CCS Clinical Procedures & Protocols 3 — Questions and Answers
Question 1: During cardiac catheterization, a patient's oxygen saturation step-up is detected at the right ventricular level. What is the most likely diagnosis?
- Atrial septal defect
- Ventricular septal defect (Correct answer)
- Patent ductus arteriosus
- Pulmonary arteriovenous malformation
Correct answer: Ventricular septal defect
An oxygen saturation step-up at the RV level indicates a left-to-right shunt at the ventricular level, consistent with a ventricular septal defect.
Question 2: Which parameter measured during right heart catheterization is most useful for diagnosing pulmonary arterial hypertension (PAH) versus pulmonary venous hypertension?
- Mean pulmonary artery pressure (mPAP)
- Pulmonary vascular resistance (PVR)
- Pulmonary capillary wedge pressure (PCWP) (Correct answer)
- Cardiac output by thermodilution
Correct answer: Pulmonary capillary wedge pressure (PCWP)
A PCWP ≤15 mmHg distinguishes pre-capillary PAH from post-capillary (pulmonary venous) hypertension caused by left heart disease.
Question 3: A cardiovascular specialist performs a pericardiocentesis for cardiac tamponade. After needle entry, which finding confirms intrapericardial position before catheter advancement?
- Bloody aspirate that clots rapidly
- Pressure waveform showing RV morphology
- Injection of agitated saline showing microbubbles in pericardial space on echo (Correct answer)
- Negative pressure on aspiration
Correct answer: Injection of agitated saline showing microbubbles in pericardial space on echo
Injecting agitated saline and visualizing microbubbles in the pericardial space on echocardiography confirms correct needle placement before catheter advancement.
Question 4: What is the recommended activated clotting time (ACT) target during percutaneous coronary intervention (PCI) when unfractionated heparin is used without a glycoprotein IIb/IIIa inhibitor?
- 150–200 seconds
- 200–250 seconds
- 250–350 seconds (Correct answer)
- 350–400 seconds
Correct answer: 250–350 seconds
The ACT target for PCI with unfractionated heparin alone is 250–350 seconds to balance anticoagulation efficacy and bleeding risk.
Question 5: A patient undergoing cardioversion for persistent atrial fibrillation has an INR of 1.8 despite warfarin therapy. What is the most appropriate next step according to current guidelines?
- Proceed with cardioversion immediately
- Perform TEE to rule out left atrial thrombus before cardioversion (Correct answer)
- Delay cardioversion until INR is therapeutic for 4 weeks
- Switch to a direct oral anticoagulant and cardiovert in 48 hours
Correct answer: Perform TEE to rule out left atrial thrombus before cardioversion
TEE-guided cardioversion is an acceptable alternative to 3–4 weeks of therapeutic anticoagulation when the INR is subtherapeutic, as it can rule out left atrial appendage thrombus.
Question 6: During device implantation, a cardiac implantable electronic device (CIED) pocket infection is identified 3 weeks post-implant. What is the definitive management?
- Long-term oral antibiotics alone
- IV antibiotics with pocket irrigation and retention of hardware
- Complete device and lead extraction with antibiotics (Correct answer)
- Percutaneous aspiration and local antibiotic injection
Correct answer: Complete device and lead extraction with antibiotics
Complete system extraction combined with appropriate antibiotic therapy is the definitive treatment for CIED pocket infection to prevent persistent infection and endocarditis.
Question 7: In the hemodynamic assessment of constrictive pericarditis, what echocardiographic Doppler finding most distinguishes it from restrictive cardiomyopathy?
- Reduced E/A ratio on mitral inflow
- Respiratory variation >25% in mitral inflow E velocity (Correct answer)
- Elevated E/e' ratio >15
- Tissue Doppler e' velocity <8 cm/s
Correct answer: Respiratory variation >25% in mitral inflow E velocity
Exaggerated respiratory variation (>25%) in mitral inflow E velocity reflects ventricular interdependence, a hallmark of constrictive pericarditis not seen in restriction.
CCS Clinical Procedures & Protocols 3
During cardiac catheterization, a patient's oxygen saturation step-up is detected at the right ventricular level.
What is the most likely diagnosis?