變時(shí)性功能不全的起搏治療課件

1、變時(shí)性功能不全的起搏治療 波士頓科學(xué)，于鵬*Chronotropic competence is defined by the Model of the Cardiac Chronotropic Response to Exercise, Wilkoff et al. A mathematical model of the cardiac chronotropic response to exercise. Journal of Electrophysiology 1989:3: 176-180. Refer to the Physicians System Guide for more in

2、formation on adaptive-rate therapy. Additional clinical performance was assessed using INSIGNIA Ultra clinical data with the AutoLifestyle feature programmed On. Data on file*. Boston Scientific Corporation. ALTRUA 60 Pacemaker System Guide. 2008. pg 1-28直方圖Note: Individual symptoms, situations, cir

3、cumstances and results may vary. Patients should consult a physician or qualified health provider regarding their medical condition and appropriate medical treatment. The information provided is not intended to be used for medical diagnosis or treatment or as a substitute for professional medical ad

4、vice. This information is to be used in conjunction with other resource material, which may include the applicable patient handbook, device physicians manual, and any implant accessories instructions for use. 你對(duì)這個(gè)直方圖作何分析? 有什么建議?什么是變時(shí)性功能不全？有什么危害？變時(shí)性功能不全(CI)是_ 適應(yīng)證1變時(shí)性功能不全在患者植入起搏器后的發(fā)生率約為_% 2,3變時(shí)性功能不全是不

5、斷進(jìn)展、惡化的4:患者植入起搏器后2年內(nèi): 53%患者植入起搏器4年后: 70%1 /qualityandscience/clinical/guidelines/dbt/DBT_Pocket_Guide.pdf for full ACC/AHA/HRS 2008 guidelines2 Coman et al, “A Blended Sensor Restores Chronotropic Response More Favorably than an Accelerometer Alone in Pacemaker Patients”, PACE, p. 1433-1442, Nov 200

6、8:313 Lukl J, Doupal V, Sovava E, et al. Incidence and significance of chronotropic incompetence in patients indicated for primary pacemaker implantation or pacemaker replacement. PACE. 1999;22:1284-1291.4 Gwinn N, Leman R, et al. Chronotropic incompetence: A common and progressive finding in pacema

7、ker patients. Am Heart J. 1992;123:1216-1219.34% to 42I 類變時(shí)性功能不全（CI）的四種表現(xiàn)形式Lau, CP., Rate Adaptive Cardiac Pacing, 1993實(shí)線為正常竇房結(jié)功能。虛線為變時(shí)性功能不全患者。 A： CI患者在極量運(yùn)動(dòng)過程中，最大心率明顯低于相應(yīng)年齡的預(yù)測(cè)值，且運(yùn)動(dòng)的初始及恢復(fù)階段心率反應(yīng)顯著降低；B：運(yùn)動(dòng)中最大心率與預(yù)測(cè)值接近，但運(yùn)動(dòng)的初始階段心率的反應(yīng)明顯下降或延遲；C：運(yùn)動(dòng)的初始反應(yīng)及最大心率值接近正常，但是在運(yùn)動(dòng)結(jié)束后，心率迅速下降，并可出現(xiàn)長(zhǎng)間歇；D：運(yùn)動(dòng)中心率變化波動(dòng)很大，無規(guī)律，呈忽快忽

8、慢的趨勢(shì)，但最快心率明顯低于正常值。CI具有動(dòng)態(tài)演變的特點(diǎn)，同一患者在不同的時(shí)間可表現(xiàn)以上多種方式。頻率適應(yīng)性起搏日常活動(dòng) 頻率適應(yīng)性起搏固定頻率起搏正常心率150100500睡眠醒來坐起走路跑步休息心率 bpm頻率應(yīng)答與新陳代謝需求的關(guān)系研究證明需整合一種反應(yīng)快速的感應(yīng)器與一種相對(duì)反應(yīng)較慢的感應(yīng)器共同運(yùn)作來貼近正常人代謝需要的心率反應(yīng)，包括：靜息至中度運(yùn)動(dòng)量時(shí)（日常活動(dòng)時(shí)），需快速起搏，以達(dá)到快速增加心率，從而減少缺氧；在高代謝水平時(shí)（劇烈運(yùn)動(dòng)時(shí)），應(yīng)均衡提供與代謝增加相貼近的心率變化，是相對(duì)慢的頻率反應(yīng)?！癙hysiologic demand during submaximal and m

9、aximal exercise mayRequire different heart rate responses”PACE, Oct.1995, Dr.Neal Kay頻率適應(yīng)性起搏加速度計(jì)目前的加速度計(jì)具有壓電特性的物質(zhì)固定在跳板樣的隨運(yùn)動(dòng)彎曲的混合電路板上加速度計(jì)測(cè)量身體運(yùn)動(dòng)的幅度與頻率轉(zhuǎn)化為電信號(hào)傳至傳感器電路傳感器 信號(hào)加速度計(jì)信號(hào)處理 加速度計(jì)根據(jù)身體運(yùn)動(dòng)轉(zhuǎn)換的電信號(hào)計(jì)算合適的起搏頻率Activity threshold坐走跑平均Sensor signals加速度計(jì)加速度計(jì)方向加速度計(jì)懸于X軸方向,主要記錄前后方向的運(yùn)動(dòng) （上下運(yùn)動(dòng)較前后運(yùn)動(dòng)不敏感）加速度計(jì)感知不同類型的活動(dòng)起搏器

10、的朝向與此反應(yīng)無關(guān)Vertical = Z axisLateral = Y axisAnterior/posterior = X axisBody Motion Signal StrengthWalkingBicyclingStrongWeak z x y y x z MV混合傳感器 (MV BLENDED) 歐姆定律 R=V/I無關(guān)電極分鐘通氣量 測(cè)量經(jīng)胸阻抗與潮氣量及呼吸頻率相關(guān) 獨(dú)特的4極設(shè)計(jì) 快速，深大呼吸使經(jīng)胸阻抗增加，從而使傳感器頻率_增加MV混合傳感器測(cè)量胸腔阻抗獨(dú)特的四極設(shè)計(jì)使用普通標(biāo)準(zhǔn)雙極導(dǎo)線與潮氣量和呼吸頻率相關(guān)加速度計(jì)傳感器 (XL)潮氣量呼吸間期分鐘通氣量（MV） = 潮氣量 x 呼吸頻率如 XL SiR MV SiR，傳感器進(jìn)行混合 如 MV SiR XL SiR，100% MV加速度計(jì)對(duì)活動(dòng)的反應(yīng)迅速，MV傳感器在整個(gè)運(yùn)動(dòng)及恢復(fù)期間可恢