IBHRE PRACTICE TEST LATEST TEST | ALL QUESTIONS AND CORRECT ANSWERS | ALREADY GRADED A+, Exams of Engineering

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IBHRE PRACTICE TEST LATEST TEST | ALL QUESTIONS AND CORRECT ANSWERS | ALREADY GRADED A+ | VERIFIED ANSWERS | JUST RELEASED What has NOT been used as ERI magnet response? ------CORRECT ANSWER---------------Abrupt decrease in rate What has NOT been used as an indicator of battery depletion? ------ CORRECT ANSWER---------------Pulse width stretching The term virtual electrode describes? ------CORRECT ANSWER--------------- The lead electrode and surrounding myocardium The energy delivered by an icd is based on the relationship between what? ------CORRECT ANSWER---------------Initial voltage and final voltage on a capacitor The horizontal asymptote of a strength duration curve is termed: ------ CORRECT ANSWER---------------Rheobase Over time, the battery cell impedance of a lithium iodine powered pacemaker does what? ------CORRECT ANSWER---------------Remains constant Tapping on a pulse generator with which type of sensor will increase the pacing rate? ------CORRECT ANSWER---------------Piezoelectric activity A MDT style 3.2mm low profile lead with no sealing rings and a long pin fits appropriately with which header? ------CORRECT ANSWER---------------VS- 1 B (sealing rings in header) DBS (Drawn Brazed Strand) is a term associated with: ------CORRECT ANSWER---------------Silver & nickel alloy conductor material A likely benefit but possible concern of a ventricular detection enhancement such as "stability" would be best described as what? ------CORRECT ANSWER---------------Increase the specificity but decrease the sensitivity In order to charge a capacitor, and ICD must provide current of approximately: ------CORRECT ANSWER---------------2 amps The cardioinhibitory response to carotid massage may be manifested by? -- ----CORRECT ANSWER---------------Advanced AV block Sinus Brady PR prolongation What type of patient would benefit most from a feature like rate drop response? ------CORRECT ANSWER---------------Carotid sinus hypersensitivity Early results have shown which of the following categories of CHF patients to benefit from BiV pacing? ------CORRECT ANSWER---------------NYHA class III with BBB What potential pacemaker/defibrillator interaction can result in defibrillator inhibition in a patient implanted with both? ------CORRECT ANSWER-------- -------Pacemaker failure to sense VF When defibrillating a pacemaker patient, the defibrillator pass should be positioned how? ------CORRECT ANSWER---------------Anterior/ posterior What drug is known to increase chronic pacing thresholds and decrease chronic defibrillation thresholds? ------CORRECT ANSWER--------------- Sotalol What drug increases DFT thresholds but decrease action potential duration and refractory periods? ------CORRECT ANSWER---------------Lidocaine Which of the following is NOT a class I or II indication for ICD implantation? -VT not due to reversible cause - severe symptoms,attributed to VT while waiting for transplant - incessant VT - nonsustained VT, prior MI, +EP stufy ------CORRECT ANSWER------------- --Nonsustained VT, prior MI, +EP study On the radiodensity scale what would appear the most radiolicent? ------ CORRECT ANSWER---------------Air If one doubles the distance away from the radiation source, the exposure level is ____ compared to original? ------CORRECT ANSWER--------------- 1/4 less What lead insulation materials are known for reducing fibroblast in growth and susceptibility to MIO and ESC? ------CORRECT ANSWER--------------- ePTFE and 80A polyurethane What are the two most common causes of ventricular safety pacing ? ------ CORRECT ANSWER---------------Ventricular ectopy and loss of atrial sensing What electrode material would most likely result in higher pacing thresholds and high polarization? ------CORRECT ANSWER---------------Elgiloy Which phase of the action potential would correlate to the relative refractory period? ------CORRECT ANSWER---------------Phase 3 The ventricoloatrial conduction time of a pacemaker patient with a typical endless loop tachycardia may be calculated by what equation? ------ CORRECT ANSWER---------------None What parameter would not be useful to prevent typical crosstalk? ------ CORRECT ANSWER---------------Safety pacing What conductor technology combines a silver core with a high strength metal (MP35N0) to obtain a strong low resistance wire? ------CORRECT ANSWER---------------DFT Which of the current ICD capacitor technologies provide the highest energy density and does not require reform? ------CORRECT ANSWER--------------- Tantalum electrolytic For treatment of arrhythmias, most drugs work by ? ------CORRECT ANSWER---------------Altering conductivity or refractoriness What battery discharge curve shape does a lithium silver vanadium oxide battery make ? ------CORRECT ANSWER---------------Two humps 1.67 Hz would equal how many bum? ------CORRECT ANSWER-------------- -100 bpm T wave frequencies are typically ? ------CORRECT ANSWER--------------- Low What is the electrical circuit that converts a signal with both positive and negative components into a signal with only one component ? ------ CORRECT ANSWER---------------Rectifier If one has the physiologic substrate for reentry which of the following would be necessary to intiate the reentry tachycardia ? ------CORRECT ANSWER---------------Unidirectional block of one pathway Which of the following sensing related parameters represents the maximal rate of change of the electrical potential between the sensing electrode and is the first derivative of the egm? ------CORRECT ANSWER--------------- Slew rate Real time measured telemetry yields a bipolar impedance reading of 100ohms and a unipolar reading of 450 ohms, which of the following is most likely concerning the lead ? ------CORRECT ANSWER--------------- Coaxial design The isovolumetric time from electrical depolarization of the heart to mechanical systole describes which of the following terms ? ------ CORRECT ANSWER---------------Pre ejection interval The basic unit of capacitance is called? ------CORRECT ANSWER------------ ---Farad The term S2 refers to the ? ------CORRECT ANSWER---------------First premature stimulus The wedensky effect may be greatest, reaching clinical significance with threshold testing at which of the following parameters? ------CORRECT ANSWER---------------Short pulse widths What test is typically performed during exercise with heart rates in the range of 105-110bpm and was shown to have a negative predictive value in the MADIT II and SCD-HeFT type patients ? ------CORRECT ANSWER-- -------------Microvolt t wave alternans Faster and longer range telemetry, new therapies and physiologic sensors in pacemakers requires higher peak power outside the range of Li/I2 batteries. Which of the following battery chemistires Is now incorporated into some pacemakers? ------CORRECT ANSWER---------------Lithium silver vanadium oxide and lithium carbon monofluoride Which of the following tests is performed over 10-20 beats following a PVC and whose absence is a predictor of cardiac mortality following an MI? ------ CORRECT ANSWER---------------Heart rate turbulence What current ICD capacitor technologies provide the highest energy density and does not require reformation? ------CORRECT ANSWER--------- ------Tantalum Electrolytic 1.67 Hz would equal how many bpm? ------CORRECT ANSWER-------------- -100 bpm 1 bpm = 0.0166667 Hz Which pace/sense lead designs would one expect the highest current density w/ a bipolar impedance reading of 1100 ohms? ------CORRECT ANSWER---------------Brady lead w/ anode of 4.2 mm2 and cathode 5.2 mm2 What is the voltage measurement of a pacing system w/ impedance of 500 ohms, current of 5.0 milliamp and pulse width of 0.4 ms and rate of 60 bpm? ------CORRECT ANSWER---------------V = 2.5 V V=I x R = 5.0 milliamps x 500 ohms = 2,500 millivolts =2,500/1000 What condition is shown to have an increase stimulation threshold, wide QRS, latency, or under sensing? ------CORRECT ANSWER--------------- Hyperkalemia (high potassium) What is the estimated battery longevity of a pacemaker with 1.0 amp-hour battery and 20 microamp drain ? ------CORRECT ANSWER--------------- Longevity = 114 x (amp-hours/microamp drain) = 114 x (1.0/20) = 5.7 years Which sensing related parameter represents the maximal rate of change of the electrical potential between the sensing electrode and is the first derivative of the electrogram? ------CORRECT ANSWER---------------Slew rate The isovolumetric time from electrical depolarization of the heart to mechanical systole describes what term? ------CORRECT ANSWER--------- ------Pre-ejection interval Most commonly utilized battery in current ICDs? ------CORRECT ANSWER---------------Lithium silver vanadium oxide What does one French size equal in mm? ------CORRECT ANSWER--------- ------0.3mm What drug will increase DFT within 2 days? ------CORRECT ANSWER------- --------Flecainide What drug might be given to reduce pacing thresholds? ------CORRECT ANSWER---------------Isoproterenol IV Which pacing indication would most likely use Rate drop response, sudden Brady response or rate hysteresis? ------CORRECT ANSWER--------------- Carotid sinus hypersensitivity What was a secondary endpoint finding CTOPP and MOST studies comparing atrial vs ventricle pacing? ------CORRECT ANSWER--------------- Reduced onset of AF Patient with long QT getting ICD. What drug should be avoided due to increased risk of Torsades De Pointes ------CORRECT ANSWER------------- --Erythromycin What drug may reduce digoxin clearance by 30% resulting in the need to reduce digoxin dose and retitrate based on serum levels? ------CORRECT ANSWER---------------Amiodarone What drug may significantly lower myocardial stimulation thresholds? ------ CORRECT ANSWER---------------Verapamil Proper lead position in a child who has undergone a Fontan procedure? ---- --CORRECT ANSWER---------------Epicardial V lead, with subsequent transvenous A lead What causes cardiac C fibers in patients exhibiting vasodepressor syncope? ------CORRECT ANSWER---------------Vigorous squeezing of relatively empty ventricles Approximate infection rate of CRTD implant in a normal healthy male? ------ CORRECT ANSWER---------------2-4% Lead extraction morbidity and mortality rate? ------CORRECT ANSWER----- ----------1-3% What is the normal range of PCWP? ------CORRECT ANSWER--------------- 4-12 mm/Hg What is the most dangerous interaction between RF ablation and pacemakers? ------CORRECT ANSWER---------------Runaway pacing Most common reason for ICD classify false VT/VF? ------CORRECT ANSWER---------------EMI Which of the following is a Class III indication for ICD implant? - VT not due to reversible cause - severely symptomatic VT while patient awaits transplant - Incessant VT - NSVT, previous MI, positive EP Study ------CORRECT ANSWER------------ ---VT not due to reversible cause An EP takes a retrospective look at 360 consecutive ICD patients to gather data one his patient survival statistic. It uncovers one pharmacological factor was linked to better patient survival, what is it ? ------CORRECT ANSWER---------------Beta blocker therapy What may likely occur as a result of reversing the distal and proximal shock coils in the header of an integrated defibrillator system? ------CORRECT ANSWER---------------May result in change of therapy efficacy and oversensing What is the goal of optimizing via echo for AV delay and ventricular synchrony? ------CORRECT ANSWER---------------E and A waves separating with the end of diastole coinciding with beginning of systole What lab finding indicates HF exasperation? ------CORRECT ANSWER----- ----------Elevated BMP The horizontal asymptote of a strength duration curve defines which of the following? ------CORRECT ANSWER---------------Rheobase Match the unit: watt-second ------CORRECT ANSWER---------------Energy This test has been used as a tool for assessing autonomic modulation of the sinus node. This parameter decreases in heart failure patients as a result of down regulation of beta receptors? ------CORRECT ANSWER------ ---------Heart rate variability Normal ejection fractions are in which of th following ranges ? ------ CORRECT ANSWER---------------50-65% Which of the following pacemaker components is most susceptible to cumulative damage from high doses of radiation? ------CORRECT ANSWER---------------CMOS (the circuitry) Which of the following studies using an end point of total mortality looked at rate vs rhythm control and concluded rate control with anti coagulation was as effective ? ------CORRECT ANSWER---------------AFFIRM Defibrillation energies exceed pacing energies by a factor ? ------ CORRECT ANSWER---------------1,000,000 A band pass filter modifies incoming signals according to which of the following units of measure ? ------CORRECT ANSWER---------------Hertz Which of the following pacing modalities has been shown to reduce p wave amplitudes and has also shown beneficial effects in patients with intraatrial conduction delays and atrial tachyarrhythmias ? ------CORRECT ANSWER- --------------Bachmans bundle pacing Which of the following uses the same MICS and might cause long range interference with CRM device remote monitoring ? ------CORRECT ANSWER---------------Weather balloons Upper arm movement interference is a sensor driven idiosyncrasy linked to transthoracic impedance measurement in which of these ? ------CORRECT ANSWER---------------Minute ventilation AV block occurs in approximately what % of congenital open heart surgeries ? ------CORRECT ANSWER---------------1-3% In order to have a pacing system automatically assess capture and stimulation thresholds, the essential electrode characteristics would be? ---- --CORRECT ANSWER---------------Minimal electrode after potential characteristics An IS-1 bipolar lead is compatible with which of the following connector blocks? ------CORRECT ANSWER---------------VS-1A long cavity with no sealing rings, IS-1 unipolar connector block, VS-1B long cavity with sealing rings In a normal person, stroke volume increases by what % when exercising ? ------CORRECT ANSWER---------------50% Which of the following EMI sources has recently been implicated in causing over sensing and telemetry interference in pacemakers ? ------CORRECT ANSWER---------------IPODS/MP3 players/headphones A surface electrode is placed over conducting tissues. What does the ECG look like when the depolarization is directly below/under the electrode ? ---- --CORRECT ANSWER---------------No waveform deflection The arithmetic difference etween the rate of events in the experimental and control groups is best described by the term ? ------CORRECT ANSWER--- ------------Absolute risk reduction Which of the following values would most likely indicate nearing ERI in the lithium iodide pacemaker ? ------CORRECT ANSWER---------------5000 ohms Which of the following is most likely to trigger the EOL in an ICD? ------ CORRECT ANSWER---------------Capacitors charging In a circuit with resistance of 500ohms and 600ohms in parallel, the circuit resistance would be ? ------CORRECT ANSWER---------------273 ohms First or second degree AV block with symptoms suggestive of pacemaker syndrom is which of the following indications ? ------CORRECT ANSWER--- ------------Class IIa During the late stages of expertise test on a treadmill, a symptomatic pt demonstrates both mobitz 1 and intermittent mobitz 2 blocks. What should be done next for this pt? ------CORRECT ANSWER---------------Implant a pacemaker A patient is having an ICD battery change and the physician notices an insulation problem on the sense/pace portion of the lead.he puts in a new lead and hooks it into the pace/sense portion of the ICD. During DFT testing there is a loud pop in the pocket. What can one expect to find ? ----- -CORRECT ANSWER---------------Low HV impedance During an implant the physician suspects that he has perforated the RV and the retracts and repositions the lead. Which of the following clinical sequela and test combinations would be the most common clinical outcome and desirable test for monitoring this patient with an acute RV perforation ? ------CORRECT ANSWER---------------No clinical sequela, echocardiogram During ICD testing the introducer guide wire is inadvertently left in position in the RA. The result could be ? ------CORRECT ANSWER---------------Non conversion of VF A young boy has congenital CHB. What factor would be considered most important for him to receive a pacemaker ? ------CORRECT ANSWER------- --------A wide qrs with mild ventricular dysfunction Which of the following would be the drug of choice in terminating an SVT of 200bpm in a 35 year old patient ? ------CORRECT ANSWER--------------- Adenosine A 65yo pt experiences syncope and wrecks his car while turning his head to make a sharp right turn. Further follow up yields a 3.1 second pause during carotid sinus massage in the absence of cardioinhibatory medications. This hx would fall under which can of the following pacing indications ? ------CORRECT ANSWER---------------Class 1 Which of the following is the most likely indication for a pacemaker in a pt following an orthotropic heart transplant ? ------CORRECT ANSWER--------- ------Chronotropic incompetence Which of the following was a secondary endpoint finding of the CTOPP and MOST studies comparing atrial and versus ventricular based pacing ? ------ CORRECT ANSWER---------------Reduced onset of AF An elderly woman had been taking the following meds: lasix and maxide. Her son wanted to save money on his mothers meds so he had her double up on the lasix and stops the maxide. Ten days later his mother died. One possible cause of her death could be ? ------CORRECT ANSWER------------- --Loss of potassium led to ventricular arrhythmias A pt with long QT is scheduled for an ICD. Which of the following drugs should be avoided due to an increased risk for torsades de pointes? ------ CORRECT ANSWER---------------Erhythromycin A 28 yo presents with orthostatic hypotension and 3 episodes of sudden syncope I the last 3 months. A routine physical exam, blood work and ECG reveal no abnormalities. What test might be recommended to determine the cause of syncope ? ------CORRECT ANSWER---------------Tilt table test A pt presents with pulse less arrest. Which of the following energies should be utilized for a monophasic AED when multiple shocks are required? ------ CORRECT ANSWER---------------360-360-360J Which of the following drugs would have the least analgesic effect? ------ CORRECT ANSWER---------------Midazolam iatrogenic CHB occurs in aproximately _________ % of patients undergoing ablation of the slow pathway for AV nodal reentry tachycardiaR? ------CORRECT ANSWER---------------1% Which of the following risk factors would carry the highest risk for infection? ------CORRECT ANSWER---------------Long term immunosuppresive therapy What drug may reduce digoxin clearance by 30% resulting in the need to reduce digoxin dose and retitrate based on serum level determinations? ---- --CORRECT ANSWER---------------Amiodarone Each of the following limited sensitivity diagnostic tools has been shown to be a positive predictor for increased risk of sudden cardiac death except ? - -----CORRECT ANSWER---------------P wave dispersion A device pt has a known allergy to penicillin. Which of the following antibiotics would stand the best chance of the pt not having an allergic to ? ------CORRECT ANSWER---------------Azithromycin Which of the following drugs is noticed for both reducing DFT thresholds and has th side effects of torsades de pointes due to lengthening of the qt interval ? ------CORRECT ANSWER---------------Chagas' disease What is the approximate infection rate of a CRTD implant in an otherwise normal healthy male? ------CORRECT ANSWER---------------0.5-1.5% The most frequent adverse effects of this drug, which may be used at implant are respiratory depression, bradycardia and hypotension? ------ CORRECT ANSWER---------------100mcg fentanyl Which of the following low molecular weight heparin drugs might be implicated in a large hematoma post device implant ? ------CORRECT ANSWER---------------Enoxaparin Lead extraction morbidity and mortality is in the following range nationally? ------CORRECT ANSWER---------------1-3% A 95yo has a ppm change out. The next day it's realized that the ventricular lead should have been replaced as well so the doc wants to bring the pt back for a new lead. The pt states he doesn't want to have the procedure. Which of the following factors is preeminent in deciding whether the procedure is performed? ------CORRECT ANSWER---------------The informed consent of the patient A 5 yo child requires a better change for an epicardial/unipolar single chamber, abdominal system that was implanted 3 years earlier. Which of the following would be most preferable at the time of change out in the majority of patients ? ------CORRECT ANSWER---------------Upgrade to a bipolar endocardial dual chamber pectoral position A pregnant woman is undergoing a pacemaker implant. What would be most protective for the baby? ------CORRECT ANSWER---------------Shield with lead There is a 4 he CRT case with a very obese patient. The doctor has to warn the pt about the symptoms he may experience from the amount of radiation he received from the fluoro. What would be the likely symptom? -- ----CORRECT ANSWER---------------Redness and skin peeling on back With which of the following would one expect the highest infection rate ? --- ---CORRECT ANSWER---------------ICD change out A patient is allergic to ampicillin and is now going to receive vancomycin 20mg/kg IV. When should the vancomycin be administered in relation to the device implant? ------CORRECT ANSWER---------------Within 2 hours of the initial incision Which of the following therapies should be in place, immediately following complete A-V nodal ablation for uncontrolled a fib? ------CORRECT ANSWER---------------Pacing 90bpm, warfarin Which of the following is the most common cause of sudden cardiac death in the young ? ------CORRECT ANSWER---------------Hypertrophic cardiomyopathy If you were to see a lead protruding out of the skin what should be done first ? ------CORRECT ANSWER---------------Blood and generator pocket cultures Which of the following is considered a class II indication for lead removal ? ------CORRECT ANSWER---------------Nonfunctional leads in a young patient Which of the following most commonly results from a stenosed subclavian following a left sided implant ? ------CORRECT ANSWER---------------No symptoms During a generator change out the physician uses the electrocautery and a fire breaks out. What was the most likely cause ? ------CORRECT ANSWER---------------Oxygen build up under tented drapes A pt is given midazolam (1-4mg) for a conscious sedation of a device implant. During the case the pt stops breathing. The circulation nurse performs a chin thrust to open the airway. The pH is 7.2, pO2 68mmHg, and HCO3 24mEq/L. What should be done next? ------CORRECT ANSWER---------------Use a mask with valve and begin to bag Which of the following parameters would one likely program to correct inappropriate mode switching due to Fairfield sensing during the PVARP? - -----CORRECT ANSWER---------------Increase PVAB Which of the following would most commonly account for a failure to mode switch in the presence of atrial flutter ? ------CORRECT ANSWER------------- --Atrial blanking An active fixation ventricular lead placement results in significant current of injury with ST segment elevation of 6mV and an increase in the ventricular EGM by 80ms. Thirty seconds post lead fixation R waves measure 8mV and the stimulation threshold measures 1.5V. Which course of action is best advised for acceptable lead parameters ? ------CORRECT ANSWER--- ------------Current lead position is good Characteristics of AV desynchronization arrhythmia (also called repetitive non-reentrant VA synchrony ) include? ------CORRECT ANSWER------------- --Retrograde conduction, functional nonsensical and functionalnoncaoture What was used as a primary endpoint in the CTOPP trial ? ------CORRECT ANSWER---------------Cardiovascular death or stroke Increase optvol and decreased TI would indicate ? ------CORRECT ANSWER---------------Pt is going into acute CHF Multiple different daily recorded p waves may be explained by ? ------ CORRECT ANSWER---------------The development of paroxysmal AF A pt's weight goes up and activity level goes down what should be done ? - -----CORRECT ANSWER---------------Increase the patients diuretics Which of the following has been the most dangerous device interaction between RF ablation and pacemakers ? ------CORRECT ANSWER----------- ----Runaway pacing A pt recently implanted with a pacemaker comes into follow up complaining of palpitations at rest . After 10 minutes the pt sensor rate is about 100bpm. What programming parameter change is indicated ? ------CORRECT ANSWER---------------Sensors threshed What is the most optimal programming for a pt withCHB not receiving cardioinhibitory meds? ------CORRECT ANSWER---------------DDD 60, 150ms AV, circadian rate 50bpm What is most optimal programming programming for a pt with neurocardogenic syncope and no cardio inhibitory meds? ------CORRECT ANSWER---------------DDD, 100bpm, 250ms AV, rate hysteresis 40ppm What is the most optimal programming for a 56yo NYHC III pt with a LBBB on cardioinhibitory meds ? ------CORRECT ANSWER---------------DDDR, 60ppm, 125ms AV, MTR 150pppm, pvarp off What implantable device has not reported an interaction with MRI that can directly affect the patients health ? ------CORRECT ANSWER--------------- Implantable loop recorder Which of the following is more likely to occur in a unipolar versus bipolar pacing system ? ------CORRECT ANSWER---------------Far fields sensing, pocket stimulation, double counting with some diagnostics and monitoring equipment A pacemaker follow up clinic reports that it is seeing a consistent decline in p wave amplitudes at their patients post implant check as compared to the measured p wages at implant. This decline can be attributed to ? ------ CORRECT ANSWER---------------Inflammatory response at the lesd/tissue interface Which of the following programming avail abilities would be the most desirable when implanting an epicardial pacemaker in an 18 month old with congenital heart block? ------CORRECT ANSWER---------------Base rate 110, dynamic PVARP & AV, high output A pt underwent high dose radiation therapy without taking device precautions. The device is not capturing now, what should be done ? ------ CORRECT ANSWER---------------Replace the device A DDD programmed pt presents with VVI pacing at 65bpm. What would be the best way to determine if the device is at ERI or in power on reset mode ? ------CORRECT ANSWER---------------Battery voltage reading Approximately what % of sinus node disease patients develop AV block? -- ----CORRECT ANSWER---------------1-1.5%/year A 25 year old idiopathic cardiomyopathy patient, with an EF of 15% is implanted with an ICD. At the time of implant, there is a concern that he may be too unstable to tolerate DFT testing. An advantage of performing the DFT testing would be? ------CORRECT ANSWER---------------check integrity of the system, check lead connections, confirm adequate VF sensing Optimal biphasic shocks for patients with higher DFTs tend to have which of the following polarity and waveform characteristics? ------CORRECT ANSWER---------------RV (+) and phase 1 1.5-2x's longer than the 2nd Which of the following would NOT be a reason for utilizing a single coil versus dual coil tachycardia pacing lead in a child? ------CORRECT ANSWER---------------programmable vectors Which of the following factors tend to be the most common denominator as to whether or not there are EMI/device interactions? ------CORRECT ANSWER---------------distance from the EMI The SCD-HeFT trial showed a clinically and statistically significant benefit for which of the following? ------CORRECT ANSWER---------------ICDs in heart failure patients with EF's <35% Which of the following conclusions most closely correlates with the findings from MADIT-RIT ? ------CORRECT ANSWER---------------program a rate cutoff of 200bpm or therapy delay of 60s At implant a patient receives two 31 J shocks that both fail. Of the choices listed which should be tried next? ------CORRECT ANSWER--------------- change shock waveform if programmable Three primary prevention trials in post-infarction patients showing reduced mortality with ICD mortality of 54%m 55% and 31% respectively? ------ CORRECT ANSWER---------------MADIT, MUSTT, MADIT II While reviewing a patients chart prior to an ICD implant, you discover from the patients history that the referring physician had noted that the patient had exhibited Ashmans phenomenona. Which discriminator would best address this? ------CORRECT ANSWER---------------stability A patient is implanted with an ICD that is programmed to deliver shocks with a fixed pulse width waveform. At implant the high voltage impedance is measured and found to be 35 ohms. At a follow up visit 6 months later the impedance has increased to 50ohms. Based on this information you would expect the? ------CORRECT ANSWER---------------tilt to decrease Which of the following ICD patients would tend to have the lowest DFT? ---- --CORRECT ANSWER---------------very distal RV coil positioning A pt with a hx of being resuscitated from sudden cardiac death a few years earlier. Her idiopathic VT/VF episodes, some treated and some not, have been increasing in frequency, VT/AF triggers have been multifocal in origin. What should be done next? ------CORRECT ANSWER---------------send her to a VT ablation specialist Which of the following findings was a result of the MADITT II trial? ------ CORRECT ANSWER---------------ICDs reduced mortality by 31% in this pt population Which of the following might be considered both a benefit and possible adverse reaction antiarrhythmic drugs in an ICD patient? ------CORRECT ANSWER---------------Increased VT cycle length Which of the following statements is most consistent with the AHA guidelines for driving with an ICD post cardiac arrest? ------CORRECT ANSWER---------------patients can begin driving after being shock-free for 6 months Which of the following factors is most crucial in influencing the probabilistic nature nature of DFTs? ------CORRECT ANSWER---------------the degree of tissue refractoriness with shock delivery Which of the following is a class 3 indication for ICD implantation? ------ CORRECT ANSWER---------------incessant VT Why are higher outputs advantageous for ATP vs. bradycardia pacing? ----- -CORRECT ANSWER---------------the excitable gap can incorporate tissue that is in relative refractory that may capture at a higher output Which of the following might one expect from a pneumothorax resulting from a right subclavian stick? ------CORRECT ANSWER---------------a mediastinal shift to the left with an increase in intrathoracic impedance Studies have shown which of the following V-V intervals to most likely be optimal in the majority of patients when the LV lead is place lateral or posterolateral? ------CORRECT ANSWER---------------LV first by 5 to 30 ms Which of the following statements is true concerning optimization of the AV delay for ventricular resynchronization? ------CORRECT ANSWER------------ ---E & A wave-separation with the end of diastole coinciding with the beginning of systole Which of the following PVARP programmings would be most beneficial for biventricular pacing for heart failure in a pt with VA conduction of 200msec? ------CORRECT ANSWER---------------250ms Biventricular pacing has seen a resurgence of which of the following complications? ------CORRECT ANSWER---------------Lead dislodgements & extra cardiac stimulation In the ACC and AHA guidelines for the four stages of heart failure, which of the stages is defined as: pt at high risk for development of heart failure but has no apparent structural abnormality of the heart? ------CORRECT ANSWER---------------Stage A Which of the following findings would most likely indicate heart failure? ------ CORRECT ANSWER---------------BNP 700pg/ml Which of the following heart failure approved drugs have shown an increased survival & EF? ------CORRECT ANSWER---------------carvedilol and metoprolol Which of the following hemodynamic effects would most likely result from too long an AV delay in a pt being paced for cardiac resynchronization ? --- ---CORRECT ANSWER---------------decrease CO & increase MR Which of the following heart sounds is produced by rapid passive filling of a distended or non-compliant LV? ------CORRECT ANSWER---------------S3 A pt with a hx of renal failure and diabetes has to undergo a BiV ICD implant. The physician wants to inject contrast ti visualize to the coronary sinus and its tributaries. Which of the following drug options would be most helpful? ------CORRECT ANSWER---------------N-acetylcysteine A 47yo CRT pt is beginning to experience some frequent bouts of typical atrial flutter with a rapid ventricular response. Which of the following choices would be the next best course of action? ------CORRECT ANSWER---------------An AV nodal ablation Approximately what percentage of CRT patients, are non-responders? ------ CORRECT ANSWER---------------30% Which of the following would lead one to believe that a patient is having VT and not an SVT with a LBBB? ------CORRECT ANSWER---------------V1-V6 are negative Name three causes of atrial standstill ------CORRECT ANSWER--------------- Myocardial Infarction Digitalis glycosides Hyperkalemia A 59 yo female with ischemic cardiomyopathy presents with palpitations, lightheadedness, insomnia and feels jittery. She has a CRT-D device. Takes Furosemide, potassium, lisinopril, carvedilol and amiodarone. Seeing short runs of VT on her device interrogation. ------CORRECT ANSWER---------------Hyperthyroidism What would be your best next step for ordering tests? ------CORRECT ANSWER---------------Thyroid panel Which antiarrhythmic drug is least likely to increase defibrillation thresholds? ------CORRECT ANSWER---------------Sotalol is least likely to increase defibrillation thresholds and may in fact decrease it. In contrast all other drugs mentioned are likely to INCREASE defibrillation thresholds, which is why DFT testing is sometimes performed on patients newly started on other drugs (Flecainide, Verapamil, Amiodarone, Mexiletine). Coexisting illnesses like diabetes Periprocedural issues (including the failure to administer properly timed pre op antimicrobial prophylaxis Device or lead revision (2-4x higher vs. initial implant) The amount of indwelling hardware (number of leads) and operator experience. ------CORRECT ANSWER---------------Therapeutic dose low molecular weight heparin (LMWH) is associated with a substantial risk for perioperative bleeding and hematoma formation. In contrast, it has been shown to be much less in patients on Vitamin K antagonists such as warfarin even at therapeutic doses. Many operators now recommend uninterrupted warfarin therapy perioperatively especially for patients at high risk for thromboembolic events. Ibuprofen is associated with low risk, while aspirin and clopidogrel have an increased risk, but nowhere near as high as LMWH. How is energy consumption of the device calculated? What is Ohm's law? ------CORRECT ANSWER---------------Energy = V x I x t (V = volts, I = current, t = time) V = IR E = V2 x t/R (R = resistance) Which bacteria is most likely to cause post op infection? ------CORRECT ANSWER---------------Staphylococcus infection is responsible for 80% of all device infections. Infections months afterward is due to Staphylococcus epidermis. Acute, purulent device infections are usually caused by S. aureus. LV pacing is most often associated with what? ------CORRECT ANSWER--- ------------LV pacing is most often associated with a RBBB pattern since the depolarization starts in the LV and arrives late in the RV. Stimulation of the RV apex and RV free wall will have what pattern? ------ CORRECT ANSWER---------------Stimulation of the RV apex and RV free wall will have a LBBB pattern. The RVOT has an inferior axis and LBBB pattern. Which leads on the ECG represent the septum? ------CORRECT ANSWER---------------leads V1 and V2 What factors result in a positive CRT response? ------CORRECT ANSWER- --------------Wide QRS width (especially when combined with LBBB morphology) Female Gender Non ischemic cardiomyopathy as the underlying pathology of heart failure. Less consistently echo signs of dyssnychrony were found to predict response. What is associated with less favorable response to CRT? ------CORRECT ANSWER---------------Coronary artery disease Think presence of ischemic cardiomyopathy as the cause of decreased LV function is clearly associated with a less favorable response to CRT (especially regarding LV reverse remodeling). This is likely due to irreversible myocardial scarring. Which leads represent the lateral wall? ------CORRECT ANSWER------------- --Lead 1, AVL, V5 and V6 represent the lateral wall. Which study investigated the efficacy of a single burst of ATP (8 pulses, 88% cycle length) in VT and fast VT? ------CORRECT ANSWER--------------- The PainFREE and the PainFREE II. The success rate was 85% and 72%. Acceleration of VT's by a burst of ATP were rarely observed. Based on this data at least one burst of ATP before or during charging should be programmed in virtually all patients. Dependent patients ------CORRECT ANSWER---------------Switch to asynchronous pacing in order to prevent oversensing from both electrocautery and device manipulation. Application of only short bursts of electrocautery or using a bipolar cautery system will reduce the risk of over sensing. Activity sensor should be turned off (for all patients) in order to minimize inappropriate increases in heart rate due to device manipulation. Placement of transthoracic pacing pads. Bipolar (NOT UNIPOLAR) pacing configurations should be used when possible, as once the generator is out of the pocket there is no longer a pacing circuit and loss of capture resulting in asystole in a pacemaker dependent patient. Electrical pairs ------CORRECT ANSWER---------------Joule - Energy Coulomb - charge Watt - Power Henry - inductance Insulation defects in patients is most consistent with? ------CORRECT ANSWER---------------Extracardiac stimulation - in patients with insulation defects, shunting from the conductor to extracardiac tissue occurs, which may result in loss of capture (especially in unipolar systems). Current drain is high and lead impedance is low. As a result of the insulation break, stimulation of extracardiac muscle may occur (depending on the localization of the defect). The surface ECG usually shows a large pace artifact in unipolar systems and also in bipolar systems with an outer insulation defect. What is the purpose of the reed switch? ------CORRECT ANSWER----------- ----To close when a magnet is placed over it. This is a mechanical magnetic switch. All new devices use a Hall effect sensor to replace the reed switch. What is the most significant limitation of single pass dual-chamber leads? -- ----CORRECT ANSWER---------------Allows only atrial sensing High impedance electrodes meet delivered pacing energy requirements because of which of the following? ------CORRECT ANSWER--------------- High impedance leads were designed with a small pacing surface area which creates a high charge density at the tip for efficient use of the battery. This charge concentration also increases polarization at the tip. What is the most common reason for syncope in young adults? ------ CORRECT ANSWER---------------The most common reason for syncope is vasovagal in nature, neurocardiogenic reflex is the correct answer. What is non-ischemic ------CORRECT ANSWER---------------Non-Ischemic cardiomyopathy is a generic term which includes all causes of decreased heart function. other than those caused by heart attacks or blockages in the arteries of the heart. • The most common causes of non-ischemic cardiomyopathy are viral infection (viral myocarditis), drug. What is COPD? ------CORRECT ANSWER---------------Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. What is the best option for a patient with a poor EF, large left atrium with a lot of mitral regurgitation? ------CORRECT ANSWER---------------Think patient not likely to maintain sinus rhythm with medication or AF ablation. Rate smoothing is not going to do anything due to the rapid native rates. The best option if patient already has a CRT device is ablation of the AV node. Will lead to significant functional improvement due to 100% CRT pacing, as well as prevent ICD therapies being delivered due to atrial fibrillation and rapid ventricular response. Cardiac Tamponade ------CORRECT ANSWER---------------Think compression on the heart. Cant pump out oxygen to the body. Sac around heart fills with blood. Look for drop in oxygen saturation levels and uneven QRS complexes. Pericardial sac creates pressure on heart, effecting cardiac output. Think low oxygen out to the body. This sac is like a water bed which limits friction as the heart contracts. Restlessness, dizziness (syncope), fatigue and tachycardia are all signs of low cardiac output. Body compensating for reduced oxygen. Think BEC (Beck's Triad) B - Big jugular veins distension (JVD) E - Extreme Low BP (Hypotension) C - Can't hear heart sounds (muffled) Pulses paradoxes (Blood pressure gets pushed lower) Systolic drop by 10 mmHg upon respiration. Narrowed pulse pressure. 120/80-40 pulse pressure 100/90-10 pulse pressure Think DROWNED D - Distended jugular veins R - Respiratory tract and lungs clear O - Oxygen Saturation Low W - Weak rapid pulses (thready pulses) N - No pulse (death is a complication) E - ECG QRS complexes short and even D - Decreased cardiac output During implantation of a pacemaker as the pocket is about to be closed, a fire erupts during the use of electrocautery. Which of the following is the most likely cause? ------CORRECT ANSWER---------------Oxygen pooling under a drape that is tented over the patient. Total pacing impedance is a function of which of the following? ------ CORRECT ANSWER---------------Conductor Resistance (low) Electrode Resistance (Moderate to high) Polarization Impedance that occurs at the tissue interface (low or high depending on lead design and output) Pacing leads with a short distance between the cathode and anode are most likely to reduce which of the following clinical phenomena? ------ CORRECT ANSWER---------------Sensing of the ventricular electrogram on the atrial lead Far field sensing of the ventricular EGM on the atrial channel is a frequent problem. By using a short dipole (think distance between cathode and anode) on the atrial lead, the amplitude of the far-field signal is decreased, reducing the problem of atrial oversensing of the ventricle. When using automated capture verification algorithms, the most significant difficulty is caused by? ------CORRECT ANSWER---------------Polarization forces Since most capture verification algorithms use the evoked response after a pacing pulse to determine if capture has occurred or not. Think polarization is essentially noise, making it more difficult for the device to detect actual cardiac signals it is looking for. High polarization leads are generally not suitable for systems using this type of capture confirmation algorithm. Diurnal variation refers to changes during the day with waking and sleeping. They are managed by the automatic threshold determination as are changes due to lead maturation and drug induced threshold changes. In a patient with left bundle branch block (LBBB) which of the ICD detection features is most helpful in differentiating VT from Sinus Tachycardia? ------ CORRECT ANSWER---------------Dual chamber detection algorithm The presence of VA dissociation is one of the best criteria for determining whether a fast rhythm is VT or SVT, therefore dual chamber detection algorithms are the best. Template based morphology can be fooled by? ------CORRECT ANSWER-- -------------Wide complex tachycardia seen with VT. During automatic threshold testing, oversensing of the evoked response is most likely to cause which of the following? ------CORRECT ANSWER------- --------Loss of capture Which of the following best describes the function of the DDIR mode compared with the VVIR mode during an episode atrial fibrillation? ------ CORRECT ANSWER---------------There is no difference between the DDIR mode and VVIR mode Describe upper limit of vulnerability (ULV) testing ------CORRECT ANSWER---------------upper limit of vulnerability (ULV) testing is an alternative method to determine defib threshold during ICD implant. It used the lowest energy for a shock on T-wave that still induces VF. Patient with post ICD pocket hematoma took no meds before procedure but he received a single dose of an oral drug 12 hours ago. Which was most likely administered? ------CORRECT ANSWER---------------Clopidogrel is a potent anti-platelet drug, more effective than aspirin. Warfarin takes several days to have an effect, and erythromycin and acetaminophen don't affect clotting in any significant way. Name the three categories of blood thinners ------CORRECT ANSWER------ ---------Anti platelets Anti Coagulants Thrombolytics How many categories of antiplatelets? ------CORRECT ANSWER------------- --Cox-1 inhibitor PDE3 inhibitors ADP (P2Y) receptor antagonists Glycoprotein IIb/IIIa receptor antagonists Thrombin (PAR-1) Receptor Antagonists A patient with AF with RVR could be given what? ------CORRECT ANSWER---------------Carvedilol could be increased. The AV node needs to be blocked down either pharmacologically or by performing an AV node ablation. Mode switching in response to paroxysmal tachyarrhythmia is possible during which of the following types of pacing? ------CORRECT ANSWER---- ----------- SIR stands for what? ------CORRECT ANSWER---------------Sensor indicated Rate Extended Max tracking rate and shorten PVARP in order to allow higher rates and prevent the loss of P-wave tracking from happening Integrated bipolar RV leads are more prone to what? ------CORRECT ANSWER---------------Integrated bipolar systems are more prone to oversensing of myopotentials. Especially of the diaphragm and in the context of long R-R intervals where the automatic gain control algorithm becomes very sensitive to even very small signals. The sensing vector is between RV tip to an distal RV-coil as opposed to a true bipolar lead that uses the tip to a small anode ring. If patient episodes occurred during workouts at the gym and the RV pace inhibition was not reproducible by arm maneuvers, makes myopotential the more likely explanation. Anode is negative or positive? ------CORRECT ANSWER---------------Anode is positive Cathode is negative or positive? ------CORRECT ANSWER--------------- Cathode is negative In a unipolar pacing system what is the anode? ------CORRECT ANSWER-- -------------The can is the anode in unipolar pacing system (Think positive) In a unipolar pacing system the lead tip is what? ------CORRECT ANSWER---------------The lead tip in the cathode (think negative) in a unipolar pacing system. Pacing occurs when what? ------CORRECT ANSWER---------------Pacing occurs when a potential difference (Voltage) is applied between 2 electrodes. Electron flow: Anode (+ positive pole) to cathode (-negative pole) Think positive to negative flow of electrons Bipolar pacing is what? ------CORRECT ANSWER---------------Bipolar pacing: electrons flow from proximal ring (+anode) to lead tip (-cathode); think minimizing stimulation artifact. Ventricular oversensing would lead to what? ------CORRECT ANSWER----- ----------Ventricular oversensing would lead to INHIBITION of pacing. During ventricular undersensing a pacemaker spike may follow shortly after QRS. Indicating the pacemaker has not sensed the preceding ventricular depolarization. There is no QRS complex following the pacing impulse because it has fallen into the absolute refractory period of the ventricle (also known as function non-capture). Atrial oversensing leads to what? ------CORRECT ANSWER--------------- Atrial oversensing would lead to an increase in ventricular pacing. Stimulation of the RV apex and RV free wall will have what pattern? ------ CORRECT ANSWER---------------Stimulation of the RV apex and RV free wall will have a LBBB pattern. LV pacing is most often associated with what pattern? ------CORRECT ANSWER---------------LV pacing is most often associated with a RBBB pattern since the depolarization starts in the LV and arrives late in the RV. What factors are predictive of a positive CRT therapy response? ------ CORRECT ANSWER---------------Wide QRS width (especially if combined with LBBB morphology), female gender and non-ischemic cardiomyopathy as the underlying pathology of heart failure. Presence of ISCHEMIC cardiomyopathy as the cause of the decreased LV function is clearly associated with less favorable response, especially regarding LV reverse remodeling This is likely due to the irreversible myocardial scarring. PainFREE and PainFREE II are associated with? ------CORRECT ANSWER---------------Data shows one burst of ATP before or during charging should be programmed in virtually all patients. Decreasing PVARP will not do what? ------CORRECT ANSWER--------------- Decreasing PVARP will not increase detection of atrial fibrillation, as events occurring during PVARP are already registered towards the mode switch count (although no AV delay is started during this period). Shortening the PVAB will potentially result in what? ------CORRECT ANSWER---------------Shortening the PVAB will potentially result in more atrial events not being blanked, which are counted toward mode switch. There are 2 kinds of inotropes: positive inotropes and negative inotropes. Positive inotropes strengthen the force of the heartbeat. Negative inotropes weaken the force of the heartbeat What is the underlying cause of vasovagal syncope? ------CORRECT ANSWER---------------Neurocardiogenic reflex Think the most common cause of syncope in young adults is vasovagal in nature. Name a low molecular weight heparin product? ------CORRECT ANSWER-- -------------Enoxaparin Think very high probability of bleeding and hematomas in patients undergoing procedures. Secundum atrial septal defect is a indication or contraindication for implantation of a transvenous pacemaker or ICD? ------CORRECT ANSWER---------------The main issue here is that of a potential shunt in a patient undergoing a device implant that would allow blood to go from the right side (pulmonic) circulation to the left side (systemic). An ASD could allow a clot that might develop on a pacing lead to go across to the left atrium and embolize to the brain or other organ. 6000 mGy is that point at which? ------CORRECT ANSWER--------------- Erythema may be expected as a result of radiation burn. Divide total by radiation level is 200 mGy/min / 6000 = 30 minutes If tracing shows both intermittent failure to output and failure to capture what is the most likely cause? ------CORRECT ANSWER---------------A fractured lead is the most likely cause. Polarization forces are essentially? ------CORRECT ANSWER--------------- Polarization forces are essentially noise making it difficult for the device to detect the actual cardiac signal it is looking for. High polarization leads are generally not suitable for systems using this type of capture confirmation algorithm. In a patient with LBBB which of the the ICD detection features is most helpful in differentiating VT from sinus tach? ------CORRECT ANSWER------ ---------Dual chamber detection algorithm Think presence of VA dissociation is one of the best criteria for determining whether a fast rhythm is VT or SVT. What approach does ULV (upper limit of vulnerability) testing use to determine DFT threshold? ------CORRECT ANSWER---------------It uses the lowest energy for a shock on T-wave that still induces VF. Is clopidogrel more or less effective than aspirin? ------CORRECT ANSWER---------------Clopidogrel is more effective than aspirin. Clopidogrel is a potent anti-platelet drug. Permanent pacemaker implantation is indicated for congenital third-degree AV block in the infant with a ventricular rate less than 55bpm or with congenital heart disease and a ventricular rate less than 70bpm ------ CORRECT ANSWER---------------This is class 1 indication for a pacemaker.