起搏器培训课件：生理性AdaptivCRT™ 算法介绍

动态优化，随心而跳。生理性AdaptivCRT 算法介绍 Note: All technical information within this guide is based on Medtronic VivaTM XT Manual.Change in a patients disease and/or indications may alter the efficacy of a devices programmed parameters or related features and may impact longevity.起搏频率黄线= 自身激动白线 = 起搏刺激标准的双室起搏模式= LV and RV Pace标准的双室起搏模式在过去10年中一直都是按照固定的AV间期进行心脏再同步治疗。（PAV/SAV：130/100）AdaptivCRT 算法1. 生理性CRT起搏：提供动态的生理性的CRT起搏模式，鼓励右室自身下传。2. 动态调整：每分钟评估和优化CRT起搏模式，AV间期，VV间期；根据不同的患者个性化的采取适应性的LV起搏和双室起搏。 AdaptivCRTMVPAdaptivCRT Algorithm*Normal if: SAV 200 ms, PAV 250 ms下传是否正常*?HR100 bpm?yes节律规整?noBi V PacingnoyesLV 起搏Adaptive LV pacingAV=shorter of either:70% of the intrinsic AVIntrinsic AV 40 msAV = shorter of either:P wave + 30 msIntrinsic AV 50 ms VV: If fusion and QRS 100 bpm, or2.延迟的房室传导, orAS-VS 200 msAP-VS 250 ms3.左室阈值管理确保左室夺获Adaptive LVSAV = 140 msAs-RVs = 205 msAdaptive BiVSAV = 110ms动态左室起搏到动态双室起搏的自动转换动态左室起搏每分钟自动检查动态双室起搏AdapitvCRT算法3. 优化间期1. 评估自身传导2. 决定起搏模式动态左室起搏和动态双室起搏1. 评估自身传导每分钟测量自身下传间期，判断间期是否正常或者是延长通过延长SAV到300ms来实现测量。测量时可以通过发放VSR来满足同步起搏需要*AV conduction checks will be delayed if AV block is suspected.2. 决定起搏模式根据自身心率高低和下传间期的长短来决定不同的起搏模式3. 优化起搏时间Adaptive LV动态优化AV间期提前起搏左室，同步右室。Adaptive BiV 动态优化AV间期，VV间期同步起搏。根据患者活动度和自身下传状态，动态优化起搏间期提高CRT治疗的效果1.动态LV起搏LV起搏与右室下传同步心率动态左室起搏= LV 起搏, RV 感知 对于传导正常的患者，动态左室起搏可以提供同步治疗，减少右室起搏，增加CRT寿命。动态左室起搏通过提前起搏左心室并与自身下传的右心室形成再同步。 左室起搏AV间期（取小值）: 70% 自身下传AV 自身下传AV 40msCRT每分钟自动测量自身传导时间，动态左室起搏自动调整AV间期同步右室，保持提供最优化的CRT治疗延长后的SAV2.动态左室起搏根据不同运动状态调整CRT治疗Adaptive LV = LV paced, RV sensed 由于各种活动原因导致自身传导发生变化时，动态LV起搏优化CRT治疗以适应变化。当运动或下传变快，动态LV 起搏缩短AV间期。运动造成自身下传AV间期缩短心率变快使得自身PR间期变短，小于SAV，导致VS出现，而触发VSR工作，这时的VSR是一个左室起搏。心率变快PR缩短测量PR间期的分钟计时器到时后，AV间期会自动调整为300ms以测量变化后的PR间期。VS之后触发一个左室的VSR。重新测量PR在重新测量完PR间期后，SAV随之进行优化（缩短），左室起搏按照调整后的AV间期发放，CRT治疗被优化。缩短后的SAV3.动态左室起搏转到动态双室起搏根据自身下传延长（房室阻滞）调整CRT治疗Adaptive LV = LV Paced, RV Sensed当自身PR间期延长时，或者发生AVB时，自动转换成动态双室起搏当PR间期过长时（或发生AVB），动态左室起搏转换成动态双室起搏。传导的AV间期延长超出时间PR间期延长或者放室传导阻滞当每分钟PR间期测试时间到达时，AV间期延长到300ms，右室下传在280ms时出现，并触发一个VSR。延长后的SAVAV间期的测试结果指出动态左室起搏的条件已经不满足（ SAV 200 ms ），这时CRT自动转换成动态双室起搏。换成为双室起搏动态双室起搏的运行状态中，AV间期和VV间期也是在进行动态的调整和优化。动态双室起搏4.动态双室起搏动态AV间期优化（P波、QRS波测量）调整CRT治疗动态双室起搏动态 BiV = 左室、右室同步起搏动态双室起搏通过调整房间传导延迟来维持心房收缩房间传导延迟当房间传导延迟时，P波增宽并破坏（infring）到了双室起搏，造成心房收缩末期同时的心室收缩。P波增宽每16个小时，波形宽度测试开启，AV间期自动延迟到300ms，无VSR发放。CRT测量5个周期的P波和QRS波宽度。（运用LECG的通道）测量P和QRS波宽波宽测量以后，自动优化AV间期使得心房完全收缩后再双室起搏。同时VV间期也得到优化。延长AV，优化房室顺序AdaptivCRT患者的一天生活.动态优化，随心而跳患者老王I类适应证植入了带有AdaptivCRT功能的CRTD，心功能II级，EF28%。并在手术后恢复到正常的生活起居。AdaptivCRT患者的一天生活每一分钟，你的心跳都在改变。每一分钟，AdaptivCRT都在优化。AdaptivCRT患者的一天生活AdaptivCRT患者的一天生活AdaptivCRT通过自动优化CRT设置，鼓励自身生理激动，提高CRT的反应率.1,2Note: All demonstrated data are fictitious and for demonstration purposes only.老王6个月的随访数据：Total VP = 98% Adaptive LV pacing = 70% Adaptive BiV or Nonadaptive BiV pacing = 30%AdaptivCRT 优化了CRT治疗，在大多数时候都鼓励自身右室下传，并同步左室起搏。1 Martin, D.O., et. al. Heart Rhythm (2012), doi: 10.1016/j.hrthm.2012.07.009. 2 Singh JP, Shen J, Chung ES. Clinical Response with Adaptive CRT algorithm compared to echo-guided AV optimization. Presentation at European Society of Cardiology Congress August 2012. “Day in the Life” Summary 每一分钟，你的心跳都在改变。AdaptivCRT患者的一天生活AdaptivCRT通过自动优化CRT设置，鼓励自身生理激动，提高CRT的反应率.1,2Note: All demonstrated data are fictitious and for demonstration purposes only.老王6个月的随访数据：Total VP = 98% Adaptive LV pacing = 70% Adaptive BiV or Nonadaptive BiV pacing = 30%AdaptivCRT 优化了CRT治疗，在大多数时候都鼓励自身右室下传，并同步左室起搏。1 Martin, D.O., et. al. Heart Rhythm (2012), doi: 10.1016/j.hrthm.2012.07.009. 2 Singh JP, Shen J, Chung ES. Clinical Response with Adaptive CRT algorithm compared to echo-guided AV optimization. Presentation at European Society of Cardiology Congress August 2012. References1 Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. June 13, 2002;346(24):1845-1853. 2 Medtronic Viva XT CRT-D manual.3 Martin DO, Lemke B, Birnie D, et al. Investigation of a Novel Algorithm for Synchronized left ventricular pacing and Ambulatory Optimization of Cardiac Resynchronization Therapy. Heart Rhythm October 2012 (in press). Brief StatementViva XT CRT-D Model DTBA1D4, Viva XT CRT-D Model DTBA1D1Indications for Use: The Viva XT CRT-D system is indicated for ventricular antitachycardia pacing and ventricular defibrillation for automated treatment of life threatening ventricular arrhythmias and for providing cardiac resynchronization therapy in heart failure patients who remain symptomatic despite optimal medical therapy and meet any of the following classifications: New York Heart Association (NYHA) Functional Class III or IV and who have a left ventricular ejection fraction 130 ms, left ventricular ejection fraction 30%, and NYHA Functional Class II. The system is also indicated for use in patients with atrial tachyarrhythmias, or those patients who are at significant risk for developing atrial tachyarrhythmias.Lead Integrity AlertThe RV Lead Integrity Alert feature is intended primarily for patients who have a Medtronic ICD or CRT-D device and a Sprint Fidelis lead (Models 6949, 6948, 6931, and 6930). At the discretion of the clinician, the feature may be used with other RV leads manufactured by Medtronic.Contraindications: The Viva XT CRT-D system is contraindicated for patients experiencing tachyarrhythmias with transient or reversible causes including, but not limited to, the following: acute myocardial infarction, drug intoxication, drowning, electric shock, electrolyte imbalance, hypoxia, or sepsis. The device is contraindicated for patients who have a unipolar pacemaker implanted. The device is contraindicated for patients with incessant VT or VF. The device is contraindicated for patients whose primary disorder is chronic atrial tachyarrhythmia with no concomitant VT or VF. Warnings and Precautions: Changes in a patients disease and/or medications may alter the efficacy of the devices programmed parameters. Patients should avoid sources of magnetic and electromagnetic radiation to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage, induction of an arrhythmia, device electrical reset, or device damage. Do not place transthoracic defibrillation paddles directly over the device. Certain programming and device operations may not provide cardiac resynchronization. Potential Complications: Potential complications include, but are not limited to, rejection phenomena, erosion through the skin, muscle or nerve stimulation, oversensing, failure to detect and/or terminate tachyarrhythmia episodes, acceleration of ventricular tachycardia, and surgical complications such as hematoma, infection, inflammation, and thrombosis. See the Device Manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at 1 (800) 328-2518 and/or consult Medtronics website at . Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. UC20130771 ENJanuary 2013