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?
TEE
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?
At the site
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
PaO2
80- 100
SaO2 normal value
95-100%
During fluoroscopic imaging the LAO displays what?
On face through tricuspid, can differentiate Left from right, Spine will be on the right
During fluoroscopic imaging the RAO displays what?
Differentiates atria from ventricles, Spine on left
During RF ablation of AVNRT there is a loss of retrograde conduction. The proper response would be what?
Stop the RF application
Hypoventilation causes PaCO2 to do what? What happens to the pH?
Increases , Decreases
What should you do with used needles?
place directly in sharps container no need to cap them
What VT are often provoked with exercise?
Idiopathic left ventricular tachycardia, RVOT, LQTS 2
What are forms of ionizing radiation?
CT, fluoroscopy, nuclear medicine
How do you adjust voltage when measuring a capture threshold testing for permanent pacemaker implant.
Start at output of 5 volts then decrease incrementally until loss of capture. The amount of output that then restores capture after being lost is the capture threshold determination.
What are the benefits of subcutaneous ICD?
decreased risk of vascular complications, decreased risk of pneumothorax, decreased risk of surgical site
A patient comes in for a BI-V ICD but he is left handed but side should the tech prep?
Right Pectoral
What file format allows hospitals to transmit clinic images?
Dicom
A carotid massage would be preformed on a patient presenting with syncope and what else?
A negative ep study
What is lateral view?
90 degree of left side
What is an example of a class I recommendation for the extraction of chronic pacing and defibrillation leads?
Life threatening arrythmia due to a retained lead fragment
Just prior to using the laser sheath for lead extraction, a _____ should be used first to attempt removal
locking stylet
What functions are programmable in both VVI and DDD pacemakers?
Sensitivity, voltage output, rate smoothing
What is the indications for Bi-V device insertion?
EF less than or equal to 30 and a QRS >150
What is AVNRT?
A form of SVT with dual AV nodal pathways
What is the mechanism for AVNRT?
Micro Reentry
what is typical AVRNT?
down the slow pathway then up the fast
What is atypical AVNRT?
down the fast pathway then up the slow
What catheters are used in AVNRT Studies
HRA, HIS, CS, RVA
Where should you ablate for AVNRT?
below the AV node
How do you know if you have successfully ablated AVNRT?
You will get a Slow junctional rhythm, Also if AVNRT is not inducible
When you are ablating for AVNRT you see a fast junctional rhythm. what should you do?
Stop ablation due to being to close to the AV node
What medication is used to induce AVNRT?
Isoproterenol
When pacing from the CS and measuring laterally, what activation time would likely indicate successful ablation of typical atrial flutter?
greater than 150 ms
What is the method of activation for Atrial Flutter?
Re entry
At what degree could a steam pop occur?
100 Degrees
The most common reason for pacemaker or ICD device failure is
Battery Depletion
To employ entrainment mapping, it is vital to distinguish reentrant arrhythmias from those due to
Automaticity
How many types of fixation mechanisms are available for use in pacing? and what are they?
2; Passive and active
A standard diagnostic EP (electrophysiologic) study for the investigation of supraventricular tachycardia uses how many catheters? Which ones?
4; HRA, HIS, RVOT, RVA
The ICD (Implantable cardioverter-defibrillator) is the only treatment that reliably reduces the risk of death from which conditions?
Ventricular Arrythmias
Propanolol, Acebutolol, Esmolol, and metroprolol are all in which class of drugs according to the Vaughn-Williams classification system?
Class II
What would reverse the effects of the heparin on a patient?
Protamine Sulfate
Once the patient has had a pacemaker implanted, how often does the lithium cell battery need to be replaced?
Every 5-10 years
What does not have an affect on the pacers stimulation threshold
Lead Fractures
How is AVNRT induced when it comes to pacing?
By programmed electrical simulation pacing (PES)
What drug is given to terminate AVNRT?
Adenosine
What would two echo beats indicate?
indicated that AVNRT circuit has not been successfully ablated
What does AVNRT stand for?
AV Node Reentry Tachycardia
What does AVRT stand for?
Atrial Ventricular Re- Entrant Tachycardia
What is the Mechanism of activation for AVRT?
Macro reentry
What type of arrythmia is WPW?
It is a form of AVRT
How do you distinguish WPW?
There will be delta waves, Short PR
What is the difference between antidromic and orthodromic?
Orthodromic is normal conduction
Antidromic is a retrograde conduction
What catheters are used in AVRT study?
HRA, HIS, CS, RVA
A-A (Atria to Atria) Normal Values
600-1200ms , 50-100 bpm On HRA, HIS, or CS
V-V (V spike to V spike) Normal Value
600- 1200ms, 50-100 bpm
PA interval normal value
25-45 ms
AH (A spike of HIS to H Spike on HIS) Normal value
50-120ms
HV (H Spike on HIS to onset of V spike of all ECG/EGM) Normal Value
35-55ms
What is the A-A interval measuring
The interval time from onset of atrial deflection to the following atrial deflection
What is the PA interval measuring
Measuring intra- atrial conduction time
What is the AH interval measuring
Indicates conduction time across the AV node
What does the HV interval measure?
Measures total conduction activation time of the His bundle to the Purkinje fibers
QT interval Normal value
250-400 ms
What is the QT measuring?
Ventricular activation and repolarization
What is the formula for QTC?
QT divided by the square root of RR
What is the Normal value of PR?
120-200 ms
What is the normal RR?
600-1200 ms or 50-100 bpm
What is normal value for QTc?
<450 ms for males <470 ms for females
What is P-P normal value?
600-1200ms or 50-100 bpm
What does the PR interval measure?
The conduction in the atrium, AV node, and HIS- Purkinje
What is the normal value for QRS?
<100 ms >100 is IVCD >120 BBB
What is the QRS measuring?
Ventricular depolarization
Measuring the onset of the signal deflection to the onset of the following signal deflection is what?
Onset approach
Measuring the precise moment when the depolarization wave front passes through the midpoint between the electrode pair?
Zero- Crossover Approach
The failure of the SA node to appropriately generate Electrical impulse for atrial depolarization?
Failure of impulse generation
The failure to appropriately propagate or transmit electrical impulse
Failure of impulse propagation
What are the different mechanisms of activations for Tachyarrythmias?
Automaticity, triggered, reentry
What kind of mechanisms it is when cells other than the SA and AV node spontaneously generate impulses?
Automaticity
What kind of mechanism is it when the same electrical impulse continue to excite the circuit of the heart?
Reentry
What are the three things that reentry mechanism requires?
Slow zone of conduction, unidirectional block, slow enough conduction allowing tissues to be refectory
Reentry is the mechanism for what Arrhythmia?
Ischemic VT, Atrial flutter, AVNRY AND AVRT
What mechanism is the double activation of a cardiac cell from a single initial activation?
Triggered activity
In what phase does EAD or Early After depolarization occur?
Phase 2 or 3
Which phase does delayed after depolarization (DAD) occur?
phase 4
How can triggered activity be initiated?
With programmed electrical stimulus (PED)
When there is an AV block above the HIS bundle what is the morphology?
A junctional escape rhythm with a narrow complex 40- 60 bpm
When there is a AV block below the HIS bundle what is the morphology?
A ventricular escape rhythm with a wide QRS 20-40 bpm
What is the cause of Symptoms in episodes of Bradycardia?
Decreased cardiac output (Blood Volume)
Why does bradycardia occur?
There are insufficient impulses by the SA node
What is a sinoatrial exit block?
A sudden pause in atrial depolarization due to the electrical impulse being delayed or blocked on the way to the atria.
How is a sinoatrial block different from an AV block?
It occurs in the SA node not the AV node
What is a 1 degree AV block?
a prolonged PR greater that 200 ms
What is a second degree Mobitz Block Type 1?
Wenckebach, PR gets longer than a QRS is dropped
What is a 2nd degree AV Block Type II?
A PR is consistant and the PR randomly drops
What is a 3rd degree heart block?
Multiple p’s with no QRS following, There is no association
What kind of catheter is a HRA?
Quadrapolar
What kind of catheter is the HIS
Quadrapolar or hexapolar
What type of catheter is the RVA?
Quadrapolar
What spikes will you see on the HRA?
A spikes
What spikes will you see on the HIS?
A, H, V
What spikes will you see on the CS?
A, V
What spikes will you see on the RVA?
V
What is SNRT?
the interval time it takes or SA node to recover from burst pacing.
How long is burst pacing preformed?
30-60 seconds
Explain CSNRT?
SNRT depends on the sinus cycle length therefore a corrected SNRT is determined through CSNRT-SCL
What is SACT?
Sino- atrial conduction time, it detects the delayed conduction from the SA node through the atrium
What does a short H-V interval imply?
The presence of an accessory bypass tract such a WPW
Atrial Tachycardia is a form of what?
SVT
Where does Atrial Tachycardia originate?
Right or Left atrium or structures attached to the Atria
What is the HR for Atrial Tachycardia?
140-220 bpm
What are some indications of Atrial Tachycardia?
Different P wave morphology than NSR, P-P is regular, R-R is regular
What is multifocal Atrial Tachycardia?
At least 3 different wave morphologies, Irregular P-P, R-R, and the PR varies
What is inappropriate sinus tachycardia (IST)
HR greater than 100 bpm, P-P and R-R are regular, SP wave morphology is the same as Sinus
What is the most common source of left atrial tachycardias?
Pulmonary veins
What is the most common source for Focal AT?
Crista Terminalis
What are the mechanisms of activation for Atrial tachycardias?
Automaticity, Triggered Activity, And Reentry
What is the mechanism of activation for Focal Atrial Tachycardia (FAT)?
Automaticity
What do the P waves look like in FAT?
a single stable P wave morphology differing from sinus
Multifocal Atrial Tachycardia is what?
A tachycardia where there are multiple foci that initiate and sustain resulting in the creating of varying p waves. usually short Burst onset
What kind of catheter is CS?
Decapolar or octapolar
How do you terminate AT with Pacing?
Burst atrial pacing at 240 ms
How many joules for cardioverting a narrow regular Rhythm?
50-100 J
How many joules to cardiovert a narrow irregular Rhythm?
120-200 J Biphasic or 200 J monophasic
How many joules do you use when cardioverting a wide regular rhythm?
100 J
How many joules do you use when cardioverting a wide irregular rhythm?
120 J Biphasic ot 260 monophasic not synchonized
What is the primary treatment for AT?
Rate controlling drugs that slow AV conduction such as Beta Blocker and Calcium channel blockers
Atrial flutter is what kind of Arrhythmia?
A form of SVT
If Leads II, III, and aVF have negative deflection and positive deflection in V1 what type of AFL is it?
Typical Counter clockwise Atrial flutter
If Leads II, III, and aVF have positive deflection and negative deflection in V1 what type of AFL is it?
Typical Clockwise Atrial Flutter
What is atypical flutter?
Flutter that does not fit the classification of typical flutter and does not use the cavotricuspid isthmus as a zone of slow conduction
What catheters are used when measuring AFL?
H,TA, or CT, HIS, CS
What kind of catheter is a Halo (H) or Tricuspid Annulus (TA)?
Duo deca (20)
what kind of catheter is the Crista Terminalis (CT)?
Decapolar
What kind of catheter is a CS?
Deca or octapolar
What is Post- Pacing Interval?
A measurement derived from pacing in a specific chamber to assess wether the pacing catheter is sending stimulus pacing within the tact or circuit of reentrant arrhythmia
When pacing is performed from within the reentrant circuit what will the paced beats look like?
They will have the same morphology as the tachycardia beats, and the PPI will match the TCL.
How do you determine wether the pacing site is in circuit?
you subtract the PPI from the TCL and it has to be less than or equal to 20 ms
How do you initiate AFL by pacing?
Burst pacing or decremental pacing faster than the SCL, or atrial PES
How do you terminate AFL?
Through atrial burst pacing 20-50% faster than the flutter rate
What kind of medications are used to treat AFL?
Anti arrythmic drugs
What should be done prior to cardioverting atrial flutter patients?
they much be anti-coagulated several days prior
Where do you ablate for AFL?
Cavotricupid isthmus. Starts on the ventricular side of the tricuspid annulus across the cavotricuspid isthmus to the IVC
How do you know when ablation lesions are effective in ALF?
Decrease in voltage amplitude and display fragmentation
Where does Atrial fibrillation originate?
Left atrium
The pulmonary veins are the most common contributors to what kind of AF?
Paroxysmal AF
Why is the esophagus a key landmark in AF ablation?
Ablation can lead to a severe complication of esophageal fistula
Where is a transeptal puncture done?
From the RA to the LA via the inreratrial septum through the fossa ovalis
Pulmonary Vein Isolation (PVI) and complex fractionated atrial electro gram (CFAE) are what?
Ablative techniques utilized when ablating fib
What is an entrance block in contact to a fib?
It is the absence of impulse from the LA into the pulmonary veins
How is an entrance block shown on the EGM?
Through the lasso catheter you will see normal sinus the all of a sudden the signal will be gone.
What is an exit block in regards to AF?
the absence of impulse from the PV to the LA
Near field is displayed how?
Narrow sharp signal deflections
Far field is displayed how?
Wide and muted signal deflections
Why do patients experience AF?
Structural abnormalities and electrophysiological mechanism abnormalaties
What mechanisms of activation occur in AF?
Enhanced automaticity, triggered activity and reentry
Paroxysmal AF is
2 or more episode within 7 days
Persistant AF?
Sustained episode for more than 7 days
Permanent AF?
Continuous episode of AF greater than a year
What are the catheters used in AF?
PV catheter, Ablation catheter, CS
What kind of catheter is an ablation catheter?
quadrapolar
How many electrodes do specialty catheters usually have?
8-20+
How can you induce AF?
Atrial programmed extra stimulus pacing (PES) or burst pacing from the distal cs <250 ms
What leads are usually shows on Surface ECG?
Lead II, III, and V1
What is it if you see AF on one part of the EGM but not other catheters?
This means that the AF is being blocked from that area to other areas.
ex. AFIb is Seen in lasso lead but not in CS
What is the typical therapy for AF?
Rate control or Rhythm control
What is done when ablating for AF?
Circumferential lesions are made around left and R PV
What is MAZE?
an open heart surgery to produce scars to prevent AF
What is the reason for a LAA closure
Helps reduce the risk of stroke or clot from LA
What is the ACT value when doing a LAA closure?
250-300 s
What is done prior to AF ablation
A TTE or TEE is done to verify there is no Left arial clot
What kind of needle is used in transeptal puncture?
Brockenbrough
Activiation clotting times should be at what during a procedure?
300-400 sec
When can you pull a sheath?
When ACT is below 160-180 seconds
A condition of fluid and blood buildup of the pericardial sac from disease, trauma or perforation to the myocardium, acutely associated with excessive heat and ablation application.
Cardiac Tamponade
What procedure needs to be done when cardiac tamponade occurs?
Pericardiocentesis
Where is pericardiocentesis access point?
Subxyphoid
What type of catheter is used in pericardiocentesis?
6 fr pigtail
What is the rate for AVNRT?
140-280 bpm
The fast pathway is also known as what?
Beta Pathway
The slow pathway is also known as what?
alpha
What is the purpose of the tricuspid valve annulus?
it aids in keeping the atria and ventricles isolated from one another
How is a “Jump” noted on the EGM?
The AH interval will change because it will go from a fast pathway to the slow pathway. Looks like a rate change on an ECG
What is an echo beat?
an echo beat is a beat that returns back to its origin
What is typical AVNRT?
When the first activation of AVNRT the slow pathway
What is atypical AVNRT?
When the first activation of AVNRT the fast pathway
What catheters are used in AVRNT study?
HRA, HIS, CS, RVA
a 50ms prolongation in the A-H interval with a 10ms decrease of the S1-S2 coupling interval.
A jump from Fast pathway to slow pathway
Long AH interval represents what?
AVNRT
How do you terminate AVNRT with meds?
Adenosine
For an AVNRT ablation, the optimal ratio of atrial to ventricular intracardiac signal (A:V) displayed on the mapping/ablation catheter is
1:4
What path way is routinely ablated for AVNRT?
Slow pathway
Where is the fast pathway located?
Superior to the triangle of Koch
What is a concealed accessory pathway?
AN AP that conducts in a retrograde fashion
What is a manifest accessory pathway?
An AP that always conducts anterograde and my also conduct retrograde. There will be delta waves
WPW is a form of what?
AVRT with a manifest accessory pathway
What is a concentric activation?
normal activation SA node to AV node to ventricle
What is an eccentric activation?
Abnormal conduction not through AV Node
A Typical AP is also known as what?
Bundle of Kent
What catheters are used in a AVRT study?
HRA, HIS, CS, RVA
What shows right sided conduction?
A Ventricular deflection of the RVA proceeds the V on the HIS
What shows a left sided conduction?
In the ventricular deflection of the proximal CS precedes the V deflection on the His
Delta wave on V1 is negative?
Right sided AP
Delta wave on V1 is positive
Left sided AP
negative delta wave on (II,II,aVF)
Right sided poster-septal
Positive delta wave on (II,III,aVF)
Right sided anteroseptal
How are left sided pathways ablated?
Retrograde aortic approach or transeptal approach
What is the end point of AVRT ablation
Eliminated the delta wave
Which best describes a “manifest” accessory pathway (AP)?
Presence of a delta wave preceding the QRS complex surface ECG.
During manifest activation, the delta wave will become more __________as more of the ventricle is activated via the accessory pathway during rapid atrial pacing (burst pacing).
Prominent
A Mahaim Fiber is a type of AP located similarly to the AV node on the tricuspid annulus and displays decremental properties, directly connecting to the fascicle of a bundle branch rather than the ventricle like the typical AV nodal accessory pathway.
T/F
True
What components are necessary to complete an AVRT circuit?
Atria, AV Node, Ventricle, AP
A patient in AVRT has a V-A time of 165 ms. The patient then develops a left bundle branch block (LBBB) and the V-A times jumps +50 ms, patient most likely has ________________.
a left sided accessory pathway
What are the indications for ventricular tachycardia
Rate 100-200 bpm, no PR interval, wide complex
a common structure of interest with regard to premature ventricular contraction (PVC’S) and VT’s,
Ventricular Tachycardia
The most common site for idiopathic VT
RVOT
Common for monomorphic VT
RV
Common site for polymorphic VT
LV
What does idiopathic mean?
unknown cause or spontaneous origin
what are the methods of activation for VT
Automaticity, Triggered, Reentry
What is the mechanism for abnormal impulse formation?
Automaticity and triggered
What is the mechanism for abnormal impulse conduction?
Reentry
What is the most common mechanism of activation for VT?
Reentry
Stable VT is defined as
when cardiac output is sufficient to maintain BP and perfusion
Unstable VT is defined as
When cardiac output in insufficent to maintain blood pressure and adequate perfusion
Idiopathic left ventricular tachycardia morphology
RBBB with LAD
Arrhythmogenic Right Ventricular Dysplasia morphology
LBBB morphology
Long QT syndrome morphology
an idiopathic VT that can initiate a polymorphic VT known as torsades
Catheters used for VT
HRA, HIS,RVA, RVOT
What is the preferred way to initiate VT?
PES
What is the first line to terminate VT?
Cardioversion
What are the two forms of therapy to terminate VT via ICD?
Internal Cardioversion and to pace patients out
Which chamber is most susceptible to ischemic, scar based VT’s?
LV
The condition where fatty tissue infiltrates or fibrous tissue replaces normal myocardial tissue of the RV is known as
Arrhythmogenic Right Ventricular Dysplasia (ARVD)
This is a genetic disorder that affects the ion channels (sodium, potassium) of cardiac cells and can result in an arrhythmia called torsade’s de points
Long QT Syndrome (LQTS)
These devices have been proven to reduce mortality of selected patients at risk for sudden cardiac death is
ICD’s
What is coupling interval?
The interval of time between two paced beats
Paced beats that cause depolarizations of the chamber being paced
Capture
The interval of time between two cardiac beats
Cycle length
The longest coupling interval that fails to capture
Effective refectory period
To repeatedly increase or decrease the paced cycle length
Incremental pacing
To shorten the paced cycle length
Decremental pacing
8 paced beats at a fixed cycle length
Drive train
What is the drive train labeled as
s1
Introduction of a pacing stimulus at a fixed cycle length known at s1
Burst pacing
Stimulus pacing while adjusting the cycle length in small increments
Incremental pacing
interval for a premature stimulation which does not conduct the atrium
Atrial Effective Refractory Period (AERP)
The longest coupling interval of a premature stimulus which does not conduct to the AV node
AV Node Effective Refractory Period (AVNERP)
The longest coupling interval for a premature stimulus that does not conduct to the ventrice
Ventricular Effective Refectory Period (VERP)
The longest coupling interval for a premature stimulus that does not conduct retrograde to the atrium
VA Effective Refractory Period (VAERP)
The introduction of one or more premature paced beats at a shorter cycle length
Programmed Extra- Stimulus (PES)
After the drive train the first premature beat is known as what? The second? The Third?
S2, S3, S4
What is synchronized Defibrillation?
A low energy shock where the shock is delivered at the peak of the QRS complex
How do you determine threshold?
Begin at 5 mA then decrease until the loss of capture is noted.
What is the acceptable range for mA to capture in the atrium?
<1 mA
What is the acceptable range for mA to capture in the atrium?
< 3 mA
What is adequate safety margins to maintain consistent pacing?
2x the capture threshold or atleast 1mA above capture threshold
Where do you ablate for AFL?
From Ventricular side of tricuspid annulus across the cavotriscupid isthmus to the IVC
Where do you ablate for AFL?
pulmonary veins
The saline coolant is recirculated through an external pump to maintain cooling. What kind of irrigation?
Closed Loop
saline coolant that is pumped through and out of the catheter electrode through multiple holes in the electrode, providing increased convective cooling. What kind of irrigation?
Open- Loop
Prior to transferring a patient from the table to the bed, the technologist must do what?
Secure the femoral lines
When draping a patient for a pacemaker implant, the technologist must drape which area of the
drapes the area that has been disinfected for use
During ventricular entrainment pacing of SVT, a post response of A-A-V is noted, this response is consistent with what?
Atrial Tachycardia
Carotid Massage would be preformed on a patient presenting with syncope and what else
a positive VT induction
What 12 lead ECG findings are commonly associated with ARVD?
Epsilon waves and t wave inversion
What is most likely to perforate coronary venous vasculature?
Guide wires
Hypoventilation causes what?
PCO2 will increase and pH will decrease
Hyperventilation causes what?
PCO2 will decrease and pH will increase
Tachycardia initiated by an impulse that blocks in the fast pathway and conducts through the slow pathway is described as?
AVNRT
During RF ablation of AVNRT there is a loss of retrograde conduction, the proper response would be to do what?
Stop RF ablation
What are the indications for single or dual chamber ICD’s?
Heart failure, cardiomyopathy, Secondary prevention
DFT may be preformed when?
Failed therapy delivery, congestive heart failure, appropriate therapy delivery
a biohazard bag should be used to dispose of what?
items saturated with blood or bodily fluids
HIS bundle disease or damage is indicated by prolongation of what?
H-V interval
RVOT, Idiopathic left posterior fascicular VT, VT associated with ARVC
Exercised induced VT’s
The activation sequence of a left lateral pathway is characterized by what?
Distal CS A first
What information in the patient’s medical history is contraindicated to proceed with a transseptal procedure?
History of Stoke
The patient’s physician decides to perform an electric cardioversion for atrial fibrillation with irregular ventricular rates after a CFAE AF ablation. What is the most appropriate setting to cardiovert the patient from AF into normal sinus rhythm?
150 J Synchronized
A technique to verify successful access to the pericardial space involves attaching an ECG lead to the access needle. Doing so will produce what ECG effect when making needle contact with the ventricle?
ST elevation
