除颤起搏器的临床应用.ppt

除颤起搏器的临床应用 山东省千佛山医院 心内科 闫素华 Contents nICD History nBasic functions of defib nSensing, detection and therapies nICD indicationswho gets one or not nImplant procedurehow do we test the device . History of ICDs Internal defibrillator Late 1940s to 1950s Unit shown is from the early 1960s Pioneer of ICD Technology Michel Mirowski, MD Dedicated his life to developing the ICD after his research partner died in his arms from a ventricular arrhythmia Created the first implantable ICD, which started clinical trials in 1980 1985 - First approved ICD Bulky, heavy Short-lived (18m) Abdominal implant Thoracotomy required Non-programmable Limited therapy options Ventak is a trademark of Cardiac Pacemakers, Inc. The next milestone for ICDs Pectoral implants approved by the FDA in 1995 More comfortable for patients Faster implants Smaller but just as powerful as older devices “Active Can” Technology Traditional System RV-Can Evolution of ICD Technology 19911995 The First ICDs Featured Epicardial Leads Transvenous Leads and Advanced Therapy Increase Effectiveness of ICD Therapy Pectoral ICDs Reduce Costs and Increase Surgical Ease 1985 “Dual Chamber” ICDs nIntroduced in 1997 nCombine dual chamber pacing with ventricular arrhythmia detection and therapy nAbility to sense atrial activity during arrhythmias uSVT Discrimination: The ability to withhold therapy for non-lethal arrhythmias Basic Functions of ICD nAutomatically detect and treat Ventricular Tachycardia (VT) uAntitachycardia pacing (ATP) uCardioversion nAutomatically detect and treat Ventricular Fibrillation (VF) uDefibrillation nBrady pacing uVVI, VVIR, DDDR How it works nSensing nDetection nTherapy Auto-Adjusting Sensitivity n n Designed to sense fine VFDesigned to sense fine VF Post-sensed sensitivity adjustment Post-paced sensitivity adjustment Programmed sensitivity Post-pace blanking Marker Channel Telemetry V PACE V PACE V SENSE V PACE V SENSE Rectified EGM Changing Threshold Post-PacePost-Sense 10x 4.5x 0.3 mV Three Zone Detection nVT nFVT nVF VT Detection n n Ventricular sensitivityVentricular sensitivity n n Tachy detection interval (TDI)Tachy detection interval (TDI) n n VT initial NIDVT initial NID n n VT redetect NIDVT redetect NID VFFVTVT Detection Status:ONOFFON Interval (ms):320400 Initial NID:12/1612 Sensitivity (mV):0.3 VT Counter Value:123456789101112 200 ms V S V S V S V S V S T S T S T S T S T S T S T S T S T S T S T S T D VF Detection n n Ventricular sensitivityVentricular sensitivity n n Fibrillation detection interval (FDI)Fibrillation detection interval (FDI) n n VF initial NIDVF initial NID n n VF redetection NIDVF redetection NID FVT Detection via VF Counter VFVFFVTFVTVTVT Detection Status:Detection Status:ONONONONOFFOFF Interval (ms):Interval (ms):320320260260 Initial NID:Initial NID:12/16 12/16 T F T F 121110987654321 T F T F T F T F T F T F T F T F T F T F V S V S V S V S V S LOOKBACK WINDOW (8 INTERVALS BEFORE NID) FVT Detection via VT Counter VFVFFVTFVTVTVT Detection Status:Detection Status:ONONONONONON Interval (ms):Interval (ms):320320380380500500 Initial NID:Initial NID:12/16 12/16 1212 121110987654321 LOOKBACK WINDOW (8 INTERVALS BEFORE NID) V S V S V S T S T S T S T S T S T S T S T S T S T F T S T F VF Counter: Increased VT Detection Specificity Sinus Tachycardia Atrial Tachycardia Atrial Flutter Atrial Fibrillation Morphology X X X X Onset X Stability X Therapies nATP uBurst uRamp uRamp+ nCardioversion nDefibrillation Burst Ramp Ramp+ ICD Indications, who gets one or not n n Class IClass I: Evidence/general agreement regarding benefit, usefulness, : Evidence/general agreement regarding benefit, usefulness, and effectivenessand effectiveness n n Class IIClass II: Conflicting evidence/divergence of opinion regarding : Conflicting evidence/divergence of opinion regarding usefulness/effectivenessusefulness/effectiveness uuIIa: Weight of evidence/opinion in favor of IIa: Weight of evidence/opinion in favor of usefulness/effectivenessusefulness/effectiveness uuIIb: Usefulness/effectiveness less well established by IIb: Usefulness/effectiveness less well established by evidence/opinion.evidence/opinion. n n Class IIIClass III: Evidence/general agreement regarding lack of : Evidence/general agreement regarding lack of usefulness/effectiveness (harmful in some cases)usefulness/effectiveness (harmful in some cases) Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209. 1998 Class I Indications for ICD Therapy 1. 1. Cardiac arrest due to VF or VT not due to a transient or reversible Cardiac arrest due to VF or VT not due to a transient or reversible cause. cause. (Level of evidence: A)(Level of evidence: A) 2. 2. Spontaneous sustained VT. Spontaneous sustained VT. (Level of evidence: B)(Level of evidence: B) 3. 3. Syncope of undetermined origin with clinically relevant, Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective, not tolerated, or not at EP study when drug therapy is ineffective, not tolerated, or not preferred. preferred. (Level of evidence: B)(Level of evidence: B) 4. 4. Nonsustained VT with coronary disease, prior MI, LV dysfunction, and Nonsustained VT with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at EP study that is not suppressible by a inducible VF or sustained VT at EP study that is not suppressible by a Class I antiarrhythmic drug. Class I antiarrhythmic drug. (Level of evidence: B)(Level of evidence: B) Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209. 1998 Class II Indications 1. 1. Cardiac arrest presumed to be due to VF when EP testing is Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditions.precluded by other medical conditions. (Level of evidence: C)(Level of evidence: C) 2. 2. Severe symptoms attributable to sustained ventricular Severe symptoms attributable to sustained ventricular tachyarrhythmias while awaiting cardiac transplantation. tachyarrhythmias while awaiting cardiac transplantation. (Level of (Level of evidence: C)evidence: C) 3. 3. Familial or inherited conditions with a high risk for life-Familial or inherited conditions with a high risk for life- threatening ventricular tachyarrhythmias such as long QT threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy. syndrome or hypertrophic cardiomyopathy. (Level of evidence: B)(Level of evidence: B) Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209. 1998 Class II Indications (cont.) 4. 4. Nonsustained VT with coronary artery disease, prior MI, and Nonsustained VT with coronary artery disease, prior MI, and LV dysfunction, and inducible sustained VT or VF at EP study. LV dysfunction, and inducible sustained VT or VF at EP study. (Level of evidence: B)(Level of evidence: B) 5. 5. Recurrent syncope of undetermined etiology in the presence of Recurrent syncope of undetermined etiology in the presence of ventricular dysfunction and inducible ventricular arrhythmias at ventricular dysfunction and inducible ventricular arrhythmias at EP study, when other causes of syncope have been excluded. EP study, when other causes of syncope have been excluded. (Level of evidence: C)(Level of evidence: C) Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209. 1998 Class III Indications 1. 1. Syncope of undetermined cause in a patient without inducible Syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias. ventricular tachyarrhythmias. (Level of evidence: C)(Level of evidence: C) 2. 2. Incessant VT or VF. Incessant VT or VF. (Level of evidence: C)(Level of evidence: C) 3. 3. VF or VT resulting from arrhythmias amenable to surgical or catheter VF or VT resulting from arrhythmias amenable to surgical or catheter ablation; for example, atrial arrhythmias associated with the Wolff-ablation; for example, atrial arrhythmias associated with the Wolff- Parkinson-White syndrome,Parkinson-White syndrome, r right ventricular outflow tract VT, ight ventricular outflow tract VT, idiopathic leftidiopathic left ventricular tachycardia, or fascicular Vventricular tachycardia, or fascicular VT T (Level of (Level of evidence: C)evidence: C) 4. 4. Ventricular tachyarrhythmias due to a transient or reversible disorder Ventricular tachyarrhythmias due to a transient or reversible disorder (e.g., AMI, electrolyte imbalance,(e.g., AMI, electrolyte imbalance, drugs, trauma).drugs, trauma). (Level of evidence: C) (Level of evidence: C) Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209. 1998 Class III Indications (cont.) 5. 5. Significant psychiatric illnesses that may be aggravated by device Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up. implantation or may preclude systematic follow-up. (Level of evidence: (Level of evidence: C)C) 6. 6. Terminal illnesses with projected life expectancyTerminal illnesses with projected life expectancy 6 months. 6 months. (Level of evidence: C)(Level of evidence: C) 7. 7. Patients with coronary artery disease with LV dysfunction and Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the