-02-2016 AM 10:11:26
vi Contents
4. Atrioventricular Nodal Reentrant Tachycardia 99
Understanding and Managing Atrioventricular Nodal Reentrant
Tachycardias (AVNRT) 99
Differentiating Atrioventricular Nodal Reentrant Tachycardias from
Other Tachycardias 117
Catheter Ablation of Atrioventricular Nodal Reentrant Tachycardia 121
Catheter Ablation of Atypical Atrioventricular Nodal Reentrant
Tachycardia Substrates 124
5. Accessory Pathways 127
Understanding and Evaluating Accessory Pathways (APs) 127
6. Atrioventricular Reciprocating Tachycardia 133
Arrhythmias Associated with Accessory Pathways (APs) 133
Atrioventricular Reciprocating Tachycardia (AVRT) 133
Atrioventricular Reentrant Tachycardias 137
Special Circumstances 148
Catheter Ablation of Atrioventricular Reciprocating Tachycardia (AVRT) 149
7. Focal Atrial Tachyarrhythmia 165
Understanding and Managing Focal Atrial Tachycardia 165
Catheter Ablation of Atrial Tachyarrhythmia (AT) 173
8. Atrial Flutter and Macroreentrant Atrial Tachycardia 177
Atrial Flutter (AFL) 177
Catheter Ablation of Macroreentrant Atrial Tachycardia (MRAT) 181
Catheter Ablation of Cavotricuspid Isthmus Macroreentrant Atrial
Tachycardia (MRAT) 185
9. Atrial Fibrillation 193
Understanding and Evaluating Atrial Fibrillation (AF) 193
Atrial Fibrillation (AF) Ablation 204
Atrial Fibrillation (AF) Ablation — Pulmonary Vein Isolation 206
Atrial Fibrillation (AF) Ablation — Left Atrial Linear Ablation 216
Atrial Fibrillation (AF) Ablation — Complex Fractionated Atrial
Electrogram (CFAE) Ablation 219
Recurrent Atrial Tachyarrhythmias After Atrial Fibrillation (AF) Ablation 222
Complete Atrioventricular (AV) Node Ablation 224
10. Ventricular Tachycardia 229
Understanding and Managing Ventricular Tachycardia (VT) 229
Catheter Ablation of Ventricular Tachycardia (VT) 238
Idiopathic Right Ventricular Tachycardia (VT) 245
Bundle Branch Reentrant Ventricular Tachycardia (BBR-VT) 250
Fascicular (or Idiopathic) Left Ventricular Tachycardia (VT) 255
Premature Ventricular Complexes (PVCs) 261
11. Sinus Tachycardia 263
Understanding and Managing Sinus Tachycardia (ST) 263
The Clinical Cardiac Electrophysiology Handbook.indb 6 01-02-2016 AM 10:11:26
Contents vii
12. Bradycardia and Blocks 269
Sinus Bradycardia and Sinoatrial (SA) Node Dysfunction 269
First-Degree Atrioventricular (AV) Node Conduction Block 272
Second-Degree Atrioventricular (AV) Node Conduction Block 274
Third-Degree (Complete) Atrioventricular (AV) Node Conduction Block 278
13. Cardiac Implantable Electronic Devices 281
Permanent Pacemakers 281
Cardiac Implantable Electronic Devices (CIEDs) Timing Cycles 284
Implantable Cardioverter-Defibrillator (ICD) 287
Complications of Devices 291
Assessment of the Cardiac Implantable Electronic Device (CIED) Patient 293
Approach to Pacemaker and Implantable Cardioverter-Defibrillator (ICD)
Interrogation 294
Problem Solving Cardiac Implantable Electronic Devices (CIEDs) 297
Managing the Patient with an Implantable Cardioverter-Defibrillator (ICD)
Therapy 300
Arrhythmic or Electrical Storm 303
Cardiac Implantable Electronic Devices (CIEDs): Special Considerations 305
Defibrillator Threshold Testing 310
Non-Responders to Cardiac Resynchronization Therapy (CRT) 311
Cardiac Implantable Electronic Device (CIED) Infections 313
14. Sudden Cardiac Death and Inherited Arrhythmias 317
Sudden Cardiac Death (SCD) 317
Identifying Patients at Risk of Sudden Cardiac Death (SCD) 319
Sudden Cardiac Death (SCD) in Athletes 323
Channelopathies 324
Catecholaminergic Polymorphic Ventricular Tachycardia (VT) 330
Brugada Syndrome 331
Arrythmogenic Cardiomyopathy 334
Left Dominant Arrhythmogenic Cardiomyopathy (LDAC) 340
Hypertrophic Cardiomyopathy (HCM) 340
15. Syncope 347
Understanding and Managing Syncope 347
Tilt Table Testing 353
Index 355
The Clinical Cardiac Electrophysiology Handbook.indb 7 01-02-2016 AM 10:11:26
abouT The a uThors
Jason G. Andrade, MD
Montreal Heart Institute
Université de Montréal, Montreal, Canada
University of British Columbia, Vancouver, Canada
Contributors
Matthew T. Bennett, MD
University of British Columbia, Vancouver, Canada
Marc W. Deyell, MD, MSc
University of British Columbia, Vancouver, Canada
Nathaniel Hawkins, MD
University of British Columbia, Vancouver, Canada
Andrew D. Krahn, MD
University of British Columbia, Vancouver, Canada
Laurent Macle, MD
Montreal Heart Institute
Université de Montréal, Montreal, Canada
Stanley Nattel, MD
Montreal Heart Institute
Université de Montréal, Montreal, Canada
ix
The Clinical Cardiac Electrophysiology Handbook.indb 9 01-02-2016 AM 10:11:26
prefaCe
The clinical science of interventional cardiac electrophysiology is a rapidly evolving area.
In the early days, it was referred to as “His bundle electrophysiology,” because about the
only procedure available was to record the electrical potential arising in the common
bundle of His with a catheter electrode and use the results to localize/quantify conduc-
tion abnormalities to identify patients needing pacemakers. But a lot has changed since
then: Programmed stimulation produced a revolution in the 1970s, followed in the 1980s
by ablation and more advanced recording methods (beginning with the recording of
potentials from accessory pathways). Progress advanced to include sophisticated invasive
and noninvasive mapping systems and complex access and intervention approaches.
Implantable devices were introduced as simple right ventricular pacemakers implanted by
surgeons, developing over time into implantable defibrillators, and from there to highly
sophisticated units capable of complex data recording and acquisition, high levels of
programmability and interrogation capacity, complex antitachycardia pacing algorithms
combined with intelligent defibrillation maneuvers, and even leadless devices. Basic
science advances have revolutionized our understanding of arrhythmia mechanisms
and created exciting new therapeutic possibilities. Large, randomized clinical trials have
provided solid bases for clinical decision-making.
One consequence of these formidable developments has been the challenging mass of
information that needs to be mastered in order to understand and apply clinical cardiac
electrophysiology interventions. This volume of knowledge is particularly daunting to
trainees and paramedical personnel, who perform vital functions requiring high-level
skills but who lack the extensive training, knowledge base, and experience of established
clinical electrophysiologists.
This was the reason to create The Clinical Cardiac Electrophysiology Handbook: to offer in
a succinct presentation all the practical information needed to understand the subtleties
of a wide range of cardiac electrophysiology problems and approaches. Our focus is on
the “how to,” with the goal of providing key knowledge about approaches to identify,
diagnose, and manage a broad range of cardiac rhythm disorders. However, the user will
also find a lot of information on the “why”—the underlying fundamental and clinical
science basis for clinical electrophysiology decision-making.
We took the approach that our book should look like what you might expect to find if
a brilliant clinical electrophysiology fellow had transcribed notes about all that he or she
was taught and was able to obtain from the literature, including all the most important
information without any filler in between. It is intended to be a quick source for informa-
tion in the EP lab or on the wards, as well as a guide to learning—offering the ability to
quickly review the essential components prior to a case or to rapidly reinforce new notions
and practices encountered during a case.
xi
The Clinical Cardiac Electrophysiology Handbook.indb 11 01-02-2016 AM 10:11:26
xii Preface
Overall, we hope users will find that The Clinical Cardiac Electrophysiology Handbook
constitutes a valuable new tool, occupying an important niche that was largely empty
prior to its completion and offering readers a key contribution to the learning material
in this area.
—Stanley Nattel, MD
The Clinical Cardiac Electrophysiology Handbook.indb 12 01-02-2016 AM 10:11:26