RCES EXAM REVIEW QUESTIONS Flashcards
What exits the patient during fluoroscopy to create a radiographic image?
Remnant beam
Which medication is commonly administered to facilitate AVNRT?
Isoproterenol
A properly RV pacing lead should produce what Morphology on the surface lead?
LBBB
A properly LV pacing lead should produce what morphology on the surface lead?
RBBB
What pacemaker adjustment would change the unit from the demand mode to the asynchronous mode?
Decreased sensitivity
What is the name of the ridge of tissue in front of the inferior vena cava?
Eustachian Ridge
Which of the following is the most important consideration when selecting the site for a peripheral IV in a patient undergoing a device implant?
the planned side of implant
Immediately following transeptal puncture, which medication should be given to a patient who is heparin- induced platelet aggregation (HIPA) positive?
Integrellin
What is the high/low pass filter for intracardia electrograms in Hertz?
30/500
What is the high/low pass filter for surface electrograms in Hertz?
.5/100
While assisting with a pacemaker generator change on a pacemaker dependent patient, the doctor attaches the new generator but nothing happens until it is placed back into the pocket why is this?
Its a unipolar generator
What functions are programmable in Both VVI and DDD pacemakers?
Sensitivity, Voltage output, rate smoothing
Prior to placing a left ventricular pacing lead, what should be preformed?
a coronary sinus venogram
The following prerequisites describe which type of tachycardia mechanism?
Two pathways (A&B) must be connected
One pathway must be conduct more slowly
The slower pathway must have a shorter effective refractory period
Re entry
The AV node is located at the base of the?
RA, at the apex of the triangle of Koch
Most coronary sinus pacemaker leads can accept a wire with a maximum diameter of?
0.035”
After correctly positioning the transeptal sheath for a transeptal puncture into the LA, which fluoroscopic position is ideal for viewing the intraatrial septum?
RAO
Which ventricular tachycardias are often provoked with exercise?
RVOT, idiopathic left posterior fascicular VT, VT associated with ARVC
What is the most common catheter position for preforming an initial VT Study?
HRA, HIS, RVOT, RVA
What filter adjustment minimizes signal overlap without adjusting voltage amplitude?
Clipping
Which cardiac structure is present during fetal development that may remain patent in adults?
Foramen Ovale
When removing a venous sheath, manual pressure should be held where?
on the puncture site
What are the benefits of a subcutaneous ICD?
Decreased risk of Pneumothorax, Decreased vascular complication, decreased post procedural patient discomfort
What is most likely to perforate the coronary venous vasculature?
Guide wires
Which blood test would be ordered prior to pulling a sheath?
ACT
What is the most important consideration when selecting a site for an IV in a patient undergoing a device implant? and why?
You want to take into consideration the side the device is going on. Usually the opposite of their dominant hand. This is due to wanting the IV to be on the same side to put contrast in to reduce risk of pneumothorax
What should the ACT level be before pulling a sheath?
<160
During a pacemaker implant, the sterile gloved hands of the scrub staff must be kept ______ at all times and not drop below_______.
In front of chest and, below the scrub staff waist
SVT has just been induced at a cycle length of 278. What is the heart rate and how do you get it?
HR= 216 bpm you take 60,000 and divide it bt 278
During an atrial fibrillation procedure, a physician preforms a transeptal puncture and proceeds to advance long wire into the left atrium. What would you expect to see on the screen?
The wire should enter the pulmonary veins
The patient begins to complain of shortness of breath after a venography, The patient is exhibiting signs of what?
They could be having an allergic reaction to the contrast
The corrected QT interval for a patient with an RR interval of 857 ms and a QT of 395 ms is what? How do you get that?
.43 You convert ms to s 857=.857 395=.395 you then do the QT in s divided by the square root of the RR in seconds
Peaked T waves on a 12 lead ECG is associated with what?
Hyperkalemia
The name of the ridge of tissue in front of the inferior vena cava
The eustachian ridge
Class IIa recommendation indicates that effective prevention and therapy are supported by what classification of recommendations?
IT is reasonable to preform (moderate)
Class 1 recommendations indicate that the procedure is what?
Useful and beneficial and effective (strong)
Class IIb recommendations indicate that the procedure is what?
Less favorable
Class III
The procedure is not useful or is harmful ( No benefit)
According to ACLS protocol for an adult patient, what would an acceptable respiration rate during a cardiac implant device procedure?
12-18
Focal arrhythmia are typically characterized by presystolic activation timing of a minimum of how many msec
200
The BCL is 850 and the SNRT is 1095 msec. What is the CSNRT and how do you get that
The CSNRT is SNRT-BCL(Cycle Length)
245 msec
Relative to the coronary sinus the IVC lies where?
Inferior and laterally
While advancing the RV catheter, the patient suddenly goes into complete heart block. What would be the most likely explanation for this?
The patient has an underlying LBBB
When handling sterile items, it is important to do what?
Keep them within the sterile field
Prior to scheduled idiopathic VT ablation, an acceptable pre procedural potassium (K) value is what?
3.5-5.4
The most common cause of non- cardiac syncope is what?
vasovagal
During ventricular entrainment pacing of an SVT, a post-pacing response of A-A-V is noted. This response is consistent with?
Atrial Tachycardia
While ablating near the osmium of coronary sinus, a sudden 60ohm increase in impedance is observed . What does this finding mean?
The catheter has fallen into the CS
According to the Joint Commission standards, the critical aspects for patient identification are what?
Verbal confirmation of two identifiers with patient
Prior to starting the case, and after explaining the procedure to the patients well as identifying risks and potential complications, permission is given to proceed with the study. This is known as what?
Informed Consent
One of the complications specific to PVI is
atrioesophageal fistula
For IV conscious sedation, a typical initial dose of fentanyl would be what?
25-50 mcg
What are the electrical properties of the cardiac cell?
Excitability, automaticity, conductivity
A patient is taken off Coumadin (warfarin) for one week prior to an RF ablation procedure. The INR yields a value of 4. What is the next logical step?
Send the patient home and repeat the INR at a later date
What is the normal range for INR for individuals on Coumadin?
2.0-3.0
What is the normal range for INR for individuals not on Coumadin?
0.9-1.2
Which technology, in addition to fluoroscopy, is most frequently used to identify anatomical landmarks prior to transeptal puncture?
TEE
What nerve lies over the right atrial appendage and affects diaphragmatic motion?
Phrenic Nerve
When preparing a patient for NIPS, what is the most important thing to have?
Back up defibrillator just incase the patient ICD doesn’t shock them out of the arrhythmia
What is the file format that allows healthcare systems to receive and transmit clinic images?
DICOM
During LAA Closure device insertion, it is recommended that the ACT is maintained at what?
250-350 / 300-400
The activation sequence of the Left Lateral pathway is characterized by what?
Distal CS Activating first
DFT may be preformed in what circumstances
failed therapy delivery, Congestive HF, Appropriate therapy delivery
At the time of device implant, the atrial sensing threshold should be at least?
1.5 mV
Lead conductor fracture usually leads to what
High impedance
A properly functioning RV catheter pacing should produce what kind of morphology?
LBBB
Give an example of when a pacemaker would be needed?
A symptomatic 1st degree AV block with the His Purkinje Disease
A properly functioning LV catheter pacing should produce what kind of morphology?
RBBB
What is likely to happen with lead maturation?
Electrode encapsulation
Which temporary pacemaker adjustment would change the unit of demand mode to asynchronous mode?
Decrease the sensitivity
The primary source of airborne bacteria is what?
The healthcare team
The physician orders ibutilide 1 mg IV. What aspect of the patients rhythm should be monitored?
The QT interval
Give an example of a class 1a antiarrythmic
Procainanmide
Give an example of a class IB AAD
Lidocaine
Give an example of a class Ic AAD
Flecainide and propafenone
Give an example of a Class II AAD
BB Metoprolol
Give an example Class III AAD
Amiodarone
Give an example Class IV AAD
Verapamil or Diltiazem
Give an example Class V AAD
Adenosine
During an open irrigated ablation, the pump alarms. What should you do?
Stop ablation and notify physician
Burst pacing protocol consists of what?
a fixed pacing sequence
Repetitive delivery of 8 atrial beats at the same cycle length followed by a 9th at a shorter cycle length describes what?
Decremental atrial pacing
Tachycardia has just been induced in a patient who did not have an VA block with adenosine. The tachycardia has a V-A of 180 ms. Suddenly, the patient develops a LBBB and the V-A increases to 220 ms. The patient most likely has what?
A left sided AP
What is retrograde conduction?
Backward conduction, example Ventricles to atria
What is the result of moving the ground patch closer to the site of RF energy?
Decreased impedance
During RF ablation, a high impedance reading continually shuts off the RF generator. The first trouble shooting attempt should be what?
check if the patient ground id secure
Prior to using the laser sheath for lead extraction a _____ should be used as first attempt.
Locking stylet
During monitoring of an RF ablation, you observe the catheter temp reach 80 degrees Celsius. What is the next action?
Alert the physician and stop the ablation delivery because of potential coagulum
What is the most common site for idiopathic VT?
RVOT
What is the normal range for pacemaker lead impedance?
300-1200 ohms
Following an EP/ ablation procedure, what instruction should be included on the post EP discharge education?
No heavy lifting
What four structures outline the triangle go Koch?
Tendon of Todaro, Bundle of His, Septal leaflet of tricuspid annulus , CS os
Hypoventilation causes what?
PCO2 to increase and pH to decrease
Hyperventilation cause what?
PCO2 to decease and pH to increase
resistance in measured in what unit?
Ohms
What is the HR in beats for a tachycardia rate of 320 ms? how do you figure that out?
60,000/320= 188 bpm
How would you measure a capture threshold testing for permanent pacemaker implant?
Starts at 5 mV, decrement voltage until capture is lost, the increase voltage until capture comes back and document that value
A patient presents with an infected ICD pocket, to prepare for a laser lead extraction, the best source to find lead sizing information for a laser sheath would be where?
The SLS reference
Hysteresis is used to do what?
Promote inartistic conduction
What should be done prior to using a temporary pacemaker for pacing?
Check date of the last battery change
The mA of the stimulator is conventionally set at what?
2x the diastolic threshold
While providing patient education post-pacer implant, signs of pacemaker malfunction would include what?
Dizziness, dyspnea, angina, peripheral edema, return of previous symptoms
What medication prolongs the action potential and hence refractoriness?
Amiodarone
What should be done after a venous subclavian puncture and why?
Chest X-ray, due to the risk of a pneumothorax and to confirm correct placement of the catheter
A delta wave is cause by what?
antegrade AP conduction pre-exciting the ventricular tissue
Notification by the EP team to recovery room RN, post accessory pathway ablation, summarizing procedural activities is known as what?
Hand-off-report
His bundle disease, or damage, is indicated by the prolongation of what?
The H-V interval
During a cardiac resynchronizing therapy device implant, real-time pacing support, and device programming is achieved by which of the following?
Pacing system analyzer (PSA)
Repetitive delivery of 8 atrial beats at the same cycle length followed by the 9th beat which is delivered with a progressively shorter cycle length?
Decremental atrial pacing
What are two examples of pure class III AAD?
Dofetilide and ibutilide
What is most appropriate action to take when you are unable to discern a pedal pulse on a palpitation?
You assess the pulse using a doppler and then make sure it it noted that you used a doppler
ICD conductor fracture should be suspected when there is an impedance increase from the baseline of what value?
1500 Ohms
The on face view of the tricuspid and mitral valve
LAO
Differentiates atria from ventricles
RAO
Differentiates Left and Right side of the heart
LAO
What view helps locate the CS?
RAO
To reduce radiation exposure the fluoroscopic frame rate should be set at how many frames per second?
15 on average, some can get down to 10
What 12 lead ECG findings are commonly associated with Arrhythmogenic right ventricular cardiomyopathy/ dysplasia?
Epsilon Waves, and T wave inversion
What is the most appropriate drug to treat WPW?
amiodarone
Circulation distal to the femoral artery is best assessed by what pulse?
Dorsalis pedis pulse
Cardiac signals that display a low and wide signal are described as what?
Far field
Cardiac signals that display a sharp and narrow signal are described as what?
Near field
A 12 lead ECG shows an atrial rate of 200ms with a negative saw tooth pattern in leads II,III, and aVF. What is the arrythmia?
Typical Counterclockwise flutter
A 12 lead ECG shows an atrial rate of 200ms with a positive saw tooth pattern in leads II,III, and aVF. What is the arrythmia?
Typical clockwise flutter
What is the best way to describe the threshold for a single chamber implantable pacemaker?
The minimum about of mA required to elicit a response from the chamber paced
How is the left atrium activated simultaneously with the right atrium?
Via the Bachman’s bundle
The imaging directional term meaning anatomically “Superior”
Cranial
How is Wilson central terminal average calculated?
limb leads RA, LA, and LL
A potential complication of VVI pacing is what?
Pacemaker syndrome
Explain crosstalk when it comes to pacemakers
Cross talk is when a lead from one chamber is sensed by the lead in the other chamber. It can only happen in dual pacing
Explain Pacemaker syndrome
since there is no atrial sensing lead to guide the ventricle, the ventricle contracts at the programmed rate regardless of the timing of atrial contraction. This leads to loss of AV synchrony
Prior to the patient being put on the table for an implant, the procedure staff must do what
What are the indications for a BI-V device insertion?
EF less than or equal to 30 and a QRS greater than 150
What is the normal value for sodium?
135-145
What is the normal value for calcium?
8.5-10
What is the normal value for magnesium?
1.5-2
What is the normal value for Chloride?
95-105
What is normal glucose levels?
65-110
What is normal Cholesterol levels
130-200
What is the normal value for Aterial blood saturation (SaO2)
95-100%
What is normal blood pressure?
120/80
What is normal temperature?
97.8-99.1
What is normal oxygen saturation?
greater than 95%
What is normal PaCO2?
35-45
What is normal PaO2
80-100
What is normal bicarbonate (HCO3)
22-26
What are normal troponin levels?
0.0-0.4
Normal creatine kinase?
25-200
GFR below 15 means? What do you want your GFR to be?
Kidney Failure, Above 90
What is normal pH of the blood?
7.35-7.45
What should be done with used needles?
They should be put in the sharps, no need to cap them
If a patient is left handed what site would you prepare?
Normally you place a pace maker on the left side however, if someone is left handed you would prep the right side
Prior to transferring a patient from the table to the bed what must you do?
Secure the femoral lines to avoid them being removed
What must be done before the surgery?
A time out session where the staff verifies the patient, what procedure they are doing, and marking the correct site.
When pacing from the CS measuring laterally, what activation time would likely indicate successful ablation of typical flutter?
200
During open-irrigated ablation, the pump alarms. What should be done?
Stop ablation and notify physician
During the monitoring of a radiofrequency ablation procedure, you observe the catheter temperature reach 80 degrees. What should you do next?
Alert the physician and stop the ablation delivery because of potential coagulum
During RF ablation, a high impedance reading continually shuts off the RF generator. What should be your first line of trouble shooting?
Check if the patient ground is secure
What should be placed in a biohazard bag?
All items saturated with blood or bodily fluid
What does a low impedance mean during a follow up post pacemaker implant?
it means there’s is a possible lead insulation break
What does it mean when impedance changes by more than 200 ohms
failure in the pacing system or an insulation break.
What does it mean when impedance changes by more than 700 ohms?
Lead wire fracture
If the impedance is greater than 1500 what does that mean?
Lead wire fracture
What does it mean if impedance is less than 300?
Insulation break
During an RF ablation of AVNRT, there is a loss of retrograde atrial conduction. What do you do next?
Stop RF application as the ablation is complete once there is not dual pathway present
Tachycardia initiated by an impulse that blocks in the fast pathway and conducts through the slow pathway is described as what?
AVNRT
Where is the tricuspid valve?
On the right side of the heart
Where is the mitral valve?
On the left side of the heart
When looking at the tricuspid and mitral valve from the superior portion where is the aortic valve and pulmonary valve?
The aortic valve in medial and slightly superior and then the pulmonary valve sits right above the aortic valve
When draping a patient for a pacemaker implant what area do you drape?
You drape the area closest to you to continue to keep a sterile environment and avoid any on sterile items coming in contact with you.
ICD conductor fracture should be suspected when there is an impedance from the baseline of what?
1500 Ohms (300-1200 is normal)
alpha particles, beta particles, gamma rays, and X-rays (Fluoroscopy). These are all examples of what?
Ionizing radiation
Ultra-Violet light, visible light, infrared, radio-frequency (EP ablation) and microwaves. These are examples of what?
Non- ionizing radiation
With exception of the local stimulus of above normal strength, which of the following refractory periods describe the timing during depolarization in which the longest coupling interval of input into a tissue fails to produce capture?
Effective
the time elapsed between the end of ERP to the beginning of phase 4 of the action potential.
relative
is the shortest coupling interval between two successive conducted impulses, measuring both refractoriness and conduction velocity of the tissue of interest.
Functional
Depolarization of the cell occurs at what phase and why?
Phase 0.This occurs because the sodium channels open allowing positively charge sodium ions to to rush into the cell
Repolarization of the cell occurs at what phase and why?
Phase 0-3. this occurs because the sodium channels close ending the influx of sodium ions into the cell. Potassium ions begin to flow out of the cell starting the repolarization process. Next calcium channels will open allowing calcium ions to move into the cell. Finally calcium channels close but potassium keeps coming out of the cell. the sodium potassium pump pushes sodium out of the cell and pulls potassium back in. 3 sodium to 1 potassium
Explain phase 0 action potential
Sodium channels open allowing sodium ions to rush into the cell
Explain phase 2 action potential
calcium channels open allowing calcium ions into the cell known as the absolute refractory period where the cell cannot be depolarized.
Explain phase 3 action potential
calcium channels close but potassium ions keep coming out of the cell. a sodium potassium pump pulls sodium ions out of the cell and pulls potassium ions back into the cell completing depolarization repolarization. This is the relative refractory period of a cardiac cell – during this time the cell will depolarize if given a strong enough stimulus.
Explain phase 4 action potential
The distribution of sodium and potassium ions is restored, and the cell is available for depolarization.
Explain phase 1 action potential
sodium channels close stopping sodium ions to come into the cell. Potassium ions begin flowing out of the cell
What are indications for single or dual chamber ICD implants?
Primary and secondary preventions, incessant VT
After connecting the ablation catheter to the ablation cable, it is observed on the recording system that one of the bipolar is not displaying any information. What is the FIRST step to take?
Disconnect and reconnect the ablation cable
During an ablation 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 a pacemaker
Defibrillation threshold testing (DFT) may be preformed in which circumstances?
Congestive Heart Failure, Post MI, failed therapy delivery
During an electro-anatomical mapping procedure the system gives a patient movement warning. What is the next recommended step?
No action required
During an RF ablation, the baseline impedance is 180 ohms as measure through the ablation catheter this can be corrected by what?
Adding a second grounding patch or moving the patch closer to the heart. The closest to the heart the lower the impedance, the further away from the heart the higher the impedance
What is normal impedance for ablations?
90-120 ohms
High impedance in ablations can cause what?
Char, or thrombus
How do you know based on impedance if you have achieved a successful lesson formation?
There will be a 5-10 ohms drop
What is normal temperature for ablation catheters?
50-70 degrees c
Catheter temps above 70 can cause what?
Char and thrombus
Catheter temps above 100 can cause what?
Steam pops
What is the normal power for an ablation
20-60 watts
Low power will do what?
ineffective lesion
High power can cause what?
Promotes char, thrombus, steam pops
What is the relationship between power and temperature
The higher the power the higher the temperature. The lower the power the lower the temperature
A 300 pound patient is prepped for an RF ablation. Baseline impedance is 200 ohms. The next step would be to do what?
Dextrocardia is what?
When the heart is on the right side of the body instead of the left
What is transportation of the great vessels?
the aorta starts from the right ventricle and the pulmonary artery from the left ventricle. instead of normal position where the aorta starts from the Left ventricle and the pulmonary artery starts from the right ventricle
What is persistent Left Superior vena cava?
A defect where the PLSVC runs between the left pulmonary veins and the left atrial appendage enlarging the coronary sinus as it enters the atrium.
When preparing to transport a patient for a cardiac device implant, what documents must be updated and reviewed?
H&P, signed patient consent
When ablating the osmium of the coronary sinus, a sudden 60 ohm drop occurs. What does this finding indicate?
Ablation catheter has fallen into the CS
How can you tell the difference on an EGM of PVI entrance block vs exit block
Entrance block will occur in the proximal leads and fade as they get to the distal leads, an exit block will start at the distal leads and fade as it moves more proximal
What is PMT in a pacemaker?
Pacemaker mediated tachycardia is a type of arrhythmia that happens in patients with dual-chamber pacemakers
what is mode switching in a pacemaker?
the ability of a pacemaker to reprogram itself from tracking to non-tracking mode in response to atrial tachyarrhythmias, and to regain tracking mode as soon as the tachyarrhythmia terminates.
What meds should be given to a patient with WPW who comes in with wide complex VT?
Amiodarone
What pacing protocol are most likely to induce typical atrial flutter?
PES from the proximal cs and from the lateral RA
carotid massage would be preformed on a patient with syncope and?
a negative EP study
If a QRS is wide during AVRT what does that mean?
It means the AVRT is antidromic, or in a retrograde fashion
If a QRS is narrow during AVRT what does that mean?
it means its orthodromic, in a normal fashion
how do you decide if a AVRT is right or left sided?
If its right sided it then the ventricular deflection of the RVA proceeds the “V” deflection of the His EGM. If it is left sided. If ventricular deflection of the proximal CS precedes the “V” deflection of the His EGM
(-) delta wave on V1 =
right sided
(+) delta wave on V1=
left sided
AVNRT is what kind of mechanism of activation?
Macro- reentry
What is a normal AH interval?
50-120
What is a normal HV interval?
35-55
What is a normal QRS?
less an 120
During tachycardia, if “A” and “V” signals are fused on the distal CS (1-2), the AP resides on
Left side
f the “A” and “V” signals are fused on the proximal CS (9-10), the AP resides on the
right side
Increase in V-A interval if RBBB develops
Right side
Increase in V-A interval if LBBB develops
Left sided
WPW is a form of what tachycardia?
Orthodromic AVRT
