Question 1

Which of the following RV leads would be least prone to anodal stimulation in an extended bipolar configuration with a unipolar LV lead, when biV pacing?

A a brady lead with an anode 5mm2 and cathode 1.2mm2

B a brady lead with an anode 4.2mm2 and cathode of 5mm2

C an integrated ICD lead with an anode 450mm2 and cathode 2mm2

D a dedicated bipolar ICD lead with an anode 6mm2 and cathode 2.5mm2

Question 2

Normal ejection fractions are in which of the following ranges?

A 20-40%

B 50-65%

C 70-85%

D 85-100%

Question 3

The information in figure 1 suggests which of the following

A probable lead dislodgment

B lead insulation failure

C patient going into acute CHF

D patient needs to reduce diuretics

Figure 1

Question 4

Studies have shown which of the following VV intervals to most likely be optimal in the majority of patients when the lead is placed lateral or posterolateral?

A simultaneous

B LV 1st by 5-30ms

C LV 1st by 40-80ms

D RV 1st by 20-40ms

Question 5

Which of the following CS lead positions would be the most optimal in the majority of CRT patients (figure 2)?

A 2

B 3

C 4

D 5

Figure 2

Question 6

The lead and connector cavity in figure 3 is representative of which of the following?

A IS1

B VS1

C DF1

D IS4

Figure 3

Question 7

Which NYHA class represents end stage heart failure?

A I

B II

C III

D IV

E V

Question 8

Which electrode in Figure 4 is responsible for anodal stimulation shown in Figure 5?

A 1

B 2

C 3

D 4

Figure 4

Figure 5

Question 9

Which output does the anodal stimulation cease in Figure 5?

A 3V

B 2.8V

C 2.6V

D 2.4V

Question 10

Which of the following PVARP programming options would be most beneficial for biventricular pacing for heart failure in a patient with VA conduction of 200ms?

A 250ms

B 350ms

C PMT termination algorithm ON

D +PVARP after PVC ON

Question 11

Which of the following statements is true concerning optimisation of the AV delay for ventricular resynchronisation?

A program a very short AV delay to shorten the A wave (on echo)

B program a long AV delay allowing spontaneous mitral valve closure

C create a fused E and A wave (echo) allowing a delay between mitral closure and onset of systole

D E and A wave separation with the end of diastole coinciding with the beginning of systole

Question 12

A PRWT V1 – PRWT V6 value of 10 ms with a RBBB morphology indicates what?

A left septal capture

B selective left bundle area capture

C non selective left bundle area capture

D RV only capture

Question 13

Mrs Bullock has a biventricular ICD implanted for NYHA III, with paroxysmal rapid atrial fibrillation (AF) with a left bundle branch block and an LVEF of 20%. After experiencing palpitations and poorly controlled ventricular rates in AF she undergoes an AV node ablation in hopes to increase her biventricular pacing percentage. At 6 weeks post ablation, the procedural success was declared. 12 months on, she is still only receiving 85% biventricular pacing. Which of the following is an unlikely cause of this low pace percentage?

A conducted AF

B high burden of VPBs

C Oversensing is occurring leading to pacing inhibition

D Intermittent loss of LV capture with LV protection period turned on

Question 14

What is a normal HV interval?

A 0-20ms

B 20-40ms

C 40-55ms

D 55-70ms

Question 15

Mr Federer has biventricular pacemaker implanted for sinus rhythm with left bundle branch block, NYHA II, LVEF 25%? He presented for a routine ECG where the rhythm showed sinus tachycardia, however no biventricular pacing was occurring. Which of the following is NOT a possible reason for why biventricular pacing is not occurring?

A PVARP is too short

B UTR is lower than the rate of the sinus tachycardia

C AV delays are programmed too long

D RR AV delays are not ON

E tracking preference is not turned ON

Question 16

Which of the following HF approved drugs have shown an increased survival and EF?

A Flecainide and Sotolol

B Lasix and Digitalis

C Carvedilol and Minax

D Amiodarone and Propranolol

Question 17

Which of the following hemodynamic effects would most likely result from too long AV delays in a CRT patient?

A increase diastolic filling and increase stroke volume

B decrease cardiac output and increase mitral regurgitation

C increase cardiac output and increase LVEDP

D decrease mitral regurgitation and increase EF

Question 18

What function is NOT responsible for the markers shown in Figure 6?

A V sense response

B DDT mode

C Adaptive CRT pacing

Figure 6

Question 19

Mrs Morrison has her routine 6 month pacemaker check where a doctor is not available on site. Her cardiac compass is featured in Figure 7. When she is asked about her symptoms she reports feeling short of breath. What do you do next?

A Advise her to review with her GP

B Advise her to increase her fluid tablets

C Try and minimise ventricular pacing

D Organise an echo to evaluate her heart function

Figure 7

Question 20

The patient in Figure 8 has a CRTD. Based on the information in the cardiac compass, the patient would have

A No VT events, normal sinus rhythm, 5% ventricular pacing

B PAF, 75% ventricular pacing, bed rest

C Treated VT events, chronic AF, 25% ventricular pacing

D Treated VT events, chronic AF, moderate activity

Figure 8

Question 21

The ECG is Figure 9 most likely demonstrated pacing from which position?

A RVOT

B LVOT

C RV apex

D RV mid-septum

E Lateral LV

Figure 9

Question 22

The ECG in figure 10 belongs to a patient with a CRT. RV output has been programmed sub threshold and the LV has been programmed to 4V. These findings are most consistent with which of the following?

A intermittent anodal capture

B LV only capture

C RV only capture

D intrinsic conduction

E none of the above

Figure 10

Question 23

This information applies to the next 3 questions (23-25)

Mr Clive had a dual chamber pacemaker implanted for complete heart block. After several years of having his device he began to develop heart failure like symptoms. An echo was performed which showed an EF of 25%. The treating physician decided to upgrade his device to a CRTP.

Unfortunately the physician was unable to implant a traditional coronary sinus lead into the LV.

Which of the following options is NOT a potential reason for abandoning CS lead implantation.

A Venous access

B Obstructive Eustachian valve

C phrenic stimulation below ventricular thresholds in all positions

E Obstructive thebesian valve

Question 24

Which of the following is a feasible alternative for Mr Clive?

A Cardiac contractility modulation

B leadless LV lead (wise CRT)

C Deep septal left bundle lead

D Both B and C

Question 25

At the time of implant, if the physician device to implant a surgical LV lead at a later stage, which can configuration would be appropriate to hand up to the physician?

A IS1/IS1/IS1

B IS1/IS1/IS4

C IS1/DF4/IS4

D IS1/DF4/IS1

Question 26

During a left bundle branch area pacing implant, the physician instructs the pacemaker tech to pace at high output and low output. The LVAT at high output is 80ms, and the LVAT at low output is 95ms. What would be the next step in the implant?

A Slit the ventricular sheath

B Screw the left bundle lead in further

C retract the left bundle lead and reposition

D slightly retract the left bundle lead

Question 27

A patient presents for follow up with persistent intermittent issues of phrenic. Which of the following is least likely to help with troubleshooting?

A decreasing the output to a smaller safety margin

B programming to a closer coupled bipolar configuration

C choosing a different pacing vector

D decreasing the output voltage but allowing adequate safety by increasing the pulse width duration

E turning off autocapture algorithms

Question 28

Mr Cooper is a 65 year old male presenting with sinus rhythm with left bundle branch block (QRS 160ms), history of IHD, NYHA II and an LVEF 32%. Which of the following is the most appropriate management of this patient?

A Single chamber PPM implant

B Dual chamber ICD implant

C Biventricular PPM implant

D Biventricular ICD implant

E Medical management

Question 29

Mrs Angel is a 75 year old female presenting with sinus rhythm with left bundle branch block (QRS 160ms), NYHA III heart failure, LVEF 34%, and nonischemic cardiomyopathy. Which of the following is the most appropriate management of this patient?

A Single chamber PPM implant

B Dual chamber ICD implant

C Biventricular PPM implant

D Biventricular ICD implant

E Medical management

Question 30

The physician decided to implant a LBBAP lead for a young lady with sinus rhythm and complete heart block. The physician was positioning the lead and asked the pacing tech to come on pacing. The ECG appearance is shown in Figure 11. What would the doctor do next after seeing this pattern?

A Slit the sheath

B change the position of the lead

C place the lead in a different chamber

D screw the lead in further

Figure 11

Question 31

Which of the following does NOT assess fluid retention in a heart failure patient?

A optivol crossing

B evaluating lung sounds

C jugular venous distention

D Hepatojugular reflux

Question 32

Which of the following patients would adaptive LV pacing be most suitable for?

A AF, AVN ablation

B SR, PR 180ms, RBBB

C SR, CHB

D AF with slow conduction

E SR, PR 180ms, LBBB

Question 33

A physician was suturing up a pocket after inserting a complication free biventricular pacemaker implant. All leads were tested and confirmed to be functioning well with adequate safety margin for outputs and sensing. The 12 lead ECG is shown in Figure 12. Is there any settings that could be changed? Choose the correct answer.

A decrease the LV-RV offset

B shorten the AV delays

C Increase the LV-RV offset

D lengthen the AV delays

E No changes necessary

Figure 12

Question 34

Which of the following is not a limitation of multi point pacing

A Has a larger battery current drain

B More likely to have issues with phrenic stimulation

C Depending on myocardial tissue, may not be able to MPP due to non-capture

D MPP patients are less likely to respond to biventricular pacing

Question 35

Which of the following is not an appropriate treatment option for end stage heart failure?

A Palliation

B Cardiac Contractility Modulation

C Left ventricular assistance device

D Heart transplant

Question 36

Which of the following patients is most suitable for donating a heart for transplant?

A 25 year old male, structurally normal heart, HIV positive

B 80 year old male, no history of heart disease

C 45 year old female, no history of heart disease, endometriosis

D 20 year old female, history of rheumatic fever

Question 37

Which of the following patient is most suitable for receiving a heart transplant?

A 50 year old male, NYHA IV, LVEF 20%, compliant with medications, severe lung disease

B 40 year old female, NYHA IV, LVEF 30%, compliant with medications

C 60 year old female, NYHA III, LVEF 33%, compliant with medications

D 55 year old male, NYHA IV, LVEF 20%, non-compliant with medications

E 45 year old male, NYHA IV, LVEF 25%, compliant with medications, bowel cancer

Question 38

Which of the following is not a cause of heart failure?

A High blood pressure

B ischemic heart disease

C atrial fibrillation

D idiopathic

E sinus bradycardia

Question 39

A physician was suturing up a pocket after inserting a complication free biventricular pacemaker implant. All leads were tested and confirmed to be functioning well with adequate safety margin for outputs and sensing. The 12 lead ECG is shown in Figure 13. Is there any settings that could be changed? Choose the correct answer.

A decrease the LV-RV offset

B shorten the AV delays

C Increase the LV-RV offset

D lengthen the AV delays

E No changes necessary

Figure 13

Question 40

During a CRT implant, the physician is finding it difficult to access branches coming off the coronary sinus. Which of the following would not be helpful in assisting the physician?

A a different coronary sinus sheath

B a coronary wire

C an inner catheter

Question 41

When programming a device for a HIS bundle lead implantation, which of the following settings would you change from nominal settings in a Medtronic device?

A Ventricular autocapture

B Ventricular pulse width

C Ventricular pulse amplitude

D A and B

E B and C

Question 42

The following are all research findings in regards to CRT, except;

A MADIT CRT found CRT can reduce heart failure symptoms and death in mild HF (NYHA I and II)

B LV only fusion pacing is superior to biventricular pacing

C An LV offset 40ms is more beneficial than 0ms offset in CRT patients

D QLV >90ms is ideal for LV lead placement

Question 43

A physician was suturing up a pocket after inserting a complication free biventricular pacemaker implant. All leads were tested and confirmed to be functioning well with adequate safety margin for outputs and sensing. The 12 lead ECG is shown in Figure 14. Is there any settings that could be changed? Choose the correct answer.

A decrease the LV-RV offset

B shorten the AV delays

C Increase the LV-RV offset

D lengthen the AV delays

E No changes necessary

Figure 14

Question 44

Figure 15 shows a paced ECG. Where is the pacing lead?

A CS lateral LV branch

B RV mid septum

C RV apex

D HIS bundle

E Left bundle branch area

Figure 15

Question 45

Figure 16 shows a paced ECG. Where is the pacing lead?

A CS lateral LV branch

B RV mid septum

C RV apex

D HIS bundle

E Left bundle branch area

Figure 16

Question 46

This information applies to the following 3 questions (46-48).

Mrs Jackson was implanted with a Medtronic biventricular ICD. She is 80 years old with persistent longstanding atrial fibrillation and is planned for a pace and ablate strategy

Until Mrs Jacksons AV node ablation, the physician has requested back up pacing only. Which of the following should be programmed at implant? Choose the incorrect answer.

A SMART detections off

B LV autocapture off

C V sense response off

D VVI 40

Question 47

Mrs Jacksons arrives for an AV node ablation 6 weeks after ICD insertion. Which of the following should be programmed or checked immediately prior to commencing ablation. Choose the incorrect answer.

A Leads are functioning well and have consistent values compared to implant.

B ICD therapies are turned off

C Patient is on ECG monitoring

D Rates have been poorly controlled