RCES Exam Flashcards
During RF ablation, a high impedance reading continually shuts off the RF generator. The first trouble shooting attempt should be to:
Check if the patient grounding pad is secure.
During monitoring of a radio frequency ablation procedures, you observe the catheter temperature reach 100 degrees C. What is the next action?
Alert the physician and stop the ablation delivery because of potential coagulum.
The technologist is assisting the physician with a PVI. Midway through a burn, micro-bubbles appear on the ICE image. The technologist should:
Tell the physician to stop burning.
What is the usual result of moving the ground patch closer to the heart for RF energy ablation?
A decrease in impedance.
One of the complications specific to PVI is:
Atrioesophageal fistula
An impulse that blocks in the fast pathway and conducts through the slow pathway describes what arrhythmia?
AVNRT
The mA of the stimulator is conventionally set at:
2x diastolic threshold
What is the appropriate high/low pass filters for the surface lead ECG in Hertz?
0.5/100
The formula for cSNRT is:
SNRT - Sinus Cycle Length = cSNRT
What mechanisms of tachycardia is the most common?
Reentry
The most common site of triggers for atrial fibrillation is/are the:
Pulmonary Veins
Burst pacing protocol consists of delivery what?
A fixed sequence pacing train
Following successful atrial flutter ablation, the stim to activation time as measured on the distal pole of the multi-pole catheter should measure at least what?
150 msec
While advancing the RV catheter, the patient suddenly goes into complete heart block. What old be the most likely explanation for this?
The patient has an existing LBBB
What is the most common site for idiopathic VT?
The right ventricular outflow tract
With the exception of a local stimulus of above normal strength, what refractory period describe the time during repolarization in which the longest coupling interval (s1, s2) of input into a tissue fails to produce capture?
Effective Refractory Period
What is the appropriate high/low pass filters for intracranial electro grams in Hertz?
30/500
During cryoablation for atrial fibrillation, what ensures avoidance of phrenic nerve damage?
High output pacing during ablation
What may be a sign of an embolism stroke immediately after a successful transeptal puncture?
Facial weakness and drooping on one side of the patient
What is the commonly used needle to obtain transeptal access?
Brokenbrough needle
What diagnostic catheter is used to drain the pericardial sac for a percardiocentesis?
Pigtail
In a typical bundle branch reentry ventricular tachycardia, the reentry signal initiates ante-grade down the right bundle branch (RBB) to what will complete the reentry circuit?
Retrograde up the left bundle branch (LBB)
What is the most appropriate for a 14-year old female patient who requires an ablation for AVNRT?
4mm cryoablation
What is monitored and documented during a typical tilt table test?
Blood pressure, ECG rhythm, and HR
To minimize the effects of signal artifact or environmental noise, how must all EP lab equipment be set up?
Isolate all EP equipment to a separate designed power circuit
If an atrial flutter cycle length is 280bpm, then what is the cycle length in milliseconds?
214ms
Ablating which section increases concern and risk for damaging the esophagus?
Posterior Left Atrium
During an Atrial Fibrillation using the pulmonary vein isolation (PVI) technique, pacing the coronary sinus (CS) will do what?
Check for entrance block
What is an upper acceptable value for a corrected SNRT?
540ms
What cryo-ablation temperatures cause effective tissue damage and lesion formation?
45 degrees C to 65 degrees C
Successful flutter ablation should show stimulus to activation conduction time measuring at least:
> 150ms
What verifies successful isthmus conduction block for a typical atrial flutter ablation?
> 150ms
For either one of the current mapping systems, what color setting is used to distinguish health tissue during vintage mapping?
Purple
During a tilt table test, the room should be:
Quiet with lights dimmed to establish a relaxing environment
If a tachycardia cycle length is 600 milliseconds, what is its rate in beats per minute?
100bpm
Activation mapping of 3D electro anatomical mapping system provides what?
Displays border region of earliest tissue activation, shows early-meets late patterns.
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?
Reentry
Bradycardia is defined as a heart rhythm that is slow at a rate below:
60bpm
Failure of the SA node to adequately generate an appropriate number of intrinsic (native) electrical impulses define what term?
Failure of impulse generation
What are the three different mechanisms of activation that propagate tachycardias?
Reentry, triggered, and automaticity
Activity which propagates double activation of a cardiac cell from a single initial activation, resulting from the presence of upward deflections is known as what mechanism of activation?
Triggered activity
Delayed after depolarization (DAD) occur in which phase of the action potential of triggered activity?
Phase 4
Regarding tachycardias, what is the most common mechanism of activation?
Reentry
Baseline EGM measurements are generally performed at what recording speed?
200mm/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 normal value for PA interval?
25ms - 55ms
What is normal value for AH interval?
55ms - 125ms
What is normal value for HV interval?
35ms - 55ms
What is normal value for HBE interval?
<30ms
PPI - TCL =
Circuit Distance
VA time <70ms =
AVNRT or AT
VA time >70ms =
AVRT
PPI - TCL = 115ms is what?
AVNRT or AT
PPI - TCL = <115ms is what?
AVRT
The wenckebach period is just a test of what?
The overall AV conductivity
Pseudo R prime in V1 is what?
Classic AVNRT
The esophagus is closest to which side of the pulmonary veins?
Left Pulmonary Veins
What interval measurement could indicate electrolyte disturbances like hypokalemia and hypocalcemia?
QT
Bradycardia is defined as:
A slow heart rhythm with rates below 60 and dizziness
Symptoms of bradycardia can include:
Syncope, dizziness, fatigue, SOB, confusion and diminished mental acuity
These can cause bradycardia:
Sick sinus syndrome, chronotropic incompetence, and sinus arrest
First degree AV block is defined by:
A PR interval of 200ms or greater
Second degree heart block (wenckebach) is characterized by:
Progressively lengthening PR interval followed by a dropped QRS
Third degree heart block is characterized by:
Dissociated (no relationship) P-waves to the QRS complex
The tests used to try and document bradycardia are:
Holter monitor, event recorder, and implantable event recorder
A corrected sinus node recovery time (CSNRT) is characterized by:
Subtraction the sinus cycle length from the time it takes a sinus beat to occur after rapid atrial pacing.
An EP study scheduled to diagnose causes of bradycardia would include:
HRA, His, and RV catheters
A junctional escape rhythm is characterized by:
A rate of 40-60, A narrow complex QRS rhythm, A proximal AV nodal block
Describe atrial tachycardia:
- An atrial focus other than the SA node. 2. An ectopic atrial pacemaker coming from structures near the atria. 3. An atrial focus coming from the pulmonary veins causing a tachycardia rate of 15 beats per minute.
Describe the symptoms of atrial tachycardia:
Dizziness, chest pain, palpitations
The common locations for atrial tachycardia:
The crystal terminalis, the pulmonary veins, the coronary sinus ostium
The following are classified as atrial tachycardias:
Focal atrial tachycardia, multi focal atrial tachycardia, intra-atrial re-entry tachycardia
Atrial tachycardia P-wave morphology will most likely resemble the sinus P-wave for which focus?
Superior Vena Cava (SVC)
Ventricular entrainment during atrial tachycardia with tachycardia continuing after pacing reveals:
V-A-A-V response
Intra-Atrial conduction time, time it takes for the electrical signal to travel from the SA node to the AV node.
PA interval
Trans-nodal conduction, or the time it takes for the electrical signal to travel through the AV node.
AH interval
Time through His Purkinje System, the time it takes for the electrical signal to travel from the His bundle to the ventricles.
HV interval
Corresponds to the total conduction time through the His Bundle
HBE interval
In Atrial Flutter: CS 1,2 PPI - TCL = <30ms
Left Sided A. Flutter
In Atrial Flutter: CS 1,2 PPI - TCL = >30ms
Right Sided A. Flutter
In Atrial Flutter: CS 9,10 PPI - TCL = <30ms
Right Sided A. Flutter
In Atrial Flutter: CS 9,10 PPI - TCL = >30ml
Left Sided A. Flutter
Flutter waves negative in II, III, aVF and positive in V1 =
Counter Clockwise Flutter
Flutter waves positive in II, III, aVF and negative in V1 =
Clockwise Flutter
On surface ECG, the P-waves are upright in V1 and have a sawtooth pattern in the inferior leads:
Typical A. Flutter
On surface ECG by notched, upright P=waves in the inferior leads and inverted P-waves in V1 =
Atypical Flutter
The largest vein in the heart. It drains over half of the deoxygenated blood from the heart muscle into the RA.
Coronary Sinus (CS)
What catheter is important for determining activation sequence in atrial tachycardia diagnosis?
Coronary Sinus Catheter
Multi focal atrial tachycardia refers to:
A tachycardia focus from more than one area of the atrium.
Patients with atrial flutter:
- Have a higher risk of developing atrial fibrillation, 2. Have a sawtooth appearance pattern on the 12-lead ECG, 3. Have a higher risk of stroke.
Typical flutter uses all of the following structures in its circuit:
Tricuspid annulus, lateral right atrial wall, atrial septum
The perpetuation (the continuation or preservation of a situation) of typical atrial flutter requires:
The SVC
Clock-wise flutter is characterized by all of the following:
- The flutter wave front traveling down the atrial septum, 2. Positive P-wave in the inferior leads, 3. The wave front traveling up the lateral anterior right atrial wall.
Atypical atrial flutter may be the result of:
Scarred atrial tissue, previous surgical intervention, previous ablative therapies.
These are elements of entrainment:
- Is a maneuver to assist in locating the structures in the flutter circuit. 2. Requires pacing the atrial tissue at a flutter to advance to the pacing cycle length while pacing.
Atrial fibrillation is noted for:
Chaotic atrial activity
Atrial fibrillation symptoms include these:
Weakness and fatigue, palpitations and chest pain, shortness of breath and confusion.
These are causes of atrial fibrillation:
- Sleep apnea, 2. Exposure to stimulants like caffeine, tobacco, or alcohol 3. High blood pressure
This structure is a suspect in clot formation i patients with atrial fibrillation:
Left atrial appendage
Progression of atrial fibrillation is defined:
Paroxysmal, Persistent, and Permanent
Complications of A. Fibrillation ablation:
- Atrial esophageal fistula and phrenic nerve damage, 2. Cardiac tamponade form cardiac perforation, 3. Stroke and fluid overload
Entrance and Exit block of the pulmonary veins refers to:
Pulmonary vein potentials not able to exit and enter the pulmonary vein
What catheters are commonly utilized for an A. Fib ablation?
ICE, Lasso, Ablation, and Coronary Sinus
The initiation of A. Fib most commonly originates from:
Pulmonary Veins
A conduction impulse that initially blocks down the fast pathway and slowly conducts over the slow pathway to initiate a reentry to rhythm describes which arrhythmia?
AVNRT
True or False, AVNRT is a micro-reentrant tachycardia:
True
When viewing a 12-Lead ECG of AVNRT, the P-wave may not be present, if present it will occur after the QRS or be a:
Retrograde P-wave
During AVNRT, ECG will display a tachycardia with a rate of:
150 -220 bpm
To terminate AVNRT pharmacologically, what will be the initial dose of adenosine?
6mg IV
In typical AVNRT, which pathway will a premature beat initially block and then what pathway will the impulse propagate down?
Initially block down the fast pathway (FP), then propagate down the slow pathway (SP).
Conduction occurring down the slow AV nodal pathway and up the fast AV nodal pathway is:
Typical AVNRT
What non-pharmaceutical technique can also terminate AVNRT?
Carotid Massage
True or False, A jump is defined during extra-stimulus pacing (S1, S2) in which decrements of 10ms on S2 demonstrates a jump in the A2H2 interval of >50ms, indicative of refractories in the fast AV nodal pathway:
True
In AVNRT, what pacing technique typically reveals the presence of a jump?
Programmed atrial stimulation (A1, A2).
True or False, Slow junctional rhythm can be a normal finding during a AVNRT ablation:
True
True or False, The slow pathway is routinely ablated for AVNRT:
True
Where is the fast pathway located?
Superior to the triangle of Koch
A beat that returns to its origin and is actually a single beat of reentrant tachycardia that failed to sustain AVNRT is:
An ECHO beat
What is the most common form of SVT?
AVNRT
AVNRT can be initiated with what pacing maneuver?
Premature atrial pacing, also called extra-stimulus pacing
In AVNRT, a delta wave is produced as a result of:
Ante-grade accessory pathway (AP) conduction which pre-excites atrial tissue.
What best describes a manifest accessory pathway?
Presence of a delta wave preceding the QRS complex surface ECG.
True or False, An accessory pathway with anti-grade conduction, displaying a pre-excited delta wave, is known as Wolff-Parkinson-White (WPW) syndrome:
True
Orthodromic tachycardia is defined as:
Tachycardia with normal conduction down the AV node and then up the accessory pathway.
Antidromic tachycardia is defined as:
Tachycardia is when the conduction travels down the accessory pathway and then up the AV node.
True or False, During manifest activation, the delta wave will become more prominent as more of the ventricle is activated via the accessory pathway during rapid atrial pacing (burst pacing):
True
AVRT is a:
Macro Reentry Circuit
True or False, 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:
True
In orthodromic AVRT, is the QRS complex narrow or wide?
Narrow
In antidromic AVRT, is the QRS complex narrow or wide?
Wide (pre-excited)
A patient in AVRT has a V-A time of 165ms. The patient then develops a left bundle branch block (LBBB) and the V-A times jumps >50ms, patient most likely has:
Left Sided accessory pathway
The most common catheter position and sites when performing a diagnostic EP study for VT are:
HRA, HIS, RVA, RVOT
Damaged cardiac tissue as a result of diminished or no blood supply describes which type of cardiac disease tissue?
Ischemic
This is the most common site for idiopathic VT is the:
RVOT
VT is considered sustained when it is maintained for:
30 sec.
If a patient has VT and is shocked at 22 sec. Because the patient is hemodynamically unstable, the VT is considered:
Sustained
This chamber is the most susceptible to ischemic, scar based VT’s:
Left Ventricle (VT)
Reentrant criteria for reentrant VT:
- Conduction around an in-excitable obstacle. 2. Zone of slow conduction, 3. Pathway of unidirectional block
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 can result in a arrhythmia called Torsade de Pointes:
Long QT Syndrome (LQTS)
These devices have been proven to reduce mortality of selected patients at risk for sudden cardiac death is:
Implantable Cardioverter Defibrillators (ICD)
True or False, Patients with Brugada Syndrome will usually present with a right bundle branch block (RBBB):
True
Patients with Brugada Syndrome will present with stable ST segment elevation in:
V1-V3
A drive train has a series of 6-8 paced beats at a fixed cycle length is considered known as:
S1
SNRT assessment is performed by:
Pacing the atrium for 30sec. And measuring last paced A to first intrinsic A
When evaluating the sinus node function, an abnormal CSNRT value would be:
575ms
The longest coupling interval of a premature stimulus which does not conduct through to the AV node is known as:
AVNERP
The longest coupling interval for a premature stimulus which does not conduct to depolarize ventricular tissue:
VERP
Normal H-V conduction interval is:
35 - 55ms
Electrical stimuli that causes depolarization of the chamber being stimulated is known as:
Capture
The minimum current needed to capture a chamber with pacing stimulus is known as:
Threshold
When incremental burst pacing (S1) faster until loss of 1:1 ratio in AV conduction is noted, the longest S1 coupling interval that fails to conduct 1:1 is known as what?
Wenchebach
Burst pacing is:
Pacing at a fixed cycle length
Introduction of one or more premature paced beats (extra-stimulus) at a shorter cycle length after the preceding pacing train which is a fixed cycle length (s1, s2), is which type of pacing?
Incremental
When burst pacing the RVA via a EP catheter, the pacing output should be set to a least:
1.0 mA more than threshold determination.
What condition may lead to CHB while advancing an EP catheter to the RVA?
Left Bundle Branch Block (LBBB)
RV pacing with proper capture produces an ECG morphology resembling:
Left Bundle Branch Block (LBBB)
When performing threshold determination, stimulus output is conventionally set to a minimum of at least 3 mA or:
2 x threshold minimum
A typical drive train consists of:
8 beats
Ventricular arrhythmia induction is assessed with:
Programmed Electrical Stimulation pacing (PES pacing)
Dual AV node physiology is assessed with:
Decremental pacing
Atrial tachycardias may be difficult to initiate, however to most effective pacing maneuver is:
Burst or decremental pacing
What should the next step be to trouble shooting when the ablation generator shuts off with a high impedance error message?
Ensure the grounding pad is properly applied to the patient
When performing an ablation with an open irrigated ablation catheter, what must be done when the irrigation pump alarms?
Stop the pump and notify the performing physician.
What is the primary cause of temperatures observed over 100 degrees Celsius during radio-frequency ablation?
Catheter tip coagulum and char
The common tip size for a cryoablation catheter tipis:
4mm
If bubbles are observed on intra-cardiac ultrasound (ICE) during left-sided ablation, the EP staff:
Stop the pump and notify the performing physician.
What is the next step if a patient’s rhythm changes to complete heart block during ablation near the His bundle?
Stop ablation and start ventricular pacing or prep for temporary pacing.
An effective lesion formation during radio frequency ablation is marked by:
Decrease in impedance, 5-10 ohms
Moving the grounding pad closer to the heart will likely result in:
Decrease in impedance (ohms)
A severe complication to left atrial ablation that is often monitored for is:
Esophageal
What situation should require the use of a 10mm tip and/or high-output 100 watt generator for ablation?
When a larger myocardial lesion is desired, i.e. thicker tissue like the isthmus and ventricular tissues.
What nerve should be considered when ablating the lateral regions of the right heart?
Phrenic Nerve
In a typical atrial flutter case, post ablation endpoint must prove:
Bi-directional block has occurred across the area where ablation was performed.
Which type of ultrasound can be done the same day without need for sedatives?
TTE (Transthoracic ECHO)
The functional part of an ultrasound probe is the referred to as the:
Transducer
Positioning the ICE catheter in the RA, just above the terminal end of the IVC, with the transducer printed with a leftward-anterior transducer face yields which of the following views?
Home view
After insertion of the ICE imaging for transseptal access?
Clockwise rotation from 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
Aspiration is a usual complication of which type of ultrasound modality?
TEE
3D electro-anatomical mapping systems display a variety of unique mapping techniques that include:
Voltage Mapping, Activation Mapping, Propagation Mapping
In voltage mapping, voltage values of <1.5mV is considered abnormal cardiac tissue, and values <0.5mV is considered:
Scar
On the CARTO mapping system, low voltage will be depicted in which color?
Red
The technique that utilizes a recorded ECG/EGM of a cardiac activation morphology green aged by an arrhythmia to be compared against paced activation morphologies in attempts to reproduce and match morphologies, which identifies the origin of the arrhythmia is known as:
Paced mapping
The mapping technique that requires the advancement of the tachycardia rate to that of the paced cycle length without altering the morphology of the tachycardia is:
Entrainment mapping
The leading cause of syncope is:
Vagal hypersensitive it’s syndrome
Rapid and temporary interruption of cerebral perfusion manifested by loss of consciousness, for a brief duration followed with spontaneous recovery is:
Syncope
The condition in which a nervous system response of sudden decrease in blood pressure, HR and CO, preceded by prodromal symptoms including, nausea, lightheaded nests, diaphoresis and feeling of warmth is:
Vasovagal
This is a condition in which a change from the supine position to an upright position causes an abnormally large increase in HR is:
POTS (Postural Orthostatic Tachycardia Syndrome
In addition to tilt table testing, syncope may also be evaluated by:
CT, MRI scans, EEG, trans-cranial Doppler, Metabolic testing
This is a portable, wearable device that records a patient’s ECG over a period of time, generally 24-48 hours:
Holter
What is utilized specifically to prove neuro-cardiogenic (vasovagal) syncope or to rule it out?
Tilt Table Test
Indication for use of a holter monitor includes:
Complaints of palpitations increasing in frequency
Which is the correct signal path from patient cardiac tissue to the EP recording system?
Patient cardiac tissue > Catheter > Cable > J Box > EP recording system
> = to next
True or false, Sequential powering up of EP equipment is essential for proper systems communication:
True
What takes all incoming cardiac patient signals and also functions as the gateway interface to the EP recording system, stimulator?
Amplifier
What device is used to deliver therapeutic energies to cardiac tissue?
Ablation Unit
What device used to interface the inter-cardiac EGM connection from the EP catheter?
Junction Box and Pin Box
What can affect signal quality and acquisition?
Signal pathway, circuits and grounding, proper connections
What are common high/low pass filter of a typical EP recording system?
0.5 - 100Hz
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 what?
High band pass filter
The limiting of EGM signal amplitude (positive and negative), reducing signal overlapping of EGM’s is best achieved by what?
Clipping
What filter eliminates electric signal noise of 60Hz that is inherent in North American alternating current?
Notch Filter
Typical High Pass EP recording system filtering is generally set at what?
30 - 50Hz
Typical Low Pass EP recording system filtering is generally set at what?
300 - 500Hz
EGM signals recorded from localized tissue in contact between two catheter electrode pairs, displaying a narrow and sharp signal deflections is best described as what?
Near-Field
What is the corrected sinus node recovery time measured at 1395ms and a sinus cycle length measured at 775ms?
618ms
What is the formula to calculate corrected sinus node recovery time (cSNRT)?
SNRT - SCL
Ohms Law:
V = IR (voltage, current, resistance)
During open-irrigated ablation, the pump alarms beep. What should be done?
Turn off pump and notify the physician to turn flow off to patient.
The only cryoablation catheter to both map and ablate is:
4mm
During a cryoablation for atrial tachycardia near the bundle of His, a patient goes into complete heart block. The next logical step would be to :
Stop ablation and prepare for pacemaker.
A delta wave is caused by:
Antegrade accessory pathway conduction pre-exciting the ventricular tissue.
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?
6F pigtail
Two pathways (A & B) must be connected. One pathway must conduct more slowly. The slow pathway must have a shorter effective refractory period is:
Re-entry
Tachycardia has just been induced in a patient who did not have V-A block with Adenosine. The tachycardia has a V-A of 180ms. Suddenly, the patient develops LBBB and the V-A increases to 220ms. The patient most likely has:
A left sided accessory pathway
Repetitive delivery of 8 atrial beats at the same cycle length followed by the 9th beat which is delivered with a progressively shorter coupling interval describes what pacing protocols?
Atrial extrastimulus
What are the most common catheter positions for performing an initial VT study?
HRA, HIS, RVOT, RVA
When performing stimulus testing for a typical atrial flutter procedure, which of the following differences between the PPI and TCL during entrainment mapping indicates that the pacing site is within the flutter circuit?
7ms (other choices were 33ms, 55ms, or 151ms)
What information in the patient’s medical history is contraindicated to proceed with a transeptal procedure?
History of stroke
The patient’s physician decides to perform an electric cardio version for atrial fibrillation with irregular ventricular rates after a CFAE atrial fibrillation (Complex Fractionated Atrial Electrograms). What is the most appropriate setting to cardiovert the patient from atrial fibrillation into normal sins rhythm?
150 joules 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 segment elevation
What is most important in ensuring optimal ECG and EGM signal acquisition?
Grounding the patient
For stimulation pacing induction, the mA on the stimulator should be set at least at:
2 times capture threshold
What type of pacing stimulation protocol is used to obtain Wenckebach (AV node cycle length)?
Decremental Pacing
What nerve drapes over the back of the right appendage and affects diaphragm motion?
Phrenic Nerve
Pacing the grounding pad closer to the ablation catheter tip will:
Decrease impedance
In pace-mapping, ideally you are looking for:
12/12
What is pacemapping mostly used for?
Ventricular Tachycardia morphology comparison
If a tilt table test is positive, the first thing you should do is:
Lay the table down flat, placing the patient in the patient in the supine position.
A patient states that he/she experienced a contrast allergy two years prior, which included a skin rash and hives. What is most appropriate for the patient to receive as a premedication?
Prednisone 60mg PO, Methylprednisolone (Solu-Medrol) 40mg IV, Hysrocortisone (Solu-Cortef) 200mg IV
The expression Psystolic - Pdiastolic is used to derive what?
Pulse Pressure
An epinephrine IV drip is ordered during an EP procedure in response to a quick drop of the patient’s blood pressure, which is critically low. What primary mechanism of action results in the blood pressure rise once epinephrine is infusing?
Vasoconstriction
What is the most appropriate fluoroscopy view in viewing the RV apex?
RAO
What is the most appropriate fluoroscopy view in imaging the distal coronary sinus for optimal bi-ventricular lead positioning?
LAO
What has an increased risk of occurring as a result of attempting a femoral artery puncture for vascular access above the inguinal ligament?
Retroperitoneal bleeding/hematoma
What brings oxygenated blood to the left atrium?
Pulmonary Veins
A 12-Lead EKG of VT with a positive QRS in Lead I and negative QRS in aVF usually indicates:
Left Axis Deviation
What is the name of the ridge of tissue in front of the inferior vena cava?
The Eustachian Ridge
What nerve drapes itself over the right atrial appendage and affects diaphragmatic motion?
Phrenic Nerve
The left atrium is activated simultaneously with the RA via:
Bachman’s Bundle
Tall peaked T-waves on a 12-lead ECG is associated with what?
Hyperkalemia
What medication markedly prolongs the action potential duration and hence refractories?
Amiodarone
Circulation distal to the femoral artery is best assessed by:
Dorsalis Pedis Pulses
When draping a patient for a pacemaker implant, the technologist drapes the area:
Closest to themselves first
Which value directly interferes with or obstructs access into the coronary sinus (CS)?
Thebesian Valve
Invented T-wave on the inferior leads of an ECG (II, III, aVF) indicate what?
Ischemia
Lead I measures cardiac activity between which two locations and polarity configurations?
(-) right arm, (+) left arm
What is the French (Fr) size is millimeters (mm) of a 9Fr Sheath?
3mm
Where is the coronary sinus (CS) located in relation to the tricuspid valve?
Superior
What structure transmits signals through the inter atrial septal tissue to the left atrium?
Bachmann’s Bundle
When unwrapping a patient after a device implant procedure in which there is still blood on the drape and table, what technique is most appropriate?
Universal Precautions
The shortest interval that can elicit a depolarizing response from tissue is the:
Functional Refractory Period
After a diagnostic EP study, post-op discharge information includes:
Keeping the head down, Pressing on the access site when coughing or bearing down, No heavy lifting over the next 1-2 weeks
What is an acceptable ACT range for initiating arterial femoral sheath removal from groin?
Less than 170
When establishing femoral access, after palpating for a pulse, where is the most appropriate access point to stick the needle?
3 inches below the inguinal ligament
The structure that separates the thin smooth atrial muscle from the traecule muscles is:
Crystal Terminalis
This firm muscle tissue is well developed in large patients, make 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 of?
Thebesian Valve
What 3 structures comprise the Triangle of Koch?
Tendon of Todaro, CS os, and Tricuspid Valve Septal Leaflet
The 3 vessels that delivered blood into the RA:
SVC, IVC, and CS
The AV node lies superior and anterior to the:
Coronary Sinus Ostium
What ridge is a band of tissue that surrounds the fossa oval is?
Limbic Ridge
The structure in the RA known as the zone of slow conduction:
Cavotricuspid Isthmus (CTI)
What is the most anterior chambers of the heart?
RV
The origin of most idiopathic VT originates from what structure?
RVOT
The 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:
RVA & RVOT
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 Atrial Fib trigger origin?
Pulmonary Vein Ostia
This structure is responsible for the great majority of clot formation:
Left Atrial Appendage
Left atrial ridge of tissue between the left atrial appendage (LAA) and the ostium of left pulmonary veins:
Ridge of Marshall
This His Bundle can be measured and damaged in the:
Left Atrium
What contracts in systole to prevent leaflet prolapse?
Papillary Muscles
Besides the RVOT, what other region can mapping and ablation be performed for RVOT tachycardias?
LVOT
What prevents blood regurgitating back into the atria?
Chordae Tendineae (Chorda Tendinea) or Tendinous Cords
What is contra-indicated in a retrograde approach requiring valve crossing?
Bio-Prosthetic Valve
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?
Bachmann’s Bundle
An example of retrograde conduction is:
Conducting from the Purkinje Fibers to the AV node
The tract of fibers responsible for the rapid conduction of a wave front from the SA node to the LA is known as:
Bachmann’s 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
The His bundle is an extension of the:
AV node
Bundle Branch block results in a wider QRS because:
It takes longer for the ventricle to contract. The wave front has to cross the ventricular septum. The ventricles are not receiving he wave front at the same time.
The most distal part of the conduction system is:
The Purkinje Fibers
The most proximal part of the conduction system is:
The SA node
What are electrical properties of cardiac tissues?
Automaticity, Conductivity, and Excitability
The ions that mediate the electrical current cardiac cells are:
Sodium, Potassium, and Calcium
The membrane potential of the Action Potential is the difference of the electrical charge inside and outside the:
Cardiac Cell
The Cardiac Action Potential has how many phases?
5
Which Action Potential phase is known as the Quiescent Period?
4
Which Action Potential phase is known as the Plateau phase?
2
Effective Refractory Period (ERP) is described as:
The longest coupling interval that fails to capture myocardial tissue.
Phase 0 of the Action Potential is characterized as:
Depolarization because of sodium into the cell.
Calcium channels are described as what two types?
L-type and T-type
VAERP (retrograde ERP) measures the refractor period of:
The Retrograde AV node
Phase 2 of the cardiac action potential is characterized by a slow influx of:
Calcium (Ca)
Which phase of the action potential is marked by closing the rapid sodium channels?
Phase 1
Functional Refractory Period (FRP) is the:
Shortest coupling interval between two successive conducted impulses (H1-H2) that can elicit a response.
ERP refers to:
Effective Refractory Period
The refractory period with the longest coupling interval that fails to capture myocardial tissue (S1-S2), or fails to conduction an electrical impulse is:
Effective Refractory Period (ERP)
Tall, narrow, symmetrically peaked T-waves are characteristically seen in:
Hyperkalemia
A 12-Lead ECG with a QRS vector between -30 to -90 degrees indicates:
Left Axis Deviation
Einthoven’s Triangle is defined by which 3 leads on the 12-Lead ECG?
I, II, and III
The inferior leads are known as:
II, III, and aVF
The augmented limb leads are:
AVL, aVR, and aVF
The precordial leads are known as:
V1-V6
Axis determination represents:
Direction of ventricular depolarization
A QRS wave is larger and wider than a P-wave because:
Ventricular tissue is thicker and takes longer to contract
A PR interval is measured from:
Earliest onset P-wave to the earliest on set QRS in all leads
The QT interval is measured from:
The onset of the QRS to the end of the T-wave.
The Bazett formula is used to calculate:
The corrected QT interval
The Gantry, C-arm and image intensifier are all parts of:
The fluoroscopy system
Procedure rooms should have equipment to monitor what patient parameters:
BP, O2 sat, temp, intake and output, end tidal CO2, respiratory rates, blood glucose monitoring, and activated clotting time
The EP recording system, cardiac stimulator, amplifier and pin box are all part of:
The equipment necessary for an EP study
Power, Temperature, Impedance and Time are all parameters of what system?
The ablation generator
Trans-esophageal (TEE), Intra-Cardiac Echocardiography (ICE), and Sonosite are all examples of:
Ultrasound Systems
Ensite-Velocity, Carto, and Rhythmia are all examples of:
Mapping Systems
Sequential Compression Devices (SCDs) primarily help prevent what?
Deep venous clots in the lower legs
The electrophysiologist states he needs to ablate in the right coronary cusp, allied support staff should prepare for which possible procedure?
Cardiac Catheterization
It is most important to do what when handling sterile items?
Ensure items remain in the sterile field at all times
Standard precautions include:
Hand washing, gloves, gowns, and masks whenever anticipated contact occurs with patient’s body fluids
What is true when creating a sterile field:
The sterile field should be setup as close to the procedural time as possible.
What is true regarding a sterile surface?
The top of a sterile drape, (covering the patient or site) is the only portion of the drape that is considered sterile.
What is true about sterile integrity?
The rule of thumb for questionable sterility is if in doubt, throw it out.
What is true about sterile movements:
Sterile personnel must stay close to the sterile field and keep movements to a minimum to minimize airflow movements. Sterile personnel should pass each other with their backs facing each other.
Talking during a sterile procedure is unavoidable, however, talking must be kept to a minimum to minimize moisture droplets as a result of the speaking.
Non-sterile personnel must maintain this distance away form the sterile field and personnel:
18 inches
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
Which blood test is most appropriate to validate price to arterial sheath removal?
Activated Clotting Time (ACT), some say Activated Coagulation Time
Post care instruction after a PVI Atrial Fib ablation include:
No lifting of heavy objects
A patient presents with an INR of 3.5 prior to the start of an atrial Fib ablation procedure. What is the most appropriate response?
Repeat INR
If patient begins to weeze and the O2 saturation drops 10% while on 2L of oxygen therapy via nasal cannula after contrast bonus injection, the most likely cause is what?
Allergic reaction to the contrast injection
What drug is commonly utilized to increase vagal tone and initiate induction of SVTs?
Isoproterenol
During then administration of Ibutilide (convert), what interval of the patient’s rhythm should be monitored?
QT or QTc
Class I (sodium-channel blockade) anti-arrhythmic drugs (AADs) decrease conduction velocity duration and:
Increase the refractory period of the cardiac action potential
Which anti-arrhythmic drug (AAD) markedly increases the duration and refractories of the cardiac action potential?
Amiodarone
Conscious Sedation medication might include what?
Versed, Fentanyl, and Valium
Ionizing radiation includes:
Alpha Particles, Gamma Rays, and x-rays
Non-ionizing radiation includes:
UV, infrared, radio-frequency, and microwaves
Identify the principles of radiation safety within the EP lab environment:
(1) ALARA (2) Time, Distance, Shielding (3) Wearing a radiation badge
X-Rays that have directly passed through the patient on the procedure table are collected in the:
Image Intensifer
The RAO view of the heart is optimal for imaging:
Atrium and Ventricle
ALARA:
As Low As Reasonably Achievable
The greatest radiation hazard to the staff:
Scatter Radiation, not the radiation emitted from the X-ray tube itself
What is the annual radiation exposure limit for occupational workers?
5 rem/year
The acronym MAR stands for:
Medication Administration Record
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 femoral artery will allow catheters to be passed first into what heart chamber?
Left Ventricle
2-5-2 spacing of an EP catheter infers:
2mm spacing between the first electrode pair and 5mm spacing between each paired set of electrodes
Transeptal puncture infers:
Access from the RA to the LA through the atrial septum
The access point for a femoral vein or arterial access is:
2-3cm below the inguinal ligament
What is the most distal electrode pair on a standard Josephson (JSN) catheter?
1-2
What is the standard paper recording speed of a 12-Lead ECG?
25mm/second
What is the typical sweep speed of an EGM?
100mm/sec.
What term refers to a signal that is very close to the catheter and a sharp/sharper spike will be noted?
Near Field
What term refers to any signal that an EP catheter picks up from a distant location, meaning the signal will look smaller, more spread out and not sharp?
Far Field
In a normal activation sequence what is the correct signal sequence for the atrial signal?
HRA, HIS, Proximal CS, and Distal CS
The normal signal sequence when pacing from the RVA is:
RVA - HIS - HRA
Which electrode pair will measure the most lateral left atrial signal?
CS 1-2
The electrical properties of cardiac tissue include:
Conductivity, Excitability, and Automaticity
What coronary artery supplies blood to the SA node and AV node?
Right Coronary Artery
What 4 structures outline the triangle of Koch?
Tendon of Todaro, HIS Bundle, Septal Leaflet of the tricuspid annulus, and Coronary Sinus os
How is retrograde conduction defined?
Conduction from the ventricle to the atrium
A patient is taken off a 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
The functional refractory period is the:
Shortest H1-H2 that can elicit an A1-A2
What congenital heart defects (CHDs) has the high test rate of occurrence in children?
Ventricular Septal Defect (VSD)
What medication is the most appropriate to treat an irregular wide complex tachycardia?
Amiodarone
During insertion of a temporary pacemaker lead, the lead perforated the heart. What did the lead perforate?
Endocardium
Where is the fossa ovalis located in relation to the coronary sinus (CS)?
Superior
When the heart is insensitive to stimuli and cannot be depolarized by stimulation (such as pacing), it is said to be:
Refractory
Purkinje and ventricular cells have their own automaticity and intrinsic rate. These lower pacemaker rates are usually suppressed as long as:
The SA node rate is fast enough.
Sympathetic nervous stimulation of the heart primarily affects the heart rate by altering what phase of the SA node action potential?
Phase 4
What are the 3 things that change the rate (automaticity) of automatic cells?
(1) Slope of phase 4 (2) Threshold potential (3) Resting membrane potential
Concerning the ion transfer across myocardial cell membranes, throughout systole (QT interval):
Potassium leaks out
What part of the ventricular action potential is the resting membrane potential?
Phase 4
What is the trans-membrane potential when a Purkinje cell is in the resting state?
It is polarized and negatively charged inside.
Compared to myocardial cells, SA node cells are prone to a faster:
Automaticity because of their steeper phase 4
What ion rushes across the myocardial cell membrane during phase 0 of the action potential?
Sodium seeps in
SA and AV node depolarization (action potential upstroke) comes through the:
Ca++ slow channel
Propagation Velocity =
Phase 0 (upstroke)
Refractory Period =
Phase 1-2-3 (plateau & repolarization)
Automatic Rate =
Phase 4 (diastolic depolarization)
What cardiac tissue has the fasted electrical conduction velocity?
Purkinje fibers
The ERP of ventricular tissue most closely correlates with its:
Absolute Refractory Period
How does gender effect the frequency of SVT?
AVNRT is most common in women. AVRT is most common in men.
The plateau (Phase 2) of the ventricular action potential occurs on the surface ECG during the:
QT interval and during mechanical systole
What ionic flows occur across the cardiac muscle cell membrane during the plateau (phase 2) of the action potential?
Ca++ enters, K+ enters
What ionic flows occur across the cardiac muscle cell membrane during the resting phase (phase 4) of the action potential?
Ca++ exits, K+ enters
Which two cardiac tissues have a slow phase 0 action potential and thus a slow conduction velocity?
SA node & AV node
What is the response of cardiac tissues paced during the relative refractory period (RRP) compared to fully depolarized cells, stimulation in the RRP:
Requires higher mA but creates a weaker contraction
Which is the heart’s normal conduction sequence to the HIS Bundle?
SA node, RA muscle, LA muscle, and AV node
Wellness Syndrome describes:
A pattern of ECG changes, particularly deeply inverted or biphasic T-waves in leads V2-V3, that is highly specific for critical, proximal stenosis of the left anterior descending (LAD) coronary artery. It is alternatively known as anterior, descending, T-wave syndrome.
Brugada Syndrome:
Is a rare but potentially life-threatening heart rhythm condition that is sometimes inherited. RBBB with ST elevation in V1-3. Convex and concave ST variants. SCN5A mutation.
Wolff-Parkinson-White (WPW):
Pre-excitation syndrome, re-entrant bundle of AV tissue distant to AV node. Short PR interval; prolonged QRS and slurred upstroke of QRS complex (Delta Wave).
Loan-Ganong-Levine (LGL) Syndrome:
Pre-excitation syndrome. Re-entrant bundle of AV tissue close to AV node. Accessory pathway is down James fibers. No delta wave as conduction normal down bundle of HIS. Risk of Atrial Fib. Being transmitted aberrantly causing VF or VT. Requires ablation of pathway as WPW.
Romano-Ward Syndrome:
Inherited Long QT Syndrome (Autosomal dominant) defect of Na and K channels. Not associated with deafness. Long QT, T-wave alternans, notched T-wave, R on T phenomenon, Torsades.
Jervell and Lange Nielsen Syndrome:
Inherited Long QT syndrome. Autosomal recessive defect of Na and K channels. Associated with neuroses story deafness.
Takotsubo:
Cardiomyopathy with hypertrophic LV inferior and Hypotrophic superior wall (Octopus jar heart). ECG T-wave changes similar to MI but usually brought on by stressful event. Normal coronary angiogram, but require cardiology follow up.
Dual AV node physiology is found in approximately:
15 - 25% of the normal adults
When a patient receives an ICD with indications of only low EF and increased risk of sudden cardiac death, it is termed:
Primary prevention
When a patient receives an ICD for secondary prevention of sudden cardiac death (SCD) it means he or she:
Has been resuscitated from an episode of SCD
The most common arrhythmia found in patients recovering from MI is:
PVCs
The most common dysrhythmia leading to Sudden Death in patients is:
Ventricular Fibrillation
What is the most powerful predictor of sudden Cardiac Death in all patients?
Ejection Fraction <30%
Common dizziness due to sudden standing up is usually due to pooling of venous blood and termed:
Orthostatic Hypotension
Check 5 recommended things to monitor during tilt table testing?
BP, EKG, O2 sat, Symptoms, and Pulse Rate
During a tilt-table test, the angle of the table should be tilted to between:
60 - 90 degrees
After an initial passive-tilt procedure is non-diagnostic, what medications may be given?
2 most commonly used provocative agents are NTG SL & Isoproterenol (Isuprel)
The head-up tilt-table test is a procedure used to provoke neurogenic syncope that is caused by a severe:
Vasovagal response
What type of therapeutic medication would most likely be given to a patient having a positive tilt table test with neurocardiogenic syncope?
Beta-Blockers
In measuring the HV interval, the earliest ventricular activation is usually seen on:
Surface QRS wave
The AH interval measures:
AV node conduction time
The AH interval is measured from the:
Early A-wave on the his bundle catheter to the beginning of the H on the HIS bundle catheter.
Formula to convert BPM to Msec:
CL = 60,000/HR
Formula to convert Msec to BPM:
HR = 60,000/CL
Atrial ERP =
Longest A1-A2 interval recorded at a designated site (often the His Bundle region) before failure of A1-A2 to capture the atrium.
Atrial FRP =
Shortest A1-A2 interval recorded at a designated site (often the HIS bundle region) before failure of A1-A2 to capture the atrium.
AVNERP =
Shortest H1-H2 in response to any A1-A2
HPS (HIS-Purkinje System) ERP =
Longest H1-H2 not propagating to the ventricles
Ventricular ERP =
Longest S1-S2 interval that fails to capture the ventricle.
Ventricular Extra Stimulus Testing (VEST):
Drive train in the ventricle with a PVC
Atrial Extra Stimulus Testing (AEST) :
Serves for evaluation of the anterograde conduction over the AV node, atrial refractories, and induction of specific arrhythmias.
Burst Pacing:
Pacing at a fixed rate faster than the underlying rate.
Ramp Pacing:
Pacing that increases during the cycle.
Example: 360, 350, 340, 330……
When the mapping catheter is positioned correctly, when is the right bundle potential normally seen:
15-20ms later than the H, and <30ms before the V
In incremental atrial pacing or premature atrial stimuli placed during the relative refractory period, as cycle length decreases, the PR interval normally:
Increases and the AH interval normally increases
With Isuprel administration or exercise the PR interval normally:
Decreases the AH interval decreases and the HV interval stays the same.
In incremental pacing of the RA, as cycle length decreases in the relative refractory period, the AH interval normally:
Increases and the HV interval normally stays the same.
In most cardiac tissue (muscle and Purkinje), shorter cycle lengths normally:
Decrease Refractory Periods
In the AV node shorter cycle lengths normally:
Increase Refractory Periods
What is it called when conduction time of the impulse propagating through cardiac tissue decreases as the tissue cycle length shortens?
This is usually true of atrial, HIS Purkinje, and ventricular tissue, but not the AV node.
When conduction time of the impulse propagating through the AV node increases as the atrial cycle length (CL) shortens it is termed:
Decremental Conduction
In incremental or extra-stimulus test pacing of the RV, as cycle length decreases, the retrograde VA conduction time normally:
VA conduction time Increases and the HA interval increases
To evaluate SA node. Automaticity in the EP lab we do:
SNRT or CSNRT measurements
An EP test indicative of severe sinus node dysfunction is:
CSNRT >525ms is abnormal
CSNRT = SNRT - BCL
What EP technique is used to measure SNRT?
Overdrive Suppression
The technique to measure the SA node conduction time (SACT) uses:
A high RA extra-stimuli to reset the sinus node.
The SNRT evaluates sinus node automaticity. CSNRT in corrected in an attempt to compare it to normal. What is the upper limit of normal for the CSNRT?
525 - 550ms
SACT measurement is used to evaluate a patient for:
SA node exit block
The (Sino Atrial Conduction Time) is calculated by the formula:
(Return interval - BCL) divided by 2
Pacing in the CS from the distal electrodes normally initiates a depolarization in the:
Left Atrium
The HIS electrogram is normally best recorded when an electrode pair is positioned near the:
Posterior aspect of the tricuspid valve
When doing incremental atrial pacing, Wenckebach type AV conduction indicates block in the AV node, while sudden loss of conduction not preceded by slowing (Mobitz II) suggests block in the:
His-Purkinje system
Most patients with AVRT have a normal QRS because their AP can only conduct retrograde. This is termed:
Concealed-Orthodromic AVRT
Para Hisian Pacing helps to differentiate:
Septal AVRT from AVNRT
What is a maneuver used to distinguish retrograde atrial activation occurring over a septal accessory pathway from that occurring over the normal VA conduction system?
Para-Hisian pacing
What is the most common form of idiopathic left ventricular tachycardia?
Verapamil sensitive fascicles VT
What is the most common form of verapamil sensitive ventricular tachycardia?
Left Posterior Fascicular VT
A physician puts an electrophysiology catheter into the coronary sinus or pericardium because he was unable to normally map and stimulate a VT. What category of mapping is this?
Epicardial Mapping
A patient has dilated cardiomyopathy with a wide complex tachycardia. The EGM shows an H (but no A) before each V. The EGM demonstrates:
Bundle Branch Reentry VT
You wish to map a monomorphic VT circuit. Most VT in patients with structural heart disease originates as:
Reentry in the LV
When an EP electrode senses an electrogram different form the site of its contact, when an atrial electrogram shows a V-wave, this is termed:
Far-Field sensing
Entrainment mapping is most useful in:
Ischemic VT
The conduction velocity of an electrical impulse through cardiac tissue is most directly determined by:
The slope of phase 0 of the action potential
The plateau phase of the action potential is of shortest duration in:
Atrial Muscle
The depolarization phase (phase 0) of the action potential is slowest in:
AV nodal cells
The refractory period of a myocardial cell is most directly determined by:
The duration of the plateau phase of the action potential.
Phase 4 of the action potential most directly determines:
Automaticity
A reentrant arrhythmia requires all of the following:
(1) A potential circuit (2) Differences in refractory period between different parts of the circuit (3) Differences in conduction velocities between different parts of the circuit
Triggered activity involves abnormal behavior in which phases of the action potential:
Phases 3 and 4
The primary effect of class Ic anti-arrhythmic drugs is to:
Block the sodium channel and slow conduction
The primary effect of class III anti-arrhythmic drugs is to:
Increase action-potential duration and prolong the refractory period.
In systemic doses, the primary effect of class Ib anti-arrhythmic drugs is to:
Decrease action potential duration and shorten the refractory period.
Distinguishing characteristics of amiodrarone include all of the following:
(1) A remarkably long half life (2) Association with a low incidence of pro-arrhythmia (3) More effective than any other anti-arrhythmic drugs
The longest coupling interval for which a premature impulse fails to propagate through cardiac tissue is:
A effective refractory period
The longest coupling interval for which a premature impulse results in slowed conduction through cardiac tissue is:
Te relative refractory period
The shortest coupling interval in which successive impulses can conduct through a tissue is:
The functional refractory period
The type of AV nodal refractory period which most directly relates to the average rate of the ventricular response in a patient with atrial fibrillation is:
The functional refractory period
The measurement of the sinus node recovery time (SNRT) is based on which electrophysiologies property of the sinus node:
Overdrive Suppression
An abnormal sinoatrial conduction time (SACT) is most likely to be found during electrophysiologic testing in a patient with which finding on their electrocardiogram:
A rhythm showing periods of sinus exit block
True or False, AV nodal block is usually not life-threatening, because relatively stable subsidiary pacemaker are typically available below the site of the block:
True
True of False, AV nodal block can occur as a consequence of therapy with digoxin, calcium blockers, or B-blockers:
True
True of False, Mobitz I AV block is usually localized to block in the AV node:
True
True or False, Mobitz II AV block should always be considered as distal heart block:
True
True or False, In 2:1 AV block, the mobitz classification system does not apply; block could be either AV nodal or distal, and other steps should be used to localize the site of block:
True
In a patient with heart block, signs that potentially dangerous distal heart block is present include:
(1) The degree of block increase as sympathetic tone increases. (2) In second-degree block, there is no gradual prolongation of the AV interval prior to the dropped P-wave. (3) The QRS duration is 150ms.
Each of the following is itself an indication for a permanent pacemaker:
(1) A split HIS signal is found on EP testing. (2) The HV interval is greater than 120ms (3) Distal AV block is induced during incremental atrial pacing at 550ms.
Which type of evidence gathered during electrophysiologic testing is commonly used to determine the mechanism of supraventricular tachycardia:
(1) Whether activation of the ventricular myocardium is necessary for the maintenance of the SVT.
(2) Whether the SVT is readily induced with ventricular extrastiuli.
(3) The pattern of atrial retrograde activation during the SVT.
AECG during multifocal atrial tachycardia most resembles the ECG with which other supraventricular arrhythmia:
Atrial Fibrillation
A distinguishing feature of AV nodal reentrant tachycardia is that:
There is a distinct discontinuity in the atrioventricular conduction curve.
A distinguishing feature of intra-atrial tachycardia is that:
The cycle length of the tachycardia remains unchanged if AV nodal conduction is slowed.
A distinguishing feature of bypass-tract-mediated atrioventricular macro reentrant tachycardia is that:
The cycle length of the tachycardia may lengthen is bundle branch block occurs.
A patient has a regular, narrow complex tachycardia of 155 beats/min. Careful examination of the 12-Lead ECG reveals no clear P-waves in any lead. The most likely mechanism of tachycardia is:
AV nodal reentrant tachycardia
A patient has a regular, narrow-complex tachycardia of 155 beats/min. The 12-Lead ECG shows negative P-waves in the inferior leads, roughly halfway between the QRS complexes. The most likely mechanism of the tachycardia is:
Atrioventricular macro-reentrant tachycardia
A patient has a regular, narrow-complex tachycardia of 155 beats/min. The 12-Lead ECG shows biphasic P-waves prior to each QRS complex, with a PR-interval of 120ms. The most likely mechanism of the tachycardia is:
Intra-atrial reentrant tachycardia
Which of the following arrhythmias is least likely to be induced with right ventricular pacing:
Intra-atrial re-entrant tachycardia
A patient presents with three syncopated episodes within 2 hours, and their ECG shows frequent bursts of rapid, polymorphic non-sustained ventricular tachycardia. Each of the following clues, if present, would be suggestive of triggered activity due to early after-depolarizations (EAD):
(1) Sinus beats on the ECG show distinct U waves.
(2) The patient has Ben placed on so tall 3 days earlier for paroxysmal atrial fibrillation.
(3) Bursts of ventricular tachycardia invariable follow a relative pause in the underlying rhythm.
Which type of ventricular tachycardia is least likely to be treatable with ablation therapy:
Brugada Syndrome
The mechanism of ventricular arrhythmia which is most commonly responsible for sudden out-of-hospital arrhythmic deaths is thought to be:
Re-entrant ventricular arrhythmias associated with ischemic or non-ischemic cardiomyopathy.
A patient’s sustained, monomorphic ventricular tachycardia is readily inducible during baseline electrophysiologist testing. After administering sotalol, the tachycardia is no longer inducible on either of two successive days. What can be said about chronic treatment with sotalol in this patient:
Treatment of sotalol will probably reduce the frequency of recurrences, but should not be expected to prevent all recurrences.
Which of these patients probably does not have a present indication for an implantable defibrillators:
58-year-old man, myocardial infarction 3 weeks ago, LVEF 28%, NYHA class II, complex ventricular ectopy.
What tachycardia typically does not show left bundle branch morphology?
Tachycardia associated with Brugada Syndrome
Which statements about AVNRT is correct?
(1) Each of the dual pathways of AVNRT is distinctly localizable.
(2) The slow pathway in AVNRT is a posterior and inferior structure, located along the tricuspid annulus between the HIS bundle and the os of the CS.
(3) The fast pathway in AVNRT is an anterior and superior structure, located along the Tendon of Todaro.
What statements about ablating the AV junction (to produce AV block) is true:
Ventricular pacing at 90-100 bets/min should usually be done for a few days after AV junction ablation, to avoid ventricular tachyarrhythmias.
These techniques are often used for determining the location of a bypass tract:
(1) Mapping on the ventricular side of the AV groove while pacing the atrium at a rate that maximizes the size of the delta wave.
(2) Making unipolar recordings from the tip of the mapping catheter to get an idea of the direction of the cardiac impulse at various points along the AV groove.
(3) Observing a loss of pre-excitation when pressure is applied to the tip of the catheter at a particular location along the AV groove.
What is a sign that a patient has a left free-wall bypass tract:
Negative delta wave in lead I and aVL
What statement about Mahaim bypass treats is true:
While Mahaim bypass tracts are now thought to be atriofascicular tracts, they display many of the electrophysiologic characteristics of AV nodal tissue.
What statement about typical atrial flutter is true:
Typical atrial flutter can usually be ablated by placing a linear lesion between the tricuspid annulus and the inferior vena cava.
What treatment approaches is widely regarded as the most effective for ablating atrial fibrillation?
Creating a series of lesions to electrically isolate the pulmonary veins.
Each of the following techniques is sometimes used to map re-entrant, monomorphic ventricular tachycardia:
Entrainment mapping, Activation mapping, and Pace mapping
Which of the following statements about cardiac resynchronization (CRT) is true:
(1) Most patients with heart failure who are indicated for CRT therapy are also are indicated for ICD therapy.
(2) CRT has been shown to be effective in patients with NHYA class III or IV heart failure on optimal medical therapy who have left ventricular ejection fractions of 35% of less and QRS duration of 120msec or more.
(3) CRT is reasonable in patients in NYHA class I or II on optimal medical therapy who have left ventricular ejection fractions of 35% or lower and who require full-time ventricular pacing whatever their native QRS duration may be.
What statement about arrhythmias that cause syncope is true:
(1) Syncope caused by sinus nodal disease is often related to exaggerated overdrive suppression of the sinus node during transient episodes of atrial fibrillation.
(2) When supraventricular tachycardia produces syncope, the loss of consciousness is often caused by overdrive suppression of the sinus node, or by a vasodepressor reaction triggered by the SVT.
(3) In many cases, the strongest clue that a ventricular tachyarrhythmia is the cause of syncope is when the patient’s first syncopated episode occurs after the onset of significant heart disease.
What statement about the tilt-table study is true:
The tilt-table study is far less important than taking a careful medical history in making the correct diagnosis in patients with syncope.
What patient is most likely to develop rapid, incessant atypical atrial flutter?
A 40-year-old marathon runner who has had an ablation procedure for paroxysmal atrial fibrillation.
When planning an ablation procedure for frequent, symptomatic PVCs, what is likely to be used in locating a promising site for ablation?
Pacemapping, Activation mapping, and Examination of a 12-Lead ECG
Which of the following is the normal conduction sequence after an electrical impulse has traveled through the AV node?
SA node, Inter-atrial tracts, AV node, Bundle of HIS, Bundle Branches, Purkinje system
What causes fractionated electrograms?
Non-uniform anisotropy (ZigZag conduction)
The pause after rapid atrial pacing ceases is termed:
Overdrive Suppression
Most arrhythmias in the EP Lab are caused by?
Reentry
The triggered mechanism may cause an arrhythmia. Triggered arrhythmias are often associated with digitalis toxicity or elevated interventricular Ca++ levels. What mechanism causes triggered arrhythmias?
After-Depolarization
When an “A” signal is seen to progress on a CS catheter from the proximal to the distal electrode it is termed:
Concentric Conduction
When the CS leads are stacked on the reorder screen with proximal electrodes (CS 9-10) on top, the signal will normally proceed:
Diagonally downward to right
A HIS bundle electrogram has the following measurements:
AH interval = 160ms, HV interval = 40ms, QRS duration = 180ms
What diagnosis is most likely?
Supra-Hisian 1st degree Heart Block
When you see V-waves on the RA electrode it is termed:
Far Field Sensing
Surface ECG leads are usually filtered at:
0.1 to100Hz
Normal EGM filter settings for bipolar EP catheters are:
30-300Hz
If large T-waves in an electrogram interfere with A or V wave recognition you should:
Raise the high-pass filter
When filtering an EGM, a low pass filter setting of 500 means:
Frequencies >500Hz will be eliminated
Band pass filtering like 30-500Hz is used on bipolar EGMs in order to:
Eliminate far-field signals and improve signal-to-noise ratio
When a mapping catheter is guided to the site of origin of a focal tachycardia its distal bipolar EGM records the earliest intrinsic pre-systolic deflection. To confirm this as the focus, switch your mapping catheter to:
Unipolar (filter settings of 0.05-300Hz) and look for a negative QS deflection
Short AH <50ms:
Increased sympathetic tone or reduced vagal tone
Long AH >120ms:
Diseased distal conduction in all fascicles or in the HIS Bundle
Short HV <35ms:
Ventricular pre-excitation via bypass tract or accessory pathway
Long HV >55ms:
Intrinsic disease of the AV node or negative dromotropics
Slow-slow AVNRT:
Antegrade slow path, Retrograde slow path (atypical)
Slow-fast AVNRT:
Antegrade slow path, Retrograde fast path (Common)
Fast-slow AVNRT:
Antegrade fast path, Retrograde slow path (Uncommon)
What is the source of most Atrial Fib arrhythmogenic Foci?
Superior PVs
Atrial Fib commonly recurs in about half of PVI patients. All of the following are associated with recurrent Atrial Fib after initially successful PV ablations:
(1) Patients older than 65 years
(2) Patients with a history of structural heart disease.
(3) Patients with a history of systemic hypertension.
(4) Patients with a history of Diabetes and high cholesterol.
Extreme bradycardia or asystole frequently leads to syncope or a seizure-like convulsion. What is this syndrome termed?
Stokes-Adams
What is the name of the surgical treatment for atrial fibrillation, where the surgeon uses small incisions, cryoablation, or RF energy to create lines of scar tissue in the atria and around the pulmonary veins?
Maze
Degenerative diseases of the HIS-Purkinje system include:
Lenegre’s and Lev’s disease
Following Mustard/Senning, Fontan, ASD closures, or open heart surgery, what is the most common arrhythmia related to the surgery?
Atrial Flutter
Certain congenital defects may reverse the morphological RA & LA, putting the RA on the left side. The normal morphological LA is determined by it’s:
Appendage which is narrow based and finger-like.
When an apparently healthy Asian male dies suddenly in his sleep you should suspect:
Brugada Syndrome
In Brugada syndrome, “covered” ST segments are expected in leads:
V1, V2, and V3
What is true of Brugada Syndrome?
(1) Referred to as sudden unexpected nocturnal death syndrome.
(2) Associated with ST changes in V1-V3
(3) More common in males
(4) Treated with ICD implant
The most common site for origin of idiopathic VT is:
RVOT
Patients with Epstein Anomaly are more likely to have what rhythm problem?
AVRT
A group of accessory pathways that may connect RA or AV node to RV or RBB with decremental conduction are:
Mahaim Fibers
Pacing different sites in an attempt to match a previously recorded tachycardia morphology is termed:
Pacemapping
How many leads should match when pace mapping VT morphology?
12/12 Ideally all 12 of the surface leads should match in contour and timing.
Where is pace mapping most useful?
Focal VT or AT
A patient becomes hemodynamically unstable in VT. How can you map the site of origin while the patient is stable?
Pacemap & Voltage map
The electroanatomical approach to ablate AVNRT usually involves mapping the:
Slow Pathway for slow potentials
The electroanatomical approach to ablate AVNRT usually involves mapping the:
Slow pathway for slow potentials
What normal tissue setting would most likely be used on a 3D anatomic RV voltage map?
1.5mV
In 3D anatomical imaging of ventricular scar, a substrate map color-coded may be overlayed on an 3D LV shell image. What is a substrate map?
Map of peak to peak voltages sampled on endocardia surface, sometimes called a voltage or scar map.
3D isochronal maps show lines or colors:
Occurring at the same time relative to a reference EGM
What is the term for the type of mapping described? Capturing of the reentrant circuit of a tachycardia without interrupting the tachycardia, so that with cessation of pacing, the spontaneous reentrant tachycardia is still present:
Entrainment
In Atrial Flutter entrainment mapping, you reliably capture (entrain) the atrium at a rate faster than the flutter cycle length. When you stop pacing, the post pacing interval (PPI) on that electrode is an indication of:
Proximity to the primary reentry loop.
During entrainment mapping of typical A. Flutter, pacing from the cavotricuspid isthmus results in:
Concealed atrial fusion where (PPI - TCL) <30ms
Orthodromic AVRT block occurs in the AV node. Therefore:
The last impulse would be an A-wave, as it is still able to travel up the accessory pathway to the atrium.
Antidromic AVRT typically terminates with a ventricular signal as it travels:
Down the pathway, but is blocked from going up the AV node to the atrium.
For patients in AF, electrical cardio version is contraindicated in patients with:
Hypokalemia and Digitalis toxicity
In the EP lab coagulum refers to:
Denatured protein from boiled blood. (Denatured Protein: Denaturation involves the breaking of many of weak linkages, or bonds within a protein molecule that are responsible for the highly ordered structure of the protein in its natural state.)
RF ablations of either accessory pathways or AV node are typically done with a 4mm tip catheter using approximately:
30 watts at 60 deg C
During an RF ablation, must destruction (burning) of myocardial tissue is due to:
Conduction of heat into tissue
You are using a saline irrigated tip ablation catheter at 35 watts. To avoid endocardia burning and char formation it is most important to:
Increase flow rate
When delivering RF ablation energy what is a pop?
Stream formation at catheter tip
The chief factor opposing RF ablation heating of myocardium is:
Heat loss to circulating blood
After 30 seconds of ablation with a non-irrigated RF catheter, the tissue temperature 1mm below the catheter tip is typically:
42 degrees C hotter than the ablation console temperature reading
During RF ablation what is the minimum temperature the tissue needs to be heated to, so that a significant lesion is created?
50 degrees C
During ablation when the impedance rises suddenly you should?
Stop ablating and inform the doctor
You are monitoring the Fluoro & ICE screens during cooled RF ablation of AF when you see a sudden shower of small reflection in the LA. This suggests:
Boiling at electrode-tissue interface
During externally irrigated RF ablation you note a continuing rise in catheter impedance as you decrease the power to <20w. The tip temperature has risen to over 42 degrees C. The most common cause of this is :
Catheter wedging in a crevice or small vein
Some labs monitor the esophageal temperature during PVI. Keeping the temperature:
38.5 deg C (or 2 degrees above baseline) is most important when ablating the area of the posterior LA
You bring a non-pacemaker dependent patient with a DDD pacer to the EP lab for an ablation. To avoid accidental reprogramming of the PPM, before applying RF ablation it is safest to:
Reprogram the PPM to OOO or VVI at a rate lower than the intrinsic
In A. Fib or A. Flutter it may be necessary to ablate within the distal CS. It is safest to ablate only along the inner surface of the CS because of possible damage to the:
Circumflex coronary artery
What is used as the refrigerant in cryoablation?
Nitrous oxide gas
During a PVI procedure, the cryoablation (Arctic Front) should be inflated using the:
Cryoconsole start button in the LA then advanced into the PV ostium.
How and when should the cryoablation (Arctic Front) be deflated?
Technician presses the cryo-console stop button. The console waits until balloon temp is above 20 degrees C then deflates automatically.
What is a typical inflation time for the cryoablation (Arctic Front) in a PVI procedure?
3-4 min.
Prior to cryoablation, how can you tell if the inflated cryoballoon (Aortic Front) is properly positioned?
(1) Distal contrast injection remains in PV
(2) Distal pressure rises from LA to PA level
(3) Inflated balloon should be round, not oval
(4) Scan ICE color Doppler for leaks around balloon
Cryoablation of the slow pathway in AVNRT usually results in:
An ice ball, or cryo-adherence
You are cryoablation a patient with AVNRT. After 20 seconds of the cryo application complete AV block develops. You should stop ablation and expect:
Reversal of AV block with thawing
In cryomapping, formation of an ice ball at the catheter tip and adherence to the myocardium occurs when:
Distal temperature show electrical noise
The most common site of origin for focal atrial tachycardia is:
RA, Cristina terminalis
What is the typical response of an Atrial Tach focus to successful RF application:
Abrupt termination of Atrial Tach
The current cure for typical AVNRT in patients who do not with to take drugs is to ablate the:
Slow pathway to the AV node, along the tricuspid annulus.
What are the 2 approaches to ablating AVNRT in the triangle of Koch?
(1) Use ablation electrode to search for and ablate ow amplitude potentials along the atrial aspect of the tricuspid annulus.
(2) Gradually advance and ablate as you move anteriorly.
You are doing an AVNRT ablation with RF energy. The physician is worried about ablation damage to the AV node. The rhythm changes form NSR to an accelerated junction Al rhythm. You should inform the Dr. and:
Continue ablating, and start atrial pacing.
What ablation method is initially temporary and the injury is usually reversible. This allows you to test and confirm an ablation site GeForce actually destroying it. This is especially useful to prevent AV block when ablating the AV node slow pathway. This type of test ablation is termed:
Cryomapping
Your patient is having a slow pathway RF ablation for typical ANVRT. The anesthesiologist has the patient asleep with all muscles relaxed. During RF ablation the anesthesiologist stops the patient’s breathing, WHY?
To minimize catheter motion and make a better burn in the designated spot.
Your patient has typical AVNRT inducible with Atrial Extrasystoles (AES) and isuprel infusion. Isuprel was stopped and the SVT terminated after RF ablation of the Cavo-tricuspid isthmus. Testing indicates complete CTI block. To see if this ablation effectively cured the AVNRT you should:
Wait 30 minutes, then try to reinitiate AVNRT with isuprel and AES.
A patient with an EP of 40% has had 2 PVI ablation procedures returns with symptomatic persistent Atrial Fib. His rapid A. Fib is poorly controlled with dedications. You expect the treatment to be:
VVI pacemaker and AV node ablation
A 78 year old patient with paroxysmal atrial fibrillation with rapid ventricular conduction, comes into your EP lab for an AV node ablation. The patient has an underlying sinus rate of 30 bpm. His pacemaker is programmed to DDD 60 bpm that is currently pacing. What is the best method to identify CHB during AV node ablation?
Increase rate and extend the device PR interval.
While placing the HIS electrode, you advance the catheter into the RV so that the distal electrodes show a small spike just before the V, but no preceding A signal. The most likely explanation is that you went:
Too far, recording of Right Bundle.
A patient has bundle branch reentry VT with a LBBB pattern. Where should the ablation catheter be placed?
RV septum below the HIS bundle
Where is the typical ablation site for a patient with Bundle Branch Reentry?
Right Bundle Branch
The Lariat, Watchman, and Amplatzer are devices used in atrial fibrillation patients to:
Occlude the left atrial appendage and reduce risk of stroke.
Describe Watchman Device:
Endocardial placement, Parachute-shaped device consists of a national cage covered with a polyester membrane and a row of fixation barbs.
Describe Lariat Device:
Epicardial and endocardial magnet-tipped guidewires. Left Atrial Appendage lighted from the outside (pericardium) with a single ligature loop.
Describe Amplatzer/Amulet Device:
Endocardial placement, self-expanding nitinol wire mesh and polyester patch with a lobe and disk connected by a central waist.
Your patient has coronary artery disease, persistent Atrial Fib, dilated Left Atrium, and hypertension. He is scheduled for CABG surgery. What therapy would be most likely given to provide freedom from Atrial Fib without anti-arrhythmic drugs?
Minimally invasive surgical ablation (modified MAZE)
The decision to implant a permanent pacemaker for Bradycardia is usually based on:
Patient symptoms and ambulatory monitoring ECG
The most common bradyarrhythmias are caused by:
SA node disease
End of Life (EOL):
Pacemaker fails to function or dies
Elective Replacement Indicators (ERI):
Consider replacement, pacemaker will die soon (low battery)
Beginning of Life (BOL):
Original settings when pacemaker is new from factory
Power On Reset (POR):
Near death with loss of volatile memory, default backup pacing starts.
What is the most common reason to implant a permanent pacemaker in patients with symptomatic supraventricular bradycardia?
Sick Sinus Syndrome
Pacemaker Syndrome is caused by:
Non-Physiologic VVI pacing
When putting in a VVI pacemaker, how should you check to avoid future diaphragmatic stimulation?
Pace with 10 volts
In implantation of a new dual chamber PPM, after the RV lead is positioned and reasonable parameters established, the next step is to:
Tie down the RV lead to the suture sleeve and fascia.
Two months after PPM implant the patient loses ventricular capture. The measured RV lead threshold has risen from 0.6 volts at implant to 5. Volts. This is most probably due to:
Possible lead dislodgement (may or may not be seen on comparison X-ray).
Temporary disabling of a pacemaker’s sensing amplifiers after the delivery of an output pulse to prevent it from sensing its own its discharge, usually from a different chamber is termed:
Blanking period
Post Ventricular Atrial Refractory Period (PVARP):
Follows V pace, prevents QRS and T-wave sensing in atrium (extending may prevent pacer mediated tachycardia). This is the atrial equivalent to the ventricular blanking period.
Total Atrial Refractory Period (TARP):
Follows A-pace, Limits the maximum upper rate. Atrial events cannot be sensed by the atrial channel. It is the sum of the AV interval and the PVARP.
Ventricular Blanking Period (VBP):
Follows A-pace, prevents inappropriate inhibition of the ventricular system by the atrial system.
Ventricular Refractory Period (VRP):
Follows V-pace, prevents T-wave sensing in the ventricle
A 65 year old man’s heart rate was 53 bpm while exercising and 46 bpm when resting? The most likely diagnosis is:
Chronotropic incompetence
What would be most likely to stop function of modern demand pacemakers?
Arc welding and Electro-cautery. These both induce high electric currents in the body.
A patient comes to the EP lab with a Left Bundle Branch Block (LBBB) ECG pattern. While passing a RV lead, the patient develops an additional Right Bundle Branch Block (RBBB). The ECG would show:
Complete Heart Block
What is the most common reason for cardiac implanted lead removal?
Device infection
What is the most common organism causing implanted device infection?
Staphylococcus
