and my co-chair is with me as well. Good afternoon, everyone. I'm Julie Thomas. I'm co-chairing this session, which is the IBERI Review for Allied Professionals. We're hoping that this is not only for those who are preparing for IBERI, but those who are interested and also who just want to sort of get a little nice little review of EP. Our first speaker is actually gonna be Heather Ross from Arizona State University, and she will be talking about fundamentals of electrophysiology. Great, thank you very much. Oh, here we go. So while this fires up, okay, who has taken the IBERI EP or pacing exam? Show of hands. Yeah, awesome. Who is intentionally preparing for the IBERI exam? Show of hands. Yeah? Okay, awesome. Who's IBERI curious? Yeah? Great, great, super. So I have taken both pacing and EP. I have enough gray hair to have done it back in the days when you had to re-cert every 10 years, so I have taken these bad boys four times. And I was asked to speak in 12 minutes of which 35 seconds have already elapsed on the fundamentals of electrophysiology. Now I will note that this is a multi-year post-doctoral fellowship to cover the fundamentals of electrophysiology, but here we are in 12 minutes. So why are we doing this? This is basically the first third of the CEPS exam, there's plenty of this content on the CCDS exam as well. On the CEPS exam, basically these are the components, right? 5% physics, 10% anatomy and physiology, 20% fundamentals of electrophysiology. So you can go deeper, you can go broad. And in honor of my hips, I decided to go broad. So here's how we're gonna do this. I took some of the items from the bullet points, right? From the outline and just tried to give you some things to cover. So I'm gonna encourage you to take pictures of the screen because I tried to pack a lot of information onto these slides. Oh, now I've done something terrible. Let's see. Aha, here we go. And let's start with the physics of electrophysiology. So here's what you need to know. You need to know Ohm's law. Voltage equals current times resistance. Oh, and more resistance. Don't resist Ohm's law. So it's V equals IR. This is where you're gonna wanna pull out all of your algebra knowledge because on the exam, you need to be able to move that around to like solve for current, which is I, which can be confusing for English speakers. Voltage is pretty clear. Resistance is pretty clear in Ohm's. Also, that is also Ohm, just FYI, his law. I wanted to show you this picture from how signals get generated. So this is an illustration of a gentleman having an ECG done. And what I want you to notice is that both of his hands and his left foot are in saline, are in tubs of saline. It's that saline, right? The ions that allow us to get the ECG. Obviously, this is not how we still do it, but if you remember that you always need a ground, think about this picture and where is his right leg? His right leg is the ground. It's the only one not in a bucket of saline. And so that brings us to, this is one of those ones that you might want to take a picture of, ion channels. So this is how the signals get generated. So over here, oh, you can't see anything that I'm indicating. Okay, over here, or maybe, oh, if I do this now, yes. Okay, over here, this is outside of the cell. In the extracellular space, there's not a lot of potassium, but there is a lot of sodium. Intracellular space, there is a lot of potassium, not a lot of sodium. And what happens in the cell membranes, there are these specialized channels. It's like the TSA pre-check line that only certain folks get to go through it. So what we've got here is this sodium channel that allows extracellular sodium into the cell. And when it goes in, all of that positive charge increases the polarity inside the cell and causes the cell to depolarize. Now, when the charge gets to a certain level, the potassium channels, the specialized potassium channels, they open so the potassium cells can go outside of, the potassium ions, pardon me, can go outside of the cell and try to organize everything back together. But this is what causes that signal to propagate, okay, and causes the cells to depolarize. Let's go forward. And what I want to show you here, you might want to take a picture of this as well. So the top left, these are conductive cells. And this is what the propagation looks like. I didn't mention before, there's also calcium channels that open and allow calcium ions to move in and out of the cells. And in the more conductile tissue, the propagation is a little bit of a shallower curve. And you can think about this, like this is basically what the sinus node looks like when we're talking about signal propagation. And that's why the P waves aren't as spiky as the QRS complexes that we see in specialized conduction tissue and contractile tissue. And that looks more like our lower right-hand picture over here, where you can see that dramatic spike up. The other thing I want you to notice is the numbers and the scale at the top. You've got a charge of positive 20 on the one side with the sort of shallower curve. And that's gonna present on an ECG as a smaller deflection than on like a QRS complex from the specialized conduction tissue. You can see that that charges all the way up to 30. All right. And then the other thing I wanted to tell you about in this section is the biophysics of ablation. Basically, ablation works by killing cells so that they can't conduct electricity anymore. We can do that thermally using heat or cold, cleverly indicated with a flame or a snowflake. Or electroporation. This is PFA, right? It causes cell membrane damage using electrical impulses. Okay. So there's our first section, cardiac anatomy and physiology. Let's continue moving forward. So everybody knows this image. Just to orient us, we've got the heart, all of the structures in there. But what I really want you to focus on is this guy. So the anatomy of the conduction system. You might wanna take a picture of this. So the signals propagate in the high right atrium, the sinoatrial node, go to the left atrium through Bachmann's bundle, get basically transmitted down to the AV node that in the absence of accessory pathways is the only road of conduction between the top and bottom chambers. And I tell you those words because those are the words that I tell my patients. And I think that one of the best ways to help yourself prepare for these exams is to explain these concepts to your patients. It helps you learn, and it also helps elevate your patient's personal health literacy. If they know what's going on inside of their heart, trust me, it makes your job easier at the end of the day. All right. And then we've got our specialized conduction tissue, the bundle of His, and the left bundle branch with the posterior fascicle and the anterior fascicle, and then the right bundle branch. So everybody doing okay? Yeah? This is an actual T-shirt that my actual medical assistant wore to clinic one day. Yes, no joke. All right, fundamentals of EP in three and a half minutes. This is gonna be awesome. All right, so we've got a few cycles here. I want to point out for you, the P-wave, it is that shallower deflection and smaller, and now you know why, because of the ion movement. We've got the QRS complex. It's that really rapid depolarization, which results in a spiky ECG. Normal duration, 80 to 120 milliseconds. And then you've got the T-wave, which I tell my patients is the heart electrically resetting itself. We've got then in the next cycle, I tried to show some of the intervals, our PR interval normally 120 to 200 milliseconds. The QT interval on the books is 350 to 430 milliseconds normally. Of course, when we give our patients QT prolonging agents, we tolerate a longer QRS complex, or pardon me, QT interval, up to about 500 milliseconds. We don't freak out, but other people will freak out. So just remember that. And the ST segment that we don't spend generally a lot of time talking about unless we've got a brugada patient, but our friends in interventional cardiology certainly do. I also want to show you this ladder diagram, which is a handy way to be able to tell what kind of rhythm you're working with if you draw a vertical line from the P-wave, and you draw a vertical line down from the QRS complex, and then you connect them in between. If all those stair-steppies look pretty even, then you can pretty much guess you've got sinus rhythm. If you've got more A's than V's, you know that there's something going on in the atrium. More V's than A's, well, you should probably call somebody about that. Okay, this would be another good slide to take a picture of. What this slide is showing you is the different action potentials. There's a lot baked into this slide. The different action potentials mapped to how those different areas of the cardiac electrophysiology anatomy, right? The conduction system, what the different action potentials look like. And because you know everything there is to know about ions now, you know why those different action potentials look that way, because the different types of cells have different sets of ion channels that are activated differently. And I also wanna point out in the southeast corner of this slide is you've got your ECG sort of mapped with timing across the bottom. And now I wanna talk about some abnormalities of the conduction system. So this heart and the anatomy of the conduction system should look pretty familiar to you. And here we've got a rhythm, which is type one second degree AV block or wanky block. You can see it's outlined in blue and I mapped it there to the AV node also circled in blue with a blue arrow. Now we've got this technically is two to one AV block, but we know that it's type two second degree AV block also coming from an abnormality in the AV node. This is third degree or complete heart block outlined in teal. And it is teal because it's come, it could be an abnormality in the AV node in blue or in the bundle of his, depending on where the block is in green. And then finally, we have our bundle branch blocks. So we've got our left bundle branch block here in yellow from the left bundle branch. Always look in lead V1. That's gonna be your easiest lead to tell you where the bundle branch blocks are. And you can remember it like this. When you're going to make a left turn in your car, you push down on the lever, right, to turn on your left turn signal. The opposite, when you're gonna turn right, you push up on your car's turn signal to indicate your right hand turn. And that is indeed the right bundle branch block, okay? So what you push up for the right bundle branch block there or down for the left bundle branch block. And that was fundamentals of EP in 12 minutes. All right. And I think we're gonna take questions all at the end, right? All right, super. Way to get through that, Heather. So as Heather said, we're gonna do questions all at the end. Next up is Amanda Sowell, who is from Atrium Health Sanger Heart and Vascular Institute to go over pharmacologically review. I'm gonna ask some questions through the audience response system. So if you don't have your app pulled up, you can go ahead, sorry, I'm not in the mic. You can go ahead and pull that up to participate if you would like to. There's a QR code if you need it. All right, so with this, this is the pharmacology review for the IVHRE exam. We will review the content outlines. That's one of the biggest things when you're studying for the exam, is to make sure to know what is in the exam. So look at the content outlines. Will will look at some various arrhythmic medications and their uses, and then discuss some cases related to pharmacology. So the question, the first question is similar to Heather's question. What is your IVHRE situation? A, I'm at IVHRE certified, B, I'm registered to take the exam in 2025, C, you plan to take it in 2026, or D, you have no plans to take it any time soon. There used to be music with this, I don't know, sorry, y'all. Oh, there it is, thank you. All right, perfect. So it looks like we have a good mix. I think for those of you that are planning to take it here in 2025, hopefully you've started studying. And then those of you who are planning to take it in 2026, this is a good time to start thinking about your study process. So here's the current outline for the exam. They're different. The CCDS exam, it takes up 5% of that fundamentals piece that Heather just talked through. The CEPS exam, 6% of the exam is pharmacology. So there's a good bit more, I think, there, at least more questions. And then I did not see any pharmacology in the CDRMS exam outline, doesn't mean there won't be any questions, but at least there's probably not as many, I assume. So the first question related to pharmacology, flecainide has been ordered for a patient with symptomatic paroxysmal atrial fibrillation. What is a possible effect of flecainide on device function? A, no effect on device function. B, an increase in pacing burden will cause rapid battery depletion. C, the device may begin to undersense. Or D, pacing thresholds may increase. All right. So, it looks like most got it right. It is D, pacing thresholds. Can y'all hear me? Okay. Sorry. Okay. I can't hear myself. So, I'm like, um, flaconide can cause a significant increase in both acute and chronic pacing thresholds. Good job. Next question. Fluoroquinolones are known for which of the following cardiac effects? A, prolongation of the PR interval. B, prolongation of the QT interval. C, increase atrial fibrillation burden. Or D, suppress the ventric- sorry, suppress premature ventricular contraction. Awesome. Yes. B, prolong the QT interval. All right. Question four. A patient undergoing a dual chamber pacemaker generator replacement is given midazolam for conscious sedation. What is the reversal agent for midazolam? A, naloxone, B, flamazenil, C, Versed, or D, sublimase? Good job. Flanazanil is the reversal agent for midazolam, which is brand name Versed, and then naloxone is the reversal agent for fentanyl. Brand name is sublomase. Okay, next question. This ILR tracing was received on a 75-year-old female. The patient was asymptomatic with the event. No other arrhythmias have been detected. The ILR was implanted about a year ago for unexplained syncope. Her only other medical diagnosis are hypertension and diabetes, both of which are well-managed, and her only medications are imlodipine, metformin, and atorvastatin. What additional medication should be considered? I'll give you a second to look at this strip. Is everybody ready? Carvetilol, imiodarone, enalapril, or apixaban? Yay. Apixaban. So, Artesia found that in patients with subclinical atrial fibrillation and a CHA2DS2-VASc score of greater than four, the benefit of Apixaban outweighs the risk of bleeding. It doesn't mean you wouldn't start Apixaban with a lesser score or that you would with a greater. It's all part of the clinical picture and decision, but that knowing your CHA2DS2-VASc scores and how to score is, would be something I would definitely study. Question six. A patient with a CRTD had the following arrhythmia in therapy. I'll give you a second to look at this, and this is one example of, or it's not really an example, but I did want to point out that sometimes in the exam you want more information. They don't give you, they don't necessarily give you all the information you would get in the clinic. So, you don't have as much as I would like to see, but you do. There's another slide with more of the arrhythmia, just so you know. The following arrhythmia in therapy, there's more. There's one in the middle missing, but it shows the same thing. And the question, before I proceed, the question is going to be which side effect of imioduron is the most concerning for this patient? Thyroid damage, increased DFT, pulmonary toxicity, or corneal deposits. Perfect. Increased DFT. So, all of these are side effects of amiodarone, but for this patient because they had three shocks that were high energy that didn't, well the third one got them out of VF but into VT, but the first two failed. We, amiodarone would increase the DFT or could and then we'd be in trouble. More trouble. All right, another question. Which of the following laboratory values impacts the recommended dosage of defedolide? A. Creatinine clearance, B. Alkaline phosphatase, C. Thyroid stimulating hormone, or D. Triglycerides. Yes, A, creatinine clearance, dofetilide is primarily excreted by the kidney so the dosage should be adjusted based on the renal function and its effect on the QT interval. Alright, I think that is all the questions I have. This is the 40th anniversary this year of the IBHR exam and good luck to everyone. Looks like you're going to do great. Keep studying. Thank you. Our next speaker is Rachel Schreier from the Carolean Clinic and she'll be speaking on all things CIEDs. Hey everybody. While these are pulling up, so I am probably a little different than the rest of those on the, hey my files aren't coming up Julie, who are on the dais up here and I am much more like those of you who are in the room who have been IBHRE curious. And so I approach this with, we're approaching this with a beginner's mind. a review of lab material. Great, thank you. Good afternoon, everyone. Thank you, Heart Rhythm, for the invitation to be here today. Thank you, Caitlin and Julie, for chairing this session. So like my other colleagues here, I'm also a little bit stressed about presenting all of this in such a short period of time. So we'll try to go through as much as we can. And keep your apps open. The first few ARS, I'm actually just gonna skip through, because we kind of already asked these questions. And again, just in efforts to save time, if it lets me. Will it let me go through without the timer? Okay, perfect. So, the objective. So, we're going to review the appropriate preoperative patient discussions. We're going to list considerations for conscious sedation, discuss the complications associated with CIED implantation. We'll list the basic steps of implantation of transvenous CIEDs, subcutaneous, leadless. We'll touch on CS cannulation and LV lead placement. We'll also assess the important intraoperative testing and utility of fluoroscopic guidance and evaluate optimal device pocket management including incisions, closure, and periprocedural medical management. So, a lot of information here. It's one of my favorite topics and so I hope you learn something out of it. So, just to start our preoperative patient discussion. So, what are those discussions that we're having with these patients? So, I should also mention, you know, those who are considering taking the exam. I took it because I felt as though it would help empower my knowledge and also, you know, further help care for my patients. And so, certainly consider that because studying for the exam provides a great knowledge base that you can then take back to your patients in your clinic. So, to start, what are the indications of the device, most importantly? So, how are you counseling patients on whether or not they should be considered for this device? What are the risks of the procedure? You should know them because they are definitely going to ask you that and we'll go through that in the next slide. The procedure explained in a step-by-step manner. So, I really like this because it provides an expectation for the patient. So, the day I show up, what's going to happen from A to Z? And so, kind of giving them a general overview of that. I scrub in the lab with our other, our team of APPs and so I told, you know, them you should know the steps by like the back of your hand. If you are not in the lab, I really encourage you to seek the opportunity to go in and observe a procedure because that just helps better understand what the patient is not going to go through and so you can help guide them through that. Post-procedure disposition. So, do they need a ride home? Are they spending the night? What are they planning for? Post-procedure activity restrictions, wound care management, work considerations. Again, these patients, this is going to be, you know, a surgical procedure for them. So, how are they planning for that? And then, long-term device care. So, when are they going to need a battery replacement? How often do we need to see them in clinic? And what is the remote monitoring like? So, for our procedural sedation considerations, comorbidities, you want to consider, are they obese? Do they have sleep apnea? Many of our patients do. In many instances, we can do conscious sedation or nursing sedation for these implants, which is generally fentanyl and Versed. However, you want to be cognizant of reasons why you may not want to choose that route and choose perhaps anesthesia colleagues or have a max sedation. And that can be obesity or OSA. So, in the event that they're over sedated and you need to protect the airway, you know, are you skilled enough to do so? And if you're concerned that you're not, then you should really have your anesthesia colleagues on board. What is their Malin-Potty score? Do they have a history of dementia, anxiety? Are they elderly? In some of these patients, they can have a paradoxical effect. So, instead of being sedated, they get more agitated and they can be disruptive to, of course, their procedure, their proceduralist, and everyone in the room. Their dentition, do they have dentures? They lose or missing teeth? Again, in the event that you need to protect their airway, you know, what should you be mindful of? Previous adverse events to or reactions to sedation. And then, what is their ASA score? So, where do they fall in their risk stratification for sedation? What are our complications? So, these are ranges here. Hematoma, infection, pneumothorax, pericardial effusion or perforation, and lead dislodgement. They can vary, obviously, depending on institution, specific device, or lead, but these are really important numbers for you to know. Again, because the patients are going to ask you. So, you should know, you know, what's the national average and then also what's our average at the institution or whoever I'm perhaps referring to. So, how am I guiding these patients on what they may see? You know, a lot of these procedures, as we know, are very safe, but I always tell my patients, you know, with any procedure, there are risks and they should understand them. We're going to kind of fly through these, but we're going to touch on the subcutaneous ICD in a leadless pacemaker and how they're different from the transvenous. So, in the subcutaneous ICD patient population, it may look like this character here on the left side who is younger, may or may not be immunocompromised. They may have vascular access limitations. Thus, you know, we're trying to avoid the vasculature and just use the subcutaneous tissue. They may be high risk of infection or have a prior infection. Now, similarly, our leadless patient population, they may also be immunocompromised. They may have limited vascular access, especially in their upper extremities. So, think, you know, patients with prior radiation or fistula and then may be high risk of infection or have a prior infection. You also want to consider what is their underlying substrate. So, what is their past, perhaps, arrhythmia or condition? What are they higher risk for? Is it VT or VF? If it's VT, maybe we should go like the EV ICD route where they can provide ATP to terminate their VT, or if it's a VF arrhythmia, then perhaps the Boston Scientific subcutaneous ICD may be better. You also want to consider progression of disease and bradycardia because, in many instances, the subcutaneous device cannot provide pacing. And then, in our leadless pacemaker, what is the underlying rhythm? Do they need atrial pacing, ventricular? If you're giving them ventricular pacing, what is their atrial rhythm? Are they in sinus or are they in AFib? Do we need to track the sinus? And then, again, just kind of want to fly through these different sedation requirements and considerations. Some are done with conscious sedation, some with MAC sedation or general anesthesia. So, basic steps of implantation of a transvenous device. So, again, I tell my APPs you should know this like the back of your hand. It's also like baking a cake, right? So, you should know all the steps. You should have all the tools so that you are ready to implant the device. We're gonna start with the chlorhexidine skin preparation, generally using a first-generation cephalosporin within one hour of the incision, and then draping the surgical field under a sterile technique. So, this was a study that was published in CERC in 2004, and they focused on CIED infection. And so, for the purpose of this talk, I wanted to focus on prevention. And so, we know that adherence to standard infection prevention, so good hand hygiene, sterile technique, are important. Single dose of preoperative antibiotics. So, I know many, many practices will give antibiotics, you know, post-procedure, but we actually have data showing that that does not prevent infection. The most important thing is that they get a dose of IV antibiotics within an hour of incision time. We know from the RAPIT trial that the antimicrobial envelope helps prevent infection in our patients with high risk, and then hematoma prevention is super important. And we know that patients that develop hematomas are at much higher risk for infection. So, using cautery to identify bleeding areas, irrigating the pocket, using a pocket press or compression device, and then avoiding heparin within generally 48 to sometimes we say like up to six weeks post-device implant. Marking the incision. So, that may depend on what type of access we plan to get. So, are we using the delto-pectoral groove, or are we getting axillary access? You would then inject your subcutaneous lidocaine, and then dissect down to the fascia, and then create your pocket. So, in this next slide here, you can see that the image on the right, I'm just gonna use my laser here, you can see different points of access. So, this is the cephalic vein. This would be the axillary. And so, you may adjust your incision based on which access point you are planning to use. However, keeping in mind that if you plan to use the cephalic vein, that if there isn't a cephalic, or if it's not big enough, you may also need to get subclavian or axillary access. So, making sure that you have access to that. When you make your pocket, you should consider how big is the device, how many leads am I making, and will be in the pocket as well. And in some instances, you may even create a sub-pectoral pocket in patients who are quite thin, or you're concerned for device erosion over time. So, in this picture, this is a patient who's complaining about the device being too lateral. And so, as you can see, when he moves his arm, the device kind of moves with it, and it's more in his armpit. So, that incision is too lateral. This is a picture of a device that is too superficial. So, that can cause pain, and then, of course, there's concern for erosion over time. So, discussing our cephalic versus our axillary. So, here is an image where we can see this is our cephalic vein, this is our axillary and subclavian, and this is our deltoid muscle and our pectoral. And so, our cephalic lives in this delto-pectoral groove. And so, that's why, again, when we make the incision, we make it more lateral here. Some pros and cons of both. So, cephalic access, there's no risk of pneumothorax because you're outside the thorax. Generally, you don't need to use contrast, and there's less risk of lead damage. Conversely to that, you can have increased bleeding just from backflow of the cephalic vein. It requires a surgical dissection and some surgical skill. And then, in some instances, it may be too small, too deep, or you may not be able to use it. The axillary access is oftentimes, it can be faster. There's less bleeding, but there is a risk of pneumothorax, and you can have subclavian crush. So, as you can see in this image here, you know, this vein, sorry, this lead over time can be close to the clavicle and can rub and can cause a lead irritation. Whoops. Okay, lastly, we're going to talk about interoperative testing, or second to last. So, we can use our RAO, LAO, and fluoroscopy. When you implant the lead, we want to assess, you know, where is the lead? Is it stable? And what does the EGM look like? What is the sensing impedance and threshold? And most importantly, current of injury. So, current of injury is how well is the lead in contact with the endocardium? And this is an example of current of injury, where you have this sort of ST elevations, and that's a good sign. That's saying the lead is in good contact with the endocardium. Here are some images on fluoroscopy. So, generally, we use our AP, our RAO, and our LAO, and it's basically looking at the heart at different angles. RAO, so a little trick, when RAO is that the spine is going to be on the left side. In LAO, the spine is on the right side. In RAO, we like to see, you know, how distal or how apical are we. In LAO, we like to see how septal are we. So, we can see, these are great pictures because it shows multiple, you know, cavities of the heart and where our catheters are, and we can see our CS catheter crossing over to the left side here. Again, this image is showing what our valvular structure is like in our RAO and LAO, and then here is after we injected contrast into the coronary sinus. This is just a simple cartoon showing where the leads go, and then our final procedural steps. So, we'll tie down the lead with a non-absorbable suture. We'll make sure that the lead is past the set screw, and then your pocket closure, you can use two to three layers of absorbable sutures, and then steristrips, Dermabond, in some instances, staples. So, these are, this is an example. You can see our leads are past the set screw here. Okay, let's just do one quick question. I know I'm over time. So, this is a fluoroscopic example of, so I'm not sure if you can see how well you can see the images, but we see our PA X-ray, and then our lateral as well, and then I'll just move to our questions. So, is this RA lead micro dislodgement, macro dislodgement, RV lead micro, or RV lead macro? Great. Yeah, everyone got it right. So we can see that our A lead is hanging in the right atrium. Sometimes this can be hard to see because the J could be behind and you can get fooled. So you always want to look at the lateral as well to confirm that it is indeed lead dislodgement. Okay. Let's just do one more. You're implanting the RA lead. Lead testing shows below EGM appropriate impedance and threshold is 2.5 at 0.4 milliseconds. What's the next best step? So are we going to reposition the lead because the threshold is elevated? Great parameters, tie the lead down and get out, wait a couple of minutes and then repeat it? Or is there concern that the lead is perforated? We should reposition and then assess for effusion. OK, everyone's saying, elevated threshold, reposition the RA lead. Well, actually, I disagree. So this is telling you that they have good sensing. They have good impedance. The threshold is slightly elevated. However, with this great current of injury, I would anticipate the threshold to decrease within minutes. And so while you're tying the lead down, we can then recheck. And then I would guess that by the end of the case, it would be less than one. OK, so I will end here. Thank you. So we're going to go back to Rachel Schreier, who is going to be talking about all things CIEDs. So if I wasn't nervous before, apparently my slides decided to take a walkabout and went and hung out with slides from somebody else's session. But now they're back, so we'll pick back up. And honestly, not terrible that I'm going at the end, much like the rest of the group. I mean, this is a massive test. It's over 200. It's 200 questions. You get a number of hours to complete it. And it would be impossible to cover everything that you need to know in 10 to 12 minutes. So the reason why my talk might be a little helpful is that I decided to take the approach of, also as someone who is herself thinking about taking the test, I said, Julie Thomas, are you sure you want me to give an IBRI review talk? I am not IBRI certified, but I'm going to take the test. She was like, that's kind of perfect, because you're approaching it with kind of a beginner's mind and from the standpoint of someone who's trying to figure out what do you need to know to take the test. So I crowdsourced my LEAP group. Shout out to the LEAP program. And we're going to try to go through some top tips of types of questions you might expect to see on this test and how to think about it. I have no disclosures. And screaming clock face, because now we're under the time crunch. So we're going to highlight some types of questions and learn top tips from those who have taken it before. And this is a case-based approach from my own practice. So these are not going to be the most complicated cases, but meant to sort of illustrate the kinds of questions you might see. So case number one is a gentleman who came in. He's a 63-year-old with HOCUM. He has a normal EF with septal wall thickness of 2.2 centimeters. He has had improvement of his gradients on high-dose beta blocker therapy with no personal history or family history of sudden death and no prior history of syncope who came in with the CKG. So you see here the, can you see my arrow? Where's my arrow? So you can see the ventricular rate is around 40, and then you can see periodically we have some things going on on the EKG. So I do not have audience response with this in the interest of time, but the question, first question for this is, so what, this is one type of question you might see is choose all that apply. So for this patient, do we see PVCs? Do we see first degree AV block? Do we see blocked PACs or escape beats? And then the answer is B, C, and D. Here's the EKG to remind ourselves. So you can't really see the measurements, but we have a first degree AV block here. We see a couple of junctional beats coming in, and then we have a blocked PAC here. So that is the answer. So the teaching point in this is be prepared, even though this is a device-based test, to be able to interpret and understand what is going on on EKGs. Familiarize yourself with the use of electronic calipers also, which you may use for both the EKGs and also on some of the EGMs you may see with the devices. And then the other top point that I got from one of my group was tell people that you're taking the test because people will bring you cool and interesting EKGs and other cool things, EGMs, for you to look at, which is a great way for you to learn as you are starting to prepare. All right. So we'll move on to the next one. So same patient. This decision is made to implant a device in this patient due to the bradycardia. We didn't really see any more junctional escape beats. Most of it was this sort of blocked PACs, an intermittent block with a first degree. So what is the most appropriate device for this patient? You can read the options, dual chamber ICD, CRTD, dual chamber pacemaker or leadless pacemaker. My correct answer, and you may disagree, which is what we did in this patient, was C, a dual chamber pacemaker for this patient. And so the teaching point for this is, you know, a lot of the questions will cause you to need to put together different things that you might understand about a particular clinical scenario. So, for instance, for this patient, you need to understand not only the pacing indications, you know, for the bradycardia and the block that you're seeing, but also you need to be familiar with the guidelines for hypertrophic cardiomyopathy. So for this patient, for instance, you know, his septal thickness is not, you know, onerously big. He has no personal history of sudden death. I had a little back and forth with someone who reviewed slides for me about whether or not CRT might have been more appropriate for this patient. But the point being is you need to have a good understanding, foundational understanding of the guidelines. And you may need to understand multiple things in order to correctly answer a question. So there are a couple of resources that you can look for. The other thing to know is that every year, IBRI takes information from others as new guidelines come out or as new clinical trials come out, and they try to incorporate that into test questions. So what might apply now, for instance, the most recent thing is now we're all worshiping at the altar of conduction system pacing, right? So that is making its way into the test. So as new information, new data comes out, that's something that you need to be aware of as well. Okay. So he undergoes, same patient, undergoes a pacemaker, dual chamber pacemaker with a 4574 RA lead and a 5076 RV lead, so a passive atrial lead and then an active ventricular lead. Initial P waves and thresholds and impedances look great. However, when he comes back to clinic, still feels great, but you observe the following. And so then the question is, what is the most likely explanation for these findings? And then of course, you've got several options. Usually there will be one or two obvious really wrong answers that are like, nah, I can knock those out. But then there might be a couple other ones. I think for this one, this is fairly simple and straightforward for most of us, but you can usually get it down to two answers and then pick the right answer. Of course, for this patient, the correct answer is an atrial lead dislodgement. Here's the chest x-ray that shows that, easier to see on the lateral view. And so, you know, this is where some baseline understanding of different lead types and how they work can be helpful and you'll be tested on that. Your ability to recognize some change in the lead function often will be more complicated than this scenario that I presented. And then also importantly, and this is something that I got feedback from those even taking the remote device monitoring test, is that there will be more 12 lead EKGs and chest x-rays on both of those tests than you might anticipate. So very important that you get comfortable with interpreting and reviewing EKGs and see my previous statement about tele-friend so that when cool lead EKGs and chest x-rays come your way, people show them to you. One other of note, in case anyone calls me out on it, you might say, we worship at the altar a left bundle branch area pacing, and you may notice that this guy has an apical lead unique thing in this patient. The operator who put this lead in, there is some data to support that some patients with hypertrophic cardiomyopathy with a gradient might get benefit with septal pacing or pacing at the apex to cause the septum to move. So that may be a desirable patient thing in these patients. So in case anyone caught that. All right. Kind of moving on. This is an MRI question. I receive a request for MRI clearance for a patient with the following chest x-ray. What is your opinion of the MRI conditionality of the device based on this chest x-ray? So let me see if I can backspace it. So this is the chest x-ray. Maybe a little bit difficult to see. Hopefully you can see something here in case it's too tiny in the back of the room. So what's the best way to describe the MRI conditionality of this device based on the chest x-ray? It's an MRI conditional CRTP. It's a non-MRI conditional CRTD due to an abandoned atrial lead, non-MRI conditional CRTP due to an abandoned RV lead, and then non-conditional CRTP due to an abandoned RA lead. And so again, D, it's a pacemaker. You can quite easily knock out the D option. You have to recognize the lead selection, and then that gets you to your answer. The teaching point in this, because this is a fairly simple example again, is be familiar with how to interpret. The other teaching point with this is it's important to recall that this test tests based on sort of current guideline-based practice. And so even in your individual practice or facility, it's important to remember you're not taking this as how would I approach this in my center. At my particular center, we currently do not scan broken or abandoned leads. My friends up the road at UVA do. And then when in doubt, if you're thinking about how to answer the question for the test, go back to the current guidelines. So guidelines change though, and so be aware there's new information coming out. So I just bookmarked, and you may want to take a picture of this, there are a couple of great sessions coming up as there are new guidelines coming out all the time and further discussion at this meeting about how do we handle this. So a couple of great talks coming up. And then also point out, those of you who follow communities may have noted that the Scientific Documents Committee had a writing group that convened in the fall that will be putting out a new consensus document called Action Improved MRI Access for Patients with CIEDs. So that should be coming out soon. I thought it was going to be ready for this meeting, but I couldn't find it. So attend one of these other two talks. Okay. So case number three, you receive an alert for a mode switch episode on a dual chamber pacemaker. I'll let you look at the EGM here for just a minute. So how do you interpret this EGM? Does the patient actually mode switch because they have paroxysmal AFib? Are they having atrial oversensing with inappropriate RV pacing prior to mode switching? Are they having EMI for some reason? Or are they having atrial lead noise with appropriate RV pacing prior to mode switching? This is the figure again. And the answer is B, oversensing with inappropriate RV pacing prior to mode switching, as you can see. So we are going to kind of skip through because I'm down to the last minute. I'm going to make a point for Serena, who is sitting in the room. She said to make sure to tell everybody to expect to make some decisions based on dot plots. You will see dot plots. So this is my dot plot slide for her. And then let's get down to the wrap-up slide with things that were the top tips from my LEAP group that you might need to know. So a couple top tips. One, everybody recommends using an IBRE review course. These come in different flavors and forms. There are many wonderful resources that you can get free through our industry partners. I will not name names so as to keep this CME compliant. But then there are also private companies. Ask your friends. There are many wonderful review courses that you can do online or in person, and that will help you tremendously. Do not take the test cold. So a number of people I spoke with said, ah, I've been a device clinic nurse. I've run device clinics. I know how to do this. I got this. But remember, this test is meant to test people across the spectrum, people that work in device clinics, people like me who are more clinically oriented and maybe don't do only device, people who work for industry. So don't take the test cold. Make sure that you prepare for it or you will not pass it. Expect content beyond just looking at device interrogations. A couple of my device interrogation slides were a little later on in my talk. You will see plenty of that, but make sure that you are aware of guidelines, chest X-rays. Prepare to see complex clinical scenarios and management questions, MRI questions. But then also, don't forget the fundamentals, and don't forget your time management. You only get a minute or so to answer each question if you're going to stay on time. Get comfortable with multiple manufacturers. Some of us work at facilities where we have a primary manufacturer that we use, but you may see EGMs from all the different companies, and they all look a little bit different. Don't forget other fundamentals like formulas. Here is another way to look at Ohm's Law. If someone is more visual like me and likes a graphic representation, B over IR, so that you can figure out what to put over what if you're making your calculation. And then some of the more arcane things that you don't actually use in your day-to-day practice, Cronaxie and RioBase apparently come up a lot. Several people mentioned that. I had a slack rate question. And then the last point that people said was take as many practice questions as you can. You can buy standalone packs of practice questions for the EBRI test, and that was their best advice for doing the final push the last couple weeks. I believe that was Julie's recommendation, was take as many practice questions as you can the last couple weeks leading up to the exam, and that will hopefully set you up for, and me, up for success when you take the test. We're open to any questions anyone has for our panel here. And then I guess a question to the panel. I know Rachel went through some tips about taking some of the EBRI, but does anyone else here have any tips for people who are interested or sort of on the fence about taking the EBRI exam? I have one that I meant to mention earlier, is that you need to, and I think I touched on this a little bit, but have a study plan that is, that you stick to. So I always recommend studying for at least six months. You might get it done in four, but you need to, it's an expensive exam, and it carries a lot of weight, so you need to study for it like you want to pass it. You know, don't assume that you're just going to be able to, like she said, go in there, and because you're experienced, you do a good job in clinic, that you'll be able to pass it. I've seen a lot of people who are really smart not pass it, so have a plan that's structured, have goals, pretend like you're going back to school and study like you mean it, and that you'll do fine, but you have to put the energy into it. I'm going to plus one that, and on the point of, and really great point about the guidelines change, if a guideline has just changed within the past, you know, several months before you take the exam, remember those exam questions and answers are written and validated far in advance of the exam. So I invite you if you, you know, see a question that none of the answers are the answer that goes with the newest guideline that just came out two weeks ago. Yes, experience righteous indignation that they got it wrong, but still answer the question from what the old, you know, pre-two weeks ago or whatever guidelines said. I know we're out of time, but for those who have taken it, so I think it's straightforward when people are device clinic based and then, or people are EP lab based. Any suggestions about, you know, because they're outside of the remote monitoring test, there are two main tests that you can take, and maybe that's something you can speak to about. How do you pick which test is the right test for you if you're a generalist like me, and you do a little bit of everything, and you don't just live in either the lab or the device clinic? Yeah, so I'm a nurse practitioner, and I spent time, you know, in hospital, never, you know, never scrubbing like Lauren does, but, and in device clinic settings and outpatient settings, and I did opt to take both because I felt like in my role, I needed to know the entire life cycle of experience for every one of my patients. Also, like, you know, Hermione Granger is kind of my spirit animal, right? So I was like, yes, yes, me, I got that. And so if you're not that person, though, I would point out that, and many of the panel made this point, that there is a fair degree of overlap in terms of some of those basics and in terms of, you know, having to recognize radiographic images and understand ECG interpretation and things like that. So if you're going to choose one, I would suggest choosing the one that comports to where you spend most of your time. Then when you're hooked, go on in and take the other ones, too, just to show yourself that you can. All right, we are over our time at this point, so, but I think I will be around, I'm not talking about the rest of the panel if they have to run off. So if anyone wants to come up and ask additional questions, just not as a panel. But thank you, everyone, so much for being here. Thank you to the panel.

IBERI certification

electrophysiology

cardiac anatomy

implantable devices

Ohm's Law

arrhythmia management

CHA2DS2-VASc score

cardiac resynchronization therapy

pacemakers

test preparation