心脏起搏器培训资料：除颤电极导线

除颤电极导线小电极大学问电极导线的定义(HVlead)Anincrediblysophisticateddevicedesigneddowntothemolecularlevel,withoutwhich,thelumpofmetaltowhichitisconnectedtoiscompletelyuseless…一种分子级设计，精密程度超牛X的装置。少了它，ICD丫就一废铁基本结构电极导体绝缘体除颤线圈导体绝缘体连接杆SprintFamily电极导体绝缘体除颤线圈导体绝缘体连接杆19931996/971997/98200020012004TB/1coilIB/2coils TB/2PassiveActiveSprintSprintQuattro693269426943694569446947ICD除颤系统示意图ICDHeaderandpocketLeadBodyTissueInterfaceICD除颤系统示意图LeadBody导线体LeadBody导体与绝缘体除颤线圈阳极环导线体面临的苛刻条件导体与绝缘体锁骨下与第一肋骨间静脉血管三尖瓣导线体面临的苛刻条件导体与绝缘体锁骨下与第一肋骨间静脉血管三尖瓣静脉血管三尖瓣锁骨下与第一肋骨间不对称设计的导线体（四极整合）导体与绝缘体低压环状电极电缆高压除颤电缆SVC抗压腔低压螺旋电极线圈高压除颤电缆HVB抗压腔的意义Tubingwithoutcompressionlumens:压力集中在导体管腔之间tubingwithwonderlumens:压力被外放到导线体外周区域设计对比MedtronicSprintQuattro®StJudeMedicalRiata®/Durata®

BostonScientificEndotakReliance®GBiotronikLinoxSMART不对称设计和2个抗压腔对称设计不对称设计对称设计和1个抗压腔更细的导线体8.6Frenchisodiametricleadbody锁骨下与第一肋骨间更好的电缆设计导体与绝缘体低压环状电极电缆高压除颤电缆SVC抗压腔低压螺旋电极线圈高压除颤电缆HVBSilver导电性最佳MP35N增加机械强度锁骨下与第一肋骨间绝缘材料导体与绝缘体硅树脂填充ETFEPTFE聚亚氨酯MedtronicConfidential–InternalUseOnlyConductorsETFECoatedSenseCable1x19-MP35N21.5ohms/ftETFECoatedDefibCables7x7-MP35N/AgCored0.5ohms/ftPacingCoilInsulatedwithEtchedShrinkPTFE5filar-.0035MP35N/Agcore2.4ohms/ft1x19WithETFE7x7WithETFEPacingCoilwithPTFE不同的coating55D聚亚氨酯囊袋中肌肉组织能对电极导线施加高压力相对坚硬的聚氨酯（55D）覆盖电极近端能够在电极挤压、电极对电极和电极对机壳的磨损时提供保护80A聚亚氨酯在心腔内，电极所受外力很小但是需要电极有更多的灵活性以适应心脏的运动一种更柔软、易弯曲的聚氨酯（80A）用于覆盖线圈IsoGlide

涂层SprintQuattro6944’s独有的IsoGlide

意味着导线体与线圈接口没有隆起9F鞘鞘直径变小,使得血液回流更少更容易通过三尖瓣表面更光滑增加导线的韧性最大程度减少导线表面纤维化IsoGlide

导线体部(RVcoilshown)除颤线圈除颤线圈双触点设计用于降低DFT通过有限元分析得出：可以节约8%的除颤能量1冗余触点可以提高可靠性1.Finiteelementanalysisperformedonelectrodecoilswithdual

connectionsandwithdistal-onlyconnections.双触点设计6942Dualconnection6936Proximalconnection3ohms1ohms5ohms1ohms2.5ohms8ohmsTotal3.5ohmsTotal双触点设计6942Dualconnection6936ProximalconnectionMoreuniformcurrentdistributionDualconnectionandlowerresistancecoil6944双触点设计Defibfieldofdistalonlydefibcoilconnection(Guidant,St.Jude)Defibfieldofdualdefibcoilconnections(Medtronic,Biotronik)硅树脂内填充SiliconeBackfillNon-Backfilled硅树脂内填充带来的利益减少组织长入1降低拔除力度1在植入过程中稳定线圈1在拔除时保持电极导线完整性11WilkkoffBL,etal.PacingClinElectrophysiol.March2005;28(3):205-211.Forcetoremoveleadsmeasuredafterleadsimplantedinsheepfor14months:3leadswithnon-coatedcoils(>2kg)3leadswithsiliconebackfill(<1kg)3leadswithePTFEcoatedcoils(<1kg)结论:硅树脂填充或ePTFE覆盖

线圈有利于经静脉电极导线拔除硅树脂填充除颤线圈有利于在经静脉拔除电极导线时减少组织损伤无填充或涂层的后果与RelianceG对比注意ePTFE没有覆盖到远端部分(也没有充填,悲剧！)不能阻止纤维组织向内生长RelianceG8.2FrSprintFidelis6.6FrSiliconebackfilledcoilsePTFEcoveredcoils第一个长期人类研究结果使用RelianceG(model0165)随着时间延长起搏阈值明显增加25%因为起搏阈值的增加需要重新放置电极导线.ePTFE

涂层的问题CHRONICLEADPARAMETERSOFEXPANDEDPOLYTETRAFLUOROETHYLENE(EPTFE)COATEDLEADSINHUMANS,Hyderetal,HRSAbstracts,P6-81,2005.CoatedRVCoilIntegratedBipolar(PacingoccursTip-RVcoil)双线圈设计AXB双除颤线圈:AX>B更低且稳定的DFTLeadlessECG双线圈设计AXB单除颤线圈:A>B植入简单易拔出程控关闭SVC或CAN阳极环设计阳极环ConductorcabletoanodecrimpjointisareliableconnectionTensi-LockTMcabledesignsecuresthetipassemblyandprovidesgreaterleadstrengthTipsealdesignedtoreducefluidingressandfacilitatereinsertionofastyletSolidtiphousingprotectsinternalmechanismsfromdamage真双极和集成双极感知真双极TrueBipolar集成双极IntegratedBipolarTipTipRVElectrodeRingRVElectrodeNoRing真双极的优势研究显示:11％的使用集成双极感知导线的双腔ICD，有P波过感知现象

集成双极感知导线与真双极感知导线相比，T波和P波过感知更易出现Weretkaetal.PACE.2003;26:65-70可程控的除颤电极感知极性Tensi-Lock阳极环ConductorcabletoanodecrimpjointisareliableconnectionTensi-LockTMcabledesignsecuresthetipassemblyandprovidesgreaterleadstrengthTipsealdesignedtoreducefluidingressandfacilitatereinsertionofastyletSolidtiphousingprotectsinternalmechanismsfromdamageTensi-LockTM提供更大的电极强度1,这会有利于电极导线拔除2,3MedtronicDataonFile–comparesMedtronicleadsonly.SmithMC,LoveCJ.(2008),ExtractionofTransvenousacingandICDLeads.PacingandClinicalElectrophysiology,31:736–752WilkoffBL,Al-KhadraAS.TheTechniqueofTransvenousLeadExtraction.NonpharmachologicalTherapyofArrhythmiasforthe21stCentury:TheStateoftheArt.FuturaPublishingCo,Inc.,Armonk,NY,1998.Tensi-LockTensi-Lock是Medtronic特有的SprintFidelisSprintQuattro它就像内置固定钢丝增加电极导线头端的抗张强度一旦拉出，头端更可能保持完整没有Tensi-Lock,电极导线头端会松开和分开Tensi-LockRelianceGSprintFidelis没有电缆的，柔软，易弯的部分牢固的电缆焊接在ringandtip装置上增加头端的抗张强度，在拉出时使头端不易与电极导线体分离竞争对手的电极导线有电缆，但…电缆没有接触头端装置,在拉出时易松开和分开与组织接触部分-电极TissueInterface6944被动电极头端8mm12mm四极整合技术激素释放高阻抗Haloe™

头端电极(>750

)环形翼状电极头端 58,65,75,和100cm导线体部,除颤线圈=8.2Fr9Fr(不保留导引钢丝)10.5Fr(保留导引钢丝)6947主动电极头端四极整合技术激素释放高阻抗Haloe™

头端电极(>750

)螺旋电极头端 65,75,和100cm导线体部,除颤线圈=8.6Fr9Fr(不保留导引钢丝)11Fr(保留导引钢丝)6947螺旋头端伸出/回收

接口与囊袋ICDHeaderandpocketDF-1和DF-4IS-1BIDF-1RVSVCDF-1之贴心设计GuidantLongIS-1TerminalPin29,900LeadsaffectedHighstressattheendofthe

terminalpinoutsideoftheheaderBreachofconnectorinsulationtoRVcoilconductorsEdgeofDeviceHeaderTheBadGuysTheGoodGuysDF-1之贴心设计缓解三叉分支受力紧张当连接线弯曲时，分叉口处边缘需要承受很大的力量，在呈极锐角时可能会折断渐缩的分叉设计使平滑了弯曲程度DF-4之贴心设计Helicalpatternusedforcablestominimizestressexperiencedwithbending光滑的ICD机壳MedtronicSurface CompetitiveSurfaceICDheader