wpwepevaluation-,,,,,,,,,,,211107143718.pptx

wpwepevaluation-211107143718.pptx

1. EL E C T R OPH Y SIO L OGICAL EVALUATION OF WPW SYNDROME -DR. ROHIT WALSE SENIOR RESIDENT DM CARDIOLOGY SCTIMST

2. SCOPE OF DISCUSSION HISTORY TYPES OF BYPASS TRACTS BASELINE STUDY PACING MANEUVERS T A C H Y CA R DI A S T U D Y POST ABLATION MANEUVERS

3. HI S T O R Y The earliest description of an accessary pathway was reported by Stanley Kent in 1893 who suggested that impulses can travel from A to V over a node like structure other than AV node. Cohn & Fraser reported the first case of pre excitation syndrome in 1913.

4. In 1930, Louis Wolff , Sir John Parkinson and Paul Dudley White published a seminal article describing 11 young patients who suffered from attacks of tachycardia associated with an ECG pattern of bundle branch block with a short PR interval.

5. SUDDEN DEATH IN WPW SYNDROME The incidence of SCD – 0.15% to 0.39% Sudden death in WPW syndrome is related to the degeneration of atrial fibrillation with high ventricular rates into ventricular fibrillation . It is unusual for cardiac arrest to be the first symptomatic manifestation of WPW syndrome

6. TYPES OF BYPASS TRACTS AtrioVentricular bypass tracts AtrioNodal bypass tracts AtrioHisian bypass tracts Atypical bypass tracts

7. LOCATIONS OF AV BYPASS TRACTS LAO VIEW

8. DISTRIBUTION OF BYPASS TRACTS Left free wall- 46-60% Posteroseptal- 25% Right free wall – 13-21% Right superoseptal -7% Midseptum <5%

9. WPW PATTERN WPW SYNDROME ECG abnormalities related to presence of AV bypass tract [ Ventricular preexcitation : short PR, delta wave, wide QRS complex] Ventricular pre excitation + documented tachyarrhythmia /symptoms of tachyarrhythmia

10. EPIDEMIOLOGY Prevalence of WPW pattern- 0.1-0.3 % [M>F] Annual risk of developing SVT- 0.25 % Familial WPW- PRKAG2; BMP2 gene

11. GOALS OF ELECTROPHYSIOLOGICAL EVALUATION Confirm the presence of bypass tract Localization of BT Evaluation of refractoriness of BT Induction & evaluation of tachycardia Demonstration of BT role in tachycardia Termination of tachycardia

12. CATHETER PLACEMENT

13. ALL CATHETERS IN

14. BASAL INTERVALS

15. BASELINE OBSERVATIONS DURING SR Short HV interval/Negative HV QRS- fusion between AVN-HPS + BT conduction

16. BASAL STUDY- SHORT HV H H H V V V A A A HV

17. QRS FUSION A VN A VN A V + B T BT

18. WAYS TO BRING OUT VENTRICULAR PRE EXCITATION Carotid massage AVN blockers Rapid atrial pacing

19. AVN BLOCK WITH ADENOSINE 12 MG IV

20. ATRIAL PACING MANEUVERS DURING SR Incremental rate atrial pacing (IAP) Progressively premature AES (ARP) Antegrade block in AVN Brings out pre excitation Retrograde H activation ERP of BT

21. I A P A V A V A V A V A V A V A V A V

22. I A P A V A V A V A V A V A V A V A V A V A V

23. FU L L Y P R EE X C I T E D A T 26 M S

24. ARP- SHOWING MAXIMUM PREEXCITATION V V

25. T A C H Y O N A R P , A NTE R O G R A D E ER P O F PA T H W A Y V V

26. PROGRAMMED VENTRICULAR STIMULATION DURING SR PATTERNS OF VA CONDUCTION: Exclusive conduction through AVN Retrograde conduction through BT+AVN [Long PCL/ long VES coupling interval] Exclusive conduction over BT [Short PCL/short VES coupling interval] VA conduction absent [Shorter PCL/very early VES]

27. IVP- ECCENTRIC ACTIVATION

28. ECCENTRIC VA

29. INDUCTION OF TACHYCARDIA Spontaneous-APC, VPC, Catheter placement By programmed atrial stimulation (ARP) By programmed ventricular stimulation (RRP)

30. SPONTANEOUS INDUCTION OF TACHY WITH VPC V SR TACHY 

31. RRP

32. NCT INDUCED ON RRP

33. TACHYCARDIA FEATURES A:V relationship VA interval Atrial activation sequence Effects of BBB Entrainment response

34. WCT- ANTIDROMIC AVRT

35. TACHYCARDIA

36. ?WHERE DO WE MEASURE VA INTERVAL IN TACHYCARDIA

37. TACHY STUDY: SEPTAL VA 116 MS, ECCENTRIC ATRIAL ACTIVATION, EARLIEST A IN CS 3,4

38. EFFECT OF DEVELOPMENT OF BBB ON TACHYCARDIA Coumel’s law Increase in TCL with development of ipsilateral bundle branch block indicates that tachycardia circuit belongs to that sided ventricle.

39. INCREASE IN TCL WITH DEVELOPMENT OF LBBB

40. T e xt RBBB AND EFFECT ON TCL

41. RBBB DURING TACHY

42. NO INCREASE IN TCL WITH DEVELOPMENT OF RBBB

43. VENTRICULAR ENTRAINMENT Done by overdrive pacing usually from the RV apex (can be from other sites to gain specific information) Pace at a CL 10-40ms faster than the TCL Entrainment is confirmed when Atria accelerate to the pacing CL Tachycardia continues once pacing is stopped Entrain multiple times, at different CLs to confirm a consistent entrainment response

44. ENTRAINMENT- POINTS TO FOCUS VAHV versus VAAV response PPI-TCL SA-VA

45. AT VERSUS AVRT/AVNRT The VAAV response indicate the sequence of events happening after the last entrained beat In A T , the l a s t pace d b e a t ( V ) t r a v e r s e s u p the H P S - > A V N-> A and ma k es the AVN refractory and hence it cannot echo back to the ventricles . The SVT continues after cessation of pacing and causes the next A in the sequence which is conducted down to the ventricles ( V )

46. THE VAAV (OR AAV/AAHV) RESPONSE

47. THE VAAV RESPONSE The atrial activation pattern has changed This is best evident in HRA and His This confirms a true VAAV, and hence an AT

48. AVRT/AVNRT VERSUS AT AVRT/AVNRT gives a VAV (VAHV) response after entrainment The last entrained paced beat ( V ) goes up the accessory pathway (AVRT) or the fast pathway (AVNRT) and reaches the atria ( A ) comes down the AVN (slow pathway in the case of AVNRT), HPS ( H ) and reaches the ventricles ( V )

49. E NTR A I N M E N T – V A V R E SP O N S E

50. CONCEPT OF POST PACING INTERVAL

51. ENTRAINMENT RESPONSE AVRT PPI- TCL <115 msec SA-VA <85 msec AVNRT PPI- TCL >115 msec SA-VA >85 msec

52. ENTRAINMENT

53. ENTRAINMENT

54. E NT RA I N M E N T R E S PO N S E

55. EFFECT OF HIS REFRACTORY PVC AVRT : Pacing at parahisian region with PCL 10-30 msec shorter than TCL leads to early activation of A (Advancement)

56. ZIPES PVC

57. PARAHISIAN PACING- NODAL RESPONSE W W N N

58. PARAHISIAN PACING – EXTRANODAL RESPONSE W W N

59. R F A RV PACING SR TACHYCARDIA

60. VA FUSION A V

61. VA FUSION A V

62. GOOD SIGNAL, VA FUSION A V

63. POSTERIOR SEPTUM, GOOD FUSED VA SIGNALS V A

64. RF SIGNAL IN SINUS RHYTHM -AV FUSION A V

65. RFA DURING RV PACING

66. R F A D U R I N G SR

67. R F A D U R I N G SR

68. RFA DURING TACHYCARDIA

69. POST ABLATION

70. ADENOSINE INDUCED AV BLOCK, NO CONDUCTION OVER PATHWAY A A A A A A V V V

71. PARAHISIAN PACING- NODAL RESPONSE

72. PACING MANEUVERS RRP ARP ANTEGRADE AND RETROGRADE WENCKEBACK POINT CONCENTRIC ACTIVATION

73. THANK YOU