心臟起搏器培訓(xùn)資料：Intrinsic ICD

1、June 2004, UC200500470EN Intrinsic ICD The Therapeutic Role of Managing Ventricular Pacing June 2004, UC200500470EN 在Maximo雙腔基礎(chǔ)上 增加MVP功能 35 J delivered energy (39 J stored) 38 cc, 76 g June 2004, UC200500470EN 管理心室起搏 臨床需要 優(yōu)化左心室泵功能需要有遠(yuǎn)端特殊傳導(dǎo)系統(tǒng)(希氏束及其分支）參 與的同步化的正常電激動順序1-3 大部分 SND患者(77%), 包括哪些CHF患者，有完整的

2、AV傳導(dǎo)和 窄 QRS波(正常心室激動).6 傳統(tǒng)的RV心尖部起搏類似 LBBB, 導(dǎo)致QRS時(shí)限延長和心室不同 步, 對心室結(jié)構(gòu)和功能有副作用6,7 由于RV心尖部起搏“迫使”心室不同步，可增加房顫，心衰和死 亡的危險(xiǎn)性.1,4-6 1 Nielsen J, Kristensen L, Andersen H, et al. A Randomized Comparison of Atrial and Dual-Chamber Pacing in 177 Consecutive Patients with Sick Sinus Syndrome. J Am Coll Cardiol 2003;4

3、2:614-23. 2 Leclercq C, Gras D, Le Helloco A, et al. Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing. Am Heart J 1995;129:1133-41. 3 Rosenqvist M, Bergfeldt L, Hagat Y, et al. The effect of ventricular activation on myocardial performanc

4、e during pacing. Pacing Clin Electrophysiol. 1996;19:1279-1286. 4 Skanes A, Krahn A, Yee R, et al. Progression to Chronic Atrial Fibrillation After Pacing: The Canadian Trial of Physiologic Pacing. J Am Coll Cardiol 2001;38:167-72. 5 Wilkoff B, et al. on behalf of the DAVID Trial Investigators. Dual

5、-Chamber Pacing or Ventricular Backup Pacing in Patients With an Implantable Defibrillator: The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA 2002;288:3115-3123. 6 Sweeney M, Hellkamp A, Ellenbogen K, et al. Adverse Effect of Ventricular Pacing on Heart Failure and Atrial Fibril

6、lation Among Patients With Normal Baseline QRS Duration in a Clinical Trial of Pacemaker Therapy for Sinus Node Dysfunction. Circulation 2003;107:2932-2937. 7 Vassalo J, Cassidy D, Miller J et al. Left ventricular endocardial activation during right ventricular pacing: effect of underlying heart dis

7、ease. J Am Coll Cardiol. 1986;7:1228-1233. June 2004, UC200500470EN 下列研究發(fā)現(xiàn) DAVID Trial Danish I and Danish II Trials MOST Sub-study June 2004, UC200500470EN DAVID 臨床研究結(jié)果 DAVID Trial5: DDDR 模式 vs VVI 模式對死亡或新增/加重心力衰竭住 院復(fù)合終點(diǎn)的影響. 在DDDR組中, 當(dāng)RV-起搏 40% (p=0.09)患者在12個(gè)月內(nèi)心衰事 件的危險(xiǎn)性增加 June 2004, UC200500470EN D

8、AVID 試驗(yàn)結(jié)論 DAVID 試驗(yàn)顯示對于沒有起搏適應(yīng)證（AV傳導(dǎo)正常） 的LVEF40%的ICD治療患者，雙腔起搏過高的心室起 搏比例，增加死亡率和心衰住院率。 June 2004, UC200500470EN Danish Study總生存率 Andersen H, et al. Lancet 1997; 350: 1210-16. p = 0.045p = 0.045 AtrialAtrial pacingpacing VentricularVentricular pacingpacing Time (years) 0 02 24 46 68 81010 0 0 0-20-2 0-40

9、-4 0-60-6 0-80-8 1-01-0 Number of patients at risk during follow-up Atrial Ventricular 110 115 102 103 97 96 92 91 82 80 59 56 38 29 86 85 13 12 225 病態(tài)竇房結(jié)綜合征患者病態(tài)竇房結(jié)綜合征患者 (110 AAIR-, 115 VVIR-pacemakers) June 2004, UC200500470EN Danish Study心血管死亡率 Andersen H, et al. Lancet 1997; 350: 1210-16. Time (y

10、ears)Time (years) p = 0.0065p = 0.0065 Atrial pacingAtrial pacing Ventricular pacingVentricular pacing 0 02 24 46 68 81010 0 0 0-20-2 0-40-4 0-60-6 0-80-8 1-01-0 Cumulative survivalCumulative survival Number of patients at risk during follow-up Atrial Ventricular 110 115 102 103 97 96 92 91 82 80 59

11、 56 38 29 86 85 13 12 June 2004, UC200500470EN Andersen et al., Lancet 1997 Patients without atrial fibrillation 1 0,8 0,6 0,4 0,2 0 0246810 years Atrial pacing Ventricular pacing p = 0.012 Patients without Thromboembolic events 1 0,8 0,6 0,4 0,2 0 0246810 years Atrial pacing Ventricular pacing p =

12、0.023 June 2004, UC200500470EN Danish Study慢性心力衰竭死亡率 Andersen H, et al. Lancet 1997; 350: 1210-16. 1,001,00 ,80,80 ,6060 0 02 24 46 6 8 81010 Atrial pacingAtrial pacing Ventricular pacingVentricular pacing p = 0.18p = 0.18 Time (years)Time (years) Survival without death from CHF AAI: 110 102 97 92 8

13、6 82 59 38 13 VVI: 115 103 96 91 85 80 56 29 12 June 2004, UC200500470EN Danish試驗(yàn)結(jié)論 Danish 試驗(yàn)顯示對病竇綜合征，AAI起搏對降低死亡率， 減少房顫，血栓栓塞并發(fā)癥和心衰均有益處 June 2004, UC200500470EN Danish II 試驗(yàn)結(jié)果 J Am Coll Cardiol 2003;42:614-23 DDDR-l dual-chamber pacemaker programmed with a conventional fixed long AV delay of 250 ms;

14、DDDR-s dual-chamber pacemaker programmed with a conventional short rate-adaptive AV delay of 110 to 150 ms; June 2004, UC200500470EN Danish II 試驗(yàn)結(jié)論 DDDR起搏增加左房內(nèi)徑（LA）， 如果AV間期過短的DDDR起搏 同時(shí)會導(dǎo)致左室內(nèi)徑變化分?jǐn)?shù)（LVFS）的降低，AAIR起搏左房和 左室內(nèi)徑及LVFS 無變化。AAIR起搏房顫顯著降低。 June 2004, UC200500470EN Danish I8 and Danish II1 Trials:

15、 當(dāng)DDDR模式具有較高的右室起搏比例時(shí)，與AAIR模 式相比，AF發(fā)生率顯著增加 與心室起搏相比，心房起搏AF的發(fā)生率顯著降低 與心室起搏相比，心房起搏HF的發(fā)生率顯著降低 June 2004, UC200500470EN 0 1 2 3 4 5 6 7 020406080100 Cum%VP Risk of HFH relative to DDDR patient with Cum%VP=0 Sweeney MO, et al. Circulation 2003;23:2932-2937 1、在右室起搏累計(jì)比例在0%-40%之間，心衰住院風(fēng)險(xiǎn)增加，在 40 以上，相對風(fēng)險(xiǎn)成相對平緩上升狀態(tài)

16、。 2、假如心室起搏比例降到最低，心衰住院風(fēng)險(xiǎn)降到2 MOST Sub-study 研究結(jié)果(DDDR模式) Dashed lines represent 95% confidence boundaries June 2004, UC200500470EN 0 1 2 3 4 5 6 7 020406080100 Cum%VP Risk of HFH relative to DDDR patient with Cum%VP=0 0 1 2 3 4 5 6 7 020406080100 Cum%VP Risk of HFH relative to DDDR patient with Cum%VP

17、=0 Sweeney MO, et al. Circulation 2003;23:2932-2937 MOST Sub-study 研究結(jié)果(DDDR模式) 當(dāng)心室起搏40%時(shí)：心衰住院風(fēng)險(xiǎn)比起搏比例40%仍然增加2.6成， （如心室起搏比例45與85具有相似的相對風(fēng)險(xiǎn)度） 當(dāng)心室起搏40%時(shí)：心室起搏每增加10，心衰住院的風(fēng)險(xiǎn)增加 54 Dashed lines represent 95% confidence boundaries June 2004, UC200500470EN 0 1 2 3 4 5 6 7 020406080100 Cum%VP Risk of HFH relati

18、ve to VVIR patient with Cum%VP=0 Sweeney MO, et al. Circulation 2003;23:2932-2937 MOST Sub-study 研究結(jié)果(VVIR模式) 1、當(dāng)心室起搏累計(jì)比例超過80%時(shí)，心衰住院風(fēng)險(xiǎn)增加2.5成， 比起搏比例在0%-80%之間的患者。 2、心室起搏比例降到最低，對風(fēng)險(xiǎn)沒有影響 Dashed lines represent 95% confidence boundaries June 2004, UC200500470EN 0 1 2 3 4 020406080100 Cum%VP Risk of AF rel

19、ative to DDDR patient with Cum%VP=0 0 1 2 3 4 020406080100 Cum%VP Risk of AF relative to VVIR patient with Cum%VP=0 1、Sweeney MO, et al. Circulation 2003;23:2932- 2937 結(jié)論：累計(jì)心室起搏比例可以成為AF獨(dú)立風(fēng)險(xiǎn)預(yù)測因子1 MOST Sub-study 研究結(jié)果 Dashed lines represent 95% confidence boundaries June 2004, UC200500470EN MOST Sub-st

20、udy 研究結(jié)論 在具有正常QRS波寬度的病竇患者中，由于心室起搏 破壞房室同步而增加了心衰住院和房顫的風(fēng)險(xiǎn)。 June 2004, UC200500470EN 臨床試驗(yàn)結(jié)果 DAVID Trial Danish Pacemaker Study DANISH II Study MOST Trial (Sub-Study) 四個(gè)不同臨床試驗(yàn)，一個(gè)相同結(jié)論：四個(gè)不同臨床試驗(yàn)，一個(gè)相同結(jié)論： 對于具有AV傳導(dǎo)功能的起搏植入患者，減少不必要的RV心尖部起 搏，可以降低： 1、房顫的發(fā)生率 2、心衰的發(fā)生率和惡化 當(dāng)當(dāng)DDD伴較高比例的心室起搏時(shí)，心室不同步的右室起搏帶來的危伴較高比例的心室起搏時(shí)，心室

21、不同步的右室起搏帶來的危 害抵消了房室同步益處應(yīng)尋求更佳的生理性起搏害抵消了房室同步益處應(yīng)尋求更佳的生理性起搏心室同步起搏心室同步起搏 關(guān)鍵提示: 基于心房的起搏應(yīng)該是病竇患者首選的模式, 有效管理不必要的心室起搏并提 供必要心室備用起搏的DDDR系統(tǒng)為患者提供減少AF和HF危險(xiǎn)的最佳益處 June 2004, UC200500470EN 我們已經(jīng)有了 Search AV Search AV + 我們還需要更好的 June 2004, UC200500470EN 管理心室起搏在臨床中的作用 心室起搏僅在需要時(shí) 促進(jìn)自身AV傳導(dǎo) 保持正常心室激動順序(心室間同步) 管理 V-pacing % 促

22、進(jìn)基于心房起搏的AV同步 潛在的臨床結(jié)果1-7 減少由于RV心尖部起搏副作用導(dǎo)致HF惡化， AF和死亡的危險(xiǎn) 性 June 2004, UC200500470EN MVP (Managed Ventricular Pacing) Mode MVP是什么? 提供功能性AAI/R起搏伴有心室監(jiān)測和 僅在AV 阻滯事件時(shí)需要 DDD/R備用 起搏的基于心房起搏的雙腔起搏 Sweeney M, Shea J, Fox V, et al. PACE 2003. Vol. 26;4(Part II):973 Abstract ID #179. June 2004, UC200500470EN MVP 基本

23、運(yùn)行 AAI(R) Mode 基于心房允許自身AV 傳導(dǎo)的 起搏 PR 間期僅受基礎(chǔ)心房率或感知器頻率的限制；間期僅受基礎(chǔ)心房率或感知器頻率的限制； 只需先于下個(gè)只需先于下個(gè)AS or AP 發(fā)生發(fā)生VS 事件事件 June 2004, UC200500470EN MVP 基本運(yùn)行 心室備用 僅在暫時(shí)失去傳導(dǎo)情況下需要 心室起搏 June 2004, UC200500470EN MVP 基本運(yùn)行 DDD(R) 轉(zhuǎn)換 如果持續(xù)喪失A-V 傳導(dǎo)需要心 室支持 June 2004, UC200500470EN V Back-up Pace 在無心室感知事件的A-A 間期后安排起搏 在預(yù)計(jì)心房起搏后（

24、或被抑制的心房起搏） 80 ms發(fā)放 應(yīng)用程控的心室振幅和脈寬 MVP 基本運(yùn)行 V S A S V P A S A S V S A S V S A S A-A Escape 80ms June 2004, UC200500470EN 轉(zhuǎn)換為DDD(R)標(biāo)準(zhǔn): 最近4個(gè)A-A間期中有2個(gè)無傳導(dǎo)的VS事件 MVP 運(yùn)行詳情 A S V S A S V S A S A S V P A S A S V P A S V P 無無AV傳導(dǎo)傳導(dǎo)無無AV傳導(dǎo)傳導(dǎo) DDD(R) 在預(yù)定的在預(yù)定的AP后后 80 ms心室備心室備 用起搏用起搏 在預(yù)定的在預(yù)定的AP 后后80 ms心室心室 備用起搏備用起搏 程控

25、的 SAV delay June 2004, UC200500470EN AV 傳導(dǎo)檢查 (1 beat) 在一轉(zhuǎn)變?yōu)镈DD(R )發(fā)生后按設(shè)定每1, 2, 4, 8 min. . . 直至 16 hrs 臨時(shí)性應(yīng)用 AAI(R) 時(shí)間間期去監(jiān)測一個(gè)A-A間期中傳導(dǎo)的VS 通過傳導(dǎo)檢查如果VS發(fā)生, 模式從 from DDD(R) 轉(zhuǎn)為 AAI(R) DDD(R) 轉(zhuǎn)換為AAI(R) A S V P V S A S A S V P A S V P V S A S A S V P V S A S A S V P A S V P V S A S DDD(R) A S V P V S A S A S

26、 V P A S V P V S A S A S V P V S A S A S V P A S V P V S A S DDD(R) One Cycle AAI(R) Switch to AAI(R) June 2004, UC200500470EN 設(shè)定的傳導(dǎo)檢查不能發(fā)現(xiàn)傳導(dǎo)的VS 模式回到 DDD(R) 下一個(gè)設(shè)定的傳導(dǎo)檢查發(fā)生在2x 前個(gè)時(shí)間間期 (1, 2, 4, 8 min. . . 16 hrs) AV 傳導(dǎo)檢查失敗 V P V P V P A S A S A S A S A S A S A S A S A S A S V P DDD(R) One Cycle AAI(R) DD

27、D(R) No AV Conduction June 2004, UC200500470EN 動態(tài)ARP (心房不應(yīng)期) 避免在PACs未下傳和遠(yuǎn)場R波的情況下不適當(dāng)轉(zhuǎn)換為DDD(R) 模式，及僅在真P波后重整 A-A 逸搏間期 設(shè)置: 600 ms 如果心率低于75 bpm 75% R-R 周長 if 心率 75 bpm ARP不能長于600 ms AAI(R) Mode A S V S A S V S V S A P A P A P V S V S A R PAC MVP 增強(qiáng)的時(shí)間規(guī)則 June 2004, UC200500470EN 對 PVCs and PVC runs的反應(yīng) 心房抑

28、制 重整V-A 間期設(shè)定AP MVP 增強(qiáng)的時(shí)間規(guī)則 傳統(tǒng)AAI(R) 時(shí)間間期 PVCs時(shí)非同步起搏 MVP AAI(R) 時(shí)間間期 PVCs時(shí)無心房起搏 June 2004, UC200500470EN 檢查應(yīng)用檢查應(yīng)用 AT/AF 事件計(jì)事件計(jì) 數(shù)數(shù) 起搏和感知計(jì)數(shù)可迅速顯示 自上次隨訪后的V-pacing. 目前 MVP運(yùn)行狀態(tài)顯示在實(shí)時(shí)波形 的上面 June 2004, UC200500470EN * This Cardiac Compass collected from Marquis ICD with MVP Cardiac Compass 趨勢可提供 重要的關(guān)于MVP運(yùn)行和疾病

29、進(jìn)程 的信息*. 長至14 個(gè)月的趨勢數(shù)據(jù), 包括: VT/VF episodes/day (burden) V Rate during VT/VF AT/AF burden V Rate during AT/AF %AP and VP Average V. Rate (day 4(Part II):973 Abstract ID #179. GEM III DR MVP 可行性研究 Cumulative Percent Ventricular Pacing June 2004, UC200500470EN Marquis DR MVP 下載研究 Percent Ventricular Pac

30、ing by Patient (n = 69) With MVP ON: Median %VP = 0.01% Mean %VP = 4% Median relative reduction of VP = 99.9% Mean relative reduction of VP = 95% Mueller M. April 2004; Medtronic, Inc. Data on File June 2004, UC200500470EN Distribution of percent ventricular pacing with MVP ON (n = 69) 0% 20% 40% 60

31、% 80% 100% 0-10%10-20%20-30%30-40%40-50%50-60%60-70%70-80%80-90%90-100% %VP % of Patients 0% 20% 40% 60% 80% 100% 0-1%1-2%2-3%3-4%4-5%5-6%6-7%7-8%8-9%9-10% 78% 患者心室起搏小于1% 超過 90% 患者心室起搏小于 5% Marquis DR MVP 下載研究 June 2004, UC200500470EN 0% 20% 40% 60% 80% 100% 0-10%10-20%20-30%30-40%40-50%50-60%60-70%

32、70-80%80-90%90-100% %VP % of Patients Marquis DR MVP 下載研究 Distribution of percent ventricular pacing with MVP OFF (n = 69) 平均%VP = 78%當(dāng)MVP關(guān)閉 平均 %VP = 4% 當(dāng)MVP打開 June 2004, UC200500470EN Percent of Atrial Pacing 0 20 40 60 80 100 MVP OffMVP On Percent Atrial Pacing Marquis DR MVP 下載研究 Percent Atrial P

33、acing by Patient (n = 69) With MVP ON: Mean %AP = 49% With MVP OFF: Mean %AP = 47% 此研究觀察顯示在需要 心房起搏支持 患者中 MVP起搏模式對心房 起搏沒有影響 June 2004, UC200500470EN AV Intervals in MVP mode (n=75) 0.4%0.3% 8.4% 54.1% 29.4% 6.7% 0.5% 0.1%0.1%0.1%0.2%0.3% 6.2% 33.4% 34.0% 14.4% 4.5% 6.9% 0% 10% 20% 30% 40% 50% 60% 400

34、 AV Interval (ms) Percentage of Intervals AS-VS Intervals AP-VS Intervals Marquis DR MVP 下載研究 June 2004, UC200500470EN The cumulative time spent in each mode (all 76 patients with crossover data) Pacing Mode Distribution During MVP Operation DDIR (3.7%) DDD/R (6.7%) AAI/R (89.6%) (n = 76) Marquis DR

35、 MVP 下載研究 June 2004, UC200500470EN Pacing Mode Distribution During MVP Operation 0% 20% 40% 60% 80% 100% Patients (n=76) AAI/RDDD/RDDIR AT/AF AVB Marquis DR MVP 下載研究 June 2004, UC200500470EN MVP 臨床結(jié)果1 GEM III DR MVP可行性研究 30名植入GEM III DR無AV阻滯的患者入選，并下載MVP運(yùn)算 法則 隨機(jī)交叉研究， 3.79% 80.55% 0% 20% 40% 60% 80% 100% 120% DDDRMVP %VP Sweeney M, Shea J,