Fundamentals in EP Studies

Terminology, Electrogram Interpretation and

Stimulation Protocols

Carol J. Gilbert, RN, BSN, MBA, FHRS

Testamur NASPExAM AP/Pacing
Testamur NASPExAM AP/Electrophysiology

Wisconsin Electrophysiology group

Heart Care Associates, Milwaukee, WI.

Aurora Sinai & St. Luke’s Medical Centers, Milwaukee, WI

Disclosure-of-Relationship

Fundamentals in EP Studies
Terminology, Electrogram Interpretation and Stimulation Protocols
Carol Gilbert
No relationships to disclose
relative to this presentation.
 Basic Intervals

Interval - the temporal duration between two points.

P-R Interval:
Measures transit of depolarization from exit at the sinus
node through the atria, the AVN and HPS to the
ventricular muscle.
`Point 1 -Beginning of P
`Point 2 - First recognizable portion of the a qRS.

120-150 ms

P - R INTERVAL
 I. The Atrium
Measurements:
a Inter-atrial Conduction –
Surface P or HRA: A to the HBE: A (low, right, medial atrial)
a Inter-atrial Conduction –
Surface P or HRA: A to the Distal CS A (low, left, lateral
atrial)

Applications
a Atrial arrhythmias including atrial fibrillation
a Presence or absence of pre-excitation with Accessory
pathway
 P-R
1
qRs Inter-atrial Conduction
P
2 Surface P or HRA: A [green arrow]
to
P
3 the HBE: A (low, right, medial atrial)
[orange arrow/dotted line]
A
HRA

A V
LA CS p

AH V
HB
 II. The AV Node
Measurements
a Trans-nodal conduction – A on the HBE to the earliest His.
Applications
a Conduction disorders, Mobitz I blocks
a Dual AV nodal pathways
a Accelerated conduction, bypasses

1
65-140 ms

HB

A-H
 III. The His Bundle and
Bundle Branches

Measurements
a His-Purkinje Conduction – Onset of His to the earliest
Ventricular activation on whatever channel it is noted.
a His – RB recording – Onset of His to Onset of Right
Bundle Potential (within the HB - V interval)

1
33-55 ms

HB
H-V
RB
RB
 III. The His Bundle and
Bundle Branches

Measurements
a Intra-Hisian conduction – Earliest His to the latest His of
split recording, longer H-V interval

1
H-H1

HB

H-V
 III. The His Bundle and
Bundle Branches

Applications
a Conduction disturbances. Mobitz II blocks (Block below
the His)
a Intraventricular re-entry (Associated with prolonged H-
V)
a Accessory pathways (H-V appears shorter than normal
because of ventricular pre-excitation or bypass of the
HPS by conduction directly between the A and V)
 IV. The Ventricles

Measurements
a QRS duration – Beginning of surface QRS to end of QRS (80-
110 ms)
a Ventricular Conduction – Earliest Ventricular deflection to the
end of the latest
a Intra-ventricular conduction – RV to LV or LV to RV 1
Applications
a Ventricular dysynchrony
a BB Blocks
a Pre-excitation HB
a Intra-ventricular reentry
a Ventricular tachycardia
RV
Pacing Protocols

S
 I. “Straight” Pacing
Pacing at a constant cycle length (stable S1S1)
or constant rate

Applications:
a Control and regularize heart rates for consistent
excitation and refractory periods
a Sinus node recovery time or sino-atrial activation
measurements
a Evaluate intra-atrial, intra-ventricular conduction.
 II. Decremental pacing

Pacing at increasing rates i.e., decreasing cycle

lengths
Applications:
a AV nodal, intra-hisian conduction evaluation
a Overdrive capture of tachyarrhythmias
 Decremental Atrial Pacing

600 msec / 100 BPM 1:1 AV conduction

A H V

400 msec / 150 BPM

A H V

No His - then resume

350 msec / 171 BPM Wenckebach AV block conduction with shorter AH

A no H no V
A H V A H V A H V A H V
AH V

Cl < 540
 III. Incremental pacing

Pacing at decreasing rates, i.e., increasing cycle

lengths

Applications:
a Reverse hysteresis, fall-back rates.
 IV. Extra-stimuli (S1-S2)

Pacing at a constant cycle length for 6-12

beats followed by introduction of a
premature beat or series (S2,S3, S4, etc.) of
premature beats.

Applications
a Measuring refractory periods
a Induction of arrhythmias.
 Refractory Periods:

Measured using extrastimuli pacing with

closer and closer coupling.
 I. Effective refractory period (ERP)
A. Anterograde

Failure of a tissue to respond to a stimulus.

Antegrade Refractory Periods:

a AVCS: Longest A1A2 that fails to conduct to the
ventricles.
a AV Nodal ERP: Longest A1A2 that fails to conduct to the
His, i.e., no H2.
a HPS ERP: Longest H1H2 that fails to conduct to the
Ventricle, i.e., no V2.
a Atrial ERP: Longest S1S2 without that fails to
pace/stimulate the Atria, i.e., no A2
 Extra-stimuli (S1-S2)
Anterograde ERP

A S1 600 S1 350 S2

A H V A H V

AVCS: Longest A1A2 that

B S1 600 S1 250 S2
A1 A2 fails to conduct to the
ventricles
A H V
A H

HPS ERP: Longest H1H2

Unusual to achieve due to proximal delay that fails to conduct to the
extends to H1H2 His, i.e., no V2.
 Extra-stimuli (S1-S2)
Anterograde ERP (con’t)
B S1 600 S1 250 S2

A H V
A1 A2 H

C S1 600 S1 230
S2 AV Nodal ERP: Longest
A1A2 that fails to conduct
A H V A1 A2 to the His, i.e., no H2.

230-450 ms
D S1 600 S1 210 S2
Atrial ERP: Longest
S1S2 without that fails
A1 to conduct to the His,
i.e., no A2

160-360 ms
 I. Effective refractory period (ERP):
B. Retrograde .

Failure of a tissue to respond to a stimulus.

Retrograde Refractory Periods:

a VACS: Longest V1V2 that fails to conduct to the atria.
a HPS ERP: Longest V1V2 that fails to conduct to the His,
i.e., no H2.
a Ventricular ERP: Longest S1S2 that fails to
pace/stimulate the ventricles, no V2
 II. Functional Refractory Periods:
A. Antegrade Conduction

Shortest conduction through a tissue.

a VACS: Shortest V1V2 in response to A1A2.
a AVN: Shortest H1H2 in response to A1A2.
a HPS: Shortest V1V2 in response to H1H2.

Applications
a Rapidity of anterograde conduction during atrial
fibrillation
a Selection of therapeutic interventions
a Evaluation of therapies
 FRP AVCS
A S1 600 S1 350 S2 V1 550 V2

A H V A H V
A1A2 350

V1 520 V2
B S1 600 S1 300 S2
A1 A2

A H V
A H A1A2 300

C S1 600 S1 250 S2 V1 570 V2

A1A2 320
 II. Functional Refractory Periods:
B. Retrograde Conduction

Shortest conduction through a tissue.

a VACS: Shortest A1A2 in response to V1V2.
a AVN: Shortest H1H2 in response to V1V2.
a HPS: Shortest A1A2 in response to H1H2.

Applications
a Rapidity of anterograde conduction during atrial
fibrillation
a Selection of therapeutic interventions
a Evaluation of therapies
 III. Relative refractory periods

Conduction delays are seen that increase

conduction times beyond the FRP of the issue.
Examples:
a Lengthening of an AH interval
a Widening of a QRS (BBB)
a Prolongation of AV
Applications:
a Conduction delays associated with reentrant arrhythmias
CT02: Fundamentals in EP Studies Chair: Karen Belco

Session Objective:
At the end of this session, you will be able to cite the
terminology and stimulation protocols used in the EP
lab, as well as identify and recognize the relation of
anatomy, imaging and intracardiac electrograms.

1. Terminology, Stimulation protocols:

Carol Gilbert, RN
2. Anatomy and imaging (fluoroscopy, ICES):
Craig Swygman, CVT
3. Practice tracings and images:
Tom Foley (EP tech)