1. EP Laboratories in Korea 1610 patients in 1998 RF ablation1,034 cases EP study576 cases Seoul 9 수원 1 인천 1 대전 1 대구 3 부산 4 마산 1 광주 1

2. Arrhythmias Early beats Unexpected pauses TachycardiasBradycardias Bigeminal rhythms Group beating Total irregularity Regular non-sinus rhythms at normal rates By HJL Marriot Patients’ symptoms Patients’ survival

3. Enemies... BradyarrhythmiaTachyarrhythmia Pause Supraventricular BlockVentricular Sudden Cardiac Death Sudden Cardiac Death Syncope of Unknown Origin Syncope of Unknown Origin Afghanistan_2002

4. EPS A crystal ball to see what lies ahead? Local electrograms Ability to record Ability to reflect the electrical state Programmed stimulation Ability to induce and terminate Reentry > Triggered activity > Increased automaticity

5. Anti-arrhythmic drugs Device: pacemaker Device: defibrillator Ablation: catheter-based Ablation: surgery Treatment Arrhythmias Early beats Unexpected pauses TachycardiasBradycardias Bigeminal rhythms Group beating Total irregularity Regular non-sinus rhythms at normal rates rhythms at normal rates Treatment of Arrhythmias Patient’s symptoms Risk associated with arrhythmias

6. Goal of EP Study 1.Diagnosis of Arrhythmia 2.Treatment of Arrhythmia 3.Evaluation of Treatment 4.Estimation of Risk-Prognosis

7. Facts, Solved Bradycardia without reversible causes with symptoms PacemakerEPS To confirm the causal relationship between patients’ symptoms and observed bradyarrhythmia

8. 77/F Recurrent syncope 54/M Dizziness and effort intolerance 62/M Syncope

9. 2 sec after RF: AP conduction block RAO 30 o Map/RF CS HRA RVA His EP study For Catheter ablation

10. Facts, Solved 0 20 40 60 80 100 AVJAVNRTAPVTAFLATIST Success Complication NASPE 1998 Prospective Catheter Ablation Registry 3,357 patients(3,423 sessions) Complication 2.59% No procedure-related death Scheinman MM, Huang S. PACE. 2000;23:1020-1028.

11. Solved with Catheter Ablation EP study for treatment Structural HDPrognosisTreatment Atrial APCGood Atrial tachycardia NonsustainedGood Sustained(+)/AT-relatedVariableD, Curable PSVTGoodCurable WPW with afibCan be lethalCurable Atrial flutter(+)VariableD, Curable Atrial fibrillation(+)/(-)Lethal VentricularVPC Ventricular tachycardia(-)GoodD, Curable Nonsustained(+)Poor Sustained(+)Poor Ventricular fibrillationLethal ARVD, Brugada, Long QTLethal

12. Ventricular tachyarrhythmias with significant risk of death Aborted sudden cardiac death Syncope of unknown origin Mortality-determining Factors WeaponsDrug Catheter-based ablation ICD Facts, Should be solved

13. VTMyocardial Infarction LV dysfunction or Not Cardiomyopathy Dilated, Hypertrophic PMVT/VFChannelopathy Brugada, Long QT Aborted SCD Syncope

14. High inducibility and reproducibility in monomorphic VT EP-guided drug treatment Ventricular Arrhythmias with MI

15. Incidence of Sudden Death in Stratified Patients with Non-sustained VT Wilber DJ. Circulation. 1990;82:350-358. Noninducible (N = 57, SD/CA = 2) Inducible/Suppressed (N = 20, SD/CA = 1) Inducible/Not Suppressed (N = 20, SD/CA = 7) P < 0.001 10 20 30 40 50 60 70 80 901004812162024 Follow-up (months) Survival (%) Facts, we’ve learned

16. How to evaluate and predict the efficacy of treatment? Guided Therapy Spontaneous(sustained or repetitive) Chronic atrial fibrillation, Repetitive MVT, Frequent PVCs  Anti-arrhythmic treatment(drugs or ablation, etc)  Termination or suppression of arrhythmia Sporadic Noninvasive Prolonged monitoring to evaluate arrhythmia behavior Prolonged monitoring to evaluate arrhythmia behaviorInduction Noninvasive challenge with TMT, isoproterenol Noninvasive challenge with TMT, isoproterenol Invasive challenge with programmed electrical stimulation Invasive challenge with programmed electrical stimulation  Anti-arrhythmic treatment(drugs or ablation, etc) Reapplication of evaluating methods  No inducible arrhythmia or significantly modified

17. 95% of Inducibility in Monomorphic VT EP-guided drug treatment Limitation of drug treatment, especially in patients’ with risk Ventricular Arrhythmias with MI

18. CAST Trial Cardiac Arrhythmia Suppression Trial 80 85 90 95 100 091182273364455 Days After Randomization Patients Without Event (%) Placebo (n = 743) Encainide or Flecainide (n = 755) P = 0.001 CAST investigators, NEJM 1989;321:406-412 Facts, we’ve learned

19. 95% of Inducibility in Monomorphic VT EP-guided drug treatment Limitation of drug treatment, especially in patients’ with risk No superiority of EP-guided treatment Ventricular Arrhythmias with MI

20. ESVEM VT, Cardiac Arrest, Syncope Randomize EPS Holter Monitor ESVEM Investigators. Circulation. 1989;79(6):1354-1360. Follow-Up > 10 PVCs/Hour on Holter and Inducible at EPS Drug 1 Drug N ETT Drug 1 Drug N ETT Facts, we’ve learned

21. CASCADE Trial: Cardiac Arrest in Seattle Conventional vs. Amiodarone Drug Evaluation Out-of-Hospital VF Arrest Not Associated with Q-wave MI Randomization Empiric Amiodarone EPS or Holter-Guided “Conventional” Antiarrhythmic Endpoints:Cardiac Arrest from VF Cardiac Mortality Syncope Followed by ICD Shock Facts, we’ve learned

22. Total Cardiac Survival CASCADE Investigators. Am J Cardiol. 1993;72:280-287. Sudden Death Survival CASCADE Survival 100% 75% 50% 25% 0% 01234567 Years P =.007 by Log Rank Statistic Amiodarone(113) Conventional(115) 01234567 Years P <.001 by Log Rank Statistic

23. 95% of Inducibility in Monomorphic VT EP-guided drug treatment Limitation of drug treatment, especially in patients’ with risk No superiority of EP-guided treatment Superiority of ICD treatment, especially in patients’ with risk Ventricular Arrhythmias with MI

24. ICD for prevention of death Secondary: AVID, CASH, CIDIS Primary:MADIT, CABG-PATCH,SCD-HeFT Facts, we’ve learned

25. AVID Trial (Antiarrhythmics Versus Implantable Defibrillators) Patients with near-fatal ventricular arrhythmias Empiric amiodarone, sotalol or guided sotalol or guided sotalolversus Implantable defibrillators 1016 patients Significant mortality reduction in ICD group 39±20%27±21% 31±21% Facts, we’ve learned

27. MADIT (Multicenter Automatic Defibrillator Implantation Trial) Inclusion Criteria Prior Q-wave MI Unsustained VT EF  35% Inducible, non-suppressible VT NYHA Class I – III Age 25 - 80 > 3 weeks from last MI No requirement for revascularization Exclusion Criteria Hx of VF or syncopal VT Symptomatic hypotension in stable rhythm MI within last 3 weeks Recent PTCA or CABG (  2 - 3 months) Advanced cerebrovascular disease Any non-cardiac disease associated with reduced likelihood of survival Moss AJ. New Engl J Med. 1996;335:1933-1940. Facts, we’ve learned

28. MADIT Patient Flow Non-inducible (n = 139) Patients meeting inclusion criteria (N = 483) EP study Suppressible with IV procainamide (n = 91) Refused study (n = 57) Inducible (n = 344) Non-suppressible (n = 253) Signed consent form, randomized (n = 196) MADIT FDA Info Pack. May 16, 1996. Facts, we’ve learned

29. MADIT Survival Moss AJ. New Engl J Med. 1996;335:1933-1940. Year1.00.8 0.6 0.4 0.2 0.0 01234 5 Probability of Survival Conventionaltherapy Defibrillator No. of patients Defibrillator95805331173 Conventional101674829170 therapy Facts, we’ve learned

30. MADIT Antiarrhythmic Therapy Use Medication Antiarrhythmic medication Amiodarone742457 Beta-blockers826527 Class I antiarrhythmic agents10121111 Sotalol7194 Beta-blockers or sotalol15271431 No antiarrhythmic medication8562344 Other cardiac medication Angiotensin-converting-55605157 enzyme inhibitors Digitalis38583057 Diuretics52534752 Other cardiac medication Angiotensin-converting-55605157 enzyme inhibitors Digitalis38583057 Diuretics52534752 Moss AJ. New Engl J Med. 1996;335:1933-1940. One Month Last Contact Conventional Therapy (N = 93) Defibrillator (N = 93) Conventional Therapy (N = 82) Defibrillator Defibrillator (N = 86) Facts, we’ve learned

31. EP study and Cardiomyopathy Dilated CMP Low inducibility Poor correlation with clinical efficacy of guided-treatment Limitation of drug selection Hypertrophic CMP Patients with syncope, VT, VF High chance of induction

32. VT with MI Stable without LV dysfxEP-guided drug Tx Catheter ablation Unstable* without LV dysfxICD EP-guided drug Tx Stable with LV dysfxICD, Catheter ablation Amiodarone, sotalol Unstable* with LV dysfxICD NSVT with MI Without LV dysfx With LV dysfxEP study VT with CMP StableAmiodarone UnstableICD Amiodarone Facts, justified

33. MADIT Patient Flow Non-inducible (n = 139) Patients meeting inclusion criteria (N = 483) EP study Suppressible with IV procainamide (n = 91) Refused study (n = 57) Inducible (n = 344) Non-suppressible (n = 253) Signed consent form, randomized (n = 196) MADIT FDA Info Pack. May 16, 1996. Facts, we want to know

34. MADIT II No ICD Patients with LV dysfuction (LVEF  30%) Regardless of the occurrence of NSVT Randomization ICD Device-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, we want to know SCD-Heft Patients with LV dysfuction (LVEF  35%) CAD+DCMP, NYHA II+III Randomization ICD Conventional Rx + Placebo Conventional Rx + Amiodarone

35. Syncope of Unknown Origin Head-up tilt table test, esp. in structurally normal heart patients Predictive factors for positive EP study LV dysfunction Presence of bundle branch block Coronary arterial disease Myocardial infarction Use of class I antiarrhythmic drugs Krol RB, Morady F, et al. JACC 10(2):358-63. Facts, we’ve learned

36. Diagnostic Yield in Unexplained Syncope 86 patients with unexplained syncope Sra JS. Ann Intern Med. 1991;114:1013-1019. 29 patients (34%) 57 patients tilt table test Abnormal resultNormal result EP study 34 patients (40%) 23 patients still with unexplained syncope (26%) Syncope elicited Normal response

37. Findings and Treatment of Syncope Patients with Abnormal EP Study Findings in EP-positive patients (N = 29) SVT (n = 5) VT (n = 21) Sinus node dysfunction or conduction disease (n = 3) Permanent pacemaker (n = 3) Antiarrhythmics only (n = 3) Ablation (n = 2) ICD (n = 10) Catheter or surgical ablation (n = 6) Antiarrhythmics only (n = 4) Sra JS. Ann Intern Med. 1991;114:1013-1019.

38. Risk of Mortality from Syncope Based on Outcome of EP Study Bass EB. Am J Cardiol. 1988;62:1186-1191. % Total Mortality 100 80 60 40 20 0 06121824303642485460 Months of Follow-Up = Positive EPS Patients = Negative EPS Patients

39. History of EP Study 1969His bundle electrogram 1970sProgrammed electrical Stimulation Endocardial mapping of Ventricular tachycardia Surgical ablation of arrhythmias 1980s Catheter ablation of arrhythmias with DC current Radiofrequency catheter ablation Introduction of ICD 1990s Newer mapping techniques 2000s 1969His bundle electrogram 1970sProgrammed electrical Stimulation Endocardial mapping of Ventricular tachycardia Guided treatment for arrhythmias Surgical ablation of arrhythmias 1980s Catheter ablation of arrhythmias with DC current Radiofrequency catheter ablation Introduction of ICD CAST trial, IMPACT trial 1990s ESVEM trial, CASCADE, CMIAT, EMIAT, etc... AVID trial, MADIT, MUSTT Newer mapping techniques 2000sExpansion of indications for RFCA MADIT-II, SCD-Heft MADIT-II, SCD-Heft

40. EPS A crystal ball to see what lies ahead? Observation Anti-arrhythmic Drugs Devices Defibrillator PacemakerOperationAblation Purpose of study Cost of Treatment Patient’s life Can it be justified?

41. Treatment of Arrhythmia