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EP Procedures - Catheter Placement

Vascular Access & Catheter Placement

In any EP study, the number of sheaths and catheters used is often dependant upon the suspected arrhythmia and the physician’s preferred technique. In this section, we will review a standard placement for catheters and then discuss some of the variations you may encounter in the lab.

Because basic EP uses predominately bipolar contact catheters, a standard set up that allows quick visualization of the activation sequence is commonly used. To achieve this, catheters are placed at key locations within the heart.

1. The Sinus Node / High Right Atrium – One of the first steps in EP is to look at what is normal for the given patient. In most patients, the sinus node is located high in the right atrium on the posterior lateral wall at the SVC/RA junction.
2. The His Bundle region – By placing a catheter just across the tricuspid valve annulus, signals may be recorded from the atrium, the His bundle and the ventricle. As this is usually the last activation in the right atrium and because of the importance of the His bundle function, this location is commonly used.
3. The Coronary Sinus – The coronary sinus lies between the left atrium and left ventricle on the posterior side of the heart. When a catheter is placed in this location, activation of both the left atrium and left ventricle can be visualized. The first atrial signal after the His should be the proximal CS signal. For this reason, the waveforms are usually viewed proximal to distal on all catheters with the exception of the RF catheter. The last atrial signal should be seen on the distal CS electrode pair.
4. RV Apex – In many cases, activation sequence plays a secondary role on ventricular catheters. Many times, the greatest value from an RV catheter is the ability to pace in the ventricle. Pacing may be performed from the apex or the catheter may be moved to the right ventricular outflow track.

The images below show an anatomical diagram and a fluoro image of standard catheter placement.

Catheter placement to RA, His,
Coronary Sinus and RVA

Fluoro Image showing catheters placed in Rt Atrium, His, RVA
Images courtesy of St Jude Medical


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