Catheter ablation is a rapidly evolving science and has proved to be a good solution in most of the patients suffering from recurrent arrhythmia, which limit their productivity and hinder their lifestyle. The use of catheter ablation was first introduced in the late 1960s; it was designed first for recording, where the surgical treatment of the cardiac arrhythmia was the main concept. In 1967, the concept of induction of cardiac arrhythmia was first introduced through programmed electrical stimulation. In the late 1970s, Wellen was able to perform PES and record the activation sequences from more than one recording catheter, followed by the development of both the surgical ablation and the intracardiac recordings. Previously the arrhythmia was terminated by surgical maneuvers, for example, surgical excision of the triggered arrhythmogenic focus for atrial tachycardia and cryo excision of the AV junction in case of resistant supraventricular tachycardia. The maze procedure is one of the well-known procedures, particularly during mitral valve surgery complicated with atrial fibrillation (AF), for AF termination.

In 1981, the concept of the transvenous catheter was first defined when a patient that was undergoing an electrophysiological recording following defibrillation, where a high-voltage discharge was emitted when the defibrillator electrode hit the catheter electrode at His. This energy caused damage to underlying tissue (Gonzales et al.).

Direct current cardioversion was first used in atrial fibrillation ablation. The direct current was delivered to the distal electrode and a surface electrode; this led to uncontrollable tissue damage.

In the 1990s, radiofrequency ablation replaced the direct current. RF energy is an alternating current generated with a frequency of 350 kHz to 700 kHz (usually 500 kHz on commercially available RF generators) delivered in a continuous, unmodulated sinusoidal manner to create thermal injury. The current is delivered in a unipolar fashion from the tip of the catheter electrode to a large surface (100 cm2 to 250 cm2). A patch is placed against the skin where the electric energy is delivered and converted to thermal injury when it passes through the tissue (resistive heating). Large patches are placed on the patient back as a ground to avoid skin burns. Tissue in direct contact with the catheter is damaged by resistive heating while deeper and surrounding tissues are heated and damaged by conductive heating. Acute lesions show inflammation and hemorrhage around a central area of coagulative necrosis. Areas with inflammation at the border of central necrosis explain the recurrence of arrhythmias later, as the area may contain viable arrhythmogenic tissue that is acutely non-conductive at the time of ablation but can conduct later after the healing process takes place.[1][2][3][4][5]

The venous system approaches mostly right and left femoral veins. In the case of difficult coronary sinus cannulation, the internal jugular or subclavian vein approach may be used. Diagnostic catheters are inserted to allow pacing, stimulation, and signal recording at the high right atrium, right ventricle (apex or RVOT), His bundle and the coronary sinus. The left side can be accessed through an antegrade transeptal puncture from the right atrium into the left atrium or a retrograde aortic approach.

Indications include:

1. SVT due to recurrent, refractory  AVNRT and AVRT 
2. Accessory pathway ablation
3. Atrial fib ablation
4. Atrial flutter ablation.
5. VT ablation, for those with normal heart (outflow tract tachycardia, ARVD/c, fascicular tachycardia)
6. VT ablation for those with ischemic induced VT

The contraindications are limited to vascular access contraindication as DVT for femoral vein access and PAD and aortic dissection in case of retrograde aortic approach.

Also, the presence of intracardiac thrombi, to prevent the risk of embolization.

Bleeding complications are one of the main contraindication for catheter ablation. Usually, the electrophysiologist can interfere with the patient safety with the INR up to 3.

Catheters

A variety of catheters is available with at least two ring electrodes that can be used for bipolar stimulation and recording. The catheter may be made of woven Dacron or the newer synthetic materials such as polyurethane. Woven Dacron catheters are preferred because of their greater durability and physical properties. These catheters have a variable number of electrodes, electrode spacing, and curves to provide a range of options for different purposes. Although they have superior torque characteristics, their greatest advantage is that they are stiff enough to maintain a shape and yet they soften at body temperature so that they are not too stiff for forming loops and bends in the vascular system to adopt a variety of uses.

Synthetic catheters cannot be manipulated or change shapes within the body, so they are less desirable. The synthetic catheters are cheaper and offer smaller sizes (2 to 3 French). Currently, most electrode catheters are size 3 to size 8 French. The smaller sizes are used in children. In adult patients, sizes 5 to 7 French catheters are routinely used. Other diagnostic catheters have a deflectable tip. These are used to reach and record from specific sites (e.g., coronary sinus, crista terminalis, tricuspid valve). In most instances, the standard woven Dacron catheters suffice, and they are significantly cheaper. Mapping catheters fall into two general categories:

A. Deflectable catheters to facilitate positioning for mapping and delivering ablative energy.

B. Catheters with multiple poles (8 to 64) that allow simultaneous acquisition of activation points. 

Some ablation catheters have a cooled tip, one through which saline is infused to allow for enhanced tissue heating without superficial charring (Biosense Webster and St Jude) or internal cooling.

Ablation catheters deliver RF energy through tips that are typically 3.5 to 5 mm in length but maybe as long as 10 mm. Catheters delivering microwave, laser, cryothermal, or pulsed-ultrasound energy to destroy tissue are currently under active investigation. The cryothermal catheters have been approved by the FDA for A-V nodal modification for A-V nodal tachycardia but are also being evaluated for atrial fibrillation developing the Cryoballoon catheter (Arctic; Medtronic).

In the second category, standard catheters with up to 24 poles that can be deflected to map large and/or specific areas of the atrium (e.g., coronary sinus, tricuspid annulus). Shaped catheters as “halo” record from around the tricuspid ring or a lasso catheter on a deflectable shaft to record from 10 to 20 electrodes in the pulmonary vein/ostia, (Biosense Webster and St Jude) and basket catheters which have up to 64 poles or prongs that spring open and which are used to acquire simultaneous data from within a given cardiac chamber.

A catheter is available from which has five flexible splines with four electrodes on each spline allowing on to acquire 20 sites of activation. The 2-mm interelectrode distance allows for high-density mapping. The floppiness of the splines sometimes makes for variable contact in misinterpretation of data.

More recently a new catheter was has been developed a 64-pole roving catheter. This mapping (mini basket) catheter has an 8 F bidirectional deflectable shaft and a basket electrode array (usual mapping diameter 18 mm) with eight splines, each spline containing eight small (0.4 mm2), low-impedance electrodes (total 64 electrodes). The interelectrode spacing along the spline is 2.5 mm (center-to-center). Mapping can be performed with the basket in variable degrees of deployment (diameter ranging 3 mm to 22 mm). The location of each of the 64 electrodes is identified by a combination of a magnetic sensor in the distal region of the catheter and impedance sensing on each of the 64 basket electrodes. The location of each basket electrode is obtained whether the basket is fully or only partially deployed.

Junction Box

The junction box is a rectangular box that receives the intracardiac signals from the catheters and provides the interface to the physiologic recorder. Multiple switches within the junction box are designated to a recording and stimulation channel which can be selected through the recording apparatus.To minimize noise on the channels, the junction box is mounted close to the patient foot.

Recording Apparatus

The physiologic recorder records, displays, and stores intracardiac and surface recordings. It consists of filters, amplifiers, display screens, and recording software. From the junction box, the physiologic signals are introduced into the recorder. These signals are typically low in amplitude and are amplified before displaying and recording. The recording system amplifies and filters each input channel separately, with most current systems supporting up to 64 or more channels. The amplifiers can automatically or manually adjust gain control. The amplifiers should be mounted as close to the patient table as possible, to reduce the cable length of the intracardiac connections and surface ECGs, which minimizes the signal noise. The amplifier is then connected to the main physiologic recorder through a channel, which, ideally, should run separately from electric power cables. Filters are used to eliminate unnecessary signals that distort electrograms (EGMs).

 High pass filters eliminate signals below a given frequency while low pass filters eliminate signals above a given frequency. Most intracardiac electrograms are clearly identified when the signal is filtered between a high pass of 40 Hz and a low pass of 500 Hz.

Stimulator

A programmable stimulator is necessary to obtain electrophysiologic data beyond measurements of conduction intervals. Stimulators are capable of various modes of pacing, including rapid pacing, delivery of single or multiple extra stimuli following a paced drivetrain, and delivery of timed, extra stimuli following sensed beats. Stimulators are capable of delivering variable currents, from 0.1 mA to 10 mA. With the satisfactory positioning of catheters, current thresholds under 2 mA (with 2 ms pulse width) can usually be achieved in both the atrium and ventricle. Higher outputs are seen in the diseased myocardium, within the coronary sinus, and with the use of anti-arrhythmic medications. The output is usually set at twice the diastolic threshold. Pacing at higher outputs is discouraged because may led to the far-field capture and altered the QRS and EGM configuration and may mislead diagnosis, the recommendation is either to start at low amplitude until capture, or start at high output and go low until failure of capture then increase a step.

Cardioverter/Defibrillator

A primary and backup cardioverter/defibrillator should be available throughout all EP studies, defibrillators deliver energy in a biphasic waveform which offers enhanced defibrillation success. Defibrillation pads are attached to the patient and electrically grounded.

Radiofrequency Ablation

Radiofrequency ablation uses alternating current delivered between the catheter tip and grounding source to deliver energy to tissue, resulting in necrosis. Radiofrequency generators deliver current with a frequency between 300 kHz and 750 kHz, with the generation of heat occurring as a result of resistive and conductive heating. Monitoring of time, power, and impedance is necessary to ensure safe and effective ablation lesions.

Catheter Positioning

This depends on the type of the ablation procedure we are going to.

A. SVT cases we use:

1. HRA catheter: quadripolar fixed curve catheter in the right atrium near the SAN.
2. His catheter: quadripolar catheter fixed curve at the His region, it passes from the IVC and just passes the tricuspid valve to be straddling both the low RA and the RV, it should have three recordings (A-H-V) catheters.
3. RV catheter: quadripolar fixed curve catheter at the RV apex, and can move the RVOT.
4. Decapolar fixed or steerable catheter into the coronary sinus.

Catheters that are for diagnostic purposes are inserted Via the left femoral vein, while the ablation catheters and those that require manipulation during the procedure are inserted along the right side.

B. Atrial flutter:

The same basic catheters, plus the Halo catheter, it’s a duo Decapolar catheter, which occupies the whole RA in order to determine the activation sequence in case of atrial flutter.

C. Atrial fibrillation involves the basic catheters; the Lasso catheter is introduced, in addition to the ablation catheter to map the pulmonary veins and test for exit block.

D. VT ablation

We use the RVA and the C.S catheter, together with Pentary and the steerable deflectable ablation catheter.

Methodology

The electrophysiologic study should consist of a systematic analysis of dysrhythmias by recording and measuring a variety of electrophysiologic events with the patient in the basal state and by evaluating the patient's response to programmed electrical stimulation. To perform and interpret the study correctly, we have to understand certain concepts and methods, including the different types of electrogram recordings, measurement of atrioventricular (A-V) conduction intervals, activation mapping, and response to programmed electrical stimulation. Knowledge of the significance of the various responses, particularly to aggressive stimulation protocols, is mandatory before employing such responses to make clinical judgments.

Electrogram Recordings

Electrograms can be recorded as unfiltered or filtered unipolar signal or bipolar signals.

1. Unipolar signals provide precise activation and give directional information. Unfiltered shows significant far-field activity is recorded that can make it difficult to see small local unipolar signals without increasing the size of the signal so much it swamps the amplifier. Respiratory drift is another problem. Filtering the unipolar signal gives precise localization and removes far-field activity but often results in a very small signal, particularly in infarcted tissue.
2. Bipolar signal approximates the timing recorded by the filtered unipolar signal, particularly with narrow interelectrode distances (less than or equal to 2 mm) and removes far-field signals, but does not give the directional information of the unfiltered unipolar signal. For ablation, particularly for the WPW syndrome and idiopathic PVCs/VT, it is important to record both simultaneously to assure the earliest components of the bipolar signal are derived from the distal pole, which is used for ablation, and not the proximal pole.