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EP Exam Review Book Examples

Sample Questions - Page 1 of 3
(Note: Images shown here in color, will appear gray scale in the book)

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46. When an "A" signal is seen to progress on a CS catheter from proximal to distal electrode as shown, it is termed:

EP Exam Review - Ques. 46 - Concentric Conduction
  1. Eccentric conduction
  2. Concentric conduction
  3. Concealed conduction
  4. Antegrade conduction
ANSWER: b. Concentric conduction

Concentric conduction is normally from left to right, i.e. from the central crux out to the lateral LA. Eccentric conduction is opposite; it moves from the outside in, i.e. From the lateral LA inward. This is easily seen on the stacked CS electrograms by following the earliest to latest CS activation.

Depending on physician preference he may chose to have the electrodes stacked differently on the monitor. Some physicians like the distal electrode on top. I like it proximal to distal because it shows normal concentric conduction progress from left to right.

137. How does sensing effect pacing? In general with temporary VVI pacing, oversensing causes _____ and undersensing causes _____.

EP Exam Review Ques. 137. - Over/Under Sensing
  1. Overpacing, Overpacing
  2. Underpacing, Underpacing
  3. Underpacing, Overpacing
  4. Overpacing, Underpacing

ANSWER: c. Underpacing, Overpacing.

Oversensing will inhibit the pacemaker from firing, when it shouldn't. Perhaps it will sense a T wave thinking it is a QRS and not fire. Undersensing will miss QRS complexes and will fire anyway, perhaps at the wrong time or on a T wave, putting in too many unneeded pacer spikes. See: Medtronic.com

170. Match each RA anatomic feature with its location:

EP Exam Review - Ques. 170 - RA Anatomic Matching
a. CS is located ______ I. Anterior to the IVC
b. Fossa Ovale is located ____ II. Superior - posterior to the CS os
c. Crista terminalis is _______ III. Posterior to the tricuspid valve
d. Atrial appendage is _____ IV. Superior to the Fossa ovalis

Correctly matched answers are:

Cs is located ______ III. Posterior to the tricuspid valve
Fossa ovale is located ____ II. Superior - posterior to the CS os
Crista terminalis is _______ I. Anterior to the IVC
Atrial appendage is _____ IV. Superior to the Fossa ovalis

See above right heart diagram. Note spacial relationships of all RA structures.

203. Inspiration normally results in an immediate ________ in intracardiac pressure and a/an ________ in venous return.

EP Exam Review - Ques. 203 - Inspiration
  1. Increase,   Increase
  2. Increase,   Decrease
  3. Decrease,   Increase
  4. Decrease,   Decrease

ANSWER: c. Decreased,   Increased.

The intracardiac pressures all drop immediately by the amount of the negative inhalation. Pressures drop with the diaphragm. This negative pressure sucks blood into the thorax and RA with inspiration and increases venous return. It also reflexively increases the heart rate. Within a few seconds the increased venous return will increase the output of the left heart and BP (unless followed immediately by another inspiration). See: Braunwald, chapter on "Auscultation."

EP Exam Review - Ques.298 - Xray Views

298. What is the view?

  1. AP
  2. RAO
  3. LAO
  4. Lateral

 

 

 

 

ANSWER: c. LAO

EP Exam Review - Ques. 298a - Answer for Xray View

The 2 Halo catheters outline the RA & LA respectively. The CS catheter is in the left AV groove. The 30 degree LAO looks down the barrel of the ventricle. RAO nicely separates the right heart from the left, but the atria and ventricles overlap. That is why it is essential to use a combination of views.

 

 

 

331. When ICE is used to confirm the location of the transseptal needle prior to puncture you look for "tenting." What is tenting?

EP Exam Review - Ques. 331 - What is Tenting
  1. V shaped indentation in fossa
  2. Curved position of the fossa like a reversed C
  3. Burst of echo contrast (bubbles) in fossa Ovale
  4. Opening flap into the LA (septum secundum)

ANSWER: a. V shaped indentation, like a >.

A "tent" is the shape a canvas makes when pushed up with a pole, like a >. This is like the indentation the transseptal needle makes as you push it lightly into the thin fossa. Then as you advance the needle the taut fossa pops and collapses as you make the "stick." Medical dictionary says, 'tenting' can also be the symmetrical 'peaking' of T waves.

Issa says, "The sheath, dilator, and needle assembly is introduced into the RA and the dilator tip is positioned against the fossa ovale, as described earlier. Before advancing the Brockenbrough needle, continuous ICE imaging should direct further adjustments in the dilator tip position until ICE confirms the tip is in intimate contact with the middle of the fossa, confirms proper lateral movement of the dilator toward the fossa, and excludes inadvertent superior displacement toward the muscular septum and aortic valve. With further advancement of the dilator, ICE demonstrates tenting of the fossa. If the distance from the tented fossa to the LA free wall is small, minor adjustments in the dilator tip position can be made to maximize the space. The Brockenbrough needle is then advanced. With successful transseptal puncture, a palpable "pop" is felt, and sudden collapse of the tented fossa is observed. Advancement of the needle is then immediately stopped. With no change in position of the Brockenbrough needle, the transseptal dilator and sheath are advanced over the guidewire into the LA,..."

See: Issa, chapter on "EP testing"

347. You are setting up the sterile table for an EP study. The patient is brought in and put on the table. The Physician then calls and cancels the procedure. What should you do with the sterile table that is set up in the room?

  1. Leave it open and save it for the next case, immediately to follow.
  2. Tear it down and discard all disposable items. Start a new table for next case.
  3. Cover it with a sterile cloth drape. It is considered sterile for only 6 hours.
  4. Discard all solutions and cover it with a sterile plastic drape. It is considered sterile for 12 hours.

ANSWER: b. Tear it down and start completely over for the next case.

Surgery Encyclopedia says, "The environment contains potential hazards that may spread pathogens through movement, touch, or proximity… restrict traffic in the operating room. Sterile packages or fields are opened or created as close as possible to time of actual use." The safety of the next patient to enter the room is the most important. If you can cover the dry table before the patient enters the room it may be saved and used on the next case. See: SurgeryeEcyclopedia.com/A-Ce/Aseptic-Technique.html

Keywords: Don't hold over sterile tables

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