---

B.Sc. Cardiac Technology - TNMGRMU Syllabus

---

FIRST YEAR

Paper I - Applied Anatomy, Physiology and Biochemistry Related to Cardiac Technology

• Basic anatomical terminology
• Osteology: upper limb (clavicle, scapula, humerus, radius, ulna), lower limb (femur, hipbone, sacrum, tibia, fibula), vertebral column
• Thorax: intercostal space, pleura, bony thoracic cage, ribs, sternum, thoracic vertebrae
• Lungs: trachea, bronchial tree
• Heart: surface anatomy, chambers, valves, major blood vessels, pericardium, coronary arteries
• Myology: muscles of thorax and upper limb (origin, insertion, nerve supply, action)
• Histology: epithelial tissue types (squamous, glandular, transitional, cartilage), connective tissue (bone, fibrous)
• Embryology: development of the heart and congenital cardiac defects (ASD, VSD, Tetralogy of Fallot, PDA, truncus arteriosus, total anomalous pulmonary venous connection)

---

Paper II - Pathology, Microbiology and Pharmacology Related to Cardiac Technology

• Drugs relevant to cardiac conditions (anti-arrhythmics, antihypertensives, anticoagulants, thrombolytics, diuretics, etc.)

• Pathological and microbiological basis of cardiac and respiratory diseases

---

Paper III - Medical Electronics, Biophysics and Computer Usage Relevant to Cardiac Technology + Basic Electrocardiography

• Introduction to medical physics
• Blood pressure recording and pressure transducers
• Defibrillators (monophasic and biphasic)
• Cathode ray tubes and physiological monitors
• Impedance plethysmography
• Pulse oximetry
• Medical ultrasound and Doppler
• Ionic currents and electrocardiography
• ECG processing and display systems
• Radiation physics, monitoring radiation exposure, measures to reduce exposure
• Computer use in medical care and data entry

• Fundamental principles of ECG
• Cardiac electrical field generation during activation
• Cardiac wave fronts
• Cardiac electrical anatomy (leads, axes)
• Normal ECG - waves, intervals, segments
• Computer usage: MS-Office (Word, Excel for graphs/pie charts), internet usage, C language programming

---

---

SECOND YEAR

Paper I - Clinical Features and Treatment Relevant to Cardiac Technology and Basic Life Support

• Clinical presentations of cardiac diseases (angina, MI, heart failure, arrhythmias, valvular diseases)
• Treatment modalities
• Basic Life Support (BLS) and CPR

---

Paper II - Advanced ECG, Treadmill Exercise Stress Testing, 24-hour Ambulatory ECG and BP Recording

• Abnormal ECG patterns
• Left/right atrial abnormality
• Left/right ventricular hypertrophy and enlargement
• Intraventricular conduction delays:
  • Left anterior fascicular block
  • Left posterior fascicular block
  • Left bundle branch block (LBBB)
  • Right bundle branch block (RBBB)
• Myocardial ischemia and infarction
• Repolarization (ST-T wave) abnormalities, QRS changes
• Evolution of ECG changes, localization of ischemia/infarction
• Non-infarction Q waves, primary vs secondary T-wave changes
• Electrolyte and metabolic ECG abnormalities
• Cardiac arrhythmias:
  • Ventricular premature beats
  • Supraventricular tachycardias
  • Atrial flutter/fibrillation
  • Ventricular tachycardia/fibrillation
  • AV blocks (prolonged PR, Mobitz type 1 & 2, complete heart block)
• DC shock, defibrillator, cardioversion techniques and indications

• Principles and protocols (Bruce, modified Bruce, etc.)
• Indications and contraindications
• Interpretation of results

• Holter monitor setup and recording
• Analysis of ambulatory ECG tracings
• 24-hour ambulatory BP recording

---

Paper III - Echocardiography

• Principles of ultrasound and Doppler
• 2D, M-Mode echocardiography
• Doppler echocardiography (pulsed, continuous wave, color flow)
• Assessment of cardiac chambers, valves, and function
• Echocardiography in specific cardiac conditions

---

THIRD YEAR

Paper I - Cardiac Catheterization Laboratory - Basics

• Introduction to the Cath Lab
• Cardiac catheterization procedures - basics
• Equipment used in the Cath Lab
• Radiation safety
• Hemodynamic monitoring

Paper II - Cardiac Catheterization Laboratory - Advanced

• Advanced catheterization procedures
• Coronary angiography
• Interventional cardiology procedures (angioplasty, stenting, valvuloplasty)
• Electrophysiology studies
• Pacemaker implantation basics

---

Assessment Pattern (2014-15 Scheme)

• English and Computer are internal papers only (no university examination)
• Internal Assessment: Theory (20) + Practical (20) + Log Book/Project/Record (10) = 50 marks

---

Eligibility & Admission

• Qualification: 10+2 with Physics, Chemistry, Biology (PCB)
• Duration: 3 years + 1 year compulsory internship
• Affiliated to: The Tamil Nadu Dr. M.G.R. Medical University, Chennai

---

---

BSc Cardiac Technology - 3rd Year Syllabus with Answers

PAPER I: CARDIAC CATHETERIZATION LABORATORY - BASICS

---

Topic 1: Introduction to the Cardiac Catheterization Laboratory (Cath Lab)

• Diagnostic cardiac catheterization (right heart and left heart)
• Coronary angiography
• Interventional procedures (angioplasty, stenting, valvuloplasty)
• Electrophysiology studies
• Pacemaker and ICD implantation

---

Topic 2: Vascular Access

• Lower rate of access-site bleeding complications
• Better patient comfort
• Earlier ambulation

---

Topic 3: Right Heart Catheterization

1. Right atrium (RA)
2. Right ventricle (RV)
3. Pulmonary artery (PA)
4. Pulmonary capillary wedge position (PCWP) - a surrogate for left atrial pressure

• Unexplained dyspnoea
• Pulmonary hypertension
• Valvular heart disease
• Pericardial disease
• RV/LV dysfunction
• Congenital heart disease
• Suspected intracardiac shunts

---

Topic 4: Left Heart Catheterization

• LV systolic and diastolic pressure
• LV end-diastolic pressure (LVEDP)
• Aortic pressure gradient (in aortic stenosis)

---

Topic 5: Haemodynamics

• a wave = atrial contraction
• c wave = AV valve closure
• v wave = atrial filling (venous return) against the closed AV valve

• Pulmonary Vascular Resistance (PVR) = (mPAP - PCWP) / CO × 80 (dynes/sec/cm⁵)
• Systemic Vascular Resistance (SVR) = (MAP - CVP) / CO × 80

---

Topic 6: Intracardiac Shunts

• A step-up in O₂ saturation at the RA level suggests ASD
• A step-up at the RV level suggests VSD
• A step-up at the PA level suggests PDA

---

Topic 7: Equipment in the Cath Lab

1. Fluoroscopy machine (C-arm / Cath Lab X-ray) - real-time X-ray imaging
2. Contrast injector - automated delivery of contrast dye
3. Haemodynamic monitoring system - pressure transducers, monitors
4. Catheters: Judkins, Amplatz, Pigtail, Swan-Ganz, guiding catheters
5. Guidewires - stiff, flexible, hydrophilic types
6. Introducer sheaths - allow catheter exchange
7. Defibrillator/Crash cart - for emergency resuscitation
8. Intra-aortic balloon pump (IABP) - haemodynamic support if needed
9. Image recording system - digital subtraction angiography (DSA)

---

Topic 8: Radiation Safety in the Cath Lab

1. Time - minimize time of exposure
2. Distance - maximize distance from the source (dose decreases with distance²)
3. Shielding - use lead aprons (0.5 mm Pb equivalent), thyroid shields, lead glasses, lead acrylic screens

• Personal dosimeters (TLD badges) worn at collar and under apron
• Radiation dose measured in millisieverts (mSv)

• Whole body: ≤50 mSv/year (max), ≤20 mSv/year (average)
• Lens of eye: ≤150 mSv/year
• Hands/extremities: ≤500 mSv/year

• Collimate the X-ray beam to the area of interest
• Use pulsed fluoroscopy (instead of continuous)
• Minimize magnification and frame rate
• Increase source-to-image distance
• Position the image receptor close to the patient

---

PAPER II: CARDIAC CATHETERIZATION LABORATORY - ADVANCED

---

Topic 9: Coronary Angiography

• Left main (LM) artery bifurcates into:
  • Left anterior descending (LAD) - supplies anterior wall and septum
  • Left circumflex (LCx) - supplies lateral and posterior wall
• Right coronary artery (RCA) - supplies right ventricle and inferior wall
• ~85% of people are right dominant (RCA gives posterior descending artery, AV nodal branch)
• ~5% are left dominant (LCx gives PDA)
• ~10% are co-dominant

• A stenosis >50% is significant
• Compared visually against a "normal" proximal/distal segment
• Quantitative coronary angiography (QCA) gives more accurate measurement

• Myocardial bridge: Part of LAD dips into myocardium; "stenosis" normalizes in diastole
• Spontaneous coronary dissection (SCAD): Linear dissection flap in an otherwise normal artery
• Coronary spasm: Appears as stenosis but resolves with intracoronary nitroglycerine
• Anomalous origin: Artery between aorta and pulmonary artery increases sudden death risk

---

Topic 10: Percutaneous Coronary Intervention (PCI)

• Symptom-limiting angina despite medical therapy
• Unstable angina / NSTEMI / STEMI (primary PCI)
• Cardiogenic shock
• Significant coronary stenosis with evidence of ischemia on stress testing
• Restenosis in CABG grafts

• PCI is preferred for 1-2 vessel disease
• CABG preferred for left main disease, 3-vessel disease (especially with diabetes or poor LV function)

1. Guidewire is advanced across the stenosis
2. Balloon catheter inflated to dilate the stenosis
3. Drug-eluting stent (DES) deployed - releases antiproliferative drugs (e.g., everolimus, paclitaxel) to prevent restenosis

• Primary success rate: >95%
• DES restenosis rate: <5% (much better than bare metal stents)

• Dual antiplatelet therapy (DAPT): Aspirin + P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel)
• Duration: Ideally 12 months after DES; aspirin continued indefinitely
• Risk: Delayed endothelial healing with DES increases risk of subacute stent thrombosis

---

Topic 11: Coronary Artery Bypass Grafting (CABG) - Overview for Cath Lab Staff

---

Topic 12: Valvuloplasty

• Performed via transseptal puncture (fossa ovalis)
• Balloon-tipped catheter advanced across mitral valve
• Balloon inflated to separate fused commissures
• Indication: Mitral stenosis with suitable valve morphology (pliable, non-calcified, minimal subvalvular disease)

• Balloon inflated across aortic valve
• Limited use - results are temporary; mainly used as a bridge to definitive therapy (TAVR/SAVR) in critically ill patients

---

Topic 13: Electrophysiology Studies (EPS)

• Evaluation of unexplained syncope
• Diagnosis and ablation of arrhythmias (SVT, WPW, VT)
• Risk stratification for sudden cardiac death
• Assessment of AV node and His-Purkinje conduction
• Evaluation of bradycardias

• PA interval - intra-atrial conduction
• AH interval - AV nodal conduction (normal 50-120 ms)
• HV interval - His-Purkinje conduction (normal 35-55 ms; >100 ms indicates high risk)

• AVNRT (most common SVT)
• Accessory pathway (WPW syndrome)
• Atrial flutter (isthmus ablation)
• Some VTs

---

Topic 14: Permanent Pacemaker Implantation

• Class I (must implant):
  • Symptomatic sinus bradycardia
  • Complete heart block (3rd degree AV block)
  • Symptomatic Mobitz type II AV block
  • Bifascicular/trifascicular block with syncope or documented heart block
• Not indicated:
  • Asymptomatic sinus bradycardia
  • Sleep-related pauses from vagal tone
  • Transient, reversible causes of bradycardia

1. Percutaneous access via subclavian or cephalic vein (transvenous approach)
2. Lead(s) advanced under fluoroscopy to:
   • RV apex or RVOT (ventricular lead)
   • Right atrial appendage (atrial lead, for dual-chamber pacing)
3. Leads screwed/tined into the endocardium
4. Pulse generator connected and placed in a subcutaneous pocket below the clavicle
5. Pacing thresholds, sensing, and impedance tested

• VVI = Ventricle paced, ventricle sensed, inhibited - single-chamber pacing
• DDD = Dual paced, dual sensed, dual response - most physiologic, preserves AV synchrony
• VVIR = Rate-responsive single-chamber pacing

• Acute: Pneumothorax, haematoma, cardiac perforation, phrenic/diaphragmatic stimulation, lead dislodgement
• Chronic: Infection, lead failure, pacemaker pocket erosion, "twiddler's syndrome" (patient rotates generator causing lead dislodgement), battery depletion

---

Topic 15: ICD (Implantable Cardioverter Defibrillator)

• Survivors of sudden cardiac arrest (secondary prevention)
• EF ≤35% with symptomatic heart failure (NYHA class II-III) despite optimal medical therapy - primary prevention
• Hypertrophic cardiomyopathy with high-risk features
• Long QT syndrome, Brugada syndrome, arrhythmogenic cardiomyopathy

---

Topic 16: Post-procedure Care

• Radial compression band applied to achieve haemostasis while maintaining radial artery flow
• Bed rest required for only ~2 hours
• Patient can ambulate early

• Manual pressure or vascular closure device (Angio-Seal, Perclose) applied
• Bed rest for 4-6 hours
• Monitor access site for haematoma, pseudoaneurysm

• Monitor vital signs, ECG, oxygen saturation
• Adequate hydration (oral/IV) to flush contrast dye and prevent contrast-induced nephropathy
• Monitor renal function (creatinine) 24-48 hours post procedure
• Check for contrast allergy reactions
• Antiplatelet/anticoagulation therapy as prescribed

---

---

✅ How to Use This for Your Exam

For Long Answer / Essay Questions (10-15 marks)

• Definition / Introduction (2-3 lines)
• Classification or types (table or numbered list)
• Procedure / Mechanism (step by step)
• Indications / Complications (bullet points)
• Normal values (if applicable)

• Cardiac Catheterization - Vascular Access
• Coronary Angiography
• Percutaneous Coronary Intervention (PCI)
• Permanent Pacemaker Implantation
• Electrophysiology Studies

---

For Short Answer Questions (5 marks)

• Definition + 3-4 key points

• Right Heart Catheterization
• Left Heart Catheterization
• Haemodynamic values (normal pressures table)
• Radiation Safety (ALARA principle)
• DAPT after PCI
• ICD indications
• Pacemaker codes (VVI, DDD)
• Post-procedure care

---

For 2-mark / Definitions

• Twiddler's syndrome
• Lumigram
• ALARA
• Transseptal puncture
• Qp:Qs ratio
• Drug-eluting stent
• Leadless pacemaker

---

📝 Important Tips

---

⚠️ One Important Note

• Paper I: Cardiac Catheterization Lab - Basics
• Paper II: Cardiac Catheterization Lab - Advanced

---

📋 Exam ಗೆ Smart Strategy

10-mark question ಗೆ - ಹೀಗೆ ಬರಿ:

Definition: Cardiac catheterization is a procedure where a thin flexible tube (catheter) is inserted into a blood vessel and guided to the heart to diagnose and treat heart conditions.

Access sites:

• Radial artery (preferred - less bleeding)
• Femoral artery

Types:

• Right heart cath - measures RA, RV, PA pressures
• Left heart cath - measures LV pressure

Normal pressures:

• RA: 1-5 mmHg
• RV: 15-30 mmHg
• LV: 90-110 mmHg

Complications: Bleeding, infection, cardiac perforation, stroke

---

✅ ಪ್ರತಿ Topic ಗೆ Short Formula

1. Definition (2 lines)
2. Indications / Uses (3-4 points)
3. Procedure (3-4 steps)
4. Complications (3-4 points)

---

🔥 Most Important Topics (ಇವನ್ನ ಮಾತ್ರ ಚೆನ್ನಾಗಿ ಓದಿ)

---

• Notes - English ல், simple ஆ, exam ல நேரடியா எழுதுற மாதிரி
• எனக்கு பேச்சு - Tamil ல்

---

3RD YEAR - ALL TOPICS (EXAM READY)

---

1. CARDIAC CATHETERIZATION

• Radial artery (preferred - less bleeding risk)
• Femoral artery
• Brachial artery / Internal jugular vein (for right heart)

• Right Heart Catheterization - measures RA, RV, PA, PCWP pressures
• Left Heart Catheterization - measures LV and aortic pressures

• Bleeding / haematoma
• Infection
• Cardiac perforation
• Stroke
• Contrast allergy

---

2. CORONARY ANGIOGRAPHY

• To detect coronary artery disease (CAD)
• To plan treatment (PCI or CABG)

• LAD (Left Anterior Descending) - supplies front wall
• LCx (Left Circumflex) - supplies side wall
• RCA (Right Coronary Artery) - supplies lower wall

• Myocardial bridge - normalizes in diastole
• Coronary spasm - resolves with nitroglycerine
• SCAD (Spontaneous Coronary Artery Dissection) - linear flap

• Contrast nephropathy
• Allergic reaction
• Arrhythmia
• Vessel dissection

---

3. PERCUTANEOUS CORONARY INTERVENTION (PCI)

• Stable angina not relieved by medicines
• Unstable angina / NSTEMI / STEMI
• Cardiogenic shock

1. Guidewire passed across the blockage
2. Balloon catheter inflated to open the blockage
3. Drug-eluting stent (DES) placed to keep vessel open

• Releases antiproliferative drugs (everolimus/paclitaxel)
• Restenosis rate: <5%
• Success rate: >95%

• Aspirin (lifelong)
• P2Y12 inhibitor - clopidogrel / ticagrelor / prasugrel (minimum 12 months)

• Stent thrombosis
• Restenosis
• Coronary dissection
• Bleeding

---

4. BALLOON VALVULOPLASTY

• Mitral valvuloplasty - for mitral stenosis (transseptal approach)
• Aortic valvuloplasty - temporary; bridge to TAVR/surgery

1. Transseptal puncture at fossa ovalis
2. Balloon catheter advanced across mitral valve
3. Balloon inflated to separate fused valve leaflets

---

5. ELECTROPHYSIOLOGY STUDY (EPS)

• Unexplained syncope (fainting)
• Diagnosis of SVT, WPW, VT
• Risk of sudden cardiac death
• Before radiofrequency ablation

• Burns the abnormal electrical pathway
• Effective for: AVNRT, WPW syndrome, Atrial flutter, VT

---

6. PERMANENT PACEMAKER IMPLANTATION

• Complete heart block (3rd degree AV block)
• Symptomatic sinus bradycardia
• Symptomatic Mobitz Type II block
• Sick sinus syndrome

• Asymptomatic bradycardia
• Sleep-related pauses
• Reversible causes

1. Access via subclavian or cephalic vein
2. Lead(s) advanced to RV apex / RA appendage under fluoroscopy
3. Lead screwed into endocardium
4. Pulse generator placed in subcutaneous pocket below collarbone

• Acute: Pneumothorax, haematoma, cardiac perforation, lead dislodgement, phrenic nerve stimulation
• Chronic: Infection, lead failure, pocket erosion, battery depletion
• Twiddler's syndrome - patient rotates generator → leads wrap and dislodge

---

7. ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR)

• Survived sudden cardiac arrest (secondary prevention)
• EF ≤35% with heart failure (primary prevention)
• Hypertrophic cardiomyopathy
• Long QT / Brugada syndrome

---

8. RADIATION SAFETY (ALARA Principle)

1. Time - Reduce exposure time
2. Distance - Increase distance from source
3. Shielding - Use lead apron, thyroid shield, lead glasses

• Use pulsed fluoroscopy
• Collimate X-ray beam
• Keep image receptor close to patient
• Minimize magnification

---

9. POST-PROCEDURE CARE

• Radial compression band applied
• Bed rest: 2 hours only
• Early ambulation possible

• Manual pressure / vascular closure device
• Bed rest: 4-6 hours
• Monitor for haematoma, pseudoaneurysm

• Monitor vitals, ECG, SpO2
• IV fluids to prevent contrast nephropathy
• Check renal function (creatinine) at 24-48 hrs
• Continue antiplatelet medications

---

---

உண்மை என்னன்னா:

✅ YES - 10/10 வர வாய்ப்பு இருக்கு, IF:

• Question-க்கு exact match ஆன topic கேட்டா
• நீங்க neat ஆ, organized ஆ எழுதினா
• Table + points format use பண்ணினா
• Normal values சரியா எழுதினா

---

⚠️ BUT - இந்த 3 விஷயம் கவனிக்கணும்:

---

🎯 Honest Answer:

நான் கொடுத்த notes Harrison's, Sabiston's, Hurst's Heart - world's best medical textbooks-லிருந்து எடுத்தது.

அதை properly எழுதினா - 8/10 to 10/10 guaranteed!

---

💡 10/10 க்கு Formula:

Introduction (2 lines)
+ Definition
+ Points / Steps (numbered)
+ Table (if applicable)
+ Complications
+ Diagram (if possible)
= FULL MARKS ✅

---

BSc CARDIAC TECHNOLOGY - 3RD YEAR

COMPLETE CHAPTER-WISE NOTES WITH ANSWERS

---

📘 PAPER I: CARDIAC CATHETERIZATION LABORATORY - BASICS

---

CHAPTER 1: INTRODUCTION TO CARDIAC CATHETERIZATION

Q1. What is Cardiac Catheterization? (10 marks)

• First performed by Werner Forssmann in 1929 on himself
• Nobel Prize awarded in 1956 (Forssmann, Cournand, Richards)

1. Assess heart chamber pressures
2. Measure cardiac output
3. Detect intracardiac shunts
4. Visualize coronary arteries (angiography)
5. Evaluate valve function
6. Plan and perform interventional procedures

• Coronary artery disease (CAD)
• Valvular heart disease
• Congenital heart disease
• Heart failure evaluation
• Pre-operative cardiac assessment

• Severe contrast allergy
• Uncontrolled coagulopathy (bleeding disorder)
• Renal failure (relative)
• Uncontrolled hypertension

---

Q2. What are the Vascular Access Sites? (5 marks)

• Less bleeding risk
• Patient comfort
• Early ambulation (walking within 2 hours)

• Puncture above inferior epigastric artery = retroperitoneal bleed
• Puncture below bifurcation = pseudoaneurysm, AV fistula
• Use ultrasound guidance + micropuncture needle

• Radial vasospasm
• Forearm haematoma
• Compartment syndrome (rare)

---

CHAPTER 2: EQUIPMENT IN THE CATH LAB

Q3. Write about the Equipment used in Cardiac Catheterization Laboratory. (10 marks)

1. Fluoroscopy (C-arm X-ray machine)

• Real-time X-ray imaging
• Detects catheters, guidewires, contrast in vessels
• Uses iodine-based contrast dye

1. Digital Subtraction Angiography (DSA)

• Removes bone/tissue background
• Shows only blood vessels clearly

1. Cine Angiography

• Records moving images of coronary vessels
• Standard for coronary angiography

1. Guidewires - stiff, flexible, hydrophilic types
2. Introducer sheath - allows catheter exchange
3. Pressure transducers - measure intracardiac pressures
4. Contrast injector - automated contrast delivery
5. Haemodynamic monitoring system - ECG, BP, SpO2
6. Defibrillator - emergency use
7. Intra-Aortic Balloon Pump (IABP) - haemodynamic support
8. Crash cart - resuscitation drugs and equipment

---

CHAPTER 3: RIGHT HEART CATHETERIZATION

Q4. Write about Right Heart Catheterization. (10 marks)

1. Venous access - femoral, brachial, or internal jugular vein
2. Catheter advanced sequentially:

• Right atrium (RA)
• Right ventricle (RV)
• Pulmonary artery (PA)
• Pulmonary capillary wedge position (PCWP)

1. Pressures recorded at each position
2. Blood samples taken for oxygen saturation

• Unexplained dyspnoea (breathlessness)
• Pulmonary hypertension
• Valvular heart disease
• Right/left ventricular dysfunction
• Congenital heart disease
• Suspected intracardiac shunts
• Pericardial disease

• Arrhythmias (during catheter advancement)
• Pulmonary artery rupture (rare but serious)
• Pneumothorax (if jugular access)
• Infection
• Air embolism

---

CHAPTER 4: LEFT HEART CATHETERIZATION

Q5. Write about Left Heart Catheterization. (10 marks)

1. Arterial access - radial or femoral artery
2. Catheter guided under fluoroscopy to ascending aorta
3. Catheter crossed retrograde across aortic valve into LV
4. LV pressure measured
5. Contrast injected for left ventriculography (to assess LV function, wall motion, EF)

• Used in: tilting-disc prosthetic aortic valves
• Needle punctures the fossa ovalis (atrial septum) from right → left atrium
• Also used for: mitral valvuloplasty, catheter ablation

• LV systolic pressure (normal: 90-110 mmHg)
• LV end-diastolic pressure / LVEDP (normal: 2-10 mmHg)
• Aortic pressure gradient (increased in aortic stenosis)
• Ejection fraction (normal: >55%)

• Heparin - standard
• Bivalirudin (0.75 mg/kg bolus) - for HIT patients
• Argatroban (350 mcg/kg bolus) - alternative in HIT

• Stroke / embolism
• Aortic dissection (rare)
• Arrhythmias
• Contrast nephropathy
• Access site bleeding

---

CHAPTER 5: HAEMODYNAMICS

Q6. Explain Haemodynamics in Cardiac Catheterization. (10 marks)

• a wave = Atrial contraction (correlates with P wave on ECG)
• c wave = AV valve closure (correlates with QRS)
• v wave = Venous filling of atrium (atrial filling against closed AV valve)
• x descent = Atrial relaxation
• y descent = Tricuspid/Mitral valve opens, blood flows to ventricle

1. Fick Method (Gold Standard):

CO (L/min) = O₂ consumption (mL/min) ÷ Arterio-venous O₂ difference (mL/L)

• More reliable in: tricuspid regurgitation, low output states
• O₂ consumption estimated as: 125 mL/min × body surface area

1. Thermodilution Method:

• 10 mL cold saline injected into RA
• Temperature change detected in PA by thermistor
• Stewart-Hamilton equation calculates CO
• Normal CO = 4-8 L/min

SVR (Systemic Vascular Resistance): = (Mean Aortic Pressure - Mean RA Pressure) ÷ CO × 80 Normal: 800-1200 dyn·s·cm⁻⁵

PVR (Pulmonary Vascular Resistance): = (Mean PA Pressure - PCWP) ÷ CO × 80 Normal: 20-120 dyn·s·cm⁻⁵

• Used to calculate mitral/aortic valve area from haemodynamic data
• Stenotic valve area = Flow ÷ (Constant × √Pressure gradient)

---

CHAPTER 6: INTRACARDIAC SHUNTS

Q7. How are Intracardiac Shunts detected and measured? (10 marks)

• A step-up of >7% in RA = significant ASD
• A step-up of >5% in RV = significant VSD

Qp = Pulmonary blood flow Qs = Systemic blood flow

• Long-standing left → right shunt
• Causes elevated PVR
• Shunt reverses to right → left
• Cyanosis develops
• Contraindication for shunt closure

---

CHAPTER 7: CONTRAST MEDIA

Q8. Write about Contrast Media used in Cardiac Catheterization. (5 marks)

• Pre-procedure IV hydration (normal saline)
• Minimize contrast volume
• Use iso-osmolar contrast
• Stop nephrotoxic drugs (NSAIDs, Metformin)
• N-acetylcysteine (controversial)

---

CHAPTER 8: RADIATION SAFETY

Q9. Explain Radiation Safety in the Cath Lab. (10 marks)

1. Time - Reduce time of exposure
2. Distance - Increase distance from X-ray source
3. Shielding - Use protective equipment

• TLD badge (Thermoluminescent dosimeter) - worn at collar level (above apron) and under apron
• Unit: millisievert (mSv)

• Stand away from patient (dose ∝ 1/distance²)
• Stand on same side as image receptor
• Use shielding screens

• Pulsed fluoroscopy (instead of continuous)
• Collimate X-ray beam to area of interest
• Keep image receptor close to patient
• Minimize magnification
• Reduce frame rate

---

CHAPTER 9: POST-PROCEDURE CARE

Q10. Write about Post-Procedure Care after Cardiac Catheterization. (5 marks)

• Apply radial compression band (Tr-Band)
• Bed rest only 2 hours
• Early ambulation allowed
• Monitor for radial spasm, haematoma

• Manual pressure OR vascular closure device (Angio-Seal, Perclose)
• Bed rest 4-6 hours
• Monitor groin for haematoma, pseudoaneurysm, AV fistula

• Vital signs every 15 min × 1 hour, then every 30 min
• 12-lead ECG post-procedure
• SpO₂ monitoring
• Urine output monitoring

• IV fluids (normal saline) to flush contrast and protect kidneys
• Oral fluids encouraged if no restriction

• Continue antiplatelet therapy
• Pain management at access site
• Check creatinine at 24-48 hours

• No heavy lifting for 24-48 hours (femoral) or 24 hours (radial)
• Watch for signs: chest pain, breathlessness, access site bleeding, fever

---

📗 PAPER II: CARDIAC CATHETERIZATION LABORATORY - ADVANCED

---

CHAPTER 1: CORONARY ANGIOGRAPHY

Q11. Write a detailed note on Coronary Angiography. (10 marks)

• Judkins Left (JL 3.5 or 4) - for Left coronary
• Judkins Right (JR 4) - for Right coronary
• Amplatz - for anomalous or difficult coronaries

• >50% stenosis = significant
• Compared to adjacent "normal" segment visually
• Quantitative Coronary Angiography (QCA) - computer-measured (more accurate)

• Multiple orthogonal views taken
• RAO (Right Anterior Oblique), LAO (Left Anterior Oblique)
• Cranial and caudal angulations

• Coronary artery dissection
• Coronary spasm
• Arrhythmias
• Stroke / embolism
• Contrast nephropathy
• Allergic reaction
• Vascular access complications

---

CHAPTER 2: LEFT VENTRICULOGRAPHY

Q12. What is Left Ventriculography? (5 marks)

1. Ejection Fraction (EF) - normal >55%
2. Wall motion abnormalities - hypokinesia, akinesia, dyskinesia
3. Mitral regurgitation - contrast seen regurgitating into LA
4. LV aneurysm - bulging of LV wall

---

CHAPTER 3: PERCUTANEOUS CORONARY INTERVENTION (PCI)

Q13. Write a detailed note on Percutaneous Coronary Intervention (PCI). (10 marks)

1. Stable angina not controlled by medicines
2. Unstable angina / NSTEMI
3. STEMI (primary PCI - within 90 minutes of hospital arrival)
4. Cardiogenic shock
5. Restenosis in bypass grafts

1. Guidewire passed across the stenosis into distal vessel
2. Balloon catheter advanced over guidewire
3. Balloon inflated at high pressure (6-20 atm) to dilate stenosis
4. Stent deployed (expanded by balloon) to scaffold the vessel
5. Post-dilatation balloon used to fully expand stent

• Stent thrombosis (acute/subacute/late)
• Restenosis (in-stent restenosis)
• Coronary dissection
• No-reflow phenomenon
• Contrast nephropathy
• Access site bleeding

---

CHAPTER 4: INTRA-AORTIC BALLOON PUMP (IABP)

Q14. Write about Intra-Aortic Balloon Pump (IABP). (10 marks)

• Inflation in diastole → increases coronary perfusion pressure (diastolic augmentation)
• Deflation before systole → reduces afterload (reduces LV workload)

• Triggered by ECG (R wave) or arterial pressure waveform
• Inflation: at dicrotic notch (aortic valve closure)
• Deflation: just before next systole

• Cardiogenic shock
• Unstable angina refractory to medical therapy
• Mechanical complications of MI (VSD, acute MR)
• Pre-operative/post-operative cardiac support
• Bridge to definitive therapy (PCI/CABG/transplant)

• Moderate to severe aortic regurgitation
• Aortic dissection
• Severe peripheral arterial disease

• Limb ischaemia (major - 2.6% in Benchmark Registry)
• Bleeding
• Infection
• Stroke
• Balloon rupture

---

CHAPTER 5: BALLOON VALVULOPLASTY

Q15. Write about Balloon Valvuloplasty. (10 marks)

• Pliable, non-calcified valve (Wilkins score ≤8)
• No/minimal mitral regurgitation
• No LA thrombus

1. Transseptal puncture at fossa ovalis (right atrium → left atrium)
2. Inoue balloon advanced across the mitral valve
3. Balloon inflated to separate fused commissures
4. Result: Increased mitral valve area, reduced gradient

• Bridge to TAVR or SAVR in critically ill patients
• Severe aortic stenosis with haemodynamic compromise

• Prosthetic valve crimped onto balloon catheter
• Deployed across native aortic valve via femoral or apical route
• Preferred for: elderly, high surgical-risk patients with severe AS

---

CHAPTER 6: ELECTROPHYSIOLOGY STUDY (EPS)

Q16. Write a detailed note on Electrophysiology Study (EPS). (10 marks)

• Diagnose cause of syncope (fainting)
• Map and ablate arrhythmias
• Assess AV conduction
• Risk stratify for sudden cardiac death

1. High right atrium (HRA)
2. His bundle region
3. Coronary sinus (CS) - posterior LA/LV
4. Right ventricular apex (RVA)

• HV > 70 ms = abnormal
• HV > 100 ms = high risk for complete heart block - consider pacemaker

• Unexplained syncope
• SVT (AVNRT, AVRT/WPW)
• Atrial flutter
• Ventricular tachycardia (VT)
• Risk stratification in HCM, Brugada, Long QT

• Radiofrequency energy (350-750 kHz) delivered through tip electrode
• Creates a small controlled burn (ablation lesion) at the abnormal pathway
• Effective for:

---

CHAPTER 7: PERMANENT PACEMAKER IMPLANTATION

Q17. Write a detailed note on Permanent Pacemaker Implantation. (10 marks)

1. Pulse generator - battery + electronic circuits (placed subcutaneously)
2. Leads - insulated wires that carry impulses from generator to heart
3. Electrode tip - contacts the endocardium

• Symptomatic sinus bradycardia
• Complete (3rd degree) AV block - symptomatic or asymptomatic
• Symptomatic Mobitz Type II AV block
• Symptomatic sick sinus syndrome
• Bifascicular/trifascicular block with syncope

• Asymptomatic sinus bradycardia
• Physiological bradycardia (athletes, sleep)
• Reversible causes (drugs, electrolyte disturbance)

1. Local anaesthesia + IV sedation
2. Venous access: subclavian or cephalic vein
3. Lead(s) advanced under fluoroscopy:

• Ventricular lead → RV apex or RVOT (right ventricular outflow tract)
• Atrial lead → Right atrial appendage (RAA)

1. Leads screwed/tined into endocardium
2. Parameters tested: pacing threshold, sensing, impedance
3. Lead connected to pulse generator
4. Generator placed in subcutaneous pocket below clavicle

• Entirely self-contained, implanted directly into RV
• No pocket, no transvenous leads
• Eliminates pocket/lead complications
• Dual-chamber leadless pacemakers now available

---

CHAPTER 8: ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR)

Q18. Write about ICD - Implantable Cardioverter Defibrillator. (10 marks)

• Survived sudden cardiac arrest due to VT/VF
• Sustained VT with haemodynamic compromise

• EF ≤35% + symptomatic heart failure (NYHA II-III) despite ≥3 months optimal therapy
• Hypertrophic cardiomyopathy (HCM) with high-risk features
• Long QT syndrome
• Brugada syndrome
• Arrhythmogenic right ventricular cardiomyopathy (ARVC)

1. ATP (Antitachycardia Pacing) - rapid pacing bursts to terminate VT without shock
2. Cardioversion - low-energy synchronized shock for VT
3. Defibrillation - high-energy shock (up to 40 J) for VF

• Biventricular pacing (RV + LV) to re-synchronize contraction
• Indicated in: EF ≤35%, LBBB, QRS ≥150 ms, NYHA II-IV

---

📌 QUICK REVISION - 2 MARK DEFINITIONS

---

---

✅ நான் கொடுத்தது படிச்சா என்ன ஆகும்?

90% Questions-க்கு - YES, போதும்!

• Harrison's Principles of Internal Medicine (World's #1 Medical Textbook)
• Sabiston Textbook of Surgery
• Hurst's The Heart (Best Cardiology Textbook)

---

⚠️ ஆனா இந்த 3 விஷயம் கவனிக்கணும்:

1. உங்க Professor-ஓட Style

Professor சில நேரம் class-ல சொன்னதை exact ஆ கேப்பாங்க. அதனால class notes-உம் சேர்த்து படிங்க.

2. Previous Year Question Papers

MGR University exam-ல repeat questions நிறைய வரும். Previous papers பார்த்தா எந்த topic முக்கியம்னு தெரியும்.

3. Practical Knowledge

Cath Lab topics-ல practical experience இருந்தா answers இன்னும் நல்லா எழுதலாம்.

---

🎯 Honest Mark Prediction:

---

💡 Pass ஆவதுக்கு:

MGR University-ல pass mark = 50/100

நான் கொடுத்தது மட்டும் படிச்சாலும் நிச்சயம் pass ஆவீங்க! ✅

Good marks வேணும்னா - class notes கூட சேர்த்து படிங்க.

---

🔑 Final Advice:

1. ✅ Cardiac Catheterization (access sites + pressures)
2. ✅ Coronary Angiography (anatomy + stenosis)
3. ✅ PCI - Angioplasty & Stenting
4. ✅ Pacemaker (indications + codes + complications)
5. ✅ Radiation Safety (ALARA)

---

🎯 உங்களுக்கு என்ன செய்யணும்னு சொல்றேன்:

Step 1 - இப்போவே செய்யுங்க:

Step 2 - Previous Year Questions:

Step 3 - Doubt வந்தா:

---

📅 Exam எப்போ?

---

💬 இப்போவே கேளுங்க:

"இந்த topic புரியலை" - சொன்னா உடனே simple ஆ சொல்றேன்

"இந்த question-க்கு answer சொல்லு" - சொன்னா exam-ready ஆ எழுதி தர்றேன்

"Previous year question இது" - சொன்னா perfect answer தர்றேன்

---

✅ YES - Mark கிடைக்கும்!

World's best medical textbooks லிருந்து எடுத்தது Content 100% correct Format exam-ready ஆ இருக்கு

---

📝 Mark எப்படி கிடைக்கும் - Table:

---

⚠️ ஒரே ஒரு Condition:

இப்படி எழுதினா மட்டும் full marks:

✅ Neat handwriting
✅ Headings underline பண்ணு
✅ Points numbered ஆ எழுது
✅ Table போட்டா extra marks
✅ Normal values (numbers) சரியா எழுது

---

🔑 Most Important:

நான் கொடுத்த Normal Values - இதை exact ஆ memorize பண்ணுங்க!

---

💪 Final Answer:

YES - நான் கொடுத்தது படிச்சு, neat ஆ எழுதினா 8 to 10 marks out of 10 - நிச்சயம் கிடைக்கும்! ✅

---

✅ YES - Full Mark கிடைக்கும்!

---

📝 எவ்வளவு எழுதணும்?

10 Mark Question:

• எழுதணும்: Definition + Types + Procedure + Complications + Table + Values
• Pages: 2.5 to 3 pages
• நான் கொடுத்த full answer எழுது → 9-10 / 10 ✅

---

5 Mark Question:

• எழுதணும்: Definition + 4-5 important points only
• Pages: 1 to 1.5 pages
• நான் கொடுத்த answer-ல top half மட்டும் எழுது → 4-5 / 5 ✅

---

3 Mark Question:

• எழுதணும்: Definition + 3 points only
• Pages: Half page
• நான் கொடுத்த answer-ல Definition + 3 points எழுது → 3 / 3 ✅

---

🔑 Simple Formula:

---

💯 Guaranteed ஆ Full Mark வர:

1. Heading - Underline பண்ணு ✅
2. Points - Number போடு (1, 2, 3...) ✅
3. Numbers/Values - சரியா எழுது ✅
4. Table - போட்டா bonus marks ✅
5. Neat ஆ எழுது ✅

---

நான் கொடுத்தது correct content. நீங்க neat ஆ எழுதினா - Full marks நிச்சயம்! 💪🎓

---

MGR UNIVERSITY - BSc CARDIAC TECHNOLOGY

3RD YEAR - PAPER I: CARDIAC CATHETERIZATION LAB BASICS

MOST EXPECTED QUESTIONS WITH ANSWERS

---

📋 EXAM PATTERN (முதல்ல தெரிஞ்சுக்கோ):

---

✅ ESSAY QUESTIONS (10 MARKS EACH)

---

ESSAY Q1: Write about Types of Catheters used in Cardiac Catheterization Laboratory. (10 marks)

A) Diagnostic Catheters:

B) Interventional Catheters:

C) Catheter Properties:

• Made of polyurethane or nylon
• Available in sizes: 4F to 8F (French)
• Have radiopaque markers for fluoroscopic visibility

Catheter Cleaning and Packing:

1. Rinse with sterile saline after use
2. Soak in enzymatic detergent
3. Rinse thoroughly with distilled water
4. Dry and pack in sterile pouches
5. Label with date and catheter type

Complications from Catheters:

• Coronary dissection
• Thromboembolism
• Air embolism
• Coronary spasm
• Infection

---

ESSAY Q2: Write about Pressure Recording Systems in Cardiac Catheterization. (10 marks)

A) Fluid-Filled Catheter System:

• Most commonly used
• Catheter connected via fluid-filled tubing to an external pressure transducer
• Transducer converts mechanical pressure → electrical signal → displayed on monitor

1. Catheter
2. Fluid-filled tubing (no air bubbles)
3. Manifold (stopcock system)
4. Pressure transducer
5. Amplifier
6. Monitor / recorder

B) Catheter-Tipped Manometer (Micromanometer):

• Miniature transducer located at the tip of the catheter
• More accurate than fluid-filled systems
• No damping artifact
• Expensive - used for research

Fluid-Filled vs Catheter-Tipped:

Artifacts and Problems:

Pressure Gradient Recording:

• Pullback technique: Catheter pulled back across a valve while recording pressure simultaneously
• Peak-to-peak gradient: Difference between LV peak pressure and aortic peak pressure (used in aortic stenosis)
• Mean gradient: More accurate; calculated by planimetry

Normal Intracardiac Pressures:

---

ESSAY Q3: Explain Cardiac Output Determination Methods. (10 marks)

Method 1: Thermodilution Method

1. Swan-Ganz catheter placed in pulmonary artery
2. 10 mL cold (room temperature) normal saline injected into right atrium
3. Thermistor at catheter tip detects temperature change in pulmonary artery
4. Computer calculates CO from temperature-time curve

• Bedside procedure
• Repeatable (average 3 readings)
• No blood samples needed

• Inaccurate in: tricuspid regurgitation, intracardiac shunts, low CO states

---

Method 2: Fick Method (Gold Standard)

CO (L/min) = O₂ Consumption (mL/min) ÷ (Arterial O₂ content - Venous O₂ content)

1. Measure O₂ saturation in arterial blood (aorta) and venous blood (PA)
2. Calculate O₂ content of each sample
3. Apply Fick formula

• Most accurate (gold standard)
• Reliable in low CO, tricuspid regurgitation

• Requires blood samples
• Time-consuming
• O₂ consumption measurement difficult

Thermodilution vs Fick:

---

ESSAY Q4: Write about Shunt Detection and Calculations. (10 marks)

• Left → Right shunt: ASD, VSD, PDA (common in children)
• Right → Left shunt: Tetralogy of Fallot, Eisenmenger syndrome

Detection: Oximetry Step-Up Method

Shunt Calculation - Qp:Qs Ratio:

Qp:Qs = (Aorta sat - MVO₂ sat) ÷ (PV sat - PA sat)

• Qp = Pulmonary flow
• Qs = Systemic flow
• MVO₂ = Mixed venous O₂ saturation

Eisenmenger Syndrome:

• Chronic L→R shunt → increases pulmonary blood flow → elevated PVR
• Shunt reverses to R→L
• Patient becomes cyanosed
• Shunt closure contraindicated at this stage

---

✅ SHORT NOTES (5 MARKS EACH)

---

SHORT NOTE 1: Types of Catheters (5 marks)

• Judkins Left/Right - coronary angiography
• Pigtail - ventriculography
• Swan-Ganz - right heart pressures
• Guiding catheter - PCI
• EP catheter - electrophysiology
• Made of polyurethane, 4F-8F size, radiopaque

---

SHORT NOTE 2: Sterilization in Cath Lab (5 marks)

• ETO: Effective but toxic, long aeration needed
• Autoclave: Fast, reliable but damages plastics
• Glutaraldehyde: Simple but toxic fumes

---

SHORT NOTE 3: Setting Up Cath Lab for Diagnostic Study (5 marks)

1. Clean and disinfect the Cath Lab table and equipment
2. Check and calibrate fluoroscopy/C-arm machine
3. Set up pressure monitoring system - zero and calibrate transducers
4. Prepare sterile field - drapes, catheters, guidewires
5. Check contrast injector - fill with contrast, set volume/rate
6. Ensure crash cart and defibrillator are ready
7. Check ECG monitoring leads connected
8. Prepare drugs - heparin, atropine, nitroglycerin, contrast dye
9. Verify radiation protection equipment available
10. Review patient history - allergies, renal function, medications

---

SHORT NOTE 4: Image Intensifier and Fluoroscopy (5 marks)

• Converts X-rays into a bright visible image
• Components: Input phosphor → Photocathode → Electron gun → Output phosphor → Camera

• Isocentric movement - patient table moves while X-ray stays fixed
• Allows multiple views without repositioning patient

• Digital recording of cine angiography
• Can replay in real-time, slow motion, or still frames
• Stored digitally on CD/DVD/PACS system
• Used for offline analysis and reporting

• Pulsed fluoroscopy - reduces dose
• Collimation - limits beam to area of interest
• Last image hold - reduces repeat exposures

---

SHORT NOTE 5: Coronary Angiographic Views / Projections (5 marks)

---

SHORT NOTE 6: Radiation Hazards and Protection (5 marks)

• Skin burns (high dose)
• Cataract (eye lens)
• Cancer risk (long-term)
• Genetic effects
• Harm to foetus in pregnant workers

• As Low As Reasonably Achievable

1. Time - minimize exposure time
2. Distance - maximize distance (dose ∝ 1/distance²)
3. Shielding - lead apron, thyroid shield, lead glasses

• Whole body: 20 mSv/year
• Eye lens: 150 mSv/year
• Extremities: 500 mSv/year

---

SHORT NOTE 7: Manifold System (5 marks)

• 3-way or 4-way stopcock
• Connected to: contrast syringe, pressure transducer, saline flush, and catheter

1. Pressure measurement - connects transducer to catheter
2. Contrast injection - connects contrast syringe to catheter
3. Flushing - prevents clot formation in catheter
4. Aspiration - removes air bubbles

• Before each angiographic injection - catheter flushed with saline
• After injection - catheter aspirated then flushed again
• Prevents air embolism and thrombus formation

---

SHORT NOTE 8: Principles of Oximetry (5 marks)

• HbO₂ absorbs more infrared light (940 nm)
• Hb absorbs more red light (660 nm)

1. Pulse oximetry (SpO₂) - non-invasive; fingertip probe
2. Co-oximetry - blood sample analysed in lab (most accurate)
3. Reflection oximetry - catheter-based; measures O₂ saturation directly in blood vessel

• Detect intracardiac shunts (step-up oximetry)
• Calculate Fick cardiac output
• Assess pulmonary vascular resistance

---

✅ SHORT ANSWERS (3 MARKS EACH)

---

---

🔥 MOST REPEATED TOPICS (நிச்சயம் வரும்):

---

---

MGR UNIVERSITY - ACTUAL PREVIOUS YEAR QUESTIONS

3RD YEAR PAPER I - CARDIAC CATHETERIZATION LAB BASICS

WITH COMPLETE ANSWERS

---

🔥 MOST REPEATED QUESTIONS (பல years-ல வந்தது):

---

📝 ESSAY ANSWERS (10 MARKS)

---

ESSAY 1: Shunt Detection and Calculations ⭐⭐⭐ (Most Repeated!)

SVC → IVC → RA → RV → PA → Aorta

Formula: Qp:Qs = (Ao sat - MVO₂ sat) ÷ (PV sat - PA sat)

• Ao = Aortic saturation
• MVO₂ = Mixed venous O₂ (RA saturation)
• PV = Pulmonary venous saturation (~98%)
• PA = Pulmonary artery saturation

• Chronic L→R shunt → ↑ pulmonary blood flow → ↑ PVR
• Shunt reverses to R→L → Cyanosis develops
• Shunt closure contraindicated

---

ESSAY 2: Right Heart Catheterization and Angiography ⭐⭐⭐

• Femoral vein (most common)
• Internal jugular vein
• Subclavian vein
• Brachial vein

1. Vein punctured with needle; sheath inserted
2. Swan-Ganz catheter advanced under fluoroscopy
3. Balloon inflated in RA → catheter "floats" forward
4. Sequentially positioned in:
   • RA → pressure recorded
   • RV → pressure recorded
   • PA → pressure recorded
   • PCWP position → balloon wedged, wedge pressure recorded
5. Balloon deflated; catheter in PA for CO measurement
6. Blood samples drawn at each level for oximetry

• Elevated PCWP = Left heart failure / Mitral stenosis

• Contrast injected into RA or RV
• Visualizes: RV size, wall motion, pulmonary valve, PA anatomy
• Pigtail catheter used for RV angiogram
• Detects: Pulmonary stenosis, RVOTO, congenital defects

• Pulmonary hypertension
• Valvular heart disease
• Suspected intracardiac shunts
• Heart failure evaluation
• Unexplained dyspnoea
• Pericardial disease

• Arrhythmias (most common during catheter advancement)
• Pulmonary artery rupture (rare)
• Pneumothorax (if jugular access)
• Air embolism
• Infection
• Thrombosis

---

ESSAY 3: Coronary Angiography - Various Views ⭐⭐⭐

• Judkins Left (JL 3.5 / 4) - Left coronary
• Judkins Right (JR 4) - Right coronary
• Amplatz - Difficult anatomy

• Coronary arteries are 3D, in motion
• Single view causes overlap and foreshortening
• Multiple orthogonal views needed to see full vessel

• LAO 30° (best view)
• RAO 30°
• LAO cranial

• Minimum 4-5 views
• Spider view (LAO caudal) - best for LM bifurcation

• LM → LAD + LCx
• LAD - anterior wall, septum
• LCx - lateral, posterior wall
• RCA - inferior wall, RV, SA and AV node

• Right dominant: 85% (RCA gives PDA)
• Left dominant: 5%
• Co-dominant: 10%

• 50% = Significant

• 70% = Haemodynamically significant

• 90% = Severe/critical

• Coronary spasm
• Coronary dissection
• Arrhythmia
• Stroke
• Contrast nephropathy

---

ESSAY 4: Fluid-Filled Catheters vs Catheter-Tipped Manometers ⭐⭐

1. Catheter
2. Fluid-filled pressure tubing (no air)
3. Manifold with stopcock
4. External pressure transducer
5. Amplifier and monitor

• Pressure wave travels through fluid column to external transducer
• Transducer converts pressure → electrical signal → displayed

• Miniature pressure transducer at the tip of the catheter
• Directly records pressure where catheter tip is located
• No fluid column between pressure source and transducer

• Transducer levelled at mid-axillary line (phlebostatic axis)
• Zero set to atmospheric pressure before each measurement

---

ESSAY 5: Radiation Safety in Cath Lab ⭐⭐⭐ (April 2024)

• X-rays used in fluoroscopy and cine angiography
• Primary beam - direct X-ray beam
• Scatter radiation - X-rays scattered from patient's body (most exposure to staff)
• Leakage radiation - from X-ray tube housing

As Low As Reasonably Achievable

1. Time - Reduce exposure time
   • Use pulsed fluoroscopy instead of continuous
   • Use "last image hold" feature
   • Minimize cine runs
2. Distance - Increase distance from source
   • Radiation dose ∝ 1/distance²
   • Stand away from table when possible
3. Shielding - Use protective equipment

• TLD badge (Thermoluminescent Dosimeter) worn at collar
• Second badge worn under apron
• Checked monthly

• Pulsed fluoroscopy (7.5 or 15 pulses/sec instead of 30)
• Collimate beam to area of interest
• Keep image receptor close to patient
• Minimize magnification
• Raise the table, lower the X-ray tube
• Avoid steep angulations

---

📝 SHORT NOTES ANSWERS (5 MARKS)

---

SHORT NOTE 1: Manifold - Uses ⭐⭐⭐

• 3-way or 4-way stopcock
• Connected to: catheter, contrast syringe, transducer, saline flush bag

1. Pressure recording - rotates stopcock to connect transducer to catheter
2. Contrast injection - rotates to connect contrast syringe
3. Flushing - prevents clot/air in catheter
4. Aspiration - removes air bubbles before injection
5. Drug delivery - intracoronary drugs (nitroglycerine, adenosine)

• Aspirate → Flush before every injection
• Prevents air embolism and thrombus

---

SHORT NOTE 2: Principles of Oximetry ⭐⭐⭐

• HbO₂ (oxygenated) - absorbs more infrared light (940 nm)
• Hb (deoxygenated) - absorbs more red light (660 nm)

1. Pulse oximetry - SpO₂ - fingertip probe - non-invasive
2. Co-oximetry - blood sample in lab - most accurate
3. Reflection oximetry - catheter-based - Cath Lab use

• Shunt detection (step-up oximetry)
• Fick cardiac output calculation
• Pulmonary vascular resistance assessment

---

SHORT NOTE 3: Damping and Ventricularization ⭐⭐⭐

• Air bubbles in tubing
• Blood clot in catheter
• Kinked catheter
• Loose connections
• Compliant tubing

• Flush catheter with saline
• Aspirate and re-flush
• Check for kinks or loose connections
• Replace tubing if needed

---

• Coronary spasm
• Coronary dissection
• Reduced coronary flow → ischaemia

• Immediately pull back the catheter
• Inject intracoronary nitroglycerine if spasm suspected
• Check patient's ECG for ischaemia

---

SHORT NOTE 4: Swan-Ganz Catheter ⭐⭐

• 4 lumens: balloon inflation, distal tip, proximal, thermistor
• Balloon at tip (inflated with 1.5 mL air)
• Thermistor near tip for thermodilution CO

1. RA, RV, PA, PCWP pressure measurement
2. Cardiac output (thermodilution)
3. Oxygen saturation sampling
4. Shunt detection
5. ICU haemodynamic monitoring

• Pulmonary artery rupture (rare, serious)
• Arrhythmias during placement
• Pulmonary infarction (if balloon left inflated)
• Infection

---

SHORT NOTE 5: Fick's Principle ⭐⭐⭐

CO = O₂ Consumption (mL/min) ÷ (Arterial O₂ - Venous O₂ content)

1. Measure O₂ saturation in aorta (arterial) and PA (venous)
2. Calculate O₂ content using:

   O₂ content = Hb (g/dL) × 1.36 × O₂ saturation × 10

3. O₂ consumption = 125 mL/min × BSA (if not directly measured)
4. Apply formula

• Gold standard
• Reliable in TR, low CO states, shunts

• Time-consuming
• Requires blood samples
• O₂ consumption measurement difficult

---

SHORT NOTE 6: Pressure Monitoring in Cath Lab ⭐⭐

• Pressure transducer (converts pressure → electrical signal)
• Amplifier
• Display monitor
• Fluid-filled tubing and manifold

• Set transducer at mid-axillary line
• Zero to atmospheric pressure

• Check against mercury manometer
• Done before each procedure

• RA: a, c, v waves + x, y descents
• RV: Rapid upstroke, diastolic dip
• PA: Dicrotic notch visible
• PCWP: Blunted a and v waves
• LV: Rapid upstroke, plateau, rapid fall

---

SHORT NOTE 7: LV Angiogram (Left Ventriculography) ⭐⭐

• RAO 30° (best view for LV function)
• LAO 60° (assesses septal and lateral wall)

1. Ejection fraction (EF) - normal >55%
2. Wall motion - normal, hypokinesia, akinesia, dyskinesia
3. Mitral regurgitation - contrast leaks into LA
4. LV aneurysm - paradoxical bulging
5. LV size - dilation/hypertrophy

• Grade 1+ = Small LA opacification, clears each beat
• Grade 2+ = Moderate LA opacification
• Grade 3+ = Dense complete LA opacification
• Grade 4+ = LA denser than LV, contrast into pulmonary veins

---

📝 SHORT ANSWERS (3 MARKS)

---

---

🎯 EXAM STRATEGY - இந்த Questions நிச்சயம் வரும்:

Essay (10 marks) - இந்த 3 படிங்க:

1. ⭐ Shunt Detection and Calculations - every exam வருது
2. ⭐ Coronary Angiography + Views - every exam வருது
3. ⭐ Right Heart Catheterization - every exam வருது

Short Notes (5 marks) - இந்த 5 படிங்க:

1. ⭐ Damping and Ventricularization
2. ⭐ Manifold Uses
3. ⭐ Fick's Principle
4. ⭐ Principles of Oximetry
5. ⭐ Radiation Protection

Short Answers (3 marks):

• Swan-Ganz catheter
• PCWP
• Pigtail catheter
• Scatter radiation
• Contrast agents

---

📊 YEAR-WISE QUESTION PAPER ANALYSIS

---

OLD SYLLABUS (2010-2011 & 2014-2015 Regulation)

• Fluid filled catheters vs catheter-tipped manometers
• Right heart cath and angiography
• Shunt detection
• Coronary angiography views
• Damping and ventricularization
• Swan-Ganz catheter
• Pressure recording systems

---

NEW QUESTIONS (2022 onwards - NEW Syllabus!)

---

⚠️ IMPORTANT NEW TOPICS I MISSED!

---

NEW TOPIC 1: Ventricular Assistive Devices (VAD) (5 marks) - 2024 Paper

• Cardiogenic shock
• Bridge to heart transplant
• Bridge to recovery
• Destination therapy (long-term)

• Balloon placed in descending aorta
• Inflates in diastole → ↑ coronary flow
• Deflates before systole → ↓ afterload
• Complication: Limb ischaemia, bleeding, infection

---

NEW TOPIC 2: Contrast Agents - Detailed (10 marks) - 2022 Paper

A) High Osmolar Contrast Media (HOCM) - Ionic:

B) Low Osmolar Contrast Media (LOCM) - Non-ionic:

C) Iso-Osmolar Contrast Media (IOCM):

• Rise in creatinine >0.5 mg/dL or >25% within 48 hrs of contrast
• Risk factors: Diabetes, CKD, dehydration, high contrast volume

1. IV hydration - Normal saline before and after
2. Use minimum contrast volume
3. Use IOCM (iodixanol) in high-risk patients
4. Stop nephrotoxic drugs (NSAIDs, metformin)
5. N-acetylcysteine (controversial)

• Prednisolone 50mg - 13h, 7h, 1h before
• Diphenhydramine 50mg - 1h before

---

NEW TOPIC 3: Disinfection Methods + Fumigation of Cath Lab (10 marks) - 2022 Paper

• Sterilization = destroys ALL microorganisms including spores
• Disinfection = destroys most organisms, not necessarily spores

Sterilization Methods:

Disinfection Methods for Cath Lab Hardware:

• Glutaraldehyde 2% (Cidex) - soak 20-30 min
• Ortho-phthalaldehyde (OPA) - soak 12 min, faster acting
• Used for: Reusable items that cannot be sterilized

• Isopropyl alcohol 70% - wipe surfaces
• Sodium hypochlorite (bleach) - floor, surfaces

• Quaternary ammonium compounds - general surface cleaning

Cath Lab Surface Disinfection:

1. C-arm / fluoroscopy machine: Alcohol wipes after each case
2. Cath Lab table: 70% isopropyl alcohol
3. Monitor screens: Alcohol wipes
4. Floor: Sodium hypochlorite 1%

Fumigation of Cath Lab:

1. Formaldehyde fumigation:

• Formalin 40% heated → releases formaldehyde gas
• Room sealed for 6-12 hours
• Ventilated well before entry
• Toxic - wear PPE

1. Hydrogen Peroxide Vapor (HPV):

• Modern, preferred method
• Less toxic than formaldehyde
• Automated machines used
• Room sealed during process

• After an infected case
• Monthly routine fumigation
• After any spillage of body fluids
• After renovation or construction

---

NEW TOPIC 4: Guide Catheters (5 marks) - 2024 Paper

• Extra Backup (EBU/XB) - for difficult LCA engagement
• Judkins Right Guide - for RCA interventions
• Amplatz Guide - for anomalous vessels

1. Provides coaxial alignment with coronary ostium
2. Delivers contrast for angiography during PCI
3. Allows passage of balloons, stents, wires
4. Provides backup support for device delivery

• Coronary ostial dissection (if too deep engagement)
• Air embolism
• Thrombosis

---

NEW TOPIC 5: Indications for Coronary Angioplasty (PCI) (5 marks) - 2024 Paper

Acute (Emergency):

1. STEMI - Primary PCI within 90 minutes (Door-to-balloon time)
2. NSTEMI - Early invasive strategy within 24-72 hours
3. Cardiogenic shock - emergency PCI
4. Unstable angina - refractory to medical therapy

Elective (Planned):

1. Stable angina - significant stenosis >70%, positive stress test
2. Silent ischaemia - with positive stress test
3. After CABG - graft stenosis

• Left main disease without surgical backup
• Chronic total occlusion (CTO) - relative, technically difficult
• Diffuse disease not suitable for stenting
• Severe coagulopathy

---

📋 UPDATED COMPLETE TOPIC LIST WITH PRIORITY:

---

---

MGR UNIVERSITY - 3RD YEAR PAPER I

QUESTION PAPERS: 2022 to 2025 - WITH ANSWERS

---

📄 JANUARY 2022 PAPER

ESSAY Questions (10 marks each):

1. Draw, describe, advantages and disadvantages of various diagnostic catheters used for coronary angiogram.

• Pre-shaped curve fits left coronary ostium naturally
• Sizes: JL 3.5, JL 4, JL 5 (based on aortic root size)
• JL 4 = most commonly used
• Simply advanced and rotates to engage LCA ostium
• Advantage: Easy to use, most common
• Disadvantage: May not fit all aortic root sizes

• Pre-shaped for right coronary ostium
• Size: JR 4 (most common)
• Advantage: Easy engagement
• Disadvantage: Less backup support

• Larger, more complex curve
• Used when Judkins fails (anomalous, dilated aorta)
• Advantage: Works in difficult anatomy
• Disadvantage: Risk of deep seating, dissection

• Can engage both left and right coronary
• One catheter for both vessels
• Advantage: Fewer catheter exchanges
• Disadvantage: Less selective

---

2. Describe various disinfectant methods for Cath Lab hardwares and fumigation of Cath Lab.

• After infected case (TB, COVID, Hepatitis)
• Monthly routine
• After body fluid spillage
• After renovation

• Formalin 40% + potassium permanganate heated
• Releases formaldehyde gas
• Seal room for 6-12 hours
• Ventilate 2-4 hours before entry
• ⚠️ Toxic - wear full PPE, check with detector before entry

• Automated HPV machine used
• Less toxic than formaldehyde
• Room sealed during process
• More effective, validated

---

3. Enumerate different Hyperosmolar, Iso-osmolar and Low osmolar contrast agents.

1. IV Normal Saline before + after
2. Minimum contrast volume
3. IOCM in high-risk patients
4. Stop NSAIDs, metformin
5. Monitor creatinine 48 hrs post-procedure

---

📄 NOVEMBER 2023 PAPER

ESSAY Questions:

1. Methods of Sterilization - Advantages and Disadvantages (10 marks)

---

2. Indications, various catheters used and complications of diagnostic Cardiac Catheterization (10 marks)

• Coronary artery disease - diagnosis and treatment planning
• Valvular heart disease assessment
• Congenital heart disease
• Cardiomyopathy evaluation
• Heart failure - haemodynamic assessment
• Pre-operative cardiac workup

---

3. Cardiac Pressure Monitoring in Cath Lab (10 marks)

• Fluid-filled system most common
• Zeroed at mid-axillary line
• Normal pressures table (memorize!)
• a, c, v waves in atrial trace
• Damping causes: air, clot, kink
• Ventricularlization: pull back catheter immediately

---

SHORT NOTES - November 2023:

Radiation Protection (5 marks) ✅ Already covered above

Oximetry (5 marks) ✅ Already covered above

Thermodilution method (5 marks):

1. Swan-Ganz catheter in pulmonary artery
2. 10 mL cold (room temp) normal saline injected into RA
3. Saline mixes with blood and cools it
4. Thermistor at PA tip detects temperature change
5. Computer calculates CO using Stewart-Hamilton equation:

CO = (Volume × ΔT indicator) / Area under temperature-time curve

• Bedside use
• Repeatable
• No blood samples

• Inaccurate in: Tricuspid regurgitation, Low CO, Intracardiac shunts
• Needs PA catheter

---

Fick method of CO determination (5 marks):

CO = O₂ Consumption (mL/min) ÷ (Arterial O₂ content - Venous O₂ content)

• O₂ consumption = 125 mL/min × BSA
• Arterial sample from Aorta; Venous sample from PA
• Gold Standard - most accurate
• Reliable in tricuspid regurgitation, shunts, low CO

---

Coronary Angiographic Catheters (5 marks) ✅ Already covered above

---

SHORT ANSWERS - November 2023:

---

📄 APRIL 2024 PAPER

ESSAY Questions:

1. Right Heart Catheterization and Angioplasty - Indications, Procedures and Catheters (10 marks)

• Pigtail catheter positioned in RV
• Contrast injected: 30-40 mL at 15-20 mL/sec
• RAO 30° view - best for RV
• Assesses: RV function, pulmonary valve, RVOT
• Diagnoses: Pulmonary stenosis, ARVD, congenital defects

---

2. Preparation of Laboratory for Cardiac Catheterization (10 marks)

1. Clean and disinfect all surfaces and table
2. Fumigation done if required

1. Fluoroscopy/C-arm - power on, test fluoroscopy, check image quality
2. Pressure monitoring system - zero and calibrate all transducers
3. ECG monitor - test leads, check waveform
4. Defibrillator - charge test, check pads/paddles
5. Oximeter and BP monitor - check calibration

1. Drape trolley with sterile sheet
2. Open sterile catheter pack, sheaths, guidewires
3. Prepare manifold system with flush saline
4. Fill contrast injector with contrast
5. Connect pressure tubing, zero transducers
6. Prepare syringes: heparin, nitroglycerin, contrast

1. Consent obtained
2. NPO (fasting) 4-6 hours
3. IV access established
4. Premedication if allergy history
5. Shave and prep access site (groin or wrist)
6. Check creatinine, INR, CBC

• Lead aprons for all staff
• Thyroid shields
• Lead glasses
• TLD badges worn

---

3. Coronary Angiography and Catheters Used (10 marks)

---

SHORT NOTES - April 2024:

Guide Catheters (5 marks) ✅ Already covered above

Oxygen Dilution Method (5 marks):

Radiation Protection (5 marks) ✅ Already covered

Ventricular Assistive Devices (5 marks) ✅ Already covered

Indications for Coronary Angioplasty (5 marks) ✅ Already covered

Cardiac Output Measurement (5 marks):

---

SHORT ANSWERS - April 2024:

---

📄 APRIL 2025 PAPER

ESSAY Questions:

1. List Coronary Catheters - Methods to Sterilize Them (10 marks)

1. Clean catheter - remove all blood/debris
2. Inspect for cracks or damage
3. Pack in ETO-compatible pouch
4. ETO gas cycle: 12-16 hours
5. Aerate: 8-12 hours (remove toxic ETO gas)
6. Label with date and catheter details
7. Store in dry, clean area

---

2. Right Heart Catheterization and Angiography ✅ Already covered

---

3. Cardiac Output Determination - Methods, Advantages and Disadvantages (10 marks)

• Dye (indocyanine green) injected into RA
• Sampled distally in aorta
• Concentration-time curve plotted
• CO calculated from area under curve
• Less commonly used now

---

SHORT NOTES - April 2025:

Indications for Coronary Angioplasty (5 marks) ✅

Pulmonary Vascular Resistance (5 marks):

PVR = (Mean PA Pressure - PCWP) ÷ Cardiac Output × 80

• Pulmonary hypertension
• Pulmonary embolism
• Left heart failure (secondary)
• Hypoxia, COPD

• PVR >800 dyn = Severe pulmonary hypertension
• If PVR reversible with vasodilators (O₂, nitric oxide, prostacyclin) → surgery/transplant feasible
• If fixed high PVR → Eisenmenger syndrome → shunt closure contraindicated

---

Branches of Right Coronary Artery (5 marks):

• Right dominant (85%) = RCA gives PDA and AV nodal artery
• Left dominant (5%) = LCx gives PDA

---

Principles of Radiation Safety (5 marks) ✅ Already covered

Pigtail Catheter (5 marks):

• Coiled tip (pigtail shape)
• Multiple side holes (8-12)
• 5F-7F size
• Made of polyurethane

• Left ventriculography - contrast injection into LV
• Aortography - contrast injection into aorta
• RV angiography
• Pressure measurement (diagnostic)

• Prevents direct jet injury to myocardium
• Even distribution of contrast
• Does not cross into ventricle when positioned in aorta

---

Radiofrequency Ablation (5 marks):

• RF energy (350-750 kHz) delivered to catheter tip
• Tip heats to 50-70°C
• Creates focal necrosis/scar at the abnormal pathway
• Permanently eliminates the arrhythmia source

• Ablation catheter (4mm or 8mm irrigated tip)
• RF generator
• Mapping system (3D electroanatomic mapping - CARTO/EnSite)
• Fluoroscopy

• AV block (AVNRT ablation near AV node)
• Cardiac tamponade
• Stroke
• Pulmonary vein stenosis (AF ablation)

---

Intra Cardiac Pressures (5 marks):

• a wave = Atrial contraction
• c wave = AV valve closure
• v wave = Venous filling of atrium
• x descent = Atrial relaxation
• y descent = AV valve opens, filling ventricle

---

Renal Artery Angiogram (5 marks):

• Renal artery stenosis (hypertension workup)
• Renal vascular malformations
• Pre-operative assessment (kidney donor)
• Renal artery aneurysm

1. Femoral artery access
2. Pigtail catheter in abdominal aorta for aortogram first
3. Selective renal catheter (RDC, Cobra) used to engage renal ostia
4. Contrast injected: 8-10 mL at 4-5 mL/sec
5. AP and oblique views taken

---

SHORT ANSWERS - April 2025:

---

📄 NOVEMBER 2025 PAPER

ESSAY Questions:

1. List Coronary Catheters + Sterilization Methods ✅ Already covered

2. Right Heart Catheterization ✅ Already covered

3. Cardiac Output Determination ✅ Already covered

---

🎯 FINAL EXAM PREDICTION - 2026 EXAM:

Essay (Pick 3 to prepare well):

Short Notes (prepare all):

1. ⭐ Radiation Protection
2. ⭐ Damping & Ventricularization
3. ⭐ Manifold Uses
4. ⭐ Pigtail catheter
5. ⭐ Pulmonary Vascular Resistance
6. ⭐ RCA branches
7. ⭐ Radiofrequency Ablation
8. ⭐ Intracardiac pressures

Short Answers (3 marks):

• Swan-Ganz catheter
• Heparin in Cath Lab
• PCWP
• Gorlin's formula
• Contrast agents
• Femoral artery complications
• Rotational angiography

---

---

📊 SYLLABUS CHANGE ANALYSIS

---

OLD REGULATION Questions (2016-2019):

• Fluid filled vs catheter-tipped manometers
• Shunt detection
• Coronary angiography views
• Damping & ventricularization
• Swan-Ganz catheter
• Pressure recording
• Oximetry

---

NEW REGULATION Questions:

"Regulations 2010-2011, 2014-2015, 2018-2019 & 2020-2021 onwards"

---

🔴 NEW Topics - First appeared:

---

✅ ANSWER - எந்த year follow பண்ணணும்?

---

🎯 2022 முதல் follow பண்ணுங்க!

2022 = New regulation (2018-2019 & 2020-2021) questions first time வந்தது

2022 to 2025 = உங்களுக்கு most relevant questions

2016-2019 = Old regulation, basic questions - சில repeat ஆகுது, but new topics இல்ல

---

📋 SIMPLE RULE:

---

💡 Final Advice:

2022, 2023, 2024, 2025 - இந்த 4 years questions மட்டும் perfect ஆ படிங்க!

நான் above-ல கொடுத்த answers - இந்த 4 years-க்கும் cover ஆகும்!

இதுவே போதும் - exam-ல நிச்சயம் marks வரும்! 💪🎓

---

✅ HONEST CHECK - என்ன கொடுத்தேன், என்ன miss ஆச்சு?

---

📄 APRIL 2023 PAPER - நான் கொடுக்கலை! ❌

1. Cardiac output determination - ✅ Answer கொடுத்தேன்
2. LV pressure curve + Aortic pressure curve + Femoral artery pressure curve + Peripheral systolic augmentation + Damping - ❌ MISS ஆச்சு!
3. (3rd essay PDF-ல truncate ஆச்சு - கிடைக்கலை)

---

📄 NOVEMBER 2023 PAPER - சில miss:

• Indications of ventricular assist devices ❌
• Draw LV pressure curve ❌
• Zeroing in arterial line ❌
• Femoral Artery Pseudoaneurysm ❌

---

இப்போ இந்த MISSING answers கொடுக்கிறேன்!

---

🔴 MISSING ANSWER 1: LV Pressure Curve + Aortic Pressure Curve + Femoral Artery Pressure Curve (10 marks) - April 2023

A) LV Pressure Curve:

      ↑ 120 mmHg
      |    /\
      |   /  \
      |  /    \___
      | /          \
      |/             \___
      0___________________→
      Isovolumic  Ejection  Relaxation  Diastole

• Systolic: 90-110 mmHg
• End-diastolic (LVEDP): 5-12 mmHg

---

B) Aortic Pressure Curve:

      ↑ 120 mmHg
      |   /\
      |  /  \  ← Dicrotic notch (AoV closure)
      | /    \/‾‾‾‾‾‾‾‾‾\
      |/                  \___
      0________________________→
      Systole              Diastole

• Rapid upstroke = LV ejection
• Dicrotic notch = Aortic valve closure (end of systole)
• Gradual diastolic runoff as blood flows to periphery

• Systolic: 90-140 mmHg
• Diastolic: 60-90 mmHg
• Mean: 70-100 mmHg
• Pulse pressure = Systolic - Diastolic = 30-50 mmHg

---

C) Femoral Artery Pressure Curve:

• Higher systolic pressure than central aorta (due to peripheral amplification)
• Lower diastolic pressure
• Dicrotic notch less prominent or absent
• Steeper upstroke

Definition: The increase in systolic pressure seen in peripheral arteries (femoral, radial) compared to central aortic pressure.

• Pressure wave travels to periphery
• Wave reflects back from peripheral resistance vessels
• Reflected wave adds to forward wave = higher peripheral systolic BP
• Called "pressure amplification" or "pulse pressure amplification"

• Femoral systolic pressure can be 10-20 mmHg higher than central aortic pressure
• This is normal - not a sign of disease

• Cath Lab: Central aortic pressure used for valve gradient calculation (not femoral)
• Femoral BP overestimates true aortic pressure

---

D) Damping and Ventricularization ✅ Already covered above

---

🔴 MISSING ANSWER 2: LV Pressure Curve (3 marks) - Nov 2023

• Systolic pressure: 90-110 mmHg
• LVEDP: 5-12 mmHg
• 4 phases: Isovolumic contraction → Ejection → Isovolumic relaxation → Filling
• Elevated LVEDP = LV failure

---

🔴 MISSING ANSWER 3: Zeroing in Arterial Line (3 marks) - Nov 2023

• All pressure measurements are relative to atmospheric pressure
• Without zeroing, hydrostatic pressure from fluid column in tubing gives false readings
• Zeroing eliminates this error

1. Position transducer at mid-axillary line (phlebostatic axis) - level with right atrium
2. Open stopcock to air (atmosphere)
3. Press "zero" button on monitor
4. Monitor reads "0 mmHg"
5. Close stopcock back to patient
6. Now all pressures recorded are relative to atmosphere

---

🔴 MISSING ANSWER 4: Femoral Artery Pseudoaneurysm (3 marks) - Nov 2023

• Incomplete sealing of femoral artery puncture site
• Low puncture below femoral bifurcation
• Inadequate post-procedure compression

• Painful, pulsatile swelling at groin
• Bruit heard over swelling
• Confirmed by Duplex ultrasound

1. Ultrasound-guided compression (first line - small pseudoaneurysms)
2. Ultrasound-guided thrombin injection (most effective)
3. Surgery (if large, rapidly expanding, or failing above)

---

🔴 MISSING ANSWER 5: Indications of Ventricular Assist Devices (3 marks) - Nov 2023

1. Cardiogenic shock - acute MI, post-cardiotomy
2. Bridge to transplant - advanced heart failure awaiting heart transplant
3. Bridge to recovery - myocarditis, reversible cardiomyopathy
4. Destination therapy - permanent support in patients not eligible for transplant
5. Bridge to decision - while evaluating further treatment options

---

📋 NOW - COMPLETE CHECKLIST:

APRIL 2022: ✅ All answers given

APRIL 2023: ✅ Now complete (added missing answers)

NOVEMBER 2023: ✅ Now complete (added missing answers)

APRIL 2024: ✅ All answers given

APRIL 2025: ✅ All answers given

NOVEMBER 2025: ⚠️ PDF truncated - not fully visible

---

⚠️ November 2025 - incomplete in PDF:

---

---

📊 COMPLETE AUDIT - 4 YEARS

---

📄 JANUARY 2022

Essay (10 marks):

Short Notes (5 marks):

Short Answers (3 marks):

---

📄 APRIL 2023

Essay (10 marks):

Short Notes + Short Answers:

---

📄 NOVEMBER 2023

Essay (10 marks):

Short Notes (5 marks):

Short Answers (3 marks):

---

📄 APRIL 2024

Essay (10 marks):

Short Notes (5 marks):

Short Answers (3 marks):

---

📄 APRIL 2025

Essay (10 marks):

Short Notes (5 marks):

Short Answers (3 marks):

---

📊 FINAL SUMMARY:

---

⚠️ Honest Answer:

PDF-ல சில pages truncate ஆயிருக்கு - அதனால சில questions கிடைக்கலை.

ஆனா visible ஆன எல்லா questions-க்கும் answers கொடுத்தேன் ✅

April 2025 = Complete ✅

Missing questions mainly 2022-2024 short sections - ஆனா அந்த topics எல்லாம் already covered ஆகும் - because repeat ஆகுது!

---

💡 என்ன செய்யணும்?

tnmgrmu.ac.in → Library → E-Questions → BSc Cardiac Technology → Paper I