除颤起搏器的临床应用课件

,Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Contents,ICD History,Basic functions of defib,Sensing, detection and therapies,ICD indicationswho gets one or not,Implant procedurehow do we test the device,.,ContentsICD History,1,History of ICDs,Internal defibrillator,Late 1940s to 1950s,Unit shown is from the early 1960s,History of ICDsInternal defibr,2,Pioneer of ICD Technology,Michel Mirowski, MD,Dedicated his life to developing the ICD after his research partner died in his arms from a ventricular arrhythmia,Created the first implantable ICD, which started clinical trials in 1980,Pioneer of ICD TechnologyMiche,3,1985 - First approved ICD,Bulky, heavy,Short-lived (18m),Abdominal implant,Thoracotomy required,Non-programmable,Limited therapy options,Ventak is a trademark of Cardiac Pacemakers, Inc.,1985 - First approved ICDBulky,4,The next milestone for ICDs,Pectoral implants approved by the FDA in 2019,More comfortable for patients,Faster implants,Smaller but just as powerful as older devices,The next milestone for ICDsPec,5,“Active Can” Technology,TraditionalSystem,RV-Can,“Active Can” TechnologyTraditi,6,Evolution of ICD Technology,1991,2019,The First ICDs FeaturedEpicardial Leads,Transvenous Leadsand Advanced TherapyIncrease Effectivenessof ICD Therapy,Pectoral ICDsReduce Costs andIncrease Surgical Ease,1985,Evolution of ICD Technology199,7,“Dual Chamber” ICDs,Introduced in 2019,Combine dual chamber pacing with ventricular arrhythmia detection and therapy,Ability to sense atrial activity during arrhythmias,SVT Discrimination: The ability to withhold therapy for non-lethal arrhythmias,“Dual Chamber” ICDsIntroduced,8,Basic Functions of ICD,Automatically detect and treat Ventricular Tachycardia (VT),Antitachycardia pacing (ATP),Cardioversion,Automatically detect and treat Ventricular Fibrillation (VF),Defibrillation,Brady pacing,VVI, VVIR, DDDR,Basic Functions of ICDAutomati,9,How it works,Sensing,Detection,Therapy,How it worksSensing,10,Auto-Adjusting Sensitivity,Designed to sense fine VF,Post-sensedsensitivity adjustment,Post-pacedsensitivity adjustment,Programmed sensitivity,Post-pace blanking,Marker Channel Telemetry,V,PACE,V,PACE,V,SENSE,V,PACE,V,SENSE,RectifiedEGM,Changing Threshold,Post-Pace,Post-Sense,10x,4.5x,0.3 mV,Auto-Adjusting SensitivityDe,11,Three Zone Detection,VT,FVT,VF,Three Zone DetectionVT,12,VT Detection,Ventricular sensitivity,Tachy detection interval (TDI),VT initial NID,VT redetect NID,VFFVTVT,Detection Status:ONOFFON,Interval (ms):320400,Initial NID:12/1612,Sensitivity (mV):0.3,VT Counter Value:123456789101112,200 ms,V,S,V,S,V,S,V,S,V,S,T,S,T,S,T,S,T,S,T,S,T,S,T,S,T,S,T,S,T,S,T,S,T,D,VT DetectionVentricular sensit,13,VF Detection,Ventricular sensitivity,Fibrillation detection interval (FDI),VF initial NID,VF redetection NID,VF DetectionVentricular sensit,14,FVT Detection via VF Counter,VFFVTVT,Detection Status:ONONOFF,Interval (ms):320260,Initial NID:12/16,TF,TF,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 VF Counter,15,FVT Detection via VT Counter,VFFVTVT,Detection Status:ONONON,Interval (ms):320380500,Initial 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,TS,TS,TS,TS,TS,TS,TF,TS,TF,VF Counter:,FVT Detection via VT Counter,16,Increased VT Detection Specificity,Sinus Tachycardia,Atrial Tachycardia,Atrial Flutter,Atrial Fibrillation,Morphology,X,X,X,X,Onset,X,Stability,X,Increased VT Detection Specifi,17,Therapies,ATP,Burst,Ramp,Ramp+,Cardioversion,Defibrillation,TherapiesATP,18,Burst,Burst,19,Ramp,Ramp,20,Ramp+,Ramp+,21,ICD Indications, who gets one or not,Class I,: Evidence/general agreement regarding benefit, usefulness, and effectiveness,Class II,: Conflicting evidence/divergence of opinion regarding usefulness/effectiveness,IIa: Weight of evidence/opinion in favor of usefulness/effectiveness,IIb: Usefulness/effectiveness less well established by evidence/opinion.,Class III,: Evidence/general agreement regarding lack of usefulness/effectiveness (harmful in some cases),Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.,ICD Indications, who gets one,22,2019 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 sustained 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 dysfunction, 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. 2019;31:1175-1209.,2019 Class I Indications for I,23,2019 Class II Indications,1.Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditions.,(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 cardiomyopathy.,(Level of evidence: B),Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.,2019 Class II Indications1.Ca,24,2019 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 etiology 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. 2019;31:1175-1209.,2019 Class II Indications (con,25,2019 Class III Indications,1.Syncope of undetermined cause in a patient without inducible 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,r,ight ventricular outflow tract VT, idiopathic left,ventricular tachycardia, or fascicular V,T,(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. 2019;31:1175-1209.,2019 Class III Indications1.S,26,2019 Class III Indications (cont.),5.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 duration 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 Am Coll Cardiol. 2019;31:1175-1209.,2019 Class III Indications (co,27,Implant Procedure,Insertion of defib leads,Test pacing parameters through analyzer of P / R wave, lead impedances, and pacing threshold,Connect defib leads with defib box,Test pacing impedance, threshold through the box,Induce VF, implant success criterion: two consecutive times or 3 out of 4 successful defibrillation, 10 J safety margin.,Turn of detection, close the wound,Final programming,Implant ProcedureInsertion of,28,除颤起搏器的临床应用课件,29,除颤起搏器的临床应用课件,30,