RCIS Board Exam 2023 Questions and
Answers with complete solution
What is the pressure as blood enters the right atrium? Answer- 5mmHg
What organ system in the body acts on the blood in the vessels to make a pressure of
5mmHg? Answer- Deep skeletal muscle pump system
What pressure is the blood under as it goes from the RA through the tricuspid valve?
Answer- 5mmHg
The bigger the diameter of the valve the _ pressure is needed to move blood
across it. Answer- Less
The smaller the diameter of the valve the pressure is needed to move blood
across it. Answer- more
What is the largest valve in the heart? Answer- tricuspid valve
What is the normal right ventricular systolic pressure? Answer- 25mmHg
How much smaller is the pulmonic valve than the tricuspid valve? Answer- 5x smaller.
It takes 5mmHg to get across the tricuspid valve and 25mmHg to get across the
pulmonic valve.
Which valve has a bigger diameter, the tricuspid or pulmonic valve? Answer- Tricuspid
Which valve requires more pressure to move across it, the tricuspid or the pulmonic?
Answer- pulmonic
Valve A requires 5mmHg to move blood and valve B requires 30mmHg. Which valve
has a smaller diameter? Answer- Valve B
What is the right ventricular diastolic pressure? Answer- 5mmHg
What is the RV EDP? Answer- 5mmHg
Why is the RV EDP not zero? Answer- Because some blood is not ejected out. The
heart is not a perfectly efficient pump.
What is a normal RV ejection fraction? Answer- 55-60%
What is EDP? Answer- End Diastolic Pressure. An efficient heart has an ejection
fraction of 55-60%, this leftover blood in the ventricle is under a resting (diastolic)
pressure.
What is a normal diastolic pressure in the pulmonary artery? Answer- 7-12mmHg
What is the normal left atrial pressure? Answer- 7-12mmHg
What is the normal O2 concentration of a RBC leaving the lungs? Answer- 98%
What is the normal O2 concentration of a RBC when it returns to the RA? Answer70%
How much O2 is a RBC able to give up to the organs? Answer- 30% of its O2
True/False: If someone has a higher EDP there is less damage to the heart. AnswerFalse, the higher the EDP the more damage. More blood is being left and not pumped
out.
What is a normal wedge pressure? Answer- 7-12mmHg
If the RBCs go through the lungs faster than 7-12mmHg what happens? Answer- The
RBCs have less time to get the O2 needed to fill them up fully.
True or False: The higher the wedge pressure the faster the RBCs go through the lungs
and the less O2 they are able to acquire. Answer- True.
COPD is elevated wedge pressure. True or False Answer- True. 30-40mmHg is not
unusual. RBCs move so fast that they come out of the lungs with much less than 98%
O2.
COPD O2 sats can be in the low to mid 80’s. True or false Answer- True.
Why is the wedge pressure indicative of the LA pressure? Answer- Because there are
no valves in between, just the lung system. Since no valves the pressure in the LA
should be the same. When the leaflets open up on the mitral valve it is possible to see
into the left ventricle.
When the mitral valve leaflets open up and the wedge catheter is able to see into the LV
what is the pressure that it sees? Answer- LV EDP
What is a normal LV EDP? Answer- 7-12mmHg
If the LV EDP goes up and the LA pressure goes up, what other pressure would you
expect to rise? Answer- The wedge pressure
What would increase your right atrial pressure? Answer- tricuspid stenosis
Where would you see a high RA pressure demonstrated on a patient? Answer- Jugular
vein distention
If a person has an RV MI will the RV systolic pressure be affected? Answer- No matter
how big the MI the systolic pressure will not change. The RV EDP will increase as the
RV is not as able to push the blood out as effectively as before the MI.
Would an RV MI affect the diameter of the pulmonic valve or the diameter of the
pulmonic arteries? Answer- No
If a person has an RV MI would the RV EDP be affected? Answer- Yes. If the muscle
fibers are dead the heart’s ability to squeeze is impacted so more blood is left behind.
What would cause the LV systolic pressure to increase? Answer- Aortic stenosis.
(What would prevent a RBC from moving forward from the RV?)
What would cause your LVEDP to increase but not increase your LV systolic pressure?
Answer- LV MI would increase the LV EDP because the heart is less effective as a
pump. As the LV is able to eject less blood, the end diastolic pressure gets higher.
The systolic pressure does not need to increase because that is the pressure to get the
blood past the aortic valve.
As the EF (ejection fraction) goes down the EDP (end diastolic pressure)
__. Answer- Goes up
What is the RV systolic pressure of pulmonic stenosis? Answer- Any pressure higher
than 25mmHg is pulmonic stenosis. The narrower the valve the ore pressure is needed
to move across it. The muscle fibers need to generate more pressure to get RBCs past
the stenotic valve.
What happens to the pressure in the RA in the case of tricuspid regurgitation? AnswerThe RA pressure increases.
Blood likes the path of less pressure. It will go back across the tricuspid valve when
there is less pressure due to regurgitation. This causes the RA to carry more blood
because it continues to fill with blood from the IVC and SVC in addition to the blood
flowing back from the RV through tricuspid regurgitation.
What is the PA pressure in COPD? Answer- Wedge pressure is elevated in COPD and
this causes a backflow of pressure to the PA.
What is the special protective factor of the LA? Answer- The LA has a protein that
senses volume. If the volume increases because of MS or MR then the LA will sense
that and allow the muscle fibers to get longer in the LA. The LA gets bigger to hold the
volume and to prevent the pressure from rising in the lungs.
What is the PA pressure in someone with mitral stenosis? Answer- The pulmonary
artery pressure will eventually increase because the pressure in the LA will increase,
which will cause the wedge pressure to increase, which will ultimately lead to an increas
in the pulmonary arteries
What is the pulmonary artery pressure in someone with mitral regurgitation? AnswerThis increases the volume of blood in the LA which increases the pressure there. The
LA is unique and protective, but eventually this will lead to an increase in pulmonary
artery pressure.
Which chamber of the heart is larger LV or RV? Answer- The chamber of the RV is
larger because the LV has more muscle to push past the aortic valve to the body.
Can your PA pressure ever be greater than your RV systolic pressure? Answer- No.
The pulmonary artery pressure cannot be greater because the RV would have to
increase to allow the blood to flow to the PA. Blood cannot flow up a gradient.
What is the PCWP of mitral regurgitation? Answer- In a chronic situation, because the
LA is protective, the PCWP will be elevated above the normal.
What is the PCWP of mitral stenosis? Answer- In a chronic situation, because the LA
is protective, the PCWP will elevate.
What is the PCWP of an LV MI? Answer- The EDP goes up, the LA pressure will go
up. This will cause the PCWP to increase.
What is a normal RVEDP? Answer- 5mmHg
What is a normal LVEDP? Answer- 7-12mmHg
EDP represents __? Answer- The amount of blood left after systole
When we measure CO in a patient, which ventricle are we measuring it out of?
Answer- The Right Ventricle. It is assumed to be the same as the LV.
True or False: The RV and LV have the same number of muscle fibers, but the LV
works harder and therefore gets bigger in diameter. Answer- True
What is a normal RV systolic pressure? Answer- 25mmHg
What is the normal systolic LV pressure? Answer- 120mmHg
What is the pressure as blood enters the right atrium?
5mmHg
What organ system in the body acts on the blood in the vessels to make a pressure of 5mmHg?
Deep skeletal muscle pump system
What pressure is the blood under as it goes from the RA through the tricuspid valve?
5mmHg
The bigger the diameter of the valve the __ pressure is needed to move blood across it.
Less
The smaller the diameter of the valve the _ pressure is needed to move blood across it.
more
What is the largest valve in the heart?
tricuspid valve
What is the normal right ventricular systolic pressure?
25mmHg
How much smaller is the pulmonic valve than the tricuspid valve?
5x smaller. It takes 5mmHg to get across the tricuspid valve and 25mmHg to get across the pulmonic valve.
Which valve has a bigger diameter, the tricuspid or pulmonic valve?
Tricuspid
Which valve requires more pressure to move across it, the tricuspid or the pulmonic?
pulmonic
Valve A requires 5mmHg to move blood and valve B requires 30mmHg. Which valve has a smaller diameter?
Valve B
What is the right ventricular diastolic pressure?
5mmHg
What is the RV EDP?
5mmHg
Why is the RV EDP not zero?
Because some blood is not ejected out. The heart is not a perfectly efficient pump.
What is a normal RV ejection fraction?
55-60%
What is EDP?
End Diastolic Pressure. An efficient heart has an ejection fraction of 55-60%, this leftover blood in the ventricle is under a resting (diastolic) pressure.
What is a normal diastolic pressure in the pulmonary artery?
7-12mmHg
What is the normal left atrial pressure?
7-12mmHg
What is the normal O2 concentration of a RBC leaving the lungs?
98%
What is the normal O2 concentration of a RBC when it returns to the RA?
70%
How much O2 is a RBC able to give up to the organs?
30% of its O2
True/False: If someone has a higher EDP there is less damage to the heart.
False, the higher the EDP the more damage. More blood is being left and not pumped out.
What is a normal wedge pressure?
7-12mmHg
If the RBCs go through the lungs faster than 7-12mmHg what happens?
The RBCs have less time to get the O2 needed to fill them up fully.
True or False: The higher the wedge pressure the faster the RBCs go through the lungs and the less O2 they are able to acquire.
True.
COPD is elevated wedge pressure. True or False
True. 30-40mmHg is not unusual. RBCs move so fast that they come out of the lungs with much less than 98% O2.
COPD O2 sats can be in the low to mid 80’s. True or false
True.
Why is the wedge pressure indicative of the LA pressure?
Because there are no valves in between, just the lung system. Since no valves the pressure in the LA should be the same. When the leaflets open up on the mitral valve it is possible to see into the left ventricle.
When the mitral valve leaflets open up and the wedge catheter is able to see into the LV what is the pressure that it sees?
LV EDP
What is a normal LV EDP?
7-12mmHg
If the LV EDP goes up and the LA pressure goes up, what other pressure would you expect to rise?
The wedge pressure
What would increase your right atrial pressure?
tricuspid stenosis
Where would you see a high RA pressure demonstrated on a patient?
Jugular vein distention
If a person has an RV MI will the RV systolic pressure be affected?
No matter how big the MI the systolic pressure will not change. The RV EDP will increase as the RV is not as able to push the blood out as effectively as before the MI.
Would an RV MI affect the diameter of the pulmonic valve or the diameter of the pulmonic arteries?
No
If a person has an RV MI would the RV EDP be affected?
Yes. If the muscle fibers are dead the heart’s ability to squeeze is impacted so more blood is left behind.
What would cause the LV systolic pressure to increase?
Aortic stenosis. (What would prevent a RBC from moving forward from the RV?)
What would cause your LVEDP to increase but not increase your LV systolic pressure?
LV MI would increase the LV EDP because the heart is less effective as a pump. As the LV is able to eject less blood, the end diastolic pressure gets higher.
The systolic pressure does not need to increase because that is the pressure to get the blood past the aortic valve.
As the EF (ejection fraction) goes down the EDP (end diastolic pressure) __.
Goes up
What is the RV systolic pressure of pulmonic stenosis?
Any pressure higher than 25mmHg is pulmonic stenosis. The narrower the valve the ore pressure is needed to move across it. The muscle fibers need to generate more pressure to get RBCs past the stenotic valve.
What happens to the pressure in the RA in the case of tricuspid regurgitation?
The RA pressure increases.
Blood likes the path of less pressure. It will go back across the tricuspid valve when there is less pressure due to regurgitation. This causes the RA to carry more blood because it continues to fill with blood from the IVC and SVC in addition to the blood flowing back from the RV through tricuspid regurgitation.
What is the PA pressure in COPD?
Wedge pressure is elevated in COPD and this causes a backflow of pressure to the PA.
What is the special protective factor of the LA?
The LA has a protein that senses volume. If the volume increases because of MS or MR then the LA will sense that and allow the muscle fibers to get longer in the LA. The LA gets bigger to hold the volume and to prevent the pressure from rising in the lungs.
What is the PA pressure in someone with mitral stenosis?
The pulmonary artery pressure will eventually increase because the pressure in the LA will increase, which will cause the wedge pressure to increase, which will ultimately lead to an increas in the pulmonary arteries
What is the pulmonary artery pressure in someone with mitral regurgitation?
This increases the volume of blood in the LA which increases the pressure there. The LA is unique and protective, but eventually this will lead to an increase in pulmonary artery pressure.
Which chamber of the heart is larger LV or RV?
The chamber of the RV is larger because the LV has more muscle to push past the aortic valve to the body.
Can your PA pressure ever be greater than your RV systolic pressure?
No. The pulmonary artery pressure cannot be greater because the RV would have to increase to allow the blood to flow to the PA. Blood cannot flow up a gradient.
What is the PCWP of mitral regurgitation?
In a chronic situation, because the LA is protective, the PCWP will be elevated above the normal.
What is the PCWP of mitral stenosis?
In a chronic situation, because the LA is protective, the PCWP will elevate.
What is the PCWP of an LV MI?
The EDP goes up, the LA pressure will go up. This will cause the PCWP to increase.
What is a normal RVEDP?
5mmHg
What is a normal LVEDP?
7-12mmHg
EDP represents __?
The amount of blood left after systole
When we measure CO in a patient, which ventricle are we measuring it out of?
The Right Ventricle. It is assumed to be the same as the LV.
True or False: The RV and LV have the same number of muscle fibers, but the LV works harder and therefore gets bigger in diameter.
True
What is a normal RV systolic pressure?
25mmHg
What is the normal systolic LV pressure?
120mmHg
Is the LVEF the same as the RVEF?
Yes. The LVEF and the RVEF are the same
Is the stroke volume in the RV the same as the LV?
yes. They are the same.
Is the CO the same in the LV and RV?
Yes. They are the same.
Why is the RVEDP different from the LVEDP?
As the LV muscle fibers get bigger there is less room in the left chamber for blood. The EDP is different in the LV and the RV because the RV has much more room for the blood left than the LV because it is full of dilated muscle fibers. This is the increase in pressure.
The muscle fibers of the coronary arteries run circular to the artery. True or False
False. They run longitudinal (the length) of the artery. If they wrapped around the coronary artery then the blood would be squeezed/compressed but not move. The contraction of arteries is done is a systematic way.
The intima of an artery is covered in what kind of cells?
Endothelium.
What is a major issue with endothelium in the arteries?
The endothelium do no stick to the muscle fibers of the media very well. They are washed away easily by turbulent flow.
What are the four main jobs of the endothelium?
- Create a slippery environment for blood flow
- Reproduce quickly to replace any lost endothelial cells.
- Make nitric oxide to dialate the arteries and make easier flow.
- Act as a magnet for bad cholesterol.
What is the media part of an artery?
The muscle layer
What is the adventia layer of an artery?
It is the outside layer of the coronary artery. It allows O2 to come in to give the muscle fibers that they need to do their job.
What is the pressure of the arterioles delivering O2 to a the adventia of an artery?
7-12mmHg
When you inflate a balloon into an artery and the balloon is on healthy parts of the artery, it causes muscle damage and injures the capillaries. True or False
True. This causes internal injury by the balloon. The ballon cracks the plaque, and the muscle fibers and the capillaries under the plaque are also injured.
T/F a lesion in a coronary artery exerts pressure to the cell wall causing the arterioles not to be able to deliver O2, causing the muscle fibers to start to die, and making the artery less able to expand and contract.
True
True or False: When we expand a balloon we are resetting the muscle fiber memory so that it believes that the over expansion is normal.
True
How long does it generally take for a coronary artery to “remember” their old muscle fiber memory and try to go back to it’s regular size?
31-180 days
Why were stents invented?
To prevent coronary artery muscle fibers from returning to their old muscle fiber size between 31-180 days
What starts the clotting cascade in coronary arteries?
When endothelial cells are knocked off and the muscle fiber is exposed.
Is this stent full apposed?
This stent is fully apposed
Is this stent full apposed?
This stent is not fully apposed
Is this stent full apposed?
This stent is not fully apposed
Is this stent full apposed?
This stent is not fully apposed
Is this stent full apposed?
This stent is fully apposed
What is layer 1 on this image?
Adventitia
What is layer 2 on this image?
Media
What is layer 3 on this image?
Intima
What is layer 4 on this image?
lumen
Identify the structures on this IVUS image from left to right.
adventitia, media, intima, and catheter.
What is “A” in this IVUS image?
Catheter
What is “B” in this IVUS image?
Intima or true lumen
What is “C” in this image?
Thrombus/ blood behind the flap
What is “D” in this image?
D is the flap or dissection.
What is an eccentric plaque?
Plaque that only covers part of the diameter of the artery.
What is concentric plaque?
Plaque that covers all the way around the artery.
What is the clotting cascade?
Series of chemical reactions involving 12 plasma clotting factors that lead to final conversion of fibrinogen into a stabilized fibrin mesh with the purpose of controlling bleeding.
How are platelets activated?
Platelets are not activated until they stick to the collagen on the muscle fiber of the coronary artery. This sends a message to the liver to release the first clotting factor.
What does the 1st factor, Von Willebrand factor do in the clotting cascade? Where is it release?
VWF is released by the liver. It’s job is to make sure that the platelets sticks to the muscle fiber.
What is released right after the Von Willebrand factor? What is its purpose?
Factor VIII. it’s job is to make sure that the platelets stick even better than VWF, but it cannot be released by the liver until after the VWF.
After VWF, and factor VIII are released, what is released next?
The body will release calcium, and the liver will release arachidonic acid.
What does arachidonic acid do?
Goes to the platelets allowing it to stick even more tightly. Cannot be released until after VIII.
Why do patients take aspirin (ASA) during a heart attack?
It blocks the action of arachidonic acid. The platelets are not able to stick to the muscle fibers. As a person is having a heart attack they can continue to make clots. The ASA will continue to prevent the action of arachidonic acid and help prevent the formation of more clots.
Typically we tell patients that it makes the platelets less sticky.
After the action of arachidonic acid is reported back to the liver, what does the liver release?
ADP Adenosine diphosphate
What does ADP (Adenosine diphosphate) do?
ADP prepares the IIb/IIIa sites. If we think of a platelet as looking like a stop sign, the ADP prepares each corner so that it can stick to the corner of another platelet. ADP prepares the corners of the IIb/IIIa sites for fibrin.
Where does Plavix work in the clotting cascade?
It blocks the action of ADP. It prevents it from going to the platelet plug and therefore prevents it’s action of preparing the IIb/IIIa sites for fibrin.
Where does Brillenta work in the clotting cascade?
It blocks the action of ADP. It prevents it from going to the platelet plug and therefore prevents it’s action of preparing the IIb/IIIa sites for fibrin.
Where does Effient work in the clotting cascade?
It blocks the action of ADP. It prevents it from going to the platelet plug and therefore prevents it’s action of preparing the IIb/IIIa sites for fibrin.
Where does ReaPro work in the clotting cascade?
It is a IIb/IIIa inhibitor. It sits on the IIb/IIIa site so that fibrin cannot sit there, therefore platelets cannot stick together.
What factors make up the phase 1 of clotting?
VWF (Von Willebrand), VIII, body releases calcium, AA (arachidonic acid), then TAX2 which is NOT ON THE BOARD EXAM, IIb/IIIa
All meds that work in phase one of the clotting cascade are called?
antiplatelet agents.
What are some of the antiplatelet drugs?
Aspirin, Plavix, Brillenta, Effient, ReaPro
Is ASA a antiplatelet drug?
Yes. Blocks the action of arachidonic acid.
Is Plavix an antiplatelet agent?
yes. Blocks the action of ADP.
Is ReaPro an antiplatelet agent?
Yes. Blocks the agent of IIb/IIIa.
What is the first step in phase II of the clotting cascade?
The liver releases Tissue Factor
Where are all clotting factors created?
The liver
What do all the clotting factors require?
Vitamin K.
What is the most effective agent for thinning blood?
coumadin
How does Coumadin work?
Coumadin inactivates Vitamin K
What is the reversal agent for coumadin?
Vitamin K
Where does lovanox work in the clotting cascade?
It prevents the conversion of X to Xa. It prevents the formation of thrombin. No thrombin = no fibrin
Where does heparin work in the clotting cascade?
It prevents prothrombin from transforming to thrombin.
Where does Angiomax work in the clotting cascade?
Angiomax prevents prothrombin from transforming to thrombin AND Thrombin from transforming to fibrinogen.
Which drug is more effective, Heparin or Angiomax?
Angiomax because it works to prevent prothrombin converting to thrombin and prevents thrombin from acting on fibrinogen.
What are antithrombin agents?
Heparin, angiomax, lovenox
What is the other name for Plavix? What class of medication is it?
Clopidogrel and it is antiplatelet
What class of medication is ASA?
antiplatelet
What is the other name for Effient? What class of medication is it?
Prasagrel/antiplatelet
What is the other name for Brilinta? What class of medication is it?
ticagrelor/antiplatelet
What is the other name for Heparin? What class of medication is it?
Heparin Sodium/antithrombin
What is the other name for Angiomax? What class of medication is it?
Bivalirudin/antithrombin
What is the other name for Reopro? What class of medication is it?
Abciximab/antiplatelet
What is the other name for coumadin?
warfarin/antithrombin It works by dissolving vitamin k
Often antithrombins are called _?
Anticoagulants
What is the other name for Pradaxa? What class of medication is it?
Dabigatran/antithrombin
What is the other name for Kengreal? What class of medication is it?
Cangrelor/antiplatelet
What is the best way to tell that by IVUS that a stent is properly apposed?
The struts will be equadistant
What is the best stent?
The one with the thinnest struts. The bigger the stent the more it decreases the inner diameter of the vessel and increases the internal pressure of the vessel.
What is the tip of the rotobladder made of?
It has a diamond burr.
How many revolutions per minute does the Rotobladder make?
180-220,000 revolutions per minute
What is the name the test will use for cutting balloon?
Scoring balloon
What is the best practice for inflating and deflating a scoring balloon?
1 atmosphere per second up and down. Not too fast not too slow.
What is an ICE catheter?
Intracardiac Echo catheter
When is a good time to use an ICE cathether?
during a septal closure
What is the active ingredient in topical pad closure devices?
Collagen
What is the Inoue balloon used for?
Valvuloplasty
When do you use Angiojet?
is a mechanical thrombectomy device
Where do you use a filter wire?
It is used in the carotid arteries and for vein grafts
What is the other name for Integrelin? What class of medication is it?
eptifibatide/antiplatelet
What is the other name for Lovenox? What class of medication is it?
Enoxaparin sodium/Antithrombin
When doing an IVUS pullback how fast should you go?
.5mm per second. If not using a sled it can cause an artifact
What is a mitral valve clip?
MitraClip can be sued to clip the two leaflets of the mitral valve together reducing regurgitation
What is a TAVR?
Transcatheter Aortic Valve Replacement is a minimally invasive procedure to replace a narrowed aortic valve that fails to open properly, i.e. stenosis
How should adenosine be delivered?
adenosine should be dosed based on the patients weight. It should never be given IC due to deadly reactions. IV is okay.
What is the function of pericardial fluid?
lubricates; allows heart to beat without rubbing the pericardium and keeps friction to a minimum.
What is a normal amount of pericardial fluid?
5-50cc
When do you equalize when doing FFR or IFR?
Equalizing/Normalizing should be done before the lesion.
When calculating for FFR/IFR what numbers do you use?
The mean pressure after the lesion, divided by the mean pressure before the lesion.
For example:
Proximal pressure 160/90 Mean 113
Distal pressure 100/40 Mean 62
62/113 = .55
The mean is less than .80 and therefore needs to be fixed.
When do coronary arteries perfuse?
During diastole
When the valve leaves close the ostium does what?
opens for blood
What equipment do you need for a pericardiocentesis?
Echocardiography with a cardiac probe
Sterile probe cover and sterile echo gel
16 to 18 gauge Teflon-sheathed needle
6 Fr to 8 Fr dilator and introducer sheath
J-tipped guidewire
Drainage catheter: pigtail angiocatheter 6 Fr to 8 Fr or specific pericardial drainage set
Disposable flushing system to maintain patency of the catheter
What is the function of the pericardium?
protect heart from being bruised in normal movement. Does not aid diastole or systole. Just flexible sack that moves.
What makes up the pericardial sack?
pericardial sack 2 layers with 5-30cc of fluid in between
What is cardiac tamponade?
compression of the heart by an accumulation of fluid in the pericardial sac
What can cause cardiac tamponade?
pericardial effusion or chest trauma
What is happening in cardiac tamponade?
A decrease in arterial blood pressure (hypotension) with reflex tachycardia
As the compression makes it harder for the ventricles to contract, SV goes down. To keep up cardiac output the heart beats faster. This increases how much blood gets into the pericardial space.
What are the first signs of cardiac tamponade?
O2 sats drop. PH of blood in the pericardial sack is acidic and irritates the nerves causing chest pain. Patient may become slightly unresponsive because profusion pressure is being lost to the brain.
What is the fix for cardiac tamponade?
Pericardial tap/Pericardiocentesis
What is the process for doing a pericardiocentesis?
Put the needle sub xyphoid area, elevate the patient to 30 degrees, no more than 45 (use a wedge) which puts the heart in a specific position. If patient is on coumadin, must use ultrasound to guide the needle to ensure that you do not puncture the heart.
Usually use an echo to guide.
What is pulsus paradoxus?
decrease in >10mmHG in systole during inspiration
What is the difference in pressure between pulsus paradoxus and tamponade?
PP is about 10mmHg and Tamponade has much higher pressures. Up to 20-30mmHg
Name 3 reasons why someone would need a pacemaker?
Sick Sinus Syndrome (SSS)
AV conduction issue
Needed surgery
True or false: The LV has more muscle fibers than the RV
False. Same number of fibers, but left sided fibers are bigger in diameter.
The same amount of electricity is needed to cause the RV and LV to contract. T or F
True
What is electricity of the heart measured in?
milivolts or milliamps
How is the amount of time measured when speaking of electricity in the heart?
milliseconds
What is a synchronous pacemaker?
Demand pacemaker that gives a stimulus only when needed.
What is a asynchronous pacemaker?
Fixed pacemaker that gives a stimulus regardless of the heart activity
Where can a heart be paced?
atrium, ventricle, dual
What is capture?
The amount of energy needed to cause contraction.
What is threshold?
After capture the signal is moved down to the point that the signal is lost, that is threshold.
When doing a pacemaker how long should you wait between Capture/Threshold before doing another Capture/threshold?
5-10 minutes. The second capture is usually lower as the heart adapts to the lead.
Which capture do you record and keep?
The second capture.
What is the order of electrical conduction of the heart?
SA node through the internodal pathway to the AV node, Bundle of His, L/R bundle branches to the purkinje fibers
What part of the pacemaker triggers the beat?
The generator triggers the beat.
What is the first letter in a pacemaker type?
Paced:
V – Ventricle
A – Atria
D – Dual
What is the second letter in a pacemaker type?
Sensed
V – Ventricle
A – Atria
D – Dual
What is the 3rd letter in a pacemaker type?
Response
T – Triggers
I – Inhibits pacing
D – Dual (triggers and inhibits)
What is a VVI pacer?
It paces the right ventricle, senses the right ventricle,
it inhibits the response
What type of pacemaker does this strip show?
VVI
How many leads are in this strip?
one
Where is the lead on this strip?
Right Ventricle
On a DDD pacemaker how many leads are there? Where are the leads located?
two
RV and RA
What would cause the pacing generator in a pacemaker to not send out electricity?
End of life of the generator
What happens with failure to capture?
Electricity is sent but it does not cause systole
What would cause a failure to capture?
A lead fracture or a lead that is not in contact with the wall of the heart.
What is this ekg showing?
Failure to sense
Why would someone need a Bi-ventricular pacemaker?
To reestablish between the synchrony between the right ventricle and left ventricle. (There is a slight pause between the two ventricles. Going at the same time is a problem and waiting too long is also a problem.)
If you put in a bi-ventricular device where are the leads?
One in the right atrium, right ventricle, one in the coronary sinus to pace the ventricle synchrony.
If there is only one pacemaker lead in the atrium where is the problem?
The SA Node
If there is only one pacemaker lead in the ventricle, where is the problem?
AV Conduction delay
In an AV pacer, the first spike is responsible for what?
AV Contraction
Where are leads placed for a pacemaker, in the subclavian vein or internal jugular?
Subclavian
Why do paced beats look like PVCs (upside down)?
The signal moves in a negative direction. The signal comes from the perkinje fibers up to the SA Node
Can you defibrillate a patient with a pacemaker?
Yes but do not put the paddle over the pacemaker
Where are epicardial coronary arteries?
Draped on the heart, these are the ones that we fix.
True or False: Epicardial coronary arteries dilate significantly with exercise?
False. The arterioles dialate.
What vessels bring extra O2 to cardiac muscles when exercising?
arterioles
When arterioles dilate to feed muscle fibers, what happens to the pressure?
The pressure goes down when the arterioles dilate.
What happens to the blood flow to the muscle fibers if you have an MI?
The arterioles would not need to oxygenate dead muscle so the impacted arterioles shut down, shrink and collapse.
With FFR, where do you measure the pressure?
The tip of the transducer and the tip of the guide. The two pressures should be the same.
What does adenosine do in FFR?
It dilates the arterioles
True or False: An FFR greater than 0.8 is not significant and should not be fixed.
True
What FFR score indicates that a lesion is significant and should be repaired?
less than .8
True or False: When doing FFR if the arterioles do not dilate, do not fix the lesion.
True. The arterioles not dilating is a sign that the muscle fibers are dead and there is nothing to deliver O2 to.
What is IFR?
It is similar to FFR without adenosine. IFR wire is more sensitive than FFR wire, and gets more information without requiring adenosine.
When do coronary arteries perfuse?
diastole
Where do you place the IFR wire?
As distal as possible to the lesion
In IFR what lesion calculation is too high to fix?
0.9 or greater
In IFR, what lesion calculation should you repair?
0.86
“Point 86 means you fix!”
What type of catheter is used with impella?
a pigtail catheter
What french size catheter an impella?
7 french
T/F: The proximal end of the impella catheter is located in the aorta.
True
Where is the distal end of an impella located?
LV
What are four reasons you would use an impella?
Systolic heart failure
Big MI
cardiogenic shock
high risk PCI
What is the screw type mechanism that the Impella is based on?
Archimedes Screw
Way to draw blood without using suction. Doesn’t traumatize the RBCs like a sucking device would.
How much CO can an Impella 5.0 deliver?
4-5 Liters per minute
What RPM does the Impella run at?
33,000rpm
True or false: You can turn the Impella off when it is not needed.
False. The patient must be weaned off of the Impella.
What is the proximal placement of an IABP catheter?
Left subclavian
Where is the distal tip placement of an IABP?
Distal tip is above the renal arteries.
How does the balloon pump catheter inflate?
It will inflate from the bottom down, pushing helium up to the top of the catheter.
What does a IABP do?
It decreases afterload, increases coronary perfusion, increases SV, increases CO, and decreases the extent of an MI.
How does a IABP increase SV?
It creates a vacuum in the aorta which will pull blood out fo the LV without causing the LV to work harder. It allows the aorta which will pull blood out of the LV without causing the LV to work harder. It allows the LV to rest and recover while increasing SV, which increases CO.
What are the contraindications to a IABP?
Aortic insufficiency and
abdominal aneurysm.
How is a IABP typically timed?
1:2
1:1 is difficult to achieve.
What is this?
ICE catheter
What is this item?
Amplatz Septal Occluder
What is the name of the solution cardiac biopsy samples are placed in?
formalin
What size wire does the Swan Ganz Catheter use?
0.025
In a normal inflation/deflation timing of a balloon pump, when does inflation occur?
onset of diastole, after the aortic valve closes.
Inflation point lies at or
In a normal inflation/deflation timing of a balloon pump, when does deflation occur?
During isovolumetric contraction, just before the valve opens.
When using a IABP, what is this wave form?
Patient Systole
When using a IABP, what is this wave form?
The assisted beat
When using a IABP, what is this wave form?
balloon inflation
What area is associated with an anterior wall MI?
LV
What are the signs and symptoms of a anterior wall MI?
Lung congestion, decreased 02 sat, drop in BP
An anterior MI is the most serious MI and is associated with the worst prognosis. T/F
True. 10% die within the 1st year following the anterior MI.
Can you give NTG during an anterior MI?
yes. Do not give during an inferior MI.
What is a transmural MI?
MI that involves all 3 layers of the heart.
Which area is associated with an inferior wall MI?
Right Ventricle
What are further signs of an inferior wall MI?
JVD, clear breath sounds, potential A/V block, bradycardia
Giving NTG during an inferior MI can make things worse and should not be given. T/F
True.
Low K predisposes the patient to __?
ventricular arrhythmias
Why do INR and/or PT/PTT need to be in normal range prior to cath?
It can affect hemostasis times as well as indicate there will be problems with cannulation.
Why would we want to know the WBC count?
Evaluate the patient for infection.
The lower the EF the higher the risk of complications. T/F
True.
T/F The lower the EF the more careful we must be with giving contrast.
True. With low EF give contrast, fluids, and sedation.
Lesions in the common/internal/external carotids increases the risk of stroke. T/F
True
T/F diabetics are not at an increased risk of infection when using a closure device.
False.
T/F A patient with a high WBC count is at an increased risk of infection when using a closure device.
True.
T/F A leaky Ao valve needs to have increased hold time following PCI.
True. A significant amount of blood goes back into the LV, the LV pushes harder sometimes to get it out. This causes the stretch of the artery to vary. This causes abnormal pulsations in the femoral artery. Hemostasis time can be extended 10-15 minutes longer
What can carotid message do?
slow the flow of electricity through the AV node and can be a therapy for SVT.
What are the top 3 cath complications?
MI, dissection, and stroke
T/F A longer procedure does not increase the risk of stroke.
False. The longer the procedure the greater the risk of stroke.
Frequent equipment changes increase chance of stroke. T/F
True
If cannulation of the SFA or profunda, what complication can occur?
pseudoaneurysm. Always cannulate above the bifurcation
Vaso vagal reactions are more likely when the patient is dehydrated. T/F
True
Covered stents are an indication of coronary artery perforation. T/F
True
T/F Multiple sheath exchanges within 72 hours increase the risk of infection.
True
Brachial and Radial approaches reduce infection rates. T/F
True
The best contrasts are those that are isomolar. T/F
True.
Why do we give at least 500cc IV NS before a study?
Because of the toxic effect of contrast on the kidneys. Causes kidneys to secrete antidiuretic hormone and kidneys will hold onto contrast.
What medication do you not give to patients on NPH insulin?
Protamine. body builds up antibodies to protamine when taking NPH. Can cause a significant anaphylactic reaction.
If a patient has renal artery stenosis what class of medications to lower BP should they not take?
ACE inhibitors. causes relaxation of renal arteries leading to more issues.
What view is this?
LAO of the RCA
What view is this?
LAO of left coronary arteries
What view is this?
Lateral of left coronary arteries
What view is this?
RAO LAD/CX
What view is this?
RAO/RCA
What is the mean arterial pressure needed to maintain cerebral profusion?
75-85mmHg The brain has the highest profusion need.
What do BP meds change?
Change one of: CO, SVR, HR
What is preload?
VOLUME. It is how full the heart is just prior to systole.
What is afterload?
PRESSURE. The resistance the left ventricle must overcome to circulate blood
What is the most efficient way to increase blood pressure?
Make the blood vessels smaller in diameter.
What is the most efficient way to make blood pressure lower?
Increase the diameter of the blood vessels.
What is the average stroke volume?
70 ml/beat
What is an average cardiac output?
4-6 Liters per minute
Where are baroreceptors located?
arch of the aorta and carotid arteries
How does the body correct for a drop in SV?
1st Kidneys – Renin; if stroke volume is falling brain tells the kidneys to circulate rennin in storage.
2nd angiotensinogen in liver.
Together Renin and angiotensinogen make angiotensin 1.
What is angiotensin II? How does it work?
potent vasoconstrictor. It tells the kidneys not to eliminate salt. This increases the amount of fluid in the blood, causing SV to go up and increasing CO.
What does angiotensin I and ACE equal?
Angiotensin II.
What are the beta sites on the heart stimulated by? What does this do to the heart rate?
Epinepherine/adrenaline. Increases heart rate.
Is Atropine a chronotrope or an Inotrope?
Chronotrophic. It raises the heart rate
Is Isopril a chronotrope or an Inotrope?
Chronotrophic. It raises the heart rate
Which class of drugs are negative chronotropes?
Beta Blockers such as metroprolol.
How do beta blockers work?
Beta blockers block the beta sites that adrenoline is looking to sit on, thereby lowering the heart rate.
Are beta 1-selective antagonists or non-selective antagonists?
Selective. They only choose to block the sites in the heart.
(**Beta 1 = 1 heart It only blocks the beta sites on the heart)
Are beta 2-selective antagonists or non-selective antagonists
No selective. They will block beta sites on the heart and lungs.
(Beta 2 = 2 lungs. Blocks beta sites on heart and lungs.)
What type of drugs are metoprolol/Lopressor and atenolol/Tenormin? (Be specific)
Cardio selective beta 1 blockers.
What type of drug is propranolol/inderal? (Be specific)
Non selective. Beta 2 blockers. Will narrow the airway.
What is a contraindication to propranolol/inderal?
COPD, asthma, emphysema.
How do ACE inhibitors lower blood pressure?
Keeps angiotensin 1 from converting to angiotensin II. This keeps the kidneys from being able to store up fluid, which keeps down stroke volume. This lowers blood pressure.
What are some names of ace inhibitors?
“Pril”
Captopril/Capoten
Enalapril/Vasotec
Lisinopril/Prinivil or zestril
benazepril/lotensin
fosinopril/monopril
How do ARBs work?
They look for angiotensin II and inactive it to prevent it from returning to the kidney to hold fluid.
What are some names of ARBs?
Angiotensin receptor blockers are “sartan” drugs.
azilsartan/Edarbi
candesartan/Atacand
eprosartan mesylate/ Teveten
Olmesartan/Benicar
irbesarten/Avapro
What are the most common chronotropes on the test?
isopril and atropine
What are the most common inotropes on the test?
Digoxin and albutamine
T/F NTG dialates arteries.
False! It dialates the veins. Veins hold more blood which takes blood away from the arterial system.
NTG works to decrease preload when given during an MI by dilating?
Veins.
Does NTG work on preload or afterload?
preload
Besides numbing the skin, where else can you use lidocaine in the cath lab?
Ventricular arrythmias. It works on the perkinje fibers by decreasing the flow of electricity to the perkinje fibers. This decreased sensitivity lowers the number of extra beats that are able to get through
Where does atropine act in the heart?
On the SA node. The vegas nerve controls the SA node, and atropine works directly on the vegas nerve so atropine indirectly controls the heart.
Bearing down stimulates?
The Vegas nerve. Heart rate will go down.
Does Amiodarone (Cordarone) work in the ventricles, the atria, or both?
Both. KNOW THIS. It will likely appear on the test.
Does Amiodarone slow or speed up the heart?
Slows the heart rate.
How does Amiodarone work?
It is a K+ blocker
How do calcium channel blockers work?
It blocks the calcium channels in the conduction process. It slows the movement of calcium across the K+/Ca channels and keeps cardiac muscle fibers and arteries more dilated reducing pressure.
What are some calcium channel blockers?
“Pine” meds
Verapamil/Isoptin
Cardizem/Diltiazem
amlopidine/Norvasc
nifedipine/procardia
What are the 3 doses of dopamine and what do they do?
1st dose: Low dose 1-5mcg/kg/min – renal dose only goes to the kidneys and only dilates those vessels. Slows the flow of blood through the kidneys. Improve urine output. Given to brittle diabetic to help purge contrast quicker.
2nd dose: 5-10mcg/kg/min – benefit to the kidneys is lost. Urine output goes down. This dosage goes to the heart and raises the heart rate.
3rd dose: > 10mcg/kg/min – raises BP; increases heart rate urine output almost stops.
T/F Adenosine is contraindiated for someone in heart block.
True.
How does adenosine work?
It slows electrical impulses. It affects both calcium and K+ in the conduction system. It is very effective at slowing the heart.
T/F adenosine works to slow electrical impulses in the SA and perkinje fibers.
True. Very effective at slowing the heart.
Which drugs are benzodiazapines used in the cath lab?
versed/midazolam
valium/diazepam
What is the reversal agent for benzodiazapines?
Romaizicon/flumazenil
Which drugs are opiates used in the cath lab?
Fentanyl/ Sublimaze
What is the reversal agent for opiates used in the cath lab?
Narcan/Naloxone
What two antibiotics are usually on the test?
Vancomycin — Broad spectrum
Ancef — narrow spectrum
These drugs work by preventing bacteria from building a cell wall.
What do you want the ACT to be during a PCI?
Greater than 250
250-300
What is a normal PT/PTT?
11-16 seconds
What is a normal INR?
0.8-1.2 seconds
How much heparin do you give during a PCI?
50-70 units per kg
What is a normal potassium level?
3.5-5
What are the top 3 complications from a cath?
heart attack, dissection, and stroke
The risk of stroke _ the longer the procedure goes on.
increases
T/F The number of equipment changes has no bearing on stroke complications.
False. The more equipment changes the more likely a patient is to have a stroke.
You should always cannulate _ the bifurcation.
above
Does the cathode have a positive or negative charge?
Negative.
Does the anode have a positive or negative charge?
positive
T/F The more tissues that radiation must go through, the larger the patient dose.
True
What is the safest view for the patient is _?
AP. The further you get from AP the higher the radiation dose.
Using a collimator _ the radiation dose to the patient.
Lowers.
Collimating decreases the size of the xray beam prior to having it arrive to the patient.
T/F Zooming an image decreases the radiation dose to the patient.
False. Zooming increases the patient radiation dose.
T/F It is safer to collumate than to zoom an image.
True. Zoom uses more radiation
T/F Tissue burns are more likely with collagen vascular diseases such as diabetes, hyperthyroidism, lupus and arthritis.
True. The cell wall is thicker with collagen vascular diseases.
If you have 2 patients, one with a BMI of 20 and the other with a BMI of 30:
- Which patient will generate more scatter.
- WHich patient will give you an image with less contrast (grey colors)?
- The patient with a BMI of 30 will generate more scatter.
- The patient with a BMI of 30 will have less radiation being absorbed and will be less able to interact with the film.
Two patients, same BMI
Patient #1 Image LAO 60, cranial 30
Patient #2 image from LAO 30
- Which view results in more xray absorption to the patient?
- Which image will give more scatter?
- Which image will have the clearer detail?
- 1 The furthest from AP
- 1 More tissues to permeate more scatter less radiation to make the picture.
- #2. Further from AP the less detail because more tissues to interact with. 2 because it’s closer to AP
What is isocenter?
The height we put the table at to minimize panning. This reduces the amount of radiation to the patient.
T/F Collimating reduces the skin dose
True
T/F Collimating decreases scatter?
True
T/F Collimating improves image quality?
True
T/F 0.5mm of lead equivalent protection provides approximately 95% shielding from xray scatter.
True
T/F Collar badges give a good measurement of eye exposure.
True
T/F Dose is the amount of energy absorbed by tissue from the xray beam.
True
T/F As xray passes through a person there is less available to the deeper tissues.
True
T/F An object can be delineated in an image only if the xray absorbance is sufficiently different from that of its surrounding structures to produce different exit beam intensity.
True
Glowacki thinks this is a poor question, but it frequently appears on the test.
What is the best view for visualization of a stent? LAO 60, Cranial 30 or LAO 30, cranial 0
LAO 30, cranial 0.
ALWAYS ANSWER THE VIEW THAT IS CLOSEST TO AP.
Which imaging delivers a higher amount of energy to the patient? Fluoro or Cine?
Cine
Which imaging results in an image with more noise? Fluoro or Cine?
Fluoro
True or false: Cine acquisition generates a lower dose to the patient than fluoro imaging.
false
T/F All contrast is iodine based.
True
A hypertonic contrast does what?
a greater number of particals are pulled from cells causing them to fold up on themselves
What is another word for hypertonic?
Osmolality. If one cell is hypertonic to another then it has greater ability to pull from the less hypertonic cell. This is osmolality.
Renografin is very hypertonic. True or False
True
Which contrast agent is most like the human body and has a similar number of particles?
Visipaque
T/F The best contrast is one that has low osmolality and is isoosmolar.
True
Where do dampened pressures occur?
The RCA You lose the systolic component but the diastolic stays the same.
What happens when you have a dampened pressure?
While the heart is in diastole and elongates the catheter is able to move deeper into the RCA, this is especially since the arteries are perfused during diastole. It pulls the catheter in. With systole the catheter is squeezed, and it loses the systolic component, not the diastolic component.
Where do ventricularized pressures occur?
The LCA Systole does not change, but diasole goes way down.
What happens when there is a ventricularized pressure?
Normally short left main and branch coming off early in the LM. (The catheter gets pulled into the branch during diastole and then systole squeezes the catheter the systolic component is not lost because it is measuring the pressure in the side branch. Why do we lose diastolic? The tip of the catheter as it moves occludes the pressure that is before it and looks completely down the branch. It sees the profusion pressure of the capillary. It is about the same as EDP.)
How far is the primary from the secondary curve in a JR 4?
4cm
How far is the primary from the secondary curve in a JR 5?
5cm
If the cardiologist is shooting a mammary artery and a blood pressure cuff is used what side is it on? Right, Left, Ipsilateral?
Ipsilateral arm. That is Latin for same side.
In RAO caudal in the left coronary arteries, what do you visualize?
LM, Prox LAD, and Circ
In RAO cranial in the left coronary arteries, what do you visualize?
Mid and distal LAD
In LAO cranial in the left coronary arteries, what do you visualize?
LM and prox circ
In the right coronary arteries in LAO what do you visualize?
Proximal RCA
If the spine is on the right it is a __ view.
LAO.
Of note the test will not show the spine, but it may ask this question.
If the spine is on the left side the it is a __ view.
RAO
What is the length of the LM?
4.5mm
T/F The circ is always nearest to the spine.
True
What is the length of the Circ?
3.4mm
What is the length of the RCA?
2.8mm
What is the diameter of a 6 French catheter?
2.0mm (.33mm to French)
What is the outer diameter of a 8 French Catheter?
2.6
What color is a 6f sheath?
Green
Really 4F Red
Goofy 5F Grey
Girls 6F Green
Order 7F Orange
Blue 8F Blue
Blush 9F Black
What color is a 9F sheath?
Black
Really 4F Red
Goofy 5F Grey
Girls 6F Green
Order 7F Orange
Blue 8F Blue
Blush 9F Black
Label and Name the following view seen doing an LV angio.
LAO
A- Aortic Valve
B- Posteriolateral
C- Inferior
D- Apex
E- Septum
LAO view is the one most often on the test.
Label and Name the following view seen while doing an LV angio.
RAO
A — Aortic Vavle
B — Anterior
C — Apex
D — Inferior
LAO view is the one most often on the test.
T/F The main cause of catheterization related strokes is embolic.
True
T/F The risk of stroke is higher with an intervention.
True
T/F Complications at the procedure site are the most common problems seen after a cardiac catheterization procedure.
True
T/F Procedure site complications are the single greatest source of procedure related morbidity.
True
T/F Vigorous or hard injection despite a dampened or ventricularized pressure waveform predisposes a patient to VFib or dissection of the proximal coronary artery.
True
pressures in the right and pressures occur in the left.
Dampened
Ventricularized
T/F In patients with a short or narrow aortic root, a 3.5mm tip catheter may be needed.
True
T/F Most common grafts to the LCA arise from the left anterior surface of the aorta.
True
T/F Grafts to the RCA usually originate from the right anterior surface of the aorta.
True
T/F Cannulation of the RIMA may be difficult because of the need to avoid the right internal carotid artery.
False. Only true if the question states common carotid artery.
T/F A significant rise in PA pressure mean or diastolic pressure should prompt temporary suspension of angiography to prevent pulmonary edema.
True. Patient needs to take Lasix right away.
Do the RCA and the Circumflex coronary arteries run between the AV sulcus or the intraventricular sulcus?
AV sulcus
T/F The diagonal branches supply the anterolateral free wall of the LV.
True. Also supplies the papillary muscle.
T/F The obtuse marginal supplies the lateral free wall of the LV.
False OMs supplies the posterolateral wall.
What is the Swan Ganz wire size?
.025
What is the rotobladder wire size?
.009
What is the best wire to use to cross a stenotic valve?
a straight wire
Where to position a wire in relation to a lesion?
Don’t place it as distal as possible. The answer is distal to the lesion, but not as far as possible. 3-4cm or 2-3cm have both appeared on the test. Stay in the 2-4mm range.
What are the best catheters for a high takeoff?
Amplatz, JL4 and JL5
T/F It is acceptable practice to use a single hole catheter for an LV angiogram.
False. Multihole catheter.
What is the best catheter for a dialated root?
Anything greater than 4.0
If a patient has an LV aneurysm should an LV angiogram be performed?
No. No catheter should go in the LV as it can dislodge clot causing a stroke.
How long can a wire/catheter be placed before removing it to wipe and flush it?
2-3 minutes
What type of lesion do you use a rotobladder for?
Calcified.
180-200k revolutions
What type of lesion do you use a cutting or scoring balloon?
Calcified
What type of lesion do you use angiojet for?
thrombus
What is the most common vessel to use a filter wire in?
Vein grafts and the carotids
How should a cutting balloon be inflated?
1atm per second and it should be deflated at 1atm per second.
What is the best view to check for an aortic dissection?
Anything LAO
What is the normal O2 level in the IVC/SVC/RA/RV/Pulmonary arteries?
about 70% and equal
What is the normal O2 level in the pulmonary veins, LA/LV/AO
98-100%
When a shunt is present is the CO the same on both sides?
No.
Where is the most common shunt located?
ASD. Ostium secundum center of the septum between the r and l atrium. This is a variation of the PFO.
What is the 2nd most common ASD location?
Ostium Primum ASD is located in the lower portion of the atrial septum. A mitral vavle cleft is a slit like or elongated hole in the anterior leaflet that form the mitral valve.
What is the least common ASD and its location?
Sinus Venosus. Located in the upper portion of the atrial septum.
What tool do you use to evaluate an ASD?
ICE catheter. Venous access, to the right atrium.
What can you use to occlude an ASD located in the ostium secundum?
Amplatz Occluder
What can cause a VSD?
Not a natural occurrence. Congenital or Terrible MI can cause it.
Is a PDA cyonotic or acyonotic?
Acyonotic. PA sats will be higher
What is Flamms equation?
3 (SVC) + 1 (IVC) / 4
Know what transposition of the great vessels looks like. How can a patient live with this? cyonotic or acyonotic?
cyonotic. They live only because they have a VSD
What happens with a Truncus arteriosis?
A great vessel acts as both the AO and PA and pulls blood from the R and l ventricle. It is a left to Right shunt.
Tetrology of Fallot
Pulmonic stenosis
Overriding aorta
Right ventricular hypertrophy
VSD
What is a normal PR interval?
.12-.20 seconds
What is a normal QRS?
.08-.12
What is the most common cause of sudden death?
Vfib.
What does vfib require?
Unsychronized cardioversion asap. (200-300-360)
T/F in a third degree heart block there is no relationship between the p waves and QRS complex?
True
If a patient is symptomatic with SVT what should be done?
synchronized cardioversion
Which port do you inject the thermodilution saline?
Blue injectate
What is the gold standard way to measure CO?
Fick. Must use Fick with shunts, arrythmias, tricuspid regurgitation, leaky valves, and chronically low CO
RA pressure waveform: Where can you find the a wave.
Lined up with the P wave on the ekg.
If a patient is in afib where is the A wave?
Not there. There are only v waves
What 3 things does the RV pressure wave show us?
Systolic and diastolic pressure and RVEDP
Where do you measure RVEDP on the waveform?
It is measured at the peak of the R wave on the EKG. Where it crosses the waveform is the RVEDP
What would make the RV systolic pressure rise?
PE, COPD, Pulmonic stenosis, pulmonary hypertension
What can cause your RVEDP to rise?
RV MI, and prolonged illnesses such as untreated pulmonary hypertension, chronic untreated pulmonic stenosis.
Pulmonary artery pressure 3 components:
systolic, diastolic and mean pressure
What does the diacrotic notch signify in PA pressures?
Closure of the pulmonic valve
What would increase pulmonary artery pressure?
Pulmonary Hypertension, COPD, PE
What are we reading when we measure a Pa Wedge ?
The left atrium
PA wedge will show A and V waves. T/F
True. It is reading the LA, so it shows atrial pressure. A waves are atrial contraction and V waves are filling of the LA while the mitral valve is closed.
What is a normal LA pressure?
7-12mmHg
PA and AO pressure wave forms look alike. How can you tell the difference?
Look at the scale
What happens to PCWP when mitral stenosis is present?
There will be high atrial pressure.
When a patient has mitral stenosis, what happens to the LVEDP?
With mitral stenosis the LVEDP stays the same. 7-12mmHg The LA does a great job of getting left Ventricular filling. It has to go on so long that the LA can’t fill it enough. Then the LVEDP will drop.
If mitral stenosis, you will see a __ between the LV pressure and the PCWP pressure.
Gradient
Mitral regurgitation will show increased LA __.
Increased pressure. Especially notice the pronounced v waves.
What procedure do we do in the lab that shows AO stenosis?
LV/AO pullback
What is door to balloon time?
90 minutes
With first degree heart block the delay is in the _?
AV node
In a second degree, type 2 heart block (Mobitz II) what is the PR interval?
Remains constant. Some p waves fail to conduct.
T/F Mobitz II is generally harmless.
False. It is not a good sign, and has a high risk of progressing to a complete heart block.
What should be done if a patient is in Vfib?
Vfib = Defib.
Do an unsynchronized cardioversion
What are the ACLS monophasic defibrillator settings?
200-300-360
If your patient is in SVT, has a drop in BP, diaphoretic, SOB, lightheaded/faint with chest pain what should you do?
synchronized cardioversion
What is the proper sheath placement?
Sheath below inguinal ligament, above the bifurcation of the superficial femoral and the profunda, medial to the femoral head.
What is the big risk of a high stick?
retroperitoneal bleed
What is the risk of a low stick?
PSA pseudoaneurysm
How do you do an Allen’s test?
Occlude both radial and ulnar arteries and make them move their hand. Release ulnar artery and be sure that the hand pinks up.
What is a contraindication to radial access?
an occluded ulnar artery
What is the Barbeau test?
Pulse ox on thumb or index finger. Look at pulse ox wave form. Occlude both arteries and observe that the waveform diminishes and flattens out. Then let go of the ulnar artery and look for the return of the proper waveform, and the o2 sats return to normal.
What medications could you potentially use with radial access?
Heparin, Verapamil, NTG
What access do most permanent pacemaker take?
Venous access right subclavian
Where do you go to get transseptal access?
Venous system to RA and stick through to LA
What procedures require transseptal access?
ASD repairs, mitral clips, mitral valve repair, mitrovalvuloplasty, afib ablation, tandem heart
The goal of transseptal access is to go through the __.
Fossa Ovalis because it is the thinnest part of the heart.
Immediately after crossing a septum in transseptal access what do you do?
Give hepariin. We want no clots to form and this will keep clots off of the wire, device, etc.
What are the complications of transseptal access?
Clots, air embolus, tamponade, aortic wall puncture
What TIMI flow are we aiming for in the cath lab?
TIMI 3.
What aldrete score allows a patient to leave the cath lab?
Aldrete must be at least an 8
On the New York Heart Failure classificiation is a patient’s capacity more on level 1 or level 4?
1 is better than 4.
When do we tend to see vaso vagal reactions? What should we do?
When placing the sheath.
give them fluids to increase volume. .5mg of atropine. Protect airway if needed.
What do we use to pretreat a contrast allergy?
Prednisone the night before and benedryl before procedure.
What should be monitored if a patient is on lasix?
K level.
What is the procedure for picking up a patient?
- Check for informed consent
- Use 2 patient identifiers
- Check iv
- NPO status
- Confirm with patient procedure being performed.
- ER equipment has been checked in the procedure room.
What two things should a RCIS check first when coming into the lab?
Xray and crash cart
How do you open packages?
away from you
Which side do you drape a patient on first?
the side closest to you
T/F you should locate the pulses prior to draping?
True
What is used to sterilize equipment?
ethelene oxide
What is the solution that is used to hold cardiac biopsy samples?
formalin
What septum does the LAD run down?
The interventricular septum
T/F the Cx and RCA go the right and left atrioventricular grooves.
True
What does the coronary sinus do?
Collects blood from the coronary veins and returns the blood to the right atrium.
What is the innermost layer of the heart?
endocardium, Thin layer of epithelial tissue that acts as the inner lining of the myocardium
What is the thick middle layer of the heart?
myocardium. These cells have electrical properties and can conduct electrical impulses enabling cardiac contraction.
Which heart layer has electrical properties and can conduct electrical impulses?
myocardium.
What is the pericardium?
protective sac surrounding the heart. The pericardium folds in on itself at the aorta forming the epicardium.
What is the outer protective layer of the heart?
epicardium
What layer of the heart do coronary arteries arise in?
The epicardial layer
Label this image.
a. Brachiocephalic artery
b. right subclavian
c. right common carotid
d. left common carotid
e. left subclavian
f. left coronary artery
g. Right coronary artery
What is the s1 heart sound?
-“Lubb”
-AV valves close (mitral and tricuspid)
What is the s2 sound?
“Dubb”
closure of semilunar valves (pulmonic and aortic)
What are the signs of a stroke?
face drooping, arm weakness, speech difficulty
What is the difference between Timi 0 and Timi 3 flow?
Timi 0 is no flow
Timi 3 is excellent flow
How do you do an LV angiogram on a stenotic Ao valve?
- Advance straight wire and end hole catheter like AL catheter into LV
- Exchange short wire for long 260cm J wire
- Removed end hole catheter (like the AL)
- Replace with pigtail/multiholed catheter
- Aspirate, flush, and attach injector tubing.
When using an injector for an LV gram what do the three numbers mean?
Flow rate (ex. 10ml/second)
Total volume infused (ex. 30ml)
PSI
What does setting a rate of rise on an injector do?
allows for smoother injection, limits ectopy, and there is less catheter whip
What are the steps to a myocardial biopsy?
Myocardial Biopsy:
- Jugular most common approach.
- Venous access
- Samples from right ventricle
- Samples placed in formalin
- Possible complication: RV perforation
- Done to evaluate rejection
What level do you keep a foley catheter at, at all times including transferring from bed to table?
at the level of the bladder or lower
When do we use distal protection devices?
carotid angioplasty and saphenous vein graft/angioplasty
When using a cutting or scoring balloon what are we doing?
making a controlled dissection
Who wears glasses in a laser case.
Everyone.
What happens to a lesion when using a lasor?
the lesion is vaporized.
What is the best location for TVP?
transvenous pacing the subclavian area allows the patient to move around easier. Jugular can be used as well. Patient will remain on bedrest while the pacemaker is in place.
How do you retrieve a foreign body?
snare
What is the proper heparin dose?
50-70units per kg
What is the minimum amount of time following giving heparin that you can check an ACT?
5 minutes
When do you use an impella device?
cardiogenic shock, high risk procedures, poor surgical risk that needs angioplasty. Moves 2-5 liters of blood per minute. Must be weaned off.
What are contraindications to impella?
Ao valve disease, mechanical valve, moderate to severe aortic regugitation, and if the patient has significant PAD (Sheath and catheters are large.)
Post procedure care remember:
- Bed up 30 degrees
- Fluids are allowed
- Coughing or laughing hold pressure on groin dressing
- Call RN if you feel anything warm or wet at procedure site.
How often are vital signs completed post cath?
q 15 min x4 and then every 30 minutes until discharge. (at least twice.)
If a patient has a hematoma, compare it to a fruit. T/F
False. Always measure in CM. Mark with a pen.
When calling report to a receiving nurse what do you tell them?
What we did, patients present status, and medications that will continue
What is the first thing you do when cleaning the room.
Remove the sharps
Where do you hold manual pressure when removing an arterial sheath?
2-3 cm above sheath insertion point.
What are some times that you would use a temporary pacemaker?
rotobladder, angiojet, mitral valvuloplasty, mtiral clips
What are the steps when temporary pacing is required?
- Wire through the femoral vein, through the RV, past the tricuspid valve, into the RV near the septal wall.
- The wire is then connected to the box. Make sure the box is off.
- Turn the MA up to 10
- Turn up HR until we see capture on the monitor.
- Turn down MA until capture is lost.
- Turn the MA up until you see capture again.
- Turn HR down until capture is lost.
- Turn the generator off or put it into standby. It is now programed in the event that it is needed.
What are examples of passive closure devices?
radial bands, topical pads, pressure devices
What are examples of active closure devices?
vascular closure devices such as collagen plugs, clips, sutures. Examples are angioseal, mnyx, starclose, and perclose
When holding manual pressure on an arterial sheath site, how long do you hold?
For each french size plan on 3 minutes of pressure.
What happens in a retroperitoneal bleed?
The back wall of the artery is stuck. Manual pressure/closure devices do not close the back hole and blood leaks into the retroperioneal space.
What are the signs and symptoms of a retroperitoneal bleed?
back/flank pain same side as sheath, drop in Hgb and HCT, drop in BP, tachycardia
What is the FICK Co equation?
Calculations:
Fick CO= 02 Consumption/
AVO2 difference x 10
Or
Fick CO = 02 Consumption /
(Hgb x constant x AO sat) – (Hgb x constant x PA sat) x 10
What can VO2 stand for?
O2 consumption
How do you get the arterial 02 content?
(Hgb x constant x AO sat)
How do you derive the venous 02 content?
(Hgb x constant x PA sat)
What is a thermodilution CO?
A direct measurement using a swan catheter
What is another name for angiographic cardiac output?
Left Ventricular minute flow
What is the formula for stroke volume?
EDV-ESV
What is the formula for Ejection fraction?
EDV-ESV/EDV
What is the formula for angiographic CO?
CO(a) = HR X SV/1000
What is the formula for Cardiac Index?
CO/BSA
What is the label for CO?
L/min
What is the label for Cardiac Index?
L/min/m2
What does regurgitant fraction measure?
What percentage of blood goes through a leaky valve.
What is the regurgitant fraction formula?
Regurgitant Fraction = SV (angio) – SV (thermo/fick)/SV (angio)
How many cm in an inch?
2.54cm
What is the gold standard of valve area calculations?
Gorlin Valve area
Does Gorlin measure mean gradient or peak gradient?
Mean. Peak to Peak is measured with a LV/AO pullback
What is the Gorlin Aortic constant?
44.5
What are the four steps to determining the Gorlin Aortic Valve area?
- Convert CO from L/min to ml/min.
- Calculate the systolic ejection period in sec/min (SEP will be given on the test) SEP x HR
- Calculate the Aortic valve flow: AVF = CO (converted to ml/min)/SEP (sec/min)
- Calculate the Aortic Valve Area: AVA = Aortic valve flow (AVF)/44.5 x square root of the mean gradient
What is the Gorlin constant for Mitral Valve area?
37.7
What are the steps for determining a Gorlin Mitral Valve area?
- Convert CO from L/min to ml/min
- Calculate DFP in sec/min (DFP x HR)
- Calculate Mitral valve flow MVF = CO/dfp
- Calculate the mitral valve area MVA = ___MVF_______________
(37.7)(square root of the mean gradient)
What is the label for any valve area?
cm2
What is systemic vascular resistance?
The amount of work the LV has to do to push blood out of the aorta
What is pulmonary vascular resistance?
The amount of work that the RV has to do to push blood into the pulmonary artery.
What is the biggest factor affecting resistance?
The diameter of the vessels.
What is the SVR formula?
SVR = AO mean pressure – RA mean pressure/cardiac output = _ x80 dynes/sec/cm-5
What is the PVR formula?
PA mean pressure – LA/PCWP mean pressure/cardiac output = _ x 80 dynes/sec/cm-5