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(BQ) Part 1 book Practical clinical electrophysiology presents the following contents: Anatomy in clinical electrophysiology, basic principles in clinical electrophysiology, atrial fibrillation, atrial flutter, supraventricular tachycardia.
Practical Clinical Electrophysiology EDITORS Peter J Zimetbaum, MD Associate Professor of Medicine Harvard Medical School Director, Clinical Cardiology Cardiovascular Division Beth Israel Deaconess Medical Center Boston, Massachusetts Mark E Josephson, MD Herman C Dana Professor of Medicine Harvard Medical School Chief of the Cardiovascular Division Chief Medical Officer and Chief Academic Officer of the Cardiovascular Institute of the Beth Israel Deaconess Medical Center Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service Beth Israel Deaconess Medical Center Boston, Massachusetts Acquisitions Editor: FRANCES R DESTEFANO Managing Editor: CHRIS POTASH Project Manager: ALICIA JACKSON Manufacturing Coordinator: KATHLEEN BROWN Manufacturing Manager: KIMBERLY SCHONBERGER Design Coordinator: HOLLY MCLAUGHLIN Cover Designer: LOUIS FUIANO Production Services: LASERWORDS PRIVATE LIMITED, CHENNAI, INDIA 2009 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business 530 Walnut Street Philadelphia, PA 19106 USA LWW.com All rights reserved This book is protected by copyright No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in the USA Library of Congress Cataloging-in-Publication Data Practical clinical electrophysiology/editors, Peter J Zimetbaum, Mark E Josephson p.; cm Includes bibliographical references and index ISBN-13: 978-0-7817-6603-6 ISBN-10: 0-7817-6603-6 Arrhythmia Heart—Electric properties Electrophysiology I Zimetbaum, Peter J II Josephson, Mark E [DNLM: Arrhythmias, Cardiac—physiopathology Cardiac Electrophysiology—methods Arrhythmias, Cardiac—diagnosis Arrhythmias, Cardiac—therapy WG 330 P8954 2009] RC685.A65P693 2009 616.1 28—dc22 2008028374 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 To Ben, Molly, and Roberta—for your love, encouragement, and understanding To Sylvie Tessa, Elan Robert, Joan, Rachel, Todd, Stephanie, and Jesse—for their love and support Contributing Authors David J Callans, MD Director, Electrophysiology Laboratory Professor of Medicine Cardiovascular Medicine Division Hospital of The University of Pennsylvania Philadelphia, Pennsylvania Atrial Flutter Daniel R Frisch, MD Assistant Professor of Medicine Division of Cardiology Electrophysiology Section Thomas Jefferson University Philadelphia, Pennsylvania Supraventricular Tachycardia v vi • Contributing Authors William H Maisel, MD, MPH Assistant Professor of Medicine Harvard Medical School Director of the Pacemaker and ICD Service Beth Israel Deaconess Medical Center Boston, Massachusetts Permanent Pacemakers Clinical Management of Patients with Implantable Cardioverter Defibrillators Michael McLaughlin, MD Instructor in Medicine Harvard Medical School Division of Cardiology Beth Israel Deaconess Medical Center Boston, Massachusetts Sudden Death Syndromes Implantable Cardioverter Defibrillator Indications Christopher Pickett, MD Assistant Professor of Medicine University of Connecticut Division of Cardiology University of Connecticut Health Center Farmington, Connecticut Clinical Management of Patients with Implantable Cardioverter Defibrillators Heiko Schmitt, MD, PhD Assistant Professor of Medicine University of Connecticut Division of Cardiology University of Connecticut Health Center Farmington, Connecticut Permanent Pacemakers Contributing Authors John V Wylie Jr., MD Instructor in Medicine Harvard Medical School, Director, Arrhythmia Monitoring Laboratory Division of Cardiology Beth Israel Deaconess Medical Center Boston, Massachusetts Wolff-Parkinson-White Syndrome and Variants • vii Preface The last decade has seen an explosion in the therapeutic options available for the management of cardiac arrhythmias As a result, the focus of electrophysiology training has turned toward acquiring the technical skills necessary to perform catheter ablation and complex device implantation and away from the diagnostic skills required for arrhythmia management Our goal in writing this book is to provide a succinct and practical clinical approach to the major arrhythmia disorders encountered in the clinic as well as the electrophysiology laboratory We have focused on the clinical history, electrocardiogram and diagnostic electrophysiology study More comprehensive texts are available, which delineate the details of diagnostic and therapeutic invasive electrophysiology studies We hope it will prove equally useful to the internist evaluating syncope, the cardiologist deciding if a pacemaker is needed during a myocardial infarction complicated by complete heart block, and the electrophysiology fellow learning how to differentiate the various forms of supraventricular tachycardia in the electrophysiology laboratory As is true for most fields of medicine there is as much art as there is science in electrophysiology We and the contributing authors to this book share a common ‘‘style’’ of arrhythmia management and passion for the clinical care of patients with arrhythmia disorders, which we hope will prove helpful to physicians caring for these fascinating patients Peter J Zimetbaum, MD Mark E Josephson, MD ix 104 • Practical Clinical Electrophysiology reentrant SVT or VP is diagnostic of a free wall AP For septal APs where the atrial activation is midline, there is usually a single breakthrough and the VA exceeds the VA in AVNRT (see Differentiating SVT Mechanisms in the subsequent text) Typically, the VA time ranges from 70 to 170 msec in concealed AVRT Effect of Bundle Branch Block on Ventriculoatrial Interval The development of BBB may cause an increase in the SVT CL of a tachycardia using a free wall AP However, diagnosis requires an increase in the measured VA interval compared with narrow-QRS conduction An increase in VA by ≥35 msec with BBB is diagnostic of an AP on the same (ipsilateral) side as the site of BBB (or >45 msec with RVA pacing) (see Figs 8-13 and 8-14) The VA will not change with BBB on the opposite (contralateral) side The VA in posteroseptal APs may increase with LBBB (∼10 msec) and anteroseptal APs may increase with right bundle branch block (RBBB) approximately 15 msec Requirement of Atria and Ventricles to Initiate and Sustain Tachycardia In AVRT using a concealed AP, the reentrant circuit requires the atria and ventricles; therefore if AV (or VA) block occurs, then an AP-dependent tachycardia Atrium RB RB RB LB LB HPS RB AVN Ventricle VA VA When a bundle branch block develops ipsilateral to the site of an accessory pathway (in this case a left bundle [LB] branch block in the presence of a left-sided AP) the VA interval increases with or without an increase in the tachycardia cycle length LB = left bundle RB = right bundle FIGURE 8-13 Ventriculoatrial (VA) intervals during orthodromic atrioventricular reentry tachycardia (AVRT) without and with ipsilateral bundle branch block The VA interval prolongs with bundle branch block on the same side as the accessory pathway AVN, atrioventricular node; HPS, His-Purkinje system Supraventricular Tachycardia • 105 I II III V1 V6 HRA HIS d HIS p H H H A A CS A CS CS A A A A A CS CS d A A 130 55 V V RVa Spontaneous relief of left bundle branch block during supraventricular tachycardia with decrease in VA time from 130 to 55 msec indicating the participation of left-lateral accessory pathway in the tachycardia Lines demonstrate onset of the surface QRS Shown are surface leads I, II, III, V1, and V6 as well as electrograms from the high right atrium (HRA), His bundle (His d and His p) coronary sinus from proximal to distal (CS to CS d), and right ventricular apex (RVA) FIGURE 8-14 Left bundle branch block during orthodromic atrioventricular reentry tachycardia (AVRT) utilizing a left free wall accessory pathway is excluded The failure to initiate the SVT with an APD that blocks in the AVN or HPS may be an early clue that the SVT employs an AP Effect of Atrial and Ventricular Stimulation during Tachycardia The ability to alter a tachycardia is related to the proximity of the stimulation site to the circuit (see Table 8-3) Because both the atrium and ventricles are part of the tachycardia circuit, stimulating either chamber can affect the tachycardia Programmed APDs can advance AVRT using a concealed AP with or without atrial fusion and can terminate AVRT often by producing block in the AVN or HPS Response to overdrive VP: VP at 10 to 20 msec faster than the TCL (or single VPDs) would be expected to demonstrate a V-A-V response after cessation of pacing when the atrial activation is advanced and the SVT persists During overdrive V pacing, it is possible to see an antegrade His (i.e., fusion) proving CMT 106 • Practical Clinical Electrophysiology T A B L E 8-3 Atrioventricular Reentrant Tachycardia (AVRT) Diagnostic Criteria for Orthodromic AVRT Initiation Initiation dependent on a critical AV interval (dual AV nodal pathways not necessary) Atrial activation sequence and AV relationship at onset and during SVT Earliest retrograde atrial activity variable (VA ≥60 msec) Effect of BBB on VA interval Ipsilateral bundle branch block, prolongs VA by ≥35 msec Requirement of A and V to initiate and sustain Obligatory 1:1 AV relationship with constant VA despite TCL variations Effect of A and V stimulation during tachycardia • V-A-V response upon cessation of RV pacing • Longest V1 -V2 from the RVA that advances the tachycardia subtracted from the TCL 60 msec Often 90% of the TCL from the RVA indicates a right-sided or septal AP (with AVNRT it is >100 msec) Anteroseptal or posteroseptal AP 20 msec earlier than the surface P wave Advanced mapping systems allow further characterization of arrhythmia mechanisms through mapping of the chamber of origin Activation mapping allows the establishment of the earliest to latest points of arrhythmia activation If the earliest point meets the latest in a large circuit involving the entire atrium, the diagnosis is a macroreentrant rhythm such as atrial flutter If the rhythm emanates from a point in the atrium with the latest point distant from the earliest point, the diagnosis is consistent with a focal AT The earliest mapped site of activation is the origin of the tachycardia Complications related to ablation of ATs usually develop from damage to structures in proximity to the site of ablation (e.g., sinus node damage or phrenic nerve paralysis when ablation tachycardias at the top of the crista terminalis, AV block with para-Hisian tachycardias, etc.) SELECTED BIBLIOGRAPHY Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias – executive summary J Am Coll Cardiol 2003;42(8):1493–1531 Field ME, Miyazaki H, Epstein LM, et al Narrow complex tachycardia after slow pathway ablation: Continue ablating? J Cardiovasc Electrophysiol 2006;17:557–559 Frisch D, Zimetbaum P Vagal maneuvers in uptodate, 2008 Josephson ME Clinical cardiac electrophysiology, 4th ed Philadelphia: Lippincott Williams & Wilkins; 2008 Josephson ME, Wellens HJJ Differential diagnosis of supraventricular tachycardia Cardiol Clin 1990;8(3) Katritsis DG, Ellenbogen KA, Becker AE Atrial activation during atrioventricular nodal reentrant tachycardia: Studies on retrograde fast pathway conduction Heart Rythm 2006;3:993–1000 Kistler PM, Robert-Thomson KC, Haqqani HM, et al P-Wave morphology in focal atrial tachycardia J Am Coll Cardiol 2006;48:1010–1017 Kistler PM, Sanders P, Fynn SP, et al Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins Circulation 2003;108:1968–1975 Kwaku KF, Josephson ME Typical AVNRT – an update on mechanisms and therapy Card Electrophysiol Rev 2002;6:414–421 Supraventricular Tachycardia • 117 Michaud GF, Tada H, Chough S, et al Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing J Am Coll Cardiol 2001;38:1163–1167 Miles WM, Yee R, Klein GJ, et al The preexcitation index: An aid in determining the mechanism of supraventricular tachycardia and localizing accessory pathways Circluation 1986;74(3):493– 500 Orejarena LA Paroxysmal supraventricular tachycardia in the general population J Am Coll Cardiol 1998;31:150–157 Roberts-Thompson KC, Kistler PM, Kalman JM Atrial tachycardia: mechanisms, diagnosis, and management Curr Probl Cardiol 2005;30:529–573 ... Variants 11 9 10 Ventricular Tachycardia 13 7 11 Bradycardias 16 3 12 Syncope 17 9 13 Sudden Death Syndromes 19 3 14 Implantable Cardioverter Defibrillator Indications 219 15 Permanent Pacemakers 2 31 16 Clinical. .. The sinus and atrioventricular (AV) nodes 13 14 • Practical Clinical Electrophysiology mV 30 INa/Ca lk lca.l lca.t lk1 lk1 lf lf msec −90 15 0 FIGURE 2 -1 Calcium-dependent nodal action potentials... science and clinical disease N Engl J Med 19 97;336 :15 75 15 86 Arnsdorf MF The cellular basis of cardiac arrhythmias: A matrical perspective Ann N Y Acad Sci 19 90;6 01: 263 Josephson ME Clinical cardiac