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126 Cards in this Set

  • Front
  • Back

What are three types of SA Nodal bradycardic arrhythmias?

Sustained bradycardia


Sinus arrest/ sinus block


Brady-tachy syndrome (Sick Sinus Syndrome)

What is the most common cause of bradycardia arrhythmias? (SA Nodal Dysfxn, AV Nodal Dysfxn or AV Block)

SA Nodal Dysfunction

What is SACT?

Sino-atrial Conduction Time

What is SNRT?

Sinus Node Recovery Time

What are two EP lab measurement that can be used to assess SA Node Dysfunction?

SNRT and SACT

What is SA Nodal Dysfunction generally treated with?

Permanent Pacemaker (PPM)

What is IST?

Inappropriate Sinus Tach

What is one type of SA Nodal Dysfunction that is NOT generally benign?

Inappropriate Sinus Tach (IST)

What are the signs/ symptoms/ etiology of IST?

High RHR


Rate increases greatly with minimal exertion.


Unknown cause; affects mostly women.


May also have GI, neurologic, visual, syncope, dyspnea symptoms.

What is the primary treatment for IST?

Beta Blocker (BB) therapy

Is ablation a possible treatment for IST?

Yes, ablation of the SA Node with PPM implant is a possible treatment.

How is SNRT measured?

How is SNRT measured?

1. Pace SA Node 30 seconds (overdrive).


2. Turn off pacing.


2. Measure time for SA node to begin pacing once overdrive pacing is turned off. Measure last paced beat to first spontaneous beat.


3. Repeat with faster pacing until longest SNRT is seen.

What is a recovery interval in SNRT?

Time from last paced beat to onset of spontaneous SA stimuli.

True/False: Normal SNRT values are consistent from lab to lab.

False. Normal SNRT values are widely variable and may differ slightly from lab to lab.

What is the upper limit for SNRT?

1500 ms is the generally agreed upon upper limit for SNRT

Are longer SNRT times associated with faster or slower heart rates?

Slower heart rates commonly have longer SNRT times

What is a C-SNRT used for?

C-SNRT (Corrected SNRT) is used to factor out the SNRT and BCL (basic cycle length) relationship.

What is C-SNRT equal to?

C-SNRT = SNRT - BCL where BCL is the basic cycle length (un-paced)

What is the normal upper limit of C-SNRT?

525 ms

What does Sino-Atrial Conduction Time (SACT) measure?

SACT is a measurement of how well sinus node conducts impulse to surrounding tissue.

What is the normal range for SACT?

50-115 ms

What is SA Nodal Reentry Tachycardia?

A tachy-arrhythmia initiated in the SA Node

Characteristics of SA Nodal Reentry Tachycardia?

- Resembles sinus tach


- Induced by rapid atrial pacing


- Terminated by rapid atrial pacing.

How is SA Nodal Reentry Tachycardia treated?

digitalis


beta bockers (BB)


calcium channel blockers (CCB)

What is the second leading cause of bradycardia arrhythmias? (SA Nodal Dysfxn, AV Nodal Dysfxn or AV Block)

AV Nodal Dysfxn or AV Block

What types of AV blocks are considered benign?

Proximal AV blocks (First Degree and Second Degree Type I)

What is a Second Degree Type I block also known as?

Wenchebach or Mobitz I

What types of AV blocks are potentially lethal?

Distal Blocks (Second Degree Type II and Third Degree)

What is a Second Degree Type II Block also known as?

Mobitz II

What heart rates are consistent with Distal AV Blocks?

20-40 bpm (ventricular automaticity)

What is the treatment for an asymptomatic proximal block?

Monitor only

What is the treatment for a symptomatic proximal block that is transient?

Vagal maneuvers or give atropine

What is the treatment for a persistent symptomatic or distal block?

PPM (Permanent Pacemaker)

What are two causes of Supraventricular Tachycardias (SVTs)?

Enhanced Automaticity


Re-entry

Examples of SVT Re-entry arrhythmias?

Atrial/ flutter/ A Fib/ Paroxysmal A-Tach


AVNRT


AVRT


Intra Atrial Re-entry Tach

What do AVNRT and AVRT stand for?

AV Node Reentry Tachycardia


Atrio-Ventricular Reentry Tachycardia

List the SVT Arrhythmias in order from most to least prevalent.

A Fib


PSVT


A Flutter


Other

What is PSVT?

Paroxysmal Supra-Ventricular Tachycardia

True/ False: A Fib is paroxysmal in nature at first, then becomes chronic.

True

A Fib can be labeled as what two types (based on the ventricular response rate)?

SVT (<100) or AVRT (>100)

How is SVT A. Fib characterized?

Stimulation originates in the pulmonary veins (PV) and results in ventricular response rate under 100 bpm.

How is AVRT A. Fib characterized?

Stimulation of accessory pathway results in a rapid ventricular rate above 100 bpm.

What is AVRT caused by?

AVRT is caused by an accessory pathway that creates a "macro-reentry" circuit (a normal conduction pathway plus an accessory pathway connecting ventricle to atrium)

True/ False: Most AVRTs are WPW.

False

What is WPW?

Wolf-Parkinson-White syndrome

How is AVRT treated?

Medical therapy (BB and CCB).


Ablation therapy (RF or Cryoablation)

How is WPW characterized on the ECG?

Short PR Interval


Long QRS


Delta Wave at beginning of QRS

What are symptoms associated with WPW?

Syncope


Palpitations


Dizziness

What are risks associated with WPW?

Developing rapid ventricular response A-Fib (AVRT A. Fib).


Sudden Death.

What causes AVNRT?

Dual pathways in the AV Node

True/ False: AVNRT is easy to distinguish from other narrow complex tachycardias outside of the EP lab.

False.

Treatment for AVNRT?

Vagal maneuvers


Digitalis


BB


CCB

What is Intra-Atrial Re-entrant Tachycardia?

A circuit that is entirely within the atrium.

How does Intra-atrial Re-entrant Tachycardia differ from SVT?

It is paroxysmal in nature and can be induced and terminated by pacing.

What is the treatment for Intra-atrial Re-entrant Tachycardia?

Procainamide (Class 1a anti-arrhythmic)

What does SCD stand for?

Sudden Cardiac Death

What is the leading cause of SCD?

V-Tach/ V-Fib caused by re-entry (syncope, palpitations)

True/ False. The focus on treating V-Tach/ V-Fib has shifted toward pharmacologic management.

False. The focus has shifted to correcting the cause based on how V-Tach/ V-Fib is initiated.

True/ False. Symptoms of Ventricular Arrhythmias may be minimal and include lightheadedness, palpitations, and dizziness without loss of consciousness.

True

How can V-Tach be differentiated from SVT?

If SVT - adenosine will often reveal transit AV block or either junctional escape or IVR after breaking tachycardia rhythm.


If VT - adenosine will have no effect.

True/ False. A general rule is to treat all wide complex tachy-arrhythmias as SVT.

False. Treat as VT.

What group of patients has a 50/50 chance of VT/VF as a cause of syncope and arrhythmias?

Patients with a past history of MI or cardiomyopathy.

The ability to regulate BP should be ruled out as the cause of syncope in what group of patients before considering EP study?

Patients with no history of MI or cardiomyopathy.

True/ False. Reentrant Ventricular Tachycardia often begins as PVC, inducing monomorphic ventricular tachycardia (200+ bpm).

True. If not corrected it then proceeds to ventricular fibrillation.

What is "stable VT"?

Ventricular tachycardia under 200 bpm in a conscious patient with minimal symptoms.

What is the ACLS treatment for "stable VT"?

What are the steps for inducing ventricular tachycardia in the EP lab?

1. Atrial & Nodal EP study.


2. Single, double, and triple extra-stimulus technique in RV. If not successful, incremental pacing of RV.


3. If still not successful, repeat #2 in the RV outfow tract.


4. If still not successful, administer isoproterenol and repeat #2.

Brand Isuprel

Generic isoproterenol

What is the primary goal of inducing VT in the EP lab?

To induce sustained, monomorphic VT

True/ False. Unsustained monomorphic VT is usually acceptable to call a "Positive exam" if the VT is 10 beats or more.

True

True/ False. Sustained polymorphic VT is usually acceptable to call a "Postive exam" when using the extra-stimuli technique.

False. This is a common finding when using extra-stimuli protocol and may be a "False Positive" study.

True/ False. The same methods used to induce VT are used to terminate VT.

True. Incremental pacing and Extra-stimuli techniques.

If VF is induced during the EP Study, what is done to terminate the rhythm?

Defibrillation (unsynchronized)

True/ False. Idiopathic left ventricular tachycardia is caused by both reentry and triggered activity as the mechanism.

True

What is idiopathic left ventricular tachycardia treated with?

BB & CCB

What type of VT is provoked by exercise?

Outlow tract ventricular tachycardia is provoked by exercise.

How is outflow tract ventricular tachycardia treated?

Ablation but can use BB and CCB.

Which genetic cause of VT is rare?

Right ventricular dysplasia.

How is right ventricular dysplasia treated?

ICD implantation

What is bundle branch reentry?

Bundle Branch reentry is a very rare genetic cause of VT that is treated with ablation of Right Bundle Branch.

What is Brugada Syndrome or Sudden Unexpected Nocturnal Death Syndrome (SUNDS)?

Brugada Syndrome/ SUNDS is a sodium sodium channel abnormality that occurs in asian males more than females.

How is SUNDS treated?

SUNDS is treated with ICD implant.

Which valve condition is often associated with VT but remains unproven as a cause?

Mitral Valve Prolapse

VT or SVT?

VT or SVT?

VT. There are more RV spikes than HRA spikes.

VT or SVT?

VT or SVT?

SVT. Each RV spike is preceded by a HRA spike.

What are some of the types of arrhythmia therapy?

Treat reversible causes.


Anti-arrhythmic medications.


Surgical therapy (CABG is caused by ischemia or surgical disruption of accessory pathways)


Trans-catheter ablation (requires mapping)


Device therapy (PPM, ICD)

Why is mapping performed?

Determine activation patterns of arrhythmias.


Locate sites of arrhythmia origin.


Identify areas of abnormal conduction.

CARTO is Sequential, Continous, or Non-contact mapping?

CARTO is sequential mapping.

LASSO is Sequential, Continous, or Non-contact mapping?

LASSO is continuous mapping.

EnSite is Sequential, Continuous, or Non-contact mapping?

EnSite is Non-contact Mapping.

Which mapping method uses CT/MRI to reconstruct the electro-anatomical system?

Sequential Mapping (CARTO)

In Sequential (CARTO) mapping, what do the colors red, yellow and green, and purple represent?

Red = earliest depolarizations.


Yellow and Green = intermediate depolarizations.


Purple = latest depolarizations.

Which mapping technique uses simultaneous recording of catheter location and EGM activation using an ultra-low magnetic emitter and a catheter with a magnet sensor at the tip?

Sequential (CARTO) Mapping

Which mapping technique uses catheters with 1 mm diameter electrodes that are 1-2 mm long with 3-10 mm between electrodes (splines)?

Continuous (LASSO) Mapping

What does Continuous (LASSO) mapping accuracy depend on?

Number of splines per basket.


Number of electrodes on each spline.


Percentage of electrodes in contact with endocardial surface.

What are the limitations of Continuous (LASSO) mapping?

Too small or too large of an array = poor quality.


Beating heart movement is detrimental to reconstruction.


Minimal anatomic info.


Does not map Atrial Appendage or PV.

Which mapping technique uses a balloon with an imbedded array along with another "Roving" catheter with tip in contact with wall?

Noncontact (EnSite)

True/ False. With non contact mapping (EnSite), signals are captured during systole when the points are most distant from the array?

False. With non contact mapping (EnSite), signals are captured during diastole when the points are most distant from the array?

What are some advantages of Noncontact (EnSite) mapping?

Very fast mapping time (seconds)


Global and local cardiac electrical events.

What are some disadvantages of Noncontact (EnSite) mapping?

Background noise degrades image.


Too great of distance between rover and balloon array decreases accuracy.


Complex and very expensive system.

What are three principles for success in ablation therapy?

Complete understanding of the arrhythmia.


Complete understanding of the anatomy and accessory pathways.


Correct technology used.

What are three types of ablation therapy technology?

DC ablation


RF ablation


Cryogenic ablation

Which type of ablation therapy uses very high voltage producing heat in thousands of degrees and gasses that increase pressure within the vessel?

DC Ablation

Which type of ablation therapy creates transmural lesions and was generally limited to the AV junction ablation?

DC Ablation

Which type of ablation therapy uses AC current combined with relatively low radio frequency?

RF Ablation

Advantages of RF ablation over DC ablation?

Lower voltage


Less heat.


No gas production.


Larger surface area.


Fewer transmural lesions.


Can be used on thin walled structures.


Can be used on small structures.


Less need for anesthesia.

How are RF ablation catheters different from diagnostic EP catheters?

RF catheters have a longer electrode tip to increase surface area.

Disadvantages of RF ablation?

Requires precise mapping of circuit.


May not target deep tissue or very wide areas.


RF energy delivery is not quick and requires stable electrode placement for several minutes.

Complications of RF ablation?

High grade AV blocks.


Cardiac perforation and tamponade.


Mitral or tricuspid regurgitation.


Embolization.


Pulmonary Vein stenosis.


Creation of coronary artery lesions.

What type of ablation therapy uses extreme cold for stunning of tissue at cellular level?

Cryogenic ablation.

True/ False. Cryogenic ablation does not require precise mapping of the conduction system.

False.

What must be in place prior to ablation of the AV Node/ AV Junction?

temporary pacemaker

True/ False. It is safer to ablate the AV Node than the Bundle of His.

True

True/ False. Development of accelerated junctional rhythm while ablating the AV Node/ AV Junction indicates unsuccessful outcome.

False. Indicates successful outcome.

With AV Node Reentrant Tachycardia ablation, which pathway/ side of the Koch triangle is usually the fast pathway?

Fast = Tendon of Tedaro

With AV Node Reentrant Tachycardia ablation, which pathway/ side of the Koch triangle is usually the slow pathway?

Slow = Tricuspid Annulus

After mapping, which pathway (slow/ fast) is usually ablated in AVNRT ablation?

The slow pathway (tricuspid annulus) is usually ablated.

Where is a typical atrial flutter ablation done?

between the tricuspid annulus and the IVC.

What is atypical atrial flutter typically caused by?

Scar tissue

In typical atrial flutter, is the reentry circuit usually clockwise (SVC to AVN to CS to IVC) or counterclockwise (IVC to CS to AVN to SVC)?

CCW

What type of ablation uses linear ablations around the pulmonary veins to block or direct stimuli and is similar to "Maze" surgical procedure?

A-Fib ablation.

With ablation of Ventricular Arrhythmias, what type of VT must be present and tolerable by the patient?

Monomorphic VT < 200 bpm

What type of ablation is an alternative treatment of HOCM in patients with refractory medical therapy?

Septal Alcohol ablation

How is septal alcohol ablation done?

Pure alcohol is injected into the proximal (1st) septal coronary artery to create ischemia and effect of MI in that portion of the septum.

What complications are associated with septal alcohol ablation?

AV blocks and Right bundle branch requiring pacemaker.


Reentry VT post-procedure.


High chance for VF.

What is Sick Sinus Syndrome also called?

Brady-Tachy Syndrome.