Electrophysiology
What is Electrophysiology and Pacing (EP)?
Electrophysiology means electrical phenomena associated with a physiological process. This is a branch of biology that deals with the functions and activities of living matter (as organs, tissues or cells) and the physical and chemical phenomena involved.
EP is the study of the heart’s conduction system and it’s effect on heart rhythm.
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What Procedures are Performed in the EP Lab?
The procedures performed in the EP Lab fall into the categories listed below:
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Pacemaker implants
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Defibrillator implants
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Biventricular implants
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Laser lead extractions
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Tilt Table Testing
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Electrophysiology studies
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Ventricular stimulation studies
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3 wire (Syncope) studies
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4 wire (Supraventricular tachycardia) studies
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Radio Frequency Ablations
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Cryo-ablations
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Three-Dimensional Mapping
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Defibrillation Function Testing
What Takes Place in the EP Lab?
The Electrophysiologists (specialized cardiologists) and a team of nurses and technologists works with specialized equipment and catheters to perform diagnostic and interventional procedures on patients who have electrical problems with their heart.
What is the Conduction System of the Heart?
The normal beating heart is controlled by an electrical conduction system. The heart’s electrical system is composed of:
SA Node (Sinoatrial): This is the heart’s normal pacemaker and is located at the top of the right atrium. The SA Node sends out an electrical stimulus between 60 and 100 times per minute.
AV Node (Atrioventricular): This group of cells is located between the atrium and ventricles and conducts the electrical impulse to the ventricles. It acts as a gate keeper and allows the atria to contract before the ventricles.
His-Purkinje System: These specialized conduction tracts act like high speed distributors of the electrical impulse throughout the ventricles, resulting in contraction of the ventricles.
Our Team
Learn about our team
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The Electrophysiology and Pacing Department of Lancaster General Hospital employs a wide variety of personnel in the performance of our procedures. EP lab care can also involve various ancillary departments within the hospital to compliment and assist in patient care.
The staff of the EP lab includes EP Technologists and nurses with specialized training to assist in the diagnosis and treatment of all manner cardiac rhythm disorders. The technologists come to Lancaster General from diverse backgrounds including: Registered Cardiovascular Interventional Specialists (RCIS), Radiological Technologists (RT, R), Certified Scrub Technologists (CST), Paramedics (EMT-P) and Registered Nurses (RN). The staff also includes registered nurses trained in the administration of moderate sedation. Licensed Practical Nurses (LPN’s), Certified Cardiographic Technicians (CCT) and Patient Care Assistants (PCA’s) provide the EP staff with support during your procedure. Many of our team members have advanced degrees and certifications including Bachelors of Science, Bachelors of Science in Nursing, Registered Cardiac Electrophysiology Specialists (RCES) from Cardiac Credentialing International(CCI) and, Certified Cardiac Device Specilaists (CCDS) & Certified Electrophysiology Specialists (CEPS) both from International Board of Heart Rhythm Examiners (IBHRE).
Should your pre-procedure sedation evaluation reveal risks to moderate sedation, we will consult the Anesthesia Department for care of your sedation/analgesia. The hospital employs Certified Registered Nurse Anesthetists (CRNA’s) and works with Anesthesia Associates of Lancaster to provide all aspects of anesthesia care.
The staff of the EP lab is complemented by professional team members from the various suppliers of products that are used in the EP lab. Professionals from Medtronic, Biosense-Webster, Boston Scientific and St. Jude Medical are just a few of the suppliers with representatives to assist in device implantation and EP procedures.
Conditions
Atrial Tachycardia
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Atrial tachycardia is a period of rapid and regular heart beats that begins and ends abruptly. The heart rate is usually between 160 and 200 beaters per minute. This is usually caused by a group of abnormal cells other than the SA node, located in the right or left atrium.
Paroxysmal (abrupt beginning and ending) atrial tachycardia may have several causes. The arrhythmia may be caused by a premature atrial beat that leads to tachycardia that may be focal in origin or may be a very small loop of electrical activity. Other causes stem from anxiety, stimulants, over active thyroid and in some women, the onset of menstruation.
Though seldom life threatening, this arrhythmia can be annoying, symptoms include: light headedness, chest pain, palpitations, anxiety, sweating and shortness of breath.
Your doctor may suggest that during an episode of atrial tachycardia you attempt to bear down as in a bowel movement. The doctor may also massage an area in your neck to terminate the tachycardia. A medication called adenosine may be used by the doctor to stop the arrhythmia. In some cases an electric cardioversion may be used to terminate the tachycardia.
Atrial Fibrillation
Atrial fibrillation is a disorder found in about 2.2 million Americans. During atrial fibrillation, the heart’s two small upper chambers (the atria) quiver instead of beating effectively. Blood isn’t pumped completely out of them, so it may pool and clot. If a piece of a blood clot in the atria leaves the heart and becomes lodged in an artery in the brain, a stroke results. About 15 percent of strokes occur in people with atrial fibrillation.
Causes:
Symptoms:
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Some people have chest pain. This is due to an irregularly pumping heart that may drop your blood pressure.
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Occasionally the first symptom may be a stroke caused by a blood clot to the brain.
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Some people have no symptoms
Other symptoms include:
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Irregular heart rate
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Fast heart rate
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Weakness
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Fatigue
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Lightheadedness
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Shortness of breath
Classifications:
Atrial Fibrillation is divided into three classifications:
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Paroxysmal:
Terminates spontaneously.
Occurs intermittently, varies in frequency.
Duration from a few to several days.
Short term goal is rate control, conversion to sinus rhythm and anticoagulation.
Long term goal is maintenance of sinus rhythm.
Tends to occur in younger people ages 30 to 50 years of age.
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Persistent
Does not terminate spontaneously, but can be converted to sinus rhythm
Typically seen in the older population
Rise in embolic risk with duration of atrial fibrillation.
Short term goal is rate control and cardioversion to sinus rhythm.
Long term goal is cardioversion and maintenance of sinus rhythm and rate control.
Requires continued electrical or pharmaceutical intervention.
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Permanent:
Unable to restore sinus rhythm
Long standing atrial fibrillation ( > 1 year)
Short term goal is rate control and anticoagulation
Long term goal is rate control
Complications:
The most serious complication is stroke caused by a blood clot to the brain. This is caused by the blood becoming stagnant while the atrium is not beating properly. Clots may then travel in the bloodstream to the brain where they can block flow to a part of the brain and cause a stroke to occur. Many patients with atrial fibrillation are put on anticoagulants (blood thinners) to reduce the risk of clot formation.
Treatment:
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Several approaches are used to treat and prevent abnormal beating:
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Medications are used to slow down rapid heart rate associated with atrial fibrillation. These treatments may include drubs such as digoxin, beta blockers (atenolol, metoprolol, propranolol), amoiodarone, disopyramide, calcium antagonists (verapamil, dilitazam), sotalol, flecainide, procainamide, quinidine, propafenone, etc.
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Electrical cardioversion may be used to restore normal heart rhythm with an electric shock, when medication doesn’t improve symptoms.
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Drugs (such as ibutilide) can sometimes restore the heart’s normal rhythm. These drugs are given under medical supervision, and are delivered through an IV tube into a vein, usually in the patient’s arm.
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Radiofrequency ablation may be effective in some patients when medications do not work. In this procedure, thin and flexible catheters are introduced through a vein and directed into the top chambers of the heart. Then a burst of radiofrequency energy is delivered to destroy tissue that triggers abnormal electrical signals or to block abnormal electrical pathways.
Atrial Flutter
Atrial flutter occurs when the upper chambers of the heart (atria) beat in a repetitive gasion at 300 beats per minute. This is compared to the normal 60 to 100 times per minute. The rapid heart rate reduces the effectiveness of the heart and decreases the amount of blood flow. Atrial flutter is usually seen with classic sawtooth pattern of flutter waves with negative polarity in leads I. II, III, and a VF.
Typical atrial flutter is isthmus dependant with the circuit going through the isthmus in clock-wise or counter clock-wise direction. Atypical flutter is thought to result from reentru around other functional or structional barriers to conduction.
Causes:
Atrial flutter may be caused by abnormalities or diseases of the heart itself, by a disease elsewhere in the body that affects the heart, or by consuming substances that change the way electrical impulses are transmitted through the heart. In a few people, no underlying cause is every found.
Heart disease or abnormalities that can cause atrial flutter include the following:
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Decreased blood flow to the heart (ischemia) due to coronary heart disease or blood clot.
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High blood pressure
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Disease of the heart muscle (Cardiomyopahty)
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Abnormalities of the heart valves (especially the mitral valve)
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An abnormally enlarged chamber of the heart (hypertrophy)
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After open heart surgery
Diseases elsewhere in the body that affect the heart include the following:
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Overactive thyroid gland
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Blood clot in a blood vessel in the lungs (pulmonary embolism)
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Chronic (ongoing) lung diseases (COPD), such as emphysema that lowers the amount of oxygen in the blood.
Substances that may contribute to atrial flutter include the following:
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Alcohol (wine, beer or hard liquor)
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Stimulants such as cocaine amphetamines, diet pills, cold medicines, sometimes even caffeine.
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Atrial flutter is also closely associated with atrial fibrillation. These two sometimes alternate back and forth
Symptoms:
Symptoms include heart palpitations, shortness of breath, chest pain and dizziness. Some people may experience no dizziness.
Treatment:
The goals of treatment are to control the heart rate, restore normal sinus rhythm, prevent future episodes and prevent stroke.
Control rate: The first treatment goal is to control the ventricular rate.
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If you experience serious clinical symptoms, such as chest pain or congestive heart failure related to the ventricular rate, the health care provider in the emergency department will decrease your heart rate rapidly with IV medications or electrical shock (defibrillation.)
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If you have no serious symptoms, you may be given oral medications.
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Sometimes you may require a combination of oral medications to control your heart rate.
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Surgery may be done to control heart rate, but this is rare.
Restore and maintain normal sinus rhythm: Some people with newly diagnosed atrial flutter convert to normal sinus rhythm spontaneously in 24-48 hours. The goal of treatment is to convert the atrial flutter to normal sinus rhythm and prevent recurrence of atrial flutter.
Not everyone with atrial flutter needs anti-arrhythmic medication
The frequency with which your arrhythmia returns and the symptoms it causes partly determine whether you receive anti-arrhythmic medication.
Medical professionals carefully tailor each person’s anti-arrhythmic medications to produce the desired clinical effect without creating unwanted side effects, some potentially lethal.
Prevent future episodes: This is usually done by taking daily medication to keep the heart at a safe and comfortable rate.
Prevent stroke: Stroke is a devastating complication of atrial flutter. It occurs when a piece of blood clot formed in the heart breaks off and travels to the brain, where it blocks blood flow.
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Co-existing medical conditions, such as congestive heart failure and mitral valve disease, significantly increase the risk of stroke.
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Patients with persistent atrial flutter need a “blood-thinning” drug called warfarin to lower this risk. Warfarin blocks a certain factor in the blood that promotes clotting.
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People at lower risk of stroke and those who cannot take Warfarin may use aspirin. Aspirin is now without its own side effects, including bleeding problems and stomach ulcers.
Catheter ablation: Ablation means removal. This technique inactivates the abnormal conduction pathways in the right atrium.
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The abnormal pathway(s) is found and a catheter is placed at this precise location in the conduction system.
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After proper placement, the catheter delivers radiofrequency energy, which burns or ablates a portion of the abnormal electrical conduction pathway. This inactivates the abnormal pathway to provide more consistent flow of electrical impulses.
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This technique is safe and is recommended for some, not all patients. When it is performed, atrial flutter is permanently cured. Unlike surgery, it requires little recovery time.
Bi-Ventricular Electrophysiology and Pacing.
To understand biventricular pacing and congestive heart failure, it helps to understand how a normal heart works compared to a “sick” heart.
Normal blood flow through the heart and lungs: Oxygen poor blood flows from the body into the right atrium, from the right atrium blood is pumped into the right ventricle through the tricuspid valve, blood is then pumped through the pulmonary valve into the lungs where it becomes enriched with oxygen. The oxygenated blood flows back to the heart into the left atrium, flows through the mitral valve into the left ventricle. Leaving the left ventricle, the oxygenated blood flows through the aortic valve into the body where the whole process is repeated over 100,000 times a day.
In the heart failure setting, the heart begins to fail as a forward pump. The blood begins to back up in the lungs and the rest of the body causing shortness of breath and swelling of your ankles among several other signs and symptoms. As the pressure in your heart increases, the heart begins to remodel or take on a different, less effective shape. It takes on a rounded appearance like a basketball instead of a football shape. As the remodeling takes place, the ventricles begin to beat separately (dysynchrony). This is where biventricular therapy is helpful. The right and left ventricles need to be paced at the same time to recreate synchrony. Biventricular pacing along with optimal medical therapy, heart failure can be a manageable disease.
Heart failure affects almost 5 million people in the United States, with 550,000 new cases reported each year. People diagnosed with heart failure can live a full and active life as long as they follow closely the treatment, diet and exercise plan their doctor has given them.
Do not be alarmed or mislead by the term “heart failure”. This does not mean the heart has failed and cannot work anymore. This simply means the heart is failing to pump the adequate amount of blood the body needs.
If you have had any heart problems in the past or if you have a family history of heart problems, it is important to recognize these signs and symptoms early and share them with your doctor. Swelling of your feet and/or ankles, swelling of your abdomen, shortness of breath with or without exercise, a lower then normal exercise tolerance, shortness of breath while lying down, frequent urination at night, loss of appetite, fatigue or tired feeling, confusion or palpitations. Due to the body’s attempt to compensate for the heart failure, by the time symptoms appear, damage has already been done. Therefore, the earlier you recognize the symptoms and get them treated the better the outcome will be.
Biventricular pacemaker- 3 leads are implanted through veins in either your right or left shoulder (primarily left shoulder) into your heart. One lead will pace the right atrium, one lead will pace the right ventricle and one lead will pace the left ventricle. The traditional pacemaker has only the right atrium and right ventricle lead and is limited to treating bradycardia (slow heart rates). The biventricular pacemaker has the ability to treat heart failure symptoms by recreating synchrony between the right and left ventricles. Another common part of the biventricular therapy is the ICD or defibrillator. This has the ability to shock your heart back into a normal rhythm if it is beating dangerously fast.
Venous Landmarks of Upper Chest
With three cardiology practices (8 doctors) Dr. Tatjana Sljapic of The Heart Specialists of Lancaster, Dr. Seth Worley, Dr. Douglas Gohn, Dr. R.Ward Pulliam, and Dr. Melissa McKernan of The Heart Group and Dr. Nicholas Mandalakas, Dr. Stephen Bell and Dr. Jerry Luck of Cardiac Consultants, Lancaster General Hospital implants 200-250 biventricular pacemakers/ICD each year.
EP Technologist Education
Electrophysiology is a specialized area of study and our commitment to patient care requires that our technologists are trained to assist physicians in performing the most complex procedures. The Electrophysiology Internship Program was developed to provide the Lancaster General Health EP Lab with highly trained, clinically proficient employees.
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This 1 year internship has now evolved into an Associate in Applied Science Degree in Cardiac Electrophysiology offered at Lancaster General College of Nursing and Health Sciences. This program is the first EP program in the country to receive the Joint Review Committee for Cardiovascular Technology (JRC-CVT) and the Commission on Accreditation for Allied Health Education Programs (CAAHEP) accreditation. It is also offered as a certificate program for those with a college degree. Contact Lyn Longenecker, Director of Admissions, at Jllongen@lancastergeneralcollege.edu or 717-544-5711 if interested.
Procedure Flow
Your care from the Electrophysiology and Pacing Department includes several departments prior to and following the actual procedure. This is to provide you with the very best quality care possible. Your movement through the EP Department is choreographed with every attempt to minimize your waiting time.
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You may be asked to come to the hospital the day before your procedure to be seen in our EP Clinic. A registered nurse will perform or coordinate all of your preadmission testing including lab studies, X-rays, EKG’s, Transesophageal echocardiograms and CT scans. The nurse will also perform a pre-sedation evaluation and provide you and your family with patient teaching regarding your procedure. Any pre-procedure skin cleansing preparation that is required can also be given to you at that time.
The day of your procedure, you will arrive at the hospital via James Street and park in the James Street Parking Garage. From the garage, you will go to the second floor of the hospital and to the Medical Outpatient Unit (MOPU). Any last minute lab studies or testing that is required will be performed at this time. You will be asked to change your clothing and an intravenous line (IV) will be started. When the facilitators of your procedure confirm that you and the EP lab is ready, you will be taken to the Invasive Cardiology Pre/Post area where you will be prepared for the procedure. This includes shaving, pre-op medication administration if that is ordered, etc. Your doctor may meet you in the pre/post area to complete medical paperwork and mark the surgical site if necessary.
From the pre/post area, you will proceed to the procedure room. You can expect a slightly cooler room than normal, due to the sensitive X-ray equipment that is used for procedures. The team can use warming blankets on you if needed during the procedure. Once on the procedure table, the staff will ask questions that will identify you and your procedure to ensure safe and accurate care. The team will attach numerous patches, pads, sensors and wires to you for monitoring and assess your vital signs during the procedure. We will then begin your sedation. For the majority of our patients, this is the last thing you will recall of the procedure.
Upon completion of your procedure, there may motion restrictions of your arms or legs depending on the type of procedure you have performed. After the procedure is complete, you will be returned to the pre-post area or the Post Anesthesia Care Unit (PACU) if you had anesthesia for your procedure. From there, you will either be admitted to the hospital or returned to the MOPU for discharge.
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