EP tracing in sinus rhythm while planning radiofrequency catheter ablation for AV noddal reentrant tachycardia (AVNRT) in sinus rhythm.

Upper three tracing are surface electrocardiograms leads I, II and V1 (white). Next three tracing are from the His bundle catheter His distal and proximal. The large broad deflections in this tracing is the V (ventricular electrogram) while the triphasic signal prior to it is the His potential (H). The deflection before that is the atrial electrogram (A). Five pairs of electrodes in coronary sinus are numbered from distal to proximal so that CS 9 10 is the proximal pair and CS 1 2 is the distal pair, with the other pairs in between. All the tracings from the coronary sinus electrodes are in violet colour. The earliest atrial activity is in the surface lead V1. The atrial activity in the His electrode comes after that, followed by the proximal conary sinus electrodes. Distal coronary sinus electrodes pick up the atrial activity later, reflecting later activation of the left atrium. The distal coronary sinus electrodes also show the ventricular activity, which is more delayed than the ventricular activity picked by the right ventricular electrodes (RVd: distal; RVp: proximal). The mapping electrode (ablation catheter) picks up atrial and ventricular activities and a tiny His potential. The distal mapping electrode (MAPd) picks up a fractionated atrial electrogram, a tiny His potential and a relatively smaller ventricular electrogram. This type of elctrogram is obtained while mapping the potential site for slow pathway ablation, which is between the His bundle catheter and the coronary sinus catheter, in the posterior approach for AVNRT ablation. General EP tracing during ventricular pacing showing atrial ventricular activation. The CS 910 electrode is in the proximal coronary sinus while the CS12 electrode is in the distal coronary sinus. A represents atrial activation and V represents ventricular activation. The pacing stimulus is delivered from the HISD electrode as evidenced by the polarization artefact seen in this lead. But the electrode does not seen to be in the region of the His bundle as neither the His bundle activity nor the atrial activity is seen as is usual. It seems that the lead has been pushed into the ventricle during the EP study for ventricular pacing. This is sometimes done to minimise the total number of electrodes being used during an EP study. The RFD and RFP electrodes do not seem to be connected to the recorder as these electrodes are not recording any electrical activity of the heart. The initial QRS is narrow while the subsequent two QRS complexes preceded by pacing spikes are wide. The first one is a sinus beat conducted to the ventricles while the latter two are paced beats. The atrial activity picked up by the coronary sinus leads show almost the same sequence of activation as the sinus beat, though it is retrogade activation. But the retrograde interval is longer for the second paced beat compared to the first paced beat.