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1、心力衰竭监测技术在心脏再同步治疗中的应用,中国医科大学第一医院于 波,CRT 减少心衰风险(MADIT-CRT)1,0,1,0,Cardiac Hospitalizations,HF Hospitalizations,Hospital admissions per patient-year,1.20,0.73,0.76,0.43,41%,37%,CRT 减少住院率(COMPANION)2,CRT,1 Moss,AJ.et al.;NEJM 2009;361:132938.2 Anand,IS.et al.;Circulation 2009,119:969977.,慢性心力衰竭患者获益于心脏再同
2、步治疗,Optimal pharmacological therapy,CRT-D,*Mullens,W.et al.;Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program,JACC 2009;53:76573.,CRT,CRT治疗效果不佳原因统计,CRT,即使CRT治疗患者仍有7-26%的再住院率,左室起搏比例低心律失常，尤其是AF，频发室早药物治疗方案无效或未及时调整不能及时发现心衰病情变化 肺部充血的临床表现常出
3、现较晚，不易被察觉，延误治疗的最佳时机 尽管患者临床状况改善，但出院时和肺部充血有关体征和症状没有被诊断 肺部充血可作为衡量死亡率和心力衰竭出现的重要指标,CRT 双室起搏百分比,CRT起搏92%比92%在首次植入6月的NYHA心功能很少改善CRT起搏在93-97%比 92%事件减少38%CRT起搏在98-99%与93-97%起搏患者获益相同CRT起搏在100%比98-99%起搏比风险减少22%双心室起搏百分比增加，心衰住院或全因死亡事件减少最大化CRT同步起搏(93%)是心衰状况改善的指标,Koplan B et al.J Am Coll Cardiol 2009;53:35560.,21%
4、CRT患者有房性心律失常，29%患者既往有AT，17%在随访中发生（28 周)，CRT 对心房机械重构和功能改变可能有益AF诱发心衰失代偿，心衰失代偿导致房性心律失常房颤快室率影响CRT再同步治疗，加重心衰恶化房颤负荷增加是心衰恶化的预测因素及时监测到AF发作有助于立即采取心衰防范措施，决定是否抗栓治疗AF5 min and 12 h were moderate and long-lasting PAF,1 Heist EK et al.Progress in Cardiovascular Diseases.2006;48(4),256269.2 Perego GB et al.J Inter
5、v Card Electrophysiol 2008;23(3):235-42.3 Hunt SA et al.Circulation.September 20,2005;112(12):e154-235.,房性心律失常事件,偶发室早是频发室早的重要预测因子频发室早(30/h)是联合事件和心血管事件（AMI或死亡）的重要预测因子频发室早伴有HRV降低是心源性猝死的预测因子无室早或室早偶发提示心功能状况改善，室早频发提示心衰恶化,1 Sajadieh A et al.Am J Cardiol 2006;97(9):1351-7.2 Germany R et al.Am J Cardiol 200
6、7;99(10A):11G-6G.,频发室性早搏,静息心室率增加是冠心病，心血管疾病，癌症或所有原因死亡的风险因子静息心室率增加与室性心律失常增加相关，增加心源性猝死的危险夜间心室率增加是重要的预测心衰急性失代偿发作的独立预测因子，并且与心血管原因住院和死亡相关心衰加重时，心率明显逐渐升高心率下降是生存率升高的强预测因子，平均静息心室率降低是心衰改善的指标,1 Fox K et al.J Am Coll Cardiol 2007;50(9):823-30.2 Casolo GC et al.Eur Heart J.March 1995;16(3):360-367.,平均心室率（mean ven
7、tricular heart rate）,HRV为心衰患者心源性猝死的预测因素住院或死亡的心衰患者HRV偏低事件发作3周前HRV下降CRT患者低HRV与高死亡率和高心衰住院风险呈独立相关性，CRT植入4周后，HRV仍未改善患者主要心血管事件风险升高HYNA纽约心功能分级越低，HRV越低，HRV增加心衰改善，HRV下降心衰恶化,1 Germany R et al.Am J Cardiol 2007;99(10A):11G-6G.2 Small RS et al.J Card Fail 2009;15(6):475-81.3 XSmall RS.Am J Cardiol 2007;99(10A):
8、17G-22G.4 Perego GB et al.J Interv Card Electrophysiol 2008;23(3):235-42.5 Fung JW et al.Curr Heart Fail Rep 2007;4(1):48-52.6 Adamson PB et al.Circulation.October 19,2004;110(16):2389-2394.7 Braunschweig F et al.Am J Cardiol.May 1,2005;95(9):1104-1107.,心率变异性heart rate variability（HRV）,CHF患者活动度偏低，住院
9、患者活动度明显下降CRT患者活动度低和心衰住院风险增加明显相关患者活动度是死亡率的预测因子，患者活动度提高是心衰改善的预测因子，下降是心衰加重预测因子,1 Fung JW et al.Curr Heart Fail Rep 2007;4(1):48-52.2 Small RS.Am J Cardiol 2007;99(10A):17G-22G.3 Perego GB et al.J Interv Card Electrophysiol 2008;23(3):235-42.4 Braunschweig F et al.Am J Cardiol.May 1,2005;95(9):1104-110.
10、,病人活动度（patient activity）,各级医生根据病人临床表现评估液体潴留的能力,Accurate assessment(%),42.7,55,75,Heart Failure SpecialistsStevenson et al,Primary CareConnors et al,CardiologistsEisenberg et al,0,20,40,60,80,100,颈静脉试验评估前负荷,传统门诊心衰随访模式,患者出现症状后才到医院接受治疗需要等待患者的主诉或住院检查,如何及时应对心衰患者自身病情和CRT系统状态的迅速变化,患者心衰住院率，死亡率增加,常规起搏器随访,体液潴
11、留的血流动力学基础,LV 舒张末期压力,左心房压力,肺毛细血管 压力,液体进入肺部组织,当液体在肺内积聚，胸腔内阻抗下降,正常肺脏,impedance started to decrease an average of 18 days before hospital admission at a mean of 15 days prior to the occurrence of clinical symptoms,OptiVol 液体潴留监测如何工作？,液体指数(ohm days),Days,可程控的液体阈值,OptiVol液体指数,参考阻抗,每日阻抗,不要仅重视超过阈值它必须与阻抗趋势一同
12、评估.,每天中午至下午5点隔20min从机壳到右室线圈测定阻抗，从第34天的阻抗和前3天阻抗除以4，为基础值，以后每天根据当日阻抗和昨天参考阻抗值相比较，通过一个常数计算，与参考阻抗相比较，计算差值。每日差值相加称为液体指数，当液体超过程控的值，机器报警,Medtronic,Days,OptiVol 液体滁留状态监测的临床应用,追踪胸腔内阻抗变化 每日阻抗与患者自身参考阻抗比较，持续追踪液体滁留允许根据病人实际情况程控阈值胸腔内阻抗测试可能受某些疾病影响：COPD，肺部肿块系统不会测试植入区域以外充血状态：周围性水肿,腹水,OptiVol 液体监测的程控设置,Medtronic的某些起搏器除O
13、ptiVol 外其Cardiac Compass可提供更多HF信息,节律控制：每日AT/AF负荷 评价药物治疗及剂量是否有效长时间的AT/AF是否有中风危险频率控制：AT/AF时的心室频率是否需要加大药物剂量，或者考虑射频治疗？起搏监测每日的VP%和AP%有自身传导病人，是否打开MVP白天平均心室率/夜间心律病人活动度心率变异性,CorVue 肺水肿监测原理,Unify CRT-D 测量RV Coil to Can和LV Ring to Can的经胸阻抗如果左室单极可使用RV Coil to Can/RV Ring to CanFortify ICD测量RV Coil to Can和RV Ri
14、ng to Can的经胸阻抗 如果右室为整合双极，只能使用RV Coil to Can装置在心肌生理不应期时发放阈下脉冲，通过测量两个经胸向量不同极性之间V和I变化，运用R=V/I算出经胸阻抗,ST Jude,正常：干性时的阻抗增加,淤血：湿性时的阻抗降低,CorVue 肺水肿监测方法,每天平均阻抗(12次的平均值),平均阻抗参考值(连续的144或168次阻抗值),time,每2小时测量一次,每2h测量一次经胸阻抗，12次测量计算一次平均阻抗值，称之为每天平均阻抗值最初12（ICD）或14天（CRTD）的平均数据为基础值或平均阻抗参考值一旦基线阻抗确定，装置会将每日平均阻抗值和参考阻抗值进行比
15、较，两者阻抗变化连续超出一定的天数，装置就会触发报警装置，其程控参数（天）称之为肺水肿触发建议在术后30后开启监测功能，以避免术后囊袋血肿等造成的不准确,CorVue 肺水肿监测,肺水肿天数：每天平均阻抗=参考阻抗值，阻抗指数-1，反之+1阻抗指数累计达到12，称之为1个肺水肿天数Porterfield等对75位患者经胸阻抗（CorVue）预测肺水肿研究表明：敏感性71.4%，每患者年有0.56个假阳性报警,肺水肿天数：17为总天数,1.Porterfield,J.Porterfield,LM,et al.Device Monitoring of Heart Failure.European
16、Heart Journal(2009)30(Abstract Supplement),137.,2.Yu CM,Wang L,Chau E,et al.Intrathoracic Impedance Monitoring in Patients With Heart Failure:Correlation With Fluid Status and Feasibility of Early Warning Preceding Hospitalization.Circulation 2005:112:841-848,advanced,therapy monitoring,每日监测并远程评估心衰患
17、者的治疗情况全面的临床参数帮助早期识别心衰加重,心衰监测系统 Heart Failure Monitor,Biotronic,Heart Failure Monitor心衰监测系统在线浏览,经胸阻抗测量原理：测量右室线圈和机壳之间的阻抗,*Source:,I:electric current(injected)U:voltage(measured)Z:intrathoracic impedance,现有CRT-D心衰监测比较,norm(Z),Extravascular Lung Water Index,ELWI(ml/kg),norm(Z),Impedance Z(bipolar),LV En
18、d Diastolic Pressure,LVEDP(mmHg),肺部液体滁留与经胸阻抗相关性的动物试验,1 Becher J.et al.Europace(2010)12,7317402 Braunschweig et al.Europace(2010)12,731740,Corr.Z vs.ELWI,目的：评估肺水肿诱发和恢复时经胸阻抗和直接测量胸腔内液体的相关性方法：20只羊，12例NE诱发肺水肿,5例诱发肺水肿利尿恢复,3例对照,百多力ICD测量extravascular lung water(EVLW,PiCCO system)，intrathoracic impedance(coi
19、l-can)，LVEDP,MABP,Intrathoracic blood volume(ITBV),Yu C et al.Circulation 2005;112:841-848,Intrathoracic impedance monitoring in CHF:correlation with fluid status and feasibility of early warning preceding hospitalization(midhf-trial),Yu C et al.Circulation 2005;112:841-848,Baseline Clinical Charact
20、eristics of 33 Patients With Implanted Devices,Trend of average intrathoracic impedance for first 150 days after implantation for patients not hospitalized for heart failure during this period,Yu C et al.Circulation 2005;112:841-848,Comparison of intrathoracic impedance at reference baseline and 1 d
21、ay before admission for 24 hospitalizations resulting from worsening heart failure in 9 patients,Yu C et al.Circulation 2005;112:841-848,Example from 1 patient.,Yu C et al.Circulation 2005;112:841-848,Two occasions in which fluid index exceeded nominal threshold of 60 d in same patient,Yu C et al.Ci
22、rculation 2005;112:841-848,Algorithm performance on validation data set,Yu C et al.Circulation 2005;112:841-848,nominal threshold of 60 d resulted in sensitivity of 76.9%and false-positive rate of 1.5 false-positives per pts-year of monitoring,ConclusionIntrathoracic impedance is inversely correlate
23、d with PWCP and fluid balance and decreased before the onset of patient symptoms and before hospital admission for fluid overload.Regular monitoring of impedance may provide early warning of impending decompensation and diagnostic information for titration of medication.,The Chronicle Offers Managem
24、ent to Patients with Advanced Signs and Symptoms of Heart Failure(COMPASS-HF study),To evaluate whether an implantable hemodynamic monitor(IHM)was safe and effective in reducing HF-related events(HFRE)in CHF70 pts with an EF or=50%(ie,DHF)，randomized to IHM-guided care vs.control for 6 monthsThe HFR
25、E rate in DHF pts in treatment was 0.58 events/6 months，in control was 0.73 events/6 months 20%nonsignificant reduction in the overall HFRE rate in the treatment group，29%nonsignificant reduction in the relative risk of a HF hospitalization in the DHF pts treatment compared with control The IHM was
26、safe and associated with a very low system-related and procedure-related complication rate in DHF patients.showing a non-significant 21%decrease of all heart failure related events after 6 month,J Card Fail.2008;14(10):816-23.,Echo and impedance data from HF pts with a CRTD capable of intrathoracic
27、impedance measurement for fluid accumulation 127pts(group A)LVESV decreased at 6m follow-up(LVESV at 6 m-at baseline or=0The impedances of groups A and B diverged，resulting in significant difference between 2 groups at the 6m(P=0.001).The changes in LV dimensions produced larger differences between
28、groups in the impedance measured between the LV and the RV leads(P 0.001)CONCLUSIONS:The changes in ICD-measured impedance seem associated with the LV volume changes induced by CRT.Specifically,the LV-to-RV impedance estimations seem to better correlate with paired changes of ventricular volumes,Pac
29、ing Clin Electrophysiol.2010;33(1):64-73.,Intrathoracic and ventricular impedances are associated with changes in ventricular volume in patients receiving defibrillators for CRT,282 pts with III or IV HF implanted with a CRTD w/a fluid index2 groups:based on fluid index threshold crossings or not4,7
30、25 tachyarrhythmic events in 129 pts(46%)221 fluid index crossing events in 145 pts(51%)during 10.0 3.2mTachyarrhythmic events were more frequently in pts with threshold crossing events than in those not a threshold crossing(3,241 vs.1,484 events,P0.0001)VT events mainly occurred within the first 30
31、 days after the threshold crossing event;however,a similar trend was not observed for the atrial tachyarrhythmic eventsCONCLUSIONS:Intrathoracic impedance monitoring may predict arrhythmic events,especially ventricular arrhythmias in patients with HF and provides an additional management tool,Circ J
32、.2011;75(11):2614-20.,Significant increase in the incidence of ventricular arrhythmic events after an intrathoracic impedance change measured with a CRTD,29 CHF pts(23 males,64 12 years)with CRTDOpti-vol Fluid Index 60 ohms(group A,n=7)，60 ohms(group B,n=22)within 6m after implantationBNP，LVEDV,LVES
33、V,and LVEF before and 6 m after CRTD In group B,BNP(556 88 pg/mL versus 330 70 pg/mL,P 0.05),LVEDV(177 18 mL versus 149 14 mL,P 0.01),LVESV(128 14 mL versus 100 12 mL,P 0.01)were significantly decreased，LVEF(28 2%versus 35 2%,P 0.01)was significantly increased after 6m of CRT-D implantationNo signif
34、icant changes were detected in any parameters in group AThese data showed intrathoracic impedance changes reflected reverse LV remodeling in response to CRT in patients with CHF,Int Heart J.2012;53(4):249-52.,Intrathoracic impedance changes reflect reverse LV remodeling in response to CRT in CHF pat
35、ients,Intracardiac impedance monitors SV in CRT patients,Bocchiardo M et al.Europace 2010;12:702-707,14 pts with DCM，one or two suitable implantation sites for the LV lead were selected.Following atrial,RV,and LV catheter positioning,a micro-manometer catheter was placed in the ascending aorta At ea
36、ch LV lead position,a pacing protocol was performed with bi-ventricular pacing in DDD mode,AV delay 100 ms,and VV delay 0 ms.pacing rates 80,100,120,140,and 40 ppmcorrelation between SV and intracardiac SZ has been investigated during a bi-ventricular pacingDifferent CS lead implantation sites have
37、been used,but RV lead position was always apical,Bocchiardo M et al.Europace 2010;12:702-707,LV lead positions and correlation results for all patients,SZ,stroke impedance,SV,stroke volume,PP,pulse pressure,R,correlation coefficient,Example of raw data recording(ECG,surface electrocardiogram;AortaP,
38、aortic blood pressure;Z,intracardiac impedance,Bocchiardo M et al.Europace 2010;12:702-707,Haemodynamic effects of overdrive pacing,Bocchiardo M et al.Europace 2010;12:702-707,linear correlation coefficients R with grouped for left ventricular lead position,Bocchiardo M et al.Europace 2010;12:702-70
39、7,ConclusionIn HF patients,a strong correlation between changes in intracardiac impedance and LV SV was found.Typical LV lead implant positions have been tested and all appear to be suitable for this method of LV volume monitoring.,Potential value of automated daily screening of CRTD diagnostics for
40、 prediction of major cardiovascular events:results from Home-CARE,研究目的在患者出现心衰相关事件同时长期记录经胸阻抗通过回溯评估敏感性和假阳性率来完善阻抗监测算法进一步提高心衰监测系统表现,研究设计多中心，国际性终点事件驱动Event-driven(35 HF相关事件)预期 60 HF事件预期 600 所有事件,研究时间表首例植入:2008.07入组:2008.07 2010.03随访:3,9,15,21 月最后病例结束:.2011.12,入组患者300 患者,NYHA II-IVLVEF 35%高心衰住院风险Lumax 540
41、(VR,DR,HF),Eur J Heart Fail.2011;13(9):10191027,HomeCARE II,Measurement of Thoracic Impedance,Eur J Heart Fail.2011;13(9):10191027,HomeCARE II-急性失代偿性心衰,ICD 随访后住院,Eur J Heart Fail.2011;13(9):10191027,HomeCARE II多次心衰加重,Eur J Heart Fail.2011;13(9):10191027,In pts treated with CRT-D devices capable of d
42、aily transmission of their diagnostic data via Home Monitoring，this tool may increase pts quality of life and reduce morbidity,mortality,and health economic burden,it now warrants prospective studies,小 结,CRT已成为治疗心衰患者的重要手段，但仍有部分患者无应答或由于术后管理不充分而导致心血管事件CRT的心力衰竭监护系统相比传统门诊随访模式能够及时识别患者心衰病情变化和监测 CRT治疗的有效性不断发展的心衰监测工具将进一步帮助临床医生早期预测心衰加重，更好地降低患者住院率和死亡率,
