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除顫起搏器的臨床應用山東省千佛山醫(yī)院心內科閆素華1精品醫(yī)學pptContentsICDHistoryBasicfunctionsofdefibSensing,detectionandtherapiesICDindications—whogetsoneornotImplantprocedure—howdowetestthedevice.2精品醫(yī)學pptHistoryofICDsInternaldefibrillatorLate1940’sto1950’sUnitshownisfromtheearly1960’s3精品醫(yī)學pptPioneerofICDTechnologyMichelMirowski,MDDedicatedhislifetodevelopingtheICDafterhisresearchpartnerdiedinhisarmsfromaventriculararrhythmiaCreatedthefirstimplantableICD,whichstartedclinicaltrialsin19804精品醫(yī)學ppt1985-FirstapprovedICDBulky,heavyShort-lived(18m)AbdominalimplantThoracotomyrequiredNon-programmableLimitedtherapyoptionsVentakisatrademarkofCardiacPacemakers,Inc.5精品醫(yī)學pptThenextmilestoneforICDsPectoralimplantsapprovedbytheFDAin1995MorecomfortableforpatientsFasterimplantsSmallerbutjustaspowerfulasolderdevices6精品醫(yī)學ppt“ActiveCan”TechnologyTraditional
SystemRV-Can7精品醫(yī)學pptEvolutionofICDTechnology19911995TheFirstICDsFeatured
EpicardialLeadsTransvenousLeads
andAdvancedTherapy
IncreaseEffectiveness
ofICDTherapyPectoralICDs
ReduceCostsand
IncreaseSurgicalEase19858精品醫(yī)學ppt“DualChamber”ICDsIntroducedin1997CombinedualchamberpacingwithventriculararrhythmiadetectionandtherapyAbilitytosenseatrialactivityduringarrhythmiasSVTDiscrimination:Theabilitytowithholdtherapyfornon-lethalarrhythmias9精品醫(yī)學pptBasicFunctionsofICDAutomaticallydetectandtreatVentricularTachycardia(VT)Antitachycardiapacing(ATP)CardioversionAutomaticallydetectandtreatVentricularFibrillation(VF)DefibrillationBradypacingVVI,VVIR,DDDR10精品醫(yī)學pptHowitworksSensingDetectionTherapy11精品醫(yī)學ppt
Auto-AdjustingSensitivityDesignedtosensefineVFPost-sensed
sensitivityadjustmentPost-paced
sensitivityadjustmentProgrammedsensitivityPost-paceblankingMarkerChannel?TelemetryVPACEVPACEVSENSEVPACEVSENSERectified
EGMChangingThresholdPost-PacePost-Sense10x4.5x0.3mV12精品醫(yī)學pptThreeZoneDetectionVTFVTVF13精品醫(yī)學pptVTDetectionVentricularsensitivityTachydetectioninterval(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 12200msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTD14精品醫(yī)學pptVFDetectionVentricularsensitivityFibrillationdetectioninterval(FDI)VFinitialNIDVFredetectionNID15精品醫(yī)學pptFVTDetectionviaVFCounter
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)16精品醫(yī)學pptFVTDetectionviaVTCounter
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:17精品醫(yī)學pptIncreasedVTDetectionSpecificitySinusTachycardiaAtrialTachycardiaAtrialFlutterAtrialFibrillationMorphologyXXXXOnsetXStability
X18精品醫(yī)學pptTherapiesATPBurstRampRamp+CardioversionDefibrillation19精品醫(yī)學pptBurst20精品醫(yī)學ppt
Ramp21精品醫(yī)學ppt
Ramp+22精品醫(yī)學pptICDIndications,whogetsoneornotClassI:Evidence/generalagreementregardingbenefit,usefulness,andeffectiveness ClassII:Conflictingevidence/divergenceofopinionregardingusefulness/effectivenessIIa:Weightofevidence/opinioninfavorofusefulness/effectivenessIIb:Usefulness/effectivenesslesswellestablishedbyevidence/opinion.ClassIII:Evidence/generalagreementregardinglackofusefulness/effectiveness(harmfulinsomecases)GregoratosG.JAmCollCardiol.1998;31:1175-1209.23精品醫(yī)學ppt1998ClassIIndicationsforICDTherapy1. 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;31:1175-1209.24精品醫(yī)學ppt1998ClassIIIndications1. CardiacarrestpresumedtobeduetoVFwhenEPtestingisprecludedbyothermedicalconditions.
(Levelofevidence:C)2. Severesymptomsattributabletosustainedventriculartachyarrhythmiaswhileawaitingcardiactransplantation.(Levelofevidence:C)3. Familialorinheritedconditionswithahighriskforlife-threateningventriculartachyarrhythmiassuchaslongQTsyndromeorhypertrophiccardiomyopathy.(Levelofevidence:B)GregoratosG.JAmCollCardiol.1998;31:1175-1209.25精品醫(yī)學ppt1998ClassIIIndications(cont.)4. NonsustainedVTwithcoronaryarterydisease,priorMI,andLVdysfunction,andinduciblesustainedVTorVFatEPstudy.(Levelofevidence:B)5. RecurrentsyncopeofundeterminedetiologyinthepresenceofventriculardysfunctionandinducibleventriculararrhythmiasatEPstudy,whenothercausesofsyncopehavebeenexcluded.
(Levelofevidence:C)GregoratosG.JAmCollCardiol.1998;31:1175-1209.26精品醫(yī)學ppt1998ClassIIIIndications1. 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;31:1175-1209.27精品醫(yī)學ppt1998ClassIIIIndications(cont.)5. Significantpsychiatricillnessesthatmaybeaggravatedbydeviceimplantationormayprecludesystematicfollow-up.(Levelofevidence:C)6. Terminalillnesseswithprojectedlifeexpectancy
£6months.(Levelofevidence:C)7. PatientswithcoronaryarterydiseasewithLVdysfunctionandprolongedQRSdurationintheabsenceofspontaneou
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