Greetings, this is John Miller with Heart Rhythm Society's Core Concepts in Electrophysiology. We're going to be talking about an overview of the course here. These are my industrial relationships and conflicts. Core Concepts is a relatively new iteration of this. This used to be the board review course, but it's been expanded somewhat to new name, new concept. This began in 2020 and its current iteration evolving from the previous board review course, which had been offered annually for over 20 years and been quite well received and quite successful. Heart Rhythm Society decided to make it a little bit more expansive than that. And now we're intending for this course to be anyone involved in treatment evaluation treatment of individuals with heart rhythm disorders can use this as a resource. So it's not just for board review anymore. It is designed to provide a fundamentally sound EP knowledge base for anyone working in the field. So we have a very simple goal. It should be the Core Concepts course should be the go-to resource for all who study and treat disorders of the rhythm, accessible virtually year round for anyone who wants to buff up their skills in this regard. It should fill the knowledge needs of all who are involved in care of individuals with heart rhythm disorders, including the board certified electrophysiologist, the candidate for that, advanced practice providers, nurses, EP techs, fellows, industrial personnel who work with mapping systems and device manufacturers. Anybody who has a need to know stuff about EP, this should be the go-to resource. So what to expect from the course? It's a comprehensive package with lectures on the fundamentals of electrophysiology by highly selected, eager to teach world renowned experts divided into six different sessions. When we do this on the live course this year, it's going to be virtual as it has been in 2020 and 2021. Hopefully we'll gather together in person in 2023 in the summer to be able to do this live again. We have 11 absolutely superb stellar faculty members presenting 18 different lectures, highly selected. We have special technology and technique lectures that have been added over the last couple of years. We're continuing to add to these to enhance the learning environment for individuals. Seven different topics now by six different speakers added to these 18 presentations by the 11 faculty members. We also have case-based workshops with board type questions and in-depth discussion analysis of why this answer is correct, why these answers are not correct. Nine different workshops, at least 120 cases nowadays at last count. The core concepts faculty consists of names that everyone recognizes. Sam from Mayo Clinic in Rochester, Minnesota. Ken Ellenbogen from Medical College of Virginia in Richmond. Ed Gershenfeld in San Francisco at UC San Francisco. Barry London from University of Iowa. Greg Michaud currently from Vanderbilt University in Tennessee. Frank Marchalinski from University of Pennsylvania. Bill Miles, University of Florida in Gainesville. Myself. Jeannie Poole from University of Washington in Seattle. Bill Stevenson, Vanderbilt University in Gordon-Thomaselli from New York, dean nowadays. Each faculty member has one or more workshops for which they are responsible as well. In 2020, core concepts in electrophysiology induced four special technology and technique lectures that were information that is probably not going to be on the boards, but as well suited to the practicing electrophysiologist. Dave Callens was invited to give talks on transseptic catheterization, as well as complications in electrophysiology procedures and how the recognition and handling of these. Matt Hutchinson was tapped to give a very stunning lecture on use of ultrasound electrophysiology, an evolving topic. Rod Tunn, also from Arizona, is giving a talk on pericardial access and epicardial mapping and ablation. A wonderful talk. In 2021, two more lectures were added. Pugal Vajeraman from Geisinger has given a talk on conduction system pacing, a high exciting area, continues to evolve. I am giving a talk on electron atomic mapping principles. And in 2022, Dr. Oluwadjola from UCLA was asked to give a talk on modulation. Very exciting material. The core concepts with board review contains everything in the regular core concepts, plus a couple of extra things. One is a couple of a lecture by me on preparation for the examination, how the examination questions are constructed, what the board committee does with these, how they're evaluated, question design and content, examine scored, and so on and so forth, how to approach answering questions. Dr. Greg Michaud has a wonderful brainstorm of an idea that he put into play on the spur of a moment in 2019 on testable concepts. You'll be asked a question about this. You'll be asked questions about this. You'll expect a question about that. You need to know this. You need to know that. Very concise, just a gem of a talk. Very well received, very handy for a lot of people. And then there's a self-assessment examination that has some old questions and some refresh, some fresh new questions of ABIM type that are reasonably well worked out, covering the gamut of EP experience. So this is how things break down. The simple core concepts package gives you all this information, the special technology lectures, the workshops. The board prep gives all of those, plus the exam preparation tips and self-examination questions that are very handy at testable concepts. Core concepts hopes to keep the EP community current with new and updated guidelines, consensus statements, new indications for medications and ablation and devices, newly approved and withdrawn medications and technologies as well. New workshop cases are added yearly, recycling out old ones that are not quite as relevant and hopefully reflecting current practice. Heart Rhythm Society is expanding the core concepts of vision to address needs of allied professionals, not just people who are going to be taking the board exam. We feel this is an honor and a duty to other members of our community and offers a deep dive into theoretical aspects of EP that underlie what we do and why we do things. And this core concepts for associated professionals or allied professionals will center on the practical needs of the allied professionals, such as management of new atrial fibrillation as an outpatient or as an inpatient with the inpatient consultation of which it should consist, troubleshooting of devices for those involved in this, general patient follow-up and education for helping patients on the phone or in outpatient or inpatient visits. This is useful for not only those working within the health system, but in industry as well. They need to be solid on their concepts as to mapping of abradiveness for mapping systems, troubleshooting devices and application of device algorithms for real life. That's coming soon. That's not today, but it's in development and should be within the next year or so. I want to give just a bullet point review of some of what one can expect from the lecturers that are coming. First off is Gordon Tomaselli. His basic science lecture covers basic principles of electrophysiology, ion channels, pores, gating, different ionic states of the channels, currents involved, action potentials, how they are modulated by drugs and health and disease, conduction refractory periods, modulators of these, mechanisms of clinical arrhythmias, reentry, focal processes and how one can tell which is the acting one at the time, mechanisms and actions of antiarrhythmic drugs from a cellular basis and translate that into real clinical scenarios in some situations vis-a-vis how it interacts with arrhythmia mechanisms, determinants of whether and how a drug reaches its target with current technologies and genetic modifiers of drug effect. That's a lot to cover. Gordon does a fantastic job of it. It's phenomenal to see him do this, and it's so smooth. Next is Barry London, who gives a phenomenal talk on ion and inherited channelopathies. He goes over monogenic causes of syncope as well as polymorphisms, electrical versus mechanical causes of rhythm disturbances and their family trending. He outlines a very solid approach to diagnosis and treatment of people with known or suspected inherited causes of sudden cardiac death, helps us understand the role of genetic testing, cascade testing, and the wonderful variance of uncertain significance, and helps us understand the approach to polygenic disorders. And this is a very, very fascinating talk and rapidly evolving field, and Barry does a masterful job of this and his workshops as well. I will cover some of the more pedestrian stuff about anatomy and physiology, conduction system function, both impulse formation and conduction at all levels of the conduction system and how these are modified in health and disease and drug effects. We will correlate abnormalities of impulse formation and conduction with the relevant anatomy and their clinical implications vis-a-vis whether you need a pace or not pace. That's a major question that comes up at the root of all of these discussions. ECG correlates of different types of abnormalities where Winkiebach occurs can occur in the hysperkinesis and so on and so forth. A review of different non-invasive and invasive tests for evaluating impulse formation and conduction and the pacing guidelines which are refreshed every once in a while. That's a lot to cover in one talk, but we do it. I also talked about retrograde conduction. This talk comes out of years on the American Board of Internal Medicine Exam Committee where it just came up time and again that inexplicably candidates would miss questions that had to do even peripherally with retrograde conduction, very poorly understood by many. So we thought it was worth having a special talk on this. We will cover different patterns of retrograde conduction when it's present and what they mean. Distinguish retrograde conduction from eccentric activation, which may be an atrial tachycardia, which has a pattern of eccentric activation but is not actually retrograde conduction. Retrograde dual avenomal physiology will be covered in its manifestations. Methods of distinguishing between retrograde conduction over an accessory pathway versus the AV node, how you can make these distinctions both before and after ablation procedures. I will also talk about overdrive pacing during atrial or supraventricular arrhythmias and entrainment, looking at the principles of proper use and application and interpretation of the results of overdrive pacing either in the atrium or ventricle during SVT, looking at different responses of overdrive pacing in SVT and their diagnostic implications. If they are, sometimes you'll get a question where somebody did overdrive pacing during a tachycardia and there were no meaningful findings. It was not pacing for long enough or sometimes that's important to know, be able to recognize that. Looking at the constituents of entrainment in supraventricular arrhythmias, especially how to recognize fusion when it's present and entrainment mapping, and looking at some unanticipated responses to overdrive pacing during SVT, such as non-capture, odd post-pacing intervals, what these mean, too short or too long, and termination of SVT without clear propagation of the impulse. Bill Stevenson gives a wonderful talk on entrainment of ventricular tachycardia. I don't know if anybody who does this better than he does. He could do this in his sleep and still make it look masterful. He talks about the language of entrainment and fusion manifesting and concealed, explains those very succinctly. It almost makes you cry. It's so wonderful. He talks about the importance of correct post-pacing intervals, orthodromic and angiodromic propagation, many, many examples of overdrive pacing and entrainment at the ventricle in different settings. Use of overdrive pacing to determine the presence or absence of reentry, explores the importance of distinguishing between near and far field recordings and capture. And finally, entrainment mapping, from where in the circuit are we stimulating inner loop, outer loop, exit, and so forth. This is a wonderful lecture. This is worth the price of admission just by itself. Following all that is his colleague, Greg Michaud, who will talk on two talks, because there's too much to cover in just one, on techniques to differentiate different types of SVT, one from another. This talks, this covers differentiating the major types of SVT, orthodromic SVT, apianotal reentry, atrial tachycardia, junctional tachycardia, what tests can be done to reliably distinguish or at least steer one's thoughts in one way or another. Diagnostic clues from ECG and sinus rhythm, and both in sinus rhythm and SVT. Diagnostic clues from transitions in the rhythm, from the onset of the arrhythmia, termination of the arrhythmia, development or loss of bundle branch block during tachycardia, all of these are important bearers of information for diagnostic purposes. The diagnostic value and limitations of pacing maneuvers in SVT, just as important as how to do a maneuver, and what it shows you is knowing what it can't show you, and what it won't show you if not properly done. And then the responses to pareidesis and pacing. He does an absolutely stellar job of this and follows on with the part two of this talk, observations of maneuvers that demonstrate participation versus mere presence of an accessory pathway during tachycardia. This is an important distinction mainly for board exams, but in real life also, whether it's participating or just present. Fine points of using the post-pacing enroll and essay, stimulus to A minus B to A intervals that he originated in SVT diagnosis. Interpretations of events that occur during the so-called fusion zone when you're doing ventricular overdrive pacing during an SVT, where you have some fusion complexes versus fully paced complexes, and a general approach to SVT diagnosis. It just makes it so easy and straightforward. A kindergarten doctor could get this. Dr. Stevenson returns for a masterful talk on a very broad topic, and I marvel year to year how he gets this all in here, but it just makes it look so easy again. He covers the distinction of different tachycardia mechanisms, focal emanation versus macular entry, and how once that information is obtained, you can formulate an ablation strategy and guidance on how to make the distinction between these. Typical locations of focal atrial tachycardia sources, how to recognize them on ECG, features on mapping, such as the electrogram timing relative to a reference P-wave, unipolar and bipolar electrograms, pace mapping in the atrium. All of these will be covered in depth. Pathophysiology of re-entrant atrial tachycardias, how to distinguish where common circuits are, especially post-atrial FIM ablation. This will also be covered by Dr. Gershenfeld, and tips for how to achieve and assess for the presence of bidirectional block in cubo-tricuspidismus, dependent flutter, and other forms of macular entry. It is a fantastic talk. Bill Miles comes along with a couple of talks. The first one on accessory pathways. It is just stupendous. He covers from soup to nuts on this anatomy and physiology of typical AV pathways as well as atypical pathways. Those are slowly conducting the AV pathways, atrial fascicular pathways, notoventricular notofascicular pathways, fascicular ventricular, and epicardial pathways as well. Determining if a pathway is present or participating in tachycardia. He will reinforce this. Pre-excited tachycardias, tachycardias using multiple PV accessory pathways, pathway tachycardias. Localization of ventricular and atrial insertions from the ECG and intracardiac recordings, talking about unipolar recordings, pathway slants, among the annulus. Ablation techniques and potential complications based on location. Wow, it's a lot to cover. Obviously, it's a lot to cover, and Bill does a phenomenal job of this. We're so glad he's with us on the course here. He also comes along with the other, the more common type of SVT, AV notorentry, and goes through a beautiful review of different types of AV notorentry, the anatomy and physiology of functional dual pathways and where these are, how to unveil these. ECG and intracardiac diagnosis of AV notorentry and some of its more common variants. Ablation strategies based on what you find in the EP lab. Safety and efficacy of ablation strategies, cryoablation, RF ablation, how they, subtle differences between these junctural rhythm and not junctural rhythm. Unusual cases where there's one to two double fire AV conduction. When an individual has a long PR interval at sinus rhythm and AV notorentry, how is that approached? Eccentric retrograde activation patterns during AV notorentry, how are they approached? It is a wonderful, wonderful lecture. Nobody does a better job than Dr. Miles on this one. Dr. Stephenson and I team up, my evil twin, Dr. Stephenson, and this lecture will cover general principles and limitations of ECG localization of PVCs and VT and the importance of the presence or absence of structural heart disease in making that determination, those inferences. Outflow tract regions, outflow LV and outflow tract of the right ventricle, multiple exits from a single focus are explored. ECG correlates with epicardial origins of arrhythmias in the ECG and SCAR-based, mainly post-infarct VT of some cardiopathies. Specific cases are explored, including papillary muscle, aortometric continuity, sinuses of alsalva, LEAD-2, LEAD-3 discordance. All of these are covered in multiple rich examples that Dr. Stephenson gives. To see him do this is wonderful. Dr. Marchalinsky comes along with just a wonderful review of beginning to end of ventricular arrhythmias in ischemic and non-ischemic situations. Clinical scenarios of focal versus reentrant tachycardias and how one might distinguish a priori, or at least a very good idea of what you're dealing with going into a procedure. Use of overdrive pacing to separate focal from reentrant processes, again, reinforcing what Dr. Stephenson has discussed, and evaluate a candidate sites for ablation, remote bystanders, adjacent bystanders, and the like. ECG clues to localization will be reinforced, outflow tract, outflow regions, outflow region of left ventricle, summit, arrhythmias, epicardial sources, and what to do about these, how to approach them. Strategies for mapping an ablation of both stable and unstable VTs, selection of candidates for ablation, prediction of outcomes, both of ablation as well as safety of ablation, morbidity and mortality of procedures, and preparing for VT ablation procedures. What you need to know beforehand, you need imaging of this, or do you need a coronary angiogram assessment of ischemia, drugs on or off, and VT in specific syndromes, including idiopathic VTs, right ventricular cardiomyopathy, Borgata syndrome, non-ischemic cardiomyopathies, and one of his favorites, Bonobran free entry. And all this is covered at about an hour and 10 minutes. It is phenomenal how he gets us, it makes it look so easy. Sam Azerbaid, boy, we are so fortunate to have him with us. And he talks about wide carotid tachycardia, he is just a master at this, it's a phenomenal lecture. Potential causes of wide carotid tachycardia and their relative prevalences are discussed, clues from the clinical history, sinus rhythm ECG, they've done a lot of development at Mayo Clinic about this, review and application of the standard ECG rules that we all use, and the algorithms, B1 and B6 patterns, axis, concordance, AV relationship, review of existing diagnostic algorithms and what the future might hold, and the rhythm strip, how does the episode start and stop, something as simple as this can contain extremely valuable diagnostic information. And he goes on to pre-excited tech parties as well. This is a gotta see lecture. Again, this is worth the price of admission for the whole thing. Dr. Poole from University of Washington gives us some great lectures. It's just I don't possess this knowledge myself. I marvel at this wonderful woman to be able to get all this stuff together and keep it all straight. She gives a lecture on review of the principles of clinical pharmacology, half-life, steady state, the stuff that we all studied in basic pharmacology. She's got all this down, concentration compartments, metabolism, and elimination. These are in the background of what we do, but they're important stuff. Pharmacodynamics and pharmacogenetics, classification schemes of antiretroviral drugs, the Vaughn-Williams, psyllium gambit, and so forth. Review of mechanisms of action, how to use them, when to use them, adverse effects, interactions with drugs, proarrhythmia. She covers all of this stuff. Oral anticoagulants, when to start, when to stop, specific cases, uses, all this stuff. It is a wonderful, wonderful session that she has. Ed Gersenfeld will cover a couple of things. First is atrial fibrillation, mechanisms, drugs, and ablation. That's a lot to cover in about an hour and 10 minutes. He reviews what's known about mechanisms of atrial fibrillation. It's probably many different things. We have one phenotype that we recognize, atrial fibrillation. It's probably a lot of different disorders. He discusses these pathophysiologic mechanisms. The concept of pulmonary vein triggers versus drivers as being relevant in the pathogenesis of atrial fibrillation. Electrical remodeling and how it affects atrial electrophysiology and its consequences. Use of anticoagulation, especially in the periprocedural arena. What's being done about that nowadays? What's safe? What's effective? Who are the candidates for ablation? It seems to be ever-expanding and ever-changing. What are the guidelines? How do we stay on the right side of the guidelines with this? Proper techniques of PV isolation and assuring that you have PV isolation. There's a lot of controversy about that. Adjunctive ablation techniques and persistent atrial fibrillation. Lots of controversy there. Complications of AF ablation. Current clinical trials and where we're headed. Pulmonary pacing maneuvers. This is a favorite fodder for questions on examination. Do we have exit block? Do we have entrance block? Bar field recordings from the superior vena cava, left atrial appendage, and organized atrial tachycardias, post-AF ablation, micro-entry, macro-entry, and so on and so forth. He does a phenomenal job of this. It's almost exhausting to watch this. He does such a great job of it. He comes back with biophysics of ablation. We do this. Most of us spend our lives doing ablation nowadays. A lot of it. We might as well know what we're doing. There's some new concepts coming out. I remember the eight millimeter catheter era. After the four millimeter catheter, then there was irrigation. Then there was low volume irrigation, and there was high power short duration ablation. Then there's new technologies. He's going to talk about all of these things, role of power, duration of power delivery, contact force, impedance, and how to troubleshoot when you're having a problem during the case. What do you need to modulate? What are modifiable variables? Resistive versus conductive heating with radiofrequency, what irrigation does, different sizes of electrodes, what they do, strategies for limiting collateral damage and giving radiofrequency, cryoablation advantages and disadvantages in different methods. Paradoxes of ablation, a larger electrode, necessarily giving more power or damage, that sort of thing. Pulse field ablation, where it stands with us nowadays. Obviously, this is a rapidly moving topic. Ken Allen Bowman, he will talk about implantation techniques and how to avoid problems, complications with them, venoplasty, alternate sites of defibrillation coils as it goes, subcutaneous, so on and so forth. Interpretation of stored electrograms, what they mean, what they don't mean. Some very, very, very well-learned and insightful interpretations here. Troubleshooting device malfunction. We do this on an everyday basis. It's sometimes more straightforward than others. Do we have a lead failure that cannot be remedied by choosing a different vector? Do we need a lead extraction, a new lead alongside of it? EMI, T-wave over sensing, you're in the header, a variety of things. Subcutaneous ICDs, biparticular stimulation, when do we have capture, when do we not have capture, anodal stimulation, AA, AV, and BP intervals, and offsets. All of these will be covered. It's a dizzying amount of information that he puts forth. That is the content of the board review course. It's a whirlwind tour. It is phenomenal. I highly recommend it. These people who are doing these talks are highly motivated to do better than they did before and do better than everybody else. It's a great group of people, very approachable as well. I wish you well with your learning, lifelong learning, and come visit us often. Thank you.

Core Concepts in Electrophysiology

board review course

heart rhythm disorders

electrophysiologists

lectures on electrophysiology

ablation techniques

EP knowledge base