Understanding Intracardiac EGMs: A Patient Centered Guide

352 Pages·2015·18.946 MB·English

by  Fred Kusumoto

Understanding Intracardiac EGMs
APatientCenteredGuide
ToHowardandSumikoKusumoto
Understanding
Intracardiac EGMs
A Patient Centered Guide
Fred Kusumoto MD
ProfessorofMedicine
MayoClinicCollegeofMedicine
Jacksonville,Fl,USA
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Contents
Preface,vii 16 Supraventriculartachycardiacase16:atrial
tachycardiaafteratrialfibrillationablation,195
Glossary,ix
17 Supraventriculartachycardiacase17:atrial
1 Basicelectrophysiology,1
tachycardiaafteratrialfibrillationablation,205
2 Supraventriculartachycardiacase1,17
18 Supraventriculartachycardiacase18:atrial
3 Supraventriculartachycardiacase2,45 tachycardiaafteratrialfibrillationablation,215
4 Supraventriculartachycardiacase3,55 19 Supraventriculartachycardiacase19:atrial
5 Supraventriculartachycardiacase4,67 tachycardiaafteratrialfibrillationablation,227
6 Supraventriculartachycardiacase5,83 20 Widecomplextachycardiacase1,237
7 Supraventriculartachycardiacase6: 21 Widecomplextachycardiacase2,253
baselinepreexcitation,97 22 Widecomplextachycardiacase3:
8 Supraventriculartachycardiacase7: prematureventricularcontractions,263
baselinepreexcitation,111 23 Widecomplextachycardiacase4,273
9 Supraventriculartachycardiacase8,125 24 Widecomplextachycardiacase5,281
10 Supraventriculartachycardiacase9,135 25 Widecomplextachycardiacase6,291
11 Supraventriculartachycardiacases10and 26 Syncope,297
11,143
27 Multiplechoicequestionsandanswers,303
12 Supraventriculartachycardiacase12,153
Appendix,323
13 Supraventriculartachycardiacase13,163
Index,331
14 Supraventriculartachycardiacase14:atrial
fibrillation,177
15 Supraventriculartachycardiacase15:atrial
tachycardiaafteratrialfibrillationablation,187
v

Preface
Thefieldofelectrophysiologyhasevolvedrapidlyover theelectrophysiologicevaluationofthepatient.Where
thepastthreedecadesfromanichefieldwithminimal applicable,Ihavetriedtoprovidethereaderwithinsight
clinical impact to an essential part of cardiology that with situations where different tactics for the diagnos-
warrants specialized training for two years and has a tic evaluation of tachyarrhythmias in the electrophys-
separate board certification from the American Board iology laboratory might be pursued. I will be the first
of Internal Medicine. This evolution in knowledge toacknowledgethatevaluationofintracardiacelectro-
and clinical applicability has been accompanied by grams is an art that is often subjective and that expe-
the development of many specialized tools that have rienced clinicians will have different interpretations of
facilitated procedures in the electrophysiology labora- thesamesetofrecordings.Ifthetextprovidesaflash-
tory.Althoughthesenewtoolsthatallowreproducible pointforargumentsanddiscussionatyourlaboratories,
mapping of arrhythmias in the heart, mapping with thenmyoverarchinggoalofgettingpeopletoappreciate
computerized algorithms, and advanced imaging, theimportanceofelectrograminterpretationevenwith
amongothercapabilitieshavebecomealmostessential today’stechnologyhasbeenaccomplished.
foranyfullyfunctioningelectrophysiologylaboratory,it This book can be read alone, but it also references
remainsjustasimportantforthecliniciantohaveaclear concepts illustrated from Understanding the ECG and
understanding of arrhythmias using the most funda- EGM (Wiley-Blackwell 2010). That first book takes
mentalelectrophysiologictechnique–directmappingof the traditional approach of sequentially discussing a
themyocardiumwithelectrodecathetersandevaluating known type of arrhythmia, for example, atrial flutter
theresponseofcardiactissuetoelectricalstimulation. or atrioventricular node reentry. In addition, it starts
Thisbookisdesignedasaseriesofcasesthatillustrate with basic but fundamental concepts such as filtering
the process of evaluation of arrhythmias using stan- andevaluationofbasicintervalsandrefractoryperiods,
dard electrophysiologic techniques. Although patients which are subjects that are not addressed or only
may come to the electrophysiology laboratory with a cursorily discussed in this book. In contrast, this book
tentativediagnosis,allexperiencedelectrophysiologists startsfromclinicalpresentationofanindividualpatient
knowthattheseonlyrepresent“bestguesses”andmore where the exact type of arrhythmia is not known a
often than not the guesses are partially or completely priori, the usual situation that confronts the clinical
wrong. Like any good puzzle (and perhaps to our electrophysiologist. Although the book will be more
frustration),therecanbemanytwistsandturnsduring easily read by the health professional that already
an electrophysiology study due to misinterpretation of understands some of the basics of electrophysiology, I
data and conflicting or confusing pieces of data that amhopefulthatthebookwillappealtoawideaudience
must be cobbled together into a coherent (and accu- including experienced staff in the electrophysiology
rate!) diagnosis. The cases in this book go in sequence laboratory, cardiology and electrophysiology fellows,
from initial presentation of the patient, strategies for andelectrophysiologistswhoaretakingcareofpatients
comprehensive evaluation in the electrophysiology with complex arrhythmias or are studying for their
laboratory,andwhereappropriate,therapeuticoptions electrophysiologyboards.
forablation. IwouldliketothankMelScheinman,who,overtwo
It is important to note that there are many different decades ago, first taught me the fundamentals of elec-
approaches and styles to electrophysiology studies, so trograminterpretationbutmoreimportantlyinstilledan
therewillbesomedisagreementonthebestmethodfor appreciation of the nuances of intracardiac recordings
vii
viii Preface
and the importance of curiosity, patience, and always thistakesmanylonghours,andasIamhunchedover
putting the patient first during an electrophysiology my computer tapping out these last words in the late
study. I can still fondly recall late evenings when Mel evening, I know that I am indebted to my daughters
would find me at the end of the day and take time to Miya, Hana, and Aya for putting up with an occasion-
reviewtheday’scases(doesthemanevertireofthinking ally distracted father and to my wife Laura for her
aboutelectrophysiology?).Puttingabooktogetherlike understandingandpatienceover25wonderfulyears.