Cardiac electrophysiology (EP) is the science of understanding, diagnosing and treating the electrical activities of the heart. An EP test is an invasive study which allows doctors to assess the heart's electrical system and induce arrhythmias (irregular heartbeats) under controlled conditions. During the EP study, sinus rhythms and baseline cardiac intervals are recorded. The study is done to investigate the cause, location of origin and best treatment for various abnormal heart rhythms. Before this treatment option, patients with arrhythmias could only be treated with medications that were often inadequate or had significant side effects. At best, these arrhythmias could be limited or suppressed. Now with the use of techniques such as radiofrequency ablation and implantation of cardioverter defibrillators, it is possible to cure many arrhythmias.
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Circumferential Pulmonary Vein Ablation for Atrial Fibrillation
is an invasive technique that is used in the treatment of atrial fibrillation (AF)
(a very rapid, irregular heartbeat) where a small area of unwanted tissue in the heart that is causing an abnormal heartbeat is removed or melted away.
Most AF ablations consist of isolating the electrical pathways from the pulmonary veins, which carry oxygenated blood from the lungs to the left atrium of the heart, in a procedure known as a pulmonary vein ablation (PVA). After making a small incision in the arm or groin, a thin guide wire and a small catheter (a long, thin, flexible, hollow tube) move to the heart through blood vessels. A special dye is used to help the doctor place the catheter in the right spot. As all other veins from the body (including arm and groin) lead to the right atrium, to get to the left atrium, the catheters must get across the atrial septum (wall that divides the left and right atriums of the heart). This is done by piercing a small hole in the septal wall. Once in the left atrium, the electrophysiologist may perform a wide area circumferential ablation (WACA) to electrically isolate the pulmonary vein and posterior wall from the left atrium. The electrophysiologist will then use radiofrequency heat energy to destroy or “ablate” the problem area.
Comprehensive Invasive Electrophysiology Studies, including Advanced Mapping
An Electrophysiology (EP) study is an invasive study which allows doctors to assess the heart's electrical system and induce arrhythmias (irregular heartbeats) under controlled conditions. During the study, electrophysiologists insert special catheters (a long, thin, flexible, hollow tube) into veins and arteries and guide them into the heart. These catheters sense electrical impulses and may also be used to stimulate different areas of the heart. During the EP study, the electrical system of the heart is studied. Electrophysiologists can then locate the sites that are causing arrhythmias.
This test is useful in diagnosing the mechanism and location of heart rhythm disorders, which enables decisions to be made about the most appropriate treatment method. For some arrhythmias, specialized ablation catheters can be placed at the site of the arrhythmia origin with application of heat energy to cure the arrhythmia.
Internal Cardiac Defibrillator Insertions
An internal cardiac defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at risk of sudden cardiac death due to ventricular fibrillation (when there is an uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly) and ventricular tachycardia (fast heart rhythm). An ICD is programmed to detect cardiac arrhythmia (abnormal heartbeat) and correct it by delivering a jolt of electricity.
The process of implantation of an ICD is similar to implantation of a pacemaker. Similar to pacemakers, these devices typically include electrode wire(s) that pass through a vein into the heart. The difference is that pacemakers are more often temporary and are generally designed to correct bradycardia (slow heart rate), while ICDs are often a permanent safeguards against sudden arrhythmias, however, every ICD has a pacemaker built into it.
The most recent development is the subcutaneous ICD (S-ICD). Current state-of-the-art electronics and batteries have enabled an implantable device to deliver enough energy to defibrillate the heart without the need for a lead in or on the heart. This prevents lead-related problems and the risk of dangerous infections in or near the heart. This ICD is positioned just under the skin and outside the ribcage. It can be placed during a minor procedure under conscious sedation.
Internal Cardioversion for Atrial Fibrillation
(AF) is the most common arrhythmia
(abnormal heartbeat) found in adults. AF affects approximately two million Americans. Although it is not directly life threatening, it can cause uncomfortable symptoms, such as chest pain, palpitations, shortness of breath, dizziness and fainting. AF is characterized as irregular, disorganized, electrical activity of the upper chambers (atria) of the heart. The atria quiver instead of regularly beating which causes them to move around much faster than they should (300-600 times a minute instead of 60-80 times a minute). Because of this, blood is not allowed to completely empty the upper chambers, which causes pooling in the atria.One way electrophysiologists can treat this is through cardioversion, or the process of restoring rapid, abnormal rates and/or rhythms back to normal sinus rhythm by drug or electrical shock. In internal cardioversion, two wires are placed into the heart and an electrical shock is delivered. This can be used when a traditional cardioversion fails.
Loop Recorder Insertion
A loop recorder is a small electronic device (about half the size of the little finger) that is implanted under the skin of the upper chest wall. The loop recorder is inserted to continuously monitor and record infrequent but bothersome episodes of rhythm abnormalities undiagnosed by conventional testing. When a person has a fainting episode, a small handheld device is held over the recorder to indicate the rhythm and the time of the episode. The doctor can then correlate abnormalities with symptoms.
Non-Invasive Program Stimulation (NIPS)
After your internal cardiac defibrillator (ICD) implanted, your doctor may schedule you to have a NIPS test. This can be done the day after implant while you are still in the hospital or as an outpatient procedure up to several months later.This test is done to insure that the device appropriately senses abnormal fast heart beats and successfully stops this abnormal rhythm with either overdrive pacing or a defibrillation shock.
In order to do this test, your doctor will use a special computer and your implanted ICD to put your heart into ventricular tachycardia (fast heart rhythm) or ventricular fibrillation (when there is an uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly). Since you will be receiving a shock from your ICD you will receive anesthesia through an intravenous (IV) access during the testing. This test usually takes 15 minutes.
Pacemaker Insertions, including Biventricular Pacing
A pacemaker is a medical device that uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart. The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the heart's native pacemaker is not fast enough, or there is a block in the heart's electrical conduction system. In most cases the pacemaker is inserted in the left shoulder area where an incision is made below the collar bone, creating a small pocket where the pacemaker is actually housed in the patient's body. The lead or leads (the number of leads varies depending on the type of pacemaker) are fed into the heart through a large vein using a fluoroscope to monitor the progress of lead insertion.
With a biventricular pacemaker, there are usually three leads and they pass through the vena cava and into the heart and the left ventricle to strengthen the heart. This type of pacemaker can pace both the internal and lateral walls of the left ventricle. By pacing both sides of the left ventricle, the pacemaker can resynchronize a heart whose opposing walls do not contract in synchrony, which occurs in approximately 25 to 50 percent of heart failure patients.
Ablation is an invasive technique that is used to treat irregular heartbeats by removing a small area of unwanted tissue in the heart that is causing the abnormality. After making a small incision – typically in the groin – a thin guide wire and a small catheter (a long, thin, flexible, hollow tube) move to the heart through blood vessels. A special dye may be used to help the electrophysiologist place the catheter in the right spot. After the catheter has been placed correctly, electrodes at the end of the catheter are used to stimulate the heart and locate the problem areas that are causing the abnormal heart rhythm. The doctor will use mild radiofrequency heat energy to destroy or “ablate” the problem area. This is done using high energy radio frequencies (similar to microwaves) to effectively destroy the abnormal cells.
Tilt Table Testing
A tilt table test is a medical procedure often used to diagnose syncope (fainting). Patients with symptoms of dizziness or lightheadedness, with a loss of consciousness, suspected to be associated with a drop in blood pressure or positional tachycardia (rapid beating of the heart) are good candidates for this test.
The procedure tests for causes of syncope by attempting to cause the symptoms by having the patient lie flat on a special table or bed while connected to ECG and blood pressure monitors. The table then creates a change in posture from lying to standing by tilting to different angles of degree.
A tilt table test can be done in different ways and be modified for individual circumstances. In some cases, the patient will be strapped to a tilt table lying flat and then tilted or suspended completely or almost completely upright (as if standing). Most of the time, the patient is suspended at an angle of 60 to 80 degrees. In all cases, the patient is instructed not to move. Symptoms, blood pressure, pulse, electrocardiogram, and sometimes blood oxygen saturation are recorded.