BOOK
Case Studies in Clinical Cardiac Electrophysiology E-Book
John M. Miller | Mithilesh K. Das | Douglas P. Zipes
(2016)
Additional Information
Book Details
Abstract
Keeping up with the use of new technologies in cardiology is becoming increasingly challenging. Case Studies in Clinical Cardiac Electrophysiology helps to bridge the gap between knowledge and application with 28 cases spanning both common and uncommon arrhythmias and ablation scenarios, each of which includes the clinical presentation, baseline ECG, ECG during arrhythmia, stepwise electrophysiologic diagnostic maneuvers and some of their pitfalls, and optimal therapy.
- Includes 28 cases spanning the spectrum of what an electrophysiologist is likely to see in practice.
- Shows the correct way of conducting procedures, as well as "detours" that an unwary practitioner may take: misdiagnoses and why they are wrong; incorrect therapeutic choices and why these may be not only unsuccessful but even harmful.
- Encourages you to read and interpret the ECGs, mapping diagrams, and other diagnostic information before revealing the expert opinion or actual results of each case.
- Summarizes the key learning points in each case.
- Discusses potential procedural complications, including anticipation, avoidance, recognition, and response and resolution.
- Covers complex ablations (atrial fibrillation, ventricular tachycardia) as well as prior failed ablations.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | Cover | ||
| Inside front cover | IFC | ||
| Front matter | iii | ||
| Case studies in clinical cardiac electrophysiology | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| Preface | ix | ||
| Acknowledgments | ix | ||
| Table of Contents | xi | ||
| PART 1 Sinus Node, AV Node, and His-Purkinje System | 1 | ||
| 1 Sinus node and atrioventricular conduction disease | 1 | ||
| Case presentation | 1 | ||
| Evaluation | 2 | ||
| Summary | 7 | ||
| PART 2 Supraventricular Arrhythmias | 9 | ||
| SECTION 1 AV Junctional Arrhythmias | 9 | ||
| 2 Typical (slow-fast) atrioventricular nodal reentry | 9 | ||
| Case presentation | 9 | ||
| Baseline ecgs and intracardiac recordings | 9 | ||
| Ventricular pacing | 10 | ||
| ECGs compared | 12 | ||
| Ventricular pacing in SVT | 12 | ||
| Para-hisian pacing | 13 | ||
| Ventricular extrastimuli in sinus rhythm | 14 | ||
| Ventricular extrastimuli in SVT | 14 | ||
| Atrial and ventricular pacing and extrastimuli during SVT | 15 | ||
| Cartoons and ladder diagrams of pacing | 18 | ||
| Ventricular and atrial pacing in sinus rhythm | 20 | ||
| Atrial extrastimulus testing | 21 | ||
| Ablation sites and assessments | 22 | ||
| SVT repeatedly initiated with atrial stimulation | 26 | ||
| After four attempts at slow pathway ablation, | 26 | ||
| What should you do now? | 26 | ||
| Summary | 27 | ||
| 3 Atypical (fast-slow) atrioventricular nodal reentry | 28 | ||
| Case presentation | 28 | ||
| Baseline ECG and intracardiac recordings | 28 | ||
| Any clues as to svt diagnosis? [fig. 3-2] | 29 | ||
| Baseline ventricular pacing | 29 | ||
| Does this include/exclude any diagnoses? [fig. 3-3] | 29 | ||
| Baseline coronary sinus pacing | 30 | ||
| Does this include/exclude any diagnoses? [fig. 3-4] | 30 | ||
| SVT initiation with ventricular pacing | 30 | ||
| What kinds of SVT are initiated with ventricular pacing? [fig. 3-5] | 30 | ||
| SVT ECG and intracardiac recordings | 31 | ||
| Ventricular extrastimuli and overdrive pacing during SVT | 32 | ||
| Does this include/exclude any diagnoses? [fig. 3-8] | 32 | ||
| Does this include/exclude any diagnoses? [fig. 3-9] | 32 | ||
| Does this include/exclude any diagnoses? [fig. 3-10] | 33 | ||
| Does this include/exclude any diagnoses? [fig. 3-11] | 33 | ||
| At initiation of ventricular pacing [fig. 3-12] | 34 | ||
| Initiation of atrial fibrillation with ventricular pacing | 35 | ||
| Ventricular and atrial pacing at tcl during sinus rhythm | 35 | ||
| Does this help in any way? [fig. 3-15] | 35 | ||
| Does this include/exclude any diagnoses? | 36 | ||
| Parahisian pacing | 36 | ||
| Atrial extrastimuli in SVT | 37 | ||
| Ablation site | 37 | ||
| Status | 38 | ||
| Atrial entrainment during SVT | 38 | ||
| Ablation begins | 39 | ||
| Final recordings | 40 | ||
| Summary | 40 | ||
| 4 Accelerated junctional rhythm | 41 | ||
| Case presentation | 41 | ||
| Baseline ECG and intracardiac recordings | 42 | ||
| Atrial extrastimuli in rhythm | 43 | ||
| Ventricular extrastimuli in rhythm | 44 | ||
| Where is the exact source of the abnormal rhythm? [fig. 4-6] | 44 | ||
| Ablation site | 45 | ||
| RF ablation begins | 46 | ||
| Final recordings | 46 | ||
| Fluoroscopy of catheter positions | 47 | ||
| Summary | 47 | ||
| SECTION 2 AV Accessory Pathways | 48 | ||
| 5 Left lateral concealed pathway supraventricular tachycardia | 48 | ||
| Case presentation | 48 | ||
| Baseline ECG in sinus rhythm: SVT ECG | 49 | ||
| What questions should you ask about history and prior procedures? | 49 | ||
| Baseline intracardiac recordings in sinus rhythm | 50 | ||
| Ventricular pacing at progressively rapid rates during sinus rhythm | 51 | ||
| Ventricular pacing initiates SVT | 52 | ||
| Ventricular extrastimuli in SVT | 53 | ||
| Ventricular overdrive pacing in SVT | 54 | ||
| Ventricular pacing with different coronary sinus catheter positions | 54 | ||
| Nature of “funny spikes” explored | 55 | ||
| Atrial extrastimuli during fixed-rate ventricular pacing | 55 | ||
| Are the funny spikes a, V, or bt? [fig. 5-12] | 55 | ||
| Onset of ventricular pacing at time of sinus complex | 56 | ||
| Mapping and ablation sites and results | 56 | ||
| First ablation site | 56 | ||
| Is this mapping site a good site to deliver RF energy? [fig. 5-14] | 56 | ||
| Effect of first ablation, second mapping site | 57 | ||
| Is this mapping site a good site to deliver RF energy? [fig. 5-15] | 57 | ||
| Mapping site no. 4 and ablation | 58 | ||
| Is this mapping site a good site to deliver RF energy? [fig. 5-16] | 58 | ||
| Ventricular pacing postablation (AV nodal conduction only) | 59 | ||
| Summary | 60 | ||
| 6 Antidromic supraventricular tachycardia | 61 | ||
| Case presentation | 61 | ||
| ECG in sinus rhythm | 61 | ||
| Wide-QRS tachycardia ECG | 62 | ||
| Intracardiac recordings and atrial pacing | 63 | ||
| WCT initiation (atrial and ventricular pacing) | 64 | ||
| WCT vs right ventricular pacing at tachycardia cycle length | 65 | ||
| Para-hisian pacing | 66 | ||
| These findings: | 66 | ||
| Atrial extrastimuli (premature atrial complex [PAC]) in WCT | 67 | ||
| Investigating possible accessory pathway potential | 68 | ||
| Preexcited SVT initiation | 69 | ||
| Ablation site and ablation delivery | 70 | ||
| Pre- and postablation ECGs compared | 71 | ||
| Summary | 71 | ||
| 7 Atriofascicular pathway supraventricular tachycardia | 72 | ||
| Case presentation | 72 | ||
| ECG during tachycardia | 72 | ||
| Differential diagnosis of LBBB-appearing tachycardia | 73 | ||
| What about left bundle branch block (LBBB) tachycardias? | 73 | ||
| Baseline ECG and intracardiac recordings | 73 | ||
| Atrial pacing with change in QRS and tachycardia induction | 74 | ||
| Wide QRS tachycardia | 75 | ||
| Atrial extrastimuli during tachycardia | 76 | ||
| Is any diagnosis excluded? [fig. 7-6] | 76 | ||
| Next QRS advanced while avj-a is refractory: [fig. 7-7a] | 76 | ||
| Next A advanced only to same extent as QRS: | 77 | ||
| Next QRS delayed (not while AVJ-A is refractory): [fig. 7-8a] | 77 | ||
| Next A linked to next QRS: [fig. 7-8b] | 78 | ||
| Next QRS absent (not while avj-A is refractory): [fig. 7-9] | 78 | ||
| Atriofascicular pathways | 79 | ||
| More baseline recordings (with halo catheter) | 80 | ||
| Ventricular pacing | 80 | ||
| Atrial fibrillation ECG and intracardiac recordings | 82 | ||
| Atrial pacing and premature stimulation | 83 | ||
| Mapping atriofascicular potential | 84 | ||
| Pacing ablation site | 87 | ||
| Ablation site and radiofrequency delivery | 88 | ||
| Atrial pacing postablation | 89 | ||
| Final fluoroscopy | 91 | ||
| Principles of mapping atriofascicular pathways | 91 | ||
| Summary | 91 | ||
| 8 Slowly conducting bypass tract supraventricular tachycardia | 92 | ||
| Case presentation | 92 | ||
| Prior SVT ECG | 92 | ||
| What is the differential diagnosis? [fig. 8-1] | 92 | ||
| Electroanatomic “shell” [fig. 8-2] | 93 | ||
| Baseline intracardiac recordings during sinus rhythm and SVT | 94 | ||
| What can you diagnose from this, if anything? [fig. 8-5] | 95 | ||
| Ventricular extrastimuli and overdrive pacing in SVT | 96 | ||
| Does this help? [fig. 8-6] | 96 | ||
| Does this help? [fig. 8-7] | 96 | ||
| Does this help? [fig. 8-8] | 97 | ||
| Atrial pacing at svt cycle length compared with SVT | 98 | ||
| Does this help? [fig. 8-9] | 98 | ||
| Spontaneous SVT termination | 98 | ||
| Does this help? [fig. 8-10] | 98 | ||
| Comparison of features and behavior of different SVTs | 99 | ||
| Site of ablation | 100 | ||
| During ablation SVT ceases | 100 | ||
| Ventricular pacing postablation | 101 | ||
| Final ECG | 101 | ||
| Electroanatomic map | 102 | ||
| Summary | 102 | ||
| 9 Fasciculoventricular pathway | 103 | ||
| Case presentation | 103 | ||
| Baseline ECG and intracardiac recordings | 103 | ||
| Ventricular pacing | 104 | ||
| Atrial pacing | 105 | ||
| Atrial extrastimuli | 106 | ||
| Atrial pacing at various rates | 107 | ||
| Junctional escape complex | 108 | ||
| Final ECG | 109 | ||
| Summary | 109 | ||
| SECTION 3 Focal Atrial Tachycardias | 110 | ||
| 10 Focal right atrial tachycardia | 110 | ||
| Case presentation | 110 | ||
| ECG of tachycardia | 110 | ||
| What is the differential diagnosis? [fig. 10-1] | 110 | ||
| Subsequent ECG | 111 | ||
| Baseline ecgs and intracardiac recordings in SVT | 112 | ||
| Tachycardia ecgs [fig. 10-3] | 112 | ||
| Intracardiac recordings [fig. 10-5] | 113 | ||
| Overdrive coronary sinus pacing in SVT | 114 | ||
| Midcoronary sinus pacing [fig. 10-6] | 114 | ||
| Proximal coronary sinus pacing [fig. 10-7] | 115 | ||
| Activation mapping | 116 | ||
| Various sites | 116 | ||
| Activation mapping [fig. 10-8] | 116 | ||
| Activation mapping [fig. 10-9] | 117 | ||
| Activation mapping [fig. 10-10] | 118 | ||
| Activation mapping [fig. 10-11] | 118 | ||
| Electroanatomic map | 119 | ||
| Additional sites sampled and pace mapping | 120 | ||
| Activation mapping [fig. 10-13] | 120 | ||
| Pace mapping [fig. 10-14] | 121 | ||
| Activation mapping [fig. 10-15] | 122 | ||
| Activation mapping [fig. 10-16] | 123 | ||
| Pace mapping [fig. 10-17] | 124 | ||
| Ablation | 125 | ||
| ECG postablation | 126 | ||
| Atrial activation sequence with various sites of coronary sinus pacing vs SVT | 127 | ||
| Ventricular pacing during sinus rhythm | 128 | ||
| Tachycardia 1 h after ablation | 129 | ||
| Tachycardia [fig. 10-24] | 129 | ||
| Atrial pacing induces SVT | 130 | ||
| Ventricular extrastimuli and overdrive pacing in SVT (figs. 10.26 and 10.27) | 130 | ||
| Ventricular overdrive pacing in SVT | 131 | ||
| Catheter manipulation at tricuspid annulus | 132 | ||
| Summary | 133 | ||
| 11 Focal left atrial tachycardia | 134 | ||
| Case presentation | 134 | ||
| Baseline ECG and intracardiac recordings | 135 | ||
| Ventricular pacing | 136 | ||
| What is the differential diagnosis? | 136 | ||
| Where is the block? [fig. 11-3] | 136 | ||
| What next? | 136 | ||
| Atrial pacing on low-dose isoproterenol | 137 | ||
| What is the differential diagnosis? [fig. 11-4] | 137 | ||
| Higher dose isoproterenol | 138 | ||
| Spontaneous SVT onset | 138 | ||
| What is the differential diagnosis [fig. 11-5]? | 138 | ||
| What do you need to do to figure it out? | 138 | ||
| ECG and intracardiac recordings in SVT | 138 | ||
| What is the differential diagnosis [fig. 11-6]? | 138 | ||
| SVT termination | 139 | ||
| What is the differential diagnosis? [fig. 11-8] | 139 | ||
| Ventricular pacing during sinus rhythm | 140 | ||
| What all does this tell? [fig. 11-9] | 140 | ||
| Wide-QRS complex tachycardia ECG and intracardiac recordings | 140 | ||
| What is the differential diagnosis? [fig. 11-10] | 140 | ||
| Wide-to-narrow QRS tachycardia transition | 142 | ||
| Why did the QRS narrow? [fig. 11-12] | 142 | ||
| Ventricular pacing in svt to delineate p-wave onset | 142 | ||
| What’s up with this? [fig. 11-13] | 142 | ||
| Right atrial and then coronary sinus pacing during tachycardia | 143 | ||
| What do the results of pacing during tachycardia tell US? [fig. 11-15] | 144 | ||
| Activation and pace mapping in right atrium | 144 | ||
| Is this a good site? | 144 | ||
| Well? | 145 | ||
| Electroanatomic mapping of right atrium | 146 | ||
| What next? | 146 | ||
| Activation and pace mapping left atrial site | 146 | ||
| Radiofrequency application at left atrial site | 147 | ||
| Comparison of best right and left atrial sites | 148 | ||
| Electroanatomic map of left atrium | 148 | ||
| Fluoroscopic views of best right and left atrial sites | 149 | ||
| Cutaway view of atrioventricular groove | 150 | ||
| Summary | 150 | ||
| SECTION 4 Atrial Flutter (AFL) and Reentrant Atrial Tachycardia | 151 | ||
| 12 Typical atrial flutter | 151 | ||
| Case presentation | 151 | ||
| Baseline ECG and intracardiac recordings | 152 | ||
| Catheter choices? [fig. 12-1] | 152 | ||
| Strategy? | 152 | ||
| We begin with the differential diagnosis: [fig. 12-2 and 12-3] | 153 | ||
| Diagnostic maneuvers | 154 | ||
| CS distal pacing | 154 | ||
| We can eliminate at from left atrium from the differential diagnosis: [fig. 12-4] | 155 | ||
| We can eliminate focal at near cs os from our differential diagnosis: [fig. 12-5e and 12-10b] | 159 | ||
| Cs proximal pacing | 160 | ||
| Recording from CTI | 161 | ||
| Why is there no recording at the abldist and ablprox leads? | 161 | ||
| Pacing from CTI | 163 | ||
| Pacing from lateral TA | 164 | ||
| Differential diagnosis: [fig. 12-11] | 164 | ||
| Electroanatomic mapping | 165 | ||
| Ablation | 167 | ||
| Assessment of bidirectional block | 168 | ||
| Final ECG | 170 | ||
| Summary | 170 | ||
| 13 Atrial reentry after valve surgery | 171 | ||
| Case presentation | 171 | ||
| Approaches to mitral surgery | 172 | ||
| Prior SVT ECG | 172 | ||
| Any clues as to SVT diagnosis? [fig. 13-2] | 172 | ||
| Baseline ECG and intracardiac recordings | 173 | ||
| Any clues as to svt diagnosis? [fig. 13-3] | 173 | ||
| Catheter induction of SVT and ECG and intracardiac recordings | 175 | ||
| Focal or macroreentry? [fig. 13-6] | 175 | ||
| Focal or macroreentry? [fig. 13-7] | 176 | ||
| Focal or macroreentry? | 177 | ||
| Clarifying P-wave onset during SVT with ventricular pacing | 178 | ||
| Overdrive pacing during SVT | 180 | ||
| From distal and proximal coronary sinus | 180 | ||
| Focal or macroreentry? | 180 | ||
| Focal or macroreentry? | 181 | ||
| From different halo catheter sites | 182 | ||
| From coronary sinus again | 183 | ||
| Spontaneous change in atrial activation pattern in SVT | 184 | ||
| SVT termination during catheter mapping | 186 | ||
| Entrainment mapping: Is it a good site? | 187 | ||
| Ablation at site | 189 | ||
| Are we done yet? | 189 | ||
| Electroanatomic maps | 190 | ||
| Pacing from various sites postablation | 192 | ||
| Final ECG | 193 | ||
| Summary | 193 | ||
| 14 Atrial microreentry after lung transplantation | 194 | ||
| Case presentation | 194 | ||
| Differential diagnosis and time course of ats after lung transplantation | 194 | ||
| Types of lung transplantation procedures | 195 | ||
| Baseline ECG and intracardiac recordings | 196 | ||
| Status | 199 | ||
| Electroanatomic mapping | 199 | ||
| Mapping | 200 | ||
| What does this mean? [fig. 14-10] | 200 | ||
| Overdrive pacing during tachycardia from various sites | 200 | ||
| Pacing donor left superior pulmonary vein during sinus rhythm | 204 | ||
| Pacing from ablation catheter near ablation site | 205 | ||
| Approximates appearance of SVT | 205 | ||
| Initiates SVT | 206 | ||
| Replicates SVT appearance | 206 | ||
| Terminates SVT without propagation | 207 | ||
| Reinitiates SVT | 208 | ||
| Recording at ablation site | 208 | ||
| Ablation | 209 | ||
| Sinus rhythm at end | 209 | ||
| Summary | 210 | ||
| 15 Atrial reentry after pulmonary vein isolation for atrial fibrillation | 211 | ||
| Case presentation | 211 | ||
| Baseline ECGs and intracardiac recordings | 211 | ||
| What is the likely mechanism? [fig. 15-4] | 213 | ||
| Diagnostic pacing maneuvers | 215 | ||
| Pacing from RA at different rates | 215 | ||
| Pacing from different sites at same rate (figures 15-13 to 15-16) | 221 | ||
| Pacing from RA at different rates superimposed | 223 | ||
| When looking for fusion: | 223 | ||
| Mapping in left atrium | 224 | ||
| Electroanatomic mapping | 225 | ||
| Mapping and touch-up ablation in pulmonary veins | 226 | ||
| Electroanatomic mapping before and after PV isolation | 231 | ||
| Mapping and pacing at left atrial roof | 232 | ||
| Ablation at left atrial roof | 236 | ||
| Right atrial cavotricuspid isthmus ablation and assessment | 237 | ||
| Final ECG | 240 | ||
| Summary | 241 | ||
| SECTION 5 Atrial Fibrillation (AF) | 242 | ||
| 16 Pulmonary vein isolation for atrial fibrillation | 242 | ||
| Case presentation | 242 | ||
| Baseline ECG | 242 | ||
| Recordings from right inferior pulmonary vein | 243 | ||
| Recording and pacing from left superior PV | 244 | ||
| Recording from left superior PV, pacing from left inferior PV | 244 | ||
| Recording and pacing from right superior PV | 245 | ||
| Recording from right superior PV, pacing from right inferior PV | 245 | ||
| Atrial anatomy on electroanatomic maps | 246 | ||
| Progressive left PV isolation | 247 | ||
| Progressive right PV isolation | 249 | ||
| Adenosine administration | 252 | ||
| Electroanatomic maps with RF sites | 253 | ||
| Summary | 253 | ||
| 17 Pulmonary vein isolation, rotor mapping and ablation, and flutter ablation for af/flutter | 254 | ||
| Case presentation | 254 | ||
| Baseline ECGs and intracardiac recordings | 254 | ||
| What does this mean? [fig. 17-2] | 255 | ||
| What does this mean? [fig. 17-3] | 255 | ||
| What does this mean? [fig. 17-5] | 256 | ||
| Right superior pulmonary vein recordings | 257 | ||
| Is the pac coming from here? [fig. 17-6] | 257 | ||
| Left inferior PV recordings | 257 | ||
| Is the pac coming from here? [fig. 17-7] | 257 | ||
| Left pulmonary vein wide-area circumferential ablation | 258 | ||
| Baseline pacing | 258 | ||
| Start of ablation | 259 | ||
| Isolation occurs | 260 | ||
| Sinus rhythm after isolation | 260 | ||
| Exit block after isolation | 261 | ||
| Right PV wide-area circumferential ablation | 262 | ||
| Start of ablation | 262 | ||
| Flutter initiates | 262 | ||
| Flutter terminates in right atrium | 263 | ||
| Partial isolation | 264 | ||
| Full isolation | 264 | ||
| Dissociated potential seen after right WACA | 265 | ||
| What is demonstrated? [fig. 17-18] | 265 | ||
| Exit block can’t be demonstrated when pacing in vein after right waca during flutter. | 266 | ||
| What is demonstrated? [fig. 17-19] | 266 | ||
| Exit block testing when pacing in vein after right waca during flutter. | 266 | ||
| Which is demonstrated? [fig. 17-20] | 266 | ||
| Pacing during flutter | 267 | ||
| From midcoronary sinus | 267 | ||
| From proximal coronary sinus | 268 | ||
| From midtricuspid annulus | 268 | ||
| Earlier in that episode of tricuspid annulus pacing | 269 | ||
| Single extrastimulus from lateral tricuspid annulus | 270 | ||
| Ablation from cavotricuspid isthmus | 270 | ||
| Completion of cavotricuspid isthmus ablation | 271 | ||
| Burst pacing initiates atrial fibrillation | 272 | ||
| Standard intracardiac recordings and basket catheter recordings in AF | 273 | ||
| Fluoroscopy of catheters including basket in left atrium | 273 | ||
| Rotor movie/still | 274 | ||
| Ablation at rotor “core” terminates AF | 274 | ||
| Adenosine administration | 275 | ||
| Electroanatomic mapping showing ablation regions | 276 | ||
| Summary | 277 | ||
| PART 3 Ventricular Arrhythmias | 279 | ||
| SECTION 1 Ventricular Tachycardia in Absence of Structural Heart Disease | 279 | ||
| 18 Idiopathic focal right ventricular outflow tract ectopy | 279 | ||
| Case presentation | 279 | ||
| Baseline ecgs and intracardiac recordings | 280 | ||
| Where is the likely origin? [fig. 18-1] | 280 | ||
| Is this the same as what we saw earlier? [fig. 18-2] | 280 | ||
| Mapping different sites | 282 | ||
| Does this mean anything? [fig. 18-5] | 282 | ||
| Is this a good ablation site? | 283 | ||
| Is this a good site? | 284 | ||
| Algorithm says 94% match. ablate here? | 284 | ||
| Algorithm says 92% match. ablate here? | 285 | ||
| Is this a good site? | 285 | ||
| Index | 413 | ||
| A | 413 | ||
| B | 415 | ||
| C | 415 | ||
| D | 415 | ||
| E | 416 | ||
| F | 416 | ||
| H | 416 | ||
| I | 417 | ||
| J | 417 | ||
| L | 417 | ||
| M | 417 | ||
| O | 417 | ||
| P | 417 | ||
| Q | 418 | ||
| R | 418 | ||
| S | 419 | ||
| T | 419 | ||
| V | 420 | ||
| W | 420 | ||
| Inside back cover | IBC | ||
| Foreword | vii |