北大人民医院心脏起搏器基础与临床研讨班课件 09rate modulated

Copyright 2003 St. Jude Medical Cardiac Rhythm Management Division Rate Modulated Pacing 1 Copyright 2003 St. Jude Medical Cardiac Rhythm Management Division 频率适应性起搏 2 Rate Modulated Pacing Sensor technology Optimizing rate adaptation Also known as. Sensor-driven pacing Rate-adaptive pacing Rate-modulated pacing 3 频率适应性起搏 传感器技术 优化频率反应 也被称为. 传感器驱动的起搏 频率反应性起搏 频率调节的起搏 4 Rate Modulated Pacing Use of a sensor besides the sinus node to adjust the pacing rate to meet the patients metabolic needs Indicated for Chronotropic Incompetence 5 频率适应性起搏 使用除窦房结以外的一个传感器，调整起搏频率，以满 足患者新陈代谢的需要 适用于变时性功能不全的患者 6 What is Chronotropic Incompetence? Definition An inadequate heart rate for a given level of metabolic need Maximum HR 90% x (220 - age) Maximum HR 120 bpm 7 什么是变时性功能不全? 定义 心率不足以满足一特定水平的新陈代谢需要 最大心率 90% x (220 年龄) 最大心率 120 bpm 8 Normal Chronotropic Response 60 70 80 90 100 110 120 130 140 150 Increase in Metabolic Demand Decrease in Metabolic Demand ppm 9 正常的变时反应 60 70 80 90 100 110 120 130 140 150 新陈代谢需要增加 新陈代谢需要减少 ppm 10 Chronotropic Incompetence ppm Time 60 70 80 90 100 110 120 130 140 150 11 变时性功能不全 ppm 时间 60 70 80 90 100 110 120 130 140 150 12 Chronotropic Incompetence Time ppm 60 70 80 90 100 110 120 130 140 150 13 变时性功能不全 时间 ppm 60 70 80 90 100 110 120 130 140 150 14 Chronotropic Incompetence ppm Time 60 70 80 90 100 110 120 130 140 150 15 变时性功能不全 ppm 时间 60 70 80 90 100 110 120 130 140 150 16 Chronotropic Incompetence Causes of Chronotropic Incompetence Aging Drugs Heart disease Diagnosis of History Holter or telemetry monitoring Exercise testing 17 变时性功能不全 变时性功能不全的原因 老年 药物 心脏疾病 变时性功能不全的诊断 病史 Holter或遥测监护 运动试验 18 Normal Sinus Node The gold standard for pacemaker sensors 19 正常的窦房结 起搏器传感器的金标准 20 Characteristics of the Ideal Sensor Physiologic Sensitive Rapid onset and offset Linear response to workload Responds to metabolic demand Emotions Fever Unaffected by cardiac medications 21 理想的传感器特点 生理学方面 灵敏 快速启动和频率补偿 对工作量的线性反应 对新陈代谢需要的反应 情绪 发热 不受心脏药物的影响 22 Characteristics of the Ideal Sensor Technical Reliable and stable Utilizes standard leads Minimal battery drain Standard connector Standard implant technique Simple to program and follow 23 理想的传感器特点 技术方面 可靠和稳定 使用标准导线 最小的电池消耗 标准接头 标准植入技术 程控和随访简单 24 Todays Sensors Non-physiologic sensors Vibration Acceleration Ball sensor Physiologic Minute Ventilation Temperature Q-T Interval Closed Loop System (CLS) Combination sensors (blended) 25 今天的传感器 非生理性传感器 振动 加速度计 球传感器 生理性传感器 每分钟通气量 温度 Q-T间期 闭环系统 (CLS) 混合传感器 26 Casino Ball Used in Microny Products 27 Casino球 被使用于Microny起搏器 28 Piezoelectric Crystal Circuit board Piezoelectric Crystal Sensor mounted to can Easy to manufacture Rapid response to onset of activity Compatible with standard pacing leads Sensolog (Siemens) and Synchrony and Trilogy DR (Pacesetter) 29 压电晶体 电路板 压电晶体 传感器固定在机壳上 容易生产 对活动的反应快速 与标准的起搏导线兼容 Sensolog (Siemens)、Synchrony和Trilogy DR (Pacesetter) 30 Accelerometer Circuit Board Accelerometer Low current drain Easy to manufacture Rapid response to onset of activity Compatible with standard pacing leads Not responsive to pressure applied to can Used in all current St. Jude Medical pacemakers (began with Trilogy DR+) 31 加速度计 电路板 加速度计 电流消耗低 容易生产 对活动的反应快速 与标准的起搏导线兼容 对施加在机壳上的压力没有反应 使用于目前所有SJM公司的起搏器上(开始于Trilogy DR+) 32 Standard Bipolar Lead Signal Generated Between the Ring and the Can r = 0.97 with NSR Minute Ventilation No special sensor Sends low-level electrical signals to measure transthorasic impedance Requires bipolar pacing leads Tempo 标准的双极导线 在环和机壳之间产生信号 r = 0.97 with NSR 每分钟通气量 没有特殊的传感器 发送低水平的电信号以供 测量经胸阻抗 需要双极起搏导线 Tempo Base rate Max tracking rate (DDDR) Max sensor rate Threshold Slope Reaction time Recovery time Programming of Rate-Modulated Pacemakers 35 基本频率 最大跟踪频率 (DDDR) 最大传感器频率 阈值 斜率 反应时间 恢复时间 频率适应性起搏器的程控 36 Normal Sinus Node Heart Rate Workload 37 正常的窦房结 心率 工作量 38 Pacing Rate Workload Sensor Signal Maximum Sensor Rate (MSR) (220 - Age) x 0.9 Maximum Sensor Rate 39 起搏频率 工作量 传感器信号 最大传感器频率 (MSR) (220 年龄) x 0.9 最大传感器频率 40 Maximum Sensor Rate Settings: 80-150 ppm in steps of 5 160-180 ppm in steps of 10 Nominal - Victory and Zephyr = 130 ppm 41 最大传感器频率 设置: 80-150 ppm，步幅 5 160-180 ppm，步幅 10 默认值Victory 和 Zephyr = 130 ppm 42 Threshold The amount of activity required to initiate sensor activity Programmable from 1-7 Lower number requires less activity Nominal is Auto +0 Automatic Threshold available on all devices 43 阈值 启动传感器所需的活动量 可以程控为 1-7 较低的数值需要较少的活动度 默认值 自动+0 SJM所有的起搏器上都有自动阈值 (AUTO) 44 THRESHOLD 1 2 3 4 5 6 7 Workload Sensor Signal Base Rate Threshold Set at “2” Activates sensor Threshold Set at “4” Activates sensor Threshold 45 阈值 1 2 3 4 5 6 7 工作量 传感器信号 基本频率 阈值设置为“2” 活动传感器 阈值设置为“4” 活动传感器 阈值 46 Auto Threshold Measures variance in last 18 hours of activity More active patients have higher MAS Less active patients have lower MAS Measured Average Sensor (MAS) value displayed on interrogation 47 自动阈值 测量最近18h活动度的变化 活动较多的患者，MAS较高 活动较少的患者，MAS较低 询问时将显示测得的平均传感器(MAS)值 48 Auto Threshold Offset values for Auto Threshold Auto -0.5, +0.0, +0.5, +1.0, +1.5, +2.0 Nominal = Auto +0.0 Adjusts automatically If device calculates the MAS to be 2.5 and the Auto Threshold setting was Auto (+1.0) will result in an effective threshold value of 3.5 49 自动阈值 自动阈值调整的偏移值 自动 -0.5, +0.0, +0.5, +1.0, +1.5, +2.0 默认值 = 自动 +0.0 自动调整 如果ICD计算出的MAS为2.5，自动阈值设置为自动 +1.0，那么有效阈值为3.5 50 Slope The sensor-driven heart rate for a given level of activity programmable from 1-16 Higher values = higher heart rate Nominal = 8 Slope of 1 would allow sensor driven rate to go 20 bpm above Base Rate Slope of 16 would allow sensor driven rate to go to MSR 51 斜率 一特定活动度水平的传感器驱动心率，可程控为1-16 较高的值 = 较高的心率 默认值 = 8 斜率1可使传感器驱动频率增加至高于基本频率 20bpm 斜率16可使传感器驱动频率增加至MSR 52 Sensor Signal 16 1 8 Pacing Rate Workload 120 100 90 70 Base Rate 12 4 Threshold Set to “2” Starts Slope Max Sensor Rate Slope 53 传感器信号 16 1 8 起搏频率 工作量 120 100 90 70 基本频率 12 4 阈值设置为“2” 开始斜率 最大传感器频率 斜率 54 Sensor Signal Slope 55 传感器信号 斜率 56 Auto Slope Automatic Slope adjust according to changes in patient- specific activity (Measured Average Sensor value) Weekly changes in Auto Slope are limited to a maximum change of two Slope settings Creates a new Activity Variance Histogram every 7 days to calculate a new Slope Research shows normal heart rate stays within 23% of heart rate reserve for 99% of the time If Auto Slope values are selected, you are automatically forced to utilize Auto Threshold 57 自动斜率 根据患者的活动度(测得的平均传感器值)变化，而自动调 整斜率 自动斜率的每周变化受限于最多2个斜率设置的改变 每7天产生一个新的活动度变化直方图，从而计算出一 个新的斜率 研究表明，在99%的时间内，正常心率保持有23%心 率储备 如果选择了自动斜率，那么你也就选择了自动阈值 58 Pacing Rate Time Very slow Very fast Basic Rate Sensor Indicated Rate (SIR) FastSlow Reaction Time Time to increase from Base Rate to Maximum Sensor Rate Settings: Very Fast, Fast (nominal), Medium, and Slow 59 起搏频率 时间 慢 非常快 基本频率 传感器指示频率(SIR) 快中 反应时间 从基本频率上升至传感器指示频率所需的时间 设置: 非常快、快(默认值)、中和慢 60 Basic Rate Sensor Indicated Rate (SIR) Very Slow Very Fast Pacing Rate Recovery Time Time to decrease rate from Maximum Sensor Rate to Base Rate Settings: Fast, Medium (Nominal), Slow and Very Slow 61 基本频率 传感器指示频率 (SIR) 非常慢 非常快 起搏频率 恢复时间 从传感器指示频率下降至基本频率所需的时间 设置: 快、中(默认值)、慢和非常慢 62 63 64 Heart Rate and Sensor Histogram Records if sensor programmed to ON or PASSIVE Displays % distribution of sensor atrial paced rates as yellow dots Date read Total Time Sampled Date Last Cleared Re-programming sensor from OFF to another setting will clear the histogram 65 心率和传感器直方图 如果传感器程控为打开或观察，则记录 用黄色的点显示传感器驱动的心房起搏频率分布百分比 日期 取样总时间 上次清除日期 重新程控传感器(从关闭改为其他设置)，将清除直方图 66 67 68 Heart Rate and Sensor Histogram Benefits Assess behavior of the sensor independent of other algorithms or behaviors Facilitates programming the sensor when the pacemaker is inhibited by native rhythm Eliminates the need for formal exercise testing to assess sensor function Provides an overview of the sensor function 69 心率和传感器直方图 好处 独立于其他运算或功能，评价传感器行为 当起搏器被自身节律所抑制时，易于程控传感器 消除了对正规运动测试评价传感器功能的需求 提供了传感器功能的概况 70 Heart Rate and Sensor Histogram Normal sensor function Avg. patient spends 99% of their time with heart rates below 23% of their heart rate reserve Largest number of atrial paced events are in the lower rate bins Progressively smaller number of atrial paced events are in the higher bins Smallest percentage of atrial paced events are at rates above 100 ppm 71 心率和传感器直方图 正常的传感器功能 在99%的时间内，患者的心率低于心率储备23% 绝大多数的心房起搏事件在较低的心率 较小部分的心房起搏事件在较高的心率 极少数心房起搏事件的频率高于100ppm 72 #1 No Rate Response 73 #1 没有频率反应 74 #2 Chaotic distribution 75 #2 无序的分布 76 #2 Chaotic distribution 77 #2 无序的分布 78 Example - sensor too sensitive Cardiac Output Pacing Rate THRESHOLD 1 2 3 4 5 6 7 ( MAS 2.1 ) Programmed Threshold 2.0 Sensor Signal Because Threshold Is Set Lower (More Sensitive) than the MAS, the Sensor Activates with Less Patient Activity Z Z Z Z Workload #2 Chaotic distribution Sensor Indicated Rate Histogram 79 举例传感器太敏感 心脏输出 起搏频率 阈值 1 2 3 4 5 6 7 ( MAS 2.1 ) 程控的阈值 2.0 传感器 信号 因为阈值设置得比MAS更低(更敏感)，所以较低的患者活动即导致传感器启动 Z Z Z Z 工作量 #2 无序的分布 SIR直方图 80 #3 Does this patient use the sensor? 81 #3 该患者使用了传感器吗? 82 Rate Response Optimization Allows analysis of different sensor settings based on the patients everyday activities Displays intrinsic heart rates, sensor predicated rates, and p