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1、除颤起搏器的临床应用,山东省千佛山医院 心内科闫素华,Contents,ICD HistoryBasic functions of defibSensing,detection and therapiesICD indicationswho gets one or notImplant procedurehow do we test the device.,History of ICDs,Internal defibrillatorLate 1940s to 1950sUnit shown is from the early 1960s,Pioneer of ICD Technology,Mi
2、chel Mirowski,MDDedicated his life to developing the ICD after his research partner died in his arms from a ventricular arrhythmiaCreated the first implantable ICD,which started clinical trials in 1980,1985-First approved ICD,Bulky,heavyShort-lived(18m)Abdominal implantThoracotomy requiredNon-progra
3、mmableLimited therapy options,Ventak is a trademark of Cardiac Pacemakers,Inc.,The next milestone for ICDs,Pectoral implants approved by the FDA in 1995More comfortable for patientsFaster implantsSmaller but just as powerful as older devices,“Active Can”Technology,TraditionalSystem,RV-Can,Evolution
4、of ICD Technology,1991,1995,The First ICDs FeaturedEpicardial Leads,Transvenous Leadsand Advanced TherapyIncrease Effectivenessof ICD Therapy,Pectoral ICDsReduce Costs andIncrease Surgical Ease,1985,“Dual Chamber”ICDs,Introduced in 1997Combine dual chamber pacing with ventricular arrhythmia detectio
5、n and therapyAbility to sense atrial activity during arrhythmiasSVT Discrimination:The ability to withhold therapy for non-lethal arrhythmias,Basic Functions of ICD,Automatically detect and treat Ventricular Tachycardia(VT)Antitachycardia pacing(ATP)CardioversionAutomatically detect and treat Ventri
6、cular Fibrillation(VF)DefibrillationBrady pacingVVI,VVIR,DDDR,How it works,SensingDetectionTherapy,Auto-Adjusting Sensitivity,Designed to sense fine VF,Post-sensedsensitivity adjustment,Post-pacedsensitivity adjustment,Programmed sensitivity,Post-pace blanking,Marker Channel Telemetry,VPACE,VPACE,VS
7、ENSE,VPACE,VSENSE,RectifiedEGM,Changing Threshold,Post-Pace,Post-Sense,10 x,4.5x,0.3 mV,Three Zone Detection,VTFVTVF,VT Detection,Ventricular sensitivityTachy detection interval(TDI)VT initial NIDVT redetect NID,VFFVTVTDetection Status:ONOFFONInterval(ms):320400Initial NID:12/1612Sensitivity(mV):0.3
8、,VT Counter Value:123456789101112,200 ms,VS,VS,VS,VS,VS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TS,TD,VF Detection,Ventricular sensitivityFibrillation detection interval(FDI)VF initial NIDVF redetection NID,FVT Detection via VF Counter,VFFVTVTDetection Status:ONONOFFInterval(ms):320260Initial NID:12/16,TF,TF,
9、12,11,10,9,8,7,6,5,4,3,2,1,TF,TF,TF,TF,TF,TF,TF,TF,TF,TF,VS,VS,VS,VS,VS,LOOKBACK WINDOW(8 INTERVALS BEFORE NID),FVT Detection via VT Counter,VFFVTVTDetection Status:ONONONInterval(ms):320380500Initial NID:12/16 12,12,11,10,9,8,7,6,5,4,3,2,1,LOOKBACK WINDOW(8 INTERVALS BEFORE NID),VS,VS,VS,TS,TS,TS,T
10、S,TS,TS,TS,TS,TS,TF,TS,TF,VF Counter:,Increased VT Detection Specificity,Sinus TachycardiaAtrial TachycardiaAtrial FlutterAtrial Fibrillation,MorphologyXXXX,Onset X,Stability X,Therapies,ATPBurstRampRamp+CardioversionDefibrillation,Burst,Ramp,Ramp+,ICD Indications,who gets one or not,Class I:Evidenc
11、e/general agreement regarding benefit,usefulness,and effectivenessClass II:Conflicting evidence/divergence of opinion regarding usefulness/effectivenessIIa:Weight of evidence/opinion in favor of usefulness/effectivenessIIb:Usefulness/effectiveness less well established by evidence/opinion.Class III:
12、Evidence/general agreement regarding lack of usefulness/effectiveness(harmful in some cases),Gregoratos G.J Am Coll Cardiol.1998;31:1175-1209.,1998 Class I Indications for ICD Therapy,1.Cardiac arrest due to VF or VT not due to a transient or reversible cause.(Level of evidence:A)2.Spontaneous susta
13、ined VT.(Level of evidence:B)3.Syncope of undetermined origin with clinically relevant,hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective,not tolerated,or not preferred.(Level of evidence:B)4.Nonsustained VT with coronary disease,prior MI,LV dysfuncti
14、on,and inducible VF or sustained VT at EP study that is not suppressible by a Class I antiarrhythmic drug.(Level of evidence:B),Gregoratos G.J Am Coll Cardiol.1998;31:1175-1209.,1998 Class II Indications,1.Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditio
15、ns.(Level of evidence:C)2.Severe symptoms attributable to sustained ventricular tachyarrhythmias while awaiting cardiac transplantation.(Level of evidence:C)3.Familial or inherited conditions with a high risk for life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic
16、cardiomyopathy.(Level of evidence:B),Gregoratos G.J Am Coll Cardiol.1998;31:1175-1209.,1998 Class II Indications(cont.),4.Nonsustained VT with coronary artery disease,prior MI,and LV dysfunction,and inducible sustained VT or VF at EP study.(Level of evidence:B)5.Recurrent syncope of undetermined eti
17、ology in the presence of ventricular dysfunction and inducible ventricular arrhythmias at EP study,when other causes of syncope have been excluded.(Level of evidence:C),Gregoratos G.J Am Coll Cardiol.1998;31:1175-1209.,1998 Class III Indications,1.Syncope of undetermined cause in a patient without i
18、nducible ventricular tachyarrhythmias.(Level of evidence:C)2.Incessant VT or VF.(Level of evidence:C)3.VF or VT resulting from arrhythmias amenable to surgical or catheter ablation;for example,atrial arrhythmias associated with the Wolff-Parkinson-White syndrome,right ventricular outflow tract VT,id
19、iopathic left ventricular tachycardia,or fascicular VT(Level of evidence:C)4.Ventricular tachyarrhythmias due to a transient or reversible disorder(e.g.,AMI,electrolyte imbalance,drugs,trauma).(Level of evidence:C),Gregoratos G.J Am Coll Cardiol.1998;31:1175-1209.,1998 Class III Indications(cont.),5
20、.Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up.(Level of evidence:C)6.Terminal illnesses with projected life expectancy 6 months.(Level of evidence:C)7.Patients with coronary artery disease with LV dysfunction and prolonged QRS d
21、uration in the absence of spontaneous or inducible sustained or nonsustained VT who are undergoing coronary bypass surgery.(Level of evidence:B)8.NYHA Class IV drug-refractory congestive heart failure in patients who are not candidates for cardiac transplantation.(Level of evidence:C),Gregoratos G.J
22、 Am Coll Cardiol.1998;31:1175-1209.,Implant Procedure,Insertion of defib leadsTest pacing parameters through analyzer of P/R wave,lead impedances,and pacing thresholdConnect defib leads with defib boxTest pacing impedance,threshold through the boxInduce VF,implant success criterion:two consecutive times or 3 out of 4 successful defibrillation,10 J safety margin.Turn of detection,close the woundFinal programming,
