EP equipment and setting( EP的基本設定 )

國立成功大學附設醫院心肺室 劉明端組長

EP Lab Equipment• Fluoroscopy unit

• EP recording system

• For viewing and recording intracardiac EGM and surface ECG

• Cardiac stimulator…

• essentially an enhanced temporary pacemaker…

• used to introduce artificial stimuli for inducing and terminating arrhythmias

• Ablation generator

• 3-D mapping and navigation system

• Intracardiac ultrasound unit

硬體設備• X 光機 (Philips, Siemens, GE, Toshiba)(單向或雙

向 )• 多頻道記錄器 (Channels-32,64,96,128)• 刺激器( 機械式、電腦式 )• 電燒器( 溫控式或磁導式 3-D)• 注射式幫浦 (Isuprel,Proternol-L)0.2mg(1amp)in 50ml

N/S=4ug/ml,15ml/h(1ug/min)/3min 30ml/h by heart

rate 100 bpm﹥• 電極導管與電燒導管• 去顫器• 急救設備

Integris Allura Bi-plane 10/10

Artis zee biplane

Innova 2100/2121 EP XRay

Fd10+stereotaxis to proof existance of partnership

Polygraphy Equipment

Stimulator

• EP4

Commonly Used Ablation Generators

The radiofrequency generator is used to delivery radiofrequency energy from the distal electrode of the ablation catheter through the myocardial tissue and to the ground pad to ablate the arrhythmia.

Medtronic Atakr IMedtronic Atakr I

StockertStockert

IBIIBI

MedtronicMedtronicAtakr IIAtakr II

EPT 1000

RadionicsRadionics

EPTEPT

OsypkaOsypkaOsypkaOsypka

EPT 1000XPEPT 1000XP

Electro-Catheters

• Fixed Curve Diagnostic

• Coronary Sinus Catheters

• Deflectable Tip Diagnostic

• 20 Pole Catheters

• Specialty Catheters

bipolar (2 poles) for temporary

quadripolar (4 poles)

hexapolar (6 poles)

octapolar (8 poles)

decapolar (10 poles)

multipolar (20 poles)

FIXED CURVES

quadripolar (4 poles)

hexapolar (6 poles)

octapolar (8 poles)

decapolar (10 poles)

multipolar (20 poles)

DEFLECTABLE CURVES

DIAGNOSTIC CATHETERS

Fixed catheters • Diameter

• Length:

• N° poles:

• Spacing:

• Curves (colour):

• Connector:

• 5F• 6F• 7F

• 110cm• 115cm• 60cm (special curve)

• 2, 4, 6, 8, 10, 20

• 2, 5, 10, 2-5-2, 2-8-2mm

Electrodes

• Quadripolar(4 poles)• Hexapolar(6 poles)• Octapolar(8 poles)• Decapolar(10 poles)• Mutipolar or • Duo-Decapolar(20

poles)

1(-)2(+)

34

His(D) 1-2His(M) 2-3His(P) 3,4

Deflectable Diagnostic CathetersDesign Considerations ：• Negotiate the sharp angles that result

when attempting access to the coronary sinus

• Placement of the His catheter • Helps to minimize the excess

procedure time often associated with manoeuvring and mapping in the coronary sinus

Coronary Sinus Catheters(10o)

20 Pole and Specialty Catheters

HALOHALO XP XP

TVA Mapping

ISMUS CATH

Atrial Isthmus Mapping

Atrial Mapping; Crista Terminalis

SANTOROAtrial Isthmus Mapping superior approach

Specialty Catheters for atrium Mapping

AFocusII double loop(SJM)200

PentaRay (Biosense Webster)200

HD Mesh Mapper (Bard)320

LASSO™ Circular Mapping Catheter

AFib Opportunity

AFib – most common form of all sustained arrhythmias

Atrial premature beats initiate AFib from ectopic foci within the pulmonary veins

Formerly: lack of effective method for mapping of the ectopic beats inside the veins

銀鐸實業有限公司 20

Standard Ablation Catheters

•CELSIUSLivewire TCTM

EP study catheter setting (SVT)

•靜脈 (Vein) RA 、 His 、 RV 、 CS 、 Ablation catheter

(for AVNRT)•動脈 (arterial) Ablation catheter (for Lt side AVRT )

步驟： (for AVNRT or AVRT)

• 四極電導管於上腔靜脈與右心房交接處即 high right atrium (HRA)作為記錄與刺激• 四極電導管置於希氏束 (His Bundle) 作為記錄• 四極電導管置於右心室頂 (RV apex) 作為記錄 與刺激• 多極 (6-10) 電導管置於冠狀靜脈竇 (coronary sinus, CS) 記錄左心房與左心室之電訊號

Catheters used in SVT studies:Catheters used in SVT studies: Quadripolar in the Quadripolar in the HRA HRA (usually fixed curve)(usually fixed curve) Quadri, hexa, octa, or decapolar at theQuadri, hexa, octa, or decapolar at the HBE HBE (fixed curve or (fixed curve or

steerable)steerable) Quadripolar in the Quadripolar in the RVARVA (usually fixed curve) (usually fixed curve) Hex, octa, or decapolar in theHex, octa, or decapolar in the CS CS (fixed curve or steerable)(fixed curve or steerable) Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter

Catheters used in VT studies:Catheters used in VT studies: Quadripolar in the Quadripolar in the HRA HRA (sometimes omitted)(sometimes omitted) Quadripolar (most common) at the Quadripolar (most common) at the HBE HBE (fixed or steerable)(fixed or steerable) Quadripolar in the Quadripolar in the RVARVA (steerable is common so that it can be (steerable is common so that it can be

moved to the RVOT)moved to the RVOT) Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter

Catheters used in SVT and VT Studies

Catheters used in standard EP studies:Catheters used in standard EP studies:Quadripolar in the HRA (usually fixed curve)Quadripolar in the HRA (usually fixed curve)Quadri, hexa, octa, or decapolar at the HBE Quadri, hexa, octa, or decapolar at the HBE

(fixed curve or steerable)(fixed curve or steerable)Quadripolar in the RVA (usually fixed curve)Quadripolar in the RVA (usually fixed curve)Hex, octa, or decapolar in the CS (fixed curve Hex, octa, or decapolar in the CS (fixed curve

or steerable)or steerable)

Catheters used in a EP Study

Catheters used in a Conduction System Study

• Quadripolar for HRA

• Quadripolar for HBE

• Quadripolar for RVA

Evaluate sinus node function

Evaluate antegrade AV node conduction

Evaluate retrograde AV node conduction

Basic 13-Channel Mapping for SVT

Catheter positioning

HRA

CS

His

RV

Catheter Positioning – Fluoroscopic Imaging

HRAHRA CSCS

HISHIS

RVRV

Electrogram (EGM)

Electrical System- Atrial conduction

Diagnostic catheter position with signals

Electrical System- Automaticity

Diagnostic catheter position with signals

Diagnostic catheter position with signals

Electrical System- Ventricular conduction

Diagnostic catheter position with signals

Baseline EGM recording

Electrical System- Localized difference in conduction

測量 (1)

•心房間傳導時間：由表面心電極最早之 P 波 或 (HRA之 A 波 ) 至 HBE之 A 波間距•房室結傳導時間：由 HBE之 A 波至 H 波的間距 (50ms-120ms)• His-Purkinje纖維傳導時間：由 HBE之 H 波 至最早出現 QRS波或V 波之間距 (35ms-55ms)

測量 (2)

• 右傳導束傳導時間從最早 V 波到 RV apex V 波 之間距• PA間距延長，表示心房室束傳導出問題，可 能心房擴大而傳導時間增加結果• AH間距 (55-130msec)若有延長，表示房室結 傳導有問題• HV間距 (30-55msec)若有延長，表示 His-Purkinje

纖維傳導問題

記錄與頻道設定 •表面心電圖極 (I,aVF,V1) ， HRA ， HBE ，( 可分為近端與遠端 ) ， CS( 共 5 頻道 )以及 RV

• 於 HRA所記錄仍為竇房結 (SA node)附近心房去級化波通常可記錄一較大的 A 波以及遠端心室去級化之一小的 V 波

• HBE所記錄除了近房室結 (AV node)心房去級化波 A 波，更可直接記錄 His Bundle去級化 H 波及心室去極化波 V 波

• CS所記錄仍是在二尖瓣膜環後面之左心房 及左心室去極化波 A 與 V 波• RV所記錄主要為右心室頂之去級化波 V 波•記錄紙速度通常為每秒 100mm or 200mm，為

心電圖記錄紙 4 倍快速 ( 間距變寬 )•測量單位為 60sec×1000 ＝ 60,000msec

刺激方式 (Pacing Protocol)

Electrophysiology Study

• Measurement of baseline conduction intervals

• Atrial Pacing- Assessment of SA nodal automaticity and

conductivity- Assessment of AV nodal conductivity and

refractoriness- Assessment His-Purkinjie system conductivity

and refractoriness- Assessment of atrial refractoriness

Electrophysiology Study con t

• Ventricular pacing– Access retrograde conduction– Access ventricular refractoriness

• Arrhythmia Induction– Atrial extrastimulus testing– Atrial burst pacing– Ventricular extrastimulus testing– Ventricular burst pacing

心房漸進式刺激atrial incremental pacing

(Antegrade)

通常採用比正常竇性節律稍快的刺激頻率，給予 8 次稱之為 S1)，緊接給予一比 S1稍短頻率之心房刺激 ( 稱之為 S2)，此類似給予一心房早期收縮，此種刺激模式重複進行，但每次 S2刺激頻率比前次早10ms，由於 S2愈早，其房室結傳導時間愈拉長 (AH間距延長 ) ，重複刺激一直到心房疲乏期 (atrial effective refractory period ,AERP) 發生。

• 當 S2刺激提早至有A 波而沒有H 及 V 波之最長的 S1 S2間距，稱之為房室結疲乏期 (AV node ERP)• 此時 S2又提早至只有刺激 S2波而無心房A 波之最長 S1 S2間距，稱之為心房疲乏期疲乏期 (AERP)• 利用此方式刺激不緊可以明瞭房室結的傳導功能 ( 尤其是否有雙套或多套傳導系統 )• 測量房室結，心房及額外傳導束 (kent纖維) 之疲 乏期 (ERP)，更可誘出臨床表現之心博頻脈 (tachycardia)

• SNRT

• SACT

• AV Decremental Properties

• AV Wenckebach cycle length (Incremental pacing only)

• AVNERP

• AERP

Standard Conduction System Study - Antegrade Stimulation

心室漸進式刺激 (ventricular incremental pacing)

• 與心房刺激相同方式，但是在右心室給予 8 次之 S1，緊接給予一早期收縮 S2，重複進形直到心

室疲乏期發生。藉以了解房室結逆向傳導功能，及Kent纖維之特性，或誘導心博頻脈。

• 正常逆傳導時，其逆向之 A 波最早應在 His極上或者是冠狀靜脈竇開口處 (CS之 os極 ) 。

• 當 S2提早至有 V 波而無逆向傳導之 A 波時之最長 S1S2間距稱之為 VAERP• S2又提早至只有刺激 S2波，而無心室之 V 波之

最長 S1S2間距稱之為 VERP

• 測試竇房結 (SA node)功能，會測量竇房結至心 房之傳導時間( 簡稱 sinoatrial conduction time, 簡稱 SACT)• 心房短期快速刺激，以測量竇房結恢復時間 (SN recovery time)• 竇房結恢復時間減去心房刺激前之正常竇性結 律時之 RR間距，稱之為矯正後竇房結恢復時間 (Corrected SN recovery time)＜ 525ms

為正常

Evaluate sinus node function (Evaluate sinus node function (sinus node sinus node recovery time, sino-atrial conduction timerecovery time, sino-atrial conduction time))

Evaluate antegrade AV node conduction Evaluate antegrade AV node conduction ((AVNERP, AERP, AV Wenckebach cycle AVNERP, AERP, AV Wenckebach cycle lengthlength))

Evaluate retrograde AV node conduction Evaluate retrograde AV node conduction ((VAERP, VERP, VA Wenckebach cycle VAERP, VERP, VA Wenckebach cycle lengthlength))

Standard Conduction System Study

Pacing – Incremental Pacing

• Incremental Pacing - is pacing the heart at a fixed rate. The rate is increased (pacing interval decreased) with each set of beats.

S1-S1=400 S1-S1=390 S1-S1=380 S1-S1=370

Pacing – Decremental Pacing• Decremental Pacing – pacing at a

progressively increasing heart rate by decreasing the amount of time between each paced beat. Used primarily to induce or terminate tachycardias. It is also called “ramp” pacing.Sns Sns Sns Sns

TACHY.SENSE

S 1 S 1S 1S 1S 1 SnsSnsSns

RAMP

Pacing – Extra Stimulus Pacing

For the standard EP study to test the refractory periods, one extrastimulus (S2) will be used. If a second extrastimulus is used, it is usually for arrhythmia induction and is called “S3”. Up to 3 (S4) extrastimuli (S2, S3, S4) can be given in a standard EPS. Any more than 3 extrastimuli would induce a non-clinical arrhythmia. That is, it could induce an arrhythmia in a normal subject.

Exrastimulus Pacing

DRIVETRAIN

Sensed S1 S1 S1 S1 S1 S1 S1 S1 S2

Single extras

Standard EP Study Protocol Cont. – Atrial Pacing

Atrial pacing is performed with the HRA catheter to determine the following:– AV decremental properties– AVNERP– AV Wenckebach cycle length– AERP

Pacing spikeA wave

With Wenckebach there are grouped beats with gradual prolongation of the AH interval until conduction to the ventricle eventually drops. Therefore only an occasional “A” wave will not conduct to produce a “V” (see the dropped “V” above). This occurs as pacing is hitting far into the relative refractory period.

AH Intervals

Dropped beat

Standard EP Study Protocol Cont. –

AV Node Conduction Curve – AV Wenckebach

The ERP of the AV node is reached when conduction from the atrium to the ventricle is blocked due to reaching the refractory period of the AV nodal tissue. This would be evidenced by an “A” wave after the pacing spike not followed by a His potential or a “V” wave. AVNERP = 280 - 450 msecs

No His or “V”

Pacing spike

Standard EP Study Protocol Cont. –

AV Node Conduction Curve – AVNERP

AV

The ERP of the atrial tissue is reached when you pace at a rate faster than the absolute refractory period of the atrial tissue. This would be evidenced by a pacing spike not followed by an “A” wave. Consequently there would be no His potential or “V” wave.

Pacing Spike

VNo “A” waves

Standard EP Study Protocol Cont. –

AV Node Conduction Curve – AERP

AERP No local atrial electrogramPacing “spike”

Standard EP Study Protocol Cont. –

AV Node Conduction Curve – AERP

AERP = 200 - 270 msecs

VERP

Pacing “spike”

No local ventricular electrogram

VERP = 200 - 270 msecs

Standard EP Study Protocol Cont. –

Retrograde Conduction Study – VERP

V A V A V A V V A V

No “A” wave

Note that on the 4th and 6th beats no “A” wave follows the “V” wave. This is called VA block.

Standard EP Study Protocol Cont. –

Retrograde Conduction Study – VA Block

4th 6th

VA Conduction Patterns

Midline

Right eccentric

Left eccentric

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