起搏器培训课件：美敦力四极系统简介

1、 Click to edit Master text styles Second level Third level Fourth level Fifth level 美敦力四极系统简介 CRT 治疗过程中, 从植入到患者管理挑战无处不在 患者选择很复杂 静脉解剖的多变使得植入不可预知 左室阈值的变化会导致CRT治疗丧失或发生膈神经刺激 (PNS) 其他心衰管理问题 (依从性不好，并发症的影响，患者失随访) 均影响疗效1,3 1 Abraham WT, et al. N Engl J Med. 2002;346:1845-1853. 2 Bristow MR, et al. N Engl J

2、Med. 2004;350:2140-2150. 3 Young JB, et al. JAMA. 2003;289:2685-2694. 4 Abraham WT, et al. Circulation. 2004;110:2864-2868. 5 Abraham WT, et al. Heart Rhythm. 2005;2:S65. 6 Chung ES, et al. Circulation. 2008;117:2608-2616. 7 van Gelder BM, et al. J Cardiovasc Electrophysiol. 2008;19:939-944. 1/3的患者无

3、法从CRT治疗中完全获益.2,4-7 CRT 无反应的诸多因素 Mullens W, Grimm RA, Verga T, et al. Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program. JACC. March 3, 2009;53(9):765-7723. 左室电极位置，左室阈值以及左室阈值在保障左室夺获和膈神经刺激之间是影响 CRT疗效的很重要因素 Viva Quad CRT-D 9 (10): 1368-1

4、374. Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Advanced Quadripolar Lead 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes

5、to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P 2 Biffi M, et al. Effect of Bipolar Electrode Spacing on Phrenic Nerve Stimulation and Left Ventricular Pacing Thresholds, Circ Arrhythm Electrophysiol. 2012;5:815-820 3 Biffi M1, Zanon F, Bertaglia E, et al., Short-spaced dipole for ma

6、naging phrenic nerve stimulation in patients with CRT: the phrenic nerve mapping and stimulation EP catheter study Heart Rhythm. 2013 Jan;10(1):39-45 短双极电极间距选项可有效避免 PNS1-3 所有电极均为类固醇激素电极 与美敦力鞘中鞘兼容 为不同的患者解剖提供 更多的形状选择 Advanced Quadripolar Lead: 短双极电极间距减少PNS 的发生 Attain Performa 1.3 mm的短双极电极间距导致明显更高的膈神经阈

7、 值，从而减少膈神经刺激的发生 1 Biffi M, et al.Circ Arrhythm Electrophysiol. 2012;5:815-820. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% LV1-RV coil LV1-LV2 LV1-LV3 LV1-LV4 LV2-RV coil LV2-LV1 LV2-LV3 LV2-LV4 LV3-RV coil LV3-LV1 LV3-LV2 LV3-LV4 LV4-RV coil LV4-LV1 LV4-LV2 LV4-LV3 PNS present at 8V Advanced Quadripol

8、ar Lead: 短双极电极间距减少PNS的发生1 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P Attain Performa at 6 months (Models 4298, 4398, 4598 combined) 0 0.5 1 1.5 2 2.5 3 3.5 4 LV1-RVcoil LV1-LV2 LV1-LV3 LV1-LV4 LV2-R

9、Vcoil LV2-LV1 LV2-LV3 LV2-LV4 LV3-RVcoil LV3-LV1 LV3-LV2 LV3-LV4 LV4-RVcoil LV4-LV1 LV4-LV2 LV4-LV3 PNS threshold - PCT threshold (V) 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P Advanced Quadripolar

10、Lead: 短双极间距使PNS阈值和 PCTs之间的差距更大1 Attain Performa at 6 months (Models 4298, 4398, 4598 combined) Advanced Quadripolar Lead: 所有电极均包含激素以最小化起搏阈值(PCT) 4个激素洗脱电极最大化可程控 的起搏向量设置 激素使所有起搏向量的长期 PCTs 更稳定1 1 Lunati MG, Gasparini M, Landolina M, et al. Long-Term Effect of Steroid Elution on the Electrical Performan

11、ce of Coronary Sinus Leads for Cardiac Resynchronization Therapy. Presented at HRS 2012 (AB10-05). 注：Pacing Capture Thresholds (PCT) Advanced Quadripolar Lead: 激素电极是行业标准 1 Mond HG, et al. Pacing Clin Electrophysiol. 1988; Vol 11 右室激素洗脱电极的使用是行业标准，而且多年来已证实比非激素电极 更优1 除RV之外, 我们看到激素运用在LV也同样有益: 激素帮助维持显著降低

12、的长期LV起搏阈值1 节省30%的能量损耗，从而延长使用寿命 减低 PNS发生1 1 Lunati MG, et al. Long-Term Effect of Steroid Elution on the Electrical Performance of Coronary Sinus Leads for Cardiac Resynchronization Therapy. Presented at HRS 2012 (AB10-05). Advanced Quadripolar Lead: 激素最小化起搏阈值（PCT) Pacing Capture Thresholds (PCT) Adv

13、anced Quadripolar Lead: 4个激素电极导致低的长期 PCTs1 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation Attain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01

14、Heart Failure Issues in Clinical Outcomes. 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation Attain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01

15、Heart Failure Issues in Clinical Outcomes. 2 Tomassoni Gery, Baker , James, et. al., Postoperative Performance of the Quartet Left Ventricular Heart Lead, J Cardiovasc Electrophysiol, Vol. 24, pp. 449-456, April 2013 Advanced Quadripolar Lead: 4个激素电极导致低的长期 PCTs1 Advanced Quadripolar Lead: 脱位率低1 Medt

16、ronic1St. Jude Medical S形1.7% (6 months) 3.5%2 (3 months) 直0.3% (6 months) Shape Not Available 成角2.0% (6 months) Shape Not Available 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation A

17、ttain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01 Heart Failure Issues in Clinical Outcomes. 2 Tomassoni Gery, Baker , James, et. al., Postoperative Performance of the Quartet Left Ventricular Heart Lead, J Cardiovasc Electrophysiol, Vol. 24, pp. 449-456, Apri

18、l 2013 45984398 4298 Advanced Quadripolar Lead: 成角导线植入注意事项 (4298) 中等扭曲血管 中等直径血管 Advanced Quadripolar Lead Case Advanced Quadripolar Lead: 与美敦力鞘中鞘兼容 Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Attain Performa 提供了16种可选择起搏向量 VectorExpress 摒弃了手动向量评估的复杂操作

19、，为选择最优 起搏向量提供便利 2分钟完成所有向量测试8+分钟完成所有向量测试 1 Demmer W. VectorExpress Performance Results. Medtronic Data on File. January 2013. 手动测试VectorExpress VectorExpress: 2分钟内提供临床可行的数据1 替代耗时的手动多种 向量测试 VectorExpress 测试 结果与手动PCT测试 匹配率为95% 1 1 Johnson B, et al, Accuracy of an Automated Pacing Capture Thresholds Alg

20、orithm for Quadripolar Left Ventricular Leads. HRS 2014, Poster presentation, PO04-185 VectorExpress: 2分钟内提供16个向量临床可行的数据1 1. 起搏心房，测量AP-VS的传导时间 AP VS VectorExpress利用LVCM技术确定起搏阈值 2. AP后起搏LV，在预计心房自身下 传的VS前出现右室感知事件，则说明 左室夺获 AP Expected VS LV Pace Blankin g Capture Window LOC VS (LV-RV conduction) AP VS

21、VectorExpress利用LVCM技术确定起搏阈值 1. 起搏心房，测量AP-VS的传导时间 3. 降低测试电压直至失夺获 AP VS AP Expected VS LV Pace Blankin g Capture Window LOC VS (LV-RV conduction) VectorExpress利用LVCM技术确定起搏阈值 1. 起搏心房，测量AP-VS的传导时间 2. AP后起搏LV，在预计心房自身下 传的VS前出现右室感知事件，则说明 左室夺获 Viva Quad CRT-D and Attain Performa System VectorExpress Advance

22、d Quadripolar Lead AdaptivCRT 创新：CRT的生理性起搏模式 1. 适应性LV起搏：提前激动左室，融合右室自身传导，维持房室结功能 2. 动态BiV同步起搏：每分钟自动优化AV间期，VV间期 3. 每分钟自动测量：通过精密算法保证左右室同步收缩的有效性 CRT的生理性起搏模式AdaptivCRT 1Martin, et al. Heart Rhythm 2012; 9:1807-14. 2Medtronic Viva XT CRT-D manual. 适应性 单LV起搏 动态 BiV起搏 每分钟调整 AdaptivCRT 的临床获益1-5 临床获益安全性有效性提高反

23、 应率 减少右 室起搏 减少AF减少HF住 院率和死 亡率 减少30 天再入 院率 Adaptiv CRT 12% 44%46%21%40% 1 Martin et al., Heart Rhythm. 2012 Nov; 9(11): 1807-14. 2 Krum H, et al. Am Heart J. 2012;163:747-752.e1. 3 Singh JP, et al. Presentation at European Society of Cardiology Congress August 2012. 4 Birnie D. et al., Presented at t

24、he American Heart Association Scientific Sessions 2012. Abstract #: 11672 5Randall C. Starling. Presented at Heart Rhythm Socity Sessions 2014. Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Advanced Quadripolar Lead 唯一具有短双极电极间距的四极LV电极导线，以达到期望的起搏位点和避免膈神

25、经刺激 唯一每个电极均包含激素以延长使用寿命 为不同的患者解剖提供更多的导线形状，并与美敦力亚选择鞘管兼容 VectorExpress 2分钟内提供临床可行的信息，以管理起搏阈值，使用寿命和CRT反应率1 替代耗时的手动多种向量测试，为患者选择最优的起搏向量 AdaptivCRT 美敦力 Viva Quad XT CRT-D 系统结合了advanced quadripolar lead 的植入优 势和AdaptivCRT 已证实的临床获益 2 Viva Quad CRT-D and Attain Performa 总结 1 Demmer W. VectorExpress Performance

26、 Results. Medtronic Data on File. January 2013. 2 Birnie D, Lemke B, Aonuma K, et al. Clinical outcomes with synchronized left ventricular pacing: Analysis of the adaptive CRT trial. Heart Rhythm. September 2013; 9 (10): 1368-1374. 美敦力左室电极导线 Click to edit Master text styles Second level Third level

27、Fourth level Fifth level 33 BravaTM Quad CRT-DAttainTM Performa 4298 Quadripolar Lead 曲面设计 减少皮肤张力,降低囊袋感染风险 ATP智能放电 无痛治疗 VectorExpressTM 一键向量选择 快速为患者选择最优起搏向量 短间距设计短间距设计 避免膈神经刺激，避免膈神经刺激，使得术者可以轻松植使得术者可以轻松植 入最优的起搏位置入最优的起搏位置 全激素覆盖全激素覆盖 长期稳定阈值以延长使用寿命长期稳定阈值以延长使用寿命 与美敦力左室递送系统兼容与美敦力左室递送系统兼容 有效减少手术时间有效减少手术时间 Features and benefits Click to edit Master text styles Second level Third level Fourth level Fifth level 34 Features and benefits VivaTM XT Quad CRT-DAttainTM Performa 4298 Quadripolar Lead AdaptivCRTTM 创新CRT生理起搏模式 减少不