心脏起搏器培训资料：PR-Logic 全方位详解

1、3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 全方位详解 PR Logic TM 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic全方位详解 PR Logic 算法 增强型PR Logic PR Logic 应用 PR Logic 程控 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 单腔ICD SVT标

2、准的局限性 稳定性(Stability) 和突发性(Onset) 的局限性 不能识别节律均匀、突发的SVT 若药物改变了其特点，需重新程控 EGM Width的局限性 不能识别 BBB, 窄QRS的VT or 起搏心律 若药物改变了其特点，需重新程控 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta *医生怎样解释这份ECG? *ICD怎样解释这份 ECG? 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 医生与P

3、R-Logic的比较 心室率 心房率 心室节律的规律性 房室分离 心房与心室事件关系模式 P、R波形态 心室率 心房率 心室节律的规律性 房室分离 心房与心室事件关系模式 有无远场R 波 医生分析ECG 的方法的方法 PR Logic分析腔内心电图方法 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 常见室上速类型 房颤 房扑 窦速 阵发性室上速（SVT） 其它 1:1 SVT (AVNRT) 3 Bakken Education Center, Atlanta 3 Bakken Education C

4、enter, Atlanta PR Logic 基本运算指标: 频率 (A&V) 模式 (A&V 关系) 规律性 (心室) 房室分离 远场R波感知 模式模式 频率频率 规律性规律性 AV 分离分离 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic AF Evidence Sinus Tach Other 1:1 Rate Regularity Pattern FFRW Reg Irreg VF/FVT VT/FVT Not Met Not Met Not Met AF Evidence

5、AFib / Aflutter Double Tach Rate Regularity Pattern FFRW Reg Irreg VF/FVT VT/FVT Not Met Not Met Not Met AV dissociation 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic算法详解 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式模式 频率频率 规律性规律性 AV 分离分离 频

6、率 (A&V) 模式 (A&V 关系) 规律性 (心室) 房室分离 远场R波感知 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Rate -频率 心房、心室的频率提示了当前心脏的节律，代表了一些节 律的特征： 正常窦律和窦速、房速、AVNRT，心房心室率相同 房颤/房扑时，心房频率比心室频率快 心室频率用于决定何时应用PR-Logic运算(TDI SVT limit) 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlan

7、ta Rate -频率 心动周期的中位数 分别计算心房与心室频率 滚动计算每次心跳间期 实时计算12次心跳间期 由低至高排列心跳间期 选取两中位数较大者 Actual Sequence: 350 370 390 390 350 350 380 400 390 350 360 400 Sorted Sequence: 350 350 350 350 360 370 380 390 390 390 400 400370 380 Median Interval = 380 ms 3 Bakken Education Center, Atlanta 3 Bakken Education Center,

8、 Atlanta CHECKPOINTS: GEM DR WORKSHEET PR Logic - Rate Sort the intervals in the sequence below and determine the median atrial and ventricular rates. V-V Intervals: 350 370 390 390 350 350 380 400 390 350 360 400 A-A Intervals: 280 270 290 300 270 260 280 290 290 270 250 300 250 260 270 270 270 280

9、 280 290 290 290 300 300 RR Median = 280 350 350 350 350 360 370 380 390 390 390 400 400 RR Median = 380 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern-模式 有些特殊节律是以相同心房心室除极顺序重复着，即房室 事件出现的位置是相对固定的： 正常窦律 窦速 房室结折返性心动过速 PR-Logic将这些规则的房室位置关系分成不同的类型或叫 模式，当一系列相同的模式出现，就可确定其心律类型

10、 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式模式 频率频率 规律性规律性 AV 分离分离 频率 (A&V) 模式 (A&V 关系) 规律性 (心室) 房室分离 远场R波感知 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 选取2 个相邻心室间期 (3 次心跳) 计算其中的心房事件数目 评估心房事件的位置 分为19种模式编码 Pattern-模式 3 Bakken Education Center, At

11、lanta 3 Bakken Education Center, Atlanta 交界性节律逆传性前传性 VS VSVS 心房事件分类标准 Pattern-模式 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律 “A” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律 “A” 3 Bakken Education Center, Atlanta 3 Bakken Education

12、 Center, Atlanta 模式: 窦性心律 “A” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律伴室早 “A” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律伴室早 “B” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律伴室早 “C” 3 Bakken Edu

13、cation Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律伴室早 “E” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式: 窦性心律伴室早 “A” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta A B C D E F G H I J K L M N O P Q Y Z 1 2 12 22 00 Anything else 19 种模

14、式编码 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern-模式 通过一系列的V-V模式编码分析房室间传导模式判断节律： 窦速 规律传导的AFib/AFlutter 其它 1:1 SVTs 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern-模式 房颤

15、事件 没有规律的模式存在 不使用模式识别 使用房颤计数器标准 考虑到 PVCs, PACs, 和偶尔漏感知到的心房事件 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 模式模式 频率频率 规律性规律性 AV 分离分离 频率 (A&V) 模式 (A&V 关系) 规律性 (心室) 房室分离 远场R波感知 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Regularity规律性 指心室间期的变异性。 规律性能帮助鉴别

16、出现的心律类型，例如： 有规律的心室间期：NSR，ST，VT 不规律的心室间期：AF，VF 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 使用最近的 18个V-V 间期 通过周长分类进不同“组”中 计算两个出现频率最高的组所占百分比 75% 为规律；如50% 不规律。 每一个心室事件都更新规律性 Regularity规律性 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 240 250 260 270 280

17、290 300 310 320 330 340 350 360 370 380 390 400 实时连续18个V-V间期统计(规律） (ms) 75%为规律 Regularity规律性 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 实时连续18个V-V间期统计(不规律） 240 250 260 270 280 290 300 310 320 330 340 350 360 370 380 390 400 (ms) 6时，此标准满足 (最大计数是 10) 只要计数器中 5，此标准保持满足 3 Bakke

18、n Education Center, Atlanta 3 Bakken Education Center, Atlanta AF 事件标准 记数器受V-V间期中心房事件的数目影响 1:1 传导 记数器加 1 1:1 传导 记数器减 1 无变化 当不确定或不一致时，或识别到远场R波； P R Atrial Fibrillation +1+1+0-1+1+1+1 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta AF 事件标准 当记数器达到 6，ICD即判断节律为房颤 记数器最大为10 一旦满足，会一直保持

19、AF诊断直到计数小于5 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta CHECKPOINTS: GEM DR WORKSHEET PR Logic AF Evidence Counter Label the increment counter -1, 0, +1 Label the AF Evidence Counter for each pattern code in the strip below ? . At which ventricular beat is the AF evidence c

20、ounter met? +1 AV Evidence Counter 34? ? _ 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta CHECKPOINTS: GEM DR WORKSHEET PR Logic AF Evidence Counter Label the increment counter -1, 0, +1 Label the AF Evidence Counter for each pattern code in the strip below ? . At which ventri

21、cular beat is the AF evidence counter met? +1 AV Evidence Counter 345545 67 +1 +1+1 -1 0 +1 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 远场 R波-FFRW 如果1个 V-V 间期中落入两个心房事件,即开始分析A-A的 模式是否为FFRW； FFRW的出现，会误导PR-Logic鉴别正在进行着的节律 FFRW模式必须是一致的（即始终存在或不出现） 3 Bakken Education Center, Atla

22、nta 3 Bakken Education Center, Atlanta 远场R波标准 远场R波模式定义： 每一个V-V间期，有两个心房事件 一个短长模式的A-A间期 短 PR 间期 (60 ms), 或 . 短 RP 间期( 10/12 (当当VT 计数计数 = NID) ST counter w/FFRW = 13 (is satisfied throughout EGM) 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta FFRW Note: A-A 间期像两条铁轨 3 Bakken Educa

23、tion Center, Atlanta 3 Bakken Education Center, Atlanta 临床常见问题1 何时应用PR logic？ SVT limit NID，not RNID 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta SVT Limit 确定最短的PR-Logic应用的范围（心室间期）， 可以程控为最快240ms ，最慢 600ms。 Blue Box 3 Bakken Education Center, Atlanta 3 Bakken Education Center

24、, Atlanta AT NID NID 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 何时PRligic不工作？ 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 临床常见问题临床常见问题2 2 当心律发生变化， 由SVT变为VTorVF，PR logic 怎么确认？ 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 在

25、SVTs向VT/VF转换 PR Logics “transition counter”-转换计数器 在不同 SVTs 间或 SVT 向VT (or VF)节律转换时，会继续保持前面识别 的节律不变 保持已存在的 “规则” ，持续 6 个心跳 (标记不变) 既减少延误释放必要的恰当治疗，又能保持很高的鉴别SVT 的特异性 不能程控 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Transition Counter 在工作 Transition counter 5 4 3 2 1 0 3 Bakken E

26、ducation Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic算法小结算法小结 使用四个元素鉴别SVT/VT.VF Rate (A&V) Pattern (A&V Relationship) Regularity (Ventricular) AV Dissociation PATTERN RATE REGULARITY AV DISSOCIATION 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 增强型PR Logic 3 Ba

27、kken Education Center, Atlanta 3 Bakken Education Center, Atlanta Gem III DR: 增强的 PR Logic 1:1 VT-ST 边界可程控： 增强的 FFRW标准 增强的Transition Counter 出厂时 2 个PR Logic Rules 为ON Sinus Tach A-Fib / A-Flutter 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta GemIII增强的 PR Logic VT-ST 边界 3 Bakk

28、en Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic: GEM DR 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic: Gem III DR Source: Retrospective study using GEM DR data of all SVT and VT episodes from 6 patients exhibiting long PR SVT. Data was reproc

29、essed using a 1:1 VT-ST Boundary of 66%. 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 其他增强标准 增强的FFRW Criterion 此改变仅适用于 Sinus Tach规则 达到4 of 12 间期就满足 以前是 10 of 12 增强的 Transition Counter 10 intervals 以前是 6 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Tr

30、anstion Counter AntegradeJunctionalRetrograde - PR Logic continues to withhold therapy for 6-10 beats. - After 6-10 beats, if no consistent pattern is found, therapy is delivered. - “Transitional Counter” or “Sticky Counter” 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Lo

31、gic的应用 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta VT NID Counting.9VT is in progress 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta VT NID Counting.11 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta VT NID Counting.13 3 Bakken E

32、ducation Center, Atlanta 3 Bakken Education Center, Atlanta NID Met VT NID Met.16 PR Logic Activated! 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Sinus Tach+FFRWWithhold Therapy PR Logic - 19 Pattern Codes Sinus Tach/FFRW Pattern Therapy Withheld PR Logic Activated! VT NID

33、Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Sinus Tach+FFRWWithhold Therapy PR Logic - 19 Pattern Codes Therapy Withheld Sinus Tachy + FFRW Pattern VT NID Met.16 Therapy Still Withheld 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern Chan

34、geWithhold Therapy PR Logic - 19 Pattern Codes 1 Pattern Changing Transition Counter “Sticky Counter” Pattern VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern ChangeWithhold Therapy PR Logic - 19 Pattern Codes 2 Pattern Pattern Changing Transition Counter “

35、Sticky Counter” VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern Changing Transition Counter “Sticky Counter” Pattern ChangeWithhold Therapy PR Logic - 19 Pattern Codes 3 Pattern VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, At

36、lanta Pattern Changing Transition Counter “Sticky Counter” Pattern ChangeWithhold Therapy PR Logic - 19 Pattern Codes 4 Pattern VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern Changing Transition Counter “Sticky Counter” Pattern ChangeWithhold Therapy PR L

37、ogic - 19 Pattern Codes 5 Pattern VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Pattern Changing Transition Counter “Sticky Counter” ?Withhold Therapy PR Logic - 19 Pattern Codes 6 Pattern VT NID Met.16 3 Bakken Education Center, Atlanta 3 Bakken Education Cente

38、r, Atlanta ?Deliver Therapy Pattern VT NID Met.16 PR Logic Deactivated 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic AF Evidence Sinus Tach Other 1:1 Rate Regularity Pattern FFRW Reg Irreg VF/FVT VT/FVT Not Met Not Met Not Met AF Evidence AFib / Aflutter Double Tach

39、Rate Regularity Pattern FFRW Reg Irreg VF/FVT VT/FVT Not Met Not Met Not Met AV dissociation 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 双重心动过速标准双重心动过速标准(VT Zone) VT 计数器或计数器或VT由联合计数器由联合计数器 满足满足 规律性规律性 心室节律整齐心室节律整齐 AV 分离分离 分离节律分离节律 AF 标准标准 节律节律 中中 P:R 规律规律 1:1 心房、心室的感知及起搏的事件

40、心房、心室的感知及起搏的事件 Rhythm Characteristics 五条都符合五条都符合? no yes VT+SVT FVT via VT + SVT 未满足未满足 PR Logic Is Ventricular Rate in zone where SVT criteria apply? 心室率是否落在心室率是否落在 SVT 标准应用区标准应用区? PATTERN RATERegularity AV Dissociation 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 双重心动过速标准双

41、重心动过速标准(VF Zone) AV 分离分离 分离节律分离节律 AF 标准标准 节律节律 中中 P:R 规律规律 1:1 心房、心室的感知及起搏的事件心房、心室的感知及起搏的事件 Rhythm Characteristics 所有四条所有四条 都符合？都符合？ no yes VF + SVT FVT via VF + SVT 未满足未满足 心室率是否落在心室率是否落在 SVT 标准应用区标准应用区? VF 计数器或计数器或VF 由联合计数器由联合计数器 满足满足 3 Bakken Education Center, Atlanta 3 Bakken Education Center, At

42、lanta 双重心动过速(VT/FVT+SVT)识别标准 VT计数满足 心室心动周期长度(ms) SVT Limit AF事件标准满足 AV分离性标准满足 规律的 V-V 间期 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 双重心动过速 (VF/FVT+SVT)识别标准 VF标准满足 心室平均心动周期长度(ms) SVT Limit AF事件标准满足 AV分离性标准满足 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atla

43、nta 窦速窦速 SVT 标准标准 窦速模式窦速模式 无无 far field R-wave sensing 或或 连续连续 的的 far field R-wave sensing 心房、心室的感知及起搏的事件心房、心室的感知及起搏的事件 Rhythm Characteristics 两个都是两个都是? no yes Sinus Tachycardia Not Met 心室率是否落在心室率是否落在 SVT 标准应用区标准应用区? 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta ( A | ABCEA |

44、 ADEA | ABZAA | ALMAA )* ABCD EL MZ P . AA BC EA P R A BC 窦性心动过速识别标准窦性心动过速识别标准 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta Afib/Aflutter SVT 标准标准 规律性规律性 心室节律不整齐心室节律不整齐 Median P-P Interval 室率室率 AF Evidence 1:1 P:R 关系关系, 不是由于不是由于 远场远场R波引起波引起 心房、心室的感知及起搏的事件心房、心室的感知及起搏的事件 Rhyth

45、m Characteristics 四条都是四条都是? no yes 未满足未满足 Afib/Aflutter(规则的规则的 R-R intervals) 模式模式 模式与模式与 far field R-wave Sensing无关无关 都是都是? Afib/Aflutter yes Afib/Aflutter no Not Met 心室率是否落在心室率是否落在 SVT 标准应用区标准应用区? 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 房颤/房扑标准模式 ( Q | Y | D | E | P |

46、 PO )* P Q 2 1 2 2 D E P10P20 P1+P23 Y O 1 2 . Q POQ P P R QOQQQ 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 其他其他 1:1 SVT 标准标准 Other 1:1 模式模式 心房、心室感知及起搏的事件心房、心室感知及起搏的事件 Rhythm Characteristics 都是都是? no yes Other 1:1 SVT 未满足未满足 心室率是否落在心室率是否落在 SVT 标准应用区标准应用区? 3 Bakken Educatio

47、n Center, Atlanta 3 Bakken Education Center, Atlanta 其它1:1SVT标准模式 ( (房室结折返室速房室结折返室速( (AVNRTAVNRT) )，交界性心动过速，交界性心动过速) ) ( | OHJ | OHIHJ )* 其中其中 =( F | G ) FGH IJO 1 2 . AVNRT FOHJFF P R FFFF 其它1:1SVT识别标准 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 心室率在心室率在VF区域区域? 实施实施VF治疗治疗

48、心室率在心室率在SVT区域区域? SVT标准标准 On? 双重心动过速双重心动过速? No Yes 实施实施VT治疗治疗 No 继续监测继续监测 Yes 满足满足SVT标准标准? Yes Yes 实施实施VT治疗治疗 No 或 Redetect PR Logic 工作流程 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 考考你的记忆力 Dual chamber discrimnator 6,10,5=PR Logics AF Evidence 8=Lookback Eight 6-10=Transiti

49、on Counter Beats (GEM-GEMIII) 18=Regularity(PR Logic) 4/12=FFRW Criterion for Marquis 10/12=FFRW Criterion for GEM 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta PR Logic 程控 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 常规程控: 3 Bakken Education Center,

50、Atlanta 3 Bakken Education Center, Atlanta SVT limit怎样设置？ 一般来讲，SVT limit应该程控在患者临床诊断的 心律失常频率范围中，所以常常程控进入VFzone GEM DR clinical (N=916), 医生的选择 Mean Standard Deviation FDI 314 21 ms TDI 395 40 ms SVT Limit 260 112 ms 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 何时将SVT limit程控到VFzone？ 鉴别快速传导的AF Minimum SVT Limit: 240 ms (250 bpm) 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 当仅打开VFzone 如需要PR Logic ON，SVT limit FDI. 3 Bakken Education Center, Atlanta 3 Bakken Education Center, Atlanta 当VTzone打开 PR Logic is nominally ON and effective between