Term
| State the contraindications to the femoral approach |
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Definition
Femoral Approach Contraindications
•Patients with peripheral vascular disease (femoral bruits or diminished peripheral pulses)
•Abdominal aortic aneurysm
•Marked iliac tortuosity
•Prior femoral arterial graft surgery
•Gross obesity. |
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Term
| State the indications and contraindications to the brachial approach |
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Definition
Brachial Approach Indications
•Severe peripheral vascular disease, making upper extremity vascular access preferable.
•A need for early ambulation or mobility (severe back pain, outpatient procedures)
•Urgent or emergent catheterization with an increased risk for bleeding (anticoagulant or thrombolytic therapy)
Contraindications
•Absence of brachial pulse
•Presence of an arteriovenous fistula
•Overlying soft tissue infection
•Severe ipsilateral axillary or subclavian vascular disease
•Inability to extend the arm at the elbow or supinate the hand. |
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Term
| List the factors influencing the choice of approach in the cath lab |
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Definition
•Patient issues (aortic occlusion, morbid obesity)
•Procedural issues (need for use of larger bore catheters)
•Patient/operator preference |
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Term
| Select the side effects of contrast agents |
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Definition
•Transient hemodynamic depression with arterial hypotension.
•Electrophysiologic changes. T wave inversion
•Sinus slowing or arrest.
•Prolonged PR, QRS, QT intervals
•Significant arrhythmia (asystole or v-tach/v-fib).
•Myocardial Ischemia owing to interruption of oxygen delivery or inappropriate arteriolar vasodilation.
•Allergic reaction.
•Cumulative Renal toxicity
•Hot flashes due to powerful vasodilation.
•Transient nausea and vomiting. |
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Term
| State the definition and methods of prevention for the formation of a hematoma, pseudoaneurysm, and arteriovenous fistula |
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Definition
• Psuedoaneurysm –
-Develops if a hematoma remains in continuity with the arterial lumen after dissolution of the clot clogging the arterial puncture site. Blood flowing in and out of the arterial puncture expands the hematoma cavity during systole.
-They keys to avoiding pseudoaneurysm formation are accurate puncture of the common femoral artery and effective initial control of bleeding after sheath removal.
• Hematoma –
-a collection of blood within the soft tissues.
-Accurate puncture and puncture site compression or closure technique to minimize hematoma formation are essential parts of good catheterization technique.
• AV Fistula
-Ongoing bleeding from the femoral puncture site that decompresses into an adjacent venous puncture site to form an arteriovenous fistula.
-The most common findings at surgery are a low puncture (the superficial femoral or profunda, transecting a small venous branch), emphasizing the importance of careful puncture technique. |
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Term
| Define vasovagal reaction and how it is characterized as one of the more common complications in the cardiac cath lab setting |
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Definition
•Inappropriate systemic arteriolar vasodilation.
•Triggered by pain and anxiety, particularly in the setting of hypovolemia. |
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Term
| State what patients should not receive protamine sulfate |
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Definition
| •Patients on NPH insulin. |
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Term
| Discuss the J-loop technique when performing a right heart catheterization with a balloon tipped catheter when approaching from both the SVC and the IVC |
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Definition
Femoral-
•Bend the tip of the catheter against the lateral right atrial wall or engage the ostium of the hepatic vein forming a large “J”.
•Rotate the loop clockwise so that the catheter tip sweeps the anterior and anteromedial Right Atrial walls to cross the tricuspid valve into the RV.
•Advance the catheter to PA through the RVOT by rotating clockwise causing the tip of the catheter to point upward into the RVOT.
SVC-
•The catheter should be advanced so the tip catches on the lateral right atrial wall and the catheter looks like the letter J on fluoroscopy.
•Next, the catheter is rotated counterclockwise so that the tip of the J sweeps the anterior right atrial wall (avoiding the coronary sinus) and jumps across the tricuspid valve into the RV.
•Because the catheter usually retains it’s J curve its tip will be pointing toward the RVOT and can easily be advanced into the PA. |
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Term
| Select the reasons for performing a transseptal left heart catheterization |
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Definition
•Direct LA pressures recording due to pulmonary venous disease.
•Distinguish between IHSS and catheter entrapment.
•Failure to get retrograde LH cath due to AS or Peripheral vascular disease.
•Danger of damaging prosthetic valves.
•Percutaneous mitral or aortic valvuloplasty. |
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Term
| State which two areas are used to draw oxygen saturations in order to determine if there is a possible left-to-right shunt |
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Definition
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Term
| Select the oxygen percent step-up used to determine if there is a left-to-right shunt |
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Definition
| •If the saturation between the SVC and PA is > or = to 8%, a left to right shunt may be present. |
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Term
| Select the percentage of patients that have a right-dominant, left-dominant, and co-dominant coronary artery circulation |
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Definition
•Right Dominant – 85%
•Left Dominant – 8%
•Co-dominant – 7% |
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Term
| Select the criteria used to determine if a patient has a right-dominant, left-dominant, or co-dominant/balanced coronary artery circulation |
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Definition
Right dominant
•RCA gives rise to PDA and the posterolateral LV branches which supply the inferior aspect of the LV and IVS.
•Supplies one or more posterior LV branches after the origin of the PDA.
•The LAD has septal branches that curve down into the IVS and diagonals over the anterolateral free wall.
Left Dominant
•Posterolateral branch, PDA and AV nodal arteries are supplied by terminal portion of the left circumflex.
•RCA supplies only the RA and the RV.
Co-Dominant
•RCA gives rise to the PDA and then terminates.
•Circumflex gives rise to all the Posterior LV branches and perhaps a parallel PDA that supplies the IVS. |
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Term
| List the mistakes that may lead to an incomplete, uninterpretable or misinterpreted study |
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Definition
•Inadequate number of projections
•Inadequate injection of contrast
•Superselective injection
•Catheter induced coronary spasm.
•Congenital variants of coronary origin/distribution
•Myocardial bridges
•Total Occlusion |
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Term
| Choose the optimal location for the catheter while performing left ventriculography |
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Definition
| Midcavity of the Left Ventricle, without ectopy, not interfering with mitral valve function. |
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Term
| Select the complications of cardiac ventriculography |
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Definition
•Arrhythmia
•Intramyocardial Staining
•Embolism
•Fasicular Block
•Hot Flash
•Depressed arterial pressures due to vasodilation
•Increased heart rate
•Depressed LV contraction
•Transient nausea and vomiting |
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Term
| State the main hazard of endomyocardial biopsy, to include the area of the heart that it is most likely to occur at and the steps that should be taken in order to detect for it. |
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Definition
Ventricular perforation
•Usually a complication of injury to the RV free wall
• Steps:
•1. Pt. complains of sharp pain- visceral pain within 1-2 minutes may develop bradycardia and hypotension.
•2. Complaints should be investigated by: Fluoroscopy of the heart border, measurement of the RA pressure waveform or performance of a portable echocardiogram.
•3. Tamponade is confirmed by cardiovascular collapse or electrical mechanical disassociation (or echo) the operator must be prepared to do an immediate pericardiocentsis. |
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Term
| Match the mode or function for the intersociety commission for heart disease resources five-position code for pacemakers |
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Definition
Position I Chamber Paced
V - Ventricle
A - Atrium
D – Atrium and Ventricle
Position II Chamber Sensed
V – Ventricle
A – Atrium
D – Atrium and Ventricle
O – None
Position III Modes of Response
T – Trigger
I – Inhibited
D – Double
O – None
Position IV Programmable Functions
P – Programmable rate and/or Output
M – Multi-programmable
C – Communicating
R – Rate Modulation
O – None
Position V
Anti tachyarrythmia fcn
B – Bursts
N – Normal rate competition
S – Scanning
E – External |
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Term
| State the greatest benefit of the cephalic stick as opposed to the subclavian stick |
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Definition
| The greatest benefit of the cephalic approach is its margin of safety compared to the subclavian stick, there is almost no risk of pnuemothorax or hemothorax. |
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Term
| Choose the area in the right atrium that is optimal for pacemaker lead placement. |
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Definition
| The right atrial appendage has become the preferred implant site for atrial leads because of it’s trabeculated nature. If poor electrical values are obtained initially it is best to search for a new position. The better the electrical characteristics the more probable long term pacing will be successful. |
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Term
| Choose the contraindications for intra-aortic balloon counterpulsation |
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Definition
Contraindications
•Significant Aortic regurgitation
•Uncontrolled bleeding diathesis.
•Abdominal aortic aneurysm
•Aortic dissection
•Uncontrolled septicemia
•Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery
•Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease |
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Term
| Select the correct reason why intra-aortic balloon counterpulsation timing is adjusted when the console is set at 1:2 pumping |
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Definition
| Counterpulsations are begun at 1:2 ratio so that preliminary timing adjustments can be made so that arterial pressure tracings with or without counterpulsation can be compared. |
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Term
| Name the correct part of the central aortic wave form and the EKG waveform that is used to time the inflation and deflation of the intra-aortic balloon |
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Definition
•Inflate at the dicrotic notch (T wave on EKG)
•Deflate before systole (at or before the “R” wave) |
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Term
| Choose the characteristics of demand and fixed mode settings for temporary pacemakers |
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Definition
-Demand mode – means the pacemaker paces when the heart rate drops below the level set by the demand rate.
-Fixed mode – the pacer works continuously at the rate set. |
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Term
| Select the characteristics of cardiac tamponade |
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Definition
Cardiac Tamponade is characterized by:
•Pulsus paradoxus.(Pg 726)
•Identical elevation of left and right-sided diastolic pressures with the loss of y descent.
•Jugular venous distension
•Compression of cardiac chambers
•Increase in ventricular interdependence (pg 725)
•The mainstay of diagnosis is echocardiography (pg 726) |
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Term
| Given the following four types of supplemental oxygen systems: nasal cannula, face mask, face mask with oxygen reservoir, and the venturi mask, select the distinguishing characteristics of each |
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Definition
a.Nasal Cannula
-Low flow system in which tidal volume mixes with ambient gas(room air)
-Provides up to 44% Oxygen
-For every l/min, the oxygen concentration will increase by 4%.
1 – 6 l/min flow rate, 21% - 44% concentration.
b.Face Mask
-Provides up to 60% oxygen concentration.
-Oxygen flow should be 6-10 LPM
c.Face Mask with Oxygen Reservoir
-Constant flow of oxygen enters an attached reservoir.
-6 l/min will provide approximately 60% concentration.
-Each l/min will increase the concentration by 10%.
-At 10 l/min it delivers 100% oxygen.
d. Venturi Mask
-Can accurately control the proportions of inspired oxygen.
-Use in patients with chronic hypercarbia (high CO2/COPD).
-Concentrations can be adjusted to 24%, 28%, 35% and 40%. |
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Term
| Select the advantages of endotracheal intubation |
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Definition
•Keeps the airway patent
•Enables delivery of a high concentration of oxygen
•Facilitates delivery of a selected tidal volume to maintain adequate lung inflation
•May protect the airway from aspiration of stomach contents or other substances in the mouth, throat, or upper airway
•Permits effective suctioning of the trachea
•Provides an alternative route for administration of resuscitation medications when intravenous (IV) or intraosseous (IO) access cannot be obtained. These medications are atropine, vasopressin, epinephrine, and lidocaine. Note however that drug delivery and drug effects following endotracheal administration are less predictable than those delivered by the IV/IO route. |
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Term
| Choose the possible complications associated with hyperventilation |
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Definition
| •Hyperventilation (too many breaths per minute or too large a volume per breath) can be harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output. It may also increase gastric inflation and predispose the patient to vomiting and aspiration of gastric contents. |
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Term
| State the correct definition of pulsus paradoxus |
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Definition
| Pulsus paradoxus is an exaggeration of then normal inspiratory decrease in systolic arterial blood pressure. In the normal state there is a 10 mmHG or less reduction in systolic art4rial pressure during inspiration. This occurs because the decrease in intrathoracic pressure that occurs during inspiration is transmitted to the heart an aorta, and because the inspiratory increase in right ventricular stroke volume does not reach the left ventricle until it has traveled through the pulmonary arteries and veins. |
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Term
| Explain, in 50 words or less, the advantages for, and reasons behind, atrial/ventricular synchrony when pacing the heart |
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Definition
Some individuals have marked drops in blood pressure when ventricular pacing is instituted. Although this is not the typical response to ventricular pacing some individuals do have dramatic and symptomatic decreases in systemic blood pressure. Several Mechanisms may be responsible for this phenomenon. Loss of LV preload volume from mistimed atrial contraction (loss of atrial “kick”).
Cardiac Output significantly increases with properly timed atrial contraction, because the atrial kick adds volume to the ventricular filling, thus increasing the end diastolic volume. |
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Term
| Given a coronary artery bypass graft, match that graft to its most common origin from the aortic wall |
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Definition
Grafts to the LCA arise form the left anterior surface of the aorta, with graft to the circumflex somewhat higher on the aorta than those to the LAD or diagonal branches.
Grafts to the RCA or distal portions of a dominant Circumflex usually originate from the right anterior surface of the aorta somewhat behind the plane of the native right coronary ostium. |
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Term
| Select the reasons for systolic pressure amplification in the periphery |
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Definition
| When radial, brachial, or femoral arterial pressures are measured and used to represent aortic pressure, it must be remembered that peak systolic pressure in these arteries may be considerably higher (by 20 to 50 mmHg) than peak systolic pressure in the central aorta. The change in waveform of arterial pressure as it travels away from the heart, is largely a consequence of reflected waves. McDonald and Murgo presented convincing evidence that the change in waveform is largely a consequence of reflected waves. These waves, presumably reflected from the aortic bifurcation, arterial branch points, and small peripheral vessels, reinforce the peak and trough of the antegrade pressure waveform, causing amplification of the peak systolic and pulse pressures. |
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Term
| List the mechanism of action under which percutaneous transluminal coronary angioplasty operates |
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Definition
-Disruption of plaque and the arterial wall.
-Loss of elastic recoil.
-Redistribution and compression of plaque components.
-Stents-scaffold the lumen and plaque open, holding back dissection flaps and stopping recoiling and renarrowing of the lumen. |
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Term
| List and discuss the characteristics of the ideal stent and stent delivery system |
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Definition
Stent-
-Biocompatibility (non-thrombogenic)
-Flexibility (for passing through catheters and tortuous vessels)
-Radiographic visibility
-Expandability (maximizing radial strength, conforming to vessel bends)
SDS-
-Profile
-Trackability
-Flexibility
-Stent crimped tightly enough to prevent dislodgment
-Balloon overhang minimized to avoid vessel trauma outside the stent
-Balloon ability to withstand high pressures without rupture
-Balloon low compliance to facilitate predictable sizing and avoid excessive growth outside the stent |
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Term
| Choose the most feared complication associated with stent implantation |
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Definition
| Subacute Stent Thrombosis |
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Term
| Given a situation involving a patient, choose the next correct step using the following algorithms |
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Definition
A.Ventricular Fibrillation / Pulseless Ventricular Tachycardia (VF/VT)
B.Pulseless Electrical Activity (PEA)
C.Asystole
D.Bradycardia
E.Tachycardia
F.Electrical Cardioversion |
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Term
| State the indications and contraindications to cardiac catheterization and angiography |
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Definition
a. Indications
•Diagnosis of obscure or confusing problems in heart disease such as chest pain of unknown cause.
•Consideration for heart surgery, as it can provide a precise and complete roadmap.
•Research.
•Acute coronary syndrome
•Incapacitating or progressive angina
•Patients with high-risk stress test.
•Diagnosis/investigation -AS;AI;MR;TR;Congestive HF;MS;PS;TS PHTN
•Endomyocardial biopsy.
b. Contraindications
•The only absolute indication is patient refusal.
•Uncontrolled ventricular irritability.
•Uncorrected Hypokalemia or Digitalis toxicity.
•Uncorrected hypertension.
•Intercurrent febrile illness.
•Decompensated heart failure (pulmonary edema).
•Anticoagulated state (PT >18sec).
•Severe allergy to radiographic contrast agents.
•Severe renal insufficiency or anuria. |
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Term
| State how microorganisms are removed |
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Definition
| •Resident Microorganisms are removed by performing a mechanical scrub |
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Term
| List the contraindications associated with PTCA |
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Definition
-Unsuitable coronary artery.
-Extremely high-risk coronary anatomy in which closure of vessel would result in patient death.
-Contraindication to coronary bypass graft surgery (however, some patients have PCI as their only alternative to revascularization)
-Bleeding diathesis.
-Patient noncompliance with procedure and post PTCA instructions.
-Multiple PTCA restenoses.
-Pt’s who cannot give informed consent. |
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Term
| Select the difference between mean arterial pressure and coronary driving pressure |
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Definition
| In patients with normal LV filling pressures, average coronary driving pressure approximates mean aortic pressure. |
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Term
| Define coronary flow reserve and list the factors responsible for microvascular disease and reduction of coronary flow reserve |
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Definition
Coronary Flow Reserve: (Pg 347)(more info on 338)
(CFR,CVR, or CFVR) is defined as the ratio of maximal to basal coronary flow and is a measure of the ability of both the epicardial artery and the microvascular resistances to achieve maximal blood flow.
Factors Responsible: (Table 18.5)
Abnormal vascular reactivity
Abnormal myocardial metabolism
Abnormal sensitivity toward vasoactive substances
Coronary vasospasm
Myocardial infarction
Hypertrophy
Vasculitis syndromes
Hypertension
Diabetes
Recurrent ischemia |
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Term
| Given one or more of the three layers of the arterial wall, match the characteristics of each to the corresponding layer |
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Definition
Intima (tunica interna) The inner coat of an arterial wall and is composed of a lining of endothelium and a basement membrane (elastic tissue or internal elastic lumina).
Tunica Media – usually the thickest layer. It consists of elastic fibers and smooth muscle.
Adventitia (tunica externa) outer layer of the arterial wall. It is composed principally of elastic and collagenous fibers. An external elastic lamina may separate the tunica externa from the tunica media. |
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Term
| Choose the proper injection technique for performing high-quality coronary injections to include the complications associated with an injection that is to timid or to vigorous |
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Definition
•High quality coronary injection requires selective injection of contrast at an adequate rate and volume to essentially replace the blood contained into the affected vessel and cause slight but continuous reflux into the aortic root.
•Too timid of an injection allows the entry of nonopaque blood into the coronary artery (producing streaming which makes interpretations of lesions difficult), and fails to visualize the coronary ostium and the proximal vessels. Too vigorous an injection may cause coronary dissection or excessive myocardial blushing, and too prolonged an injection may contribute to increased myocardial depression or bradycardia.
Adjust the rate and duration of manual contrast injection to match the filling pattern observed during the run. Injection velocity should be built up gradually during the first second until it is adequate to replace antegrade blood flow into the coronary ostium. Maintain this rate until the entire vessel is opacified and then terminated while filming the distal vessels or late filling branches continues. |
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Term
| Given an area of infarction, list the EKG leads used to determine if it is an anterior, inferior, lateral, or posterior infarction |
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Definition
•Inferior Infarction – II, III, aVF
•Lateral Infarction – I, aVL, V5, V6.
•Posterior Infarction – V1, V2, V3
•Anterior Infarction – V1, V2, V3, V4 |
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Term
| Describe the EKG changes associated with myocardial injury, ischemia, or infarction |
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Definition
Injury – elevated ST segment
-Signifies an acute process, ST returns to baseline with time.
-If “T” wave is also elevated off baseline, suspect pericarditis.
-Location may be similar to infarction location.
-If ST depression, suspect digitalis effect or subendocardial infarction.
Ischemia – inverted “T” wave
-Inverted “T” wave is symmetrical
-“T” waves are usually upright in leads, I, II, V2 – V6 so check these leads for T wave inversion.
Infarction – Q wave
-Small Qs may be normal in V5 and V6.
-Abnormal Q must be one small square wide (.o4 secs).
-Also abnormal if Q wave depth is greater than 1/3 of QRS height in lead III. |
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Term
| State the normal amount of fluid contained in the unstretched pericardium as well as when the pericardial effusion becomes significant |
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Definition
•15-35 ml
When there are signs of hemodynamic compromise |
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Term
| List and discuss the three types of angioplasty balloon types |
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Definition
a. Over the Wire Balloon Catheter
-Has a central lumen throughout the length of the catheter for the guidewire and another separate lumen for the wire inflation.
b. Rapid Exchange Balloon Catheter
-Also called Monorail
-Only a variable length of the shaft has two lumens, one for the wire and the other for the balloon.
c. Fixed-wire Balloon Catheter
-Balloon is mounted on the wire with a distal flexible steering tip
-Have only one enclosed lumen, for balloon inflation. |
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Term
| List the normal caliber of the major coronary arteries and of a 6fr guide catheter |
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Definition
Left Main – 4.5 + 0.5 mm
LAD - 3.7 + 0.4 mm
Non Dominant Circ – 3.4 + 0.5mm
Dominant Circ- 4.2 + 0.6mm
Non Dominant RCA- 2.8 + 0.5mm
Dominant RCA- 3.9 + 0.6mm
6fr equals 2mm |
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Term
| Explain, in 100 words or less, the reasons for obtaining an echocardiogram before performing a pericardiocentesis |
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Definition
•Echo documents the presence, location, and size of effusion as well as reveal the extent to which the pericardial pressure is compromising cardiac function by showing diastolic collapse of the RV.
•The probability of success and safety of the pericardiocentesis is related to the size of the effusion because it has been shown that the procedure is likely to be uncomplicated if both anterior and posterior free spaces (>10mm) are present. (page 730) |
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Term
| State the reasons for propping up a patient at a 45-degree elevation while performing a pericardiocentesis |
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Definition
| The patient is seated at 30-45 degree elevation to permit pericardial fluid to pool on the inferior surface of the heart. |
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Term
| Choose the hemodynamic differences between a pericardial constriction and cardiac tamponade |
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Definition
| The pericardial restraint of the left and right ventricles in cardiac tamponade is coupled by uniform liquid pressure on the heart, whereas it is uncoupled in constriction given regional differences in surface pressure. Tamponade produces greater ventricular interdependence, so that increased inspiratory filling of the RV results in highly coupled reduction in filling of the LV (hence pulsus paradoxus), whereas constriction has a more modest effect on ventricular interdependence but more prominently reduces the effective elastance of the thin-walled RV (hence the Kussmal sign, an increase in RA pressure during inspiration). Normal and tamponade patients demonstrate a fall in systemic venous and RA pressures during inspiration, where there is typically little respiratory variation in constriction (negative intrathoracic pressures are not communicated to the intrapericardial space and the right heart) and in extreme cases increases during inspiration. |
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Term
| Describe the benefits of intraaortic balloon counterpulsation to include the hemodynamic effect, and the effects on oxygen demand from the heart |
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Definition
| IABP counterpulsation increases myocardial oxygen supply and decreases myocardial oxygen demand. Inflation at the onset of diastole (dicrotic notch) results in diastolic pressure augmentation, which increases coronary artery and systemic perfusion. Deflation of systole just prior to systole (anacrotic notch) results in decreased ventricular afterload, which decreases myocardial oxygen consumption and increases the cardiac output. |
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Term
| Choose the correct position of the IAB |
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Definition
| • The marker at the tip of the balloon should be left 1 to 2 cm below the top of the aortic arch. Fluoroscopic observation of the balloon inflated above the renal arteries confirms optimal placement. |
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