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ContentsICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindications—whogetsoneornotImplantprocedure—howdowetestthedevice.ContentsICDHistory1HistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’sHistoryofICDsInternaldefibr2PioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin1980PioneerofICDTechnologyMiche31985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.1985-FirstapprovedICDBulky4ThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin2019MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevicesThenextmilestoneforICDsPec5“ActiveCan”TechnologyTraditional
SystemRV-Can“ActiveCan”TechnologyTraditi6EvolutionofICDTechnology19912019TheFirstICDsFeatured
EpicardialLeadsTransvenousLeads
andAdvancedTherapy
IncreaseEffectiveness
ofICDTherapyPectoralICDs
ReduceCostsand
IncreaseSurgicalEase1985EvolutionofICDTechnology1997“DualChamber”ICDsIntroducedin2019CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias“DualChamber”ICDsIntroduced8BasicFunctionsofICDAutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDRBasicFunctionsofICDAutomati9HowitworksSensingDetectionTherapyHowitworksSensing10
Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed
sensitivityadjustmentPost-paced
sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel?TelemetryVPACEVPACEVSENSEVPACEVSENSERectified
EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mV
Auto-AdjustingSensitivityDe11ThreeZoneDetectionVTFVTVFThreeZoneDetectionVT12VTDetectionVentricularsensitivityTachydetectioninterval(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 12200msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTDVTDetectionVentricularsensit13VFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNIDVFDetectionVentricularsensit14FVTDetectionviaVFCounter
VF FVT VTDetectionStatus: ON ON OFFInterval(ms): 320 260InitialNID: 12/16T
FT
F?121110987654321T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?V
SV
SV
SV
SV
SLOOKBACKWINDOW
(8INTERVALSBEFORENID)FVTDetectionviaVFCounter 15FVTDetectionviaVTCounter
VF FVT VTDetectionStatus: ON ON ONInterval(ms): 320 380 500InitialNID: 12/16 12121110987654321LOOKBACKWINDOW
(8INTERVALSBEFORENID)V
SV
SV
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
F?T
ST
F?VFCounter:FVTDetectionviaVTCounter 16IncreasedVTDetectionSpecificitySinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillationMorphologyXXXXOnsetXStability
XIncreasedVTDetectionSpecifi17TherapiesATPBurstRampRamp+CardioversionDefibrillationTherapiesATP18BurstBurst19
RampRamp20
Ramp+Ramp+21ICDIndications,whogetsoneornotClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectiveness ClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases)GregoratosG.JAmCollCardiol.2019;31:1175-1209.ICDIndications,whogetsone222019ClassIIndicationsforICDTherapy1. CardiacarrestduetoVForVTnotduetoatransientorreversiblecause.(Levelofevidence:A)2. SpontaneoussustainedVT.(Levelofevidence:B)3. Syncopeofundeterminedoriginwithclinicallyrelevant,hemodynamicallysignificantsustainedVTorVFinduced
atEPstudywhendrugtherapyisineffective,nottolerated,ornotpreferred.(Levelofevidence:B)4. NonsustainedVTwithcoronarydisease,priorMI,LVdysfunction,andinducibleVForsustainedVTatEPstudythatisnotsuppressiblebyaClassIantiarrhythmicdrug.(Levelofevidence:B)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIndicationsforI232019ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.
(Levelofevidence:C)2. Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3. Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIIndications1. Ca242019ClassIIIndications(cont.)4. NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5. RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.
(Levelofevidence:C)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIIndications(con252019ClassIIIIndications1. 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.2019;31:1175-1209.2019ClassIIIIndications1. S262019ClassIIIIndications(cont.)5. Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6. Terminalillnesseswithprojectedlifeexpectancy
￡6months.(Levelofevidence:C)7. PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneousorinduciblesustainedornonsustainedVTwhoareundergoingcoronarybypasssurgery.(Levelofevidence:B)8. NYHAClassIVdrug-refractorycongestiveheartfailureinpatientswhoarenotcandidatesforcardiactransplantation.(Levelofevidence:C)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIIIndications(co27ImplantProcedureInsertionofdefibleadsTestpacingparametersthroughanalyzerofP/Rwave,leadimpedances,andpacingthresholdConnectdefibleadswithdefibboxTestpacingimpedance,thresholdthroughtheboxInduceVF,implantsuccesscriterion:twoconsecutivetimesor3outof4successfuldefibrillation,10Jsafetymargin.Turnofdetection,closethewoundFinalprogrammingImplantProcedureInsertionof28除顫起搏器的臨床應(yīng)用課件29除顫起搏器的臨床應(yīng)用課件30ContentsICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindications—whogetsoneornotImplantprocedure—howdowetestthedevice.ContentsICDHistory31HistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’sHistoryofICDsInternaldefibr32PioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin1980PioneerofICDTechnologyMiche331985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.1985-FirstapprovedICDBulky34ThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin2019MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevicesThenextmilestoneforICDsPec35“ActiveCan”TechnologyTraditional
SystemRV-Can“ActiveCan”TechnologyTraditi36EvolutionofICDTechnology19912019TheFirstICDsFeatured
EpicardialLeadsTransvenousLeads
andAdvancedTherapy
IncreaseEffectiveness
ofICDTherapyPectoralICDs
ReduceCostsand
IncreaseSurgicalEase1985EvolutionofICDTechnology19937“DualChamber”ICDsIntroducedin2019CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias“DualChamber”ICDsIntroduced38BasicFunctionsofICDAutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDRBasicFunctionsofICDAutomati39HowitworksSensingDetectionTherapyHowitworksSensing40
Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed
sensitivityadjustmentPost-paced
sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel?TelemetryVPACEVPACEVSENSEVPACEVSENSERectified
EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mV
Auto-AdjustingSensitivityDe41ThreeZoneDetectionVTFVTVFThreeZoneDetectionVT42VTDetectionVentricularsensitivityTachydetectioninterval(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 12200msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTDVTDetectionVentricularsensit43VFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNIDVFDetectionVentricularsensit44FVTDetectionviaVFCounter
VF FVT VTDetectionStatus: ON ON OFFInterval(ms): 320 260InitialNID: 12/16T
FT
F?121110987654321T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?T
F?V
SV
SV
SV
SV
SLOOKBACKWINDOW
(8INTERVALSBEFORENID)FVTDetectionviaVFCounter 45FVTDetectionviaVTCounter
VF FVT VTDetectionStatus: ON ON ONInterval(ms): 320 380 500InitialNID: 12/16 12121110987654321LOOKBACKWINDOW
(8INTERVALSBEFORENID)V
SV
SV
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
F?T
ST
F?VFCounter:FVTDetectionviaVTCounter 46IncreasedVTDetectionSpecificitySinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillationMorphologyXXXXOnsetXStability
XIncreasedVTDetectionSpecifi47TherapiesATPBurstRampRamp+CardioversionDefibrillationTherapiesATP48BurstBurst49
RampRamp50
Ramp+Ramp+51ICDIndications,whogetsoneornotClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectiveness ClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases)GregoratosG.JAmCollCardiol.2019;31:1175-1209.ICDIndications,whogetsone522019ClassIIndicationsforICDTherapy1. CardiacarrestduetoVForVTnotduetoatransientorreversiblecause.(Levelofevidence:A)2. SpontaneoussustainedVT.(Levelofevidence:B)3. Syncopeofundeterminedoriginwithclinicallyrelevant,hemodynamicallysignificantsustainedVTorVFinduced
atEPstudywhendrugtherapyisineffective,nottolerated,ornotpreferred.(Levelofevidence:B)4. NonsustainedVTwithcoronarydisease,priorMI,LVdysfunction,andinducibleVForsustainedVTatEPstudythatisnotsuppressiblebyaClassIantiarrhythmicdrug.(Levelofevidence:B)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIndicationsforI532019ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.
(Levelofevidence:C)2. Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3. Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIIndications1. Ca542019ClassIIIndications(cont.)4. NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5. RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.
(Levelofevidence:C)GregoratosG.JAmCollCardiol.2019;31:1175-1209.2019ClassIIIndications(con552019ClassIIIIndications1. Syncopeofundeterminedcauseinapatientwithoutinducibleventriculartachyarrhythmias.(Levelofevidence:C)2. IncessantVTorVF.(Levelofevidence:C)3. VForVTresultingfromarrhythmiasamenabletosurgicalorcatheterablation;forexample,atrialarrhythmiasassociatedwiththeWolff-
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