Dr Mohammed Haroon Rashid

Fellow, Electrophysiology.
Basic EP Intervals
Basic Principles
Determination of atrioventricular conduction
properties to stimuli helps to evaluate the AV
conduction system.
Decremental Conduction: The development of AV
Block at fast atrial rates is a normal response & is
called as Decremental conduction.
The cycle length at which the relationship
between atrial stimulus & ventricular response is
no longer 1:1 is called the atrioventricular block
cycle length (AVBCL)
Gradual prolongation of AV node conduction until
a dropped beat, that is only atrial electrogram &
no His electrogram is know as Wenckebach
Block.
Basic Principles
Traditionally a train of 8 beats at a cycle length
faster than the spontaneous sinus rate is called
Drive Cycle Length (S1).
The addition of a premature stimuli within the
DCL is known as Premature Stimuli (S2).
The interval in which no action potential can be
produced is called the Absolute Refractory Period
& the period in which abnormal activation occurs
is called as Relative Refractory period.
It is the relative differences in refractoriness that
are responsible for the development of reentry,
which is the most common mechanism for
tachyarrhythmias.
Recognition of delayed conduction to
atrial extrastimuli
Tissue Response
Atrial tissue Prolongation of the interval between the stimuli & atrial
electrogram
AV Node Prolongation between the interval of atrial electrogram
to His electrogram
His-Purkinje
system
Prolongation between the interval of His electrogram to
initial deflection in the QRS complex
Ventricular
activation
Widening of QRS interval
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Important Refractory Periods
Refractory Period Signal Observed
Atrioventricular Node Effective
refractory Period (AVN-ERP)
Premature atrial stimulus, atrial
depolarization, but no His Signal & no
ventricular depolarization
Atrial Effective Refractory Period (A-
ERP)
Premature atrial stimulus without atrial
depolarization
Ventriculoatrial Refractory Period (VA-
ERP)
Premature ventricular stimulus, ventricular
depolarization but no atrial activity
Ventricular effective refractory period
(V-ERP)
Premature ventricular stimulus with no
ventricular response.

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Normal

Haroon
6
Capture
Atrial
Capture
Normal Conduction
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Atrial Effective Refractory Period (A-
ERP)

Haroon
7
Haroon
280ms
No Atrial Signal
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om
AVN-ERP

Haroon
No QRS Complex
No His Signal subsequently
Haroon
8
V-ERP

Haroon
9

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Source PA interval AH Interval HV Interval
Mark Josephson
(ms)
60-125 35-55 10-25
Francis Murgatroyd
(ms)
25-55 55-125 35-55

Entrainment of Reentrant
Tachycardia
Defined as an increase in the rate of a tachycardia to
a faster pacing rate, with resumption of the intrinsic
rate of the tachycardia upon either abrupt cessation of
pacing or slowing of pacing beyond the intrinsic rate
of the tachycardia
Entrainment is the continuous resetting of a reentrant
circuit by train of capturing stimuli.
Entrainment is said to be present when two
consecutive extrastimuli conduct orthodromically
through the circuit with the same conduction time,
while colliding antidromically with the preceding paced
wave front.
Entrainment is the continuous resetting of a
tachycardia circuit.
Entrainment of Reentrant
Tachycardia
Surface ECG criteria for establishing the
presence of entrainment
Fixed fusion of the paced complexes at a constant
pacing rate
Progressive fusion or different degrees of fusion at
different pacing rate
Resumption of the same tachycardia morphology
following cessation of pacing, with the first post
pacing complex displaying no fusion but occurring
at a return cycle equal to the pacing cycle length.