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,ICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindicationswhogetsoneornotImplantprocedurehowdowetestthedevice.,HistoryofICDs,InternaldefibrillatorLate1940sto1950sUnitshownisfromtheearly1960s,PioneerofICDTechnology,MichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin1980,1985-FirstapprovedICD,Bulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptions,VentakisatrademarkofCardiacPacemakers,Inc.,ThenextmilestoneforICDs,PectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevices,“ActiveCan”Technology,TraditionalSystem,RV-Can,EvolutionofICDTechnology,1991,1995,TheFirstICDsFeaturedEpicardialLeads,TransvenousLeadsandAdvancedTherapyIncreaseEffectivenessofICDTherapy,PectoralICDsReduceCostsandIncreaseSurgicalEase,1985,“DualChamber”ICDs,Introducedin1997CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias,BasicFunctionsofICD,AutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDR,Howitworks,SensingDetectionTherapy,Auto-AdjustingSensitivity,DesignedtosensefineVF,Post-sensedsensitivityadjustment,Post-pacedsensitivityadjustment,Programmedsensitivity,Post-paceblanking,MarkerChannelTelemetry,VPACE,VPACE,VSENSE,VPACE,VSENSE,RectifiedEGM,ChangingThreshold,Post-Pace,Post-Sense,10 x,4.5x,0.3mV,ThreeZoneDetection,VTFVTVF,VTDetection,VentricularsensitivityTachydetectioninterval(TDI)VTinitialNIDVTredetectNID,VFFVTVTDetectionStatus:ONOFFONInterval(ms):320400InitialNID:12/1612Sensitivity(mV):0.3,VTCounterValue:123456789101112,200ms,VS,VS,VS,VS,VS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TD,VFDetection,VentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNID,FVTDetectionviaVFCounter,VFFVTVTDetectionStatus:ONONOFFInterval(ms):320260InitialNID:12/16,TF,TF,12,11,10,9,8,7,6,5,4,3,2,1,TF,TF,TF,TF,TF,TF,TF,TF,TF,TF,VS,VS,VS,VS,VS,LOOKBACKWINDOW(8INTERVALSBEFORENID),FVTDetectionviaVTCounter,VFFVTVTDetectionStatus:ONONONInterval(ms):320380500InitialNID:12/1612,12,11,10,9,8,7,6,5,4,3,2,1,LOOKBACKWINDOW(8INTERVALSBEFORENID),VS,VS,VS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TF,TS,TF,VFCounter:,IncreasedVTDetectionSpecificity,SinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillation,MorphologyXXXX,OnsetX,StabilityX,Therapies,ATPBurstRampRamp+CardioversionDefibrillation,Burst,Ramp,Ramp+,ICDIndications,whogetsoneornot,ClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectivenessClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases),GregoratosG.JAmCollCardiol.1998;31:1175-1209.,1998ClassIIndicationsforICDTherapy,1.CardiacarrestduetoVForVTnotduetoatransientorreversiblecause.(Levelofevidence:A)2.SpontaneoussustainedVT.(Levelofevidence:B)3.Syncopeofundeterminedoriginwithclinicallyrelevant,hemodynamicallysignificantsustainedVTorVFinducedatEPstudywhendrugtherapyisineffective,nottolerated,ornotpreferred.(Levelofevidence:B)4.NonsustainedVTwithcoronarydisease,priorMI,LVdysfunction,andinducibleVForsustainedVTatEPstudythatisnotsuppressiblebyaClassIantiarrhythmicdrug.(Levelofevidence:B),GregoratosG.JAmCollCardiol.1998;31:1175-1209.,1998ClassIIIndications,1.CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.(Levelofevidence:C)2.Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3.Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B),GregoratosG.JAmCollCardiol.1998;31:1175-1209.,1998ClassIIIndications(cont.),4.NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5.RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.(Levelofevidence:C),GregoratosG.JAmCollCardiol.1998;31:1175-1209.,1998ClassIIIIndications,1.Syncopeofundeterminedcauseinapatientwithoutinducibleventriculartachyarrhythmias.(Levelofevidence:C)2.IncessantVTorVF.(Levelofevidence:C)3.VForVTresultingfromarrhythmiasamenabletosurgicalorcatheterablation;forexample,atrialarrhythmiasassociatedwiththeWolff-Parkinson-Whitesyndrome,rightventricularoutflowtractVT,idiopathicleftventriculartachycardia,orfascicularVT(Levelofevidence:C)4.Ventriculartachyarrhythmiasduetoatransientorreversibledisorder(e.g.,AMI,electrolyteimbalance,drugs,trauma).(Levelofevidence:C),GregoratosG.JAmCollCardiol.1998;31:1175-1209.,1998ClassIIIIndications(cont.),5.Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6.Terminalillnesseswithprojectedlifeexpectancy6months.(Levelofevidence:C)7.PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspo