Invasive cardiac electrophysiology studies
- Munther K Homoud, MD
Munther K Homoud, MD
- Associate Professor of Medicine
- Tufts University School of Medicine
Invasive cardiac electrophysiology (EP) is a collection of clinical techniques for the investigation and treatment of cardiac rhythm disorders [1,2]. These techniques permit a detailed analysis of the mechanism(s) underlying the cardiac arrhythmia, precise location of the site of origin, and, when applicable, definitive treatment via catheter-based ablation techniques. Thus, electrophysiology studies can accomplish the following goals (table 1):
●Definitive diagnosis of an arrhythmia (supraventricular or ventricular tachyarrhythmias or a bradyarrhythmia)
●Establish the etiology for syncope (bradyarrhythmia or tachyarrhythmia), especially in patients with structural heart disease
●Stratification for risk of sudden cardiac death
●Evaluate the feasibility or outcome of nonpharmacologic therapy (eg, transcatheter radiofrequency ablation, antiarrhythmic surgery, or implantable cardioverter/defibrillator therapy)
- Rahimtoola SH, Zipes DP, Akhtar M, et al. Consensus statement of the Conference on the State of the Art of Electrophysiologic Testing in the Diagnosis and Treatment of Patients with Cardiac Arrhythmias. Circulation 1987; 75:III3.
- Subcommittee to Assess Clinical Intracardiac Electrophysiologic Studies. Guidelines for Clinical Intracardiac Electrophysiologic Studies. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures. Circulation 1989; 80:1925.
- Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631.
- Khairy P, Van Hare GF, Balaji S, et al. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2013; 61:e6.
- Ezri M, Lerman BB, Marchlinski FE, et al. Electrophysiologic evaluation of syncope in patients with bifascicular block. Am Heart J 1983; 106:693.
- Dhingra RC, Wyndham C, Bauernfeind R, et al. Significance of block distal to the His bundle induced by atrial pacing in patients with chronic bifascicular block. Circulation 1979; 60:1455.
- Krol RB, Morady F, Flaker GC, et al. Electrophysiologic testing in patients with unexplained syncope: clinical and noninvasive predictors of outcome. J Am Coll Cardiol 1987; 10:358.
- Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm 2013; 10:1932.
- Zipes DP. Second-degree atrioventricular block. Circulation 1979; 60:465.
- Pediatric and Congenital Electrophysiology Society (PACES), Heart Rhythm Society (HRS), American College of Cardiology Foundation (ACCF), et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm 2012; 9:1006.
- Birnie DH, Sauer WH, Bogun F, et al. HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis. Heart Rhythm 2014; 11:1305.
- Crosson JE, Callans DJ, Bradley DJ, et al. PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart. Heart Rhythm 2014; 11:e55.
- Tracy CM, Akhtar M, DiMarco JP, et al. American College of Cardiology/American Heart Association 2006 update of the clinical competence statement on invasive electrophysiologystudies,catheterablation,andcardioversion: a report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training developed in collaboration with the Heart Rhythm Society. J Am Coll Cardiol 2006; 48:1503.
- Tracy CM, Akhtar M, DiMarco JP, et al. American College of Cardiology/American Heart Association Clinical Competence Statement on invasive electrophysiology studies, catheter ablation, and cardioversion: A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation 2000; 102:2309.
- Narula OS, Cohen LS, Samet P, et al. Localization of A-V conduction defects in man by recording of the His bundle electrogram. Am J Cardiol 1970; 25:228.
- Castellanos A Jr, Castillo CA, Agha AS. Symposium on Electophysiologic Correlates of Clinical Arrhythmias. 3. Contribution of His bundle recordings to the understanding of clinical arrhythmias. Am J Cardiol 1971; 28:499.
- Benditt DG, Klein GJ, Kriett JM, et al. Enhanced atrioventricular nodal conduction in man: electrophysiologic effects of pharmacologic autonomic blockade. Circulation 1984; 69:1088.
- Amat-y-Leon F, Dhingra R, Denes P, et al. The clinical spectrum of chronic His bundle block. Chest 1976; 70:747.
- Bharati S, Lev M, Wu D, et al. Pathophysiologic correlations in two cases of split His bundle potentials. Circulation 1974; 49:615.
- Kupersmith J, Krongrad E, Waldo AL. Conduction intervals and conduction velocity in the human cardiac conduction system. Studies during open-heart surgery. Circulation 1973; 47:776.
- Dhingra RC, Palileo E, Strasberg B, et al. Significance of the HV interval in 517 patients with chronic bifascicular block. Circulation 1981; 64:1265.
- Scheinman MM, Peters RW, Suavé MJ, et al. Value of the H-Q interval in patients with bundle branch block and the role of prophylactic permanent pacing. Am J Cardiol 1982; 50:1316.
- Josephson ME. Intraventricular Conduction Disturbances. In: Clinical Cardiac Electrophysiology. Techniques and Interpretations, 3rd ed, Josephson ME (Ed), Lippincott, Philadelphia 2002. p.110.
- McAnulty JH, Rahimtoola SH, Murphy E, et al. Natural history of "high-risk" bundle-branch block: final report of a prospective study. N Engl J Med 1982; 307:137.
- Strauss HC, Bigger JT, Saroff AL, Giardina EG. Electrophysiologic evaluation of sinus node function in patients with sinus node dysfunction. Circulation 1976; 53:763.
- Narula OS, Shantha N, Vasquez M, et al. A new method for measurement of sinoatrial conduction time. Circulation 1978; 58:706.
- Cramer M, Hariman RJ, Boxer R, Hoffman BF. Electrograms from the canine sinoatrial pacemaker recorded in vitro and in situ. Am J Cardiol 1978; 42:939.
- Cramer M, Siegal M, Bigger JT Jr, Hoffman BF. Characteristics of extracellular potentials recorded from the sinoatrial pacemaker of the rabbit. Circ Res 1977; 41:292.
- Gomes JA, Kang PS, El-Sherif N. The sinus node electrogram in patients with and without sick sinus syndrome: techniques and correlation between directly measured and indirectly estimated sinoatrial conduction time. Circulation 1982; 66:864.
- Hariman RJ, Krongrad E, Boxer RA, et al. Method for recording electrical activity of the sinoatrial node and automatic atrial foci during cardiac catheterization in human subjects. Am J Cardiol 1980; 45:775.
- Reiffel JA, Bigger JT Jr. Current status of direct recordings of the sinus node electrogram in man. Pacing Clin Electrophysiol 1983; 6:1143.
- Reiffel JA, Gang E, Gliklich J, et al. The human sinus node electrogram: a transvenous catheter technique and a comparison of directly measured and indirectly estimated sinoatrial conduction time in adults. Circulation 1980; 62:1324.
- Dhingra RC, Wyndham C, Denes P, et al. Sinus nodal responses to atrial extrastimuli in patients without apparent sinus node disease. Am J Cardiol 1975; 36:445.
- Strauss HC, Saroff AL, Bigger JT Jr, Giardina EG. Premature atrial stimulation as a key to the understanding of sinoatrial conduction in man. Presentation of data and critical review of the literature. Circulation 1973; 47:86.
- Rakovec P, Jakopin J, Rode P, et al. Clinical comparison of indirectly and directly determined sinoatrial conduction time. Am Heart J 1981; 102:292.
- Heddle W, Dorveaux LD, Tonkin AM. Use of rapid atrial pacing to assess sinus node function. Clin Prog Electrophysiol Pacing 1985; 3:299.
- Josephson ME. Sinus Node Dysfunction. In: Clinical Cardiac Electrophysiology. Techniques and Interpretations, 3rd ed, Josephson ME (Ed), Lippincott, Philadelphia 2002. p.68.
- Wellens HJ, Brugada P, Bär FW. Indications for use of intracardiac electrophysiologic studies for the diagnosis of site of origin and mechanism of tachycardias. Circulation 1987; 75:III110.
- Brugada P, Farré J, Green M, et al. Observations in patients with supraventricular tachycardia having a P-R interval shorter than the R-P interval: differentiation between atrial tachycardia and reciprocating atrioventricular tachycardia using an accessory pathway with long conduction times. Am Heart J 1984; 107:556.
- Denes P, Wu D, Amat-y-Leon F, et al. The determinants of atrioventricular nodal re-entrance with premature atrial stimulation in patients with dual A-V nodal pathways. Circulation 1977; 56:253.
- Yu WC, Chen SA, Chiang CE, et al. Effects of isoproterenol in facilitating induction of slow-fast atrioventricular nodal reentrant tachycardia. Am J Cardiol 1996; 78:1299.
- Josephson ME, Caracta AR, Ricciutti MA, et al. Electrophysiologic properties of procainamide in man. Am J Cardiol 1974; 33:596.
- Tonkin AM, Heddle WF, Tornos P. Intermittent atrioventricular block: procainamide administration as a provocative test. Aust N Z J Med 1978; 8:594.
- Akhtar M, Damato AN, Caracta AR, et al. Electrophysiologic effects of atropine on atrioventricular conduction studied by His bundle electrogram. Am J Cardiol 1974; 33:333.
- Dimarco JP, Garan H, Ruskin JN. Complications in patients undergoing cardiac electrophysiologic procedures. Ann Intern Med 1982; 97:490.
- Horowitz LN, Kay HR, Kutalek SP, et al. Risks and complications of clinical cardiac electrophysiologic studies: a prospective analysis of 1,000 consecutive patients. J Am Coll Cardiol 1987; 9:1261.
- Haines DE, Beheiry S, Akar JG, et al. Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety. Heart Rhythm 2014; 11:e9.
- INDICATIONS AND CONTRAINDICATIONS
- PREPROCEDURAL EVALUATION
- PREPARATION AND MONITORING
- VASCULAR ACCESS AND ELECTRODE CATHETER PLACEMENT
- ELECTROCARDIOGRAPHIC AND ELECTROPHYSIOLOGIC RECORDINGS
- Baseline recordings
- AH interval
- His bundle electrogram duration
- HV interval
- VA conduction
- Sinoatrial conduction time (SACT)
- Sinus node recovery time
- PROGRAMMED ELECTRICAL STIMULATION
- MEDICATIONS USED FOR DIAGNOSTIC PURPOSES DURING EPS
- MAPPING AND ABLATION
- COMPLICATIONS OF INVASIVE CARDIAC ELECTROPHYSIOLOGY STUDIES
- Complications with concomitant catheter ablation
- SUMMARY AND RECOMMENDATIONS