**********EP STUDY (SYNCOPE + BBB)*************
EP PROCEDURE NOTE
DATE OF PROCEDURE:
PRE-OPERATIVE DIAGNOSIS:
1. Syncope
2. Evidence of Distal Conduction Disease with _____
POST-OPERATIVE DIAGNOSIS:
PROCEDURES PERFORMED:
1. EP Study with induction
2. Drug infusion with ________
ELECTROPHYSIOLOGIST:
ASSISTANT:
CLINICAL PROFILE:
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 10 cc.
MEDICATION USED:
Please see anesthesia note for regarding sedation records.
FLUOROSCOPY TIME = min
DAP = Gycm2
AIR KERMA = mGy
DETAILS OF PROCEDURE:
The risks and benefits of the procedure were explained to the patient in
full, and in simple terms. Alternative therapy options were given,
including no procedure. The risks of the procedure include, but are not
limited to: pain, bleeding, infection, pneumothorax, perforation of
vessels or heart, pericardial effusion, unstable heart rhythm, lead
dislodgement, inappropriate shocks, and death. The risks of blood
transfusion were discussed, and include fever, transfusion reaction, and
infection. All questions were answered, and the patient voices
understanding. The patient acknowledged the risks of the procedure,
and still wanted to proceed.
The patient was brought into the Electrophysiology Lab in a fasting and
hemodynamically stable condition.
SHEATHS AND CATHETERS:
Access the femoral vein and femoral artery were obtained using the
seldinger technique: The right femoral vein was successfully cannulated
with the needle. A guidewire was then passed through the needle easily.
A blade was used to make a nick at the entry site to widen the entry point.
The needle was then retracted. A sheath was then placed over the guidewire
and then flushed. This was repeated in a similar fashion for the right
femoral artery.
Right Femoral Vein:
6Fr Sheath: A non-deflectable quadripolar catheter was positioned
into the high right atrium
6Fr Sheath: A SJM CRD-2 non-deflectable quadripolar catheter was
positioned into the His Bundle region
6Fr Sheath: A non-deflectable quadripolar catheter was positioned
into the Right Ventricle.
***Right Femoral Artery:***
5Fr Sheath: arterial line for hemodynamic monitoring
BRADYARRHYTHMIA STUDY:
Baseline intervals were obtained, which demonstrated:
Sinus Cycle Length =
PR interval =
QRS interval =
QT interval =
AH interval =
HV interval =
We then began to pace from the high right atria catheter, with atrial pacing
cycles > or = to 400 msec. With this pacing manever, we
**************HV > 70 msec at baseline***********************************
observed evidence of infranodal block at baseline, with an HV interval of ___
As per the ESC Guidelines, it is a Class I indication for permanent pacing in
that: "Pacing in indicated in patients with syncope, BBB, and positive EPS
defined as HV interval of > or = 70 ms, or second-or third-degree His-Purkinje
block demonstrated during incremental atrial pacing or with pharmacologoical
challenge" (Brignole, Michele et al. 2013 ESC Guidelines on cardiac pacing
and cardiac resynchronization therapy. Europace (2013) 15, 1070-1118).
Thus, given the patient's syncope in the setting of LBBB, during our EP study
we found:
(a) HV interval > or = 70 msec at baseline
(b) Atrial Pacing > 400 msec resulting in 2nd or 3rd degree AV Block
and thus had met Class I indication for pacing, and we then proceeded with
pacemaker implantation.
****************HV < 70 msec at baseline**********************
did NOT observe evidence of infranodal block. Given the fact that the HV
interval was < 70 msec and there was no evidence of 2nd or 3rd degree intra or
infra Hisian block, we next proceed with a Na+ Channel blocker drug challenge to
stress the distal conduction system.
We administered Flecainide 2mg/kg IV and then remeasured baseline intervals, and
performed atrial pacing, which yielded the following results:
(a) AH =
(b) HV = (abnormal > or = 100 msec)
(c) While pacing from the HRA at a PCL > 400 msec, we observed
....Second or third degree infra or intra Hisian block (with PCL
> 400 msec) before or during incremental atrial pacing or
after class I drug adminsitration.......
The above findings are consistent with a positive EP Study (Roca-Luque, Ivo et al. "Flecainide Versus Procainamide in Electrophyiological Study in Patients with Syncope and Wide QRS Duration." JACC: Clinical Electrophysiology Vol. 5, No. 2, 2019 February 2019: 212-9) and as such, we then proceeded with implantation of a PPM.
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VENTRICULAR TACHYARRHYTHMIA STUDY:
We proceeded with pacing from the right ventricular apex. We performed
an aggressive VT stimulatoin protocol using the Morady Protocol. We used
drive trains of 600, 400, and 350 msec with triple extra-stimuli from the RV
apex. We then moved the catheter into the RV outflow tract and repeated the
protocol.
No sustained ventricular tachyarrhythmias was observed, so we then
started isoprel at 1 mcg/min and titrated until the baseline heart rate
increased by 20% over baseline. We then performed the above protocol on
isoprel (drive trains of 600, 400, 350 msec with extra stimuli, pacing from
both the right ventricular outflow tract and the right ventricular apex).
***As the patient therefore had inducible sustained monomorphic VT resulting
in hemodynamic collapse, class I criteria for a ICD has been met.****
*******************************************************************************
At this point, we scrubbed out and re-prepared the patient. The left chest
wall was vigorously washed, prepped, and sterilely draped. The chest wall was
anesthetized with lidocaine.
A left subclavian venogram was performed and the left subclavian vein is
patent.
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