Mayo Clinic Electrophysiology Manual
Over the past decade there has been a rapid evolution of the techniques of invasive electrophysiology, mapping, and ablation. Considerable progress has been made in identifying the mechanisms and anatomic location of cardiac arrhythmias, thereby allowing the cure of most arrhythmias with ablation techniques. Although several excellent textbooks are available with content on basic and clinical electrophysiology, and cardiac rhythm management devices, as well, there remains a clear gap in textbooks focusing on contemporary invasive electrophysiology and ablation techniques. In an attempt to bridge this gap in contemporary textbooks, Dr Asirvatham has assembled a team of Mayo Clinic contributors to produce a manual rather than a textbook. This practical, superbly illustrated 711-page manual is focused on contemporary techniques of invasive electrophysiology including mapping, imaging, diagnostic maneuvers, and ablation.
The book is a practical, concise, multiauthored text written and edited by colleagues from the Mayo Clinic. It consists of 2 sections, including 9 chapters in section I. This is followed by 20 case studies in section II designed to test the principles presented in the initial section of the manual. The chapters include an introductory 62-page masterfully written contribution by Dr Asirvatham covering fluoroscopic views, electrograms, and relevant anatomy. It is replete with high-quality radiographic images effectively coupled with color anatomic images of the heart in similar views. The quality of these images rivals those presented in the premier atlases of cardiac anatomy. These are supplemented with high-quality graphic representations of relevant cardiac anatomy. Intracardiac electrograms are well annotated, representing multiple normal and abnormal phenomena and arrhythmias. Most of the content on the ablation of atrial fibrillation is contained in this initial chapter. Many of the tables focus on fluoroscopic catheter positions in relation to cardiac anatomy that is important for ablation. These tables are concise yet comprehensive.
The initial flagship chapter is followed by a more concise, well-written chapter on intracardiac echocardiography. It contains 16 figures, including 34 separate images, anatomic photographs, or drawings. The text is well written and contains practical information that covers basic information on intracardiac echocardiography as used by the electrophysiologist. The subsequent chapter on electroanatomic mapping is also practical and concise. The basic principles of each of the available mapping technologies are adequately covered. Multiple high-resolution color maps are presented in the figures with representation of all available mapping technologies.
The forth chapter, entitled “Diagnostic Maneuvers Commonly Used in the Electrophysiology Laboratory: Understanding the Rationale, Techniques, and Interpretation,” is a 49-page summary of all of the relevant techniques and maneuvers needed to diagnose common and more complex arrhythmias. Similar to the initial chapter written by Dr Asirvatham, this chapter is a superb summary that is essential reading for all those performing invasive electrophysiology studies and ablation. It also serves as a very useful study aid for those preparing for the initial or recertification clinical cardiac electrophysiology examination. The concepts of reentry, transient entrainment, and concealed entrainment are explained with great clarity in the subsequent chapter contributed by Dr Win-Kuang Shen. These topics are supplemented by useful chapters on wide QRS tachycardia, antiarrhythmic drugs, and ablation and device therapy in congenital heart disease.
There is a single chapter on basic cardiac electrophysiology that covers the essential structure and function of ion channels and the cardiac action potential. The concepts of refractoriness and impulse propagation are effectively presented in the context of mechanisms of cardiac arrhythmias. Included in this chapter is the topic of inherited arrhythmia syndromes that recently have assumed greater clinical relevance. The content in this chapter would be particularly valuable for those preparing for the initial or recertification examination in clinical cardiac electrophysiology.
The second section of the manual includes 20 cases presented with a series of questions in a workbook fashion, encouraging the reader to interpret and make decisions that are clinically relevant. These cases, representing the core of this manual, are interesting and challenging clinical scenarios that constitute 459 of the 711 pages (64%) of the manual. These cases cover a spectrum of common and uncommon electrophysiological scenarios including accessory pathways, atrioventricular nodal reentry, atrial tachycardia, atrial fibrillation, atrial flutter, Brugada syndrome, Mahaim fibers, ventricular tachycardia, and arrhythmias associated with congenital heart disease. They are accompanied by superb summary tables, including 1 entitled “The Difficult Case in the Electrophysiology Laboratory,” with helpful strategies to minimize the difficulty.
The manual is unique in multiple respects. All contributors are from a single institution. Detailed anatomic photographs and graphic images place emphasis on cardiac anatomy through the entire manual. Through a unique collaboration of the electrophysiologists contributing to this book with a Mayo pathologist, the interdependence of cardiac anatomy with contemporary electrophysiology is developed as a major theme. This liberal use of high-quality color figures for anatomic photographs, drawings, intracardiac maps, and electrograms is particularly noteworthy. Many chapters begin with a question about a figure, tracing, or anatomic section. These questions and the 20 cases provide a clinical context for the principles and concepts in the text. This approach is highly effective in allowing the reader to understand and retain the clinical relevance of the content of the manual. A helpful and comprehensive index allows the reader to readily find all locations in the text where a particular topic is mentioned. By design, the book is not intended to be a comprehensive or scholarly compendium of clinical cardiac electrophysiology. It does not contain information on pacemakers or implantable defibrillators other than in the context of congenital heart disease. Also absent are any references or bibliography traditionally found in textbooks but commonly omitted in manuals or workbooks.
In summary, Mayo Clinic Electrophysiology Manual is an important attempt to address several aspects of contemporary electrophysiology and clinical cardiac electrophysiology. With this focus, it complements and successfully bridges a gap in the currently available textbooks with its current content on invasive electrophysiology. The editors have amassed a wealth of practical information through the contributors of each chapter while meeting the challenge of avoiding the redundancy inherent in any multiauthored book. The manual also has educational value for all healthcare professionals participating or interested in arrhythmias, electrocardiography, cardiac electrophysiology, or ablations. It should be considered an indispensible tool for all trainees and others interested in having a better understanding of cardiac anatomy, electrophysiology, mapping, and ablation.
N. A. Mark Estes III, MD
Tufts Medical Center
Cardiac Arrhythmia Service
- © 2014 American Heart Association, Inc.