Dear EP Managers & Staff,
I hope your summer has gone well. With muchexcitement Sue Steadman, RN, MSN will be as-sisting with the creation and development of oureducational programs, including monthly EP eRe-ports. In the near future these will include freeCEU’s.
This newsletter will begin a collection of classesthat vary between basic (or review) and advancedto improve your understanding of and efficiencywith EP. We hope to make them monthly. Ourbest to you and your EP mates.
Excitedly,Steve Miller, RN & The Staff at EPreward
The Foundation of Electrophysiology
Once you have made the decision to become amember of the electrophysiology team, you willneed to know where to start. There is an overabundance of knowledge to gain and manybooks to read. This task alone can create feel-ings of exuberance and at time sensations offear. You may feel overwhelmed while question-ing your decision to work in the EP lab. If youare fortunate enough to have a mentor, then youare one lucky soul. Go to the Blaufuss.org web-site for an interactive video of the hearts electri-cal system (SVT) and click on the sections as wemention them as well as exploring the otherrhythms (you may need to follow the prompts todownload Adobe Shockwave to see the video).
Understanding the basics is the best approach.The initial phase of conduction within the heartbegins in the high right atrium with normal SAnode impulses going from the right to left atrium,then from the atrial chambers through the AVNode and HIS purkinje system to the ventricles.
Learn to correlate the anatomical progression ofelectrical impulses within the heart, with the pat-tern on the surface ECG as well as the Intercar-diac Electrograms (IEGM). Start with the normalheart, then progress to the areas of abnormality.Refer to: (Blaufuss–NSR 12 lead, click on ViewAnimation at the bottom right).
Superior & Anterior View
The Sino Atrial Node is located in the posteriorsection of the right atrium at the junction of thesuperior vena cava and the high right atrium.(Click on the Blaufuss Sinus Rhythm). The im-pulse initiated here spreads out to both atria viathe anterior internodal track, known as Bach-man’s Bundle. This is located at the internodal septum which connects the SA node to leftatrium. (There are two more internodal trackscalled the Middle, or Wenckebach’s, and the Posterior internodal track, called Thorel’s (Lessig, M. L., Lessig, P.M. (1998). Alspach,1998, p.147). There is an additional accessorypathway called Kent’s accessory pathway. Thispathway affects patients with Wolf Parkinson’s White Syndrome (WPW, click on WPW onBlaufuss) which will be discussed in the future.
Conduction continues through the both atriadown to the AV node. The AV disc, which iscomposed of non-conducting fibrous tissue, elec-trically separates the atria from the ventricles.The AV Node is the natural opening through theAV disc. The proximal portion of the AV node islocated “superior and anterior to the coronary sinus ostium.” The distal portion is connected to the HIS Bundle (Cohen, T.J. 2009, p. 21). Thepurpose of the AV node is to slow the conductionfrom the atrium, thus, being a gatekeeper. Thisslowing of the impulse allows for the ejection ofblood out of out of the right and left atrium andinto the ventricles. Conduction then branchesdown to the Bundle of His and continues to theleft and right bundle. The Bundle of His runsdown to the Purkinje fibers which propagate ven-tricular conduction.
Inferior and Anterior View
Anatomically, “the Bundle of His runs through the” subendocardial tissue, “down the right side of the interventricular septum.” The Bundle of HIS divides into Left and Rignt BundleBranches.” These branches then divide further into the Left Posterior and anerterior fascicle.The Right Bundle Branch divides into laterial an-terior and posterior fascicles.”The Right Bundle Branch runs to the right side of the interventricu-lar septum toward the right apex.” (Davie, The-lan, Urden, 1992,p.114).
One important point to remember, when the phy-sician is ablating near the AV node, one of yourprimary functions as an EP nurse or Tech is toassist, observe, and alert the physician when thepatient develops any form of block. If you ablatetoo much, you may end up buying a pacemakerfor the patient.
(Blaufuss, view other rhythms as well).
Now let’s take this information into the EP lab and look at the catheters used along with thesurface and intracardiac Electrograms that arestudied.
Catheters & Placement: The types of cathetersused by Electrophysiologists vary greatly accord-ing to their training, experience, and needs. AHRA and RV catheter will commonly have 4 poles(Quadrapoloar or Quad with a tip and threebands). The Bundle of HIS (HIS) catheter will of-ten have six poles, also referred to as a Hex. ADecapolar, or catheter with 10 electric poles, isoften used for the coronary sinus. There aremany times during specific procedures that a duo-deca- polar catheter, (20- poles) will be used forthe coronary sinus. There are several companieswho make these curved catheters.
Here are two examples of fixed curve cathetersused in the EP lab. They are the Josephson andthe Cournand. These catheters are named respec-tively by their inventors and are used for the waythe curve sits inside the heart. A Josephson isusually a quad catheter and is used in the RightAtrium and in the Right Ventricle. The Cournandcatheter is frequently chosen for the AV Node &HIS location. This catheter has two specificcurves, a CRD and CRD-2.
The Decapolar and Duo-Deca Catheter are com-monly known as Coronary Sinus (CS) cathetersbut can be used to map atrial or ventricular con-duction as well. These catheters can reach aroundposteriorly to the left side of the atrium as they areguided within the great cardiac vein. Many cathe-ters have distal ends which are deflectable orsteerable, assisting the physician with placementin specific parts of the heart.
Baseline Measurements: These are performedif or when the patient is in sinus rhythm, beforethe procedure and after the ablation process.Each physician will have their protocols and willgive you an idea of what they want you to dowhen you are recording on your specific system.Some physicians’ will want you to also do some measurements on the patient when they are inatrial fibrillation or atrial flutter. (Blaufuss AtrialFlutter)
Below is an image of the locations of the threebasic catheters: High Right Atrium, HIS Bundleand Right Ventricle.
Intracardiac Electrograms: Start with the basiccycle length (BCL) measurements of the A-A, P-R, P-A, A-H, H-V, V-V, QRS, AND Q-T. We en-courage you to obtain a screen printout of yourpatients to practice measurements. Be sure tocut off any patient related information.
The A-A measurements start with High RightAtrium (HRA) catheter. The atrial (A) contractionis in conjunction of the P wave. The Atrial IEGMmay line up before the surface P wave in manypatients due to the fact that the catheter is meas-uring directly from the heart; whereas, the exter-nal ECG measures the conduction from a distantpoint of view, through skin and other tissue, thus,a delayed deflection will show on your screen.
Now measure the PA interval. The normal rangeis 24- 55 ms. The A spike represents depolari-zation of the tissue in the low right atrium as theconduction is entering the AV node The AV nodehas a slow conduction, therefore you may notsee a deflection on the screen. You will see adeflection when the impulse leaves the AV nodeto the HIS Bundle. This will be represented bythe H spike. The deflection from the beginning ofthe A to the H is called the AH interval. Thisrepresents the conduction time through the AVnode. A normal conduction time is 50 or (60) -120 ms. the interval from the beginning of the Hto the V spike represents conduction timethrough the Purkinje fibers. Normal conduction isroughly 35-55 ms.
Each measurement is started at the beginningof the electrical deflection as it leaves the base-line and measured until that deflection goesback to the baseline.
The V-V measures the ventricle conductiontime. Specific catheters are used in areas of theheart to collect the electrical activity. A quad-rapolar, or Josephson, catheter is used in theHigh Right Atrium (HRA). This means 4 electri-cal poles or points are noted on the catheter.They collect electrical data from each pole. Asecond catheter with 4 electrical poles can alsobe positioned in the Right Ventricle. This meas-ures the Right ventricular conduction (RVA).
Not all patients will have the same electrical footprint. However, this is a good start. This was acondensed review of the very basics that willhelp you to understand what is being done inthe EP Lab during a typical procedure. In thefuture we will go over stimulation and testing,ablations and mix in more advanced matters.
Susan B. Steadman, MSN, RN. Please send usyour suggestions for future topics and learningactivities. Thank you and have a good end toyour summer.
EPreward Serving the Heart of Cardiologywww.epreward.com 877-663-8686 EP eReport Vol # 12
SELL YOUR UNUSED EP CATHETERSAND EQUIPMENT
We sell your unused catheters &equipment to other labs.
EP Catheters, Sheaths andTransseptal Supplies
as well as Ablation Generators,Stimulators, Recording Systems.
Visit us to purchase new supplies at50% to 70% below the Mfg. price.
Medical Materials, or call 877-663-8686.
DON’T Cut Your TipsSell Your Used Ultrasound& Diagnostic EP Catheters
For diagnostic catheters that are not re-processed, Catheter Buy Back will pay youmore for the whole catheter than the tip.
Base Pricing:AcuNav & SoundStar = $60 ea (NO tip value)Fixed Curve = $8 eaSteerable = $14 eaLoop, Halo, Lasso, DuoDeca = $18 ea
Contact us for more information or call 877-663-8686.
UPCOMING CLASSES & CONFERENCES
An Abundance of September Classes
The California Heart Rhythm Symposium: La Jolla, CA.9/1/11
Arrhythmias in the Real World 2011: Paris, France 9/8/11Electrophysiology Innovations Congress 2011: Wash. DC.
9/9/112011 Catheter Ablation Course: Chicago, IL. 9/10/1119th Annual State-of-the-Art Arrhythmia Symposium:
Philadelphia, PA. 9/12/11Introduction to Cardiac Electrophysiology: Brisbane, QLD
Australia. 9/13/11.Vocational Graduate Diploma of Cardiac Electrophysiol-
ogy: Brisbane, Australia. 9/14/11EP in Aspen 2011: Aspen, CO. 9/15/1115th Annual Understanding and Managing Pacemakers,
ICDs, and CRT for the Allied Professional Minneapolis,MN. 9/16/11.
South Atlantic Society for Electrophysiology for AlliedProfessionals Workshop: My rtle Beach, SC. 9/16/11.
2nd Annual Northeast Lead Management Symposium:Boston, MA. 9/17/11.
4th Asia Pacific Heart Rhythm Society Scientific Session(APHRS 2011) : Fukuoka, Japan. 9/21/11.
15th Annual Scientific Meeting of the Heart Failure Soci-ety: Chicago, IL. 9/21/11.
Board Review Course in Cardiac Electrophysiology andABIM CCEP Recertification Prep Course: Chicago, IL.9/21/11.
21st Annual Controversies in Cardiac Arrhythmias: Wash-ington, DC. 9/23/11.
EP and Device Therapy for Allied Professionals: ApplyingKnowledge to Clinical Practice Beyond the Basics: NewHav en, CT. 9/24/11
October Classes
Heart Rhythm Congress 2011: Birmingham, England.10/2/11. EPreward will be here. Contact us about dinner.
Venice Arrhythmias 2011: Venice, Italy. 10/12/11.6th Annual International Symposium on Ventricular Ar-
rhythmias: Pathophysiology and Therapy: Philadelphia,PA. 10/21/11.
Guthrie.org
Normal’s vary from source to source.
Purchase new EP catheters at50%to 70%below the MSRP
from Medical Materials.
Manufacturers includeBard, Biosense Webster, Boston Scientific
and St. Jude Medical.
Contact us at 877-0663-8686 or go towww.medicalmaterials.com
to receive our available inventory.
Quad to HRA andSinus Node
Quad to RV
Hex HIS
SA node
Post Article Test:Questions:
1. Which type of catheter would be inserted into the Right Atrium and ventricle for an EP study?2. How many electrical poles does a Duo-Deca Catheter have on its end?3. What electrical conduction problem would the Kent Bundle cause?4. Where does Bachman’s Bundle travel to and from?5. What is the Middle intermodal electrical track called?6. What catherter is commonly placed near the HIS bundle during an EP procedure?
Answers:1. Josephson2. 203. WPW4. Anterior nodal track from right atrium to left atrium.5. Wenckebach’s6. Cournard
