RCES THE FINAL EXAM 2025 SOLUTION

In patients with CHF and LBBB that are severely symptomatic, properly performed CRT-P (without defib) reduces sudden death and mortality by: - 40-50% Three reasons to use multipolar CS/LV leads in resynchronized therapy are: - Stimulate LV in area of lowest threshold, stimulate LV in area of greatest asynchrony, prevent phrenic nerve stimulation by changing the LV pacing vector Implanting the LV lead in small diameter coronary veins, which type of resynchronization lv lead design generally has the smallest diameter? - Unipolar over the wire A minority of patients treated with bi-v pacing do not improve clinically. Most of the following are characteristics of non responder patients. What characteristic will also suggest the patient is more likely to be a good responder to CRT? A. Ischemic heart disease B. LBBB (vs rbbb) C. Transmural MI Scar D. Enter your corner vein lead placement - LBBB The most common problem associated with pacing from the LV from the coronary vein is: - Diaphragmatic stimulation The only significant difference between implanting an ICD and a CRT-D device is a - CS lead Most patients that receive a BIV pacemaker also get a - Implantable defibrillator In resynchronization therapy, after the LV lead is placed, it should be tested for: - Adequate pacing threshold & an absence of diaphragmatic pacing In resynchronization therapy, after the LV lead is properly placed and tested the next thing to do is: - The guider sheath is sliced and removed. The main long-term benefit of CRT on the left ventricle is: - Reduced end diastolic size and LV mass CRT pacemakers are usually programmed to: - Pace 100% of the time BIV pacers/CRT devices are generally used to treat patients with: - CHF What are the expected benefits of CRT implant in appropriately responding patients? - Increased EF by 5-10%, reduced hospitalizations from CHF, improved quality of life. What type of pacemaker is shown in this X-ray - CRT ACC, AHA, HRS guidelines recommend CRT for patients who have CHF with functional class III or IV on optimal medical therapy with an EF < _____and a QRS > _____ - 35%, 0.12 sec Prior to implanting an ICD on a 12 year old female patient with generic cardiomyopathy an initial EP study induced VT and VF. But, during the ICD implant procedure the implanted lead fails to provide an adequate DFT. What should be recommended? - Implanting lead array In two coil ICD's the shocking electrodes are usually configured to shock between the: - SVC and RV - During ICD testing when VF is induced and the ICD fails to fire, all the following are true except: - Defibrillating over the ICD may do damage to device, delay ACLS for up to one minute to allow the ICD detect and treat the VF, epicardial ICD patches may insulate the heart against anterior-lateral shocks, if your initial shock fails try a different paddle position. **** The incorrect answers to delay ACLS per up to one minute***** During ICD testing after implant, how is VF induced? - 50 Hz burst pacing or shock on T wave After implantsing an ICD in a patient, testing found the defibrillation threshold to be 5 J. For an appropriate safety margin, it is conventional to set the defibrillator output level at: - 15 joules (10 over threshold) When programming a patient's ICD, if there was not defribrilation threshold measurement, it is most common to set the ICD output for VF at: - 10 J below maximum output of ICD A CRT-D is about to be implanted in a man with LBBB that had a large anterior MI three years ago, and was recently resuscitated from cardiac arrest. During the CRTD implant the DFT is not adequate, all the following are recommended options except: Reversing shock polarity, change in shock vector, repositioning the CS lead, implanting a high output device - Repositioning the CS lead. . The CS lead is used in CRT to pace the LV. CS leads are too small to act as defibrillator electrodes Where is the SICD lead electrode tunnel placed? - Left parasternal border from the xiphoid to the angle of Louis The Metronic subcutaneous implantable cardioverter shocks at: - 80 J Advantages of the SICD (sub Q) compared to standard implantable trans venous ICDs: - No fluoro needed, easy to explant, and no risk for vascular injury This x-ray shows a _________, after implantation this Boston Scientific device is programmed to shock at _______J. - S-ICD, 80 J What type of device is shown on the x-ray and post implant test? - Sub Q ICD, successful defibrillation Which ICD patient would it be best to add an array (or an additional coil depending on the device company) - Enlarged LV During an ICD generator change it is important to be sure it's sensing circuits are turned off because: - Cautery can cause the device to defibrillate. After patients ICD is implanted and the DFT is measured what power level is usually set to provide adequate safety margin for subsequent defibrillations - 10 J higher than the DFT The EP team has just implanted an ICD and is about to test it. The most important role of the circulator or other ACLS certified staff in DFT testing is to: - Stand by the external defibrillator Which of the following poses the greatest risk to an ICD patient: Microwave oven, electric blanket car, kitchen appliances, Airport metal detector, or gasoline powered chainsaw - Gasoline powered chainsaw In tiered ICD therapy with three ventricular rate zones, the fastest zone (280 to 240 ms) is termed the _______ zone. The primary therapy in this zone uses______ - VF, High energy defibrillation Why do ICDs have different zones which classify arrhythmias by rates and duration? - To treat different arrhythmias differently Current ICDs use high efficiency cardioversion and defibrillation. The most efficient shock wave forms are: - Biphasic The energy ranges available for ICD shocks range from: - 0.1-40 Joules A relatively healthy 76-year-old obese female was implanted with an ICD after witnessed VT. One year later there is no longer capture on the ventricular lead. A chest X-ray revealed the ventricular lead was dislodged and twisted around the ICD generator. What was the most likely cause? - Twiddler's Syndrome ACC, AHA, HRA Guidelines have a class 1 recommendation for implanting ICD patients who have an ejection fraction less than 40% and - EP study showing inducible VF or sustained VT Which clinical trial showed that an EP study was not necessary for ICD therapy to be effective in patient's with low EF and prior MI? - MADIT-II What is the effect in placing in a magnet over all models of ICDs - Varies with the ICD manufacturer The physician decides to cardiovert a patient with SVT. After placing the Cardioverter/defibrillator in synchronized mode and administering a sedative and analgesic to the patient, the patient suddenly becomes unresponsive and pulseless. This is the rhythm is as shown. The doctor says, shock her now! But when holding down the discharge button on the defibrillator nothing happens, why? - Fibrillation waves won't trigger the synchronizer. Need unsynchronized defibrillation Most defibrillators are constructed such that one cannot cardiovert when monitoring the patient's ECG through the: - Quick look pedals When does synchronized cardioversion deliver a shock? - A few milliseconds after the peak R wave within the QRS When defibrillating a patient in VF, what is the last step before you discharge the defibrillator? - Ensure that no one is in contact with the patient or stretcher During an EP study, a patient goes into VF. Several shocks were given through the R2 defibrillation pads. They are in effective converting the VF. While other members begin ACLS resuscitation what else should be done? - Use the second defibrillator to shock along a different axis The most important intervention to revive patients in cardiac arrest is: - Prompt defibrillation A single chamber pacemaker was implanted. The next day upon device interrogation the following EGM is recorded. What is the most likely explanation? - Loose set screw