Pr inciples of EP (His bundle, Mapping

techniques)

Dr. Meenu

PA – 4 wire

• Prep• Routine EP study• 2 kinds of pacing:

– ES <

– Incremental <

SNRT

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 PathwaysFast Slow

A-H JumpDefinition

AV N ReentryTypical AV N echo Initiation of AVNRT

AV N ReentryTypical 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

• 1st AVB

• 2nd AVB

• HVB

• CHB

T hank you .