起搏器培訓(xùn)課件：美敦力四極系統(tǒng)簡(jiǎn)介

1、 Click to edit Master text styles Second level Third level Fourth level Fifth level 美敦力四極系統(tǒng)簡(jiǎn)介 CRT 治療過程中, 從植入到患者管理挑戰(zhàn)無處不在 患者選擇很復(fù)雜 靜脈解剖的多變使得植入不可預(yù)知 左室閾值的變化會(huì)導(dǎo)致CRT治療喪失或發(fā)生膈神經(jīng)刺激 (PNS) 其他心衰管理問題 (依從性不好，并發(fā)癥的影響，患者失隨訪) 均影響療效1,3 1 Abraham WT, et al. N Engl J Med. 2002;346:1845-1853. 2 Bristow MR, et al. N Engl J

2、Med. 2004;350:2140-2150. 3 Young JB, et al. JAMA. 2003;289:2685-2694. 4 Abraham WT, et al. Circulation. 2004;110:2864-2868. 5 Abraham WT, et al. Heart Rhythm. 2005;2:S65. 6 Chung ES, et al. Circulation. 2008;117:2608-2616. 7 van Gelder BM, et al. J Cardiovasc Electrophysiol. 2008;19:939-944. 1/3的患者無

3、法從CRT治療中完全獲益.2,4-7 CRT 無反應(yīng)的諸多因素 Mullens W, Grimm RA, Verga T, et al. Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program. JACC. March 3, 2009;53(9):765-7723. 左室電極位置，左室閾值以及左室閾值在保障左室奪獲和膈神經(jīng)刺激之間是影響 CRT療效的很重要因素 Viva Quad CRT-D 9 (10): 1368-1

4、374. Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Advanced Quadripolar Lead 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes

5、to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P 2 Biffi M, et al. Effect of Bipolar Electrode Spacing on Phrenic Nerve Stimulation and Left Ventricular Pacing Thresholds, Circ Arrhythm Electrophysiol. 2012;5:815-820 3 Biffi M1, Zanon F, Bertaglia E, et al., Short-spaced dipole for ma

6、naging phrenic nerve stimulation in patients with CRT: the phrenic nerve mapping and stimulation EP catheter study Heart Rhythm. 2013 Jan;10(1):39-45 短雙極電極間距選項(xiàng)可有效避免 PNS1-3 所有電極均為類固醇激素電極 與美敦力鞘中鞘兼容 為不同的患者解剖提供 更多的形狀選擇 Advanced Quadripolar Lead: 短雙極電極間距減少PNS 的發(fā)生 Attain Performa 1.3 mm的短雙極電極間距導(dǎo)致明顯更高的膈神經(jīng)閾

7、 值，從而減少膈神經(jīng)刺激的發(fā)生 1 Biffi M, et al.Circ Arrhythm Electrophysiol. 2012;5:815-820. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% LV1-RV coil LV1-LV2 LV1-LV3 LV1-LV4 LV2-RV coil LV2-LV1 LV2-LV3 LV2-LV4 LV3-RV coil LV3-LV1 LV3-LV2 LV3-LV4 LV4-RV coil LV4-LV1 LV4-LV2 LV4-LV3 PNS present at 8V Advanced Quadripol

8、ar Lead: 短雙極電極間距減少PNS的發(fā)生1 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P Attain Performa at 6 months (Models 4298, 4398, 4598 combined) 0 0.5 1 1.5 2 2.5 3 3.5 4 LV1-RVcoil LV1-LV2 LV1-LV3 LV1-LV4 LV2-R

9、Vcoil LV2-LV1 LV2-LV3 LV2-LV4 LV3-RVcoil LV3-LV1 LV3-LV2 LV3-LV4 LV4-RVcoil LV4-LV1 LV4-LV2 LV4-LV3 PNS threshold - PCT threshold (V) 1 Biffi M, et al, Utilizing Short Spacing between Quadripolar LV lead Electrodes to Avoid PNS. Cardiostim 2014, Poster presentation, Session 56P Advanced Quadripolar

10、Lead: 短雙極間距使PNS閾值和 PCTs之間的差距更大1 Attain Performa at 6 months (Models 4298, 4398, 4598 combined) Advanced Quadripolar Lead: 所有電極均包含激素以最小化起搏閾值(PCT) 4個(gè)激素洗脫電極最大化可程控 的起搏向量設(shè)置 激素使所有起搏向量的長(zhǎng)期 PCTs 更穩(wěn)定1 1 Lunati MG, Gasparini M, Landolina M, et al. Long-Term Effect of Steroid Elution on the Electrical Performan

11、ce of Coronary Sinus Leads for Cardiac Resynchronization Therapy. Presented at HRS 2012 (AB10-05). 注：Pacing Capture Thresholds (PCT) Advanced Quadripolar Lead: 激素電極是行業(yè)標(biāo)準(zhǔn) 1 Mond HG, et al. Pacing Clin Electrophysiol. 1988; Vol 11 右室激素洗脫電極的使用是行業(yè)標(biāo)準(zhǔn)，而且多年來已證實(shí)比非激素電極 更優(yōu)1 除RV之外, 我們看到激素運(yùn)用在LV也同樣有益: 激素幫助維持顯著降低

12、的長(zhǎng)期LV起搏閾值1 節(jié)省30%的能量損耗，從而延長(zhǎng)使用壽命 減低 PNS發(fā)生1 1 Lunati MG, et al. Long-Term Effect of Steroid Elution on the Electrical Performance of Coronary Sinus Leads for Cardiac Resynchronization Therapy. Presented at HRS 2012 (AB10-05). Advanced Quadripolar Lead: 激素最小化起搏閾值（PCT) Pacing Capture Thresholds (PCT) Adv

13、anced Quadripolar Lead: 4個(gè)激素電極導(dǎo)致低的長(zhǎng)期 PCTs1 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation Attain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01

14、Heart Failure Issues in Clinical Outcomes. 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation Attain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01

15、Heart Failure Issues in Clinical Outcomes. 2 Tomassoni Gery, Baker , James, et. al., Postoperative Performance of the Quartet Left Ventricular Heart Lead, J Cardiovasc Electrophysiol, Vol. 24, pp. 449-456, April 2013 Advanced Quadripolar Lead: 4個(gè)激素電極導(dǎo)致低的長(zhǎng)期 PCTs1 Advanced Quadripolar Lead: 脫位率低1 Medt

16、ronic1St. Jude Medical S形1.7% (6 months) 3.5%2 (3 months) 直0.3% (6 months) Shape Not Available 成角2.0% (6 months) Shape Not Available 1 Crossley GH, Biffi M, Johnson WB, et al. A Novel Quadripolar Lead with Narrow-Spaced Bipole Allows for Effective LV Pacing While Avoiding Phrenic Nerve Stimulation A

17、ttain Performa LV Lead Study Primary Results. AHA November 2014 Poster Session APS.506.01 Heart Failure Issues in Clinical Outcomes. 2 Tomassoni Gery, Baker , James, et. al., Postoperative Performance of the Quartet Left Ventricular Heart Lead, J Cardiovasc Electrophysiol, Vol. 24, pp. 449-456, Apri

18、l 2013 45984398 4298 Advanced Quadripolar Lead: 成角導(dǎo)線植入注意事項(xiàng) (4298) 中等扭曲血管 中等直徑血管 Advanced Quadripolar Lead Case Advanced Quadripolar Lead: 與美敦力鞘中鞘兼容 Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Attain Performa 提供了16種可選擇起搏向量 VectorExpress 摒棄了手動(dòng)向量評(píng)估的復(fù)雜操作

19、，為選擇最優(yōu) 起搏向量提供便利 2分鐘完成所有向量測(cè)試8+分鐘完成所有向量測(cè)試 1 Demmer W. VectorExpress Performance Results. Medtronic Data on File. January 2013. 手動(dòng)測(cè)試VectorExpress VectorExpress: 2分鐘內(nèi)提供臨床可行的數(shù)據(jù)1 替代耗時(shí)的手動(dòng)多種 向量測(cè)試 VectorExpress 測(cè)試 結(jié)果與手動(dòng)PCT測(cè)試 匹配率為95% 1 1 Johnson B, et al, Accuracy of an Automated Pacing Capture Thresholds Alg

20、orithm for Quadripolar Left Ventricular Leads. HRS 2014, Poster presentation, PO04-185 VectorExpress: 2分鐘內(nèi)提供16個(gè)向量臨床可行的數(shù)據(jù)1 1. 起搏心房，測(cè)量AP-VS的傳導(dǎo)時(shí)間 AP VS VectorExpress利用LVCM技術(shù)確定起搏閾值 2. AP后起搏LV，在預(yù)計(jì)心房自身下 傳的VS前出現(xiàn)右室感知事件，則說明 左室奪獲 AP Expected VS LV Pace Blankin g Capture Window LOC VS (LV-RV conduction) AP VS

21、VectorExpress利用LVCM技術(shù)確定起搏閾值 1. 起搏心房，測(cè)量AP-VS的傳導(dǎo)時(shí)間 3. 降低測(cè)試電壓直至失奪獲 AP VS AP Expected VS LV Pace Blankin g Capture Window LOC VS (LV-RV conduction) VectorExpress利用LVCM技術(shù)確定起搏閾值 1. 起搏心房，測(cè)量AP-VS的傳導(dǎo)時(shí)間 2. AP后起搏LV，在預(yù)計(jì)心房自身下 傳的VS前出現(xiàn)右室感知事件，則說明 左室奪獲 Viva Quad CRT-D and Attain Performa System VectorExpress Advance

22、d Quadripolar Lead AdaptivCRT 創(chuàng)新：CRT的生理性起搏模式 1. 適應(yīng)性LV起搏：提前激動(dòng)左室，融合右室自身傳導(dǎo)，維持房室結(jié)功能 2. 動(dòng)態(tài)BiV同步起搏：每分鐘自動(dòng)優(yōu)化AV間期，VV間期 3. 每分鐘自動(dòng)測(cè)量：通過精密算法保證左右室同步收縮的有效性 CRT的生理性起搏模式AdaptivCRT 1Martin, et al. Heart Rhythm 2012; 9:1807-14. 2Medtronic Viva XT CRT-D manual. 適應(yīng)性 單LV起搏 動(dòng)態(tài) BiV起搏 每分鐘調(diào)整 AdaptivCRT 的臨床獲益1-5 臨床獲益安全性有效性提高反

23、 應(yīng)率 減少右 室起搏 減少AF減少HF住 院率和死 亡率 減少30 天再入 院率 Adaptiv CRT 12% 44%46%21%40% 1 Martin et al., Heart Rhythm. 2012 Nov; 9(11): 1807-14. 2 Krum H, et al. Am Heart J. 2012;163:747-752.e1. 3 Singh JP, et al. Presentation at European Society of Cardiology Congress August 2012. 4 Birnie D. et al., Presented at t

24、he American Heart Association Scientific Sessions 2012. Abstract #: 11672 5Randall C. Starling. Presented at Heart Rhythm Socity Sessions 2014. Viva Quad CRT-D and Attain Performa System VectorExpress Advanced Quadripolar Lead AdaptivCRT Advanced Quadripolar Lead 唯一具有短雙極電極間距的四極LV電極導(dǎo)線，以達(dá)到期望的起搏位點(diǎn)和避免膈神

25、經(jīng)刺激 唯一每個(gè)電極均包含激素以延長(zhǎng)使用壽命 為不同的患者解剖提供更多的導(dǎo)線形狀，并與美敦力亞選擇鞘管兼容 VectorExpress 2分鐘內(nèi)提供臨床可行的信息，以管理起搏閾值，使用壽命和CRT反應(yīng)率1 替代耗時(shí)的手動(dòng)多種向量測(cè)試，為患者選擇最優(yōu)的起搏向量 AdaptivCRT 美敦力 Viva Quad XT CRT-D 系統(tǒng)結(jié)合了advanced quadripolar lead 的植入優(yōu) 勢(shì)和AdaptivCRT 已證實(shí)的臨床獲益 2 Viva Quad CRT-D and Attain Performa 總結(jié) 1 Demmer W. VectorExpress Performance

26、 Results. Medtronic Data on File. January 2013. 2 Birnie D, Lemke B, Aonuma K, et al. Clinical outcomes with synchronized left ventricular pacing: Analysis of the adaptive CRT trial. Heart Rhythm. September 2013; 9 (10): 1368-1374. 美敦力左室電極導(dǎo)線 Click to edit Master text styles Second level Third level

27、Fourth level Fifth level 33 BravaTM Quad CRT-DAttainTM Performa 4298 Quadripolar Lead 曲面設(shè)計(jì) 減少皮膚張力,降低囊袋感染風(fēng)險(xiǎn) ATP智能放電 無痛治療 VectorExpressTM 一鍵向量選擇 快速為患者選擇最優(yōu)起搏向量 短間距設(shè)計(jì)短間距設(shè)計(jì) 避免膈神經(jīng)刺激，避免膈神經(jīng)刺激，使得術(shù)者可以輕松植使得術(shù)者可以輕松植 入最優(yōu)的起搏位置入最優(yōu)的起搏位置 全激素覆蓋全激素覆蓋 長(zhǎng)期穩(wěn)定閾值以延長(zhǎng)使用壽命長(zhǎng)期穩(wěn)定閾值以延長(zhǎng)使用壽命 與美敦力左室遞送系統(tǒng)兼容與美敦力左室遞送系統(tǒng)兼容 有效減少手術(shù)時(shí)間有效減少手術(shù)時(shí)間 Features and benefits Click to edit Master text styles Second level Third level Fourth level Fifth level 34 Features and benefits VivaTM XT Quad CRT-DAttainTM Performa 4298 Quadripolar Lead AdaptivCRTTM 創(chuàng)新CRT生理起搏模式 減少不