Many of you have responded to the discussion group via our new online site at http://eplabdigest.com/
discussion-questions. See below for a sampling of recent activity.

New Question:

Cable Disorganization

Our lab has an abundance of cables that often becomes tangled and inevitably damaged. Last week, damaged cable resulted in an intraprocedure delay of over 1 hour. Our Biomedical Engineers have authorized our department to contact a third party vendor for consultation. Has anyone had similar issues, and if so, how did you correct the problem? Does anyone know of a vendor that services this type of problem?

— anonymous

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Under Discussion:

Distinguishing Block

What are your tips for distinguishing between second-degree atrioventricular block type 1 and 2?

— name withheld by request

My tip for distinguishing between second-degree AV block, Mobitz type 1 and 2 on the surface electrogram is to pay close attention to the PR interval.

If the PR interval varies with an occasional dropped QRS, it is type 1 or commonly referred to as Wenckebach. Specifically, the PR interval lengthens with each beat until it is blocked and does not conduct through to the ventricle. This is shown on the surface electrogram as a dropped beat. After the dropped QRS complex, the PR interval resets and the cycle repeats.

In second-degree, type 2 there will be more P waves than QRS complexes. However, the PR interval for those beats that a QRS follows a P wave, the PR interval will remain constant and unchanged. The ratio of P waves (atrial activation) to QRS complexes (ventricular activation) is expressed as a ratio. This ratio may be constant or variable. Example: If a surface electrogram displays two P waves for every QRS complex and the PR interval is always the same, the rhythm would be second-degree AV block type 2 with 2:1 conduction.

— D. Passey, RCIS, RCES

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AF Ablations

Two physician groups at our hospital have recently recruited AF docs. We do not currently have an AF program in our EP lab. Plans have been made to purchase an ESI (St. Jude Medical) mapping system, and we use EP MedSystems. Does anyone have suggestions or a guide on how we should go about training our staff? The biggest part of learning is the plan; any help would be appreciated, especially orientation timelines, classes that would be helpful and/or books that could be helpful for the beginner staff. We currently do more simple ablations (i.e., atrial flutter, SVT, WPW).

— anonymous

I currently work at a facility that does AF ablations. I am a registered nurse.

We use ESI and have EP MedSystems. (We also use Carto.) We trained ourselves and have maintained a standard AF set up, so I cannot guide on training lengths; speak to ESI and EP MedSystems and see what classes they can provide.
Standard AF set up:

Patient prep: NavX pads, NPO after midnight. The odd case is done under anesthesia.