心脏起搏器培训资料：Marquis DR7274 室速鉴别诊断

1、Marquis DR7274 室速鉴别诊断 患者信息 男； 心梗后三月，发生室速； 植入美敦力Marquis DR 7274 双腔ICD 术后10月，发生ICD治疗事件； 入院观察； 调出当时的记录心电图； 事件描述： 三次ATP治疗 持续时间 心室频率 162bpm 心房频率 162bpm 鉴别诊断方法 房扑房颤鉴别 窦速鉴别 室上速鉴别上限频率：250bpm 事件发生时心电图： 模拟体表图模拟体表图 心室腔内图心室腔内图 第一次ATP治疗：治疗成功 VT体表图VP（心室起搏）体表图Vs体表图:窦律 第二次ATP治疗：治疗成功 VP VS V T 第三次ATP治疗：治疗成功 为什么心房率，心

2、室率一致？ 心室和心房间期140ms左右，应该是心室逆传的心房波； 多个独立临床研究进行ICD功能比较 电击原因和解决方案：SVT的鉴别 MADIT II. J Am Coll Cardiol. April 2008;51(14):1357-1365. Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial. Heart Rhythm Society Conference. 2004. Head-To-Head Comparison of Arrhythmia Discriminatio

3、n Performance of Subcutaneous and Transvenous ICD Arrhythmia Detection Algorithms: The START Study MICHAEL R. GOLD, MD, PhD; DOMINIC A. THEUNS, PhD; BRADLEY P. KNIGHT, MD; J. LACY STURDIVANT, MD; RICK SANGHERA, BSEE; KENNETH A. ELLENBOGEN, MD; MARK A. WOOD, MD; and MARTIN C. BURKE, DO Gold MR, Theun

4、s DA, Knight BP, et al. Medtronic analysis of Head-to-Head Comparison of Arrhythmia Discrimination Performance of Subcutaneous and Transvenous ICD Arrhythmia Detection Algorithms; The START Study. J Cardiovasc Electrophysiol. Published online October 28, 2011 START Study Design and Methods * Perform

5、ance from simulated testing may not reflect actual clinical performance. Patients Undergoing TV-ICD Implant; n = 64 Induce Arrhythmias Atrial n = 50 Ventricular n = 46 Compare Classification S-ICD vs. 3 TV-ICD Create Electronic Arrhythmia Library 前瞻，多中心 两个阶段 建立记录诱发的房性和室性心动过速的 测试库 直接比较受试ICD系统对测试库中心律

6、失常分类* 两个研究者的团队对事件进行分 类 22 TV-ICD = Transvenous ICD; S-ICD = Subcutaneous ICD START Study Transvenous Results Single-Chamber ICDDual-Chamber ICD BSCSJMMDTBSCSJMMDT Episodes (n)505050494949 Appropriate352146391644 Inappropriate 1529410335 Specificity70.0%42.0%92.0%79.6%32.7%89.8% Prospective Compariso

7、n of Discrimination Algorithms to Prevent Inappropriate ICD Therapy: Primary Results of the Rhythm ID Going Head to Head Trial (RIGHT) Michael R. Gold, Saleem Ahmad, Kevin Browne, Kellie Chase Berg, Lisa Thackeray, Ronald D. Berger Funding Sources: This trial is sponsored in full by Boston Scientifi

8、c Gold MR, Ahmad S, Browne K, Berg KC, Thackeray L, Berger RD. Prospective comparison of discrimination algorithms to prevent inappropriate ICD therapy: Primary results of the Rhythm ID Going Head to Head Trial. Heart Rhythm. Published online October 4, 2011 RIGHT研究的临床背景 比较Boston Scientific的有Rhythm

9、ID功能的Vitality 2 和美敦力有PR- Logic/Wavelet功能的ICD 由于临床研究方案的限定，在美敦力ICD的设置中并没有设置PainFree以及在VF区中设置SVT 的鉴别诊断，NID也是出厂设置 选用的美敦力ICD包括：Maximo, Marquis, Intrinsic, Virtuoso or Entrust ICD RIGHT研究的临床结果 Vitality2 与美敦力的ICD相比， 不恰当治疗风险增加34%，特别体现在单腔ICD 无论是单腔还是双腔，不恰当的放电增加63% 美敦力ICD通过 PR logic 以及Wavelet功 能进行SVT（室上速）的鉴别诊断

10、； 通过SVT Limit的设置（譬如240ms），将 SVT鉴别区间扩大到VF区，避免快的SVT直 接被电击治疗； 电击原因和解决方案：ATP 终止FVT MADIT II. J Am Coll Cardiol. April 2008;51(14):1357-1365. Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial. Heart Rhythm Society Conference. 2004. VF区中没有电击延迟的ATP：充电期间给 予ATP ATP During Char

11、ging ATP During Charging vs 标准 ATP:缩短治疗时间 * Medtronic Maximo II system reference guide. + Middle-of-Life charge time simulation. June 2007. Medtronic data on file. * BostonScientific: A Closer Look. ICD and CRT-D Electrive Replacement Indicators. February 1, 2007. + Boston Scientific: Vitality DR HE

12、 ICD and Contak Renewal 3 HE CRT-D System Guide. 电电极极导线导线 断裂断裂2 48% LIA T波波过过感知感知2 48% 可程控的可程控的 RV 感知感知 EMI2 4% 2 Gunderson BD, Gillberg JM, Swerdlow CD. Importance of Oversensing in Inappropriate Detection of Ventricular Fibrillation by Chronically-Implanted ICDs. Heart Rhythm. 2004;1:S244. Abstrac

13、t. 1 Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial. Heart Rhythm. 2004. 1 3 Abstract: Patel AS, et al. Modification to Lead Integrity Alert Improves Performance. HRS Conference 2009. / 减少T波过感知引起的电击 T波波过过感知感知2 48% 可程控的可程控的 RV 感知感知 RV 感知的程控 RVtip to Rvring 真双极 RVtip

14、 to Rvcoil 假双极 非创伤的选择帮助解决过感知或感知不良 电电极极导线导线 断裂断裂2 48% LIA T波波过过感知感知2 48% 可程控的可程控的 RV 感知感知 EMI2 4% 2 Gunderson BD, Gillberg JM, Swerdlow CD. Importance of Oversensing in Inappropriate Detection of Ventricular Fibrillation by Chronically-Implanted ICDs. Heart Rhythm. 2004;1:S244. Abstract. 1 Poster: Po

15、ole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial. Heart Rhythm. 2004. 在 电极导线断裂的患 者中，只有LIA能至少提 前3天准确自动预警3 1 3 Abstract: Patel AS, et al. Modification to Lead Integrity Alert Improves Performance. HRS Conference 2009. / 减少电极导线断裂导致的电击 *LIA for Vision 3D devices Abstract: Patel AS

16、, et al. Modification to Lead Integrity Alert Improves Performance. HRS Conference. 2009. 2/3原原则则触触发发* Action Taken Audible alerts Automatic parameters changes DEVICE Automatic changes Extends VF NID to 30/40 阻抗异常 感知完整性计数 非常快的非持续性 VT 已证实的美敦力减少电击策略 减少电击的潜在益处减少电击的潜在益处: 减少因电击导致的门诊随访1 更多的患者接受ICD治疗2 减少3/4的电击改善患者的生活质量 延长ICD寿命 1 Ahmad M, Bloomstein L, Roelke M, B