1. Electrophysiological Study forPacemaker Implantation 2013/03/23Chun-Chieh Wang / Electrophysiological Study forPacemaker Implantation1. Establish diagnosisg2. Assist in pacemaker parametersettings3. Confirm efficacy of ATP therapy(DDDRP)4. Assist in future troubleshooting5. ???1

2. Pacemaker / ICD Troubleshooting1. Rhythm strips / 12-lead ECG2. Initial PM/ICD parameters3 Stored i f3. d information i4. Underlying rhythm / event markers5. A/V sensing threshold tests6. A/V capture threshold tests7. Atrial pacing tests (AV relationship)8. Ventricular pacing tests (VA relationship)9. Final PM / ICD parameters10.Images Technique1. Conventional EP study2. Noninvasive EP study2 3. Electrophysiological Study forPacemaker Implantation 1. Establish diagnosis & confirmindication for permanent pacing 2. Assist in pacemaker parametersettings 3. Confirm efficacy of ATP therapy(DDDRP) 4. Assist in future troubleshooting 5. ??? Case Study 1-170 y/o female, ER visit for recurrent syncoperecently with resultant blunt head traumaECG rhythm monitoring at ER3 4. Case study 1-2Baseline 12-lead ECG before EPS Case study 1-34 5. Case study 1-412-lead ECG after atropine 1mg i.v.Cardiac rhythm diagnosis of this patient?Before atropine 1mg i.v.After5 6. Case study 1-512-lead ECG after atropine 1mg i.v.Case study 1-66 7. Case study 1-75 minutes after atropine 1mg i.v. Case study 1-8 Rapid atrial pacing7 8. Case study 1-9Rapid atrial pacing Case 2 History 57 y/o Female DCM, LVEF26%, mild MR, mod to severe TR,mod pulmonary H/T, NSRH/T Admission for fluid overload and acutedecompensated HF (ADHF) Improved after i.v. Bumetanide, shortcourse of Dobutamine i.v. infusion and OMT Chronic HF NYHA Fc III~ ambulatory IV Past history: TIA, hepatitis B carrier. history Personal history: smoking (-), alcohol (-) Laboratory exam: within normal limitincluding thyroid function and electrolytes. 8 9. 9 10. CRT? 10 11. 11 12. 12 13. Primary Prevention of SCD with ICDLVEF 35% Optimal Medical TherapyCOMPANIONMADIT-CRT, RAFT , CRT D CRT-DNYHA Class III IVYESNO CLBBB? NOPrior MINo Prior MIEF 40%EF 35%SyncopeEPS +EPS +EPS + Bundle branch VTMUSTTMADITDEFINITEICDRF ablationPA view LAO view13 14. Electrophysiological Study beforePacemaker Implantation1. Establish diagnosisg2. Assist in pacemaker parameter settings AV delay PVARP PVAB Special algorithms: MVPalgorithms3. Confirm efficacy of ATP therapy (DDDRP)4. Assist in future troubleshooting5. ??? Case study 4-1 14 15. Case study 4-2Case study 4-3 15 16. Case study 4-4Case study 4-5 16 17. Case study 4-6Case study 5-1 17 18. Case study 5-2Case study 5-3 18 19. Case study 5-4Case study 5-5 19 20. Case study 5-5Case study 5-6 4020 21. Case study 5-8APLAO Case study 5-7 PVARP 250ms42 21 22. Case study 5-8 PVC Response280ms Electrophysiological Study beforePacemaker Implantation1. Establish diagnosisg2. Assist pacemaker parametersettings3. Confirm efficacy of ATP therapy(DDDRP)4. Assist in future troubleshooting5. ???22 23. Atrial Antitachycardia Pace-termination (ATP) TherapiesA-Burst+ Burst train followed by 2 premature pulsesAtrial Antitachycardia Pace-termination (ATP) Therapies A-Ramp Decrements between each pulse, and p adds one pulse to each sequence23 24. Electrophysiological Study beforePacemaker Implantation1. Establish diagnosisg2. Assist in pacemaker parametersettings3. Confirm efficacy of ATP therapy(DDDRP)4. Assist in future troubleshooting5. $$$ Case study 6-1 General Data 64 y/o, male Retired merchant Taiwanese Married C.C. sudden and transient LOC < 10s at home CAD, two vessel disease, post LCX stentingin 2008/10 , and type 2 DM Propranolol, atorvastatin, and aspirin at CVclinic Smoking: quitted 10+ years, alcohol (-) 24 25. ECG 2008/10/28ECG 2011/09/29 25 26. ECG 2011/09/29ECG 2011/10/01 26 27. TET 2011/10/04TET 2011/10/04 27 28. TET 2011/10/04TET 2011/10/04 28 29. Cath 2011/10/05Cath 2011/10/1129 30. Cath 2011/10/11Cath 2011/10/1130 31. Cath 2011/10/11Cath 2011/10/1131 32. Cath 2011/10/11ESC Guidelines for the Diagnosis and Management of SyncopePacing in BBB & AV blockEur Heart J 2009;30:2631-71 64 32 33. Permanent Pacing in Chronic Bifascicular Block ACC/AHA/HRS 2008 Guidelines I IIa IIb III Permanent pacemaker implantation is pp indicated for advanced second-degree AV block or intermittent third-degree AV block. I IIa IIb III Permanent pacemaker implantation is indicated for type II second-degree AV block. I IIa IIb III Permanent pacemaker implantation is indicated for alternating bundle-branch block. Permanent Pacing in Chronic Bifascicular Block I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia. I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of a markedly prolonged HV interval (greater than or equal to 100 milliseconds) in asymptomatic patients. y pp I IIa IIb III IIb III Permanent pacemaker implantation is reasonable for an incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological.ACC/AHA/HRS2008 Guidelines 33 34. Permanent Pacing in ChronicBifascicular BlockI IIa IIb III PM implantation may be considered in the setting of neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy (limb-girdle dystrophy (limb girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or without symptoms.I IIa IIb III Permanent pacemaker implantation is not indicated for fascicular block without AV block or symptoms.tI IIa IIb III Permanent pacemaker implantation is not indicated for fascicular block with first-degree AV block without symptoms.ACC/AHA/HRS 2008 GuidelinesTechnique1. Conventional EP study2. Noninvasive EP study34 35. 35 36. 36 37. 37 38. 38 39. 39 40. 40 41. 41 42. 42 43. 43 44. Th k you f your attention!Thankfor tt ti ! 8744