CCI Invasive Catheterization Procedures 5 — Questions and Answers
Question 1: A patient with hypertrophic obstructive cardiomyopathy (HOCM) undergoes catheterization. Which maneuver will increase the outflow tract gradient?
- Passive leg raise to increase preload
- Handgrip exercise to increase afterload
- Valsalva maneuver or standing (decreased preload) (Correct answer)
- Administration of phenylephrine to increase afterload
Correct answer: Valsalva maneuver or standing (decreased preload)
The Valsalva maneuver decreases LV preload (venous return), which reduces LV cavity size and worsens dynamic LVOT obstruction in HOCM.
Question 2: What does the 'Brockenbrough-Braunwald-Morrow sign' demonstrate during catheterization?
- Increased post-extrasystolic LV systolic pressure with decreased aortic pulse pressure — pathognomonic of HOCM (Correct answer)
- Decreased LVEDP following contrast ventriculography
- Equalization of diastolic pressures after pericardiocentesis
- Increase in PCWP following rapid fluid challenge
Correct answer: Increased post-extrasystolic LV systolic pressure with decreased aortic pulse pressure — pathognomonic of HOCM
The Brockenbrough sign shows that after a premature ventricular beat, LV systolic pressure increases while aortic pulse pressure paradoxically decreases, pathognomonic for dynamic LVOT obstruction in HOCM.
Question 3: During transseptal puncture, which anatomical landmark is used to confirm correct needle position before puncture?
- The His bundle electrogram signal
- The 'tenting' of the fossa ovalis observed on fluoroscopy and confirmed by pressure monitoring (Correct answer)
- The right ventricular apex visualized on RAO fluoroscopy
- The coronary sinus os visualized in LAO projection
Correct answer: The 'tenting' of the fossa ovalis observed on fluoroscopy and confirmed by pressure monitoring
Tenting of the fossa ovalis seen fluoroscopically and confirmed by a right atrial pressure waveform at the needle tip confirms correct positioning before transseptal puncture.
Question 4: Which finding on coronary angiography is described as TIMI 2 flow?
- No antegrade flow beyond the point of occlusion
- Partial perfusion with contrast filling the distal vessel slowly, not clearing by the end of 3 cardiac cycles (Correct answer)
- Complete and rapid filling of the distal vessel equal to a non-culprit artery
- Partial perfusion with contrast filling but clearing by 3 cardiac cycles
Correct answer: Partial perfusion with contrast filling the distal vessel slowly, not clearing by the end of 3 cardiac cycles
TIMI 2 flow describes partial perfusion where contrast fills the distal coronary bed beyond the lesion but clears more slowly than normal (not within 3 cardiac cycles).
Question 5: What is the primary role of the Allen test prior to transradial cardiac catheterization?
- Assessing radial artery diameter to select sheath size
- Confirming adequate ulnar collateral circulation to the hand before radial artery cannulation (Correct answer)
- Determining the patency of the brachial artery
- Measuring radial artery blood pressure for baseline comparison
Correct answer: Confirming adequate ulnar collateral circulation to the hand before radial artery cannulation
The Allen test assesses ulnar artery collateral flow to ensure the hand will remain perfused if the radial artery becomes occluded during or after the procedure.
Question 6: A patient develops a large retroperitoneal hematoma after femoral arterial access. Which initial presentation finding should raise suspicion for this complication?
- Visible groin hematoma with ecchymosis
- Unexplained hypotension and ipsilateral flank or back pain without an obvious groin hematoma (Correct answer)
- Pulsatile mass in the antecubital fossa
- Sudden onset of unilateral leg swelling and erythema
Correct answer: Unexplained hypotension and ipsilateral flank or back pain without an obvious groin hematoma
Retroperitoneal hematoma classically presents with hypotension and ipsilateral flank/back pain but may have minimal external signs because bleeding is contained within the retroperitoneal space.
Question 7: In the Fick method for cardiac output calculation, what happens to the calculated output if the arteriovenous oxygen difference is doubled while oxygen consumption remains constant?
- Cardiac output doubles
- Cardiac output is halved (Correct answer)
- Cardiac output remains unchanged
- Cardiac output increases by 25%
Correct answer: Cardiac output is halved
By the Fick principle, CO = VO₂ ÷ (CaO₂ – CvO₂); doubling the AV O₂ difference while keeping VO₂ constant halves the calculated cardiac output.
CCI Invasive Catheterization Procedures 5
A patient with hypertrophic obstructive cardiomyopathy (HOCM) undergoes catheterization.
Which maneuver will increase the outflow tract gradient?