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Handbook Of Cardiac Electrophysiology


The second edition of this bestseller provides a practical, user-friendly manual guiding the theory and practice of cardiac electrophysiology. The handbook provides the specialist in training with a thorough grounding procedures, and clinical findings for clinicians. It provides a review of the main kinds of arrhythmia with illustrations of typical ECG findings supported where appropriate by correlative imaging. It also details the principal diagnostic and therapeutic procedures include implantation of pacemakers, resynchronization therapy, and ablation techniques.




Handbook of Cardiac Electrophysiology



Oussama Wazni, MD, is currently the Section Head of Electrophysiology at the Cleveland Clinic. He specializes in electrophysiology with special interest in atrial fibrillation, ventricular tachycardia and complex device management.Dr. Wazni is principal investigator in several ongoing research studies related to device management, atrial fibrillation and ventricular tachycardia ablation, genetics of ventricular tachycardia, and long term follow-up after AF ablation.


Dr. Shivkumar is a physician scientist who serves as the director of the UCLA Cardiac Arrhythmia Center & EP Programs (since its establishment in 2002). His is a graduate of the UCLA STAR Program (class of 2000) and his field of specialization is interventional cardiac electrophysiology. He leads a large group at UCLA (comprising a diverse group of fifteen faculty members, several trainees and sixty staff + allied health professionals) involved in clinical care, teaching, research and biomedical innovation. Currently Dr. Shivkumar oversees a 15-university NIH consortium on neural control of the heart.


This expanded second edition of a comprehensive overview of the complex subject of electrophysiology focusing on the intricate clinical aspects of diagnosis and treatment. It addresses the updated aspects of pacemaker and ICD technology as well as the advances in ablation therapy. The objectives laid out by the editors are adequately met and the use of detailed graphics, ECGs, charts, and graphs provides excellent visual aids to guide physicians in understanding the objectives. It builds a framework for the understanding of complex concepts by starting with the diagnosis of specific arrhythmias and incrementally adding more complexity to the treatment. The use of numerous ECG examples with arrows and detailed explanations helps to conceptualize sophisticated electrophysiology. The use of other figures, charts, and graphics significantly helps readers solidify their understanding of the text. This book is a valuable resource for cardiology fellows in training interested in electrophysiology, electrophysiology fellows, and electrophysiologists. The quality of ECGs and the content of the book is excellent.


This extensively revised second edition provides a practically applicable guide for the management of cardiac arrhythmia. This subject has continued to expand rapidly, and it is therefore critical to understand the basic principles of arrhythmia mechanisms in order to assist with diagnosis and the selection of an appropriate treatment strategy. Comprehensively revised chapters cover a variety of aspects of cardiac electrophysiology in an easy-to-digest case-based format. For each case of arrhythmia, relevant illustrations, fluoroscopy images, ECGs and endocavity electrograms are used to describe the etiology, classification, clinical presentation, mechanisms, electrophysiology set up and relevant trouble-shooting procedures. New topics covered include the application of new antiarrhythmic drugs in tandem with ablation, techniques for the ablation of atrial fibrillation and electrophysiological assessments available for identifying instances of atrial tachycardia.


Clinical Handbook of Cardiac Electrophysiology presents a comprehensive overview of cardiac electrophysiology, making it a valuable reference for practicing and trainee cardiac electrophysiologists, cardiologists, family practitioners, allied professionals and nurses.


Dr. Benedict M. Glover is the Director of the Heart Rhythm Centre, Schulich Heart Centre, Sunnybrook Hospital and an Associate Professor in the Department of Medicine in the University of Toronto. He has a specific interest in atrial fibrillation, high definition cardiac mapping, catheter ablation and device therapy.


Dr. Andrea Natale is the Medical Director for the Center for Atrial Fibrillation, Director of the Electrophysiology Laboratories, and Section Head of Pacing and Electrophysiology in the Cleveland Clinic Department of Cardiovascular Medicine. As a cardiologist, he is certified by the American Board of Internal Medicine in internal medicine, cardiology and clinical cardiac electrophysiology, and by the Italian Board of Medicine and the Italian Board of Cardiology. Dr. Natale specializes in the treatment of abnormal heart rhythms. He has pioneered some of the present catheter based cures for atrial fibrillation. He was also the first electrophysiologist in the nation to perform percutaneous epicardial radiofrequency ablation, which is a treatment for patients who fail conventional ablations. In 2004, Dr. Natale was named among the "Best Doctors in America."


Dr. Natale was born in Siracusa, Italy. He graduated summa cum laude from the Medical School of the University of Firenze, Italy in 1985 and summa cum laude from the Catholic University School of Cardiology in Rome, Italy. Dr. Natale received his clinical training in cardiology at Methodist Hospital, Baylor College in Houston, Texas and at the University of Western Ontario, London, Ontario, Canada. After completing a clinical fellowship in cardiology (electrophysiology) at the University of Western Ontario in 1991, he further trained in cardiology (electrophysiology) at the University of Wisconsin, Sinai Samaritan Medical Center in Milwaukee. He was appointed to the Cleveland Clinic in 1999.


Results: The MCG-based 3D-EAI has proven useful to localizewell-confined arrhythmogenic substrates, such as focal ventriculartachycardia or preexcitation, to understand some causes for ablation failure,to study atrial electrophysiology including spectral analysis andlocalization of dominant frequency components of AF. However, MCG is stillmissing software tools for automatic and/or interactive 3D imaging, andmultimodal data fusion equivalent to those provided with systems for invasive3D electroanatomical mapping.


Since cardiac electrophysiology (EP) procedures have become morecomplex, a better knowledge of heart chamber anatomy has been required todefine cardiac structures, to optimize catheter navigation and to targetarrhythmogenic substrates (1-3). New methods are increasingly developed tomerge cardiac anatomy with electrophysiological information gathered withnon-fluoroscopic three-dimensional (3D) imaging of catheter mapping ofelectric signal, by incorporation of pre-operative volumetric multidetectorcomputer tomography (MDCT) or magnetic resonance (MR) data sets (4-9). Thishas allowed for more detailed maps of cardiac anatomy to be usedintra-operatively; however, due to positional and physiological changes, theintra operative cardiac anatomy can be different from that depicted in thepre-operative data. Therefore, methods are also under development to improveintegration of 3D preoperative anatomic images with the interventionalelectroanatomical reconstruction (10, 11). A combination of preoperative andintraoperative data sets are then visualized and segmented intra-procedurallyto provide anatomical data and surface models for intervention guidance. The3D electroanatomical imaging (EAI) is increasingly used in the EP laboratorybut, despite continuous developments to improve automatization of data fusionand to enhance accuracy during the intervention, there are still difficultieswhich might lead to interventional failure or complications (12, 13). Thissuggests that there can be still place and need for non-invasive tools togather preoperative information, which can be relevant for selection of themost appropriate interventional approach data (14).


Indeed non-invasive imaging of cardiac electrogenesis with bodysurface potential mapping (BSPM) (15-18) and/or with magnetic field (MF)mapping (19, 20) has been proposed much earlier than first method forinvasive 3D electroanatomical mapping (1). The proposal to usemagnetocardiographic mapping to guide aimed electrophysiology and ablation ofcardiac arrhythmias is more than 20 years old (21). Multiple modeling,experimental and clinical studies have assessed the accuracy of MCG and BSPMfor non-invasive localization of arrhythmogenic substrates (15, 16, 22-25).Compared to BSPM, MCG has the advantages to be contactless, with fixedsensors position and less sensitive to the contribution of tissueconductivity, thus faster and theoretically more practical for routineclinical use (26). Recent clinical work has shown that MCG is a reliable toolfor non-invasive 3D-EAI of well-defined arrhythmogenic substrates such asventricular preexcitation or focal tachycardias (27-29), can also providedynamic imaging of atrial tachyarrhythmias (30, 31), study theelectrophysiological substrate of atrial fibrillation (AF) (32-34) andidentify AF patients who will not respond to surgical AF ablation (35).


In this paper, we will summarize our experience in developing aclinical setup aimed to implement MCG-based 3D-EAI as a routine procedure inthe diagnostic cascade of arrhythmic patients, candidates to ablation. Wewill also show preliminary examples of innovative signal processing of MCG ofAF patients carried out in our unique unshielded laboratory for simultaneousMCG and interventional electrophysiology (45).


Our experience with clinical MCG accounts for 1439 MCG studies;more than 500 patients with cardiac arrhythmias have been studied so far,with different MCG instrumentations (45). In the present configuration ourunshielded laboratory for interventional clinical electrophysiology isequipped with a 36-channel mapping system (CardioMag Imaging Inc,Schenectady, NY), based on DC-SQUID sensors coupled to second-order axialgradiometers (pick-up coil 19 mm and 55-70 mm baselines), with an intrinsicsensitivity of 20 fT/[square root of Hz] in the frequency range of clinicalinterest (47). With a single data acquisition of 90 seconds, the z-component(Bz) of local magnetic field at 36 positions in a plane (6 x 6 grid, coveringan area of 20 x 20 cm) is recorded. Magnetocardiographic signals weredigitally recorded in the DC-100 Hz bandwidth with a Windows-basedacquisition system (24 bits A/D conversion, with automatic electronic noiserejection, at 1 kHz sampling rate) (Fig. 1). 041b061a72


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