IBRHE EXAM BUNDLE 3 LATEST VERSIONS (VERSION A,B AND C WITH ACTUAL DETAILED ANSWERS
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IBRHE 3
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IBRHE 3
IBRHE EXAM BUNDLE 3 LATEST VERSIONS (VERSION A,B AND C
WITH ACTUAL DETAILED ANSWERS IBRHE EXAM BUNDLE 3 LATEST VERSIONS (VERSION A,B AND C
WITH ACTUAL DETAILED ANSWERS IBRHE EXAM BUNDLE 3 LATEST VERSIONS (VERSION A,B AND C
WITH ACTUAL DETAILED ANSWERS IBRHE EXAM BUNDLE 3 LATEST VERSIONS (VERS...
A 59 yo female with ischemic cardiomyopathy presents with palpitations, lightheadedness, insomnia and
feels jittery. She has a CRT-D device.
Takes Furosemide, potassium, lisinopril, carvedilol and amiodarone. Seeing short runs of VT on her
device interrogation.
Hyperthyroidism
What would be your best next step for ordering tests?
Thyroid panel
Which antiarrhythmic drug is least likely to increase defibrillation thresholds?
Sotalol is least likely to increase defibrillation thresholds and may in fact decrease it.
In contrast all other drugs mentioned are likely to INCREASE defibrillation thresholds, which is why DFT
testing is sometimes performed on patients newly started on other drugs (Flecainide, Verapamil,
Amiodarone, Mexiletine).
Two max shocks fail to terminate VF from ICD. Patient rescued externally. What would the next steps be?
Reprogram shock waveform and / or shock vector.
If this fails implantation of a subcutaneous shock coil is very likely to be successful but requires an
invasive procedure.
,Repositioning of the RV lead rarely helps (unless the lead is in the RV inflow tract and can be placed far
out into the RV apex). Implantation on the right side is unlikely to solve the problem as right sided
implantations generally have a higher DFT.
Amiodarone is likely to further increase DFT and should therefore be avoided in this patient.
What does the noise on atrial channel signal?
Lead noise during exercise is suggestive for a problem with the atrial lead.
When looking closely at the X-ray image, an insulation defect can be detected on two of the three leads.
One defect is found on the abandoned atrial lead and the second on the active atrial lead. These findings
together with low lead impedance, make diagnosis of atrial lead insulation damage the most likely
explanation.
Atrial lead conductor problems could also result in atrial noise but impedance would be expected to
increase in this situation.
There is no indication of a ventricular lead problem. Myopotential oversensing in the context of a
unipolar atrial electrode is possible but would not explain the X ray findings and low atrial lead
impedance.
What is A00 pacing mode?
A00 mode in itself causes undersensing.
MADIT RIT trial
MADIT RIT programming devices implanted for primary prevention with a single zone at 200 bpm with a
2.5 second delay before the initiation of therapy was found to reduce inappropriate shock as well as
mortality. This was also found with a three zone system with delayed therapy using a 60 second delay at
170 bpm, and a 12 second delay at 200 bpm and a 2.5 second delay at 250 bpm.
A worse outcome was found for conventional programming using a 2 zone system with a 2.5 second
delay at 170 bpm and a 1.0 second delay at 200 bpm.
In general switching off ATP in VT zones as well as turning SVT discriminators are clearly not
recommended.
Which drugs have little to no effect on capture threshold?
Beta blockers usually have little to no effect on capture threshold.
Example: Metoprolol is clearly least likely to have elevated RV pacing thresholds in a patient.
Name drugs that can increase pacing thresholds?
,Both class IC antiarrhythmics (propafenone, but flecainide in particular) as well as class III
antiarrhythmics (amiodarone and sotalol) may lead to an increase in pacing thresholds.
(Though sotalol can IMPROVE DFT).
What factors increase risk for device infection?
Immunosuppression (corticosteroid use)
Renal dysfunction
Oral anticoagulation (increase risk of hematoma and infection)
Coexisting illnesses like diabetes
Periprocedural issues (including the failure to administer properly timed pre op antimicrobial prophylaxis
Device or lead revision (2-4x higher vs. initial implant)
The amount of indwelling hardware (number of leads) and operator experience.
Therapeutic dose low molecular weight heparin (LMWH) is associated with a substantial risk for
perioperative bleeding and hematoma formation. In contrast, it has been shown to be much less in
patients on Vitamin K antagonists such as warfarin even at therapeutic doses. Many operators now
recommend uninterrupted warfarin therapy perioperatively especially for patients at high risk for
thromboembolic events.
Ibuprofen is associated with low risk, while aspirin and clopidogrel have an increased risk, but nowhere
near as high as LMWH.
How is energy consumption of the device calculated?
What is Ohm's law?
Energy = V x I x t (V = volts, I = current, t = time)
V = IR
E = V2 x t/R (R = resistance)
Which bacteria is most likely to cause post op infection?
Staphylococcus infection is responsible for 80% of all device infections.
Infections months afterward is due to Staphylococcus epidermis. Acute, purulent device infections are
usually caused by S. aureus.
LV pacing is most often associated with what?
LV pacing is most often associated with a RBBB pattern since the depolarization starts in the LV and
arrives late in the RV.
Stimulation of the RV apex and RV free wall will have what pattern?
, Stimulation of the RV apex and RV free wall will have a LBBB pattern.
The RVOT has an inferior axis and LBBB pattern.
Which leads on the ECG represent the septum?
leads V1 and V2
What factors result in a positive CRT response?
Wide QRS width (especially when combined with LBBB morphology)
Female Gender
Non ischemic cardiomyopathy as the underlying pathology of heart failure.
Less consistently echo signs of dyssnychrony were found to predict response.
What is associated with less favorable response to CRT?
Coronary artery disease
Think presence of ischemic cardiomyopathy as the cause of decreased LV function is clearly associated
with a less favorable response to CRT (especially regarding LV reverse remodeling).
This is likely due to irreversible myocardial scarring.
Which leads represent the lateral wall?
Lead 1, AVL, V5 and V6 represent the lateral wall.
Which study investigated the efficacy of a single burst of ATP (8 pulses, 88% cycle length) in VT and fast
VT?
The PainFREE and the PainFREE II.
The success rate was 85% and 72%.
Acceleration of VT's by a burst of ATP were rarely observed. Based on this data at least one burst of ATP
before or during charging should be programmed in virtually all patients.
Dependent patients
Switch to asynchronous pacing in order to prevent oversensing from both electrocautery and device
manipulation.
Application of only short bursts of electrocautery or using a bipolar cautery system will reduce the risk of
over sensing.
Activity sensor should be turned off (for all patients) in order to minimize inappropriate increases in
heart rate due to device manipulation.
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