北大人民医院心脏起搏器基础与临床研讨班课件 03pacemaker

Indications for Device Therapy Paul A. Levine, M.D., FACC Vice President and Medical Director St. Jude Medical CRMD Clinical Professor of Medicine Loma Linda University School of Medicine Updated December 3, 2001, Re-edited 1 起搏器治疗适应证 2 Causes of Conduction Defects Coronary Artery Disease Idiopathic Degeneration Calcification Endocarditis Heart Surgery RF Ablation 3 传导缺陷的病因 冠状动脉疾病 特发性退化 钙化 心内膜炎 心脏手术 射频消融 4 Symptomatology + Documented Events ECG documentation in the medical record is essential ! Reliable Indications for Pacing = Indications For Pacing 5 症状 + 记录到的事件 病历中的ECG记录非常重要! 可靠的起搏适应证= 起搏适应证 6 Symptoms May be varied and can include: Irritability Fatigue Forgetfulness Palpitations Chest Pain Dyspnea 7 症状 可能有所不同，但可以包括: 易怒 易疲劳 健忘 心悸 胸痛 呼吸困难 8 Documented Events 24-hour Holter Moniter Tilt Table Test EP Testing Temporary Pacing 9 记录的事件 24h Holter监测 倾斜试验 EP测试 临时起搏 10 Diagnosing Indications Noninvasive History ECG Ambulatory Monitoring Stress Test Carotid Massage 11 诊断 非侵入性 病史 心电图 动态心电图（Holter） 负荷试验 颈动脉按摩 12 Diagnosing Indications Invasive Catheterization Lab EP Lab 13 诊断 侵入性 心导管检查 EP检查 14 ACC/AHA/HRS 起搏适应证指南 美国心脏病学会 （American College of Cardiology ACC) 美国心脏协会 （American Heart Assioation AHA) 美国心律协会 （Heart Rhythm Society HRS) 15 ACC/AHA Guidelines for Pacemaker and ICD Implant Class I: conditions for which there is good evidence and/or general agreement that the therapy is appropriate Class II: conflicting evidence or divergence of opinion IIa: favor of usefulness/efficacy IIb: less well established Class III: evidence and/ or general agreement that the therapy is not useful or effective 16 ACC/AHA/HRS指南 起搏器和ICD植入 I类: 证据和/或一致意见均认为正在进行的医疗操 作和治疗是有益、有用和有效的 II类:对于正在进行的医疗操作和治疗的有用性和有 效性存在不同的证据和/或相反的意见 IIa: 证据或意见更倾向于该医疗过程和 治疗是有用和有效的 IIb: 证据或意见更倾向于该医疗过程和 治疗是无用和无效的 III类: 证据和/或一致意见均认为正在进行的医疗操 作和治疗是无用和无效的，在某种情况下甚至是 有害的 17 Level of Evidence (Cardiology) data derived from multicenter randomized trials data from limited or non-randomized studies or observational studies expert consensus but no formal studies ACC/AHA Guidelines for Pacemaker and ICD Implant 18 ACC/AHA/HRS指南 起搏器和ICD植入 证据分级 1.A级：数据来源于多中心随机临床试验 2.B级：数据来源于有限的或非随机临床 研究或观察研究 3.C级：多数专家的意见，但没有正式的 临床研究 19 Sick Sinus Syndrome Heart Block Carotid Sinus Hypersensitivity and Neurocardiogenic Syncope HOCM, DCM Indications For Pacing 20 病窦综合征 房室传导阻滞 颈动脉窦过敏综合征和 血管迷走性晕厥 肥厚型梗阻性心肌病 起搏适应证 21 Sinus Bradycardia Sinus Arrest SA Exit Block Bradycardia-Tachycardia Syndrome Symptomatic chronotropic incompetence Sinus Node Dysfunction (Sick Sinus Syndrome) 22 窦性心动过缓 窦性停搏 窦房传出阻滞 房颤伴慢心室率 慢快综合征 有症状的变时性功能不全 窦房结功能障碍（病窦综合征） 23 Sinus Node Dysfunction Class I Symptomatic bradycardia, even drug induced if medication cannot be discontinued (Level of evidence: C) Symptomatic chronotropic incompetence (Level of evidence: C) 24 窦房结功能障碍 I类 有症状的心动过缓，包括必需药物治疗所导致的 (C) 有症状的变时性功能不全 (C) 25 Sinus Node Dysfunction Class II a SND occurring spontaneously or as a consequence of Rx with heart rates below 40 with a clear association with symptoms (Level of evidence: C) Syncope of unexplained origin when SND is discovered on EP study ( C ) Class II b Minimally symptomatic patient, chronic heart rate 3.0 seconds or escape rate 3.0s或逸搏心率 40 bpm ( B, C ) “Asymptomatic” Type II 2nd Degree AV block ( B ) “Asymptomatic” Type I even infra-His ( B ) FIRST degree AV block with symptoms ( B ) Class II b First degree or second degree AV block with symptoms similar to those of pacemaker syndrome ( B ) Previous guidelines required documentation of alleviation of symptoms with temporary pacing. This is no longer required First degree AV block (PR 300 ms) with LV dysfunction and CHF with documented hemodynamic improvement symptoms ( C ) Neuromuscular disease (myotonic muscular dystrophy, Erbs dystrophy, Kearns-Sayre syndrome, ) with any degree of AV block (even first degree) with or without symptoms as progression is unpredictable ( C ) 42 房室传导阻滞 IIa类 无症状的完全性房室传导阻滞，心率 3 seconds of asystole in absence of vagomimetic meds ( C ) Class II a Recurrent syncope, + CSM, no other etiology ( C ) Class II b Recurrent syncope, + tilt table test with marked cardioinhibitory component ( C ) 56 神经介导综合征 I类 自发性颈动脉刺激和颈动脉按压诱导的心室停搏时 间3s导致的反复性晕厥 (C) IIa类 反复性晕厥，没有确切的颈动脉刺激事件，高敏感 性心脏抑制反应心室停搏时间3s者 (C) IIb类 有明显症状的神经心源性晕厥，伴有自发性或直立 倾斜试验时出现明显的心动过缓 (C) 57 Neurally Mediated Syndromes Carotid Sinus Massage Check for bruits Always monitor ECG One side at a time Gentle 58 神经介导综合征 颈动脉窦按摩(CSM) 检查杂音 监测ECG 每次仅按摩一侧 动作轻柔 59 Neurocardiogenic Syncop Type II Cardioinhibitory Tilt-test 60 神经介导性晕厥 II型心脏抑制型 倾斜试验阳性 61 Hypertrophic Obstructive Cardiomyopathy Class I Standard indications+ Class II b Medically refractory, symptomatic with significant gradient shown to respond to temporary pacing ( C ) 62 肥厚型梗阻性心肌病 I类 标准适应证 IIb类 药物治疗无效，伴明显的流出道梗阻症状，对临床 起搏有反应 (C) 63 Hypertrophic Obstructive Cardiomyopathy Fananapazir, CIRD 1992 64 肥厚型梗阻性心肌病 Fananapazir, CIRD 1992 65 Dilated Cardiomyopathy Class I Standard indications Class II b Symptomatic drug refractory with prolonged PR interval ( C ) Medically refractory NYHA class III or IV with wide QRS ( 130 ms), LVEDD 55 mm and EF 3.0秒 2. IIoII型