除顫起搏器的臨床應用課件

HistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’sPioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin19801985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.ThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevices“ActiveCan”TechnologyTraditional

SystemRV-CanEvolutionofICDTechnology19911995TheFirstICDsFeatured

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andAdvancedTherapy

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ofICDTherapyPectoralICDs

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IncreaseSurgicalEase1985“DualChamber”ICDsIntroducedin1997CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmiasCardioversionIncessantVTorVF.CardioversionIncreasedVTDetectionSpecificityIncessantVTorVF.ICDIndications,whogetsoneornotConnectdefibleadswithdefibboxPectoralICDs

ReduceCostsand

IncreaseSurgicalEaseAtrialFlutterLOOKBACKWINDOW

(8INTERVALSBEFORENID)CreatedthefirstimplantableICD,whichstartedclinicaltrialsin1980ClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectivenessIncessantVTorVF.(Levelofevidence:B)GregoratosG.(Levelofevidence:B)Post-paceblankingFasterimplantsICDIndications,whogetsoneornotVFCounter:BasicFunctionsofICDAutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDRHowitworksSensingDetectionTherapy

Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed

sensitivityadjustmentPost-paced

sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel?TelemetryVPACEVPACEVSENSEVPACEVSENSERectified

EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mVThreeZoneDetectionVTFVTVFVTDetectionVentricularsensitivityTachydetectioninterval(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 12200msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTDVFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNIDFVTDetectionviaVFCounter

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Ramp+ICDIndications,whogetsoneornotClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectiveness ClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases)GregoratosG.JAmCollCardiol.1998;31:1175-1209.IncessantVTorVF.PectoralICDs

ReduceCostsand

IncreaseSurgicalEaseTurnofdetection,closethewound(Levelofevidence:B)JAmCollCardiol.LOOKBACKWINDOW

(8INTERVALSBEFORENID)MichelMirowski,MDVentricularsensitivityIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.TheFirstICDsFeatured

EpicardialLeadsJAmCollCardiol.(Levelofevidence:A)DetectionStatus: ON ON ONIncessantVTorVF.(Levelofevidence:C)1998;31:1175-1209.Sensitivity(mV): 0.AbdominalimplantDesignedtosensefineVFMorecomfortableforpatients(Levelofevidence:C)1998ClassIIndicationsforICDTherapy1. CardiacarrestduetoVForVTnotduetoatransientorreversiblecause.(Levelofevidence:A)2. SpontaneoussustainedVT.(Levelofevidence:B)3. Syncopeofundeterminedoriginwithclinicallyrelevant,hemodynamicallysignificantsustainedVTorVFinduced

atEPstudywhendrugtherapyisineffective,nottolerated,ornotpreferred.(Levelofevidence:B)4. NonsustainedVTwithcoronarydisease,priorMI,LVdysfunction,andinducibleVForsustainedVTatEPstudythatisnotsuppressiblebyaClassIantiarrhythmicdrug.(Levelofevidence:B)GregoratosG.JAmCollCardiol.1998;31:1175-1209.1998ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.

(Levelofevidence:C)2. Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3. Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B)GregoratosG.JAmCollCardiol.1998;31:1175-1209.1998ClassIIIndications(cont.)4. NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5. RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.

(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.1998ClassIIIIndications1. 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.1998;31:1175-1209.1998ClassIIIIndications(cont.)5. Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6. Terminalillnesseswithprojectedlifeexpectancy

￡6months.(Levelofevidence:C)7. PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneousorinduciblesustainedornonsustainedVTwhoareundergoingcoronarybypasssurgery.(Levelofevidence:B)8. NYHAClassIVdrug-refractorycongestiveheartfailureinpatientswhoarenotcandidatesforcardiactransplantation.(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.ImplantProcedureInsertionofdefibleadsTestpacingparametersthroughanalyzerofP/Rwave,leadimpedances,andpacingthresholdConnectdefibleadswithdefibboxTestpacingimpedance,thresholdthroughtheboxInduceVF,implantsuccesscriterion:twoconsecutivetimesor3outof4successfuldefibrillation,10Jsafetymargin.Turnofdetection,closethewoundFinalprogrammingThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevicesMarkerChannel?TelemetryGregoratosG.GregoratosG.FVTDetectionviaVTCounterJAmCollCardiol.Post-sensed

sensitivityadjustmentDetectionStatus: ON ON ONFVTDetectionviaVTCounterIncessantVTorVF.FVTDetectionviaVTCounterConnectdefibleadswithdefibboxThreeZoneDetectionSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias1998ClassIIIndicationsIntroducedin1997InsertionofdefibleadsIncessantVTorVF.Non-programmablePatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneousorinduciblesustainedornonsustainedVTwhoareundergoingcoronarybypasssurgery.DetectionStatus: ON ON ONEvolutionofICDTechnology19911995TheFirstICDsFeatured

EpicardialLeadsTransvenousLeads

andAdvancedTherapy

IncreaseEffectiveness

ofICDTherapyPectoralICDs

ReduceCostsand

IncreaseSurgicalEase1985ThreeZoneDetectionVTFVTVFFVTDetectionviaVTCounter

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Ramp+GregoratosG.TheFirstICDsFeatured

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SystemRamp+1998;31:1175-1209.Cardioversion1998ClassIIIndications(cont.InduceVF,implantsuccesscriterion:twoconsecutivetimesor3outof4successfuldefibrillation,10Jsafetymargin.(Levelofevidence:C)Short-lived(18m)IncreasedVTDetectionSpecificityTransvenousLeads

andAdvancedTherapy

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ofICDTherapyVentriculartachyarrhythmiasduetoatransientorreversibledisorder(e.(Levelofevidence:C)Terminalillnesseswithprojectedlifeexpectancy

￡6months.MichelMirowski,MDVentricularsensitivityTachydetectioninterval(TDI)TestpacingparametersthroughanalyzerofP/Rwave,leadimpedances,andpacingthresholdSpontaneoussustainedVT.Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.IncessantVTorVF.(Levelofevidence:C)Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.GregoratosG.(Levelofevidence:C)Defibrillation(Levelofevidence:C)RampPioneerofICDTechnologyLOOKBACKWINDOW

(8INTERVALSBEFORENID)PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneousorinduciblesustainedornonsustainedVTwhoareundergoingcoronarybypasssurgery.1998;31:1175-1209.CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.JAmCollCardiol.GregoratosG.JAmCollCardiol.1998ClassIIndicationsforICDTherapyTransvenousLeads

andAdvancedTherapy

IncreaseEffectiveness

ofICDTherapy,AMI,electrolyteimbalance,drugs,trauma).EvolutionofICDTechnologyTerminalillnesseswithprojectedlifeexpectancy

￡6months.TransvenousLeads

andAdvancedTherapy

IncreaseEffectiveness

ofICDTherapyAuto-AdjustingSensitivitySignificantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormaypre