Simultaneous use of several right heart mapping multielectrode catheters may be used for mapping complex tachycardias.

Shown here is a videoscopic view of three multi-ring mapping/ablation catheters placed into the right heart via the inferior vena cava. One of these catheters can be viewed as it is being articulated and directed into the coronary sinus. This is a decapolar, or ten electrode, catheter used for mapping procedures.

Electrophysiologic testing involves intracardiac recording using diagnostic catheters and programmed electrical stimulation of the heart.

Shown here is a unique duo-decapolar catheter design, which is being positioned within the right atrium during a mapping procedure.

Simultaneous use of several right heart mapping multielectrode catheters may be used for mapping complex tachycardias.

Shown here is a videoscopic view of a multi-ring mapping/ablation catheter placed into the right heart via the inferior vena cava. One of these catheters can be viewed as it is being positioned into the right ventricular apex during a mapping procedure.

Simultaneous use of several right heart mapping multielectrode catheters may be used for mapping complex tachycardias.

Shown here is a videoscopic view of two multi-ring mapping/ablation catheters placed into the right heart via the inferior vena cava. One of these catheters can be viewed as it is being positioned into the area of the right atrium known as the Triangle of Koch, which borders the zone where the AV node and His bundle lie. Once can see the second catheter passing through the tricuspid valve.

The pulmonary artery (PA) catheter is a highly useful multi-lumen, balloon tipped diagnostic catheter. The balloon on the tip helps to guide the catheter, acting as a ‘sail’ in the flow of blood and also reduces injury to the tissue by acting as a cushion. PA catheters can measure pressures of the heart in multiple chambers of heart, cardiac output via thermodilution, and blood oxygen saturation or tissue oxygen saturation.

The pressure monitoring of the catheter is of particular benefit due to the fact that multiple chambers can be monitored simultaneously. The right atrial, right ventricular, pulmonary artery, and indirect left atrial (‘wedge pressure’) pressures can all be monitored. Due to the fact that there is a pressure lumen distal to the balloon on the tip of the catheter, the catheter can be ‘wedged’ into a small pulmonary artery. When the balloon occludes the artery, the tip sensor is essentially detecting the pressure of the left atria because the lungs are a low resistance path of blood flow. This measurement is particularly useful in assessing fluid status, function of the right and left heart, or the presence of ventricular failure or pulmonary edema to guide therapeutic measures.

A similar video was published in 2012 in the American Journal of Respiratory and Critical Care Medicine titled The Path of a Pulmonary Artery Catheter Visualized through a Beating Human Heart.

Electrophysiologic testing of patients to identify arrhythmias involves intracardiac recording using diagnostic catheters and programmed electrical stimulation of the heart, thus facilitating the diagnoses of bradycardias and tachycardias. Generally, on the right side of the heart, catheters are placed in four locations: high right atrium (HRA), right ventricle (RV), His bundle (His or HB), and the coronary sinus (CS).

Diagnostic catheters are available with fixed curves and deflectable tips.

Cardiac mapping involves the identification of cardiac tissue that is causing the tachycardia. Delivery of radiofrequency current or cryotherapy to create a lesion in the area of interest destroys the selected tissue and prevents arrhythmias.

The HRA catheter is typically placed close to the SA node. The RV catheter is usually positioned in the ventricular apex to record right ventricular activity and for right ventricular pacing. The His bundle catheter is placed across the tricuspid valve to record a His bundle electrogram. A multielectrode catheter is placed in the coronary sinus to record electrical activity in the coronary sinus. Placement of a CS catheter is especially helpful when the arrhythmia mechanism may also involve the left atrium.

Simultaneous use of additional right atrial mapping multielectrode catheters may be used for mapping tachycardias.

Shown here is a videoscopic view of a multi-ring mapping/ablation catheter placed in the high right atrial position which was delivered to the heart via the inferior vena cava.

Right side pressure mapping as a balloon catheter is passed through the Tricuspid and pulmonary valves and finally wedged in the pulmonary trunk.

Shown here is a videoscopic view of a transseptal puncture of the fossa ovalis from the right atrium (RA). First the septum is tented and then punctured with a wire, then a dialator is advanced. Next a delivery catheter containing a cryoAblation balloon is advanced; the balloon is inflated, placed within the left atrial appendage (LAA), cooled, deflated, and then retracted.

Shown here is a videoscopic view of a cryoAblation catheter placed on the septum of the right atrium (RA). The cooling is initiated and ice forms; the clear buffer forms a clear ice block around the catheter. After therapy is complete, the cooling is stopped and the ice quickly thaws, at which time the catheter is then repositioned.

Shown here is a videoscopic view of a cryoAblation catheter placed on the endocardium (Isthmus) of the right atrium (RA) via the inferior vena cava (IVC). The cooling is initiated and ice forms; the clear buffer forms a clear ice block around the catheter. The distal end of the catheter is then tugged, but the ice formation holds the catheter tight. After therapy is complete, the cooling is stopped and the ice quickly thaws; the catheter is then manipulated as it was before and it moves easily.

The detection of arrhythmias is a complex process that requires a skilled electrophysiologist so that proper treatment can be provided. Often, the mechanism of the arrhythmia determines which treatment will be most successful.

Shown here is a videoscopic view of an ablation procedure in the right atrium. Here the goal is to ablate the slow atrial conduction pathway, therefore the tip electrode of the ablation catheter is positioned along the tricuspid annulus, near the ostium of the coronary sinus. The boundaries of the Triangle of Koch guide catheter placement precisely. One can observe the tricuspid valve below. The fossa ovalis is back lit by placing a videoscope in the left atrium. The inset on the lower right shows electrical signals being recorded (upper signal) as well as left ventricular pressures (lower trace); at times, the heart is being paced through this catheter.

Not all arrhythmias identified during electrophysiologic studies can be treated by ablation therapy. Often, the mechanism of the arrhythmia determines which treatment will be most successful. The FDA has approved the following indications for radiofrequency (RF) catheter ablation:

1. atrioventricular nodal reentrant tachycardia (AVNRT);
2. atrioventricular reentrant tachycardia (AVRT) caused by accessory conduction pathways (also called bypass tracts);
3. atrioventricular nodal tachycardias resulting in inadequate ventricular rate control;
4. ventricular tachycardia (VT) occurring in the absence of cardiovascular disease.

This therapy has also been used to treat tachyarrhythmias including:

1. atrial tachycardia (atrial flutter, atrial fibrillation, and sinus (SA) node reentry);
2. permanent junctional reciprocating tachycardia (PJRT);
3. ventricular tachycardia occurring in the presence of structural heart disease.

Shown here is the electrode tip of an ablation catheter positioned along the tricuspid annulus, near the ostium of the coronary sinus. The boundaries of the Triangle of Koch guide catheter placement precisely. As the energy is applied, one can observe a color change in the tissue being ablated.

Shown here is the videoscopic image of an electrode tip of an ablation catheter positioned along the tricuspid annulus, near the ostium of the coronary sinus. As the energy is applied, one can observe a color change in the tissue being ablated. The catheter is moved until the proper lesion is created (e.g., in a line for a linear lesion).

Shown here is a close-up videoscopic view of a delivery catheter for left-heart transvenous leads being manipulated within the coronary sinus (CS).

Shown here is a close-up videoscopic view of a delivery catheter for left-heart transvenous leads being manipulated within the coronary sinus (CS).

Shown here is a videoscopic view of a steerable delivery catheter for left-heart transvenous leads; it is being manipulated within the coronary sinus (CS).

Electrophysiologic studies require the careful placement of diagnostic electrode catheters within the heart. The use of fluoroscopy and intracardiac EMG recordings verifies the position of the electrode catheters.

Three approaches are generally used for advancing the electrode catheter to the heart: 1) femoral venous approach using the inferior vena cava (IVC); 2) subclavian, jugular, or brachial (antecubital) venous approach via the superior vena cave (SVC); or 3) femoral arterial or retrograde approach via the femoral artery.

The approach chosen depends upon the targeted area within the heart, the number of electrode catheters used during the electrophysiologic study, and physician experience and preference. Typically, the IVC and SVC approaches are used for RA, RV, His bundle, and CS electrode catheters.

Shown here is a videoscopic view of four multi-ring mapping/ablation catheters placed into the right heart via the inferior vena cava. These catheters were positioned in the high right atrium, the right ventricular apex, near the His bundle, and within the coronary sinus. This catheter placement is typical during a complex mapping procedure.

Shown here is an external view of a pre-shaped catheter being advanced into the left anterior descending vein to eventually sub-select a side branch for lead placement.

Shown here is an external view of a pre-shaped catheter and a flexible tipped intercatheter being advanced into the left anterior descending vein, and then eventually used to sub-select a side branch for lead placement.

Electrophysiologic studies require the careful placement of diagnostic electrode catheters within the heart. The use of fluoroscopy and intracardiac EMG recordings verifies the position of the electrode catheters.

Three approaches are generally used for advancing the electrode catheter to the heart: 1) femoral venous approach using the inferior vena cava (IVC); 2) subclavian, jugular, or brachial (antecubital) venous approach via the superior vena cave (SVC); or 3) femoral arterial or retrograde approach via the femoral artery.

The approach chosen depends upon the targeted area within the heart, the number of electrode catheters used during the electrophysiologic study, and physician experience and preference. The femoral arterial approach may also be used for gaining access to the left ventricle and/or left atrium.

As an extension of the IVC approach, an ablation catheter may also be advanced from the right atrium, across the interatrial septum, and into the left atrium using the transseptal approach.

During this approach, the interatrial septum must be punctured before a catheter can be advanced to the left atrium. To create an opening, a transseptal needle is advanced through a long sheath positioned at the foramen ovalis, a thin area of tissue in the interatrial septum. When the needle is withdrawn from the sheath, an ablation catheter is advanced through the septum to the left atrium. At this point the patient must be anticoagulated.

The ablation catheter may then be positioned for mapping and ablation. This approach is useful for left free-wall accessory pathway and AV nodal ablation (atrial fibrillation), as well as future indications for left atrial and left ventricular procedures (e.g., Wolf-Parkinson-White syndrome).

Shown here is a videoscopic view of the transseptal catheterization procedure to access the left atrium through the foramen ovalis (a sheath after a needle puncture).

Electrophysiologic studies require the careful placement of diagnostic electrode catheters within the heart. The use of fluoroscopy and intracardiac EMG recordings verifies the position of the electrode catheters.

Three approaches are generally used for advancing the electrode catheter to the heart: 1) femoral venous approach using the inferior vena cava (IVC); 2) subclavian, jugular, or brachial (antecubital) venous approach via the superior vena cave (SVC); or 3) femoral arterial or retrograde approach via the femoral artery. As an extension of the IVC approach, an ablation catheter may also be advanced from the right atrium, across the interatrial septum, and into the left atrium using the transseptal approach.

During this approach, the interatrial septum must be punctured before a catheter can be advanced to the left atrium. To create an opening, a transseptal needle is advanced through a long sheath positioned at the foramen ovalis, a thin area of tissue in the interatrial septum. When the needle is withdrawn from the sheath, an ablation catheter is advanced through the septum to the left atrium. At this point the patient must be anticoagulated. The ablation catheter may then be positioned for mapping and ablation. This approach is useful for left free-wall accessory pathway and AV nodal ablation (atrial fibrillation) as well as future indications for left atrial and left ventricular procedures (e.g., Wolf-Parkinson-White syndrome).

Shown here is a videoscopic view of the transseptal catheterization procedure to access the left atrium through the foramen ovalis. A sheath is placed and then a mapping/ablation catheter is positioned both within the left atrium and ventricle by passing it through the mitral valve.