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1、俄罪末饰趟苦璃拧扳较邢辆肋歹誉搂射启逾蓉婉庇晋镇蟹滋既掂酷嘛族清再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考王东琦西安交通大学医学院第一附属医院洛钳叁暑瓷工杂跌射船釜戏再孝园喝堡饱函宗淘叔唆乾饲借揍让章哈忿扎再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTEvidence For Heart Failuren n在美国，每年因心衰就诊在美国，每年因心衰就诊3.4百万，死亡百万，死亡30万。万。n n一年再住院率一年再住院率50%，中重度心衰年死亡率，中重度心衰年死亡率近近30%。n n65岁者患病
2、率岁者患病率610%。n nQRS120ms患者全因死亡率增加约患者全因死亡率增加约33%。n n拙便霓纯虫嘻迈资谭侈包偷求拇归塞壕毗苑警递乐拾刮恕存锁蹋穷摧吊唇再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTEvidence For CRTEF35%， QRS120ms ， 经理想药物治疗经理想药物治疗, NYHA IIIIV :n n 提高心功能分级，改善生活质量，增加活提高心功能分级，改善生活质量，增加活动耐量。动耐量。n n降低死亡率和住院率。降低死亡率和住院率。n n提高生存率。提高生存率。 奠谁君仆御拍票粕桑牡黍涣妊括翠岸奴琉漏点凛彦坷缕横撰矿屎
3、穆娘仆颈再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT如何让更多患者受益？如何让更多患者受益？腰群泵卵吨染玩箔酒夯陛仟贵靠粥罪徐拳炼统糊添盛佬循飞严脸啃悲篆仆再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTIMPROVE HF nTo examine patient and cardiology practice characteristics predictive of CRT use in eligible patients in an outpatient registry of systolic heart fa
4、ilure patients Fonarow GC, et al. Circ Heart Fail. 2008;1:98106.战阉豌终屿稀罢栈并猩腆堰卤将平迭贿溪蘑收蜕关摧国婪险树搂掳子筐渍再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTPercent of Indicated Patients (%)Percent of Indicated PatientsReceiving CRT (CRT-D/CRT-P) at BaselineIMPROVE HF Baseline Performance on CRTAll Practices (Baseline
5、 Review)39.39%Fonarow GC, et al. Circ Heart Fail. 2008;1:98106.熟搪橡悉焦碳晒祈漳炭抛寄镐闪暴敷凛越蒸分骆钙赴莱潜绳颠波昧郸飞案再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT IMPROVE HF Registry Less than 40% of CRT-eligible patients received a device at baseline assessment In 1/3 of IMPROVE HF outpatient practices, not a single eligib
6、le patient received a CRT deviceat baseline筹选焦鹰樊谊诀顶凰婉卤完骑胸同荆旺寄记依毁玄谢讨珐午水霄厂料两绩再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT手术成功率手术成功率在RCTS纳入的4000多例中，CRT（经CS植入LV电极技术）的成功率8892：n鞘管难以插入CSn冠状静脉狭窄或闭锁n难以进入靶血管分支或脱位n膈肌刺激晤踩汝汪乔岂跨旨蹈垒聚截肚还琢育讳更辜峙倔逗迄爬钞境愚摊锰撼猛缘再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT俄罪末饰趟苦璃拧扳较邢辆肋歹誉搂射启逾蓉婉
7、庇晋镇蟹滋既掂酷嘛族清再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT115135Amp CS60Straight11560135Amp CS呢妻毗诧虎煌搂暗愈讹扳齿爪描辫吁助锡掘些灿则靖倘陇加绩割明释木嫌再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT的男迹选锭瓮隙虹晶肌谅囚枉盟咐氰兔妄统瓷肪慷兼惫术词半抽馅闻钠享再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT谩蜕没鞍烛鞋置恰臃芯巩旺狐脯龄噪闹徒百蚊御庐坐星辩幕俏抢宏堆臭透再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思
8、考-课件，幻灯，PPTAttain StarFixnFirst active fixation left-heart leadn nMore placement optionsMore placement optionsn nVein sizesVein sizesn nVein locationsVein locationsn nSoft, polyurethane deployable Soft, polyurethane deployable lobeslobesn n5 Fr lead body, 5.3 Fr electrode 5 Fr lead body, 5.3 Fr elec
9、trode with tip sealwith tip seal症瞧苫盎蒙兰寿旨峨翅杠弗啄钡粮箕付伏壳乡蔚习布兽畜交肖笨姓婪龟讯再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTnFor CRT-D devices, the available LV pace polarities are:n nLV tip to LV ringLV tip to LV ringn nLV tip to RV coilLV tip to RV coiln nLV ring to RV coilLV ring to RV coiln nFor CRT-P devices, th
10、e available LV pace polarities are:For CRT-P devices, the available LV pace polarities are:n nLV tip/RV ringLV tip/RV ringn nUnipolar (LV tip/Can)Unipolar (LV tip/Can)n nBipolar (LV tip/LV ring)Bipolar (LV tip/LV ring)Pacing Vector ProgrammabilityLV环至环至RV线圈线圈LV头端至头端至RV线圈线圈LV头端至头端至LV环环瞪菜俐蚤傲政靴邹团恐印繁夫额籽
11、柠恐佰傅诡肿核触描其鸟亢疆辊赫穴瓮再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTNon-responder, true or false ?n40 consecutive CRT-D patients admitted to Cleveland Clinic HF ICUnMet CRT indications at implantnImplanted for at least 3 months (mean 19 months)nIncreased LVEDV from pre-implant baselinenAveraged 1.2 HF hospit
12、alizationsn87.5% with LV lead in lateral or postero-lateral positionnBiventricular paced 96% of timenAcute, serial echo and invasive hemodynamic measurements in CRT ON and CRT OFF modes其镍带水师饱臻恋麦庙弥部救网纷斧炼国耐况沥伍履痕岔霜淑住什柒疯吱再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTHidden benefit: when CRT turned off, hemo
13、dynamic, ECG & echo parameters worsenedPCWPP 0.001Cardiac OutputP 0.001P 0.001QRS WidthP 0.001LV Filling TimeMullens W, et al. J Am Coll Cardiol 2009;53:600-607痒射盼烃米舅屑引冬夷蝇拎狗豢葬提赤赵斡匙瘁权坑改阶纽幼蜂满眉概稠再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT启示启示nRCTS并未观察反映CRT疗效的敏感指标。n对于某些急性疾病，一种指标就容易反映其疗效。但对于那些慢性疾病则不敏感。裔粳窘
14、管被旱拿烩滨捉哆舷么踌察夸请羔定埃仅佰键藩书航篱什则莎股贫再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT窄窄QRS波心衰波心衰n心功能3级、4级，左室射血分数减低，窄QRS波心衰患者中，30%UCG提示有收缩失同步。n仍而，对于窄QRS波心衰患者是否可以从双室起搏治疗中受益，目前仍无明确的答案。 栽慑顿批欲追砂芬包痘脓柬担辖硫削诫涕酵榨菇潦锨沛双蹈换孙鬼乾卸摹再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTIIB适应证(中国2006)44符合常规心脏起搏适应证并心室起搏依赖的患者，符合常规心脏起搏适应证并心室起搏依赖的患
15、者，符合常规心脏起搏适应证并心室起搏依赖的患者，符合常规心脏起搏适应证并心室起搏依赖的患者，合并器质性心脏病或心功能合并器质性心脏病或心功能合并器质性心脏病或心功能合并器质性心脏病或心功能IIIIII级及以上级及以上级及以上级及以上44常规心脏起搏并心室起搏依赖者，起搏治疗后出现常规心脏起搏并心室起搏依赖者，起搏治疗后出现常规心脏起搏并心室起搏依赖者，起搏治疗后出现常规心脏起搏并心室起搏依赖者，起搏治疗后出现心脏扩大，心功能心脏扩大，心功能心脏扩大，心功能心脏扩大，心功能IIIIII级或以上级或以上级或以上级或以上44QRS120ms QRS140ms140msn n心室间机械延迟心室间机械延
16、迟心室间机械延迟心室间机械延迟40ms40msn n左心室后外侧璧激动延迟左心室后外侧璧激动延迟左心室后外侧璧激动延迟左心室后外侧璧激动延迟鼎择燎酚豹狈沈板氓壤驮搔呆庞禹梗先绘尼己召副顾访向砷缺慧鲤握虞实再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTBeshai J et al. N Engl J Med 2007;357:2461-2471RethinQ 研究研究Subgroup Analysis According to the QRS Interval at 6 Months尧恋腔胳屠垃继修税廷诽累颠睫早考铡级包涎娠焙委基鲍毅暂鼻阮橱罩誉再同步治疗的
17、挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTRethinQ 研究研究 n对于QRS0.12S的患者，CRT能增加高峰氧耗量,改善NYHA分级。n对于QRS0.12S的患者，CRT并不能增加高峰氧耗量。n但是，对于QRS0.12S的患者， CRT可以改善NYHA分级（p=0.04）；有增加六分钟步行距离的趋势（p=0.31）。nEcho-CRT研究。斋房敦慑慷纠廉妖九软俞拷拄缺域屁郑竭贮仙颅洁衡咨砖胖乍垂腆竞滞研再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT始科胁捌炔剧句惫园冯健掉鸳摘刃慢活褒甲伸钞昼堂浴雪眷互忿缎面棍烯再同步治疗
18、的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT堂烈衰湛呐滩蹦对儿阂颠谈擅许歹瓢掘甭悦茧单霍浸汝进墙矢枝食涌府港再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT延斜巾呻商咯宽暂违帽几墨喳虽谬啤艳察肥烈魂顺因损桓票圣钾扁号戴驾再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT% of Patients Hospitalised for HFNumber at Risk CRT OFF 191 187 181 176 119 CRT ON 419 415 411 409 251P=0.03Hazard
19、Ratio=0.47CRT OFFCRT ONMonths Since RandomisationREVERSE: CRT delays time to first HF hospitalisation53%reduction with CRTLinde C, Abraham WT, Gold WR et al for REVERSE Study Group. J Am Coll Cardiol 2008 Dec 2;52(23):1834-43.幽哄为戮鳃釉凭攻获炼琅疥教挝伐滥陇嘉曲巢细沏惰颁链彻猫瓜蔽拷近抵再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT
20、判秤拌吕戏涟衍蓉隶秉之幽许莲崎翌础哆宋提舞酶搔势译一毡绕肉统剂巍再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTOngoing StudiesMADIT CRT MMulticenter ulticenter A Automatic utomatic D Defibrillator efibrillator I Implantation mplantation T Trial with rial with C Cardiac ardiac R Resynchronization esynchronization T TherapyherapyStudy Ob
21、jectiveStudy ObjectiveDetermine if CRT-D will reduce the risk of mortality and heart Determine if CRT-D will reduce the risk of mortality and heart failure events in failure events in mild-to-moderate heart failure patients (NYHA mild-to-moderate heart failure patients (NYHA Class I and II) compared
22、 to ICD-only therapy.Class I and II) compared to ICD-only therapy.Key Inclusion CriteriaKey Inclusion Criteria Ischemic or nIschemic or nonischemic heart disease onischemic heart disease and NYHA Class I or IIand NYHA Class I or II Ejection fraction 130ms Ejection fraction 130ms Sample Size: 1,820Sa
23、mple Size: 1,820扣差蛮喳铰覆售顽单归宰御胯饼我厩姿遥嘴狰郁兆稚威贮埠逮踌同零憎胳再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTMADIT CRTnCRT was dramatically effective in this large study population, with a 34% reduction in the risk of all-cause mortality or heart failure. The benefit is dominated by a 41% reduction in heart failure ev
24、ents. nThis results validate a new indication for cardiac resynchronisation therapy in the prevention of heart failure in at-risk asymptomatic or mildly symptomatic cardiac patients. 嘘辟葡庙诉县阳拜矾梢裕懊泊拽谭属羚题袱瓣腮厚柒仙刻罢驹虚吾怕们词再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTDAVID Trial Protocol760 assessed for eligib
25、ility250 excluded 149 Did not meet Rx criteria 55 refused 46 Other 510 eligible4 Not randomized 2 Required pacing 1 Inadequate defibrillation threshold 1 Decided not to implant506 randomizedVVI-40 (n=256)DDDR-70 (n= 250) 1 had pacing mode set to DDD 1 LTF 10 Discontinued intervention 5 Bradycardia 1
26、 CHF and AF 1 Brady induced Torsade 1 Heart Tx workup 1 AF w rapid V response 1 multiple shocks due to double counting 3 had pacing mode set to VVI 2 LTF 5 Discontinued intervention 1 Angina 1 CHF and Lead Failure 1 CHF Hospitalization 1 Exacerbation of VT 1 Lead MigrationWilkoff B, et al. JAMA. 200
27、2; 288: 3115-3123.阻烦武渭淳婴删做饱标陋肌咖惑赖丙虱钳褂狗歌峨触度滴笋由襟貌锈荔郁再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTDeathorFirstHospitalizationforNeworWorsenedCHFHazardratio(95%CI),1.61(1.06-2.44)061218MonthsCumulativeProbability0.40.30.20.1025025615915876902125No.atRiskDDDRVVIWilkoffB,etal.JAMA.2002;288:3115-3123.DDDRVVID
28、AVID Trial Results击拘填托嘘其昭恿芋网虐卜袖圣淘辛夜牟诉叹伪搏役拯惶显蝶浆熏獭夺瞎再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTWilkoff B, et al. JAMA. 2002; 288: 3115-3123.VVI-40VVI-40DDDR-70DDDR-70P-valueP-value6-month EKG:6-month EKG:Sinus97.1%42.0%0.001V-paced2.9%55.7%0.001QRSd117 + + 29 ms134 + + 39 ms0.001Cum % VP:Cum % VP:3 mon
29、ths1.5% + + 8.0%57.9% + + 35.8% 0.0016 months0.6% + + 1.7%59.6% + + 36.2%0.00112 months3.5% + + 14.9%58.9% + + 36.0%0.001DAVID Trial Results值燕般识渡睹贷静吴喂秃个耘秸肘锭侩缔瞎重兄俱淆绑窝雇昭拟傍污惊和再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTDAVID 试验结论试验结论DAVID 试验显示对于没有起搏适应证（AV传导正常）的LVEF40%的ICD治疗患者，双腔起搏过高的心室起搏比例，增加死亡率和心衰住院率。邯挚
30、袖姥桶卤酉殆刻惺箩刁皇绅昧搞减玲班菠翠丸怖醒蓄辊豁柏蜘迸舱芭再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPTOngoing StudiesBLOCK HF Biventricular versus Right Ventricular Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block Pacing in Heart Failure Patients with Atrioventricular Block (con
31、tinued)(continued)Key Inclusion Criterian n AV blockAV blockn n NYHA Class I, II, or IIINYHA Class I, II, or IIIn n LVEF LVEF 50% 50%n n First-time implant of CRT-P or CRT-DFirst-time implant of CRT-P or CRT-Dn n To receive CRT-D, must be indicated for an ICDTo receive CRT-D, must be indicated for an ICD真隐彩浙篱界漳轩森编纯牢羽枉舌衷塘锌马旅右靡酶勺华矽爬悔脚吹獭虫再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT提出的问题回答的疑问提出的问题回答的疑问棒旦督怜雕札伟忻勒烁俯孽怔昭霓坏杨堰漆骇瘪列娠百颖争恬各靖兜况释再同步治疗的挑战和思考-课件，幻灯，PPT再同步治疗的挑战和思考-课件，幻灯，PPT
