Sample Report: EPS Study, Left Ventricular Recording, Mapping, and Central Venogram
PROCEDURE: Comprehensive electrophysiologic study with left ventricular recording, mapping of the left ventricle, central venogram.
INDICATION: Congestive heart failure.
MEDICATIONS: Versed 3 mg, fentanyl 50 mcg, and Isovue as directed.
COMPLICATIONS: None.
DETAILS OF PROCEDURE: After informed consent was obtained, the patient was brought into the electrophysiologic laboratory. The patient was prepped and draped in the usual sterile fashion. Over the course of 1 hour, he was given 3 mg of Versed and 50 mcg of fentanyl. He was on continuous pulse oximetry, noninvasive blood pressure measurements, and continuous electrocardiography. His ASA classification is III. He tolerated the procedure well, was awake, alert, and oriented. Repeated measures of respiratory rate and effort, level of sedation and consciousness were maintained throughout the study, as well as hemodynamics.
Using lidocaine, skin overlying the left femoral vessel was locally anesthetized and two 6-French sheaths were placed through the right femoral vein. Deflectable quadripolar catheter was placed in the high right atrium, demonstrating underlying atrial arrhythmia. The patient has underlying complete heart block with a permanent pacemaker and HV interval could not be obtained but the catheters were then moved to the right ventricular apex, and a second catheter was used to engage the coronary sinus. With the coronary sinus engaged, mapping was performed after physically finding the os of various lateral veins. A very posterior lateral branch was found that went to the lateral aspect of the inferolateral wall out to the apex, and a high lateral branch was also found. Intraventricular pacing between left atrial wires and right ventricular wires was used to map activation times, QRS durations, and intraventricular conduction times to assist in placement of biventricular pacing tomorrow. Finally, induction of ventricular arrhythmias was performed and then a long J wire was advanced to the central circulation. A catheter was advanced to the superior vena cava and used to engage the left subclavian vein. This was advanced over the J wire, and the venogram was performed.
FINDINGS:
1. The left subclavian vein was widely patent.
2. A high left ventricular pacing site provides longer intraventricular conduction times and narrower QRS complexes with biventricular pacing versus the large inferolateral vein.
3. Easily inducible ventricular tachycardia seen.
IMPRESSION: Successful mapping of the left ventricle of biventricular pacing, inducible ventricular arrhythmias.
RECOMMENDATIONS: Implantable cardioverter-defibrillator tomorrow.