除颤起搏器的临床应用

除颤起搏器的临床应用山东省千佛山医院心内科闫素华1精品医学pptContentsICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindications—whogetsoneornotImplantprocedure—howdowetestthedevice.2精品医学pptHistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’s3精品医学pptPioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin19804精品医学ppt1985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.5精品医学pptThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevices6精品医学ppt“ActiveCan”TechnologyTraditional

SystemRV-Can7精品医学pptEvolutionofICDTechnology19911995TheFirstICDsFeatured

EpicardialLeadsTransvenousLeads

andAdvancedTherapy

IncreaseEffectiveness

ofICDTherapyPectoralICDs

ReduceCostsand

IncreaseSurgicalEase19858精品医学ppt“DualChamber”ICDsIntroducedin1997CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias9精品医学pptBasicFunctionsofICDAutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDR10精品医学pptHowitworksSensingDetectionTherapy11精品医学ppt

Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed

sensitivityadjustmentPost-paced

sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel™TelemetryVPACEVPACEVSENSEVPACEVSENSERectified

EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mV12精品医学pptThreeZoneDetectionVTFVTVF13精品医学pptVTDetectionVentricularsensitivityTachydetectioninterval(TDI)VTinitialNIDVTredetectNID

VF FVT VTDetectionStatus: ON OFF ONInterval(ms): 320 400InitialNID: 12/16 12Sensitivity(mV): 0.3VTCounterValue: 1 2 3 4 5 6 7 8 9 10 11 12200msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTD14精品医学pptVFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNID15精品医学pptFVTDetectionviaVFCounter

VF FVT VTDetectionStatus: ON ON OFFInterval(ms): 320 260InitialNID: 12/16T

FT

F•121110987654321T

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SV

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SLOOKBACKWINDOW

(8INTERVALSBEFORENID)16精品医学pptFVTDetectionviaVTCounter

VF FVT VTDetectionStatus: ON ON ONInterval(ms): 320 380 500InitialNID: 12/16 12121110987654321LOOKBACKWINDOW

(8INTERVALSBEFORENID)V

SV

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F•VFCounter:17精品医学pptIncreasedVTDetectionSpecificitySinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillationMorphologyXXXXOnsetXStability

X18精品医学pptTherapiesATPBurstRampRamp+CardioversionDefibrillation19精品医学pptBurst20精品医学ppt

Ramp21精品医学ppt

Ramp+22精品医学pptICDIndications,whogetsoneornotClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectiveness ClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases)GregoratosG.JAmCollCardiol.1998;31:1175-1209.23精品医学ppt1998ClassIIndicationsforICDTherapy1. CardiacarrestduetoVForVTnotduetoatransientorreversiblecause.(Levelofevidence:A)2. SpontaneoussustainedVT.(Levelofevidence:B)3. Syncopeofundeterminedoriginwithclinicallyrelevant,hemodynamicallysignificantsustainedVTorVFinduced

atEPstudywhendrugtherapyisineffective,nottolerated,ornotpreferred.(Levelofevidence:B)4. NonsustainedVTwithcoronarydisease,priorMI,LVdysfunction,andinducibleVForsustainedVTatEPstudythatisnotsuppressiblebyaClassIantiarrhythmicdrug.(Levelofevidence:B)GregoratosG.JAmCollCardiol.1998;31:1175-1209.24精品医学ppt1998ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.

(Levelofevidence:C)2. Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3. Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B)GregoratosG.JAmCollCardiol.1998;31:1175-1209.25精品医学ppt1998ClassIIIndications(cont.)4. NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5. RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.

(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.26精品医学ppt1998ClassIIIIndications1. Syncopeofundeterminedcauseinapatientwithoutinducibleventriculartachyarrhythmias.(Levelofevidence:C)2. IncessantVTorVF.(Levelofevidence:C)3. VForVTresultingfromarrhythmiasamenabletosurgicalorcatheterablation;forexample,atrialarrhythmiasassociatedwiththeWolff-Parkinson-Whitesyndrome,rightventricularoutflowtractVT,idiopathicleft

ventriculartachycardia,orfascicularVT

(Levelofevidence:C)4. Ventriculartachyarrhythmiasduetoatransientorreversibledisorder(e.g.,AMI,electrolyteimbalance,

drugs,trauma).(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.27精品医学ppt1998ClassIIIIndications(cont.)5. Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6. Terminalillnesseswithprojectedlifeexpectancy

£6months.(Levelofevidence:C)7. PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneou