EP LaboratoriesEP Laboratoriesin Koreain Korea

1610 patients in 19981610 patients in 1998

RF ablationRF ablation 1,034 1,034 casescases

EP studyEP study 576 cases576 cases

Seoul 9Seoul 9수원 1

인천 1

대전 1대구 3

부산 4

마산 1

광주 1

ArrhythmiasArrhythmias

Early beatsEarly beatsUnexpected pausesUnexpected pausesTachycardiasTachycardiasBradycardiasBradycardiasBigeminal rhythmsBigeminal rhythmsGroup beatingGroup beatingTotal irregularityTotal irregularityRegular non-sinus rhythms at normal ratesRegular non-sinus rhythms at normal rates

By HJL MarriotBy HJL Marriot

Patients’ symptomsPatients’ symptomsPatients’ survivalPatients’ survival

Enemies...Enemies...

BradyarrhythmiaBradyarrhythmia TachyarrhythmiaTachyarrhythmiaPausePause SupraventricularSupraventricularBlockBlock VentricularVentricular

Sudden Cardiac DeathSudden Cardiac Death Syncope Syncope of Unknown Originof Unknown Origin

Afghanistan_2002Afghanistan_2002

EPSEPSA crystal ball to see what lies ahead?A crystal ball to see what lies ahead?

Local electrogramsLocal electrograms

Ability to recordAbility to recordAbility to reflect the electrical state Ability to reflect the electrical state

Programmed stimulationProgrammed stimulation

Ability to induce and terminateAbility to induce and terminateReentry > Reentry > Triggered activity > Triggered activity > Increased automaticityIncreased automaticity

Anti-arrh

ythmic drugs

Anti-arrh

ythmic drugs

Device: pacemaker

Device: pacemaker

Device: defib

rillator

Device: defib

rillator

Ablation: c

atheter-based

Ablation: c

atheter-based

Ablation: s

urgery

Ablation: s

urgery

Tre

atm

ent

Tre

atm

ent

ArrhythmiasArrhythmiasEarly beatsEarly beats

Unexpected pausesUnexpected pauses

TachycardiasTachycardias

BradycardiasBradycardias

Bigeminal rhythmsBigeminal rhythms

Group beatingGroup beating

Total irregularityTotal irregularity

Regular non-sinus Regular non-sinus rhythms at normal ratesrhythms at normal rates

Treatment of ArrhythmiasTreatment of Arrhythmias

Patient’s symptomsPatient’s symptomsRisk associated with arrhythmiasRisk associated with arrhythmias

Goal of EP StudyGoal of EP Study

1.1. Diagnosis of ArrhythmiaDiagnosis of Arrhythmia

2.2. Treatment of ArrhythmiaTreatment of Arrhythmia

3.3. Evaluation of TreatmentEvaluation of Treatment

4.4. Estimation of Risk-PrognosisEstimation of Risk-Prognosis

Facts, Facts, SolvedSolved

Bradycardia Bradycardia without reversible causeswithout reversible causeswith symptomswith symptoms

PacemakerPacemaker

EPSEPSTo confirm the causal relationshipTo confirm the causal relationship

between patients’ symptoms andbetween patients’ symptoms and

observed bradyarrhythmiaobserved bradyarrhythmia

77/77/F Recurrent syncopeF Recurrent syncope

54/54/M Dizziness and effort intoleranceM Dizziness and effort intolerance

62/62/M SyncopeM Syncope

2 sec after RF: AP conduction block2 sec after RF: AP conduction block

RAO 30RAO 30oo

Map/RFMap/RF

CSCS

HRAHRA

RVARVA

HisHis

EP study ForEP study For

Catheter ablationCatheter ablation

Facts, Facts, SolvedSolved

0

20

40

60

80

100

AVJ AVNRT AP VT AFL AT IST

SuccessComplication

NASPE 1998 NASPE 1998 Prospective Catheter Ablation RegistryProspective Catheter Ablation Registry3,357 patients(3,423 sessions)3,357 patients(3,423 sessions)Complication 2.59%Complication 2.59%No procedure-related deathNo procedure-related death

Scheinman MM, Huang S. PACE. 2000;23:1020-1028.Scheinman MM, Huang S. PACE. 2000;23:1020-1028.

Solved with Catheter AblationSolved with Catheter AblationEP study for treatmentEP study for treatment

Structural HDStructural HD PrognosisPrognosis TreatmentTreatment

AtrialAtrial

APCAPC GoodGoodAtrial tachycardiaAtrial tachycardia

NonsustainedNonsustained GoodGoodSustainedSustained (+)/AT-related(+)/AT-related VariableVariable D, D, CurableCurable

PSVTPSVT GoodGoodCurableCurableWPW with afibWPW with afib Can be lethalCan be lethalCurableCurable

Atrial flutterAtrial flutter (+)(+) VariableVariable D, D, CurableCurable

Atrial fibrillationAtrial fibrillation (+)/(-)(+)/(-) LethalLethal

VentricularVentricular

VPCVPC Ventricular tachycardiaVentricular tachycardia (-)(-) GoodGood D, D,

CurableCurableNonsustainedNonsustained (+)(+) PoorPoorSustainedSustained (+)(+) PoorPoor

Ventricular fibrillationVentricular fibrillation LethalLethalARVD, Brugada, Long QTARVD, Brugada, Long QT LethalLethal

Ventricular tachyarrhythmias Ventricular tachyarrhythmias with significant risk of deathwith significant risk of death

Aborted sudden cardiac deathAborted sudden cardiac death

Syncope of unknown originSyncope of unknown origin

Mortality-determining FactorsMortality-determining FactorsWeaponsWeapons Drug Drug

Catheter-based ablationCatheter-based ablationICDICD

Facts, Facts, Should be solvedShould be solved

Facts, Facts, Should be solvedShould be solved

VTVT Myocardial InfarctionMyocardial InfarctionLV dysfunction or NotLV dysfunction or Not

CardiomyopathyCardiomyopathyDilated, HypertrophicDilated, Hypertrophic

PMVT/VFPMVT/VF ChannelopathyChannelopathyBrugada, Long QTBrugada, Long QT

Aborted SCDAborted SCDSyncopeSyncope

High inducibility and reproducibility High inducibility and reproducibility in monomorphic VTin monomorphic VT

EP-guided drug treatmentEP-guided drug treatment

Ventricular Arrhythmias with MIVentricular Arrhythmias with MI

Incidence of Sudden Death in Incidence of Sudden Death in Stratified Patients with Non-sustained VTStratified Patients with Non-sustained VT

Wilber DJ. Circulation. 1990;82:350-358.Wilber DJ. Circulation. 1990;82:350-358.

Noninducible (N = 57, SD/CA = 2)Noninducible (N = 57, SD/CA = 2)Inducible/SuppressedInducible/Suppressed(N = 20, SD/CA = 1)(N = 20, SD/CA = 1)

Inducible/Not SuppressedInducible/Not Suppressed(N = 20, SD/CA = 7)(N = 20, SD/CA = 7)

P < 0.001P < 0.0011010

2020

3030

4040

5050

6060

7070

8080

9090

100100

44 88 1212 1616 2020 2424Follow-up (months)Follow-up (months)

Su

rviv

al (

%)

Su

rviv

al (

%)

Facts, Facts, we’ve learnedwe’ve learned

How to evaluate and predict the efficacy of treatment?How to evaluate and predict the efficacy of treatment?

Guided TherapyGuided Therapy

Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)Spontaneous(sustained or repetitive)

Chronic atrial fibrillation, Repetitive MVT, Frequent PVCsChronic atrial fibrillation, Repetitive MVT, Frequent PVCs

Anti-arrhythmic treatment(drugs or ablation, etc)Anti-arrhythmic treatment(drugs or ablation, etc)

Termination or suppression of arrhythmiaTermination or suppression of arrhythmia

SporadicSporadicSporadicSporadic

NoninvasiveNoninvasive Prolonged monitoring to evaluate arrhythmia behaviorProlonged monitoring to evaluate arrhythmia behavior

InductionInduction Noninvasive challenge with TMT, isoproterenolNoninvasive challenge with TMT, isoproterenol Invasive challenge withInvasive challenge with programmed electrical stimulation programmed electrical stimulation

Anti-arrhythmic treatment(drugs or ablation, etc)Anti-arrhythmic treatment(drugs or ablation, etc)

Reapplication of evaluating methodsReapplication of evaluating methods

No inducible arrhythmia or significantly modifiedNo inducible arrhythmia or significantly modified

95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially

in patients’ with risk in patients’ with risk

Ventricular Arrhythmias with MIVentricular Arrhythmias with MI

CAST TrialCAST TrialCardiac Arrhythmia Suppression TrialCardiac Arrhythmia Suppression Trial

80

85

90

95

100

0 91 182 273 364 455

Days After Randomization

Pat

ien

ts W

ith

ou

t E

ven

t (%

)

Placebo (n = 743)

Encainide or Flecainide (n = 755)

P = 0.001

CAST investigators, NEJM 1989;321:406-412

Facts, Facts, we’ve learnedwe’ve learned

95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially

in patients’ with risk in patients’ with risk No superiority of EP-guided treatmentNo superiority of EP-guided treatment

Ventricular Arrhythmias with MIVentricular Arrhythmias with MI

ESVEMESVEM

VT, Cardiac Arrest, SyncopeVT, Cardiac Arrest, Syncope

Randomize

EPS Holter Monitor

ESVEM Investigators. Circulation. 1989;79(6):1354-1360.

Follow-Up

> 10 PVCs/Hour on Holterand Inducible at EPS

Drug 1

Drug N

ETT

Drug 1

Drug N

ETT

Facts, Facts, we’ve learnedwe’ve learned

CASCADE Trial:CASCADE Trial:Cardiac Arrest in Seattle Conventional vs. Amiodarone Drug EvaluationCardiac Arrest in Seattle Conventional vs. Amiodarone Drug Evaluation

Out-of-Hospital VF ArrestOut-of-Hospital VF ArrestNot Associated with Q-wave MINot Associated with Q-wave MI

Randomization

Empiric Amiodarone

EPS or Holter-Guided“Conventional” Antiarrhythmic

Endpoints: Cardiac Arrest from VFCardiac MortalitySyncope Followed by ICD Shock

Facts, Facts, we’ve learnedwe’ve learned

Total Cardiac SurvivalTotal Cardiac Survival

CASCADE Investigators. Am J Cardiol. 1993;72:280-287.CASCADE Investigators. Am J Cardiol. 1993;72:280-287.

Sudden Death Survival

CASCADE SurvivalCASCADE Survival

100%

75%

50%

25%

0%0 1 2 3 4 5 6 7

Years

P = .007 by Log Rank StatisticP = .007 by Log Rank Statistic

Amiodarone(113)Amiodarone(113)

Conventional(115)Conventional(115)

0 1 2 3 4 5 6 7Years

P < .001 by Log Rank StatisticP < .001 by Log Rank Statistic

95% 95% of Inducibility in Monomorphic VTof Inducibility in Monomorphic VTEP-guided drug treatmentEP-guided drug treatmentLimitation of drug treatment, especially Limitation of drug treatment, especially

in patients’ with risk in patients’ with risk No superiority of EP-guided treatmentNo superiority of EP-guided treatmentSuperiority of ICD treatment, especially Superiority of ICD treatment, especially

in patients’ with riskin patients’ with risk

Ventricular Arrhythmias with MIVentricular Arrhythmias with MI

ICD for prevention of deathICD for prevention of deathSecondary: AVID, CASH, CIDISSecondary: AVID, CASH, CIDISPrimary:MADIT, CABG-PATCH,SCD-HeFTPrimary:MADIT, CABG-PATCH,SCD-HeFT

Facts, Facts, we’ve learnedwe’ve learned

AVID TrialAVID Trial(Antiarrhythmics Versus Implantable Defibrillators)(Antiarrhythmics Versus Implantable Defibrillators)

Patients with near-fatal ventricular Patients with near-fatal ventricular arrhythmiasarrhythmias

EmpiricEmpiric amiodarone, sotalolamiodarone, sotalol or or guidedguided sotalol sotalolversusversusImplantable defibrillatorsImplantable defibrillators

1016 patients1016 patientsSignificant mortality reduction Significant mortality reduction in ICD groupin ICD group

39±20%39±20% 27±21%27±21% 31±21%31±21%

Facts, Facts, we’ve learnedwe’ve learned

Facts, Facts, we’ve learnedwe’ve learned

MADIT MADIT (Multicenter Automatic Defibrillator Implantation Trial)(Multicenter Automatic Defibrillator Implantation Trial)

Inclusion CriteriaInclusion Criteria Prior Q-wave MIPrior Q-wave MIUnsustained VTUnsustained VTEF EF 35% 35%Inducible, non-suppressible VTInducible, non-suppressible VTNYHA Class I – IIINYHA Class I – IIIAge 25 - 80Age 25 - 80> 3 weeks from last MI> 3 weeks from last MINo requirement for revascularizationNo requirement for revascularization

Exclusion CriteriaExclusion Criteria Hx of VF or syncopal VTHx of VF or syncopal VTSymptomatic hypotension in stable rhythmSymptomatic hypotension in stable rhythmMI within last 3 weeksMI within last 3 weeksRecent PTCA or CABG (Recent PTCA or CABG (2 - 3 months)2 - 3 months)Advanced cerebrovascular diseaseAdvanced cerebrovascular diseaseAny non-cardiac disease associated with Any non-cardiac disease associated with

reduced likelihood of survivalreduced likelihood of survival

Moss AJ. New Engl J Med. 1996;335:1933-1940.

Facts, Facts, we’ve learnedwe’ve learned

MADIT Patient FlowMADIT Patient Flow

Non-inducibleNon-inducible(n = 139)(n = 139)

Patients meetingPatients meetinginclusion criteriainclusion criteria

(N = 483)(N = 483)

EP studyEP study

SuppressibleSuppressiblewith IV with IV

procainamideprocainamide(n = 91)(n = 91)

Refused studyRefused study(n = 57)(n = 57)

InducibleInducible(n = 344)(n = 344)

Non-suppressibleNon-suppressible(n = 253)(n = 253)

Signed consent form, Signed consent form, randomizedrandomized

(n = 196)(n = 196)MADIT FDA Info Pack. May 16, 1996.MADIT FDA Info Pack. May 16, 1996.

Facts, Facts, we’ve learnedwe’ve learned

MADIT SurvivalMADIT Survival

Moss AJ. New Engl J Med. 1996;335:1933-1940.

YearYear

1.01.0

0.80.8

0.60.6

0.40.4

0.20.2

0.00.000 11 22 33 44 55

Pro

bab

ility

of

Su

rviv

alP

rob

abili

ty o

f S

urv

ival

ConventionalConventionaltherapytherapy

DefibrillatorDefibrillator

No. of patients

DefibrillatorDefibrillator 9595 8080 5353 3131 1717 33

ConventionalConventional 101101 6767 4848 2929 1717 00therapytherapy

Facts, Facts, we’ve learnedwe’ve learned

MADIT Antiarrhythmic Therapy UseMADIT Antiarrhythmic Therapy UseMedicationMedication

Antiarrhythmic medicationAntiarrhythmic medicationAmiodaroneAmiodarone 7474 22 4545

77Beta-blockersBeta-blockers 88 2626 55

2727Class I antiarrhythmic agentsClass I antiarrhythmic agents 1010 1212 1111

1111SotalolSotalol 77 11 99

44Beta-blockers or sotalolBeta-blockers or sotalol 1515 2727 1414

3131No antiarrhythmic medicationNo antiarrhythmic medication 88 5656 2323

4444

Other cardiac medicationOther cardiac medicationAngiotensin-converting-Angiotensin-converting- 5555 6060 5151

5757 enzyme inhibitors enzyme inhibitorsDigitalisDigitalis 3838 5858 3030

5757DiureticsDiuretics 5252 5353 4747

5252

Moss AJ. New Engl J Med. 1996;335:1933-1940.Moss AJ. New Engl J Med. 1996;335:1933-1940.

One MonthOne Month Last ContactLast Contact

ConventionalConventionalTherapyTherapy(N = 93)(N = 93)

DefibrillatorDefibrillator

(N = 93)(N = 93)

ConventionalConventionalTherapyTherapy(N = 82)(N = 82)

DefibrillatorDefibrillator

(N = 86)(N = 86)

Facts, Facts, we’ve learnedwe’ve learned

EP study and CardiomyopathyEP study and Cardiomyopathy

Dilated CMPDilated CMPLow inducibilityLow inducibilityPoor correlation with clinical efficacy of Poor correlation with clinical efficacy of guided-treatmentguided-treatmentLimitation of drug selectionLimitation of drug selection

Hypertrophic CMPHypertrophic CMPPatients with syncope, VT, VFPatients with syncope, VT, VFHigh chance of inductionHigh chance of induction

VT with MIVT with MIStable without LV dysfxStable without LV dysfx EP-guided drug TxEP-guided drug Tx

Catheter ablationCatheter ablationUnstable* without LV dysfxUnstable* without LV dysfx ICDICD

EP-guided drug TxEP-guided drug TxStable with LV dysfxStable with LV dysfx ICD, Catheter ablationICD, Catheter ablation

Amiodarone, sotalolAmiodarone, sotalolUnstable* with LV dysfxUnstable* with LV dysfx ICDICD

NSVT with MINSVT with MIWithout LV dysfxWithout LV dysfxWith LV dysfxWith LV dysfx EP studyEP study

VT with CMPVT with CMPStableStable AmiodaroneAmiodaroneUnstableUnstable ICDICD

AmiodaroneAmiodarone

Facts, Facts, justifiedjustified

MADIT Patient FlowMADIT Patient Flow

Non-inducibleNon-inducible(n = 139)(n = 139)

Patients meetingPatients meetinginclusion criteriainclusion criteria

(N = 483)(N = 483)

EP studyEP study

SuppressibleSuppressiblewith IV with IV

procainamideprocainamide(n = 91)(n = 91)

Refused studyRefused study(n = 57)(n = 57)

InducibleInducible(n = 344)(n = 344)

Non-suppressibleNon-suppressible(n = 253)(n = 253)

Signed consent form, Signed consent form, randomizedrandomized

(n = 196)(n = 196)MADIT FDA Info Pack. May 16, 1996.MADIT FDA Info Pack. May 16, 1996.

Facts, Facts, we want to knowwe want to know

MADIT IIMADIT II

No ICDNo ICD

Patients with LV dysfuction (LVEF Patients with LV dysfuction (LVEF 30%)30%)Regardless of the occurrence of NSVT Regardless of the occurrence of NSVT

RandomizationRandomization

ICDICD

Device-based EPSDevice-based EPS To know the effect of ICD To know the effect of ICD in the non-inducible patients in the non-inducible patients

Facts, Facts, we want to knowwe want to know

SCD-HeftSCD-HeftPatients with LV dysfuction (LVEF Patients with LV dysfuction (LVEF 35%)35%)CAD+DCMP, NYHA II+IIICAD+DCMP, NYHA II+III

RandomizationRandomizationICDICD

Conventional Rx + PlaceboConventional Rx + Placebo

Conventional Rx + AmiodaroneConventional Rx + Amiodarone

Syncope of Unknown OriginSyncope of Unknown Origin

Head-up tilt table test, Head-up tilt table test, esp. esp. in structurally normal heart patientsin structurally normal heart patients

Predictive factors for positive EP studyPredictive factors for positive EP study

LV dysfunctionLV dysfunctionPresence of bundle branch blockPresence of bundle branch blockCoronary arterial diseaseCoronary arterial diseaseMyocardial infarctionMyocardial infarctionUse of class I antiarrhythmic drugsUse of class I antiarrhythmic drugs

Krol RB, Morady F, et al. JACC 10(2):358-63.

Facts, Facts, we’ve learnedwe’ve learned

Diagnostic Yield in Unexplained SyncopeDiagnostic Yield in Unexplained Syncope

86 86 patients withpatients withunexplained syncopeunexplained syncope

Sra JS. Ann Intern Med. 1991;114:1013-1019.

29 patients(34%)

57 patients

tilt table test

Abnormal result Normal result

EP study

34 patients(40%)

23 patientsstill with

unexplained syncope(26%)

Syncope elicited

Normal response

Findings and Treatment of Syncope Findings and Treatment of Syncope Patients with Abnormal EP StudyPatients with Abnormal EP Study

Findings in EP-positive patients (N = 29)Findings in EP-positive patients (N = 29)

SVT (n = 5)VT (n = 21) Sinus node dysfunctionor conduction disease(n = 3)

Permanent pacemaker (n = 3)

Antiarrhythmicsonly (n = 3)

Ablation (n = 2)

ICD (n = 10)

Catheter or surgical ablation (n = 6)

Antiarrhythmicsonly (n = 4)

Sra JS. Ann Intern Med. 1991;114:1013-1019.

Risk of Mortality from Syncope Risk of Mortality from Syncope Based on Outcome of EP StudyBased on Outcome of EP Study

Bass EB. Am J Cardiol. 1988;62:1186-1191.

% T

ota

l Mo

rtal

ity

100

80

60

40

20

00 6 12 18 24 30 36 42 48 54 60

Months of Follow-Up

= Positive EPS Patients= Negative EPS Patients

History of EP StudyHistory of EP Study19691969 His bundle electrogramHis bundle electrogram

1970s1970s Programmed electrical StimulationProgrammed electrical StimulationEndocardial mapping of Ventricular tachycardiaEndocardial mapping of Ventricular tachycardia

Surgical ablation of arrhythmiasSurgical ablation of arrhythmias

1980s1980sCatheter ablation of arrhythmias with DC currentCatheter ablation of arrhythmias with DC currentRadiofrequency catheter ablationRadiofrequency catheter ablationIntroduction of ICDIntroduction of ICD

1990s1990s

Newer mapping techniquesNewer mapping techniques

2000s2000s

19691969 His bundle electrogramHis bundle electrogram

1970s1970s Programmed electrical StimulationProgrammed electrical StimulationEndocardial mapping of Ventricular tachycardiaEndocardial mapping of Ventricular tachycardia

Guided treatment for arrhythmiasGuided treatment for arrhythmiasSurgical ablation of arrhythmiasSurgical ablation of arrhythmias

1980s1980sCatheter ablation of arrhythmias with DC currentCatheter ablation of arrhythmias with DC currentRadiofrequency catheter ablationRadiofrequency catheter ablationIntroduction of ICDIntroduction of ICD

CAST trial, IMPACT trialCAST trial, IMPACT trial1990s1990s

ESVEM trial, CASCADE, CMIAT, EMIAT, etc...ESVEM trial, CASCADE, CMIAT, EMIAT, etc...AVID trial, MADIT, MUSTTAVID trial, MADIT, MUSTT

Newer mapping techniquesNewer mapping techniques2000s2000s Expansion of indications for RFCAExpansion of indications for RFCA MADIT-II, SCD-HeftMADIT-II, SCD-Heft

EPSEPSA crystal ball A crystal ball to see what lies ahead?to see what lies ahead?

ObservationObservationAnti-arrhythmic DrugsAnti-arrhythmic DrugsDevicesDevices DefibrillatorDefibrillator

PacemakerPacemaker

OperationOperationAblationAblation

Purpose of studyPurpose of study

Cost of TreatmentCost of TreatmentPatient’s lifePatient’s life

Can it be justified?Can it be justified?

Treatment of ArrhythmiaTreatment of Arrhythmia