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The Electrophysiology Laboratory and Electrophysiologic Procedures
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Figure 6 -34 A, Demonstrated is the 12-lead electrocardiogram (ECG) of
clockwise atrial flut ter. P waves are upright in leads II, III, aVF, and V6 and
are negative in lead V1 (the opposite of that seen in typical counterclockwise
flutter). B, Reentrant circuit is the same as that seen in typical counterclockwise flutter, that is, around the tricuspid annulus, but the direction of
impulse propagation is opposite. Left anterior oblique (LAO) caudal view
electroanatomical map of the right atrium (RA) shows that the impulse
traverses around the cavo -tricuspid isthmus in a clockwise manner. This is
seen in only a minority of cases, and the targeted site of ablation is still
the cavo-tricuspid isthmus.
demonstrated as pacing medial to the RF line. Achievement of conduction block across this structure correlates with long-term success.
Rarely, the ECG pattern may show P-wave polarity opposite to that seen
in typical atrial flutter (Fig. 6-34, A). In this situation, the reentrant
circuit is the same as in typical counterclockwise flutter, that is, around
the tricuspid annulus, but the direction of impulse propagation is
opposite. The LAO caudal view electroanatomical map of the RA (see
Fig. 6-34, B) shows that the impulse traverses around the cavo-tricuspid
isthmus in a clockwise manner. The targeted site of ablation is still the
cavo-tricuspid isthmus. In the era of AF ablation, atrial flutters are seen
where the reentrant circuit is in the LA. A detailed discussion of LA
flutters is beyond the scope of this chapter; at the end of the chapter,
the reader is referred to additional reading on this topic.
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The Electrophysiology Laboratory and Electrophysiologic Procedures 323
Ectopic Atrial Tachycardia
Extensive mapping of the atria is crucial in ablation of ectopic atrial
tachycardia. Initially, mapping used to take place with multipolar catheters, but in the current era, electroanatomical mapping is the norm
(see Fig. 6-7). Activation mapping is performed to localize the region
of earliest atrial activation. If during initial testing the tachycardia
is localized to the LA, mapping is undertaken with a trans-septal
approach via a patent foramen ovale or trans-septal puncture technique. For mapping the left side of the heart, meticulous anticoagulation must be maintained to reduce the risk of procedure-related
embolic events.
Atrioventricular Nodal Reentrant Tachycardia
In AV nodal reentry, the circuit consists of slowly conducting and
rapidly conducting pathways. Anatomically, these pathways are
located in the perinodal interatrial septum and compact AV node,
respectively. The current approach to ablation for AV nodal reentry,
termed AV nodal modification, is selective ablation of the slow pathway.
In rare cases, a fast or intermediate pathway ablation must be performed for successful AV nodal modification.
Mapping of the slow pathway is performed around the inferior
and posterior perinodal area in the posterior septal region of the RA,
extending inferiorly to the os of the coronary sinus. Radiofrequency
energy is delivered along the tricuspid annulus, where low-amplitude
fragmented atrial electrograms are recorded (Fig. 6-35). Radiofrequency energy can be delivered during AVNRT or in sinus rhythm.
Successful ablation is heralded by termination of the tachycardia
when energy is delivered during SVT or by development of accelerated
junctional rhythm when ablating in sinus rhythm.
Complete elimination of the slow pathway results in the inability
to induce AVNRT or show conduction along the slow AV pathway. After
ablation, routine programmed electrical stimulation is repeated to
evaluate for the presence of slow-pathway conduction or inducible AV
nodal reentry. If the slow pathway is not functional in the drug-free
state, infuse isoproterenol to validate noninducibility. Success rates for
AV nodal modification are ≥95%, and the risk of major complication
is estimated to be 1% to 5%. Potential complications include iatrogenic
high-degree AV block, pericarditis, cardiac perforation with tamponade, and vascular complications related to access. The estimated
recurrence rate is 5%.
AV node
Fossa ovalis
Tricuspid valve
Coronary sinus os
His bundle catheter
Ablation catheter
Figure 6-35 Typical catheter position for ablation of the slow pathway for
atrioventricular (AV) nodal reentry tachycardia. The ablation catheter is
positioned on the atrial side of the tricuspid valve in the vicinity of the coronary sinus os. The ablation catheter is inferior and posterior to the His
bundle catheter. (From Haines DE, Di Marco JP: Curr Probl Cardiol 27:409–
477, 1992.)
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PREABLATION POSTABLATION
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The Electrophysiology Laboratory and Electrophysiologic Procedures
Accessory Pathways
The technique used for ablating accessory pathways is different
depending on the location and the conduction properties of the accessory pathways. Before ablation, the patient undergoes a comprehensive EPS to determine presence and electrical properties of accessory
pathways. The pathways that conduct antegrade in sinus rhythm and
exhibit a delta wave (manifest preexcitation) can be mapped during
sinus rhythm. The general location of the accessory pathway can be
identified by the axis of the delta wave on the 12-lead ECG. However,
EPS and mapping are required to localize precisely the site of the
accessory pathway. With a manifest accessory pathway, the mapping
catheter is maneuvered slowly along the valve annulus to locate
optimal electrode placement that will result in the earliest ventricular
activation during sinus rhythm or atrial pacing (Fig. 6-36). Discrete
electrical potentials from the accessory pathway have often been
recorded at the successful ablation site and are referred to as
way potentials. For pathways capable only of retrograde conduction,
mapping is performed by determining the site of earliest retrograde
atrial activity during ventricular pacing or induced orthodromic reciprocating tachycardia. Accessory pathways on the left side of the heart
can be ablated by a trans-septal approach using a patent foramen ovale, the Brockenbrough technique (Fig. 6-37), or the more
path-
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Figure 6- 36 Sequence of antegrade ventricular activation before and after
radiofrequency ablation of a left-sided accessory pathway. Displayed are
surface leads I, aVF, and V1. The earliest ventricular activation during sinus
rhythm occurs in the midcoronary sinus (CS2 to CS3) region. Electrograms
recorded from the ablating catheter at the successful ablation site radiofre quency (RF) show early ventricular activation and a short A-to-V interval.
Shown at postablation is a normal sequence of antegrade activation. Note
lengthening of the A-to-V interval in the coronary sinus electrograms and
the electrogram recorded from the ablation catheter. CS1 to CS5, Recordings
from the coronary sinus, with CS1 the most-proximal coronary sinus recording and CS5 the most distal; HBE, His bundle electrogram; HRA, high right
atrial electrogram; RVA, right ventricular apex electrogram.
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The Electrophysiology Laboratory and Electrophysiologic Procedures 325
conventional retrograde approach, in which the ablating catheter is
prolapsed across the aortic valve (Fig. 6-38).
The overall success of radiofrequency ablation for accessory
pathways depends on operator experience and location of the accessory pathway. Success rates of more than 95% are reported for leftsided pathways. Right-sided pathways are usually reported to be less
successful, with efficacy rates of more than 90%. The complication rate
for accessory pathway ablation is estimated to be 1% to 2%, and most
complications result from catheter manipulation and not from delivery
of radiofrequency energy. Complications include iatrogenic highdegree AV block (most commonly seen with anteroseptal accessory
Accessory
pathway
Trans-septal ablation
mapping catheter
Coronary sinus os
Figure 6-37
a trans-septal approach. The catheter is passed through a sheath that has
been placed through the atrial septum and then positioned above the mitral
valve annulus in close proximity to the accessory pathway located near the
coronary sinus catheter. (From Haines DE, Di Marco JP: Curr Probl Cardiol
27:409–477, 1992.)
Accessory pathway
Retrograde LV
ablation catheter
Coronary sinus
mapping catheter
catheter
Coronary sinus
Catheter position for ablation of a left free wall pathway using
Coronary sinus os
Figure 6- 38 Catheter position for ablation of left free wall accessory
pathway via the retrograde approach. The ablation catheter is prolapsed
across the aor tic valve and positioned under the mitral valve leaflet, in close
proximity to the accessory pathway located near the coronary sinus catheter. LV, Left ventricular. (From Haines DE, Di Marco JP: Curr Probl Cardiol
27:409–477, 1992.)
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The Electrophysiology Laboratory and Electrophysiologic Procedures
pathway ablations), pericarditis, cardiac perforation with tamponade,
and vascular complications related to access associated with radiofrequency ablation of accessory pathways. Mortality is rare but has
been reported to be approximately 0.3%. Complications, including
procedure-related deaths, are higher in low-volume laboratories (<20
ablations/yr) than in high-volume laboratories (>50 ablations/yr). The
estimated recurrence rate after ablation for an accessory pathway is
3% to 17%; the higher recurrence rates are seen with right-sided accessory pathways. Patients who remain asymptomatic for 3 months after
the procedure have an extremely low incidence of recurrence
thereafter.
Ventricular Tachycardia
Several mapping techniques are used to target radiofrequency application during treatment for VT. These techniques usually are used in
combination to locate the optimal site of energy delivery. They can be
used for idiopathic VTs (the most common being RV outflow tract
tachycardia) or VTs associated with coronary artery disease. Initially,
a gross estimation of tachycardia origin can be made from the 12-lead
ECG of VT. This estimate helps to direct mapping efforts to the RV or
LV and to specific regions within the appropriate ventricle.
During activation mapping, the mapping catheter is maneuvered
to an endocardial location that shows the earliest activation time
in tachycardia (Fig. 6-39). The presence of mid-diastolic potentials
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Figure 6- 39
tachycardia (V T) morphologies. A, VT with a right bundle-branch morphology
and right superior axis. A reference right ventricular (RV) catheter is shown
along with multiple ventricular recordings. The earliest ventricular activation
is recorded at LV2, which corresponds with the RV apex. B, VT with a left
bundle -branch block (LBBB) pattern in right inferior axis. The earliest ventricular activation occurs near LV3, which corresponds to the high-septal
area. T, Time line. (From Josephson ME: Clinical cardiac electrophysiology:
techniques and interpretations, Philadelphia, 1993, Lea & Febiger.)
Endocardial catheter mapping of two different ventricular
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The Electrophysiology Laboratory and Electrophysiologic Procedures 327
identifies optimal ablation sites. Pace mapping, in which pacing from
the ablation catheter duplicates the QRS morphology of the clinical
VT, is also used to identify the appropriate site for ablation energy
application. After ablation, ventricular stimulation is undertaken again
to ensure that the tachycardia is no longer inducible. Ablation of idiopathic VT seems to have a higher success rate (~85%) than ablation of
VT associated with coronary artery disease (~60%). A survey by the
North American Society of Pacing and Electrophysiology reported a
low complication rate and mortality associated with radiofrequency
catheter ablation, despite its use in a relatively high-risk patient population. VT associated with ischemic heart disease is an extremely variable entity and must be assessed on an individual basis.
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The Electrophysiology Laboratory and Electrophysiologic Procedures
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Special Techniques
PAUL SORAJJA • CARLOS E. RUIZ •
CHAD KLIGER • MORTON J. KERN
Trans-Septal Heart Catheterization
Trans-septal heart catheterization is used for direct access to the left
atrium (LA) and its associated structures (e.g., LA appendage and
pulmonary veins) and antegrade approaches for the left ventricle (LV)
and mitral valve. In the majority of patients, hemodynamic assessment
of the left-sided chambers can be performed with antegrade rightheart catheterization (i.e., pulmonary capillary wedge measurement)
and retrograde aortic catheterization for LV pressure. However,
optimal hemodynamic assessment of the left-sided chambers requires
trans-septal catheterization in important subsets of patients (e.g., those
with mitral stenosis or obstructive hypertrophic cardiomyopathy).
New percutaneous therapies for structural heart interventions also
require operator expertise in the techniques of trans-septal heart
catheterization.
Indications
The indications for trans-septal heart catheterization are:
1. Direct hemodynamic assessment of the LA and LV for patients
in whom such data cannot be obtained using retrograde aortic
techniques, antegrade right-heart catheterization, or noninvasive
imaging evaluations
2. Access for percutaneous, structural heart interventional thera-
pies. These therapies include balloon mitral valvuloplasty, atrial
septal defect closure, LA appendage closure, transcatheter mitral
valve repair (e.g., MitraClip, Abbott Vascular), mitral valve-invalve therapy, and treatment of mitral paravalvular prosthetic
regurgitation
Contraindications
The contraindications for trans-septal heart catheterization are:
1. Patient cannot lie supine
2. LA or right atrial (RA) thrombus
3. Atrial myxoma
4. Absence of right femoral venous access to the RA due to masses,
thrombus, or other causes of obstruction
Consider trans-septal left-sided heart catheterization carefully for
patients with distorted cardiac anatomy resulting from congenital
heart disease, dilated aortic root, marked atrial enlargement, or thoracic skeletal deformity. As an alternative approach, trans-septal heart
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Special Techniques
catheterization using right internal jugular access has been performed
in select cases.
Technique
Equipment
Figure 7-1 shows the trans-septal sheath with a cur ved dilator and a
long hollow needle that are used to cross the atrial septum. The transseptal sheath frequently is 7 or 8 F, often with a side arm that facilitates
hemodynamic assessment of multiple sites with a single trans-septal
access (e.g., end-hole measurement for LV; side-arm port for LA pressure). The curved dilator and trans-septal sheath assembly accepts a
0.032-inch guidewire that is passed from the femoral vein into the
superior vena cava (SVC). The modified trans-septal needle has a
21-gauge needle tip to reduce hazard from accidental puncture of the
aorta or atrial wall. Several different shapes and sizes of the transseptal needle curve are available, with the appropriate selection
E
2 cm
70 cm 69.5 cm 71 cm
4 cm
A B C
Figure 7-1 For inser tion of the curved trans-septal catheter (A) from the
femoral vein into the right atrium (RA), the straight stylet (B) is used. The
modified trans-septal needle (C) has a 21-gauge needle tip to reduce hazard
from accidental puncture of the aorta or atrial wall, and the catheter (E)
has side holes (to enhance injection of contrast medium) and a tapered tip
to facilitate entry into the femoral vein and traversal of the atrial septum.
D, Detail of trans-septal needle tip. (From Ross J Jr: Transseptal lef t heart
catheterization a 50-year odyssey. J Am Coll Cardiol 51:2107–2115, 2008.)
D
1.5 cm
.5 cm
10°
20-Gauge tubing
18-Gauge tubing
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Dilator
Sheath
Sheath
Dilator
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Special Techniques 331
Needle
A
B
Figure 7-2
between the trans -septal needle and dilator hub (arrow) so that the needle
lies just inside the dilator. B, Frames of left ventricular (LV) cineangiogram
using trans-septal sheath and Berman catheter in LV. Left, Systolic frame;
right, diastolic frame. Note ring of prosthetic aortic valve. (A, From Weiner
RI, Maranhao V: Development and application of transseptal lef t heart
catheterization. Cathet Cardiovasc Diagn 15:112–120, 1988.)
depending on the patient’s specific anatomy (Fig. 7-2). The trans-septal
needle system is gently curved and attached to a pressure transducer
with a rotating adapter for free movement of the long needle as it
travels in the venous system through the catheter and for its manipulation toward the atrial septum.
A, Trans-septal catheter assembly. Noted is the distance
Procedural Steps
Trans-septal catheterization can be performed using fluoroscopy
alone, although adjunctive imaging with either transesophageal or
intracardiac echocardiography has been increasingly used to facilitate safety and accuracy of the puncture site. Such accuracy is mandated for certain interventional procedures (e.g., MitraClip) and can
increase the success of other percutaneous therapies (e.g., posterior
puncture for medial paravalvular defect closure). Fusion imaging with
overlay from computed tomography (CT) also has been described for
trans-septal catheterization (see Fusion Imaging to Facilitate Cardiac
Catheterization later). The following steps describe the procedure
when relying on fluoroscopy alone, with additional comments for
incorporating adjunctive echocardiography.
1. The trans-septal catheter must be measured against the transseptal needle to identify the position at which the needle extends
outside of the catheter (Fig. 7-3). This measurement is done on the
back table before inserting the catheter-needle assembly into the
patient. The operator places the catheter over the needle, notes at
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