IBHRE CEPS Exam Study Guide: Key Concepts and Answers, Exams of Advanced Education

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Ohm's law equation - ✔✔✔ - V=IR EKG monitored patient should be __________, monitor chassis should be ___________ (nonconductive). Why - ✔✔✔ - ungrounded, grounded. Grounded patient would be able to conduct leakage currents. we dont want this lb to kg - ✔✔✔ - 2.2 lb = 1 kg F to C - ✔✔✔ - C=5/9(F-32) C to F - ✔✔✔ - F=9/5C+ 3 things that change automaticity of automatic cells - ✔✔✔ - 1. slope of phase 4

2. Change of threshold potential
3. Change of resting membrane potential a systole is represented by what portion of the ECG - ✔✔✔ - QT interval What is main ion transfer during systole - ✔✔✔ - K+ seeps out, Ca2+ enters At rest, what is intracellular/extracellular environment - ✔✔✔ - inside negative, outside positive

What phase of AP is resting membrane potential - ✔✔✔ - phase 4 Nodal depolarization occurs via what channel - ✔✔✔ - Ca2+ slow channel Cardiac muscle cell depol occurs via what channel - ✔✔✔ - Na+ fast channel During which phases is cell refractory - ✔✔✔ - 1,2, TDP caused by what mechanism usually - ✔✔✔ - EAD's (triggered activity) Variance - ✔✔✔ - Take each number in sample, subtract each number from mean, square each difference, add all, divide sum by number in sample - 1 Standard deviation - ✔✔✔ - square root of variance P value - ✔✔✔ - Probability of certainty / smaller p value means the more likely the result could not occur by chance survival curve showing % of patients surviving treatment over time - ✔✔✔ - Kaplan - Meier curves when measuring EGM's, earliest atrial activation usually from _____ and earliest ventricular usually from ______ - ✔✔✔ - P wave / QRS Morady maneuver is used to differentiate - ✔✔✔ - differentiate AT from AVNRT/AVRT

Most common arrhythmia - ✔✔✔ - AF Most common SVT - ✔✔✔ - AVNRT What type of single use devices can be resterilized and why? - ✔✔✔ - Diagnostic EP electrodes because lumen and technically not a catheter because no lumen Fr to mm - ✔✔✔ - 1 Fr = .33 mm Tip inner diameter standard diagnostic cardiac catheters and why - ✔✔✔ - .038 inch / because it is supposed to be used with .035-.038 inch guide wires What is 2 rules for CMC's like spiral or lasso - ✔✔✔ - 1. Only approved for use in LA due to chordae tendinea

2. Only rotate shaft clockwise Stereotaxis catheters - ✔✔✔ - Have magnets in tip for maneuverability in response to changes in magnetic field What system remotely steers guided catheters - ✔✔✔ - Hansen robotic system ACT for using array - ✔✔✔ - ACT 250- 300 bipolar cardiac electrodes record local _________ that occur during phase _______ - ✔✔✔ - depolarizations / phase 0

surface EKG leads usually filtered at what - ✔✔✔ - .1 - 100 Hz Normal EGM filter settings - ✔✔✔ - 30 - 300 Hz What to do if T waves interfere with A/V and why - ✔✔✔ - Increase the high pass filter because T waves are lower frequency as well as far field Unipolar filter setting - ✔✔✔ - .05 - 300 Hz How each is measured: Diagnostic catheter OD , Inflated balloon cath OD, Needle OD, Guide wire - ✔✔✔ - Diag: Fr / Balloon: mm / Needle: gauge / GW: inch (thousandth of inches) Standard sizes of micropuncture introducer sets and their purpose - ✔✔✔ - 21 gauge needle / .018 inch wire. Purpose of micropuncture introducer set is for placement of .035-.038 inch GW Best needle to use for pericardial space via subxyphoid approach - ✔✔✔ - Tuohy needle which type of guide wire is 260- 300 cm long? - ✔✔✔ - exchange guide wires (much longer than diagnostic catheter) advantage of bipolar leads - ✔✔✔ - less prone to EMI noise Unipolar leads more prone to - ✔✔✔ - 1. EMI / muscle artifact oversensing

2. pectoralis muscle stimulation (pocket stim)

Steroid tip leads reduce acute: - ✔✔✔ - inflammation and stimulation threshold Best numbers for ventricular lead - ✔✔✔ - Threshold <1 V / Sensing >4 mV programmed stimulation - ✔✔✔ - Consists of incremental pacing and extrastimuli Sharp, curved GW used to go transseptal - ✔✔✔ - SafeSept Guidewire Baylis NRG RF Transseptal needle has - ✔✔✔ - Side holes for pressure and contrast Ultrasound transducers are composed of - ✔✔✔ - Piezoelectric crystals How do ultrasound transducers work - ✔✔✔ - Transducers convert one form of energy into another. Ultrasound transducers convert electric signals into ultrasonic energy. The ultrasonic energy is transmitted into tissues, bounces back and then is converted back to electric energy doppler transducer uses what - ✔✔✔ - single piezoelectric crystal that sends and receives In cardiovascular doppler, what is target off of which ultrasound waves are reflected back - ✔✔✔ - RBC's ICE advantage over TEE - ✔✔✔ - General anesthesia not needed for ICE What is used to visualize shunts or distinguish right from left chamber - ✔✔✔ - Agitated saline

Where does conductive heating occur - ✔✔✔ - 2 - 5 mm beneath electrode typical lesion size of 7 Fr 4 mm dry tip - ✔✔✔ - 5 - 6 mm wide / 2-3 mm deep What to do when using irrigated ablation catheter at more than 30 W and why - ✔✔✔ - increase flow rate to 15-30 ml/min to avoid char formation What happens to pump when coming on ablation - ✔✔✔ - increases flow (8-30 ml/min) Never do what with cryoballoon - ✔✔✔ - never pull balloon sheath of catheter, only pull it back onto shaft / dont pull back while frozen Inner/outer diameter of FlexCath - ✔✔✔ - 12 Fr/15 Fr Cryomapping performed at what specs? - ✔✔✔ - - 30 C for <60s Adherence to tissue with cryocath is indicated by - ✔✔✔ - distal electrode electrical noise The worm like muscle strands within the RV chamber are termed? - ✔✔✔ - Trabeculae carnea Diaphragmatic surface of LV is - ✔✔✔ - inferior wall Infundibulum - ✔✔✔ - AKA Conus arteriosus / outflow track of RV (RVOT) inferior to the pulmonary valve

occlusion of dominant coronary arteries most likely leads to - ✔✔✔ - AV Block VOM location - ✔✔✔ - Branch of CS anterior to LPV's Left coronary blood flow occurs during what and why - ✔✔✔ - diastole because diastole releases compressed endocardial capillaries Where does delay occur in AVN - ✔✔✔ - upper region (AN-N) Where are baroreceptors located? - ✔✔✔ - carotid sinus and aortic arch neurotransmitter at parasympathetic nerve junctions - ✔✔✔ - acetylcholine Carotid sinus massage - ✔✔✔ - - chronotropic effect inspiration results in - ✔✔✔ - increased heart rate and RV stroke volume, increased venous return, decreased intracardiac pressure vascular resistance occurs at - ✔✔✔ - arterioles where is blood flow slowest - ✔✔✔ - capillaries vessels with greatest cross-sectional area - ✔✔✔ - capillaries

largest mean blood pressure drop occurs where - ✔✔✔ - arterioles Which vessels store largest volume of blood - ✔✔✔ - systemic veins which vessels have most smooth muscle - ✔✔✔ - large arteries fastest blood flow - ✔✔✔ - aorta lowest blood pressure - ✔✔✔ - SVC / IVC dicrotic notch - ✔✔✔ - marks beginning of LV diastole arterial pulse pressure - ✔✔✔ - the difference between systolic and diastolic blood pressure % of filling volume from different methods - ✔✔✔ - rapid diastolic filling (suction cup) = 60% Diastasis (passive filling) = 25% Atrial kick (active filling) = 15-20% second heart sound - ✔✔✔ - closure of semilunar valves first heart sound - ✔✔✔ - closing of AV valves third heart sound - ✔✔✔ - soft, low-pitched ventricular filling sound that occurs in early diastole and may be an early sign of heart failure

Fourth heart sound (S4) - ✔✔✔ - very soft, low-pitched ventricular filling sound that occurs in late diastole SV equations - ✔✔✔ - SV = CO/HR SV= EDV - ESV CO equation - ✔✔✔ - CO = HR x SV BP equation - ✔✔✔ - BP = CO x SVR EF equation - ✔✔✔ - EF = SV/EDV Most important measure of LV function - ✔✔✔ - EF Preload - ✔✔✔ - end diastolic filling or stretching of ventricles. Increased preload means increase SV Preload occurs during - ✔✔✔ - V diastole What increases cardiac filling pressure (CVP) - ✔✔✔ - 1. calf muscle contraction

2. sympathetic vasomotor activity
3. exercise ANYTHING that increase venous return and thus increases preload

Inotropism - ✔✔✔ - intrinsic ability of heart to contract with particular intensity Afterload - ✔✔✔ - The force or resistance against which the heart pumps (force opposing ejection of blood). Increased afterload will decrease CO athletes lower heart rate due to - ✔✔✔ - intrinsic decreased SAN rate Peak exercise, why BP doesnt significantly elevate even though CO may increase 7 fold? - ✔✔✔

• decreased systemic VR holding pressure: venous vs arterial sheath removal - ✔✔✔ - Venous: on the site / Arterial: just above Order of pulling sheaths - ✔✔✔ - should pull arterial, hold pressure, then pull venous (Kern) ACT when pulling - ✔✔✔ - should be less than 160 SVC obstruction usually caused by - ✔✔✔ - indwelling pacer leads (can sometimes see obstruction when shooting contrast) SVC obstruction treatment - ✔✔✔ - stents When does pericardial effusion become tamponade? - ✔✔✔ - When cardiac compression begins. The pericardial pressure equals RA and RV diastolic filling pressure. RV preload fails due to inability to fill which causes LV preload and SV to drop.

Patient position for pericardiocentesis - ✔✔✔ - Propped to 45 degrees to allow for effusion to pool in more anterior/inferior portion of heart Beck's Triad - ✔✔✔ - Acute signs of tamponade (hypotension, distended neck veins, distant heart sounds) Loculated definition - ✔✔✔ - Means effusion is in small compartments (localized to certain area in the heart) What will be seen when pericardiocentesis needle touches epicardium - ✔✔✔ - ST elevation Common complication with high femoral artery punctures - ✔✔✔ - Retroperitoneal hemorrhage or bleeding into the belly 6 P's of acute arterial occlusion - ✔✔✔ - 1. Pain

2. Pulseless
3. Paralysis
4. Paraesthesia (numbness)
5. Polar (coldness)
6. Pallor Most common chamber of perforation in right/left heart cath - ✔✔✔ - RV To rule out pneumothorax, it is most important to order a ____ - ✔✔✔ - PA and lateral chest x- ray

2 most common complications during PVI procedures - ✔✔✔ - 1. PV stenosis

2. Cardiac tamponade 2 things to monitor to prevent phrenic nerve damage - ✔✔✔ - 1. pacing phrenic
3. observe inhalation on fluoro (if one side stops moving=bad) asymptomatic phrenic nerve damage can be seen with - ✔✔✔ - hemidiaphragm on x-ray (half of diaphragm is elevated) main thing to watch for when using irrigated catheter with CHF patients/dialysis patients - ✔✔✔ - hypervolemia Instructions to patient after femoral artery puncture - ✔✔✔ - 1. Keep head down
4. hold puncture site when coughing
5. keep leg straight
6. stay in bed
7. drink fluids
8. call nurse if symptoms most common complication of uncontrolled hypertension - ✔✔✔ - cerebral hemorrhage each small box on y axis of EKG is how many mV - ✔✔✔ - 1 box = 0.1 mV 1 cm =? mV - ✔✔✔ - 1 cm = 1 mV

1 small box on EKG is how many ms/ seconds - ✔✔✔ - 40 ms / .04 s each small box on EKG is how big - ✔✔✔ - 1 mm When is ST depression significant? - ✔✔✔ - >1 mm from baseline in V5, V6 / >1.5 mm in aVF or III EKG characteristic most associated with transmural MI - ✔✔✔ - pathalogic Q waves When do pathalogic Q waves appear on MI patient - ✔✔✔ - in the first day of MI First sign of acute injury to myocardium - ✔✔✔ - ST elevation significant Q waves - ✔✔✔ - Represent a TRANSMURAL infarction (>1/3 height of QRS and

.04 sec wide (1 small box)) T wave depression - ✔✔✔ - ischemia T wave elevation/broadening - ✔✔✔ - hyperacute ischemia ST elevation - ✔✔✔ - injury EKG changes with myocardial ischemia - ✔✔✔ - Inverted T / ST depression

Bazett's formula - ✔✔✔ - corrected QT = QT/Square root of RR interval // it is used to correct for patients heart rate because QT becomes shorter at faster rates Normal QTc value - ✔✔✔ - <450 ms Long vs short QT with calcium - ✔✔✔ - Long QT = hypocalcemia short QT = hypercalcemia What landmark is used to find 2nd intercostal space - ✔✔✔ - angle of Louis (junction of manubrium and sternum - bump) how many electrodes for 12 lead EKG - ✔✔✔ - 10: RA, LA, RL, LL, V1-V Wandering baseline on EKG - ✔✔✔ - usually due to muscle tremor (patient movement) and not due to other issues like electrical notch filter - ✔✔✔ - used to filter AC (60 Hz) interference / on EKG without notch, it can look like vibrating baseline non compensatory pause vs compensatory - ✔✔✔ - non: PAC's due to resetting of SAN / comp: PVC's causing refractory AVN with following P wave not conducting leads I and III during appropriate Bi-V pacing and why - ✔✔✔ - because Bi-V pacing simultaneously conducts straight upward, I will be small/isoelectric and III will be negative. LV pacing only I and III - ✔✔✔ - I is negative and III is positive (LV pacing looks like an LV PVC with a RBBB pattern)

Earliest phase of infarction - ✔✔✔ - Seen by tall upright T waves ("hyperacute T waves") What is reciprocal ekg changes in STEMI? - ✔✔✔ - leads that face the wall opposite to the MI will start have ST depression while the ones on the wall of MI will usually have ST elevation what best diagnoses a posterior acute MI and why - ✔✔✔ - V1-V4 ST segment depression (utilizing reciprocal changes) due to the fact that there are no EKG leads on the back to show ST elevation Best leads to look at for LV acute MI (septal, anterior, lateral, posterior, inferior) - ✔✔✔ - Septal: V1, V Anterior: V3, V Lateral: 1, aVL Posterior: V1-V4 (reciprocal changes) Inferior: II, III, aVF What to administer during cardiac arrest and why - ✔✔✔ - - Should administer epinephrine every 3-5 minutes

• increases BP (is a strong vasoconstrictor) and CO
• enhances defib
• increases myocardial and cerebral blood flow ACLS definition - ✔✔✔ - advanced cardiac life support first medication given to all ACLS patients - ✔✔✔ - Oxygen

Electrical cardioversion is contraindicated in what patients - ✔✔✔ - - hypokalemia (makes them arrhythmia prone)

• Digitalis toxicity
• presence of atrial thrombus Coagulum - ✔✔✔ - - Denatured protein from boiled blood
• when blood at surface of tissue/electrode interface begins to boil at 100 C, this causes coagulum formation
• rapid rise in impedance Typical settings for ablating AP with a 4 mm dry tip - ✔✔✔ - 30 W / 60 degrees C
• usually creates a lesion 4-5 mm deep
• prevents excessive heating and usually uses a temperature controlled setting Thermal latency - ✔✔✔ - deep tissue temps continue to rise for several seconds after RF energy has stopped (conductive heating still occurring even though resistive heating has stopped) Most of the lesion is due to what and why is this important - ✔✔✔ - - conductive heating 2- 5 mm below surface
• important because it means we have to ablate for at least 30-60 seconds to allow for conductive heating to form a full lesion The main factor opposing RF heating is what - ✔✔✔ - - convective cooling (heat loss) to surrounding blood

what phase is the beginning of Ventricular diastole - ✔✔✔ - isovolumetric relaxation isovolumetric relaxation - ✔✔✔ - - Ventricles relax (no change in volume)

• Ventricular pressure becomes < aortic pressure = semilunar valves shut
• 2nd heart sound occurs in this phase (closing of semilunar valves)
• dicrotic notch occurs
• beginning of V Diastole
• all valves closed
• once V pressure is less than atrial, AV valves open and passive filling occurs (end of isovolumetric relaxation) Pericardium - ✔✔✔ - - visceral pericardium is layer closest to heart
• pericardial fluid is in between the visceral and parietal pericardium.
• the fibrous pericardium is the most outer layer on top of the parietal pericardium
• serous pericardium: visceral and parietal PVC common characteristics - ✔✔✔ - Wide (>120 ms) with bizarre shaped, opposite direction T waves TDP rates - ✔✔✔ - 200 - 250 bpm LV PVC's - ✔✔✔ - - more likely to precipitate VF
• more often associated with heart disease PEA - ✔✔✔ - - pulseless electrical activity

• organized cardiac electrical depolarizations with no mechanical contraction
• EKG usually looks like bradycardia but no pulse is detected
• most commonly caused by hypovolemia
• can be corrected by fluid administration Most common form of idiopathic VT in patients with no structural heart disease is - ✔✔✔ - RVOT VT OT VT mechanism - ✔✔✔ - cAMP mediated DAD's (triggered activity) RVOT VT EKG - ✔✔✔ - - LBBB appearance
• monomorphic
• usually non-sustained
• inferior axis
• precordial transition occurs AFTER lead V3 (usually in V4) Long QT / AV block - ✔✔✔ - - long QT = increased refractory period of ventricular tissue
• this can cause functional block between his bundle and ventricular tissue due to increased refractoriness
• can lead to 2:1 block and severe bradycardia main cause of BB reentry VT - ✔✔✔ - dilated cardiomyopathy (SHD) VF provides no - ✔✔✔ - no pulse or cardiac output, patient is clinically dead

% of pathways that are bidirectional - ✔✔✔ - 60% Main EKG difference: AVNRT vs ORT - ✔✔✔ - - ORT usually always has distinct P waves after the QRS due to sequential ventricular-atrial activation

• AVNRT usually does not have distinct P waves due to simultaneous A/V contraction Slanted AP's - ✔✔✔ - - when pacing from different sites, the orientation of the fibers of the AP can lead to different VA or AV times at certain points Verapamil drug class - ✔✔✔ - Class IV Fentanyl antagonist - ✔✔✔ - Naloxone Fentanyl use during procedure - ✔✔✔ - pain relief Propofol - ✔✔✔ - anesthetic, sedative Versed use anesthesia - ✔✔✔ - relieve anxiety, drowsiness Verapamil sensitive fascicular VT - ✔✔✔ - - Verapamil used to treat it
• Most common Idiopathic LV VT
• Reentry
• RBBB
• Left axis deviation
• usually posterior fascicle

• Blood pressure ranges - ✔✔✔ - Systolic- less than
• Diastolic- less than
• When is BP considered hypotension - ✔✔✔ - Systolic: <
• Diastolic: <
• When is BP considered hypertension - ✔✔✔ - Systolic: >
• Diastolic: >