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EP Exam Review Book Examples

Sample Questions - Page 3 of 3
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675. Beta blockers are potentially dangerous to:

  1. Patients on MAO inhibitors
  2. Patients with allergies to iodine
  3. Patients with bronchospasm or asthma
  4. Patients post heart transplant
  5. Patients with peripheral vascular disease
ANSWER: c. Asthmatics.

A common side effect of beta -blockers is bronchospasm. This would be especially bad for an asthmatic patient. Asthmatics may need the beta stimulation of epinephrine to dilate their bronchioles. If the beta sites are blocked, it may precipitate an asthmatic crisis. Opie says: "Pulmonary absolute contraindications are severe asthma or bronchospasm. . . . No patient may be given a beta-blocker without questions for past or present asthma. Fatalities have resulted when this rule is ignored. Relative: Mild asthma or bronchospasm or chronic airways disease. Use agents with cardio-selectivity plus beta2-stimulants (by inhalation)." See: AHA, ACLS Provider Manual, chapter on "Acute Coronary Syndromes"

680. Match each EP cath premedication to its average adult dosage: Medications:
  1. Valium (Diazepam)
  2. Cimetidine (Tagamet)
  3. Benadryl (Diphenhydramine)
  4. Solu-medrol (Methylprednisolone)
Dosage:
  1. 125 mg IV
  2. 5-10 mg IV or P.O.
  3. (10-50 mg IV) 25-50 mg P.O.
  4. (50-300 mg IV) 300 mg P.O.
CORRECTLY MATCHED ANSWERS:
  1. Valium (Diazepam): 5-10 Mg IM, IV, or P.O. Benzodiazapine, anti-anxiety drug
  2. Cimetidine (Tagamet):(50-300 Mg Iv) 300 Mg P.O. Given to decrease esophageal reflux
  3. Benadryl (Diphenhydramine) (10-50 mg IV) 25-50 mg P.O. Antihistamine, given to prevent allergic reactions
  4. Solu-medrol (Methylprednisolone): (125 mg IV) Steroid given to patients with contrast allergy
See: Pepine, Chapter on "Cath Techniques..." & Yaniga, chapter on premedications

707. In the EP lab the most sensitive parameter to monitor for over sedation is:

  1. BP
  2. Pulse rate
  3. O2 saturation
  4. Respiratory rate
  5. Eyelid twitch response
ANSWER: c. O2 saturation.

Patient monitoring during conscious sedation must be performed by a trained and licensed health care professional. This clinician must not be involved in the procedure, but should have primary responsibility of monitoring and attending to the patient. Equipment must be in place and organized for monitoring the patient's blood pressure, pulse, respiratory rate, level of consciousness, and, most important, the oxygen saturation with a pulse oximeter. The oxygen saturation is the most sensitive parameter affected during increased levels of conscious sedation. Vital signs and other pertinent recordings must be monitored before the start of the administration of medications, and then at a minimum of every five minutes thereafter until the procedure is completed. After the procedure has been completed, monitoring should continue every 15 minutes for the first hour after the last dose of medication(s) was administered. After the first hour, monitoring can continue as needed. Use as little sedation as possible as too much suppresses the arrhythmia you are trying to induce.
See: Sedation - Conscious

778. On this 56 year old patient with documented SVT, what type of conduction occurs post AEST?

EP Exam Review Ques. 707 - What type of conduction occurs poat AEST?
  1. VERP
  2. AERP
  3. Jump w/ Echo
  4. AVN ERP
ANSWER: d. AVN ERP

AV node effective refractory period. The physician is pacing the atrium via the CS catheter. Typically if a HRA (High right atrial) catheter is used, it would be used to pace the atrium; however, the physician was not getting reliable capture when pacing, so instead of adjusting the catheter they used the CS instead. We are definitely capturing the atrium, as you see by the pacing spike with an A wave following; however, there is no H or V wave to follow. The point at which the PAC (S2 after an 8 beat drive train) was so early that is was no longer able to conduct through the AV node to the V is the AV node ERP.

881. When delivering RF ablation energy what is a "pop"?

  1. Steam formation at catheter tip
  2. Coagulum formation at catheter tip
  3. Microbubble formation, seen on echo
  4. Short circuit between RF generator and catheter tip

ANSWER: a. Steam formation at catheter tip.

"Higher power can be used with convective cooling, but higher power can cause superheating within the tissue (with subendocardial tissue temperatures exceeding 100°C), which can result in boiling of any liquids under the electrode. Consequently, evaporation and rapid steam expansion can occur intramurally, and a gas bubble can develop in the tissue under the electrode. Continuous application of RF energy causes the bubble to expand and its pressure to increase, which can lead to eruption of the gas bubble (causing a popping sound) through the path with the least mechanical resistance, leaving behind a gaping hole (the so-called pop lesion). This is often toward the heat-damaged endocardial surface (crater formation) or, more rarely, across the myocardial wall (myocardial rupture). This is often associated with sudden impedance rise and catheter dislodgment and can cause significant tissue damage." See Issa, chapter on "Ablation Energy Sources"

900. The Lariat, Watchman and Amplatzer are devices used in atrial fibrillation patients to:

EP Exam Review - Ques. 900 - The Lariat, Watchman and Amplatzer are devices used in atrial fibrillation patients to:
  1. Ablate the Pulmonary veins and reduce AF
  2. Cardiovert AF to increase CO and reduce risk of stroke
  3. Ablate AV node to reduce risk of rapid ventricular response
  4. Occlude the left atrial appendage and reduce risk of stroke

ANSWER: d. Occlude the left atrial appendage and reduce risk of stroke.

All of these devices cut off blood flow into the LA appendage, which is the major source of blood clots leading to stroke in patients with atrial fibrillation. These procedures are an alternative to troublesome blood thinners, such as Coumadin.

Two catheters are used, one transseptal into the LA and LA appendage; a second catheter is inserted subxyphoid into the pericardial space. Each catheter has a maget on the end, so they can be hooked together. A magnet on the LA appendage catheter tip is inserted into the tip of the appendage. The epicardial catheter is guided in the pericardial space towards the LA appendage. When close, the two catheters are attracted together, with the tip of the LA appendage between them.

A proximal balloon is inflated in the appendage, and the pericardial catheter advances a snare over the two magnets and around the balloon. The snare is tightened around the balloon closing the ostium of the atrial appendage. The balloon is deflated and the magnet catheter withdrawn into thw sheath. A suture cutting attachment from the pericardial sheath then cuts the long suture leaving the tightened snare to close the appendage.

A video showing Lariat closure: Two appendage occlusion devices are also available, for LA appendage closure from the inside; the WATCHMAN Left Atrial Appendage System and AMPLATZER® Cardiac Plug shown.

913. From the EGM and X-ray shown below, what type of ablation is being performed?

EP Exam Review - Ques. 913 - EGM
  1. AVNRT
  2. Transseptal AVRT
  3. Retrograde AV node
  4. RVOT VT

ANSWER: c. Retrograde AV node.

1st notice the His signal on the ABL, D catheter. 2nd notice that the ablation catheter coming from above, not from the same place as the RVa catheter. The RVA is coming up from the IVC, whereas you can see the ablation coming up the AO and down through the AO valve. The ABL catheter is clearly not going across the septum. This is referred to as the retrograde approach. For AV node ablations you like to see a good His signal. Most of the time this is accomplished on the Rt side of the heart, but in a few cases after extensive mapping and/or ablation the physician may have to ablate from the Lt side.

In AVNRT you do not want to see the His on the ABL catheter, because this means that you are damaging the fast pathway and are near the His rather than the slow pathway. This would lead to CHB if ablation was applied.

EP Exam Review - Ques. 913 - Xray

Murgatroyd says, "Catheter ablation of the AV node, to cause complete AV block, is chiefly used in patients with permanent atrial fibrillation and poorly controlled ventricular rates. The principal goal is an improvement in quality of life due to a reduction in tachycardia-related symptoms, but a hemodynamic improvement may also occur. A successful result eliminates the need for antiarrhythmic drugs, but creates life-long pacemaker dependence. The procedure is therefore best suited to older patients, for whom it is a simple treatment, necessitating a very brief hospital stay, with an excellent outcome. Conversely, it is generally considered a treatment of last resort in younger patients."

"A location is sought where the atrial and ventricular electrograms are of comparable amplitude, and the His potential is just visible. If the ablation is performed in AF, it is sometimes not possible to identify the His electrogram, and anatomical landmarks are instead used. Allowance must also be made for the lower amplitude of atrial electrograms in AF compared with sinus rhythm. The anatomy of the AV node varies considerably between patients. Even at the successful site, complete heart block may take 10 to 20 seconds or more of RF energy to occur. If energy delivery at the location described is unsuccessful, a more aggressive approach may be necessary, aiming nearer the His bundle itself. Occasionally, it is necessary to ablate the His bundle from the left side, using a retrograde approach."

928. This diagram shows paced atrial and ventricular electrograms. Match the name of each refractory period to its number.

EP Exam Review - Ques. 928 - This diagram shows paced atrial and ventricular electrograms.
  1. Follows V pace, prevents QRS and T wave sensing in atrium ___________
  2. Follows A pace, Limits the maximum upper rate __________
  3. Follows A pace, prevents inappropriate inhibition of the ventricular system by the atrial system ________
  4. Follows V pace, Prevents T wave sensing in ventricle _______
  1. Post Ventricular Atrial Ref. Pd. (PVARP)
  2. Ventricular Refractory Period (VRP)
  3. Ventricular Blanking Period (VBP)
  4. Total Atrial Refractory Period (TARP)

CORRECTLY MATCHED ANSWERS

  1. 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.
    a. Post Ventricular Atrial Ref. Pd. (PVARP)
  2. 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.
    d. Total Atrial Refractory Period (TARP)
  3. Follows A pace, prevents inappropriate inhibition of the ventricular system by the atrial system.
    c. Ventricular Blanking Period (VBP)
  4. Follows V pace, Prevents T wave sensing in ventricle.
    b. Ventricular Refractory Period (VRP)
See: Moses, chapter on "Types of Pacemakers and Hemodynamics of Pacing"

942. Which physiologic pacemaker mode is rate- responsive with a sensed "P" wave preceding each ventricular artifact (spike)?

EP Exam Review Ques. 942 - Which physiologic pacemaker mode is rate- responsive…?
  1. AAI
  2. VDD
  3. VAI
  4. DDI

ANSWER: b. VDD, or VAT is an atrial triggered Ventricular pacer.

It replaces the AV node and provides a physiologic rate responsive pacing. This pacer requires 2 leads, one sensor in the atrium and another pacing lead in the ventricle. A sensed P wave triggers an AV delay and QRS sensor. If no intrinsic QRS is sensed within the programmed AV delay the ventricular pacer fires at it's low rate interval. The upper rate interval shown is the maximum rate the pacer will track the P waves. Above that URL the pacer Wenckebachs and refuses to pace the ventricles any faster. For rate-responsive pacing, the NBG pacer code must be either T or D to indicate that triggering is present. The sensed or paced atrial wave must trigger the ventricular pacer to fire after an appropriate AV delay.

See: Underhill, chapter on "Pacemakers."

992. This patient with a DDD pacemaker occasionally feels very tired. Judging from the ECG strip with annotations what could be wrong with the pacer?

EP Exam Review - Ques. 992 - This patient with a DDD pacemaker occasionally feels very tired. Judging from the ECG strip with annotations what could be wrong with the pacer?
  1. Ventricular undersensing
  2. Ventricular oversensing
  3. Magnet mode AV sequential pacing
  4. Occasional loss of ventricular capture

ANSWER d. Occasional loss of ventricular capture.

Complex #2 and #5 show ventricular pacing spikes (VP), with no resulting QRS complex. This indicates occasional loss of capture. The atrial spikes capture the atrium each time as noted by the p waves following the atrial pacer spikes (AP). Complexes 3, 6 and 8 indicate ventricular sensing of the patients intrinsic QRS (VS). Try increasing the ventricular pacer output or pulse width, possible insulation break.

See: Medtronic, The ECG Workbook

1022. CRT pacemakers are usually programmed to:

  1. Pace 100% of the time
  2. Pace during tachycardia (ATP)
  3. Pace when CHF is detected
  4. Synchronize atrial & ventricular pacing
  5. Pace whenever BBB is detected

ANSWER a. Pace 100% of the time.

Fogoros says, "CRT pacemakers have three pacing leads instead of two; A right atrial lead, a right ventricular lead, and a left ventricular lead. They work similarly to DDD pacemakers except for two things. First, with CRT pacing both ventricles are paced instead of just the right ventricle. Second, birventricular pacing itself, rather than rate support, is the primary desired therapy - CRT pacemakers are this programmed to pace virtually 100% of the time, under all conditions."

See: Fogoros chapter on Cardiac Resynchronization

 

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