CCS Clinical Procedures & Protocols 2 — Questions and Answers
Question 1: During a diagnostic right heart catheterization, the pulmonary capillary wedge pressure (PCWP) is obtained by inflating the balloon on the Swan-Ganz catheter. What does an elevated PCWP (>18 mmHg) most directly reflect?
- Right ventricular end-diastolic pressure
- Left ventricular end-diastolic pressure (Correct answer)
- Pulmonary artery systolic pressure
- Central venous pressure
Correct answer: Left ventricular end-diastolic pressure
PCWP approximates left atrial pressure and thus left ventricular end-diastolic pressure, making it a key indicator of left-sided filling pressures.
Question 2: A patient undergoing coronary angiography develops contrast-induced nephropathy (CIN). Which pre-procedural intervention has the strongest evidence for reducing this risk?
- N-acetylcysteine administration
- Sodium bicarbonate infusion
- Isotonic saline hydration (Correct answer)
- Furosemide administration
Correct answer: Isotonic saline hydration
Adequate pre- and post-procedural isotonic saline hydration remains the most evidence-based strategy for preventing contrast-induced nephropathy.
Question 3: When performing a transesophageal echocardiogram (TEE) to evaluate a prosthetic mitral valve, which view best demonstrates the subvalvular apparatus and leaflet motion?
- Midesophageal four-chamber view
- Transgastric long-axis view (Correct answer)
- Midesophageal two-chamber view
- Upper esophageal aortic arch view
Correct answer: Transgastric long-axis view
The transgastric long-axis view provides the best alignment for Doppler interrogation and visualization of the subvalvular apparatus of the mitral valve.
Question 4: A 58-year-old patient with known coronary artery disease is scheduled for elective noncardiac surgery. His resting ECG shows a left bundle branch block (LBBB). Which stress test modality is most appropriate?
- Standard Bruce protocol exercise treadmill test
- Dobutamine stress echocardiography
- Adenosine nuclear perfusion imaging (Correct answer)
- Exercise nuclear perfusion imaging
Correct answer: Adenosine nuclear perfusion imaging
Pharmacologic vasodilator stress (adenosine or regadenoson) with nuclear imaging is preferred in LBBB because exercise-induced septal perfusion defects can be false-positive.
Question 5: After successful primary PCI for STEMI, a patient develops cardiogenic shock refractory to vasopressors. Which mechanical circulatory support device provides the greatest reduction in left ventricular workload?
- Intra-aortic balloon pump (IABP)
- Impella CP
- Veno-arterial ECMO (VA-ECMO) (Correct answer)
- Tandem Heart
Correct answer: Veno-arterial ECMO (VA-ECMO)
VA-ECMO provides the highest level of hemodynamic support and cardiac output augmentation in refractory cardiogenic shock, though it does not directly unload the LV.
Question 6: During electrophysiology study, what maneuver is used to differentiate AVNRT from AVRT?
- His-refractory premature ventricular complex (PVC) during tachycardia (Correct answer)
- Overdrive atrial pacing
- Intravenous adenosine administration
- Carotid sinus massage
Correct answer: His-refractory premature ventricular complex (PVC) during tachycardia
A His-refractory PVC that advances or terminates the tachycardia proves accessory pathway involvement (AVRT), as the AV node is bypassed.
Question 7: A patient with severe symptomatic aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) is deemed high surgical risk. What is the most appropriate next intervention?
- Balloon aortic valvuloplasty as definitive therapy
- Transcatheter aortic valve replacement (TAVR) (Correct answer)
- Surgical aortic valve replacement (SAVR)
- Continued medical management with diuretics
Correct answer: Transcatheter aortic valve replacement (TAVR)
TAVR is indicated for patients with severe symptomatic aortic stenosis who are at high or prohibitive surgical risk per current ACC/AHA guidelines.
CCS Clinical Procedures & Protocols 2
During a diagnostic right heart catheterization, the pulmonary capillary wedge pressure (PCWP) is obtained by inflating the balloon on the Swan-Ganz catheter.
What does an elevated PCWP (>18 mmHg) most directly reflect?