CCI Invasive Catheterization Procedures 2 — Questions and Answers
Question 1: During a left heart catheterization, the operator encounters significant resistance when attempting to cross the aortic valve. Which maneuver is most appropriate?
- Increase guidewire stiffness and force advancement
- Use an Amplatz Left catheter with a looping technique through the aortic root (Correct answer)
- Abort the procedure and reschedule
- Switch to a femoral venous approach
Correct answer: Use an Amplatz Left catheter with a looping technique through the aortic root
An Amplatz Left catheter can be manipulated to loop in the aortic root and prolapse across a stenotic aortic valve when direct crossing fails.
Question 2: A patient undergoing coronary angiography develops sudden hypotension and bradycardia with contrast injection into the right coronary artery. What is the most likely cause?
- Air embolism
- Vagally mediated response from RCA contrast injection (Correct answer)
- Coronary artery dissection
- Anaphylactic reaction to contrast
Correct answer: Vagally mediated response from RCA contrast injection
Vagally mediated hypotension and bradycardia (Bezold-Jarisch reflex) commonly occur with contrast injection into a dominant right coronary artery.
Question 3: What is the correct technique for measuring the LVEDP using a fluid-filled catheter system?
- Record pressure at peak of the R wave on simultaneous ECG
- Record pressure at the Z point, just before the rapid upstroke of the LV pressure waveform (Correct answer)
- Record the mean LV pressure throughout diastole
- Record pressure at the nadir of the T wave on simultaneous ECG
Correct answer: Record pressure at the Z point, just before the rapid upstroke of the LV pressure waveform
LVEDP is measured at the Z point (end-diastolic dip), just before the rapid pressure rise from LV contraction, corresponding to the end of the a wave.
Question 4: Which catheter is most commonly used for selective engagement of the left coronary ostium via a femoral approach in a patient with a normal aortic root?
- Judkins Right 4.0
- Judkins Left 4.0 (Correct answer)
- Amplatz Left 2
- Multipurpose catheter
Correct answer: Judkins Left 4.0
The Judkins Left 4.0 catheter is the standard catheter for engaging the left coronary ostium from the femoral approach in a normally sized aorta.
Question 5: When performing a right heart catheterization, the balloon-tipped catheter wedges prematurely in the right ventricle and shows RV waveforms. What is the next step?
- Deflate the balloon and withdraw the catheter to the RA, then re-inflate and re-advance (Correct answer)
- Continue advancing with balloon deflated
- Inject contrast to verify position
- Pull back slowly to the pulmonary artery
Correct answer: Deflate the balloon and withdraw the catheter to the RA, then re-inflate and re-advance
When premature wedging occurs in the RV, the catheter should be pulled back to the RA with the balloon deflated, then re-inflated and re-floated to allow flow-directed advancement.
Question 6: A Gorlin formula calculation is performed. The calculated mitral valve area is 0.8 cm². This finding is consistent with which severity of mitral stenosis?
- Mild mitral stenosis (MVA > 1.5 cm²)
- Moderate mitral stenosis (MVA 1.0–1.5 cm²)
- Severe mitral stenosis (MVA < 1.0 cm²) (Correct answer)
- Normal mitral valve (MVA 4–6 cm²)
Correct answer: Severe mitral stenosis (MVA < 1.0 cm²)
An MVA < 1.0 cm² by Gorlin formula calculation indicates severe mitral stenosis.
Question 7: During coronary angiography, a patient develops ventricular fibrillation. What is the immediate first-line treatment?
- Administer IV amiodarone 150 mg bolus
- Immediate unsynchronized defibrillation at 200 J (biphasic) (Correct answer)
- Initiate CPR and wait for the crash cart
- Administer IV lidocaine 1 mg/kg
Correct answer: Immediate unsynchronized defibrillation at 200 J (biphasic)
Ventricular fibrillation during catheterization requires immediate unsynchronized defibrillation as the definitive treatment to restore perfusing rhythm.
CCI Invasive Catheterization Procedures 2
During a left heart catheterization, the operator encounters significant resistance when attempting to cross the aortic valve.
Which maneuver is most appropriate?