除顫起搏器的臨床應(yīng)用

除顫起搏器的臨床應(yīng)用山東省千佛山醫(yī)院心內(nèi)科閆素華1精品醫(yī)學(xué)pptContentsICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindications—whogetsoneornotImplantprocedure—howdowetestthedevice.2精品醫(yī)學(xué)pptHistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’s3精品醫(yī)學(xué)pptPioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin19804精品醫(yī)學(xué)ppt1985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.5精品醫(yī)學(xué)pptThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevices6精品醫(yī)學(xué)ppt“ActiveCan”TechnologyTraditional

SystemRV-Can7精品醫(yī)學(xué)pptEvolutionofICDTechnology19911995TheFirstICDsFeatured

EpicardialLeadsTransvenousLeads

andAdvancedTherapy

IncreaseEffectiveness

ofICDTherapyPectoralICDs

ReduceCostsand

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

Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed

sensitivityadjustmentPost-paced

sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel?TelemetryVPACEVPACEVSENSEVPACEVSENSERectified

EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mV12精品醫(yī)學(xué)pptThreeZoneDetectionVTFVTVF13精品醫(yī)學(xué)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精品醫(yī)學(xué)pptVFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNID15精品醫(yī)學(xué)pptFVTDetectionviaVFCounter

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)16精品醫(yī)學(xué)pptFVTDetectionviaVTCounter

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

(8INTERVALSBEFORENID)V

SV

SV

ST

ST

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F?VFCounter:17精品醫(yī)學(xué)pptIncreasedVTDetectionSpecificitySinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillationMorphologyXXXXOnsetXStability

X18精品醫(yī)學(xué)pptTherapiesATPBurstRampRamp+CardioversionDefibrillation19精品醫(yī)學(xué)pptBurst20精品醫(yī)學(xué)ppt

Ramp21精品醫(yī)學(xué)ppt

Ramp+22精品醫(yī)學(xué)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精品醫(yī)學(xué)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精品醫(yī)學(xué)ppt1998ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.

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

(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.26精品醫(yī)學(xué)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精品醫(yī)學(xué)ppt1998ClassIIIIndications(cont.)5. Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6. Terminalillnesseswithprojectedlifeexpectancy

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