Pr inciples of E P (His bundle, Mapping techniques) Dr. Meenu

PA – 4 wire

Prep Routine EP study 2 kinds of pacing: –ES < –Incremental <

SNRT

AES Protocol Uses

AV node antegrade conduction

AVN – decremental conduction

VES Uses : –1 –2 –3

Incremental A pacing – AV WCL

Incremental V pacing – VA WCL

Minimum protocol for diagnostic EP Measurement of basic intervals SNRT at BCLs of 800, 600, 500, 400, 350 ms V ES testing down to v refractoriness at BCLs of 600 and 400 ms Incremental V pacing from ~ > SR down to VA Wenkebach point or a min CL of 300 ms A ES testing down to refractoriness at BCLs of 600 and 400 ms Incremental A pacing from ~ > SR down to AV Wenkebach point or a min CL of 300 ms

AT- site of origin

AT - Mech Microreentry Focal: –Triggered activity –Abnormal automaticity

Typical A Fl – Macroreentrant RA circuit

Typical A Fl

AF

AVNRT – Dual AV N Pathways Fast Slow

A-H Jump Definition

AV N Reentry Typical AV N echo Initiation of AVNRT

V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP –Differential A pacing –Differential V pacing –Para Hisian pacing

Degree of pre excitn –Rel time for atr impulse to reach : AV N / AP –Time taken to conduct over : AV N / AP SR -- absent Delta –Concealed –Latent To incr pre excitn –Delay AV N –Differential A pacing

V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP –Differential A pacing –Differential V pacing –Para Hisian pacing

Normalizn with His ES

V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP –Differential A pacing –Differential V pacing –Para Hisian pacing

Retrograde atr activn – Concentric Eccentric

Ecc atr activn clearer (Other than VPCs) Adenosine block AV N Differential V pacing ( at site close to AP ) Observe orthodromic AVRT (retrogr exclusive over AP)

V pre excitation – EP diagn overview Maneuvers to increase pre excitation Normalizn of abnormal QRS Change in pattern of A activn during V pacing (retrograde A activn sequence) – AP localisn Initiation of orthodromic AVRT by APC To :manifest ( identify presence of) pre excitn + : aid localizn AP ( Shortest s -∆ interval ) –Differential A pacing – V – P His

Differential pacing

Unusual AP Rate dependent –Concealed –Anterograde Mahaim

VT PVS

Pace mapping

Activation mapping

1 st AVB

2 nd AVB

HVB

CHB

T hank you.