除颤起搏器的临床应用课件

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

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ST

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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除颤起搏器的临床应用课件29除颤起搏器的临床应用课件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-