除颤起搏器的临床应用

1、除颤起搏器的临床应用1ContentsICD HistoryBasic functions of defibSensing, detection and therapiesICD indicationswho gets one or notImplant procedurehow do we test the device.2History of ICDsInternal defibrillatorLate 1940s to 1950sUnit shown is from the early 1960s3Pioneer of ICD TechnologyMichel Mirowski, MDD

2、edicated his life to developing the ICD after his research partner died in his arms from a ventricular arrhythmiaCreated the first implantable ICD, which started clinical trials in 198041985 - First approved ICDBulky, heavyShort-lived (18m)Abdominal implantThoracotomy requiredNon-programmableLimited

3、 therapy optionsVentak is a trademark of Cardiac Pacemakers, Inc.5The next milestone for ICDsPectoral implants approved by the FDA in 1995More comfortable for patientsFaster implantsSmaller but just as powerful as older devices6“Active Can” TechnologyTraditionalSystemRV-Can7Evolution of ICD Technolo

4、gy19911995The First ICDs FeaturedEpicardial LeadsTransvenous Leadsand Advanced TherapyIncrease Effectivenessof ICD TherapyPectoral ICDsReduce Costs andIncrease Surgical Ease19858“Dual Chamber” ICDsIntroduced in 1997Combine dual chamber pacing with ventricular arrhythmia detection and therapyAbility

5、to sense atrial activity during arrhythmiasSVT Discrimination: The ability to withhold therapy for non-lethal arrhythmias9Basic Functions of ICDAutomatically detect and treat Ventricular Tachycardia (VT)Antitachycardia pacing (ATP)CardioversionAutomatically detect and treat Ventricular Fibrillation

6、(VF)DefibrillationBrady pacingVVI, VVIR, DDDR10How it worksSensingDetectionTherapy11Auto-Adjusting SensitivityDesigned to sense fine VFPost-sensedsensitivity adjustmentPost-pacedsensitivity adjustmentProgrammed sensitivityPost-pace blankingMarker Channel TelemetryVPACEVPACEVSENSEVPACEVSENSERectified

7、EGMChanging ThresholdPost-PacePost-Sense10 x4.5x0.3 mV12Three Zone DetectionVTFVTVF13VT DetectionVentricular sensitivityTachy detection interval (TDI)VT initial NIDVT redetect NIDVFFVTVTDetection Status:ONOFFONInterval (ms):320400Initial NID:12/1612Sensitivity (mV):0.3VT Counter Value:12345678910111

8、2200 msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTD14VF DetectionVentricular sensitivityFibrillation detection interval (FDI)VF initial NIDVF redetection NID15FVT Detection via VF Counter VFFVTVTDetection Status:ONONOFFInterval (ms):320260Initial NID:12/16 TFTF121110987654321TFTFTFTFTFTFTFTFTFTFVSVSVSVSVSLOOK

9、BACK WINDOW(8 INTERVALS BEFORE NID)16FVT Detection via VT Counter VFFVTVTDetection Status:ONONONInterval (ms):320380500Initial NID:12/16 12121110987654321LOOKBACK WINDOW(8 INTERVALS BEFORE NID)VSVSVSTSTSTSTSTSTSTSTSTSTFTSTFVF Counter:17Increased VT Detection SpecificitySinus TachycardiaAtrial Tachyc

10、ardiaAtrial FlutterAtrial FibrillationMorphologyXXXXOnset XStability X18TherapiesATPBurstRampRamp+CardioversionDefibrillation19Burst20 Ramp21 Ramp+22ICD Indications, who gets one or notClass I: Evidence/general agreement regarding benefit, usefulness, and effectivenessClass II: Conflicting evidence/

11、divergence of opinion regarding usefulness/effectivenessIIa: Weight of evidence/opinion in favor of usefulness/effectivenessIIb: Usefulness/effectiveness less well established by evidence/opinion.Class III: Evidence/general agreement regarding lack of usefulness/effectiveness (harmful in some cases)

12、Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209.231998 Class I Indications for ICD Therapy1.Cardiac arrest due to VF or VT not due to a transient or reversible cause. (Level of evidence: A)2.Spontaneous sustained VT. (Level of evidence: B)3.Syncope of undetermined origin with clinically relevant,

13、 hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective, not tolerated, or not preferred. (Level of evidence: B)4.Nonsustained VT with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at EP study that is not suppressible by a C

14、lass I antiarrhythmic drug. (Level of evidence: B)Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209.241998 Class II Indications1.Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditions. (Level of evidence: C)2.Severe symptoms attributable to sustained ventri

15、cular tachyarrhythmias while awaiting cardiac transplantation. (Level of evidence: C)3.Familial or inherited conditions with a high risk for life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy. (Level of evidence: B)Gregoratos G. J Am Coll Cardiol. 1

16、998;31:1175-1209.251998 Class II Indications (cont.)4.Nonsustained VT with coronary artery disease, prior MI, and LV dysfunction, and inducible sustained VT or VF at EP study. (Level of evidence: B)5.Recurrent syncope of undetermined etiology in the presence of ventricular dysfunction and inducible

17、ventricular arrhythmias at EP study, when other causes of syncope have been excluded. (Level of evidence: C)Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209.261998 Class III Indications1.Syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias. (Level of evidence:

18、C)2.Incessant VT or VF. (Level of evidence: C)3.VF or VT resulting from arrhythmias amenable to surgical or catheter ablation; for example, atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, right ventricular outflow tract VT, idiopathic left ventricular tachycardia, or fascicula

19、r VT (Level of evidence: C)4.Ventricular tachyarrhythmias due to a transient or reversible disorder (e.g., AMI, electrolyte imbalance, drugs, trauma). (Level of evidence: C)Gregoratos G. J Am Coll Cardiol. 1998;31:1175-1209.271998 Class III Indications (cont.)5.Significant psychiatric illnesses that

20、 may be aggravated by device implantation or may preclude systematic follow-up. (Level of evidence: C)6.Terminal illnesses with projected life expectancy 6 months. (Level of evidence: C)7.Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the absence of spontaneous or inducible sustained