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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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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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Brady Pacing Test - #1
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____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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Brady Pacing Test - #1
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____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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____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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Brady Pacing Test - #1
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____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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____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
BRADY PACING TEST - #2
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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Brady Pacing Test - #2 2
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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Brady Pacing Test - #2 3
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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Brady Pacing Test - #2 4
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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Brady Pacing Test - #2 5
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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Brady Pacing Test - #3 1
BRADY PACING TEST - #3
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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Brady Pacing Test - #3 3
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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Brady Pacing Test - #3 4
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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Brady Pacing Test - #3 5
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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Brady Pacing Test - #3 6
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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Brady Pacing Test - #3 7
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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Brady Pacing Test - #4 1
BRADY PACING TEST - #4
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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Brady Pacing Test - #4 2
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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Brady Pacing Test - #4 3
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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Brady Pacing Test - #4 4
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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Brady Pacing Test - #4 5
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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Brady Pacing Test - #4 11
Case #3
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Brady Pacing Test - #4 12
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Brady Pacing Test - #4 13
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Brady Pacing Test - #4 14
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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Brady Pacing Test - #4 15
CASE #4
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Brady Pacing Test - #4 16
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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Brady Pacing Test - #4 17
CASE #5
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Brady Pacing Test - #4 18
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
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BRADY PACING TEST - #2
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
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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
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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
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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
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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
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16. Identify the optimized AV delay for this patient. Explain your rationale.
AV 280 AV 240
AV 200 AV 180
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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
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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)
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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.
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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.
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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
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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
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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?
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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
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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?
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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!
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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.
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NASPE PRE-TEST
History: A VVIR pacemaker was implanted three months earlier. The ECG
demonstrated loss of capture and intermittant loss of sensing.
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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
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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
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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
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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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11
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