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Recording of his bundle electrogram from the arm
J. ELECTROCARDIOLOGY, 6 (3) 193-195, 1973
Recording of His Bundle Electrogram from the Arm* BY NAYAB ALI, M.D., F.R.C.P.(C)**, RAJASEKARAN WICKRAMASEKARAN, M.D., *** ALBERTO BARBEDO, M.D.,***, HAMID FAHDUL, M.D.,*** AND Z A K A U D D I N VERA, M.D.***
the use of the veins of the lower extremities may be relatively contraindicated, practically impossible or an additional procedure. It may, at the same time, be a dire necessity that a His-bundle electrographic study be obtained for diagnostic purposes. It was under these adverse circumstances that attempts were made to use the veins of the upper extremities for the purpose of recording His-bundle potentials. Surprisingly, it was not difficult.
SUMMARY Technique o f recording His-bundle electrograms using the arm vein is described in 14 patients. In four patients, the use o f the veins o f the lower extremity was either contraindicated or not possible. Good quality recordings were obtained and were identical to ones recorded using femoral veins in two patients. The patients in whom only the basilic veins were used felt a little less uncomfortable than those in whom femoral veins were used and the lower trunk almost immobilized.
MATERIAL Since the first report of recording of His-bundle potentials in man in 1969, l His-bundle electrocardiography has become a standard technique in the analysis and understanding of arrhythmias. 26 The technique of introducing recording catheters through the femoral vein as described in the original report has been faithfully adhered to. But under certain circumstances, tampering with the veins of the lower extremities and advancing the catheters through the veins traversing through the pelvis may be less than desirable. Patients with thrombophlebitis of the lower extremities, active pelvic inflammatory disease, pulmonary embolism (where the site of embolus is usually taken to be either deep veins of the legs or pelvis),7 extremely tortuous deep veins (through which the catheters cannot be successfully negotiated) anatomically distorted hip joints (where the thigh cannot be straightened) etc., and in patients developing arrhythmia during diagnostic cardiac catheterization where arm vein has already been isolated,
AND
METHODS
Fourteen patients had their His-bundle electrography performed using either the basilic or brachial vein. Ten patients were undergoing diagnostic cardiac catheterization and both the basilic and femoral veins were already in use. In four patients, in whom the diagnoses included pulmonary embolism, primary myocardial disease with long standing cardiac failure, and repeated pulmonary embolism with inferior vena cava ligation, the veins of the arm were exclusively used for Hisbundle electrographic studies for the diagnosis of arrhythmias. In two patients, His-bundle electrograms were obtained using both the basilic and femoral veins and recorded simultaneously. The ages of the patients ranged between 3 and 49 years. Basilic vein was entered with a No. 4 tripolar catheter (using a percutaneous technique) in one patient. In three others, a cut-d0wn was performed either on basilic or brachial vein. The rest of 10 patients had both the basilic and femoral vein in use for diagnostic cardiac catheterization. A tripolar electrode catheter (size 5-7 French) with the two distal electrodes 5 mm and the two proximal electrodes 10 mm apart was introduced and under fluoroscopic control advanced into right atrium and then laid across the tricuspid valve. The tip of the catheter was manipulated to point medially. (Fig. 1). The two electrodes were connected to the recording channels in Electronic for Medicine recorder and frequencies set at 40500 cps. The catheter was either advanced or withdrawn across the tricuspid valve until a definite deflection was visible between atrial and ventricular activity. If a deflection was
*From Cardiac Catheterization Laboratory, D. C. General Hospital and Howard University Medical Division, Washington, D.C. **Chief of Cardiac Catheterization Laboratory. Acting Chief of Cardiology, D.C. General Hospital and Assistant Professor of Medicine, Howard University Medical Division, D.C. General Hospital, Washington, D.C. ***Fellow in Cardiology, Howard University Medical Service, D.C. General Hospital, Washington, D.C. Address for reprints: Nayab Ali, M.D., Chief, Cardiac Cath Lab, D.C. General Hospital, 19th & Massachusetts Ave., S.E., Washington, D.C. 20003. 193
194
HIS B U N D L E E L E C T R O G R A M FROM A R M
seen too near the ventricular deflection, the tip was withdrawn until another deflection was seen preceding the one near the QRS. The latter was considered His-bundle deflection and it was recorded simultaneously with leads II and V1 at speeds varying from 75-200 m m / s e c with time lines marked 40 msec apart. For the sake of comparison, in two patients, His-bundle electrogram was recorded simultaneously using the two catheters introduced through basilic and femoral veins. (Fig. 2).
RESULTS
Fig. 1. Chest x-ray showing the position of tripolar recording catheter. For the purpose of clarity, the terminal part of the catheter has been retouched.
Good His-bundle electrographic studies were obtained in all the fourteen patients. Patients were free from any complication from the procedure and felt relatively more comfortable lying on the table than those patients where femoral veins were used. No immediate or late complications were noted.
DISCUSSION
Fig. 2. From top to bottom shows Lead II, His-bundle electrogram obtained from the catheter introduced through the basilic vein and the saphenous vein and Lead V~. The position of the His-bundle deflection is indicated by arrows. It may be noted that the two Hisbundle deflections appear at the same time. Beat 2 most probably is a fascicular beat because (1) His deflection is premature (2) A-H interval (for second A) is 35 msec as opposed to first A-H of 80 msec and H-Q interval is -10 msec; therefore, His-bundle deflection does not belong to preceding A, but the fascicular beat, which has right bundle branch block and leftward axis thus originating from inferior division of left bundle. It is able to depolarize the ventricles 10 msec earlier than the His-bundle in its retrograde path.
Arm veins, either using percutaneous technique or a cutdown can be used for His-bundle electrographic studies. This technique has been found to be useful in patients who have relative contraindications for using their femoral veins, e.g., active thrombophlebitis of the leg and thigh veins, pelvic inflammatory disease, bleeding diathesis, any condition causing acute abdomen, in patients where femoral veins are simply unapproachable, e.g., flexion deformity of the hip and in patients where inferior vena cava is either non-negotiable or should not be traversed by a catheter, e.g., thrombosis of IVC, ligated IVC and in patients with inferior vena cava filter umbrella. No special catheters were needed. Different catheters used for His-bundle electrographic studies using femoral vein could also be used when using the arm vein. In some cases, it was found that a larger sized catheter viz. No. 7F gave a more stable recording of the His-bundle potential than a small sized catheter. Sometimes it was necessary to hold the catheter in a certain position once His-bundle deflections were seen, but once stabilized, it could be left in place without losing His-bundle deflections. It proved to be a little less convenient than recording using the femoral vein but the ease with which atrioventricular conduction system could be studied using this technique more than compensated for the inconvenience to the investigator. d. ELECTROCARDIOLOGY,VOL. 6, NO. 3, 1973
A L l ET A L
REFERENCES 1. Scherlag, B. J., Lau, S. H., Helfant, R. H., Berkowitz, W. D., Stein, E., and Damato, A. N.: Catheter technique for recording His bundle activity in man. Circulation 39: 13, 1969. 2. Massumi, R. A., and Ali, N.: Determination of the site of impaired conduction in atrio ventricular block. J. Electrocardiol. 3: 193, 1970. 3. Damato, A. N., Lau, S. H., Helfant, R. H., Stein, E., Berkowitz, W. D., and Cohen, S.: Study of A-V conduction in man using electrode catheter recordings of His-bundle activity. Circulation 39: 287, 1969.
J. ELECTROCARDIOLOGY, VOL. 6, NO. 3, 1973
195
4. Narula, O. S., Cohen, L. S., Samet, P., Lister, J. W., Scherlag, B., and Hildner, F. J.: Localization of A-V conduction in defects in man by recording of His-bundle electrogram. Am. J. Cardiol. 25: 228, 1970. 5. Castillo, C. A., and Castellanos, A.: His-bundle recordings in patients with reciprocating tachycardias and Wolff-Parkinson White syndrome. Circulation 42: 271, 1970. 6. Rosen, K. M., Loeb, H. S., Chiquimia, R., Sinno, M. Z., Rahimtooa, S. H., and Gunner, R. M.: Site of heart block in acute myocardial infarction. Circulation 42: 925, 1970. 7. Friedberg, K. C.: Pulmonary Embolism and Acute Cor Pulmonale in Diseases of the Heart. W. B. Saunder Co., Philadelphia, 1966, p. 1529.
Recording of His Bundle Electrogram from the Arm* BY NAYAB ALI, M.D., F.R.C.P.(C)**, RAJASEKARAN WICKRAMASEKARAN, M.D., *** ALBERTO BARBEDO, M.D.,***, HAMID FAHDUL, M.D.,*** AND Z A K A U D D I N VERA, M.D.***
the use of the veins of the lower extremities may be relatively contraindicated, practically impossible or an additional procedure. It may, at the same time, be a dire necessity that a His-bundle electrographic study be obtained for diagnostic purposes. It was under these adverse circumstances that attempts were made to use the veins of the upper extremities for the purpose of recording His-bundle potentials. Surprisingly, it was not difficult.
SUMMARY Technique o f recording His-bundle electrograms using the arm vein is described in 14 patients. In four patients, the use o f the veins o f the lower extremity was either contraindicated or not possible. Good quality recordings were obtained and were identical to ones recorded using femoral veins in two patients. The patients in whom only the basilic veins were used felt a little less uncomfortable than those in whom femoral veins were used and the lower trunk almost immobilized.
MATERIAL Since the first report of recording of His-bundle potentials in man in 1969, l His-bundle electrocardiography has become a standard technique in the analysis and understanding of arrhythmias. 26 The technique of introducing recording catheters through the femoral vein as described in the original report has been faithfully adhered to. But under certain circumstances, tampering with the veins of the lower extremities and advancing the catheters through the veins traversing through the pelvis may be less than desirable. Patients with thrombophlebitis of the lower extremities, active pelvic inflammatory disease, pulmonary embolism (where the site of embolus is usually taken to be either deep veins of the legs or pelvis),7 extremely tortuous deep veins (through which the catheters cannot be successfully negotiated) anatomically distorted hip joints (where the thigh cannot be straightened) etc., and in patients developing arrhythmia during diagnostic cardiac catheterization where arm vein has already been isolated,
AND
METHODS
Fourteen patients had their His-bundle electrography performed using either the basilic or brachial vein. Ten patients were undergoing diagnostic cardiac catheterization and both the basilic and femoral veins were already in use. In four patients, in whom the diagnoses included pulmonary embolism, primary myocardial disease with long standing cardiac failure, and repeated pulmonary embolism with inferior vena cava ligation, the veins of the arm were exclusively used for Hisbundle electrographic studies for the diagnosis of arrhythmias. In two patients, His-bundle electrograms were obtained using both the basilic and femoral veins and recorded simultaneously. The ages of the patients ranged between 3 and 49 years. Basilic vein was entered with a No. 4 tripolar catheter (using a percutaneous technique) in one patient. In three others, a cut-d0wn was performed either on basilic or brachial vein. The rest of 10 patients had both the basilic and femoral vein in use for diagnostic cardiac catheterization. A tripolar electrode catheter (size 5-7 French) with the two distal electrodes 5 mm and the two proximal electrodes 10 mm apart was introduced and under fluoroscopic control advanced into right atrium and then laid across the tricuspid valve. The tip of the catheter was manipulated to point medially. (Fig. 1). The two electrodes were connected to the recording channels in Electronic for Medicine recorder and frequencies set at 40500 cps. The catheter was either advanced or withdrawn across the tricuspid valve until a definite deflection was visible between atrial and ventricular activity. If a deflection was
*From Cardiac Catheterization Laboratory, D. C. General Hospital and Howard University Medical Division, Washington, D.C. **Chief of Cardiac Catheterization Laboratory. Acting Chief of Cardiology, D.C. General Hospital and Assistant Professor of Medicine, Howard University Medical Division, D.C. General Hospital, Washington, D.C. ***Fellow in Cardiology, Howard University Medical Service, D.C. General Hospital, Washington, D.C. Address for reprints: Nayab Ali, M.D., Chief, Cardiac Cath Lab, D.C. General Hospital, 19th & Massachusetts Ave., S.E., Washington, D.C. 20003. 193
194
HIS B U N D L E E L E C T R O G R A M FROM A R M
seen too near the ventricular deflection, the tip was withdrawn until another deflection was seen preceding the one near the QRS. The latter was considered His-bundle deflection and it was recorded simultaneously with leads II and V1 at speeds varying from 75-200 m m / s e c with time lines marked 40 msec apart. For the sake of comparison, in two patients, His-bundle electrogram was recorded simultaneously using the two catheters introduced through basilic and femoral veins. (Fig. 2).
RESULTS
Fig. 1. Chest x-ray showing the position of tripolar recording catheter. For the purpose of clarity, the terminal part of the catheter has been retouched.
Good His-bundle electrographic studies were obtained in all the fourteen patients. Patients were free from any complication from the procedure and felt relatively more comfortable lying on the table than those patients where femoral veins were used. No immediate or late complications were noted.
DISCUSSION
Fig. 2. From top to bottom shows Lead II, His-bundle electrogram obtained from the catheter introduced through the basilic vein and the saphenous vein and Lead V~. The position of the His-bundle deflection is indicated by arrows. It may be noted that the two Hisbundle deflections appear at the same time. Beat 2 most probably is a fascicular beat because (1) His deflection is premature (2) A-H interval (for second A) is 35 msec as opposed to first A-H of 80 msec and H-Q interval is -10 msec; therefore, His-bundle deflection does not belong to preceding A, but the fascicular beat, which has right bundle branch block and leftward axis thus originating from inferior division of left bundle. It is able to depolarize the ventricles 10 msec earlier than the His-bundle in its retrograde path.
Arm veins, either using percutaneous technique or a cutdown can be used for His-bundle electrographic studies. This technique has been found to be useful in patients who have relative contraindications for using their femoral veins, e.g., active thrombophlebitis of the leg and thigh veins, pelvic inflammatory disease, bleeding diathesis, any condition causing acute abdomen, in patients where femoral veins are simply unapproachable, e.g., flexion deformity of the hip and in patients where inferior vena cava is either non-negotiable or should not be traversed by a catheter, e.g., thrombosis of IVC, ligated IVC and in patients with inferior vena cava filter umbrella. No special catheters were needed. Different catheters used for His-bundle electrographic studies using femoral vein could also be used when using the arm vein. In some cases, it was found that a larger sized catheter viz. No. 7F gave a more stable recording of the His-bundle potential than a small sized catheter. Sometimes it was necessary to hold the catheter in a certain position once His-bundle deflections were seen, but once stabilized, it could be left in place without losing His-bundle deflections. It proved to be a little less convenient than recording using the femoral vein but the ease with which atrioventricular conduction system could be studied using this technique more than compensated for the inconvenience to the investigator. d. ELECTROCARDIOLOGY,VOL. 6, NO. 3, 1973
A L l ET A L
REFERENCES 1. Scherlag, B. J., Lau, S. H., Helfant, R. H., Berkowitz, W. D., Stein, E., and Damato, A. N.: Catheter technique for recording His bundle activity in man. Circulation 39: 13, 1969. 2. Massumi, R. A., and Ali, N.: Determination of the site of impaired conduction in atrio ventricular block. J. Electrocardiol. 3: 193, 1970. 3. Damato, A. N., Lau, S. H., Helfant, R. H., Stein, E., Berkowitz, W. D., and Cohen, S.: Study of A-V conduction in man using electrode catheter recordings of His-bundle activity. Circulation 39: 287, 1969.
J. ELECTROCARDIOLOGY, VOL. 6, NO. 3, 1973
195
4. Narula, O. S., Cohen, L. S., Samet, P., Lister, J. W., Scherlag, B., and Hildner, F. J.: Localization of A-V conduction in defects in man by recording of His-bundle electrogram. Am. J. Cardiol. 25: 228, 1970. 5. Castillo, C. A., and Castellanos, A.: His-bundle recordings in patients with reciprocating tachycardias and Wolff-Parkinson White syndrome. Circulation 42: 271, 1970. 6. Rosen, K. M., Loeb, H. S., Chiquimia, R., Sinno, M. Z., Rahimtooa, S. H., and Gunner, R. M.: Site of heart block in acute myocardial infarction. Circulation 42: 925, 1970. 7. Friedberg, K. C.: Pulmonary Embolism and Acute Cor Pulmonale in Diseases of the Heart. W. B. Saunder Co., Philadelphia, 1966, p. 1529.