ICD的鉴别功能课件

ICDSVTDiscriminationAlgorithms美敦力CRDM谢璐佳IntroductionInappropriateTherapyIncidence:20-40%MortalityPsychologicaladverseeffectLongevityAtrialfibrillation,SupraventriculartachycardiaincludingSinustachycardiaandabnormalsensingTrialIncidenceSCD-HeFT32%MADITII36.4%AVID21%ofPatientsInappropriatetherapyinMADITIIDaubertetal,InappropriateImplantableCardioverter-DefibrillatorShocksinMADITII,Frequency,Mechanisms,Predictors,andSurvivalImpactJAmCollCardiol,2008,51(14),1357-65TypeFrequenceAtrialFibrillation44%OtherSVT36%AbnormalSensing20%InappropriatetherapyinMADITIIDaubertetal,InappropriateImplantableCardioverter-DefibrillatorShocksinMADITII,Frequency,Mechanisms,Predictors,andSurvivalImpactJAmCollCardiol,2008,51(14),1357-65ICDDiscriminationAlgorithms

Preventdetectionoftachy-arrhythmiascausedbythepresenceofanSVTPreventinappropriate,unnecessarytherapyduetorapidSVTconductionPreventinappropriatetherapyrelatedtothesensingissuesDiscriminatebasedonSVTvs.VTdifferences(Gradualvs.Abrupt,Unstablevs.StableandNarrowvs.Wide)AvailableinallMedtronicICDssinceGemVR/DRDiscriminationAlgorithms--

SVTLimitTheminimumventricularintervalsatwhichthedeviceappliesSVTdiscriminationDiscriminatorApplicationOnset:Pre-countingVTZoneStability:DuringcountingVTZoneWavelet:(VR)NIDVT/VFZonesPRLogic:(DR)NIDVT/VFZonesAppliesduringpre-countingandcanonlybeusedduringinitialdetectionPreventsgradualonsetofSTorATfrombeinginterpretedasVTSinglePVC’swillnottriggeronsetcounterReviewsrhythmbyabeat-to-beatbasisDiscriminatorApplication—OnsetAvgX(4recentventricularintervals)AvgY(prev4ventricularintervals)X(Onset)%IfAvgXis>AvgY=>gradual<AvgY=>abruptVS VS VS VS VS VS VS VS VS540530530520500490440430530msAvgY470msAvgXTDI=500ms Onset=84%530x84%=440ms470isnotshorter/fasterthan440ms=>GradualAdvantagesCanbeadjustedbyexercisetestingtodifferentiateexerciseaccelerationfromaVTrateRequiresabruptaccelerationtobesatisfiedandmaythereforeruleoutSTorATwithgradualonsetDisadvantagesIninstanceswhereitisnotaccuratelyset,itmaycauseVTdetectiontobedelayedNotrecommendedforusewhenpatienthasaSTthatresultsinan“exercise-inducedVT”wheretheVTrateoverlapswiththeexerciserateDiscriminatorApplication—Onset

Advantages&DisadvantagesAppliesduringcountingandcanbeusedduringinitialandredetectionPreventsAFwithrapidventricularresponsefrombeingdetected&treatedintheVTzoneEvaluatesintervalsintheVTandFVTviaVTzonesDiscriminatorApplication—StabliltyOncetheVTcounterreaches3onthe4thTSbeatStabilitycompareseachoftheprevious3TSbeatsIfanyvariesincyclelengthgreaterthantheprogrammablevariableinterval(ms)StabilityresetsandtheTSbeatislabeledVS.102090AdvantagesPreventsVTdetectionforrapidly,irregularlyconductedAFintervals;nominalsettingis40msWhenON,isusedforinitialdetectionandalsoforredetectionDisadvantagesCanbeinappropriatelysetanddelaydetectionofVTNotusefulwithregularlyconductedatrialarrhythmiasDiscriminatorApplication—StabliltyAbnormalventricularEGMmorphologyagainsttemplatemayindicateventriculartachyarrhythmiasUsesHaarWaveletTransformAmethodtodescribeanintracardiacwaveformasamathematicalexpressionMostEGMcomplexescanbedescribedin8to20HaarwaveletexpressionsWaveletusesupto48expressionsDiscriminatorApplication—WaveletTMWavelet-TemplateCollection

TemplateCollectionTemplateUsedforVT/SVTDiscrimination

TemplateConfirmationTemplateQualityCheckTemplateQualityOK?YesNoCreateanewTemplate123TemplateCollectionManualvs.AutoCalculatestemplatesbycollecting6samplebeats.4ofthe6samplebeatsneedto“Match”eachotherusingtheprogrammedmatchthreshold%(nominal70%)andarethenaveragedTemplateConfirmationRequiresoneVSbeatto“Match”thetemplateevery10seconds(minimumof12minutes)If70of100samples“Match”thetemporarytemplate,thentemporarytemplateisstoredandusedWavelet:QRSCheckduringNIDMatch%ofthecurrentbeatiscomparedtotheprogrammedmatchthresholdNominalmatchthresholdis70%Ifmatchpercentageequalsorexceedsmatchthreshold,beatisclassifiedas“MATCH”Need3of8“Match”beatstowithholdforSVTIfmatchpercentageislessthanthematchthreshold,beatisclassifiedas“NOMATCH”Programmable:Monitor/ON/OFFSVTWavelet:ProgrammingWavelet:ProgrammingIncreasedspecificityDeceasedsensitivityDeceasedspecificityIncreasedsensitivity40%70%97%Wavelet:LimitationsPacemakerdependentpatientsCorrelationwithpharmacologychangesRate-RelatedAberrancyInappropriateClassificationofVTasSVT

roSVTasVTPRLogic:DualChamberAppliesatNID&usedonlyduringinitialdetectionEvaluatesintervalsintheVT&VFzonesUpperlimit=SVTlimitLowerlimit=slowestzoneprogrammed“ON”ConsidersA&VrelationshiptodiscriminatebetweenSVTandVTRequiresanatrialleadCanbeusedinconjunctionwithotherdiscriminatorsOnsetStabilityPRLogic:DualChamberHowitworks:AnalyzesRate:A&VRateRegularityPatternAVDissociationWhatitlooksfor:AtrialFibrillation/FlutterSinusTachOther1:1SVT’s(i.e.AVNRT)PRLogic®Regular

≥75%=VF=VT=SVT=SVT=SVT=SVTAFEvidenceAVDissociationRegularityIfnoSVTcriteriaaremet,VT/VFtherapyisdeliveredPatternRateVF/FVTDoubleTach

VT/FVTRegAFib/AFlutter

IrregSinusTachOther1:1PatternRecognitionAssessestheposition,timing,andnumberofatrialeventsforeveryventricularintervalTakesintoaccounttwomostrecentR-RintervalsAssignsaScientificPatternCode(1of19codes)PRLogic:PatternPRLogic:PatternExamplesofPatternCodesAsAsAsAsAsAs3BakkenEducationCenter,AtlantaPattern:SinusRate{“A”3BakkenEducationCenter,Atlanta{“A”Pattern:SinusRate3BakkenEducationCenter,Atlanta{“A”Pattern:SinusRate3BakkenEducationCenter,Atlanta{“A”Pattern:SinusRateFollowedwithPVC3BakkenEducationCenter,Atlanta{“B”Pattern:SinusRateFollowedwithPVC3BakkenEducationCenter,Atlanta{“C”Pattern:SinusRateFollowedwithPVC3BakkenEducationCenter,Atlanta{“E”Pattern:SinusRateFollowedwithPVC3BakkenEducationCenter,Atlanta{“A”Pattern:SinusRateFollowedwithPVCPRLogic:PatternDefiningaRhythmSeriesofV-VpatternsHelpsdefineSinustachycardiaRegularlyconductedAFib/AFlutterOther1:1SVTs(AVNRT)HandlesPVCs,PACs,andoccasionallossofatrialsensingPRLogic:Other1:1SVTsUsedtodiscriminateforpatternsthatfallwithinthejunctionalregionsThisdiscriminatorisprogrammed“OFF”initiallyduringimplantuntiltheatrialleadmatures,intheeventtheatrialleadbecomesdislodgedPRLogic:Other1:1SVTsWhenOther1:1SVTsisprogrammed“ON”discriminatesforintervalsinthejunctionalzone.AVintervalsoflessthan80msandVAintervalsoflessthan50ms.PRLogic:Other1:1SVTs(OFF)STdetected&treatedasVTPRLogic:RegularityDeterminedbythevariabilityofventricularcyclelengthsNSR,ST,andVTgenerallyhaveregularventricularintervalsAFandVFgenerallyhaveirregularventricularintervalsVentricularcyclelengthvariabilityUsesmostrecent18V-VintervalsSortsinto“bins”bycyclelengthCalculatesthepercentageofhowoftenthetwomostfrequentintervalsoccurRegularifpercentageis>75%Irregularifpercentageis≤50%PRLogic:RegularityPRLogic:RegularityVentricularCycleLength(Regular)VentricularCycleLength(Irregular)ForAtrialFibmustbe≤50%ForDoubleTachycardiamustbe≥75%PRLogic:AVDissociationProvidesevidencethatthesensedatrialeventsareun-relatedtothesensedventriculareventsEvaluatesthemostrecent8ventricularintervalsOnlyidentifiesdoubletachycardiasPRLogic:AVDissociationRhythmsareconsideredAVdissociatedif4ofthemostrecent8V-Vintervalsaredissociated.Adissociatedintervalhaseitherofthetwocharacteristics:TheV-Vintervalcontainsnosensedatrialevents

ORThecurrentPRintervaldiffersfromtheaverageoftheprevious8bymorethan40msPRLogic:AVDissociationPRLogic:AVDissociationPRLogic:AFEvidenceAFEvidenceCounterIncrementswhen2ormoreatrialeventsoccurwithin1V-VintervalHoldswhen1atrialintervaloccurswith1:1conductionDecrementsforsubsequentintervalswith1:1conductionCriterionisinitiallysatisfiedwhencounteris>6(maxcountis10)Criterionremainssatisfiedifcounterremains>5Counter