35
Intracardiac Electrophysiology Tracings
MALINI MADHAVAN, MBBS, CHRISTOPHER J. MCLEOD, MB, CHB, PHD,
DOUGLAS L. PACKER, MD, and SAMUEL J. ASIRVATHAM, MD
The field of analysis and interpretation of intracardiac EGMs is
fascinating but complex and often intimidates the general cardio-
vascular trainee. For the cardiovascular board examination, how-
ever, a very limited and fundamental knowledge of intracardiac
EGMs is expected. In this chapter, the normal intracardiac EGM
sequence is introduced and briefly explained; tracings illustrate
the main concepts that may be tested on the cardiovascular board
examination.
Intracardiac EGMs are an extension of the surface 12-lead
ECG. The more familiar a student is with analyzing 12-lead ECGs
obtained during slow and fast rhythms, the easier it will be to
understand invasive tracings. In some ways, intracardiac EGMs
are easier to interpret than ECGs. For example, for tachyarrhyth-
mia analysis on ECG, it can be difficult to know where the P
wave is located (sometimes buried within the QRS) and, without
this interpretation, the mechanism of arrhythmia cannot be diag-
nosed. However, with invasive tracings, as will be explained, the
cardiologist knows whether and when atrial activation is occur-
ring by simply looking at whether an EGM is being recorded by
the atrial catheter typically placed in the right atrium.
In preparing for the boards, the trainee should be familiar
with recognizing atrial and ventricular EGMs and especially
recognizing the His bundle EGMs recorded on a catheter placed
in the anatomic region of the His bundle. Additional concepts
include the following:
• Diagnosing whether AV block is either suprahisian or infrahisian
• Recognizing and determining the significance of dual AV node
physiology
• Recognizing whether there are more ventricular EGMs than atrial
EGMs or vice versa and interpreting the significance
• Distinguishing AV node reentry from accessory pathway–mediated
orthodromic reciprocating tachycardia
Abbreviations and acronyms are expanded at the end of this chapter.
372
• Understanding the difference between antidromic and orthodro-
mic reciprocating tachycardia
In essentially all electrophysiology tracings, at least 1 surface
ECG will be displayed. Typically, there are 3, and Figure 35.1
shows leads I, II, and V1. The student should start by looking at
the ECG. In Figure 35.1, sinus rhythm with right bundle branch
block will be noted.
Anywhere from 3 to more than 12 intracardiac catheters with
displayed EGMs can be obtained in an actual clinical study,
depending on the complexity of the arrhythmia. In all cases,
however, 3 basic catheters will be displayed, and the student
should be familiar with the typical tracing obtained:
High right atrial catheter: This is a recording catheter in
the atrium, typically high in the right atrium, often near the
superior vena cava-right atrium junction. Anatomically,
the sinus node is located at the cranial end of the sulcus
terminalis, epicardially near the superior vena cava-right
atrium junction. Thus, this electrode will show the earliest
atrial activation in sinus rhythm.
Right ventricular apical catheter: This electrode is
placed in the right ventricle near the region of the right
ventricular apex. A ventricular EGM will be recorded on
this electrode.
His bundle electrogram catheter: His bundle electrodes
are placed in the anatomic region of the His bundle on the
superior septal tricuspid annulus.
For analyzing the basic tracings, the following approach should
be used:
1. Identify the ventricular EGMs. The QRS should be identified on the
surface ECG. Mentally, a line should be dropped down from the sur-
face ECG QRSs to the EGMs being recorded. EGMs that generally
line up with the QRS will be ventricular EGMs. On the right ven-
tricular apical catheter, as expected, only a ventricular EGM is seen.
 35 Intracardiac Electrophysiology Tracings
II
V1
RVA
HRA
HBE2
AH=75 ms HV=42 ms
Figure 35.1. Normal Intracardiac Electrogram Sequence. (See end of chapter for abbreviations used in this figure.)
On the His bundle recording, there are 3 EGMs, but only 1 lines up
with the QRS and the right ventricular EGM. This is the recording
of the ventricular EGM near the region of the His bundle.
2. The next step is to identify the atrial EGMs. The atrial EGMs will
not line up with the surface QRS; in this case, the atrial EGM clearly
precedes the ventricular EGMs and is being recorded on the right
atrial catheter.
3. Once the ventricular and atrial EGMs have been recognized, then the
His bundle catheter tracings should be analyzed. Both an atrial and a
ventricular EGM are noted (atrial EGM lines up with the high right
atrial signal and the P wave; ventricular EGM lines up with the ventric-
ular EGM on the right ventricular apical catheter and QRS). Between
these 2 EGMs, a sharp deflection, the His bundle recording, is noted.
The student should be thoroughly familiar with this normal
sequence.
Two important intervals are measured. The first is the AH
interval, which is measured between the atrial EGM and the His
bundle recording. This represents conduction time primarily
through the AV node (normal, 45–125 milliseconds). The second
is the HV interval, which is measured from the His bundle EGM
to the beginning of ventricular activation recorded anywhere
(often the start of the QRS on the surface ECG). The HV inter-
val is a measure of infrahisian conduction (His-Purkinje system).
The normal value is 35 to 55 milliseconds. The AH interval and
the HV interval are both normal in Figure 35.1.
• Be able to recognize atrial, ventricular, and His bundle EGMs.
• Be able to measure and understand the significance of the AH and
HV intervals.
Localizing the Site of AV Block
For the cardiovascular boards, it is necessary to distinguish
between suprahisian (AV node level) block and infrahisian block
on the surface ECG. Typically, Mobitz type I AV block is supra-
hisian, and Mobitz type II AV block is infrahisian. In some cases,
373
V
A
1,000 ms
an electrophysiologic study is done to be sure of the level of block
because pacemaker implantation is usually indicated for infra-
hisian block.
In Figure 35.2, the surface ECGs, high right atrial, right ven-
tricular, and His bundle tracings are seen. In addition, the arterial
blood pressure recording is shown. Once the atrial, ventricular,
and His bundle tracings are recognized, as explained above,
the AH interval prolongs until there is AV block. Note that an
atrial EGM is present but there is no ventricular EGM. This is
the equivalent of an ECG with no QRS complex. Importantly,
when the QRS complex is not seen, there is absence of not only
the ventricular EGM but also the His bundle EGM. This find-
ing indicates that the electrical wavefront did not reach the His
bundle. Thus, the level of block is within the AV node.
Contrast Figure 35.2 with Figures 35.3 and 35.4. Again, the
student should recognize the His bundle tracing. In Figure 35.3,
the AH interval is normal but the HV interval is prolonged. In
Figure 35.4, there is high-grade AV block during atrial pacing
(see the pacing spikes before the atrial EGMs and P wave). A His
bundle tracing is seen clearly, but no QRS complex or ventricular
EGMs are seen for several of the beats. Thus, the electrical wave-
front did reach the His bundle but then is blocked downstream to
the ventricle (infrahisian block).
Distinguish between suprahisian and infrahisian block:
• If with blocked beat a His bundle EGM is seen (but no ventricular
EGM), the block is infrahisian.
• If with blocked beat only an atrial EGM is seen (no His bundle or
ventricular EGM), the block is suprahisian.
Sinus Node Dysfunction and
Evaluation of Syncope
The most common way of diagnosing whether a person with
symptoms has considerable sinus node dysfunction is noninvasive
374 III Electrophysiology

II

aVF

V1

HRA

AH AH AV node block

HBE2

RVA

BP

1,000 ms

Figure 35.2. Suprahisian Block. The atria are paced (dashed arrows). (See end of chapter for abbreviations used in this figure.)

extended rhythm monitoring (eg, loop recorder, implanted loop
recorder). Occasionally, however, electrophysiologic study is
done to assess sinus node dysfunction.
In Figure 35.5, pacing is being done from the high right atrium
(arrows). Note that there is Wenckebach block (prolongation of
the AH interval). In addition, however, the student should note
that when pacing stops, there is a pause before the sinus node
recovers (hatched arrow). This pause is called the sinus node
recovery time. Thus, overdrive suppression of the sinus node is
being done with the atrial pacing, and the time taken for the
sinus node to recover is being measured. The sinus node func-
tion, however, depends on the resting sinus node rate. Naturally,

II

aVF

V1

HRA

HBE1

AH=75 ms HV=85 ms

RVA

1,000 ms

Figure 35.3. Infrahisian Disease. HV is 85 milliseconds; normal is 35 to 55. (See end of chapter for abbreviations used in this figure.)
 35 Intracardiac Electrophysiology Tracings
II
aVF
V1
HRA
HBE1
RVOT
Figure 35.4. Infrahisian Block. The atria are paced. (See end of chapter for abbreviations used in this figure.)
when there is sinus bradycardia to begin with, the recovery time
will also be longer. Thus, the more clinically relevant interval
is the corrected sinus node recovery time. The corrected time
is obtained by subtracting the sinus cycle length from the sinus
node recovery time before starting atrial pacing. For exam-
ple, in Figure 35.5, the sinus node recovery time was 1,700
milliseconds. However, the sinus cycle length before atrial pac-
ing commenced was 850 milliseconds. Thus, the corrected sinus
node recovery time is 850 milliseconds. If the corrected time is
more than 500 milliseconds, sinus node dysfunction is likely.
Figure 35.6 was obtained during carotid sinus massage. Note
the prolonged pause. No atrial or ventricular EGMs are being
recorded. Therefore, this is a sinus pause (cardioinhibitory
response). Note that when the heart rate picks up (spontaneous
or paced), the blood pressure still remains low (vasodepressor
response). Often patients do have a mixed response (vasodepres-
sor and cardioinhibitory).
Analyzing Tachycardia: Are There
More Ventricular or Atrial EGMs,
or Is the Number Equal?
The 12-lead ECG in Figure 35.7 shows a wide complex tachy-
cardia. The differential diagnosis is ventricular tachycardia,
a supraventricular tachycardia with bundle branch block, or a
supraventricular tachycardia with antegrade accessory pathway
conduction. The diagnosis, however, is easily made when ana-
lyzing the intracardiac tracing. Note that there is a ventricular
EGM for each QRS complex; however, an atrial EGM is seen
for only some of the QRS complexes. Thus, there are more ven-
tricular than atrial EGMs, a finding diagnostic of ventricular
tachycardia.
• During tachycardia:
1. If there are more ventricular than atrial EGMs: ventricular
tachycardia.
375
1,000 ms
2. If there are more atrial than ventricular EGMs: likely atrial
tachycardia.
3. If there are equal numbers of atrial and ventricular EGMs: may be
any supraventricular tachycardia with 1:1 AV conduction or ventric-
ular tachycardia with retrograde 1:1 ventriculoatrial conduction.
Another example of wide complex tachycardia is shown in
Figure 35.8. Note that there are ventricular and atrial EGMs in
all the beats. Thus, there is 1:1 AV relationship. In this instance,
neither supraventricular tachycardia with 1:1 AV conduction nor
ventricular tachycardia with 1:1 retrograde ventriculoatrial con-
duction can be completely excluded. However, this tracing likely
represents AV node reentry because this is the only arrhythmia
that frequently produces near-simultaneous AV activation (SEE
THE CHAPTER “SUPRAVENTRICULAR TACHYCARDIA”).
• In AV node reentrant tachycardia, simultaneous or near-
simultaneous ventricular and atrial EGMs are being recorded.
• The ECG equivalent is the P wave being buried in or very closely
associated with the QRS complex.
Dual AV Node Physiology and Induction
of AV Node Reentrant Tachycardia
AV node reentry is a common supraventricular arrhythmia.
In this condition, there are 2 atrial myocardial connections to
the AV node: 1 called the fast pathway located superiorly just
behind the tendon of Todaro, and 1 called the slow pathway
located inferiorly near the coronary sinus ostium (SEE THE CHAP-
TER “SUPRAVENTRICULAR TACHYCARDIA”). During atrial pacing, as
one paces faster, there is always decrement in the AV node, as
evidenced on the surface ECG by prolongation of the PR inter-
val and on the intracardiac tracings by prolongation of the AH
interval. However, this AH prolongation with pacing faster is a
gradual, continuous process. In patients with dual AV node phys-
iology, there is an abrupt increase in the AH interval, despite
376 III Electrophysiology

II

aVF

V1

HRA

HBE2

SNRT=1,700 ms
CSRT=850 ms
RVA

BP

1,000 ms

Figure 35.5. Testing of Sinus Node Function. Atrial pacing (black arrows); spontaneous return of atrial activity (red dashed arrow). (See end of
chapter for abbreviations used in this figure.)

only a minimal decrease (going faster) in the atrial cycle length.
This phenomenon is illustrated in Figures 35.9.
In Figure 35.9A, atrial pacing (S1) is being performed at a
cycle length of 600 milliseconds, and then an atrial extra stim-
ulus (S2) is being placed at a coupling interval of 350 milli-
seconds. As expected, the AH interval, as a result of the extra
stimulus, prolongs (A2H2 130 milliseconds). In Figure 35.9B,
the extra stimulus coupling interval has been shortened by just
10 milliseconds (now 320 milliseconds). However, there is an
abrupt jump in the A2H2 interval to 230 milliseconds. This find-
ing is diagnostic of dual AV node physiology.
Dual AV node physiology is defined as an increase in the
A2H2 interval (or the H1H2 interval between the His bundle
EGM during pacing and the extra stimulus) by 50 milliseconds
or more when the atrial coupling interval has decreased by 10
milliseconds or less.

Figure 35.6. Carotid Sinus Massage. (See end of chapter for abbreviations used in this figure.)
 35 Intracardiac Electrophysiology Tracings 377

Figure 35.7. Wide Complex Tachycardia. (See end of chapter for abbreviations used in this figure.)

• Patients with AV node reentrant tachycardia have both a fast and a
slow pathway input to the AV node.
• Dual AV node physiology is diagnosed when there is an abrupt
increase in the AH interval by 50 milliseconds or more when the
atrial coupling interval has decreased by 10 milliseconds or less.
In Figure 35.9B, after the jump to the slow pathway has
occurred, a few beats of AV node reentrant tachycardia were
initiated.
Coronary Sinus EGMs and AV
Reentrant Tachycardia
In Figure 35.10, the surface ECG, the right ventricular, right
atrial, His bundle, and the proximal and distal coronary sinus
EGMs are shown. The coronary sinus catheter serves as a sur-
rogate for the left atrial and left ventricular electrical activation
in the region of the mitral annulus. The figure shows a narrow
complex tachycardia with cycle length of 290 milliseconds.

II

V1

RVA

HRA

H H H H
HBE

PCS

MCS

DCS

1,000 ms

Figure 35.8. Wide Complex Tachycardia. (See end of chapter for abbreviations used in this figure.)
378 III Electrophysiology

V1

HRA S1 600 S1 330 S2

A1 A1 A2 H2 A2H2=130
H1 H1
HBE2

H1H2=380

RVA

1,000 ms

V1

S1 600 S1 320 S2
HRA

A1 A1 A2 H2 A2H2=230
H1 H1

HBE2

H1H2=475

RVA

1,000 ms

Figure 35.9A and B. Dual Atrioventricular Node Physiology. (See end of chapter for abbreviations used in this figure.)

The differential diagnosis based on the ECG is an atrial
tachycardia, AV node reentrant tachycardia, or AV reentrant
tachycardia using a retrograde conducting accessory bypass
tract (SEE THE CHAPTER “SUPRAVENTRICULAR TACHYCARDIA”). On
careful scrutiny of the ECG, what looks like a P wave is seen
possibly just following the QRS complex. This short RP tachy-
cardia favors AV reentrant tachycardia or AV node reentrant
tachycardia.
When the intracardiac EGMs are evaluated, however, the
diagnosis becomes much more straightforward. The high right
atrial catheter clearly shows atrial signals. The atrial signals (A)
are also seen on the His bundle recording catheter and on the
coronary sinus electrodes.
Because the AV node is located near the His bundle, when
retrograde atrial activation is via the AV node (as in AV node
reentrant tachycardia), the atrial EGM (A) should be earliest on
 35 Intracardiac Electrophysiology Tracings
II
V1
VV=290
RVA
A A
HRA
A H A H
HBE2
A A
PCS
A A
DCS
VA=75
Figure 35.10. Orthodromic Reciprocating Tachycardia Using a Left-Sided Accessory Pathway (See end of chapter for abbreviations used in
this figure.)
the His bundle catheter. In Figure 35.10, however, the earliest
atrial EGM is located in the coronary sinus catheter. Thus, the
left atrium is activated before the AV node region. This patient
has a left-sided accessory pathway that conducts in the retrograde
direction (from V to A). To follow the conduction pattern dur-
ing this tachycardia, therefore, antegrade conduction is through
the AV node (AHV), and retrograde conduction is through the
left-sided accessory pathway (earliest A on the coronary sinus)—
orthodromic reciprocating tachycardia using a left-sided acces-
sory pathway.
• Coronary sinus electrodes are used to map the left atrium and left
ventricle because the coronary sinus is along the mitral annulus.
• When the coronary sinus EGMs are earliest during narrow com-
plex tachycardia or ventricular pacing, suspect a left-sided acces-
sory pathway.
Recognizing Antegrade Conduction
Through an Accessory Pathway
Antegrade conduction through an accessory pathway is shown
in Figure 35.11. Note that during sinus rhythm the ventricle is
activated in 2 ways: 1 through the normal AV node and 1 through
an accessory pathway (in this case in the left free wall). Because
of the accessory pathway conduction, the typical pattern of
Wolff-Parkinson-White syndrome is seen. There is a short PR
interval because conduction proceeds across the accessory path-
way, which does not show slow or decremental conduction, and
there is a delta wave because the early ventricular activation is
through the accessory pathway directly to the ventricle, rather
than through the conduction system.
In the inset of Figure 35.11, the accompanying intracardiac
EGMs are noted. The student should see that the ventricular
379
A A A A
A H A H A H
A A A
A A A
1,000 ms
EGM is earlier in the coronary sinus (mapping the left ventricle)
than the EGM of the His bundle catheter (located on the septum).
It is earlier because of conduction through the left-sided acces-
sory pathway. An ablation catheter has been placed on the mitral
annulus (often through transseptal access). On the ablation cath-
eter, both atrial and ventricular EGMs are recorded very close to
each other because there is direct conduction from the atrium to
the ventricle through the accessory pathway.
Figure 35.12 shows a regular wide complex tachycardia.
As noted above, this could represent ventricular tachycardia,
supraventricular tachycardia with right bundle branch block, or
tachycardia utilizing a left-sided accessory pathway.
Figure 35.13 shows the intracardiac tracings, which make it
considerably easier to diagnose the mechanism of arrhythmia.
Note that there is 1:1 AV association (for every QRS complex,
an atrial EGM is seen on the right atrial recording catheter and
coronary sinus recording catheter). The His bundle EGM, how-
ever, is seen between the ventricular and atrial EGMs (hatched
arrow). Remember that when there is antegrade conduction down
the AV node, the His bundle EGM will occur between the atrial
and ventricular EGMs. The earliest ventricular EGMs (arrows)
are noted in the coronary sinus catheter. Thus, the left ventricle
is activated first, consistent with activation, antegrade through a
left-sided accessory pathway. The student should trace the circuit
in his or her mind. Antegrade activation is from the atrium to
ventricle through a left-sided pathway (thus, the early ventricular
EGM in the coronary sinus and the wide QRS complexes). Then,
retrograde activation is from the ventricle to the His bundle
through the AV node and then finally to the atrium (His bundle
EGM between ventricular and atrial EGMs and the earliest atrial
EGMs seen on the His bundle catheter). This is the circuit of
antidromic tachycardia.
380 III Electrophysiology

HBE

CS

ABL

Figure 35.11. Antegrade Conduction Through a Left Free-Wall Pathway (Wolff-Parkinson-White Syndrome). (See end of chapter for abbrevia-
tions used in this figure.)

Contrast this pattern to intracardiac EGMs obtained during
orthodromic tachycardia using a left-sided accessory pathway
that conducted in the retrograde direction (Figure 35.14). First,
this is a narrow complex tachycardia since antegrade activa-
tion is through the AV node. Second, the His bundle EGM
(hatched arrow) is seen between the atrium and ventricular
EGMs, and, fi nally, the earliest atrial EGMs (arrow) are noted
in the mid coronary sinus (left-sided accessory pathway con-
ducting retrograde). Thus, the circuit is antegrade conduction
down the AV node, retrograde conduction through the acces-
sory pathway. This is the circuit of orthodromic reciprocating
tachycardia.

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Figure 35.12. Twelve-Lead Electrocardiogram of Wide Complex Tachycardia.

 35 Intracardiac Electrophysiology Tracings 381

P1 ART
II
V1

RVp S
hRA T
HBE 2 C

HBE 1 C
CS 19, 20 C

CS 17, 18 C
CS 15, 16 C

CS 13, 14 C
CS 11, 12 C
CS 9, 10 C
CS 7, 8 C
CS 5, 6 C
CS 3, 4 C

CS 1, 2 C

Figure 35.13. Intracardiac Electrograms of Wide Complex Tachycardia Illustrated in Figure 35.12. (See end of chapter for abbreviations used in
this figure.)

P1 ART
II S
V1
RVa
HRA d
HIS 4
HIS 3
HIS 2
HIS 1
CS 19, 20
CS 17, 18
CS 15, 16
CS 13, 14
CS 11, 12
CS 9, 10
CS 7, 8
CS 5, 6
CS 3, 4
CS 1, 2 C

Figure 35.14. Left-sided Accessory Pathway With Retrograde Conduction. (See end of chapter for abbreviations used in this figure.)
382 III Electrophysiology

• Antidromic tachycardia involves antegrade conduction through an ECG electrocardiogram

accessory pathway. EGM electrogram
HV interval interval between His bundle and ventricular EGM
• If the pathway is left-sided, intracardiac EGMs will show the ear-
liest ventricular EGM during tachycardia on the coronary sinus
electrodes.
Abbreviations Used in Figures
• Orthodromic reciprocating tachycardia is a circuit in which the
accessory pathway conducts retrograde from ventricle to atrium. A atrial electrogram
ABL ablation
• With a left-sided accessory pathway, the earliest atrial EGM will
AH interval between atrial electrogram and His bundle
be on the coronary sinus.
electrogram
AV atrioventricular
Summary BP blood pressure
This chapter reviewed the basic invasive EGMs with which the CS coronary sinus
CSRT corrected sinus node recovery time
student preparing for the cardiovascular boards should be famil-
DCS distal coronary sinus
iar. Details of differential diagnosis of the various arrhythmias H His bundle electrogram
and maneuvers performed in the electrophysiology laboratory to HBE His bundle electrogram
make an exact diagnosis before ablation are beyond the scope of HRA high right atrium
this chapter and are not material tested on the boards. This mate- HV interval between His bundle electrogram and ventricu-
rial, however, could serve as a basis for the student interested in the lar electrogram
bewildering but fascinating world of invasive electrophysiology. MCS midcoronary sinus
PCS proximal coronary sinus
RVA right ventricular apical
Abbreviations
RVOT right ventricular outflow tract
AH interval interval between atrial and His bundle EGM SNRT sinus node recovery time
AV atrioventricular V ventricular electrogram
 Section IV

Valvular Heart Disease