Antitachycardia Pacing (ATP) - How it Works, How to Improve

I discuss reentrant VT, how ATP works, why it doesn't work, and how to improve the success rate of anti-tachycardia pacing. A new ATP algorithm is discussed, in the context of pace-termination mechanisms. I hope you enjoy the presentation!
Come join the EP Twitter community for real-time discussions! You can find me there: @narrowQRS

[@richardelinskas6663]

Doc, you are an incredibly gifted teacher. I hope you realize the impact this video is going to have on the pacing industry. Thank you so very much for doing this video. Thank you for putting the time into the animations and reinforcing the concepts after you explain them multiple different ways. Your videos and teaching’s will absolutely go down in history and be watched millions of times. Thank you.

[@dr.joshuacooper-arrhythmia9917]

I'm not sure about "millions" but thanks so much for the kind words! I'm so excited that these videos have been helpful for people to understand some fundamental principles of EP! I really appreciate your feedback!

[@Algalkacyo]

Once again Thank you Dr. Copper, for your wonderful educational videos. In my opinion you are the "Josephson" off our time in EP/arrhythmia, so glad you adopted youtube to reach younger audience worldwide which makes essential knowledge accessible to everyone. I can't thank you enough. As an EP/Pace/ICD technician none has come close to your teaching capabilities yet. Please continue. I'm really looking forward to understand AVRT a bit better?

[@dr.joshuacooper-arrhythmia9917]

I really appreciate your overly-generous words! I don't at all have Josephson's intellect, but at least I'm able to explain things in a teaching style that seems to resonate with those looking to establish (or re-establish) a strong foundation in EP!

[@DH-vy8hw]

Agreed!

[@vapapadopoulos6921]

Dr. Cooper thank you so much. I admire your work. I have just started the part of EP in my residency in Greece. These videos are really helpful! Please, continue this work and expand your videos in: 1) basics of EP and 2) Explanation of more EP procedures. I love this wonderful subspeciality. Thank you so much

[@paintosignup]

Dr Cooper, thank you very much for the great video. I satrted woring in a pacemaker industry over 30 years ago (Pacesetter, St Jude Medical and now Abbott) as a hardware design engineer. The company gave us Bradycardia and Tachycardia training. We know that our Pacers and ICD's have ATP function but I did not really undersatand how it works. Reading printed articles and books in those days didn't quite clear the mystery. I am retired now and have more time to watch youtube video and I found your video on ATP. This is the best explanation on how ATP works. It is really easy to undersatand eventhough I am not a medical professional. Thanks again.

[@dr.joshuacooper-arrhythmia9917]

Thank you so much for your most generous and kind comments! So glad you found the video helpful!

[@jeffreyleikachon1]

Thank you so much Dr. Cooper. I am currently a chief resident going into cardiology fellowship and I find this extremely useful!

[@dr.joshuacooper-arrhythmia9917]

Glad it was helpful! Thanks for watching!!

[@weijiawang1571]

Thank you Dr. Cooper! I learnt a lot by watching this video.

[@islammahmoud6744]

excellent you are talented. i watch every video of your channel. thank you Cooper for your great production

[@nithinkrishna9861]

Thanks Dr Coopet for the clarity you made to ATP

[@jimloops8093]

Congratulations!!! Excellent presentation and the best explanation of ATP functionality.

[@dr.joshuacooper-arrhythmia9917]

Thanks so much! It seems this talk hit the intended mark 👍

[@alexanderdegkwitz9866]

Greetings from Germany. I can only join the the former commenting people: Your videos have helped me to understand the very principles of EP-studies and i really hope there is more to come! Thank you so much!!

[@dr.joshuacooper-arrhythmia9917]

Fantastic and thank you! It is so amazing that these videos have found an international audience, and that people have found them instructive and helpful! I appreciate you taking the time to give wonderful feedback!

[@user-wy5oq3el7x]

As a EP beginner at another corner in the world (Taiwan), I really appreciate your educational videos. They are so impressive and illuminating. Thank you Dr. Cooper.

[@dr.joshuacooper-arrhythmia9917]

I can't tell you how satisfying it is to hear this type of great feedback from the international community! It really demonstrates the power of social media from an educational standpoint!

[@chinweelee2684]

best ATP explaination I can find.. hope I can learn ecgs from you as well

[@HusbandWifeOutdoorLife]

best explanation I have had. Thank you for posting.

[@dr.joshuacooper-arrhythmia9917]

Thanks so much! I'm thrilled you found this video helpful!

[@mothernature_drrm11]

Hat's off ! One of the great presentations. Sir please add more presentations about Basics of electrophysiological mannuvre .I will be obliged. Thank u again .

[@angelakucia5248]

Brilliant, thank you!

[@itonlyadds]

Wow, so good. Thank you!

[@DH-vy8hw]

I'm just going to automatically click "like" to ANYTHING you post regarding EP!!!!!!

[@dr.joshuacooper-arrhythmia9917]

Ha! You are too kind!! Thanks for the vote of confidence! :)

[@huynguyenvan3489]

Thanks Dr Cooper, great video. Where can i find more slides about iATP for learning? Thank you.

[@jenishshroff4667]

so intuitive!!

[@osamabheleel4798]

great lecture as usual . thank you very much

[@dr.joshuacooper-arrhythmia9917]

Thanks so much! I do like how this one came out - it's an important topic that people don't always think about in detail.

[@user-wk9qs9in4c]

Thank you for the amazing videos, Dr. Cooper. I had one question in mind after watching the whole video thoroughly. How does the device define long, intermediate, and short PPI? For example, long PPI >paced interval + VT interval? Short interval

[@MehrdadSaravi]

thanks professor for excellent and wonderful educational videos

[@dr.joshuacooper-arrhythmia9917]

Thanks for watching and for taking the time to give nice feedback!!

[@MehrdadSaravi]

@@dr.joshuacooper-arrhythmia9917 Dear Prof. Cooper: I really learned the concepts of electrophysiology with your talks.

[@martynaskrzynska]

Stunning video 😀 helped me a lot 😀

[@dr.joshuacooper-arrhythmia9917]

I'm really pleased with how this one came out! I think it helps people understand what ATP is trying to achieve.

[@shenle75]

Perfect thank you for your great effort

[@dr.joshuacooper-arrhythmia9917]

I'm so glad you found this video helpful! I really enjoyed making it, and hope it helps many people better understand the concept and mechanism of anti-tachycardia pacing!

[@kashifalikhan2535]

Thanks you so much ❣️

[@marcvanderpoel]

This is the best video on the subject that I have seen so far. Thank you so much for this! It has helped me a lot. I have one more question about this: Overdrive pacing seems to be practiced in an emergency situation also with transcutaneous pacemakers. However, I have not been able to find any detailed instructions on this, e.g. on device setting and concrete implementation. The product information of the device manufacturers I know of do not mention this either. Can you say a few sentences about whether the same principles apply to transcutaneous anti-tachycardia pacing that are explained in this video? Can you point me to some literature that explains the procedure in detail. Thanks again.

[@dr.joshuacooper-arrhythmia9917]

Oh my gosh, it is a spooky coincidence that you should ask this question. Literally two days ago I used surgical temporary epicardial wires to pace terminate an atrial flutter in our ICU. And then I was called last night by the ICU team because the patient went back into atrial flutter and they wanted instructions on how to do what I had done the previous day, which is basically your exact question. I think it has been a few years since I have used a temporary pacing system to do antitachycardia pacing, and here it happens to coincidently come up twice within 24 hours! Different pacing systems operate differently. We were using the Medtronic temporary pacing box, which has a rapid atrial pacing option in the menu on the bottom part of the screen, and one has to toggle between different menu functions in order to find this pacing option.

[@sconor1]

Hi Dr Cooper, love your videos. I do have a quetion. In the ATP fail scenario: S2 no capture, why do you need an S3 beat? S2 hit refractory so a well timed longer S2 should terminate right?

[@dr.joshuacooper-arrhythmia9917]

Great question! In this algorithm, the S2 coupling interval is progressively shortened, so when S2 hits refractoriness, that implies that longer intervals had already failed (presumably because the S2 beat did not successfully propagate to the circuit and inter the excitable gap at the right place). And so, S2 needs to be prolonged again in order to capture, but that will likely be insufficient for VT termination without also adding an S3. And of note, the S2 beat will "prime" the interposed myocardial tissue by shortening its refractory period, thereby allowing an even shorter S3 coupling interval to capture and propagate to a greater degree than S2 was able.

[@sconor1]

@@dr.joshuacooper-arrhythmia9917 Thanks for the explanation!

[@simoncastro7748]

Amazing!

[@dr.joshuacooper-arrhythmia9917]

Thanks so much! Glad you enjoyed it! :)

[@mingyoong614]

Hi Dr. Cooper. Great lecture! Very easy to understand. May I ask a question? Can you do this manually? Because it seems very logical and possible to adopt this manually for devices that do not have this algorithm. And secondly, when you mention long PPI for failure to reset, what are you referencing it to? Is it the PPI after a train of S1 beats (that successfully entrained the tachycardia)? So when it has "long PPI" does it mean it is longer than the PPI after S1? Thank you!

[@dr.joshuacooper-arrhythmia9917]

Thank you so much for your comments and interest! It is not possible to manually program any random device to this scheme, as standard anti-tachycardia pacing has very specific programming options including burst pacing and ramp pacing but no option for s1s2 programming. With respect to the post-pacing interval, that refers to the time between the last paced beat and the first return sensed beat after that if tachycardia is ongoing. Please refer to my video on entrainment which goes into this concept in detail and I think you will find it extremely helpful!

[@mingyoong614]

@@dr.joshuacooper-arrhythmia9917 thank you very much! for both the video and your reply!

[@asyiqraffali1539]

How about reentrant SVTs? Does ATP principles for VT apply to it? Thank you.

[@dr.joshuacooper-arrhythmia9917]

Yes indeed, ATP principles also apply to atrial reentrant arrhythmias! In fact, atrial ATP can be programmed in certain pacemakers and defibrillators. The main differences with atrial reentry include the size of the atrial flutter circuit (often large, occupying much of the chamber), the size of the excitable gap (often large), and the paucity of scar barriers in atrial reentry that are highly present in reentrant VT (often including the presence of a protected VT isthmus, embedded within a region of scar).

[@asyiqraffali1539]

@@dr.joshuacooper-arrhythmia9917 thank you Dr Cooper for your prompt reply. Your video explanation makes it really easy to understand.

[@elliottfireice4394]

6:10 well before, i mean they didn't want it before. Its blocked its blocked.