2. EP Lab Equipment
• Fluoroscopy unit
• EP recording system
• For viewing and
recording intracardiac
EGM and surface ECG
• Cardiac stimulator…
• essentially an
enhanced temporary
pacemaker…
• used to introduce
artificial stimuli for
inducing and
terminating arrhythmias
• Ablation generator
• 3-D mapping and
navigation system
• Intracardiac
ultrasound unit
10. Commonly Used Ablation Generators
The radiofrequency generator is used to delivery radiofrequency energy from the distal
electrode of the ablation catheter through the myocardial tissue and to the ground pad to
ablate the arrhythmia.
Medtronic Atakr IMedtronic Atakr I
StockertStockert
IBIIBI
MedtronicMedtronic
Atakr IIAtakr II
EPT 1000
RadionicsRadionics
EPTEPT
OsypkaOsypka
OsypkaOsypka
EPT 1000XPEPT 1000XP
15. Deflectable Diagnostic Catheters
Design Considerations ：
• Negotiate the sharp angles that result
when attempting access to the
coronary sinus
• Placement of the His catheter
• Helps to minimize the excess
procedure time often associated with
manoeuvring and mapping in the
coronary sinus
17. 20 Pole and Specialty Catheters
HALOHALO™™ XPXP
TVA Mapping
ISMUS™ CATH
Atrial Isthmus
Mapping
Atrial Mapping;
Crista Terminalis
SANTORO™
Atrial Isthmus
Mapping
superior approach
18. Specialty Catheters for atrium Mapping
AFocusII double loop(SJM)
200
PentaRay (Biosense Webster)
200
HD Mesh Mapper (Bard)
320
19. LASSO™ Circular Mapping Catheter
AFib Opportunity
AFib – most common form
of all sustained arrhythmias
Atrial premature beats
initiate AFib from ectopic
foci within the pulmonary
veins
Formerly: lack of
effective method for
mapping of the ectopic
beats inside the veins
23. Catheters used in SVT studies:Catheters used in SVT studies:
Quadripolar in theQuadripolar in the HRAHRA (usually fixed curve)(usually fixed curve)
Quadri, hexa, octa, or decapolar at theQuadri, hexa, octa, or decapolar at the HBEHBE (fixed curve or(fixed curve or
steerable)steerable)
Quadripolar in theQuadripolar in the RVARVA (usually fixed curve)(usually fixed curve)
Hex, octa, or decapolar in theHex, octa, or decapolar in the CSCS (fixed curve or steerable)(fixed curve or steerable)
Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter
Catheters used in VT studies:Catheters used in VT studies:
Quadripolar in theQuadripolar in the HRAHRA (sometimes omitted)(sometimes omitted)
Quadripolar (most common) at theQuadripolar (most common) at the HBEHBE (fixed or steerable)(fixed or steerable)
Quadripolar in theQuadripolar in the RVARVA (steerable is common so that it can be(steerable is common so that it can be
moved to the RVOT)moved to the RVOT)
Steerable large tip (4mm) mapping catheterSteerable large tip (4mm) mapping catheter
Catheters used in SVT and VT Studies
24. Catheters used in standard EP studies:Catheters used in standard EP studies:
Quadripolar in the HRA (usually fixed curve)Quadripolar in the HRA (usually fixed curve)
Quadri, hexa, octa, or decapolar at the HBEQuadri, hexa, octa, or decapolar at the HBE
(fixed curve or steerable)(fixed curve or steerable)
Quadripolar in the RVA (usually fixed curve)Quadripolar in the RVA (usually fixed curve)
Hex, octa, or decapolar in the CS (fixed curveHex, octa, or decapolar in the CS (fixed curve
or steerable)or steerable)
Catheters used in a EP Study
25. Catheters used in a Conduction
System Study
• Quadripolar for HRA
• Quadripolar for HBE
• Quadripolar for RVA
Evaluate sinus node function
Evaluate antegrade AV node
conduction
Evaluate retrograde AV
node conduction
44. Electrophysiology Study
• Measurement of baseline conduction
intervals
• Atrial Pacing
- Assessment of SA nodal automaticity and
conductivity
- Assessment of AV nodal conductivity and
refractoriness
- Assessment His-Purkinjie system conductivity
and refractoriness
- Assessment of atrial refractoriness
51. Evaluate sinus node function (Evaluate sinus node function (sinus nodesinus node
recovery time, sino-atrial conduction timerecovery time, sino-atrial conduction time))
Evaluate antegrade AV node conductionEvaluate antegrade AV node conduction
((AVNERP, AERP, AV Wenckebach cycleAVNERP, AERP, AV Wenckebach cycle
lengthlength))
Evaluate retrograde AV node conductionEvaluate retrograde AV node conduction
((VAERP, VERP, VA Wenckebach cycleVAERP, VERP, VA Wenckebach cycle
lengthlength))
Standard Conduction System Study
52. Pacing – Incremental Pacing
• Incremental Pacing - is pacing the
heart at a fixed rate. The rate is
increased (pacing interval decreased)
with each set of beats.
S1-S1=400 S1-S1=390 S1-S1=380 S1-S1=370
53. Pacing – Decremental Pacing
• Decremental Pacing – pacing at a
progressively increasing heart rate by
decreasing the amount of time between
each paced beat. Used primarily to induce
or terminate tachycardias. It is also called
“ramp” pacing.
Sns Sns Sns Sns
TACHY.SENSE
S 1 S 1S 1S 1S 1 SnsSnsSns
RAMP
54. Pacing – Extra Stimulus Pacing
For the standard EP
study to test the
refractory periods, one
extrastimulus (S2) will
be used. If a second
extrastimulus is used, it
is usually for arrhythmia
induction and is called
“S3”. Up to 3 (S4)
extrastimuli (S2, S3, S4)
can be given in a
standard EPS. Any
more than 3 extrastimuli
would induce a non-
clinical arrhythmia. That
is, it could induce an
arrhythmia in a normal
subject.
Exrastimulus Pacing
DRIVETRAIN
Sensed S1 S1 S1 S1 S1 S1 S1 S1 S2
Single
extras
55. Standard EP Study Protocol Cont. –
Atrial Pacing
Atrial pacing is performed with the HRA catheter to determine the following:
– AV decremental properties
– AVNERP
– AV Wenckebach cycle length
– AERP
Pacing spike
A wave
56. With Wenckebach there are grouped beats with gradual prolongation of the AH
interval until conduction to the ventricle eventually drops. Therefore only an
occasional “A” wave will not conduct to produce a “V” (see the dropped “V” above).
This occurs as pacing is hitting far into the relative refractory period.
AH Intervals
Dropped beat
Standard EP Study Protocol Cont. –
AV Node Conduction Curve – AV Wenckebach
57. The ERP of the AV node is reached when conduction from the atrium to the
ventricle is blocked due to reaching the refractory period of the AV nodal tissue.
This would be evidenced by an “A” wave after the pacing spike not followed by a
His potential or a “V” wave. AVNERP = 280 - 450 msecs
No His or “V”
Pacing spike
Standard EP Study Protocol Cont. –
AV Node Conduction Curve – AVNERP
A
V
58. The ERP of the atrial tissue is reached when you pace at a rate
faster than the absolute refractory period of the atrial tissue. This
would be evidenced by a pacing spike not followed by an “A”
wave. Consequently there would be no His potential or “V” wave.
Pacing Spike
V
No “A” waves
Standard EP Study Protocol Cont. –
AV Node Conduction Curve – AERP
60. VERP
Pacing “spike”
No local ventricular
electrogram
VERP = 200 - 270 msecs
Standard EP Study Protocol Cont. –
Retrograde Conduction Study – VERP
61. V A V A V A V V A V
No “A” wave
Note that on the 4th and 6th beats no “A” wave follows
the “V” wave. This is called VA block.
Standard EP Study Protocol Cont. –
Retrograde Conduction Study – VA Block
4th 6th
The radiofrequency generator is used to delivery radiofrequency energy from the distal electrode of the ablation catheter through the myocardial tissue and to the ground pad to ablate the arrhythmia. Currently there are essentially two types of temperature sensors used in ablation catheters. One is a thermistor and the other a thermocouple. Some companies like EPT and Osypka make only thermistor ablation catheters, while others like Medtronic make only thermocouple catheters. Yet others like SJM, J&J and IBI make both thermocouple and thermistor ablation catheter lines. However, only SJM has a thermocouple and thermistor in the same catheter. To match these varieties of catheters, there are many generators available and most labs have at least two different generators. The most common are the EPT, Stockert, IBI and Medtronic generators. Each has its own special features, but in general they all can be used with any companies ablation catheters (if the temperature sensor type matches) and all companies make cables to be able to connect their ablation catheter to most generators (there are some exceptions). Some generators are both thermocouple and thermistor capable, but still others are thermistor only (EPT) or thermocouple only (Medtronic). Thus, the right catheter needs to be matched to the right generator with the correct cable.
