心臟起搏的適應癥(英文版)課件

INDICATIONSFORPACINGDr.HOSSAMELMAHYCARDIOLOGYSPECIALTYREGISTRARROYALLANCASTERINFIRMARYH.ELMAHY2010AimsofthetalkTypesofpermanentpacingbyindicationBradypacing-differentindicationsPacingafterAMIContraindicationsofpacingCRTICDsH.ELMAHY2010ThemostcommonindicationforbradypacingA:Bifascicular/trifascicularBlockB:AVblockC:SinusnodediseaseD:NeurallymediatedsyncopeE:PostAVNablationH.ELMAHY2010Factorsthathelpdeterminetheneedforbradypacemakerinclude:A:Symptomssuchassyncope/presyncopeB:bradyarrhythmiaC:symptomscorrelatedtobradyarrhythmiaD:symptomsnotcorrelatedtoarrhythmiaE:noneoftheaboveH.ELMAHY2010FollowingAMIPPMisindicatedinthepresenceofA:persistent2nddegreeTypeIIAVblockB:transient3rddegreeblockwithLBBBC:Persistent3rddegreeblockD:transient2nddegreeblockwithRBBBE:alloftheaboveH.ELMAHY2010CRTisindicatedinpatientswithLVEF<35%iftheyalsohave:A:FunctionalclassNYHAIII-VIB:normalSR+wideQRS(>150msec)orwideQRS(120-149msec)withevidenceofmechanicaldyssynchronyonechoC:onoptimummedicaltherapyD:alloftheaboveE:noneoftheaboveH.ELMAHY2010GUIDELINESACC/AHA/HRS2008PACINGGUIDELINESNICE2007CRTGUIDELINESNICE2006ICDGUIDELINESH.ELMAHY2010ClassesofrecommendationinACC/AHAGuidelinesH.ELMAHY2010TypesofPermanentPacingH.ELMAHY2010BRADYPACINGH.ELMAHY2010GeneralPrinciplesofBradypacingH.ELMAHY2010DiseaseswithinAVNH.ELMAHY2010DiseasedistaltoAVNH.ELMAHY201034yoldMale,presented2weeksafterreturnfromholidayinthelakedistrictwithmuscleandjointaches,headacheandsyncope!Onexaminationhehasskinlesion(image),rightVIIpalsyandaHRof30bpm.SerologyconfirmedLymediseaseH.ELMAHY2010PPMinAVBLOCKISNOTINDICATEDWhenexpectedtoresolveand/orunlikelytorecur(e.g.Lymediseaseordrugtoxicity)Asymptomatic1stdegreeAsymptomatictypeI2nddegreeH.ELMAHY201065yoldmale,presentedwithacuteconfusion.ECGshowed3rddegreeHB.Telemetryrevealedseveralpauses.Thelongestpauseis4sec.Assumingallothercausesofacuteconfusionalstatehavebeenruledout,shouldhegetaPPM?H.ELMAHY201076yoldfemale.KnownpermanentAFandHTN.ShehascometoseeyouinOPCandthistimecomplainsofepisodesoffeelinglightheaded.Sheiscurrentlyonwarfarin,amlodipine5mgOD,digoxin125mcgODandbisoprolol7.5mgOD.HerrestingHRis70-80bpmandBP130/75.Youarrangedaneventrecorderwhichrevealedperiodsofbradycardia(40bpm)concomitantwithhersymptoms.DoessheneedPPM?H.ELMAHY2010ACC/AHAClassIindicationsforpacingin3rd(andadvanced2nd)degreeAVBH.ELMAHY2010Pacinginchronicbi/trifascicularblockINDICATEDNOTINDICATEDIntermittent3rddegreeblockAdvancedtypeII2nddegreeblockAlternatingBBBFascicularblockwithoutAVblockorsymptomsFascicularblockwith1stdegreeAVblockwithoutsymptomsH.ELMAHY2010PPMafterAMI63yoldmalepresentedwithacuteinferiorMI.hewasthrombolysed.ThirtyminuteslaterhedevelopedVFarrest.CPRcommencedandonROSChewasinCHBwithescaperateof25bpm.HewaspacedtranscutaneouslyuntilaTPWwasinserted.2weekslaterhis12leadECGshowedSRwithLAHBbutnoevidenceofAVB.ShouldhegetaPPM?H.ELMAHY2010PPMafterAMITheneedforTPWafterAMIdoesn’tautomaticallyindicateaneedforPPMTransientconductiondisturbancesorLAHBarenotindicationsforPPMafterAMI.PPMisindicatedinthepresenceofadvancedAVB(2nd/3rddegree)whether(persistent)or(transientwithassociatedBBB)H.ELMAHY201060yoldmale,c/orecurrentpalpitationsandpresyncope.Hiscontinuousmonitorleadrecordingisshownbelow.DoesheneedPPM?H.ELMAHY2010PacingSNDGenerallyPPMisindicatedwhensymptomaticbradycardiaispresentAlsoPPMindicatedwhensymptomaticbradycardiaiscausedbylong-termdrugforwhichthereisnoacceptedalternative.PPMisnotindicatedintheabsenceofsymptoms.H.ELMAHY2010PPMisindicatedinNeurallymediatedsyncopewhenthereis

recurrentsyncope+hypersensitivecardioinhibitoryresponsePPMisnotindicatedif:

1-hypersensitivecardioinhibitoryresponsewithoutsymptomsOR

2-SymptomswithouthypersensitivecardioinhibitoryresponseH.ELMAHY2010Issuedate:May2007Reviewdate:July2010NICEtechnologyappraisalguidance120CardiacresynchronizationtherapyforthetreatmentofheartfailureH.ELMAHY2010CRT-PforHFH.ELMAHY2010CRT-DforHFH.ELMAHY2010Issuedate:January2006Reviewdate:July2007TechnologyAppraisal95ImplantablecardioverterdefibrillatorsforarrhythmiasReviewofTechnologyAppraisal11H.ELMAHY2010ICD-SecondarypreventionH.ELMAHY2010ICD-PrimarypreventionH.ELMAHY2010Takehomemessage!Thereareonlytwoindicationsforpacing(excludingpacingforheartfailure):1-symptoms+slowHR2-highriskofsymptoms+slowHRdevelopinginthefutureH.ELMAHY2010ThemostcommonindicationforbradypacingA:Bifascicular/trifascicularBlockB:AVblockC:SinusnodediseaseD:NeurallymediatedsyncopeE:PostAVNablationH.ELMAHY2010Factorsthathelpdeterminetheneedforbradypacemakerinclude:A:Symptomssuchassyncope/presyncopeB:bradyarrhythmiaC:symptomscorrelatedtobradyarrhythmiaD:symptomsnotcorrelatedtoarrh