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1、如何程控ICD参数减少误治疗,王岚,每一次ICD电击都意味着拯救了一位患者?,恶性室性心律失常,除颤治疗,ICD疗法对患者的影响,生活质量的影响 除了疼痛和社会功能方面，ICD患者其他方面的生活质量明显优于应用抗心律失常药物患者 如果发生生活质量的降低，ICD 电击是主要原因 CABG试验: ICD患者的生活质量明显低于无ICD患者 没有发生电击的ICD患者的生活质量与无ICD患者相同 AVID试验: 1 电击与生活质量的下降有关,解决方案之一：减少误识别,程控Rhythm ID为ON,Rhythm ID适用于VT和VT-1治疗区域单双腔ICD 均可获得,Rhythm ID的临床表现如何？,R
2、hythm ID运算法则，当敏感性保持100%时， 特异性高达94%1,1. VITALITY US Clinical Report to FDA based on one-month VITALITY DR data (PMA P960040/S032), n = 96. 2. Lee M, Corbisier R, Nabert D, et al. Clinical results of an advanced supraventricular tachycardia detection enhancement algorithm abstract #358. Heart Rhythm.
3、2004 May supplement;1:S114, n=96. 3. Based on nine-month VITALITY DR data (Guidant data on file), n = 96. 4. Based on retrospective, theoretical analysis of nine-month VITALITY DR data (Guidant data on file), n = 96.,使用一种新的腔内心电图（EGM）的向量时间选择和相关性（VTC）运算法则进行节律鉴别 Michael R Gold, Univ. of Maryland Sch. o
4、f Medicine, Baltimore, MD; Jaeho Kim, Joe Bocek, Guidant Corp., CRM Group, Redmond, WA; William Hsu, Guidant Corp., CRM Group, St Paul, MN; Darrell Wagner, Guidant-CRM, St Paul, MN; Lorenzo Dicarlo, Guidant Corp. A new rhythm discrimination algorithm, EGM vector timing and correlation (VTC) algorith
5、m is a method to discriminate ventricular tachycardia (VT) from supraventricular tachycardia (SVT) in implantable cardioverter-defibrillators (ICDs). VTC differentiates normal conduction vectors (SVT rhythms) from abnormal conduction vectors (VT rhythms) by analyzing the timing and the correlation o
6、f the rate and shock channel EGMs. The objective of this study was to characterize the performance of the VTC algorithm prospectively using signals recorded from patients (pts) undergoing ICD implantation. METHODS: Rate and shock channel EGMs were collected from 43 pts with dual coil transvenous lea
7、ds (Endotak). A reference QRS complex of the shock channel EGM is formulated by averaging QRS complexes aligned by the peak amplitude of rate channel QRS complex during sinus rhythm (SR). Eight features are extracted from the reference QRS complex and formed a SR reference vector. Amplitude and time
8、 offset with respect to the peak amplitude of Rate channel QRS complex represent each feature. When a high rate ventricular complex is detected, VTC compares the high rate complex vector to the reference vector on a complex by complex basis. If a complex is uncorrelated, it is classified as a VT com
9、plex. If more than 7 out of 10 consecutive complexes are VT or the calculated ventricular rate is greater than the atrial rate (VA), the rhythm is classified as a VT. If not, it is classified as SVT. For single chamber (SC) analysis, VA is excluded. RESULTS:The pts were 83% male with a mean age of 6
10、210 years. The left ventricular ejection fraction was 2810%. The data set consisted of 81 VT and 121 SR/SVT rhythms, including 23 atrial fibrillation (AF), 11 sinus tachycardia and 2 atrial tachycardia. Five pts had baseline bundle branch block (BBB). The dual chamber (DC) sensitivity was 100% (81/
11、81 VT) and the specificity was 97% (35/36 SVT). The SC analysis demonstrated 99% sensitivity and 97% specificity on the same data set. CONCLUSION:The new VTC rhythm discrimination algorithm is effective for discriminating VT and SVT including AF. Specificity in the DC or SC configurations are equiva
12、lent.,Rhythm ID的临床表现如何？,Rhythm ID的临床表现如何？,Rhythm ID的概念基础,根据不同节律的传导向量的相似性和差异性，Rhythm ID使用向量计时和相关性来进行分析 正常窦性节律（NSR） SVT VT,VT 向量,NSR 向量,SVT 向量,向量计时和相关性的ECG来源,频率通道： RV心尖部的近场EGM（RV头端电极 RV线圈） 电击通道： ICD除颤电极之间的远场EGM（RV线圈 SVC线圈 + 机壳）,RV头端电极,RV线圈,SVC线圈,机壳,频率,电击,TriSpect 系统,向量计时和相关性的计时排列和EGM的区别,频率,NSR,SVT,VT,
13、频率,频率,电击,电击,电击,计时排列,排列的SVT电击信号与NSR电击信号非常相似,排列的VT电击信号与NSR电击信号非常不同,从8个指定的时间比较点的电击通道振幅计算相关性 (x1, x2, . x8; y1, y2, . y8),向量计时和相关性的未知节律与模板,NSR 模板,频率,电击,当VT频率检测标准满足时，VTC将每跳的未知节律与存储的模板对比,x1,x2,x3,x4,x5,x6,x7,x8,未知节律,特征相关性系数(FCC) =,计时排列,向量计时和相关性的未知节律与模板,NSR 模板,频率,电击,未知节律,计时排列,频率,电击,计时排列,NSR 模板,未知节律,如果相关性 9
14、4% 未知的心跳被认为“相关的” 显示SVT,如果相关性 (心房率 + 10 bpm),VT,是,是,否,心房率 200 bpm 和 心室率不稳定 ( 20 ms),否,VT,是,被检测到的落入VT或VT-1频率区域的未知节律,SVT,否,Rhythm ID的逻辑运算法则： DR模式电击后,心室率 (心房率 + 10 bpm),VT,是,否,心房率 200 bpm 和 心室率不稳定 ( 20 ms),否,VT,是,被检测到的落入VT或VT-1频率区域的未知节律,SVT,Rhythm ID的逻辑运算法则： VR模式初始识别,SVT,VT,VTC 节律相关?,是,否,被检测到的落入VT或VT-1频
15、率区域的未知节律,SVT,VT,心室率不稳定 ( 30 ms),是,否,被检测到的落入VT或VT-1频率区域的未知节律,Rhythm ID的逻辑运算法则： VR模式电击后,Rhythm ID 诊断实例,“SVTinh” 标记显示SVT抑制期间的EGM,每一次ICD识别正确的电击都恰当地拯救了一位患者?,解决方案之二,在确保患者诊断正确的前提下，减少不必要的和不恰当的电击治疗，给与恰当的ATP 治疗。,PainFREE无痛治疗的研究背景,许多被ICD 诊断为VF事件实际上是快速单形性VT1,2 ATP对“慢”VT 有很高的疗效(周长300 ms; 200 bpm). 3-5 由于对疗效，加速风险及晕厥的顾虑，通常快VT不进行ATP治疗 使用高能量电击终止FVT或VF效果很好，但有疼痛并减少电池寿命，可能导致再入院。,
