北大人民医院心脏起搏器基础与临床研讨班课件 07single chamber timing

Single Chamber Timing 1 单腔时间间期 2 Single Chamber Timing Sensing and Pacemaker Inhibition Capture Fusion and Pseudofusion Single-chamber Timing Cycles Rate Hysteresis Single-chamber Modes Single-chamber Troubleshooting 3 单腔时间间期 单腔时间间期 频率滞后 感知和起搏器抑制 夺获 融合波和假性融合波 单腔模式 单腔Troubleshooting 4 Surface ECG IEGM (Intra-cardiac Electrogram) Surface and Intracardiac 体表ECG IEGM (腔内心电图) 体表和腔内心电图 Surface and IEGM 7 体表 ECG和 IEGM 8 Pacing Interval / Pacing Rate The rate at which the pacemaker will pace if the patient does not have their own rhythm Expressed in either PPM or ms Your pacing Interval is your programmed Base Rate (Also known as Pacing Rate, Lower Rate Limit) 9 起搏频率/起搏间期 如果患者没有自身节律，起搏器将起搏的频率 用PPM或ms表示 起搏间期就是程控的基本频率间期 (也被称为起搏频率、下限频率) Base Rate 60ppm 10 Pacing Intervals Automatic Interval Escape Interval Refractory Period Refractory Period Alert PeriodAlert Period 11 起搏间期 自动间期逸搏间期 不应期 不应期 警觉期警觉期 12 Rate Hysteresis By lowering the pacing rate, allows for intrinsic rate to drop to below the Hysteresis Rate before pacing will occur On the surface ECG, looks likes a separate rate for pacing and sensing The purpose of Hysteresis is to promote intrinsic conduction 13 频率滞后 通过降低起搏频率，允许自身心率在发生起搏前降至滞 后频率 在体表ECG上，看上去像有一个分开的起搏和感知频率 滞后的目的是促进自身传导 14 Hysteresis Pacing IntervalHysteresis Interval 15 滞后 起搏间期 滞后间期 16 Single Chamber Hysteresis Hysteresis Begins Hysteresis Ends 17 单腔滞后 滞后开始 滞后结束 18 Timing Cycles Refractory period A programmable period of time that starts with pacing or sensing This period of time has two components: Absolute Refractory Period Relative or Noise Sampling Period 19 时间间期 不应期 从起搏或感知开始的一个可程控的时间周期 该时间有两个部分组成 绝对不应期 相对不应期或噪音采样期 20 = Absolute Refractory Period Absolute Refractory Period The pacemaker cannot see during this time The sense amplifier is totally shut off Timing Cycles 21 = 绝对不应期 绝对不应期 该时间内，起搏器不能看到任何信号 感知放大器被完全关闭 时间间期 22 Relative Refractory Period Relative Refractory Period The device sees electrical activity but doesnt respond 23 相对不应期 相对不应期 起搏器能看见电活动，但不会做出反应 24 Clinical Application of Refractory Periods Programmer AAI mode “A. Refractory” (nominal 275 ms) Used to blank far-field event in DDD mode (PVAB) Atrial Absolute Refractory period is programmable in AAI/R and AAT/R modes only VVI mode “Ventricular Refractory” (nominal 250 ms) Used to prevent oversensing of T-waves 25 相对不应期的临床应用 程控仪 AAI模式 “心房不应期” (默认值 275ms) 在DDD模式中，用于避免远场事件(PVAB) 心房绝对不应期仅在AAI/R和AAT/R模式中可程控 VVI模式 “心室不应期” (默认值 250ms) 用于防止T波过感知 26 Noise Sampling Period/ Relative Refractory Period Definition: Anything sensed in the noise sampling period is considered noise Designed to protect the patient against inhibition in response to electromagnetic interference or noise Requires EMI at least 400 cycles per minute Extends the relative refractory period 75 ms blanking + 25 ms relative (ADx Forward) 噪音采样期/相对不应期 定义: 任何在噪音采样期内被感知到的事件，被认为是 噪音 该设计用于保护患者避免因EMI或噪音而发生起搏抑制 要求EMI至少为每分钟400个周期 延长相对不应期 75ms 空白期 + 25ms 相对不应期 (ADx及之后的起 搏器) Noise Ventricular Refractory Period Ventricular Alert Period Ventricular Noise Sampling Period Noise Programmed Rate Sensed QRSSensed QRS When the noise is sensed it resets another refractory period, until the noise is no longer sensed. 噪音 心室不应期 心室警觉期 心室噪音采样期 噪音 程控频率 感知到的QRS波感知到的QRS波 当感知到噪音，重设 另一个不应期，直至 噪音不再被感知 Alert Period Definition: The portion of the timing cycle where the device senses electrical activity (e.g. cardiac) and responds in a preset or programmed manner 警觉期 定义: 起搏器感知电活动的时间间期的一部分，且起搏器按 照程控参数做出反应 = Relative or Noise Sampling Period = Alert Period Alert Period The period of time after the refractory period The pacemaker can see and will respond in the programmed manner 33 = 相对不应期或噪音采样期 = 警觉期 警觉期 不应期之后的一段时间 起搏器能够感知，且按程控参数做出反应 34 pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval Ventricular Refractory plus Alert Equal the Pacing Interval (Rate) = Relative or Noise Sampling Period = Alert Period Example with BR 60, V-Ref of 250 1000-250= 750ms Alert Period 35 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 心室不应期加上警觉期等于起搏间期 (频率) = 相对不应期或噪音采样期= 警觉期 举例: 基本频率 60, 心室不应期 250 1000-250= 750ms 警觉期 36 Unipolar Pacing and Sensing Lead Pacemaker 37 单极起搏和感知 导线 起搏器 38 Bipolar Pacing and Sensing Lead Pacemaker 39 双极起搏和感知 导线 起搏器 40 Bipolar vs. Unipolar Programmable in all devices Bipolar Small antenna Small spike More sensitive to intrinsic cardiac signals No myopotential inhibition EMI protected Less crosstalk Unipolar Large antenna Large spike More sensitive to interference Pectoral muscle stimulation More susceptible to EMI Smaller lead diameter 41 双极和单极比较 在所有起搏器中可程控 双极 小的感知回路 小的起搏钉 对自身心脏信号更敏感 没有肌电干扰 EMI 保护 较少的交叉感知 单极 大的感知回路 大的起搏钉 对干扰更敏感 胸肌刺激 更易受 EMI影响 较小的导线直径 42 Asynchronous Pacing Pacing without sensing Oldest mode of pacing Magnet mode for most pacemakers Magnet application turns off pacemaker sensing thus forcing it to pace Magnet uses: Assess pacer function during inhibition Troubleshooting Evaluate ERI (elective replacement indicator) and EOL (end of service life) 非同步起搏 起搏，无感知 最老的起搏模式 大多数起搏器的磁铁模式 磁铁应用关闭了起搏器的感知功能，强迫其起搏 磁铁的应用: 评价起搏器功能 Troubleshooting 评估ERI(选择性更换指示)和 EOL(使用寿命终止) VOO Paces: Senses: Response: Ventricle None None Non-Sensed R-Waves pacing interval 45 VOO 起搏: 感知: 反应: 心室 无 无 未被感知的R波 起搏间期 46 AOO Paces: Senses: Response: Atrium None None Non-Sensed P-Waves pacing interval 47 AOO 起搏: 感知: 反应: 心房 无 无 未被感知的P波 起搏间期 48 Demand Pacing Pacing with sensing Pacing pulse is inhibited by intrinsic “P-” or “R-waves” Sensed events reset the pacing interval 49 按需起搏 起搏伴感知 起搏脉冲可被自身P波或R波抑制 感知事件重启起搏间期 50 感知 感知定义：起搏器识别心脏自身电活动的能力 感知功能由感知灵敏度决定 感知阈值：起搏器能够可靠感知自身心电信号的最低值 感知异常 感知过度 感知不良 51 5 mV 2 mV 1 mV Sensing When programming sensitivity, as you lower the number you make the pacemaker more sensitive, (allow it to “see” more). 5 mV 2 mV 1 mV 感知 在程控感知灵敏度时，降低数值将增加起搏器的敏感度 (允 许它“看到”更多) 5 mV 2 mV 1 mV Sensing When programming sensitivity, as you lower the number you make the pacemaker more sensitive, (allow it to “see” more). 5 mV 2 mV 1 mV 感知 在程控感知灵敏度时，降低数值将增加起搏器的敏感度 (允 许它“看到”更多) 5 mV 2 mV 1 mV Sensing When programming sensitivity, as you lower the number you make the pacemaker more sensitive, (allow it “see” more). 5 mV 2 mV 1 mV 感知 在程控感知灵敏度时，降低数值将增加起搏器的敏感度 (允 许它“看到”更多) Ventricular Sensing / Inhibition pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval Sensed R-waves re-start the pacing interval Appropriate Ventricular sensing 58 心室感知/抑制 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 感知到的R波重新开启一个起搏间期 正确的心室感知 59 V-Sense Threshold Sensing Threshold Test To perform a sensing threshold test, encourage intrinsic activity then increase sensitivity value until sensing is lost. The sensing threshold is the lowest value in mV with 1:1 sensing 60 心室感知阈值 感知阈值测试 进行感知阈值测试，鼓励自身事件，然后增加感知灵敏度 值，直至感知丧失 感知阈值是1:1感知的最低值(mV) 61 Oversensing Definition: The sensing of events other than P or R-waves by the pacemaker circuitry Oversensing leads to underpacing 过感知 定义: 起搏器电路感知到除自身P波和R波以外的事件 过感知导致起搏不足 Ventricular Oversensing pacing interval pacing interval pacing intervalpacing interval pacing intervalpacing intervalpacing interval pacing interval 心室过感知 起搏间期 起搏间期 起搏间期起搏间期 起搏间期起搏间期起搏间期 起搏间期 T-wave Oversensing How can this be fixed? 66 T波过感知 How can this be fixed? 67 Oversensing Causes Insulation break Intermittent lead fracture Myopotentials EMI Concealed extrasystoles 过感知的原因 绝缘层破损 间歇性导线断裂 肌电干扰 EMI 隐藏的期外收缩 Rib-Clavicle Crush-Conductor Fracture Dotted line identifies lower edge of clavicle 70 肋锁骨挤压 导线断裂 虚线指示了锁骨下缘 71 Possible Solutions Program sensitivity to a higher number Program the refractory period longer 可能的解决方案 将感知灵敏度程控至一个更高的数值 将不应期程控得更长 Undersensing Definition: Failure of the pacemaker circuitry to sense intrinsic P- or R-waves Undersensing may cause the pacemaker to emit inappropriately-timed, asynchronous, or competitive output pulses Undersensing leads to overpacing 感知不足 定义: 起搏器电路不能感知到自身的P波或R波 感知不足可导致起搏器脉冲发放的时间不恰当、 不同步 或者发放竞争性输出脉冲 感知不足导致起搏过度 Non-Sensed R-Waves Ventricular Undersensing pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval 未感知到的R波 心室感知不足 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 Undersensing Causes Inadequate cardiac signal Dislodged lead Sensitivity too low (sensitivity value to high) 感知不足的原因 心脏信号不足够大 导线移位 感知灵敏度太低(感知灵敏 度值太高) Possible Solutions Program the sensitivity to a lower number Reprogram polarity 可能的解决方案 将感知灵敏度程控至一个较低的数值 重新程控极性 Capture Definition: The depolarization and resultant contraction of the atria or ventricles in response to a pacemaker stimulus. One-to-one capture occurs when each pacemaker stimulus causes a corresponding depolarization and resultant cardiac contraction 82 夺获 定义: 心房或心室对起搏器发放的刺激做出反应，除极和引 起收缩 一对一夺获: 每一个起搏器发放的刺激都能引起除极 和心脏收缩 83 pacing interval Atrial Capture pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval Pacing Stimulus Paced atrial events re-start the pacing interval 84 起搏间期 心房夺获 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏刺激 起搏的心房事件重新开启一个起搏间期 85 Ventricular Capture pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval Ventricular capture (paced ventricular beats look like PVCs or LBBB) Paced Ventricular events re-start the pacing interval 86 心室夺获 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 心室夺获 (心室起搏的QRS波很像PVC或LBBB) 起搏的心室事件重新开启一个起搏间期 87 Threshold Stimulation threshold definition: The minimum amount of electrical energy that consistently produces a cardiac depolarization Can be measured in: Voltage Pulse width (duration) Milliamperes Charge (microcoulombs) Energy (microjoules) 阈值 起搏阈值的定义: 在不应期外能稳定地产生心脏除极的最小电能量 可用以下单位测量: 电压 (V) 电流 (mA) 脉宽 / 持续时间 (ms) 电量 (C) 能量 (J) Capture Threshold Testing Decrease amplitude or pulse width until LOC is reached. The last value with 1:1 capture is your threshold. 1.0V is the V-Capture Threshold 90 夺获阈值测试 降低振幅或脉宽，直至LOC。最后一个1:1夺获的值就是 阈值 1.0V是心室夺获阈值 91 Fusion Beat Definition: The combination of an intrinsic beat and a paced beat The morphology varies; a fusion beat doesnt really look like a paced beat or an intrinsic beat Fusion beats contribute to the contraction of the chamber being paced 融合波 定义: 自身心跳和起搏心跳的结合 形态是变化的；融合波看上去既不完全像自身心跳 ，也不完全像起搏心跳 融合波对起搏心腔的收缩有贡献 Ventricular Fusion 94 心室融合波 95 Pseudofusion Beat Definition: A pacing pulse falls on an intrinsic beat. The pacing pulse is ineffective and the intrinsic complex is not altered 假性融合波 定义: 起搏脉冲落在自身心跳上。该起搏脉冲是无效的，且 自身波群未改变 Ventricular Pseudofusion 98 心室假性融合波 99 Fusion and Pseudofusion 100 融合波和假性融合波 101 Clinical Significance Fusion Contributes to the contraction Can use to determine capture Pseudofusion Does not confirm capture Output pulse ineffective To confirm capture in both situations increase the pacing rate. Once capture confirmed, consider decreasing programmed rate 临床意义 融合波 对收缩有贡献 可用于决定夺获 假性融合波 不能确定夺获 输出的脉冲无效 在此两种情况下，增加起搏频率可确认夺获 一旦确认夺获，则考虑降低程控的频率 Loss of Capture Definition: The emitted pacemaker stimulus does not cause depolarization and resultant cardiac contraction Loss of capture occurs when the pacemakers programmed energy is less than the stimulation threshold 失夺获 定义: 起搏器发放的刺激不能 引起心脏除极和收缩 失夺获：当起搏器的输出能 量低于起搏阈值时，不能夺 获心脏 功能性失夺获：起搏脉冲落 入患者自身心律的不应期时 将发生失夺获 pacing interval Loss of Capture Ventricular Loss of Capture pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval pacing interval 起搏间期 失夺获 心室失夺获 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 起搏间期 Loss of Capture Causes Dislodged lead Twiddlers syndrome Insulation break Perforation Exit block Threshold higher than programmed output 失夺获的原因 导线移位 Twiddler综合征 绝缘层破损 穿孔 传出阻滞 阈值高于程控的输出 Possible Solutions Program voltage higher Program pulse width higher Reprogram polarity Reposition pacing electrode Replace pacing electrode 可能的解决方案 将电压程控得更高 将脉宽程控得更大 重新程控极性 重新放置起搏导线 更换起搏导线 Loss of Output Definition: The pacemaker does not emit a stimulus 无输出 定义: 起搏器不能发出刺激 Ventricular loss of output Pacemaker should have paced pacing intervalpacing intervalpacing intervalpacing intervalpacing intervalpacing intervalpacing interval 114 心室无输出 起搏器应该起搏 起搏间期起搏间期起搏间期起搏间期起搏间期起搏间期起搏间期 115 Loss of Output Causes Cause for the pause Loose set screw Lead fracture Pacemaker Inhibition Concealed stimulus on ECG Battery exhaustion 无输出的原因 导致长间歇的原因 固定螺丝松动 导线断裂 起搏器抑制 心电图上刺激被隐藏 电池耗竭 Causes of Altered Pacemaker Parameters EMI Any source of electrical energy which has enough energy to enter the pacemaker circuitry causing the pacemaker to go to a “back-up” mode. i.e. electrocautery, defibrillation, cardioversion Phantom programming Some one has changed the pacemakers programmed values and not left