RCES Assessment Flashcards
During LAA closure device insertion, it is recommended that the ACT be maintained at _____ seconds
250-300
What medication would be used to treat WPW?
Procainamide or quinidine
What medication is used for cardiofversions?
Ilbutilide
What is Mallampati score associated with?
Difficulty in airway management
What is the dosage for sedation with fentanyl?
25-50 micro grams
What is the dosage for morphine for sedation?
.1mg/kg 2-10mg
What is the reversal agent for Sedatives?
Flumazenil (Romazicon) .2 mg
What is the reversal agent for opioids?
Naloxone (Narcan) .4mg-2mg
How is Coumadin (warfarin) reversed?
Vitamin K injection
Which drug is commonly utilized to increase vagal tone and initiate induction of SVTs?
Isoproterenol
During the administration of Ibutilide (Corvert), what interval of the patient’s rhythm should be monitored?
QT
Procainamide is what kind of class drug?
Class 1a
Verse, Fentanyl, Valium are all what?
Concious sedation meds
Apixaban, Coumadin, lovenox are all types of what?
Are types of anticoagulants
The structure that separates the thin smooth atrial muscle from the trabeculae muscles is _______.
Crista Terminalis
This firm muscle tissue is well developed in large patients, makes tissue contact a concern and is a challenge in flutter ablations.
Eustachian ridge
Which semi-circular fold of tissue serves as a valve to the CS os?
Thebesian Valve
What three (3) structures comprise the Triangle of Koch?
Tendon of Todaro, CS os, Tricuspid Valve Septal Leaflet
The three vessels that delivered blood into the right atrium are:
SVC, IVC, CS
The AV node lies where compared to the CS?
Superior and anterior
What ridge is a band of tissue that surrounds the fossa ovalis?
Limbic ridge
The structure in the right atrium known as the zone of slow conduction.
Cavotricuspid isthmus
What is the most anterior chamber of the heart?
Right Ventricle
The origination of most idiopathic VT originates from what structure?
RVOT
This muscular tissue which can cause obstruction in advancements of EP catheters and pacing leads in the apex region of the RV.
Moderator Band
Common pacing sites for diagnostic EP study.
RVOT & RVA
The pulmonary veins insert into what segment of the atrium?
Posterior Wall
What coronary artery distributes blood to the SA node?
Right coronary artery
Where is the most common site of AF trigger origination?
Pulmonary vein ostia
This structure is responsible for the great majority of clot formation.
LAA
Left atrial ridge of tissue between the left atrial appendage (LAA) and the ostium of left pulmonary veins.
Ridge of Marshall
Can the HIS bundle be measure and damaged in the LA
Yes
Is LA is the anterior most chamber of the heart
No the RV is
What contracts in systole to prevent leaflet prolapse?
Papillary muscles
Electrical stimulation exits the left bundle branches at this structure.
papillary muscles
Besides the RVOT, what other region can mapping and ablation be performed for RVOT tachycardias?
LVOT
Prevents blood regurgitation back into the atria.
Chordae Tendineae
What ridge tissue structure lies anterior at the junction where the IVC and RA connects?
Eustachian Ridge
What conduction structure accelerates electrical activation to the left atrium, ensuring properly timed depolarizations?
Bauchmanns Bundle
Structure responsible for conduction from the atria to the ventricles is known as the
AV node
Decremental conduction properties of the AV Node refer to
The ability to slow conduction to the ventricles
What is the most distal part of the conduction system?
The purkinje fibers
What region of the AV node is where decremental conduction (conduction delay) occurs?
nodal
The ions that mediate the electrical current cardiac cells are
Sodium, potassium, calcium
How many phases are there of the cardiac action potential
5
What is the membrane potential of the action potential?
The difference of the cardiac charge inside and outside the cardiac cell
Which Action Potential phase is known as the Quiescent Period?
4
Which Action Potential phase is known as the Plateau phase?
2
The longest coupling interval that fails to capture myocardial tissue
ERP
Depolarization because of sodium going into the cell is
Phase 0
What are the two types of sodium channels?
L and T
VAERP measures the refectory period of
The retrograde AV node
Phase 2 of the cardiac action potential is characterized by a slow influx of
Calcium ions
Which phase of the action potential is marked by closing the rapid sodium channels?
Phase 1
Shortest coupling interval between two successive conducted impulses that can elicit a response
Functional refectory period (FRP)
The shelf life of a sterile package is most affected by ____________.
temperature
Non-sterile personnel must maintain this distance away from the sterile field and sterile personnel
18 inches
Power, Temperature, Impedance and Time are all parameters of what system
The ablation generator
The Electrophysiologist states the needs to ablate in the Right Coronary Cusp, allied support staff should prepare for which possible procedure
Cardiac catheterization
A patient with an O2 saturation of 87% while receiving oxygen therapy via nasal cannula requires procedural sedation. What statement best applies to the situation?
Sedation should be administered by a CRNA or Anesthesiologist.
Once hemostasis is achieved from an initial femoral artery access, which is the MOST appropriate vessel to assess distal pulses?
Dorsalis-pedis
Which blood test is MOST appropriate to validate prior to arterial sheath removal
ACT
Alpha Particle, gamma rays, X-rays are all what?
Ionizing radiation
UV, infrared, radio- frequencies, microwaves are all what?
Non- ionizing radiation
X-rays that have directly passed through the patient on the procedure table are collected in the __________________.
image intensifier
The RAO view of the heart is optimal for imaging
atrium and ventricle
What is the greatest hazard to the staff?
Scatter Radiation
What is the annual radiation exposure limit for occupational workers?
5 rem/yr
The process for getting permission before conducting a healthcare intervention on a person is known as
informed consent
What needs to be done before the EP procedure can begin?
Physician orders, informed consent, H&P
What does MAR stand for?
medication administration record
What is MAR used for?
Pre and post procedure medication
After how many days is a patient H&P considered expired?
30
What does the H&P include?
Understanding of the health intervention to be preformed
A patient’s family member is asking for an update regarding an ICD implant being preformed what do you do?
Inform family of the procedure
Signals that are amplified from specially designed EP catheters lying on the patient’s cardiac tissue are known as
EGM
The configuration of ‘unipolar’ refers to
an electrode in contact with the heart and the other electrode is outside of the heart or on the surface of the body
The configuration of ‘bipolar’ refers to
voltage difference of the cardiac tissues between the two electrodes.
Access to the Left Femoral artery will allow catheters to be passed first into what heart chamber?
Left Ventricle
2-5-2 spacing of an EP infers
2mm spacing between first electrode pair and 5 mm spacing between each pair of electrodes
The access point for a femoral vein or arterial access is
2-3cm below inguinal ligament
What is the standard paper recording speed of a 12 lead ECG?
25mm/sec
What is the typical sweep speed of an EGM?
200 mm/sec
Sharper spikes will be noted when a signal is?
Near field
A signal will look smaller and more spread out when
its far field
In a normal activation sequence what is the correct signal sequence for the atrial signal?
HRA, HIS , Proximal CS, Distal CS
What is the Normal sequence when pacing from the RVA
RVA-HIS-HRA
Which electrode pair will measure the most lateral left atrial signal?
CS 1-2
A patient is taken off of Coumadin for one week prior to an RF ablation procedure. The INR yields a value of 4. The next logical step would be to:
Send the patient home and repeat the INR at a later date
Post procedure, an arterial line is to be disconnected. The final ACT is 450 seconds. The previous ACT was 320 seconds, with no heparin given since then. The next logical step would be to:
Repeat ACT
The influx of what ion into the cell membrane sustains repolarization during the cardiac action potential?
Calcium
Which guide wire length is MOST appropriate for over-the-wire transseptal sheath exchange?
260 cm
In order to help facilitate the induction of AVNRT, it is customary to use IV:
Isuprel
What fluoroscopy view displays the tricuspid and mitral valves in the “on face” or open clock face view?
LAO
What is the BEST fluoroscopy view to optimally image the inferior wall of the right ventricle for temporary catheter lead placement?
RAO
During insertion of a temporary pacemaker lead, the lead perforated the heart. What tissue did the lead perforate?
Endocardium
A prolonged PR interval means there is a delay in the what?
AV Node
How do you open sterile packaging?
Open part that is away from body, let it drop down the table, open the side flaps, the open flap closest to body
What distance should you maintain from the patient?
12 inches
Atrial depolarization is marked by what?
A spikes
HIS depolarization is marked by what?
H Spike
Ventricular depolarizations marked by what?
V spikes
Which mechanism is defined by (1) slow zone of conduction, (2) unidirectional block in part of the tissue, and (3) slow enough conduction allowing tissue to become refractory?
Re Entry
Failure of the SA Node to adequately generate an appropriate number of intrinsic (native) electrical impulses defines which term?
Failure of impulse generation
The intrinsic (natural) ability of cardiac cells to spontaneously and repetitively generate electrical impulse for depolarization is known as
automaticity
What are the three (3) different mechanisms of activation that propagate tachycardias?
Reentry, triggered, automaticity
What is required for reentry mechanisms?
Zone of slow conduction, allows tissue to before refectory, unidirectional block
Activity which propagates double activation of a cardiac cell from a single initial activation, resulting from the presence of upward deflections is known as which mechanism of activation?
triggered activity
Delayed after depolarization (DAD) occur in which phase of the action potential of triggered activity?
Phase 4
Baseline EGM measurements are generally performed at what recording speed?
200 mm/sec
Measuring the precise moment in time when the depolarization/activation wave front passes thought the mid-point between an electrode pair, manifested by the apex point of the EGM deflection is known as:
Zero cross over point approach
What is a normal PR Interval
Less than 210ms but more than140ms
What Is a normal QRS interval?
Less than 120 ms
What is the A-A interval?
Earliest a spike to the a Spike of the next atrial activation in any catheter
What does an abnormal A-A interval suggest?
Intra atrial delay, block, or arrhythmia
What is a PA interval?
Earliest P wave on ECG to initial A spike on His EGM.
What does an abnormal PA interval suggest?
Intra cardiac delay, disease, or drug effect
What is the AH interval?
Earliest onset of A spike to H spike on HIS EGM
What is the HV interval?
Onset of H spike on his to V spike of all the ECG/EGM
What does an abnormal HV interval mean?
long= His- Purkinje conduction disease, short= pre excitation of ventricles
What is the formula for QTc
QT divided by the square root of the cycle length
Normal A-A
600-1200 or 50-100 bpm
Normal PA value
25-45 ms
AH interval normal value
50-120 ms
HV interval normal value
35-55 ms
Normal QT value
250-400 ms
Normal V-V value
600-1200 ms or 50-100 bpm
A corrected sinus node recovery time (CSNRT) is characterized by
subtracting cycle length from the SNRT
An EP study scheduled to diagnose causes of bradycardia would include what catheters
HRA, HIS, and RV catheters
What are common locations for atrial tachycardia?
Crista terminalis, Pulmonary veins, CS os
Atrial tachycardia P wave morphology will most likely resemble the sinus P wave for which focus
Superior Vena Cava
Ventricular entrainment during atrial tachycardia with tachycardia continuing after pacing reveals
V-A-A-V
Multifocal atrial tachycardia refers to
a tachycardia focus from more than one area in the atrium
PPI-TCL= <20
in circuit
PPI-TCL= >20
close, in chamber of interest
PPI- TCL >20
Out of circuit
The only cryoablation catheter to both map and ablate is
4mm
In and effective RF burn, the impedance should
Decrease initially, then stabilize
Carotid sinus massage would be performed on a patient presenting with syncope and:
a negative catheter study
When extracting fluid from the pericardial space, what catheter is normally used?
6 fr pigtail
Explain calculations of Ohms Law?
V=IR, I=V/R, R=V/I
The physician orders 1,500 mL of normal saline over 4 hours. What is the IV infusion flow rate?
1500/4= 375
The physician orders 1000 units/hr. of heparin with a concentration of 25,000 units in 500 mL/unit. What is the IV infusion flow rate?
25000/500= 50 mL
1000/50= 20 ml
The filter setting that eliminates signal below a set frequency threshold or cut-off, allowing high frequencies to pass through the set cut off is which of the following?
High band Filter
The limiting of EGM signal amplitude (positive & negative), reducing signal overlapping of EGM’s is best achieved by which of the following?
Clipping
Which of the following filters eliminates electronic signal noise of 60 Hz that is inherent in North American alternating current?
Notch Filter
Typical High Pass EP recording system filtering is generally set at which values?
30-50
Typical Low Pass EP recording system filtering is generally set at which values?
300-500
Which of the following takes all incoming cardiac patient signals & also functions as the gateway interface to the EP recording system, stimulator?
amplifier
What is burst pacing?
Pacing that is at a fixed cycle length
What is incremental pacing?
When the pacing stimulus is adjusted in small increments
What is programmed extra- stimulus (PES)
introduction of premature beats
When pacing from the left ventricle what morphology will occur?
RBBB
When pacing from the right ventricle what morphology will occur?
LBBB
What is the acceptable threshold of the atrium?
<1ma
What is the acceptable threshold of the ventricle?
<3m
what is coupling interval?
The time between two paced beats
What is capture?
paced beat or electrical stimulation that causes depolarization of the chamber being paced
What is decremental pacing
to decrease or shorten the packaging cycle length in increments of 10 ms
What is the drive train?
A series of 8 beats paced at a fixed cycle
Intracardiac Echo (ICE) is usually introduced to the heart via the
femoral vein
Positioning the ICE catheter in the RA, just above the terminal end of the IVC, with the transducer oriented with a leftward-anterior transducer face yields which of the following views?
Home view
After insertion of the ICE imaging catheter, which maneuver sets up imaging for transseptal access?
clockwise rotation from the home view
Visual presentation of ultrasound in which the depth of echo is displayed along one axis and time is displayed along a second axis, recording ‘motion’ of interfaces away and towards the transducer is known as
m-mode
The technology of ultrasound using the high frequency sound waves to image, measure and calculate blood flow is known as
Doppler
What does the home view display?
RA, RV, Tricuspid valve
What is later view
Counterclockwise rotation from home
What do you view with lateral view?
Crista Terminalis and RAA
What is transeptal view?
Clockwise rotation from home view
What do you see in transeptal view?
Fossa ovalis, Lefr PV, Left interior Pulmonary vein, Left superior pulmonary vein
Which technology is most frequently used to identify anatomical land marks prior to transeptal puncture?
Intracardiac Echo
Which of the following filter adjustments minimize signal overlapping without adjusting voltage amplitude?
Clipping
If the pace Map matches 12/12 leads what does this mean?
It means the site being paces from matches the clinical VT morphology
During an atrial fibrillation procedure, a physician preforms a transeptal puncture and proceeds to advance into the left atrium. What would one expect to see on the imaging system as the physician advances this wire into the left superior pulmonary vein?
The wire should advance beyond the cardiac border on the image
What is the access point for a pericardiocentesis?
Subxiphoid process via a pig tail catheter
To reduce radiation exposure the fluoroscopic frame rate should be set at ___ frames per second
15
According to joint commission standards, the critical aspects for patient identification are?
Verbally verify 2 identifiers with patient
His bundle disease, or damage, is indicated by the prorogation of what interval?
The H-V interval
When removing venous sheaths, manual pressure should be held where?
Just below the puncture site because it is venous
The imaging directional term meaning anatomically “superior” is referred to as
Cranial
Interpret the following ABG
pH 7.36
PaO2 78
PaCO2 45
HCO3 24.1
Normal
What is normal value ABG pH
7.35-7.45
PCO2 Normal Value
35-45
Normal HCO3
22- 26
