ICD的基本工作原理biotronik

廖峰百多力江苏高级地区经ICD基本原理介绍,只有心室感知,以下讲解基于百多力Lumax300系列机器功能原理,Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Marker:,RR-Interval,室颤时的感知不足。所以，用固定感知灵敏度是不适合的,Sensing Concept 感知原理,Automatic Sensitivity Control (ASC),UTLTMin.,Max.,自动感知灵敏度控制,Standard Setting:Upper Threshold (UT) = 50% of RLower Threshold (LT) = 25% of RHold Off = 360 msMin. Threshold = 0.8 mV,Sensitivity 感知灵敏度,Standard: UT = 50%LT = 25%UT Hold = 360 msEnhanced VF Sensitivity: UT = 50%LT = 25%UT Hold = 100 msEnhanced T-wave Suppression:UT = 75%LT = 25%UT Hold = 360 ms,ASC: 默认设置 (Sensed Events),推荐应用于 R波 3 mV,Minimum Sensitivity 0.8 mV default,Upper Fence = 50% R-wave = 4 mV,Lower Fence = 25% R-wave = 2 mV,360 ms,“Fence” aka “Threshold” in technical manuals,R-wave = 8 mV,ASC: T-Wave Suppression,Minimum Threshold 0.8 mV default,Upper Fence = 75% R-wave,LT = 25% R-wave,Hold of Upper Threshold,360 ms,“Fence” aka “Threshold” in technical manuals,应用于 高尖T波患者,ASC: 长QT患者管理,最小阈值缺省值 0.8 mV,500 ms,延长UT锁定时间,“Fence” aka “Threshold” in technical manuals,Sensitivity 感知灵敏度,如果采用恒定的感知灵敏度，仍会出现感知不到VF,100 %,50 %,25 %,62 ms,125 ms,250 ms,100 %,50 %,25 %,100 %,50 %,25 %,125 ms,250 ms,500 ms,250 ms,500 ms,1000 ms,100 %,50 %,25 %,500 ms,1000 ms,2000 ms,16 Hz,8 Hz,4 Hz,2 Hz,Hold Off and Decrement Rate,Hold Off200 ms,0.125mV,post Vs 程控“Enhanced T-wavesuppression” 如果R波较低，采用half-waverectification/signal inversion 如果是长Q-T，延长“Hold-offupper threshold”,T波过感知两种不同的策略TWOS,post Vp 延长“Blanking after RV pacing” 提高“Minimum threshold”，从0.8mV - 1.2mV 调整“High pass”，从10Hz -20Hz,TWOS,IncomingSignal,Inversion,Half-wave,rectification,+,+,案例：TWOSRemote monitoring via IEGM-Online HD,4月19日随访,auto,参数调整后腔内图观测显示,Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Interval length (ms),Rate (bpm),Brady zone,Sinus zone,Rhythm Zones 节律分区,VT1 zoneVT2 zone,VF zone,VF Detection 室颤检测,Rate/Interval: VF zone,Detection counter: X in Y (如 8 in 12),SinusVT1400 ms 18VT2360 ms 14VF300 ms 8/126 in 127 in 128 in 12,VF detection,8 in 12,VF detection counter:,1,2,3,4,5,6,7,8,VF Detection 室颤检测8 in 12,VF zone = 300 ms (200 bpm),Example VF Detection 室颤检测8 in 12,VF detection counter:,1 2,3 4 5 6 7,8,VT Detection 室速检测,Rate/Interval: VT zone,Detection counter（计数器）Onset（突发性）,Stability（稳定性）,VT Detection Counter 检测计数器,快于VT zone的事件均被计数计数器是一个加/减计数器,快于VT zone的事件，计数器+1,慢于VT zone的事件，计数器-1（如窦性心律）,VT1 counter：VT1、VT2、VF事件均被计数VT2 counter：VT2、VF事件被计数,计数器遇下列情况减1：,VT1 zone：窦性间期（事件）,VT2 zone：VT1和窦性间期（事件）,VT Detection Counter 检测计数器,VT1 slow zone (mVT)VT2 fast zone (pVT)VF,Sinus,Sinus,VT VT VT,VT Detection Counter 检测计数器,VT counter 0,1,2,3,4,5,4,3,4,5,6,VT VT VT VT VT,VT1VT2,00,00,00,10,20,30,40,50,61,72,83,9 10 11 12 13 14 15 16 17 184 5 6 5 4 3 2 1 0 0,Sinus,VT1400ms/150bpm18VT2360ms/167bpm14VF300ms/200bpm8/12,VT1 detected,150bpm,167bpm200bpm,VT zone rate: 160 bpm (375 ms), Detection counter: 16,VT Detection Counter,VT检测的加减计数器,任何快心室率都会被计数，但只有室性心动过速才需ICD治疗附加检测标准用来鉴别:,窦性心动过速,室上性心动过速（AF）,单腔ICD，用“突发性”和“稳定性” 提高对室速鉴别的特,异性,室速和室上速的鉴别,Onset 突发性,Onset是一个加强的检测标准，用来区别窦速和室速,窦速通常都是逐渐增快室速通常是突然发作,当前R-R与前4个R-R平均值比，如果差超过了程控值（如20%），则满足Onset,且被后4个R-R平均值核实,前4个R-R平均值基于Sliding average,Onset 突发性,RRn-1 RRn,RRn-2,RRn-3,RRn-4,RRn+1 RRn+2 RRn+3,Onset 突发性Interval (ms)Old meanProgrammed onset in %New meanVT,VFTime (s),稳定性是用来区别单形性室速与室上速（AF）的,单形性室速通常具有快速的、稳定的心室节律,室上速（AF）通常是不规则地下传心室，导致不规则的心室,节律,规则：当前R-R与前3个R-R比较，都在24ms内，则满足稳定性标准如果VT计数器 3，且当前R-R间期是不稳定的，则VT计数器归0,当前R-R间期稳定性范围： 24 ms当前R-R间期满足稳定性,当前R-R间期稳定性范围： 24 ms当前R-R间期不满足稳定性,VT1 counter:,0,1 2,3,0,1,2,3,2,3,0,1,2,3,0,1,2,3 0,1,2,SinusVT1400 ms; 16Stability: 24 msVF300 ms; 8/12,No detection,敏感性 =特异性 =,ICD检测到的VT病人发作的VT真正的VTICD检测到的”VT”,提高特异性的同时不影响敏感性,特异性和敏感性,9,12,19,25,31,44,敏感性和特异性,Neuzner et al., PACE 1995,Sensitivity (VT)Specificity (VT),%100806040200,%,Onset,敏感性和特异性,0,6,12,18,24,30,35,Neuzner et al., PACE 1995,Sensitivity (VT)Specificity (VT),%10080604020,ms,Stability,Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Redetection 再检测,ICD发放治疗后，对心律的再检测,VF redetectionVT redetection,VF Redetection 室颤再检测,Rate/Interval: VF zone,同初始检测标准，即 X in Y标准,VT Redetection 室速再检测,Rate/Interval: VT zoneRedetection counter,加减计数器,VT事件+1；非心动过速的R-R，计数器-1,无Onset和Stability标准,Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Termination Detection 终止检测,检测心动过速是否终止,如果16个连续的R-R间期中有12个（不可程控）落在了Sinus zone，则满足终止检测标准,SinusVT1400 ms; 18VT2360 ms; 14VF300 ms; 8/12,Shock,9 out of 1610 out of 1611 out of 1612 out of 16,TerminationDetection满足,Redetection and Termination再检测和终止,Initialdetection,RedetectionVF: initial detectionVT: Re-counter (noonset & stability),TerminationDetection(12/16)Beginning of episode,Therapy 1ATPShock(confirmation=3/4),TerminationDetection(12/16)End of episode,RedetectionVF: initial detectionVT: Re-counter (noonset & stability),Therapy 2ATPShock(confirmation=3/4),Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Shock Confirmation 电击前确认,电击前对心律的再次确认,满足Detection后，电容器开始充电，同时启动电击前确认充电完成后，电击总是与第一个VT事件同步发放,如果第一个事件慢于VT，又不满足终止标准，则延迟电击如果4个R-R间期中，有3个窦性间期或心动过缓起搏（Bradypacing），则满足终止标准，停止充电，不再发放电击,VT,VT VT,VT VT VT,VT,VT VT,VT VT VT,VT VT,VT,VT,VT,VT VT,VT VT VT,VT,VT VT,VT VT,Sinus,Sinus,VT,VTVT,VT VTVT VT,VT VT VTVT VT VT,VTVT,VT VTVT VT,VT VT VTVT VT VT,VTVT VT,BISinus,VTVT,Vp,Capacitor charging,1,2,34,Detection,同步电击,VT,VT VT,VT VT VT,VT,VT VT VT,Sinus,Sinus,Sinus,Sinus,VT,VT VT,VT VT VT,VT,VT VT,Sinus,Sinus,BI,BI,VT,VT VT,VT VT VT,VT VT,Pace = Off,Sinus,VT,VT VT,VT VT,Sinus,VT,Sinus,Sinus,Sinus,Sinus,Sinus,Vp,Capacitor charging,1,2,4,5,Detection,Vp,Vp,BI,BI,BI,VT,VT VT,VT VT VT,VT,VT VT,VT VT VT,VT,BI,BI,BI,3,Vp,Vp,VF Detection,Shock confirmation: ON,Shock Confirmation 电击前确认,充电自动中止,Sensing Concept 感知原理Detection 检测,Redetection 再检测,Termination Detection 终止检测Shock Confirmation 电击前确认Therapy 治疗,内容,Therapy 治疗,ATP (Anti-Tachycardia Pacing ),抗心动过速起搏，用于终止室速,Shock,除颤（电击），用于终止室速和室颤,原理：将可应激的裂隙组织除极，折返环被打断,Anti-Tachycardia Pacing (ATP),BurstRamp,Burst + PES,ATP Burst,400,320,320,320,320,320,R,R,S1,S1,S1,S1,S1,ATP Ramp,400,320,310,300,290,280,R,R,S1,S1,S1,S1,S1,ATP Burst + PES,400,320,320,320,320,320,R,R,S1,S1,S1,S1,S1,S2,280,Shock,心律转复用低能量同步除颤,除颤用高能量非同步除颤,Time,40%,20%,Biphasic(Voltage control),Biphasic 2(Voltage/Time control),Voltage100%,40%,Shortening of second phase can reduce the DFT for critical patients*,* Merkely B., Lubinski A., Kiss O., et al. Shortening the second phaseduration of biphasic shocks: effects of class II antiarrhythmic drugson defibrillation efficacy in humans. J Cardiovascular Electrophysiol2001; 12:824-827,Shock Waveform 放电波形,Time,40%,2 ms,Voltage100%,40%,Shock Polarity 放电极性,Normal,t,V,Inversed,t,V,1st 30 J,2nd 40 J,3rd 40 J,4th 40 J,5th 40 J,Normal Normal Inversedunsuccessful unsuccessful successful从第一个最大除颤能量后开始交替,detection,1st shocknormal polarity,2nd shockinverse polarity,termination,Patient E