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(BQ) Part 1 book Understanding intracardiac EGMs and ECGs presents the following contents: Electrophysiology concepts (Fluoroscopic anatomy and electrophysiologic recording in the heart, programmed stimulation, bradycardia, supraventricular tachycardia, wide complex tachycardia, new technology, power sources for ablation).
Understanding Intracardiac EGMs and ECGs To Howard and Sumiko Kusumoto Understanding Intracardiac EGMs and ECGs Fred Kusumoto, MD Associate Professor of Medicine Mayo School of Medicine Director of Pacing and Electrophysiology Division of Cardiovascular Diseases Mayo Clinic Jacksonville, FL, USA A John Wiley & Sons, Ltd., Publication This edition first published 2010 © 2010 Fred Kusumoto Blackwell Publishing was acquired by John Wiley & Sons in February 2007 Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ 07030-5774, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/ wiley-blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book This publication is designed to provide accurate and authoritative information in regard to the subject matter covered It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom Library of Congress Cataloging-in-Publication Data Kusumoto, Fred Understanding intracardiac EGMs and ECG’s / by Fred Kusumoto p ; cm Includes index ISBN 978-1-4051-8410-6 Electrocardiography Heart–Electric properties I Title [DNLM: Electrophysiologic Techniques, Cardiac–methods Electrocardiography–methods WG 141.5.F9 K97u 2009] RC683.5.E5K87 2009 616.1’207547–dc22 2009013387 ISBN: 9781405184106 A catalogue record for this book is available from the British Library Set in 9.5/12pt Palatino by Graphicraft Limited, Hong Kong Printed and bound in Malaysia 2010 Contents Preface, vii Part Electrophysiology Concepts Procedural issues for electrophysiologic studies: vascular access, cardiac chamber access, and catheters, Fluoroscopic anatomy and electrophysiologic recording in the heart, 15 Programmed stimulation, 29 Bradycardia, 51 Supraventricular tachycardia, 60 Wide complex tachycardia, 86 New technology, 94 Power sources for ablation, 99 Part Specific Arrhythmias Accessory pathways, 107 10 AV node reentry, 132 11 Focal atrial tachycardia, 148 12 Atrial flutter, 161 13 Atrial fibrillation, 182 14 Ventricular tachycardia, 189 15 Implantable cardiac devices: ECGs and electrograms, 211 Index, 220 v Preface Electrophysiology has evolved from a field populated by the “nerds of medicine” to an essential mainstream specialty area within cardiology Still, much of electrophysiology remains clouded in mystery Although the electrocardiogram (ECG) is accepted as a standard clinical tool, electrograms (EGMs) recorded during electrophysiology studies are considered complex and confusing However, since electrograms and the ECG both measure the same thing – electrical activity of the heart – they provide synergistic information In fact the specialized electrode catheters that are used to acquire intracardiac electrograms can simply be thought of as ECG leads that are within the heart rather than on the skin surface It is with this relationship in mind that this book attempts to use electrograms and the ECG to discuss rhythm disorders of the heart and provide the newcomer with an introductory guide to electrophysiology studies and the interpretation of electrograms The book is divided into two broad sections In the first section, the basics of electrophysiology testing are reviewed, along with the diagnostic evaluation of general types of arrhythmias such as bradycardia, supraventricular tachycardia, and wide complex tachycardia Although the chapter discussing the electrophysiological evaluation of supraventricular tachycardia may appear daunting, once the basic tenets are understood, electrophysiology techniques provide a wonderful foundation for understanding the complexities of different tachycardias The second section discusses specific arrhythmia types, with an accompanying discussion of techniques for ablation Part of the seductiveness of electrophysiology is the opportunity to offer a “cure” rather than a treatment for certain types of arrhythmias The book is designed for any medical professional interested in beginning a study of heart rhythms and electrophysiology, whether a cardiology fellow or electrophysiology fellow, an allied professional working in the electrophysiology laboratory, or a member of industry One of the pleasures of electrophysiology is that these procedures require input from a number of people with different backgrounds collaborating to bring complex and specialized technology to bear on the treatment of a single patient There are two important topics within electrophysiology testing that can only be superficially covered in an introductory text like this First, although implantable device therapy is an important part of electrophysiology, these devices are covered only in order to discuss the application of electrogram and ECG principles The reader is referred to the many texts that discuss this important electrophysiology therapy in exhaustive detail Second, new technology has become common in the electrophysiology laboratory, but complex vii viii Preface mapping systems are only superficially discussed in this book While these techniques are important for the advanced practitioner, it is critical to understand the basics of electrograms recorded from standard catheters before moving on to these methods All of these tools use electrogram information and process them into color three-dimensional maps While essential to the modern electrophysiology practice, these advanced techniques can lead one astray if the basic concepts of electrophysiology are ignored I am indebted to Kevin Napierkowski, who was instrumental in bringing this book from conception to reality Nick Godwin provided the initial guidance for the project from the publishing side I am grateful to Kate Newell from Wiley-Blackwell for supplying the gentle prodding that provides the continuous forward momentum necessary for a project such as this I would like to thank Hugh Brazier for his clear-minded copy-editing and for ensuring that my writing conformed to the Queen’s English My staff at Mayo Clinic Florida provided important input into the figures and content of this book In particular, Missy Weisinger obtained the necessary electrograms from our digital library for many of the illustrations I would like to thank my family for putting up with a temporarily distracted husband and father and the many irreplaceable hours that a project like this takes Finally, special thanks to Sumiko and Howard Kusumoto for tolerating a young “nerd” who would incessantly ask questions (what is + + + 2?), particularly if he was trying to get out of trouble Fred Kusumoto PA RT Electrophysiology Concepts ... Part Specific Arrhythmias Accessory pathways, 10 7 10 AV node reentry, 13 2 11 Focal atrial tachycardia, 14 8 12 Atrial flutter, 16 1 13 Atrial fibrillation, 18 2 14 Ventricular tachycardia, 18 9 15 .. .Understanding Intracardiac EGMs and ECGs To Howard and Sumiko Kusumoto Understanding Intracardiac EGMs and ECGs Fred Kusumoto, MD Associate Professor... electrogram Atrial EGM (0.05 10 00 Hz) Notch “on” Atrial EGM (30 15 0 Hz) Notch “on” 14 Part Electrophysiology Concepts V1 0.05 10 00 Hz 30 10 00 Hz 10 0 15 0 Hz Figure 1. 17 Effects of filtering on a