IBHRE Quizzes

8/17/2019 IBHRE Quizzes

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BRADY PACING TEST - #1

____1. Voltage is:

a. The electromotive force pushing on electrons

b.

Moving electronsc. The opposition to current flow

d. Current divided by resistance

____2. If the Pacemaker output voltage is 5v and the measured lead resistance is 330 ohms,

then the current that flows out of the pacemaker into the heart is:

a. 1.65 mA

b. 15.15 mA

c. 66 mAd. 10 mA

____3. If a unipolar lead wire has an insulation break one would expect the resistance to:

a. Stay the same

b. Risec.

Decrease

d. None of the above

____4. For a wire fracture the resistance:

a. Increases

b.

Decreasesc. Increases then decreases

d. Has no change

____5. If the output voltage of the pacemaker is programmed from 5 volts to 2.5 volts, the

energy delivered to the heart is:

a. Doubled

b. Halvedc. Quartered

d. Quadrupled

____6. Which of the following affect the longevity of the pacemaker?

a. Output voltage b. Resistance of lead

c. % pacing

d. All of the above


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Brady Pacing Test - #1

Page 2

____7. Which patient’s pacemaker will last the longest?

a. Patient #1 - AMP = 5v, L.R. = 90 BPM, Resistance - 500 !, PW = .5ms, 100% pacing

b. Patient #2 - AMP = 5v, L.R. = 60 BPM, Resistance - 500 !, PS = .5ms, 100% pacing

c.

Patient #3 - AMP = 2.5v, L.R. = 60 BPM, Resistance - 330!

, PW = .5ms, 100% pacing

d. Patient #4 - AMP = 2.5v, L.R. = 60 BPM, Resistance - 500 !, PW = .5ms, 50% pacing

____8. The strength duration curve is dependent on the

a. Cell’s membrane capacitance, intracellular and extracellular resistance and threshold

voltage

b. Size of the cellc. Nerve intervention

d. Mitochondria

____9. A pacemaker patient on Flecainide should:

a. Have their pulse width reduced

b. Have their threshold checked

c. Have their base rate loweredd. Have no change made to their parameters

____10. The acute threshold peaking is due to:

a. Trauma and inflammation

b. Fibrosis tissue capsule

c.

Changes in the patient’s electrolyte balanced. Appropriate pulse duration setting

____11. An advantage of bipolar leads is:

a. They are less susceptible to EMI

b. They cause muscle stimulationc. Smaller IPG cases

d. Diameter of lead is smaller

____12. The two parameters that are important for ventricular sensing and should be measured

are:

a. Level detection and amplitude

b. Reversion and R-wave

c. R-wave amplitude and slew rate

d. Acute threshold and amplitude


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Page 3

____13. If an external pacemaker is set to a sensitivity setting of 5mV and some R-waves gounsensed, then you should do the following:

a. Decrease the sensing to 7mV

b.

Increase the sensing to 10mVc. Increase sensing by lowering sensitivity # to 2.5mV

d. Move the sensitivity control to asynchronous

____14. Typical acceptable R-wave amplitude values for an acute ventricular lead is:

a. Less than 5mV b. Greater than 20mV

c. 2.5mV to 5mV

d. 7 - 15mV

____15.

Typical acceptable P-wave amplitude values for an acute atrial lead is:

a. Greater than 2mV b. Less than 1.5mV

c. Greater than 7mV

d. 4mV to 10mV

____16. The slew rate is:

a. Not important to measure because they are dependent on the patient’s heart

b. Change in voltage divided by time or the slope of the EGM

c.

Acceptable in the ventricle for


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Page 5

____25. Which of the following is/are NOT factor(s) which influence pacemaker longevity?

a. Output voltage

b.

Lead resistancec. Pulse duration

d. Blanking

____26. Cardiac stimulation thresholds are expressed in terms of:

a. Voltage b. Current

c. Energy

d. All of the above

____27.

Which of the following combinations of variables interact to determine stimulationthreshold?

a. Voltage and pulse width

b. Rate and sensitivity

c. Amplitude and rate

d. Energy and rate

____28. A pacemaker that paces and senses only in the ventricle and is inhibited by

spontaneous ventricular activity is designated:

a.

VAT b. VVTc. VVI

d. VDD

____29. As pulse duration is shortened below 0.3 msec., stimulation threshold increases as

described by all of the following, except:

a. Energy b. Charge

c. Volts

d.

Current

____30. Current pacemakers employ which of the following chemical batteries?

a. Lithium-iodide

b. Mercury-zinc

c. Nickel-cadmiumd. Nickel-cobalt


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Page 6

____31. All of the following functions are programmable in both VVI and DDD pacemakers,except:

a. AV interval duration

b.

Sensitivityc. Refractory

d. Output

____32. What is the initial voltage of a lithium battery?

a. 1.50V b. 2.50V

c. 2.78V

d. 5.0V

____33.

Which of the following is not an advantage of DDD pacemakers?

a. AV synchrony is maintained b. Two leads are required

c. There is a physiologic increase in heart rate

d. Minimum programmed heart rate is maintained

____34. For a voltage of 5V, resistance of 500 ohms and pulse width of .5ms, calculate the

energy delivered:

a. 25 joules

b.

.25 joulesc. 25 microjoulesd. None of the above

____35. Which of the following factors does not contribute to development of the pacemakersyndrome with ventricular pacing?

a. Loss of AV synchrony

b. Hysteresisc. Constant VA conduction

d. Inappropriate circulatory reflexes


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Page 7

____36. Pacemaker programmability allows which of the following?

a. Modifying pacemaker function in response to changing patient status

b.

Diagnosing pacemaker ECGsc. Prolongation of battery life

d. All of the above

____37. Which of the following statements is not true of rate-responsive ventricular

pacemakers that use a sensor other than the atrium?

a. They provide the capability of a heart rate increase despite sinus node dysfunction

b. They are potentially useful in patients with atrial arrhythmia’s

c. Retrograde conduction is a potential problem with this pacing moded. They maintain constant AV synchrony

____38. Characteristic findings in patients with the pacemaker syndrome include any of thefollowing except:

a. Pacing-induced hypotension

b. Symptoms of congestive heart failure

c. Febrile signs of pacemaker infectiond. Neurological symptoms

____39. For a patient with evidence of sinus node dysfunction and intermittent heart block,which of the following pacemakers would be inappropriate?

a. DDDR b. AAI

c. VVI

d. VVIR

____40. Which parameter provides the greatest safety when operating on the rheobase of the

strength duration curve?

a. PW

b. Sensitivity

c.

Refractoryd.

Voltage


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Page 8

____41. The specific intracardiac event sensed by pacemakers is termed:

a. Threshold

b. Intrinsic deflection

c.

Pulse widthd. Slew rate

____42. Setting a low pacing rate on a demand ventricular pacemaker may have all of thefollowing benefits except:

a. Allowing a patient with sinus rhythm to maintain AV synchrony for a significantamount of time

b. Prolonging the life of the pulse generator

c. Preventing angina in patients with coronary artery diseased. Allowing a lower output setting

____43. In a bipolar pacing ventricular pacemaker:

a. The cathode is in the heart and the anode is in a remote location

b. The anode is in the heart and the cathode is in a remote location

c. Both the anode and the cathode are in the heart

d. Neither the anode nor the cathode is in the heart


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Brady Pacing Test - #2 1


CIRCLE THE LETTER OF THE CORRECT ANSWER:

1. Which of the following programmable variables would not be useful in preventing pacemaker-mediated tachycardia?

a. Automatic atrial refractory extension after PVCs b. Atrial refractory period

c. Blanking period

d. Auto PVARP

2. Extending the post-ventricular atrial refractory period results in which of the following?

a. A narrowing of the Wenckebach window if upper rate limit is kept constant b. A lower upper rate tracking limit in devices with 2:1 block upper rate behavior

c. Prevention of PMT if the new post-ventricular atrial refractory period is longer

than the ventriculo-atrial (VA) conduction timed. All of the above

ANSWER TRUE OR FALSE TO QUESTIONS 3 AND 4:

3. Some DDD pulse generators treat the first and last halves of the AV delay period

differently. (Ventricular Safety Pacing VSP, Ventricular Safety Standby, Non-

physiologic AV delay) With respect to this feature, mark the following true or false.

a. The purpose of this function is prevention of crosstalk.

b. Ventricular sense events occurring during the last half of the AV delay

period are regarded as not resulting from normal conduction of the preceding atrial stimulus.

c. This function may be invoked by crosstalk.d. This function may be invoked by PVCs occurring in the first half of the

AV delay period.

e. When this function is invoked, pacing is characterized by a long AV

delay.

4. The ventricular channel of a DDD pacemaker has two refractory periods. Which of the

following are characteristic of the first ventricular refractory period or the “blanking” period?

a. It is present in every pacemaker cycle. b. It is usually 75 - 100 ms long.

c. It occurs coincident with an atrial stimulus.

d. It is used to prevent pacemaker-mediated tachycardia.

e. If it is too long, it may prevent the sensing of PVCs occurring in the AVinterval.

f. If it is too short it may allow crosstalk.

5. Two years after implant, the sensing characteristics of the QRS complex can beaccurately determined by analysis of:


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a. The surface ECG

b. The amplitude of the R wave measured during implant

c. The characteristics of the intracardiac electrogramd. The spontaneous cardiac rate

6. The stimulation threshold is a fixed value independent of :

a. Pulse width

b. Electrode surface area

c. Electrode lead impedanced. Voltage

e. Cardiac enlargement

7. What is the optimal mode of pacing for sinus node dysfunction with paroxysmal atrial

arrhythmias, compromised AV conduction and when the patient is on medication to

control the tachyarrhythmias?

a. AAIR

b. VVIR

c. DDDR with Mode Switchingd. DDIR

e. VDD

8. What is the optimal mode of pacing for sinus node dysfunction with paroxysmal atrial

arrhythmias, intact AV conduction and anticipate starting on antiarrhythmic drugs?

a. AAIR

b. VVIRc. DDDR with Mode Switching

d. DDIRe. VDD

9. What is the best mode of pacing for a 9 year old with congenital complete heart block,sinus rate 92 bpm?

a. AAIR b. VVIR

c. DDD with Mode Switching

d. DDIRe. VDD


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10. The purpose of the ventricular blanking period is to:

a. Prevent the ventricular sensing amplifier from sensing the far-field P wave b. Limit the maximal atrial rate which the pacemaker can track 1:1

c. Prevent the ventricular sensing amplifier from sensing the far-field atrial pacing

stimulusd. Prevent sensing of the T wavee. Prevent the inappropriate inhibition of ventricular pacing by environmental

electrical noise (EMI)

11. Non-physiologic AV delay pacing (AV pacing with an AV delay shorter than

programmed) results from:

a. Retrograde atrial conduction

b. Crosstalk (ventricular channel senses the atrial stimulus)

c. Cross stimulation (current passed down the ventricular electrode during atrial

stimulation)d. Undersensing

12. The rate of the pacemaker-mediated tachycardia is more likely to be equal to the uppertracking rate if:

a. The pacemaker upper rate behavior is Wenckebach b. It is initiated by pectoral muscle sensing rather than a PVC

c. The pacemaker’s upper rate behavior is 2:1 block

d. The retrograde conduction time is long

13. Which of the following have been proposed as a sensor for rate adaptive pacing?

a. Minute Ventilation b. QT interval

c. Body activity

d. Central O2saturation

e. All of the above

14. In which of the following situations might non-synchronous rate responsive pacing be preferred to DDD pacing?

a. Chronic atrial fibrillation b. Severe sinus bradycardia at rest and during exercisec. Sinus node dysfunction with frequent paroxysmal atrial tachyarrhthmias

d. All of the above


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15. The NBG code includes an indicator for the power source of the pacemaker.

a. True b. False

16. The third position of the NBG code indicates the presence of hysteresis in the pacemakerrate.

a. True

b. False

17. Pacemaker mediated tachycardia often require therapeutic intervention with drugs and

other modalities.

a. True

b. False

18. Most reported dual chamber malfunctions are not due to mechanical or electronic

pacemaker problems, but rather to errors of interpretations on the part of the observer.

a. True

b. False

19. Dual chamber pacemakers should not be considered in patients with a history of

paroxysmal atrial fibrillation.

a. True

b. False

20. All patients who require pacing except those with chronic atrial fibrillation, should have adual chamber system.

a. True b. False

21. All of the following are absolute contraindications to DDD pacing except:

a. Chronic atrial fib/flutter

b. Chronotropic incompetencec. Retrograde atrial conductiond. Rapid atrial rhythm


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22. What is the first step to take in a patient with a DDD pacemaker experiencing a

pacemaker mediated tachycardia at the upper tracking limit?

a. Apply a magnet

b. Turn on the PMT intervention feature

c. Increase the PVARPd. Shorten the AV delaye. Turn on the PVC response feature

23. All of the following are types of upper rate behaviors except:

a. Wenckebach

b. Fallbackc. Conditional ventricular tracking limit (CVTL)

d. Rate smoothing

e. 2:1 block

24. All of the following are strategies for eliminating crosstalk except:

a. Decrease atrial output b. Decrease ventricular sensitivity

c. Enable ventricular safety pacing

d. Lengthen PVARPe. Increase ventricular blanking period


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Answer questions 1-17 by circling the best answer. There is only one correct answer for

each question.

1. Retrograde VA conduction

a. is important in the genesis of endless-loop pacemaker tachycardia

b. may contribute to the development of the pacemaker syndromec. may be present despite fixed antegrade AV block

d. all of above

2. All of the following are necessary for the development of a dual-chamber

pacemaker endless-loop tachycardia except

a. a short post-ventricular atrial refractory period.

b. an atrially sensing dual-chamber pacemaker c. retrograde VA conduction d. premature ventricular contraction

3. All of the following terms are associated with DDD upper rate behavior except

a. AV block

b. safety pacing

c. rate smoothing d. pseudo-Wenckebach response

4. Which of the following does not aid in the prevention of crosstalk?

a. a prolonged blanking period

b. high ventricular sensitivity (increasing sensitivity, lower number)

c. low atrial output d. low ventricular sensitivity ( decreasing sensitivity, higher number)

5. Which of the following drugs lower pacing stimulation thresholds?

a. Epinephrine, amiodarone, flecainide

b. Flecainide, encainide, propanolol

c. Epinephrine, dexamethasone, atropine d. Procainamide, lidocaine, sotolol


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6. One advantage that bipolar has over unipolar is:

a. increases crosstalk

b. is less susceptible to EMI

c. is more likely to cause pectoralis muscle stimulation

d. makes pacing artifacts easier to see on the ECG tracinge. leads are smaller in diameter, and thus, easier to implant with a dual chamber

system

7. A pacemaker’s low rate is programmed to 60 bpm. The interval of time between

paced beats is 1000ms and the interval of time between a sensed beat followed bya paced beat is 1200ms. This could be due to:

a. ventricular refractory period programmed to 400ms. b. a rate modulated pacing mode.

c. a sensitivity value that is too high (lower number)

d. undersensinge. a programmed hysteresis rate of 50

8. All of the following describe normal hysteresis operation except:

a. allows the patient to be in an intrinsic rhythm below the pacing rate

b. an intentionally longer escape interval vs. pacing interval

c. typically only available in single chamber pacemakers d. provides a lower pacing rate during sleep

9. All of the following describe normal hysteresis operation except:

a. to determine proper sensing of intrinsic events

b. to determine safety margin of programmed amplitude

c. to determine ERI status of a deviced. is a fast method to determine capture

10. Calculation of the atrial escape interval is made by:

a. the AV interval minus the lower rate

b. 60000 / time in ms

c. 60000 / (AV + Ref)d. the lower rate interval minus the AV interval


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11. Safety pacing (non-physiologic AV delay)

a. has an increased AV interval

b. protects the patient from the ill effects of crosstalk

c. prevents PMT from ever occurring

d. decreases the AV interval as the atrial rate risese. increases the PVARP to 400ms after a PVC occurs

12. Normal function of a DDD pacemaker can include all of the following except:

a. lower rate pacing b. atrial tracking

c. 2:1 block

d. atrial pacing with normal AV conductione. triggered response atrial pacing

13. The Wenckebach period can be calculated as

a. 6000 / (A-V + PVARP)

b. the AV delay + PVARP

c. (PVARP + A-V delay) / Upper rate periodd. the upper tracking rate – TARP

e. atrial escape interval – the AV interval

14. The two-to-one blocking pacemaker rate is:

a. caused by intrinsic AV conduction

b. AV interval and PVARPc. is determined by the programmed upper rate limit

d. 60,000 / TARP

e. lower rate - AV interval

15. The following statements are true of DDIR mode pacing except:

a. some generators switch to this mode in the presence of an SVT

b. it is the preferred mode for the patient with SSS, intermittent SVT’s, and

intact A-V conduction

c. it maintains AV synchrony in the presence of A-V blockd. it is therapeutic for chronotropic incompetence and sinus arrest

e. it is a better mode than AAIR for patients with tachy - brady syndrome


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16. The following statements are true of mode switching except:

a. it results in VVIR pacing throughout the time the device has changed ( modes

in all generators which have mode switch as an option)

b. there is always some delay from the onset of the SVT until the actual mode

switch occursc. different manufacturers use different algorithms to achieve mode switching

d. it is programmable on or off for DDD, DDDR, and VDD modes (if it is a parameter available in the generator)

17. All of the following are expected outcomes of mode switch except:

a. decreases the frequency of necessary mode reprogramming due to intermittent

SVT’s b. decreases the symptoms associated with SVT’s due to inappropriate rapid

ventricular pacing in DDD, DDDR, VDD modes

c. promotes AV conduction during the bradycardia period after the SVT hasceasedd. ensures detection of a rapid atrial arrhythmia by incorporating refractory

sensing and short blanking periods.

e. results in a return to the programmed mode after the SVT has ceased

Below is a list of transducers used in rate responsive pacing. Select the letter of thetransducer that matches the type of pacemakers:

A. Thermistor

B. LEDSC. Piezoelectric

D. Electrode and Current

E. AccelerometerF. Pressure

18. Temperature

19. Activity

20. O2 Sat.

21. Impedance

22. DP/DT


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Answer True or False:

23. A pacemaker mediated tachycardia may be initiated by:

1. Loss of atrial capture

2. A PVC3. Loss of atrial sensing

4. Oversensing EMI

24. Magnet operation can NOT be used to:

1. Assess battery status

2. Terminate a retrograde cycle

3. Assess safety margin4. Check for proper sensing

25. Ventricular safety pacing emits a pace in the ventricle at:

1. 100ms.

2. 400ms.

3. 110ms.4. 150ms.

Continued on Next Page


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Match the following terms with their definitions:

a. Asynchronous pacing

b. Oversensing

c. A-V interval

d. Physiologic pacinge. Retrograde conduction

f. Lower rate

26. In a dual chamber pacemaker, the period of time between an atrial event (sensed

or paced) and a paced ventricular event.

27. In atrial tracking dual chamber pacemakers, the programmed rate at which the

pacemaker will pace the heart in the absence of cardiac activity.

28. The propagation of depolarization from the ventricles to the atria, i.e., V-A

Conduction.

29. Inhibition of a pacemaker by events other than those, which the pacemaker was

designed to sense, i.e., myopotentials, EMI, crosstalk, etc.

30. Artificial pacing, which maintains the heart’s normal contraction sequence with

resulting hemodynamic benefits.

31. Stimulation of the heart at a fixed, preset rate, independent of any electrical and/or

mechanical activity of the heart.

(Continued on Next Page)


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Answer the following True or False:

32. In the presence of retrograde conduction, the PVARP should always be

programmed to the maximum value of 600 ms.

33. In DDD pacing, the second position of the NBG code represents thechamber (s) being sensed.

34. Appropriate rate increase results in increased cardiac output for most

hearts.

35. Without correct atrial sensing, rate increase is compromised and the

pacemaker paces sequentially at the upper rate.

36. Crosstalk is a potential problem in virtually all VVI pacemakers.

37. The Lower Rate, AV Interval, and the Upper Tracking Rate are all parameters to be selected for the DDI mode.

38. DDDR with mode switch is the therapy of choice for patients with SSS,

unreliable AV conduction or AV block, and intermittent SVT’s.


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1. Match the following modes with the appropriate descriptions:DDD, DDI, DDDR, VVIR, DOO

_______ For patients with intermittent atrial fibrillation

_______ For patients with complete heart block with normal sinus function _______ For patients with chronic atrial fibrillation

_______ For patients undergoing shoulder surgery

_______ For patients with sick sinus syndrome

2. Before implant a patient presents with the following rhythm. Which pacing mode

would you recommend?

A. DDDR

B. VVIR

C.

DDIRD. AAIR

3. Before implant a patient presents with the following rhythm. Which pacing mode

would you recommend?

A. DDDR

B. VVIRC. DDIR

D. AAIR


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After performing a final interrogation to retrieve a final printout at implant, you see the

following. Identify the problem. (The EGM source shown is from the atrium.)

4. What is the problem presented in the above ECG?

A. The atrial lead has fallen into the ventricleB. It is programmed to the DOO mode

C. Leads are reversed

D. Loose ventricular set screw

5. A strategy to verify the correct diagnosis above is to:

A. Measure lead impedances in both leads

B. Temporarily program to VVI and AAI while observing the ECG

C. Take a portable PA & Lateral Chest X-Ray

D. Place a magnet over the device and observe the intracardiac EGM

6. After performing a final interrogation to retrieve a final printout at an acute pacemaker

implant, the Quick Look screen reveals the ventricular lead impedance is 2400 ohms.During the implant, the analyzer measured the lead impedance to be 950 ohms. What is

the most likely cause of this?

A. The lead has dislodged

B. The lead was nicked by a scalpel during implant that caused an insulation

failureC. The lead was damaged due to rough handling during the implant

D. Loose set screw at the ventricular port


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You are presented with the following tracing from a patient in a pacemaker clinic for aroutine visit. The patient is not pacemaker dependent and is asymptomatic. The

information you are given is as follows:

Mode: VVI

Lower Rate: 70 PPM

7. What is the best corrective action for the problem above?

A.

Normal pacing function – no action is requiredB. Measure lead impedance and assess for lead problemC. Do a threshold test and increase output

D. Remove the magnet to resume normal function

You are presented with the following tracing from a patient in the pacemaker clinic for a

routine visit. The patient is rather stoic and initially denies any problems. With further

questioning she admits that she occasionally has a very light and very transient sensation

of light-headedness but had discounted the symptoms. The information you are given isas follows:

Mode: DDDRLower Rate: 50 ppm

Upper Rate: 110 ppm

PVARP: 160ms

8. Identify the problem in the ECG above and choose the best answer:

A. Ventricular oversensing – increase the post atrial ventricular blanking period

B. Measure ventricular lead impedance – loose set set screw

C. Loss of ventricular capture – increase outputD. Measure ventricular lead impedance – insulation failure


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You are presented with the following tracing from a patient in the pacemaker clinic for aroutine visit. The patient is asymptomatic. The information you are given is as follows:

Mode: DDD

Lower Rate: 50ppm

Upper Rate: 110ppmPVARP: 250ms

9. Is the pacemaker functioning normally? Choose the best answer.

A.

Pacemaker Mediated Tachycardia – Turn on PMT TerminationB. Normal sensing of a PVC with extended PVARP responseC. Normal synchronous pacing of atrial tachycardia

D. Ventricular tachycardia – Turn on Ventricular High Rate Diagnostic

You see the following strip at a one-week wound check appointment.

10. The ECG presents with the following. Choose the best description of the problem:

A. Leads are reversedB. Ventricular Safety Pacing

C. Loss of atrial sensing

D. Atrial lead has fallen into the ventricle


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CASE STUDIES

You will be presented with a case history with ECGs and/or programmer printoutsfollowed by a series of multiple choice questions regarding each case. Choose the BEST

answer.

CASE #1


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CASE #1

11. The narrow complex Tachycardia observed in ECG Strip #2 may have been initiated

from the atrial lead positioning.

a. true

b.

false

12. ECG Strip #3 confirms:

a. atrial sensing b. ventricular capture

c. both A and B

d. neither A or B

13. ECG Strip #4 demonstrates:

a. atrial capture b. ventricular sensing

c.

both A and Bd. neither A or B

14. Magnet application in ECG Strip #5 confirms:

a. atrial capture

b. ventricular capturec. atrial and ventricular leads are not reversed in the pacemaker header

d. all of the above

15. The PSA threshold results on these two implanted tined steroid eluting pacemaker

leads would be best described by the following:

a.

average b. unacceptable, need for repositioning of leads

c. average with exceptional P-waves

d. exceptional


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CASE #2


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CASE STUDY 2

16. Based on the findings from the initial ECG Strip #1 and EGM Strip #1, what is the

cause of this patient’s accelerated rate?

a. sensor driven pacing

b.

PMTc. balanced endless-loop Tachycardia

d. tracking atrial tachyarrhythmia

17. What is the most valuable tool for assessing this patient’s problem?

a. atrial EGM

b. ventricular EGMc. surface ECG

d. chest X-ray

18. What programmed parameter could be changed to alleviate this problem?

a.

sensed AV delay b. atrial outputc. mode switching

d. rate smoothing

e. PMT termination algorithm

19. Which diagnostic functions could be utilized to evaluate frequency of these episodes?

a. rate response optimization episodes and high atrial rate histogram

b. high atrial rate histogram and mode switch episodec. rate vs. time trend and percent total event summary

d. mode switch episode and AV conduction histogram

20. If the patient develops this arrhythmia frequently, what mode could best be utilized?

a. VVIR

b. AAIR

c. DVIRd. DDIR


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Case #3


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Case #3

21. What timing period is not present in ECG Strip #1 that is present in ECG Strip #2?

a. PVARP (320ms)

b. ventricular blanking (24ms)

c.

ventricular blanking (after V. pace – 126ms)d. atrial blanking (225ms)

22. What is consistently demonstrated in ECG Strip #1?a. atrial sensing

b. atrial capture

c. ventricular sensingd. ventricular capture

e. A and D only

23. What is the recorded basis for atrial pacing above the programmed lower rate in ECG

strip #2?a. atrial tracking b. sensor drive

c. rate smoothing

d. all of the above

24. The purpose of the shortest blanking period observed in ECG Strip #2 is to prevent:

a. PMT

b. AVDAc. crosstalk

d. atrial oversensing


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CASE #4


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CASE #4

25. The chest x-rays of this case study represent which of the following views?

a. AP and lateral

b. Left anterior oblique (LAO)

c.

Right anterior oblique (RAO)d. 2 lateral views

26. The atrial lead position appears:

a. normal

b. too openc. too closed

d. posterior

27. An atrial lead position with the electrode facing posterior as opposed to anteriorwould make the patient more susceptible to?

a. pericarditis

b. exit block

c. diaphragmatic stimulation

d. over-sensing

28. The standard view for assessing ventricular lead redundancy (slack) would be?a. AP or PA

b. Lateral

c.

RAOd. LAO

29. The ECG demonstrates?a. normal DDD function

b. loss of atrial capture

c. loss of atrial sensingd. loss of atrial capture and sensing


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CASE #5


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CASE #5

30. Which of the following do we know from ECG Strip #1?

a. atrial capture and ventricular sensing

b. atrial and ventricular sensing

c.

ventricular sensingd. none of the above

31. Which of the following do we know from ECG Strip #2?a. atrial and ventricular capture

b. atrial sensing

c. ventricular captured. atrial sensing and ventricular capture

32. Which of the following would be programmed in ECG Strip #1 to confirm atrialsensing?

a.

decrease low rate b. increase low ratec. increase AV interval

d. decrease AV interval

33. Which of the following would be programmed in to confirm ventricular sensing inECG Strip #2?

a. decrease low rate

b. increase low ratec. increase AV interval

d. decrease AV interval


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BRADY PACING TEST #1 -- ANSWERS

1.

a

2.

b I=V/R=5v/.33 Kohm 3.

c

4.

a

5.

c E=(V2/R)*t

6.

d

7.

d Lowest Amp, higherresistance, 50% pacing

8.

a

9.

b

10.

a

11.

a12.

c

13.

c

14.

d

15.

a

16.

b17.

a

18.

b

19.

b

20.

c

21.

b22.

a

23.

d

24.

b

25.

d

26.

d See Pg. 4 Hayes’ Text

27.

a

28.

c

29.

b See Pg. 5 Hayes’ Text

30.

a31. a

32.

c

33.

b

34.

c

35.

b36.

d

37.

d

38.

c

39.

b

40.

d41.

b

42.

d

43.

c


40/105


ANSWERS

1. C 9. E

2. D 10. C

3a. False 11. B

3b. False 12. A

3c. True 13. E

3d. True 14. D

3e. False 15. B - False

4a. False 16. B - False

4b. False 17. B - False

4c. True 18. A - True

4d. False 19. B - False

4e. True 20. B - True

4f. True 21. C

5. C 22. A

6. E 23. C7. C 24. D

8. D


41/105

BRADY PACING TEST - #3ANSWERS

1. D 21. D

2 D 22. F

3. B 23. All True

4. B 24. # 1-3 False,

5. C # 4 True

6. B 25. # 1&3 True,

7. E # 2&4 False8. D 26. C

9. A 27. F

10. D 28. E

11. B 29. B

12. E 30. D

13. D 31. A

14. D 32. False

15. C 33. True16. A 34. True

17. C 35. False

18. A 36. False

19. C, E 37. False

20. B 38. True


42/105

BRADY PACING TEST #4

ANSWERS

1. Match the following modes with the appropriate descriptions:DDD, DDI, DDDR, VVIR, DOO

DDI For patients with intermittent atrial fibrillation

DDD For patients with complete heart block with normal sinus function

VVIR For patients with chronic atrial fibrillation _ DOO _ For patients undergoing shoulder surgery

DDDR For patients with sick sinus syndrome

2. B 18. C

3.

A 19. B4.

C 20. D5.

B 21. B

6. D 22. E

7. C 23. B

8. A 24. C

9. B 25. D

10. D 26. B

11.

A 27. C12. C 28. A

13. C 29. D

14.

D 30. C

15. C 31. D

16.

D 32. D

17. A 33. C


43/105

CRT Quiz

1. Stages of Heart Failure (Please label as A, B, C, D)

a. Patients with structural heart disease but without signs and symptoms of

heart failure. ______ b. Patients who have current or previous symptoms of heart failure

associated with underlying structural heart disease. _______

c. Patients with structural heart disease and marked symptoms of heart

failure at rest despite maximal medical therapy. ______d. Patients at high risk (Hypertension, CAD, Diabetes, Strong family history

) _____

2. Fill in the table with the appropriate symptoms of NYHA

a. I

b. IIc. III

d. IV

3.

What 2 classes of drugs should be used with all heart failure patients?

a. ACE and BETA

b. BETA and Statins

c. BETA and Antiarrhythmicd. BETA and Digoxin

4. Epidemiological databases indicate that the mortality for patient’s who present

with heart failure is what at 2-3 years after diagnosis?

a. 15% b.

35%

c. 50%

d. 70%

5. What drug should be administered to all patients with symptomatic heart failure

when they become stable as well as patients with LV dysfunction after MI? Anti-

hypertensivea. Beta-Blocker

b. Anti-thrombolytic

c. Anti-arrhythmic6. Match the following drugs to their appropriate classification:

Furosemide A. Beta-blocker

Captopril B. ACE-inhibitorCarvedilol C. Aldosterone-antagonist

Eplerenone D. Diuretic


44/105

7. Do patient’s whose condition appear stable remain at risk for disease progression?

a. Yes b. No

8. In clinical practice, what should be done first for heart failure treatment

a. ACE inhibitor b. Beta-Blocker

c.

Diuretics to rid excess volume

9. Pacing for treatment of medically refractory dilated cardiomyopathy is designated

as what type of indication by the ACC/AHA guidelines?

a. I b. II

c. IIB

d. III

10. QRS duration has been shown to correlate with mortality?

a. True

b.

False

11. What causes the abnormal motion of the ventricular septum in a patient with a

LBBB?a. The early activation of the LV

b. The Interventricular dyssynchrony and abnormal pressure gradient

between the ventriclesc. Early opening of the Aortic valve leading to decreased ventricular filling

12. Can CRT be used in patients with RBBB?

a. Yes

b.

No

13. Where is the place on the LV that shows the greatest improvement in dp/dt and pulse pressure according to Path-CHF I?

a. Lateral

b. Posteriorc. Mid-Lateral

d. Apical

14. Is there evidence to support that a patient with a normal QRS and clinical heartfailure can have Interventricular dyssynchrony and can benefit from CRT?

a.

Yes b. No

15. What is a secondary effect of the decrease in MR and LV dimension from CRT?

a. Less VT b. Less PVC’s

c. Decrease in LA dimension


45/105

16. Identify the optimized AV delay for this patient. Explain your rationale.

AV 280 AV 240

AV 200 AV 180


46/105

17. Please identify what device operation is occurring within this strip from a patientwith an InSync III 8042?

18. What are the indications for CRT-ICD? (Mark all that apply)a. NYHA class 2, 3

b. EF 35%

c. QRS 150 ms

d.

Stable medical therapye. ICD indication


47/105

19. This is a ventricular threshold test in the InSync 8040 device. What do you think

is going on and how do you fix it?

20. Does SDANN correlate with mortality?

a. Yes

b. No

21. A positive R-wave in Lead I would suggest a signal coming from where?

a. Left ventricle to right b. Right ventricle to left

22. What are the inferior leads?a. II, III, aVF

b. I, aVL, V4

c. V4-V6

d. V1, aVR, III

23.

Will a positive deflection in V1, aVR, and III showa. Right to left b. Left to right

24. Lead I if positive suggestsa. Septal pacing

b. Inferior

c. RV apex (Middle Cardiac Vein)


48/105

25. A positive R wave in aVF suggesta. LV posterior

b. Anterior Interventricular

c. Basal

26. Label the cardiac veins in the following venogram.

A

B

D

E


49/105

27. Identify the veins in this venogram. What is the target lead placement site for the

LV lead in this venogram?

28. In the normal state, sinus impulses from the junction of the RA reach the LA

primarily through thea.

Atrial septum b. SA node

c. Roof of the atrium (Bachmanns Bundle)

29. Programming a short AV delay causes

a. Late closure of the Mitral valve

b. Early closure of the Mitral valve

30. Short AV delays cause

a. Long diastolic filling time

b. Short diastolic filling time

31. On echo, an A wave represents what?

a. Passive atrial filling b. Passive ventricular filling

c. Active atrial filling

d. Active ventricular filling

Balloon

Balloon

Catheter

Ostium

GuideCatheter

B

A

D

C


50/105

32. When should Mitral valve closure occur?a. After the E wave

b. At the very end of the A wave

c. Delayed a set time after the A wave

d. During the A wave

33.

What is a good method for evaluating V-V timing?

a. Mitral inflow b. M-Mode

c. Ritter method

d. Color

34. Do electrical and mechanical synchrony always correlate?

a. Yes

b. No

35. Septal to lateral wall delay by M-mode echo of more than what may be a good

predictor of CRT response?a. 100ms

b. 130ms

c. 150msd. 180ms

36. ICD therapy for those at risk for having arrhythmia’s isa. Primary prevention

b. Secondary prevention

37. Sudden death can be reduced to what with ICD’s?

a.

1% b. 3%

c. 5%d. 10%

38. Should meds be discontinued after a CRT implant?a. Yes

b. No

39. Should QRS duration always be used as an indictor of CRT response?a. Yes

b.

No

40. The following studies demonstrate the benefit of CRT on heart failure patient

functional status (ie, Quality of Life, NYHA Class, etc) Circle ALL that apply:

a. HOPE b. MIRACLE

c. Contak CD

d. SOLVD


51/105


52/105

CRT Quiz

1.

Stages of Heart Failure (Please label as A, B, C, D)a. Patients with structural heart disease but without signs and symptoms of

heart failure. ___ B ___

b. Patients who have current or previous symptoms of heart failure

associated with underlying structural heart disease. ___ C ____

c. Patients with structural heart disease and marked symptoms of heartfailure at rest despite maximal medical therapy. ___ D ___

d. Patients at high risk (Hypertension, CAD, Diabetes, Strong family history

) __ A ___

2. Fill in the table with the appropriate symptoms of NYHA

a.

I No Symptomsb. II Symptoms with moderate activity

c. III Symptoms with minimal activity

d. IV Symptoms at rest

3. What 2 classes of drugs should be used with all heart failure patients?

a. ACE and BETA

b. BETA and Statinsc. BETA and Antiarrhythmic

d. BETA and Digoxin

4. Epidemiological databases indicate that the mortality for patient’s who present

with heart failure is what at 2-3 years after diagnosis?a.

15%

b. 35%

c. 50%

d. 70%

5. What drug should be administered to all patients with symptomatic heart failure

when they become stable as well as patients with LV dysfunction after MI?a. Anti-hypertensive

b.

Beta-Blockerc. Anti-thrombolyticd. Anti-arrhythmic

6. Match the following drugs to their appropriate classification:

Furosemide D A. Beta-blocker

Captopril B B. ACE-inhibitor

Carvedilol A C. Aldosterone-antagonistEplerenone C D. Diuretic


53/105

7.Do patient’s whose condition appear stable remain at risk for disease progression?

a. Yes

b. No

8.In clinical practice, what should be done first for heart failure treatmentc. ACE inhibitor

d. Beta-Blocker

e. Diuretics to rid excess volume

9. Pacing for treatment of medically refractory dilated cardiomyopathy is designatedas what type of indication by the ACC/AHA guidelines?

a. I

b. II

c. IIB

d. III

10. QRS duration has been shown to correlate with mortality?

a. True

b. False

11. What causes the abnormal motion of the ventricular septum in a patient with a

LBBB?

a. The early activation of the LV

b. The Interventricular dyssynchrony and abnormal pressure gradient

between the ventricles

c. Early opening of the Aortic valve leading to decreased ventricular filling

12.

Can CRT be used in patients with RBBB?

a. Yes

b. No

13. Where is the place on the LV that shows the greatest improvement in dp/dt and

pulse pressure according to Path-CHF I?a. Lateral

b. Posterior

c. Mid-Lateral

d. Apical

14.

Is there evidence to support that a patient with a normal QRS and clinical heart

failure can have Interventricular dyssynchrony and can benefit from CRT?

a. Yes

b. No

15. What is a secondary effect of the decrease in MR and LV dimension from CRT?

a. Less VT

b. Less PVC’s

c. Decrease in LA dimension


54/105

16. Identify the optimized AV delay for this patient. Explain your rationale.

AV 280 AV 240

AV 200 AV 180

Full E & A wave without A wave truncation. Therefore we will pace the ventricles at

the end of active filling and not interfere with the atrial contribution.


55/105

17. Please identify what device operation is occurring within this strip from a patientwith an InSync III 8042? VSR

18. What are the indications for CRT-ICD? (Mark all that apply)

a. NYHA class 2, 3

b. EF 35%

c.

QRS 150 msd. Stable medical therapy

e. ICD indication


56/105

19. This is a ventricular threshold test in the InSync 8040 device. What do you thinkis going on and how do you fix it?

This is a LV lead dislodgement. The V EGM shows a large deflection after the A

sense. The LV lead is sensing atrial activity demonstrated by the initial VS that

is associated with the P wave and not the QRS complex on the surface ECG.

Also note only 1 sense with the QRS. The RV is still sensing ventricular activity

but the LV lead has dislodged and is probably in the main CS, therefore sensing

Atrial activity.

Suggest a chest X-ray and will probably need a lead revision to regain LV

capture.

20. Does SDANN correlate with mortality?

a. Yes

b. No

21. A positive R-wave in Lead I would suggest a signal coming from where?

a. Left ventricle to right

b.

Right ventricle to left

22. What are the inferior leads?

a. II, III, aVF

b. I, aVL, V4c. V4-V6

d. V1, aVR, III


57/105

23. Will a positive deflection in V1, aVR, and III showa. Right to left

b. Left to right

24.

Lead I if positive suggests

a.

Septal pacing b. Inferior

c. RV apex (Middle Cardiac Vein)

25. A positive R wave in aVF suggest

a. LV posterior

b. Anterior Interventricular

c. Basal

26. Label the cardiac veins in the following venogram.

A. Posterior branch B. Coronary Sinus C. AIV

D. Lateral branch E. MCV

B

C

D

E


58/105

27. Identify the veins in this venogram. What is the target lead placement site for the

LV lead in this venogram?

A. MCV B. Posterior Lateral C. Main CS D. AIV B is target

28. In the normal state, sinus impulses from the junction of the RA reach the LA

primarily through thea. Atrial septum

b. SA node

c. Roof of the atrium (Bachmanns Bundle)

29. Programming a short AV delay causes

a. Late closure of the Mitral valve

b. Early closure of the Mitral valve

30. Short AV delays cause

a. Long diastolic filling time

b. Short diastolic filling time

Balloon

Balloon

Catheter

Ostium

Guide

Catheter

B

A

D

C


59/105

31. On echo, an A wave represents what?a. Passive atrial filling

b. Passive ventricular filling

c. Active atrial filling

d.

Active ventricular filling

32. When should Mitral valve closure occur?

a. After the E wave

b. At the very end of the A wave

c. Delayed a set time after the A wave

d. During the A wave

33. What is a good method for evaluating V-V timing?

a. Mitral inflow

b. M-Mode

c. Ritter method

d.

Color

34. Do electrical and mechanical synchrony always correlate?

a. Yes

b. No

35. Septal to lateral wall delay by M-mode echo of more than what may be a good

predictor of CRT response?a. 100ms

b. 130ms

c. 150ms

d. 180ms

36. ICD therapy for those at risk for having arrhythmia’s is

a. Primary prevention

b. Secondary prevention

37. Sudden death can be reduced to what with ICD’s?

a. 1%

b. 3%

c. 5%d. 10%

38.

Should meds be discontinued after a CRT implant?

a. Yes

b. No

39. Should QRS duration always be used as an indictor of CRT response?a. Yes

b. No


60/105

40. The following studies demonstrate the benefit of CRT on heart failure patientfunctional status (ie, Quality of Life, NYHA Class, etc) Circle ALL that apply:

a. HOPE

b. MIRACLEc.

Contak CD

d.

SOLVDe. MUSTIC

41. The following study demonstrated the benefit of CRT in improving patient risk

for heart failure hospitalization and mortality:

a. MADIT b. CONSENSUS

c. COMPANION

d. COPERNICUSe. AVID


61/105

Defib Questions.

1. The premise of a proposed theory of defibrillation is that a shock need only

eliminate the fibrillatory wavelets in a percentage of myocardium to extinguish

the arrhythmia.

a.

Upper limit of vulnerability b. Critical mass

c. Progressive depolarizationd. Defbrillation threshold

2. Factors that can affect whether a shock will succeed include:a. fibrillation duration

b. potassium accumulation

c. circulating pharmacologic agentsd. all of the above

3.

Biphasic waveforms have been shown to result in higher implantation successrates due to:a. smaller can/device size

b. lower DFTs

c. utilization of high output devicesd. none of the above.

4. Factors favoring use of a dual chamber ICD include but are not limited to;a. chronic AF

b. need for heart rate variability diagnostics

c. standard indication for a dual chamber pacemaker

d. preservation of A-V synchrony

5. If external defibrillation is necessary, the preferred position for external Defib pad

placement in a patient with an implanted ICD is:a. anterior-posterior

b. anterior-anterior with pads placed right pectoral and left lateral

c. apex-posteriord. none of the above.


62/105

Defib Questions Answer Key

1. The premise of a proposed theory of defibrillation is that a shock need only

eliminate the fibrillatory wavelets in a percentage of myocardium to extinguish

the arrhythmia.

a.

Upper limit of vulnerabilityb. Critical mass

c. Progressive depolarizationd. Defbrillation threshold

2. Factors that can affect whether a shock will succeed include:a. fibrillation duration

b. potassium accumulation

c. circulating pharmacologic agents

d. all of the above

3.

Biphasic waveforms have been shown to result in higher implantation successrates due to:a. smaller can/device size

b. lower DFTs

c. utilization of high output devicesd. none of the above.

4. Factors favoring use of a dual chamber ICD include but are not limited to;a. chronic AF

b. need for heart rate variability diagnostics

c. standard indication for a dual chamber pacemaker

d. preservation of A-V synchrony

5. If external defibrillation is necessary, the preferred position for external Defib pad

placement in a patient with an implanted ICD is:

a. anterior-posterior

b. anterior-anterior with pads placed right pectoral and left lateral

c. apex-posteriord. none of the above.


63/105

Quiz

ICD Indications

1. Which of the following is not a class I indication for ICD implantation?a.

Cardiac arrest due to ventricular fibrillation (VF) or ventricular

tachycardia (VT) not due to a transient or reversible cause. b. Syncope of undetermined origin with clinically relevant,

hemodynamically significant sustained VT or VF induced at EP studywhen drug therapy is ineffective, not tolerated, or not preferred.

c. Patients with LV ejection fraction of less than or equal to 30%, at least one

month post myocardial infarction and three months post coronary arteryrevascularization surgery.

d. Nonsustained VT with coronary disease, previous myocardial infarction,

left ventricular dysfunction, and inducible VF or sustained VT at EP tudythat is not suppressible by a class I antiarrhythmic drug.

2.

This study showed a 54% reduction in mortality over conventional therapy in post-MI patients with an LVEF of less that 35%, asymptomatic NSVT andinducible VT on EP study.

a. MADIT II

b. SCD-HeFTc. DEFINITE

d. MADIT

3. This study showed a 34% reduction in mortality for patients with nonischemic

cardiomyopathy, NSVT and low EF who received ICD therapy vs. optimal

medical therapy.

a. MADIT II b.

SCD-HeFT

c. DEFINITE

d. CABG-PATCH

4. The trial results in the previous question were shown to be statistically

significant.a. True

b. False

5. The only clinical trial which led to a class I indication for ICD implantation

for primary prevention of SCD was:

a.

MADIT

b. MADIT IIc. SCD-HeFT

d. DEFINITE


64/105

Quiz

ICD Indications

1. Which of the following is not a class I indication for ICD implantation?

a. Cardiac arrest due to ventricular fibrillation (VF) or ventricular

tachycardia (VT) not due to a transient or reversible cause. b. Syncope of undetermined origin with clinically relevant,

hemodynamically significant sustained VT or VF induced at EP studywhen drug therapy is ineffective, not tolerated, or not preferred.

c. Patients with LV ejection fraction of less than or equal to 30%, at least

one month post myocardial infarction and three months post coronary

artery revascularization surgery.

d. Nonsustained VT with coronary disease, previous myocardial infarction,

left ventricular dysfunction, and inducible VF or sustained VT at EP tudythat is not suppressible by a class I antiarrhythmic drug.

2.

This study showed a 54% reduction in mortality over conventional therapy in post-MI patients with an LVEF of less that 35%, asymptomatic NSVT andinducible VT on EP study.

a. MADIT II

b. SCD-HeFTc. DEFINITE

d. MADIT

3. This study showed a 34% reduction in mortality for patients with nonischemic

cardiomyopathy, NSVT and low EF who received ICD therapy vs. optimal

medical therapy.

a. MADIT II b.

SCD-HeFTc.

DEFINITE

d. CABG-PATCH

4. The trial results in the previous question were shown to be statistically

significant.a. True

b. False

5. The only clinical trial which led to a class I indication for ICD implantationfor primary prevention of SCD was:a.

MADIT

b. MADIT IIc. SCD-HeFT

d. DEFINITE


65/105

Quiz

ICD Programming

1. This feature is designed to avoid delayed detection when an arrhythmiastraddles the VT and VF zones of an ICD:

a.

FVT via VF b. Auto-adjusting sensitivity

c. Combined count detectiond. Express Therapy

TM

2. Guidant ICDs use which method to maintain appropriate sensing of QRScomplexes and VF while avoiding oversensing T-waves?

a. Auto-adjusting sensitivity

b. Beat-to-beat adjustment of sensingc. Automatic gain control

d. None - fixed sensing only

3. This detection enhancement uses an abrupt change in rate to distinguish sinustachycardia from true VT.

a. Onset

b. Stabilityc. BuzzFree

TM

d. EGM Width

4. The Guidant Atrial View detection enhancements add which of the following

features to stability and onset (choose all that apply):

a. A Rate > V Rate

b. AV Dissociationc.

Lookback

d. A Fib Rate Threshold

5. ELA’s PARAD Detection enhancement utilizes each of the following to

distinguish VT from SVT except:

a. Chamber of onset b. AV Association

c. EGM morphology

d. Interval stability

6. What are the elements of PR logic?

7. What are the therapy options delivered by Medtronic’s atrial defibrillators?


66/105

Quiz

ICD Programming

1. This feature is designed to avoid delayed detection when an arrhythmiastraddles the VT and VF zones of an ICD:

a.

FVT via VF b. Auto-adjusting sensitivity

c. Combined count detection

d. Express TherapyTM

2. Guidant ICDs use which method to maintain appropriate sensing of QRScomplexes and VF while avoiding oversensing T-waves?

a. Auto-adjusting sensitivity

b. Beat-to-beat adjustment of sensing

c. Automatic gain control

d. None - fixed sensing only

3. This detection enhancement uses an abrupt change in rate to distinguish sinustachycardia from true VT.

a. Onset

b. Stabilityc. BuzzFree

TM

d. EGM Width

4. The Guidant Atrial View detection enhancements add which of the following

features to stability and onset (choose all that apply):

a. A Rate > V Rate

b. AV Dissociationc.

Lookback

d. A Fib Rate Threshold

5. ELA’s PARAD Detection enhancement utilizes each of the following to

distinguish VT from SVT except:

a. Chamber of onset b. AV Association

c. EGM morphology

d. Interval stability

6. What are the elements of PR logic?

Rate, Pattern, Regularity, AV Dissociation, Far Field R Wave and AF

Evidence (according to Hayes)

7. What are the prevention/termination therapy options delivered by Medtronic’s

atrial defibrillators?

Atrial rate stabilization, High-rate overdrive pacing, Atrial ATP, 50 Hz

burst, Atrial cardioversion


67/105

Quiz

ICD Troubleshooting

1. What are the benefits of storing a far-field electrogram for ICD episode

analysis?

2. The following strip illustrates:

a. Lead fracture on the ventricular tip conductor b. EMI

c. Lead fracture on the RV coil conductor

d. T wave oversensing

3. How can you tell whether the ventricular EGM is near-field or far-field?

4.

Is absence of symptoms prior to a shock always indicative of inappropriatetherapy? Why or why not?

5. Are multiple therapies (more than two) in a single episode always indicative

that the therapies are inappropriate? What about shocks? Why or why not?


68/105

Quiz

ICD Troubleshooting

1. What are the benefits of storing a far-field electrogram for ICD episode

analysis?

More closely resembles surface ECG, can sometimes distinguish P waves,

easier to distinguish between sinus and VT morphology

2. The following strip illustrates:

a. Lead fracture on the ventricular tip conductor

b.

EMIc. Lead fracture on the RV coil conductor

d. T wave oversensing

3. How can you tell whether the ventricular EGM is near-field or far-field?

Look at all of the noise on the EGM, then notice that the marker channel is

showing normal ventricular sensing. If the tip or ring conductors were

involved over sensing on the V channel would have been noted

4.

Is absence of symptoms prior to a shock always indicative of inappropriatetherapy? Why or why not?

No. According to at least one study more than 60% of VT episodes were

asymptomatic. Remember to program PainFREE!


69/105

5. Are multiple therapies (more than two) in a single episode always indicativethat the therapies are inappropriate? What about shocks? Why or why not?

No, although it can be a strong indicator. Many factors can contribute to

multiple therapies, such as inappropriate programming of initial therapy or

changes in DFTs over time.


70/105

1

NASPE PRE-TEST

History: A VVIR pacemaker was implanted three months earlier. The ECG

demonstrated loss of capture and intermittant loss of sensing.


71/105

2

1) Regarding the X-ray on the previous page. The ECG problems described

were most likely the result of:

A. inappropriate programming

B. twiddlers syndrome

C. lead fracture

D. right ventricular perforation

2) Regarding the X-ray on the previous page. Based on the X-ray image, the

most probable indication for pacing in this patient was:

A. sarcoidosis induced AV blockB. hypertensive cardiomyopathy

C. congential AV block

D. sick sinus syndrome

3) How would a lead conductor fracture affect battery longevity?

A. no effect

B. increase longevity

C. decrease longevity

D. it depends as to whether there is a break in the insulation as well

E. both B and C

4) Which of the following drugs is known to decrease chronic defibrillationthresholds and increase chronic pacing thresholds?

A. sotalol

B. encainide

C. flecainide

D. propafenone

5) Which of the following conditions would rule out ventricular tachycardia?

A. V rate > A rate

B. A rate > V rateC. A rate = V rate

D. none of the above


72/105

3

6) Which of the following assessments could one make from the tracingabove?

A. appropriate atrial and ventricular capture

B. appropriate atrial and ventricular sensing

C. appropriate rate response function

D. appropriate SVT discrimination

7) The most likely pacing indication for this patient would be?

A. intermittent CHBB. tachy-brady syndrome

C. hypertrophic obstructive cardiomyopathy

D. vasovagal syncope


73/105

4

8) In the printout above, which of the following measured values would not

be considered normal?

A. cell impedance and battery currentB. battery voltage and cell impedance

C. atrial and ventricular lead impedance

D. atrial amplitude and ventricular lead impedance

E. both A and C

9) Based on the printout above, which of the following would be the most

likely ECG manifestation(s) of the abnormal telemetry readings?

A. change in magnet rate

B. intermittent failure to output on the atrial and ventricular channelsC. loss of atrial capture and ventricular oversensingD. no ECG manifestations

E. premature battery depletion


74/105

5

10) Dislodgement of the atrial lead is best assessed from which fluoroscopic

view?

A. anteroposterior

B. left anterior oblique

C. right anterior oblique

D. lateral

11) Of the ECG's above (A-D), which would be the most likely ECG follow up

presentation if the patient's indication for pacing was hypertrophic obstructive

cardiomyopathy?

A. A

B. B

C. C

D. D


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12) Hypertrophic obstructive cardiomyopathy is what type of indication?

A. Class I

B. Class IIa

C. Class IIb

D. Class IIIE. Class IV

13) During a standard dual chamber ICD implant, VF sensing should be

tested:A. at the least sensitive setting

B. at the most sensitive setting

C. in the DDD mode

D. during magnet application

14) To reduce biphasic DFT in a transvenous lead system, an additional lead

may be placed in any of the following, except:

A. coronary sinus

B. superior vena cava

C. subcutaneous axillary position

D. cardiac vein

15) What is the most likely explanation for a new pacing system that fails to

pace in the bipolar configuration, but paces normally in the unipolar

configuration?

A. loose anodal setscrew

B. loose cathodal setscrew

C. unipolar lead

D. outer coil fracture

16) Which of the following detection enhancements improves specificity ina patient with Ashman's phenomena?

A. onset

B. QRS morphology

C. stability

D. AV dissociation


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History: This 63 year old male with no known structural heart disease was

implanted with a defibrillator. The patient is also on antiarrhythmic drug

therapy for his tachyarrhythmias.

17) One would interpret the above interval plot as follows:

A. sinus rhythm to atrial flutter to sinus rhythmB. sinus rhythm to VT back to sinus

C. atrial fibrillation to VT to sinus rhythm

D. sinus rhythm to VF back to sinus


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History: The following strip was saved during a mode switch episode. The

device is programmed to DDDR LR60, UTR140, USR140.

18) The pacing rate increases following the mode switch due to:

A. device switched to a tracking mode

B. rate responsive pacing at time of mode switchC. smoothing algorhythm associated with mode switch

D. atrial oversensing

E. noise reversion pacing

19) The DDD pacemaker implanted in a 75 year old male with an old

anterior myocardial infarction is set to a lower rate of 60 ppm, a MTR of 100

ppm, an AVI of 200 ms, an ARP of 350 ms and a VRP of 300 ms. The

Wenckebach interval is:A. 0 ms

B. 50 ms

C. 75 ms

D. 100 ms

20) The term virtual electrode desribes the:

A. porous surface

B. fibrous layer

C. excitable tissueD. electrolyte concentration


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21) Given the above ECG, which of the following best describes the

pacemaker function: (Mode: DDD, LR 60 ppm, AVI 200ms, UTR 100 ppm)

A. atrial oversensingB. atrial undersensing

C. pacemaker wenckebach

D. pacemaker mediated tachycardia

22) Given the above ECG, which of the following best describes the

pacemaker function. (Mode: DVI, LR 70 ppm, AVI 200 ms)

A. normal DVI pacemaker function

B. atrial undersensing or atrial oversensing

C. ventricular undersensing or ventricular oversensing

D. atrial or ventricular loss of capture

23) The transmembrane potential of a typical purkinje fiber is approximately

how many mV at the threshold of depolarization?A. -20mV to +20mV

B. -30mV to -50mV

C. -60mV to -70mV

D. -80mV to -90mV


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24) Given the above ECG/Marker Channel, which of the following is most

clearly demonstrated? (Mode DDD, LR 60ppm, AVI 200ms, UTR 125,

PVARP 225ms)

A. atrial sensingB. atrial capture

C. ventricular sensing

D. ventricular capture

25) Which of the following best approximates the point of minimum

threshold energy (microjoules) required for myocardial depolarization?

A. chronaxie

B. rheobaseC. stimulation threshold

D. intermittent threshold

E. DFT threshold

26) Which formula demonstrates that a pulse duration longer than the

chronaxie has relatively little effect on threshold voltage and stimulation

energy?

A. V = IR

B. E = V (squared) / R x TC. E = I x V x T

D. CO = SV x HR

E. None of the above


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History: A 72 year old male was implanted with his third pulse generator

for sinus node disease. In addition, the patient has had two leads implanted

coinciding with the initial implant and the first generator change. The

current generator is attached to the original lead. The ventricular threshold

measures 3.0 V and .60 ms PW with R-waves measuring 7.0 mV.

27) Regarding the X-ray image and history above. Considering the lead

system and current stimulation threshold, which of the following problemsdid this patient most likely experience?

A. diaphragmatic stimulation

B. crosstalk

C. undersensing

D. oversensing

28) Regarding the X-ray image above. Event counters indicated 23%

ventricular pacing at a rate of 60 bpm in the VVI mode. The patient

complains of some palpitations and fatigue at rest. This patient would probably best be served by programming his device to which of the

following settings?

A. VVI at 50 bpm

B. VVI at 70 bpm

C. VVIR at 50 bpm

D. VVIR at 70 bpm

E. DDD at 60 bpm


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29) What is the appropriate clinical response to a patient whose ICD reaches

the ERI after five years without a single shock?

A. conduct EP studies to determine if an ICD is needed

B. replace the ICD

C. reduce follow-up visits

D. explant the ICD and use drug therapy

30) Which of the following settings are desirable when biventricular pacing

for heart failure in a 62 year old patient with no history of significant

arrhythmias?A. mode switch on, UTR 120 ppm, ventricular sensitivity 1.4mV

B. mode switch off, UTR 120 ppm, ventricular sensitivity 2.8mV

C. mode switch on, UTR 150 ppm, ventricular sensitivity 1.4mV

D. mode switch off, UTR 150 ppm, ventricular sensitivity 2.8mV

31) When defibrillating a pacemaker patient, the defibrillation paddles

should be placed:

A. in an anteroposterior position

B. parallel to the pacing system

C. over the pulse generator

D. pacemaker patients should not be externally defibrillated

32) The VDI mode would be useful in evaluating:

A. endless loop tachycardia

B. crosstalk

C. retrograde conduction

D. upper rate behavior

33) Which of the following V-V intervals is considered optimal when the

LV lead is placed in a lateral or anterior-lateral cardiac vein?

A. LV + 0 msB. LV - 5 ms to - 30 ms

C. LV + 5 ms to + 30 ms

D. LV - 40 ms to - 80 ms


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History: A 62 year old male was implanted with a dual chamber

defibrillator.

34) The EGM and annotations featured above demonstrate:A. atrial flutter with spontaneous conversion to sinus rhtyhm

B. atrial fibrillation with successful cardioversion

C. ventricular fibrillation with spontaneous cardioversion

D. ventricular fibrillation with successful defibrillation


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35) Which of the following approximates the mortality rate of persistent

infection when infective leads are not removed?

A. 5 - 10 %

B. 15 - 25 %

C. 30 - 45 %

D. 50 - 65 %

36) The most common organism found in a chronic pacemaker pocket

infection is:

A. staphylococcus albusB. escherichia coli

C. staphylococcus aureus

D. staphylococcus epidermidis

E. streptococcus pyogenes

37) Each of the following is a requirement for a reentry tachycardia except:

A. two conducting pathways connected proximally and distally

B. differing refractory periods of two pathways

C. differing conduction velocities of two pathways

D. an area of ischemic tissue

38) Which of the following statements is true regarding atrial defibrillationthresholds?

A. they are typically lower than ventricular defibrillation thresholds

B. they are typically higher than ventricular defibrillation thresholds

C. they are equivalent to ventricular defibrillation thresholds

D. they vary significantly depending on catecholamine level and time

of day

39) Which of the following characteristics of atrial fibrillation is likely to

contribute to congestive heart failure?A. loss of atrial kick

B. rate related cardiomyopathies

C. loss of AV synchrony

D. all of the above

E. none of the above, AF does not lead to heart failure


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History: This 64 year old female was implanted with a DDD pacemaker

following an open heart procedure. The nursing staff questioned the

pacemaker functioning and called in the pacemaker representative to

evaluate the system. Below is seen an ECG tracing with a mean arterial and

pulmonary artery pressure tracing of 76 mm Hg and 53/22 mm Hg,

respectively.

40) A mean pulmonary pressure of 22 mm Hg would be considered:

A. low

B. normal

C. High

D. depends on the patient

E. pulmonary pressure is not measured in units of mm Hg

41) What would be the most likely reason for the frequent rapid ventricular

pacing in this patient?

A. pacemaker mediated tachycardia

B. intermittent tracking of atrial fibrillation

C. inappropriate rate modulation

D. tracking of atrial flutter

42) Which of the following drugs is not known for increasing the likelihood

of Torsade de Pointes?

A. lidocaine

B. quinidine

C. procainamide

D. sotalol


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History: A 78 year old male was implanted 14 months earlier with a DDDR

pacemaker for high grade AV block. The patient has a history of COPD,

CHF, and myoplasty. At the time the ECG below was recorded the patient

was in respiratory arrest. The pacemaker is programmed to DDDR with a

lower rate of 70 ppm and max tracking rate of 120 ppm.

43) Which of the following modes does the pacemaker in the ECG above

appear to be functioning?

A. DDD

B. VDI

C. DVI

D. VDD

44) Which of the following scenarios would be the MOST likely explanation

for this patient's intermittent loss of capture?A. intrinsic refractoriness of hypoxic tissue

B. unstable lead position

C. intermittent conductor fracture

D. inappropriate programming of output


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History: A 58 year old male was implanted 3 months earlier with an ICD

following an EP study performed for unexplained syncope. He has been

admitted to the hospital for reevaluation of his arrhythmias and medical

therapy due to his frequent shocks. (17 in first 3 months)

45) Based on the above ECG, which of the following would best describe

this patient's arrhythmia?

A. atrial fibrillation with aberrancy

B. monomorphic ventricular tachycardia

C. polymorphic ventricular tachycardiaD. ventricular fibrillation

46) In light of the frequent shocks and the EGM featured above, which of

the following therapies would be most appropriate to consider?

A. shock only

B. antitachy pacing then shock

C. antitachy pacing, cardioversion, then shock

D. cardioversion of the atrial fibrillation

47) When should Mitral valve closure occur?

A. after the E wave

B. during the A wave

C. at the very end of the A wave

D. delayed a set time after the A wave


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History: This 91 year old female was implanted 3.5 years ago with a

Telectronics Model 1250 pulse generator with Medtronic 4058M and 4004M

leads in the atrium and ventricle respectively. The initial indication for

DDDR pacing was tachy-brady syndrome but the patient had since

developed chronic atrial fibrillation and was programmed to VVIR mode.

The following telemetries and ECGs were obtained during routineasymptomatic follow-up. Telemetry strip #1 corresponds with ECG strip #1

and telemetry strip #2 corresponds with ECG strip #2.

Case continued on next page


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48) With regards to the case presented on the previous page and the ECG

above: Having only reviewed the ECGs and knowing the history of the

implanted hardware, one would be suspicious of the:

A. pacemaker

B. atrial lead

C. ventricular lead

D. both A and C

E. both B and C

49) In light of the telemetry readings, the most likely explanation for the

ECG strips is:A. a short circuit in the soft header connector block

B. an atrial lead fracture

C. a ventricular lead fracture

D. normal inhibition of the pulse generator


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50) X-ray "A" features which of the following angiograms?

A. coronary sinusB. circumflex

C. left hepatic

D. left anterior descending

51) Which of the following represents a significant challenge to implantation

and acute follow-up the lead system represented in x-ray "B"?

A. assessing two atrial thresholds

B. assessing two ventricular thresholds

C. the long term stability of lead "2"D. B and C


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52) A long term complication of epicardial defibrillation patches is:

A. patch crumpling

B. constrictive pericarditis

C. patch erosion

D. both A and C

E. all of the above

53) Which of the following effects of antiarrhythmic drug use in ICD

patients is considered both a benefit and a risk?

A. decreased pacing thresholdsB. increased VT cycle length

C. increased DFT threshold

D. SVT prevention

54) Doubling the distance from the radiation source reduces the level of

radiation exposure by:

A. 1/2

B. 1/3

C. 1/4

D. 1/8

E. It depends on whether the radiation is ionizing

55) Which of the following detection enhancements discriminates between

AF and VT on the basis of cycle length?

A. stability

B. onset

C. EGM width

D. morphology

56) Rate hysteresis may be misinterpreted as:

A. loss of captureB. oversensing

C. rate smoothing

D. undersensing


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History: A 79 year old male had a CPI Model 926 DDDC pacemaker

implanted for second degree Mobitz type II heart block. The patient's

chronic follow-up visits consistently demonstrated a reliable escape rhythm.

Thirty months following the implant, the patient called the clinic stating that

he did not feel well and thought his pacemaker should be checked. The

patient was instructed to come to the pacemaker clinic and the followingtelemetry and ECG strips were obtained.


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57) The fact that the pacemaker was firing intermittently in the ventricle at

360 beats per minute represents a failure of the pacemaker's:

A. reed switch

B. runaway protection circuit

C. Zener diode

D. noise reversion responseE. rate response sensor

58) If the programming change that was done resulting in the second ECG

on the previous page had not been successful, an appropriate step for the physician would be to:

A. defibrillate the patient

B. underdrive pace

C. place a temporary lead if the patient is unstable

D. cut the lead wires

59) Eligibility criteria for the MADIT and MUSTT studies of ICD therapy

included all of the following except:

A. dilated left ventricle

B. coronary artery disease

C. reduced ejection fraction

D. nonsustained ventricular tachycardia

60) Which of the following is a Class II indication for ICD therapy?

A. spontaneous sustained VT

B. familial conditions with a high risk for life-threatening VT

C. incessant VT or VF

D. NYHA Class IV drug refractory CHF

61) Which of the following responses is possible with exposure of an

implanted pacemaker to an antitheft surveillance device?A. temporary oversensing

B. inappropriate mode switching

C. reversion to back-up mode

D. circuit damage

E. inappropriate shock


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History: A patient has a history of previous myocardial infarction and

congestive heart failure. Holter monitoring reveals no complex ventricular

ectopy, but does show a brief non-symptomatic episode of heart block

during the night. The patient's ejection fraction measure 28%. The patient

recently experienced an episode of dizziness and his ECG demonstrates a

left bundle branch block with a QRS width of 200 ms.

62) Which of the following statements would be most appropriate in regard

to ICD capabilities in this patient?

A. desirable because dizziniess may have occurred due to VT

B. not necessary since the dizziness was most likely due tointermittent CHB

C. desirable due to patient's history of CHF, MI and a low ejection

fraction

D. both A and C

63) This patient's one year risk of experiencing sudden cardiac death is

about:

A. 5%

B. 10%

C. 30%

D. it depends on his/her age

This ECG was taken from a patient implanted with a DDD pacemaker for sinus

node disease.


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64) The patient's underlying atrial rate on ECG on the previous page is

approximately:

A. 47 bpm

B. 57 bpm

C. 67 bpm

D. too variable to assign one rate

65) The ECG on the previous page demonstrates:

A. atrial undersensing

B. ventricular undersensingC. atrial oversensing

D. ventricular oversensing

E. both C and D

66) Regarding the ECG on the previous page: Intrinsic R-waves measured

14 mV and Intrinsic P-waves measured 1.8 mV in this patient. Repeated

isometric testing with appropriate programming of sensitivities in this

patient would most likely yield the following results:

A. atrial undersensing

B. ventricular oversensing

C. atrial oversensi

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