Electrophysiology: The Basics: A Companion Guide for the Cardiology Fellow during the EP Rotation

248 Pages·2009·7.92 MB·English

by  Jonathan S. Steinberg MD

Electrophysiology:
The Basics
A Companion Guide for the Cardiology
Fellow during the EP Rotation
Jonathan S. Steinberg, MD
Chief, Division of Cardiology
Al-Sabah Endowed Director of the Arrhythmia Institute
St. Luke’s and Roosevelt Hospitals
Professor of Medicine
Columbia University College of Physicians and Surgeons
New York, New York
Suneet Mittal, MD
Director, Electrophysiology Laboratory
St. Luke’s and Roosevelt Hospitals
Associate Professor of Medicine
Columbia University College of Physicians and Surgeons
New York, New York
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Library of Congress Cataloging-in-Publication Data
Introductory guide to electrophysiology / [edited by] Jonathan S. Steinberg, Suneet Mittal.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978–1–60547–343–7
ISBN-10: 1–60547–343–X
1. Arrhythmia. 2. Heart—Electric properties. 3. Electrophysiology. I. Steinberg, Jonathan S.
II. Mittal, Suneet.
[DNLM: 1. Electrophysiologic Techniques, Cardiac—methods. WG 141.5.F9 I613 2010]
RC685.A65I593 2010
616.1'280645—dc22
2009025944
________________________________________________________________________
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To Alice, Rachel and Josh, for their support and encouragement.
JSS
To my wife Deepti and daughters Sonia and Priya for their
patience and support.
SM
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CONTRIBUTORS
Aysha Arshad, MD David J. Callans, MD
Director, ECG Laboratory and Professor
Attending Physician Department of Medicine
Al-Sabah Arrhythmia Institute University of Pennsylvania
St. Luke's and Roosevelt Hospitals Associate Director of Electrophysiology
Assistant Professor of Medicine University of Pennsylvania Health System
Columbia University College of Department of Medicine
Physicians and Surgeons Hospital of the University of Pennsylvania
New York, New York Electrophysiology, Founders 9129
Philadelphia, Pennsylvania
Nitish Badhwar, MBBS
Aman Chugh, MD
Assistant Professor of Medicine
Department of Cardiac Electrophysiology Assistant Professor
University of California Department of Internal Medicine—
San Francisco, California Electrophysiology
University of Michigan
Deepak Bhakta, MD Ann Arbor, Michigan
Assistant Professor of Clinical Medicine
Andrea Corrado, MD
Department of Medicine
Indiana University School of Medicine Cardiovascular Department
Staff Cardiac Electrophysiologist Dell’Angelo Hospital
Clarian Health System Via Pallagnella
Krannert Institute of Cardiology Mestre, Venezia, Italy
Indianapolis, Indiana
Iwona Cygankiewicz, MD, PhD
Noel G. Boyle, MD, PhD
Visiting Assistant Professor
Professor of Medicine Heart Research Follow-up Program
Director, EP Labs Cardiology Division
UCLA Cardiac Arrhythmia Center University of Rochester Medical Center
David Geffen School of Medicine at UCLA Rochester, New York
Los Angeles, California Associate Professor in Medicine
Department of Electrocardiology
Eric Buch, MD Medical University of Lodz, Poland
Director, Specialized Program for Atrial
Marc Dubuc, MD
Fibrillation
UCLA Cardiac Arrhythmia Center Associate Professor of Medicine
David Geffen School of Medicine Université de Montréal
at UCLA Montreal Heart Institute
Los Angeles, California Quebec, Canada
iv
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CONTRIBUTORS v
Katia Dyrda, MD, MSc, PEng Paul Khairy, MD, PhD
Electrophysiology Fellow Associate Professor of Medicine
Montreal Heart Institute Université de Montréal
Université de Montréal Montreal Heart Institute
Quebec, Canada Quebec, Canada
Kenneth Ellenbogen, MD George J. Klein, MD
Kontos Professor of Medicine Professor
Vice Chair, Division of Cardiology Division of Cardiology
Director, Cardiac Electrophysiology University of Western Ontario
Department of Internal Medicine Cardiologist
Virginia Commonwealth University London Health Sciences Center
Richmond, Virginia London, Ontario, Canada
Andrew D. Krahn, MD
Gianni Gasparini, MD
Professor
Cardiovascular Department
Division of Cardiology
Dell’Angelo Hospital
University of Western Ontario
Via Pallagnella
Cardiologist
Mestre, Venezia, Italy
London Health Sciences Center
London, Ontario, Canada
Peter G. Guerra, MD
Assistant Professor of Clinical Medicine Shuaib Latif, MD
Université de Montréal
Electrophysiology Fellow
Head of Clinical Electrophysiology
Hospital of the University of Pennsylvania
Montreal Heart Institute
Philadelphia, Pennsylvania
Quebec, Canada
Ken W. Lee, MD
Lorne J. Gula, MD, MS
Electrophysiologist
Professor Department of Cardiac
Division of Cardiology Electrophysiology
University of Western Ontario Mt Carmel Columbus Cardiology
Cardiologist Consultants
London Health Sciences Center Mt Carmel Hospital and Clinics
London, Ontario, Canada Columbus, Ohio
Gautham Kalahasty, MD Charles J. Love, MD
Assistant Professor of Medicine Professor of Medicine
Department of Internal Medicine Director, Cardiac Rhythm Device Services
Virginia Commonwealth University Division of Cardiovascular Medicine
Staff Physician Department of The Ohio State University
Medicine President, International Board of Heart
Medical College of Virginia Hospitals of Rhythm Examiners, Inc.
Virginia Commonwealth University (Formerly NASPExAM, Inc.)
Richmond, Virginia Columbus, Ohio
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vi CONTRIBUTORS
Laurent Macle, MD Antonio Raviele, MD
Associate Professor of Clinical Chief Cardiovascular Department
Medicine Dell’Angelo Hospital
Université de Montréal Via Pallagnella
Montreal Heart Institute Mestre, Venezia, Italy
Quebec, Canada
Denis Roy, MD
Jaimie Manlucu, MD
Professor and Executive Vice-Dean
Cardiology Fellow of Medicine
Division of Cardiology Université de Montréal
University of Western Ontario Montreal Heart Institute
London Health Sciences Center Quebec, Canada
London, Ontario, Canada
Melvin M. Scheinman, MD
John M. Miller, MD
Professor of Medicine
Professor of Medicine Department of Cardiac Electrophysiology
Department of Medicine University of California
Indiana University School of Medicine San Francisco, California
Director, Clinical Cardiac
John A. Scherschel, MD
Electrophysiology
Clarian Health System Senior Fellow in Electrophysiology
Krannert Institute of Cardiology Department of Medicine
Indianapolis, Indiana Indiana University School of Medicine
Senior Cardiac Electrophysiology
Suneet Mittal, MD Fellow
Director, Electrophysiology Clarian Health System
Laboratory Krannert Institute of Cardiology
St. Luke’s and Roosevelt Hospitals Indianapolis, Indiana
Associate Professor of Medicine
Kalyanam Shivkumar, MD, PhD
Columbia University College
of Physicians and Surgeons Professor of Medicine and Radiology
New York, New York Director, UCLA Cardiac Arrhythmia
Center
Fred Morady, MD David Geffen School of Medicine
Professor of Internal Medicine at UCLA
Department of Internal Medicine – Los Angeles, California
Electrophysiology
Tina Sichrovsky, MD
University of Michigan Ann Arbor,
Michigan Attending Physician
Al-Sabah Arrhythmia Institute
Stanley Nattel, MD St. Luke’s and Roosevelt Hospitals
Professor of Medicine Assistant Professor of Medicine
Université de Montréal Columbia University College
Head of Electrophysiology Research of Physicians and Surgeons
Montreal Heart Institute New York, New York
Quebec, Canada
Allan C. Skanes, MD
Mark W. Preminger, MD, FACC
Professor
Director, Implantable Device Section Division of Cardiology
Al-Sabah Arrhythmia Institute University of Western Ontario
Division of Cardiology Cardiologist
St. Luke’s and Roosevelt Hospitals London Health Sciences Center
New York, New York London, Ontario, Canada
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CONTRIBUTORS vii
Jonathan S. Steinberg, MD Raymond Yee, MD
Chief, Division of Cardiology Professor
Al-Sabah Endowed Director Division of Cardiology
of Arrhythmia Institute University of Western Ontario
St. Luke’s and Roosevelt Hospitals Cardiologist
Professor of Medicine London Health Sciences Center
Columbia University College London, Ontario, Canada
of Physicians and Surgeons
Wojciech Zareba, MD, PhD
New York, New York
Professor of Medicine (Cardiology)
Mario Talajic, MD Director, Heart Research Follow-up
Professor and Chair of Medicine Program
Université de Montréal Cardiology Division
Montreal Heart Institute University of Rochester Medical Center
Quebec, Canada Rochester, New York
Bernard Thibault, MD
Associate Professor of Clinical
Medicine
Université de Montréal
Montreal Heart Institute
Quebec, Canada
Anil V. Yadav, MD
Assistant Professor of Clinical Medicine
Department of Medicine
Indiana University School of Medicine
Staff Cardiac Electrophysiologist
Clarian Health System
Krannert Institute of Cardiology
Indianapolis, Indiana
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PREFACE
C ardiac electrophysiology has emerged as a highly specialized and complex seg-
ment of cardiovascular care, such that it requires additional focused training,
often extending 2 years beyond traditional cardiology fellowship. The reasons
for this are multiple and include a need to develop an ability to interpret complex elec-
trophysiologic patterns, master the technical skills necessary for device implantation and
catheter ablation, and incorporate a vast array of indications for treatment of a variety
of arrhythmic conditions. This substantial knowledge base and skill set can become an
intimidating barrier to acquisition of the more modest goals of the cardiology fellow, a
basic understanding of arrhythmic mechanisms and clinical presentations, comfort of
knowing which patient to refer or not refer for arrhythmia procedures and why, and an
ability to interpret and weigh the recommendations of electrophysiology specialists. This
is further compounded by the fact that the current training guidelines in the United
States require only 2 months of electrophysiology experience, far too little to reach even
modest training goals. In addition, the classic textbooks in electrophysiology are far too
dense and complex for the noninitiated or for those interested only in a nonelectro-
physiology career. Hence, we have designed a textbook specifi cally for the cardiology
fellow faced with these predicaments, deliberately providing material appropriate for the
trainee who will pursue a career in general cardiology or one of the nonelectrophysiology
cardiology specialties. The topics mirror offi cial training requirements and the text is
written for a very well defi ned target audience who will have to advance through certifi -
cation e xaminations. The book is meant to be read and its material mastered during the
rotations undertaken by cardiology trainees, or for other interested professionals. The
contributors are universally recognized for expertise in their subject matter and have
enthusiastically joined in an effort to educate future cardiologists.
Jonathan S. Steinberg, MD
Suneet Mittal, MD
viii
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CONTENTS
Contributors iv
Preface viii
SECTION I EVALUATION AND MANAGEMENT
1 Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Andrea Corrado, Gianni Gasparini, and Antonio Raviele
2 Supraventricular Tachycardia: AVNRT, AVRT . . . . . . . . . . . . . . . . . . . . . . . . . 10
Nitish Badhwar, Ken W. Lee, and Melvin M. Scheinman
3 Atrial Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Jonathan S. Steinberg, Aysha Arshad, and Tina Sichrovsky
4 Ventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Shuaib Latif and David J. Callans
5 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Suneet Mittal
6 Sudden Cardiac Death and the Cardiac Arrest Survivor . . . . . . . . . . . . . . . . . . 82
Jaimie Manlucu, Raymond Yee, Lorne J. Gula, George J. Klein, Allan C. Skanes, and Andrew D. Krahn
SECTION II THE ELECTROPHYSIOLOGY LABORATORY
7 Electrophysiology Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Mark W. Preminger
8 Electrophysiologic Testing: Indications and Limitations. . . . . . . . . . . . . . . . . 109
Aman Chugh and Fred Morady
9 Principles of Mapping and Ablation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Eric Buch, Noel G. Boyle, and Kalyanam Shivkumar
10 Indications for Cardiac Rhythm Management Devices. . . . . . . . . . . . . . . . . . 137
Gautham Kalahasty and Kenneth Ellenbogen
11 Miscellaneous Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Aysha Arshad and Suneet Mittal
SECTION III THE PACEMAKER AND DEFIBRILLATOR CLINIC
12 Device Interrogations and Utilization of Diagnostic Data . . . . . . . . . . . . . . . 169
Charles J. Love
ix
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x CONTENTS
SECTION IV MISCELLANEOUS TOPICS
13 Approach to the Patient with Wide Complex Tachycardia . . . . . . . . . . . . . . . 186
John M. Miller, Deepak Bhakta, John A. Scherschel, and Anil V. Yadav
14 Antiarrhythmic Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Katia Dyrda, Paul Khairy, Stanley Nattel, Mario Talajic, Peter G. Guerra,
Bernard Thibault, Marc Dubuc, Laurent Macle, and Denis Roy
15 Channelopathies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Iwona Cygankiewicz and Wojciech Zareba
Index 225
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