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1、除颤起搏器的临床运用山东省千佛山医院 心内科闫素华Contentsn nICD Historyn nBasic functions of defibn nSensing, detection and therapiesn nICD indicationswho gets one or notn nImplant procedurehow do we test the devicen n.History of ICDsn nInternal defibrillatorInternal defibrillatorn nLate 1940s to 1950sLate 1940s to 1950sn
2、nUnit shown is from the Unit shown is from the early 1960searly 1960sPioneer of ICD Technologyn nMichel Mirowski, MDMichel Mirowski, MDn nDedicated his life to Dedicated his life to developing the ICD after his developing the ICD after his research partner died in his research partner died in his ar
3、ms from a ventricular arms from a ventricular arrhythmiaarrhythmian nCreated the first implantable Created the first implantable ICD, which started clinical ICD, which started clinical trials in 1980trials in 19801985 - First approved ICDn nBulky, heavyBulky, heavyn nShort-lived (18m)Short-lived (18
4、m)n nAbdominal implantAbdominal implantn nThoracotomy requiredThoracotomy requiredn nNon-programmableNon-programmablen nLimited therapy optionsLimited therapy optionsVentak is a trademark of Cardiac Pacemakers, Inc.The next milestone for ICDsPectoral implants approved by the FDA in 2019More comforta
5、ble for patientsFaster implantsSmaller but just as powerful as older devices“Active Can TechnologyTraditionalSystemRV-CanEvolution of ICD Technology19912019The First ICDs FeaturedEpicardial LeadsTransvenous Leadsand Advanced TherapyIncrease Effectivenessof ICD TherapyPectoral ICDsReduce Costs andInc
6、rease Surgical Ease1985“Dual Chamber ICDsn nIntroduced in 2019n nCombine dual chamber pacing with ventricular arrhythmia detection and therapyn nAbility to sense atrial activity during arrhythmiasn nSVT Discrimination: The ability to withhold therapy for non-lethal arrhythmiasBasic Functions of ICDn
7、 nAutomatically detect and treat Ventricular Automatically detect and treat Ventricular Tachycardia (VT)Tachycardia (VT)n nAntitachycardia pacing (ATP)Antitachycardia pacing (ATP)n nCardioversionCardioversionn nAutomatically detect and treat Ventricular Automatically detect and treat Ventricular Fib
8、rillation (VF)Fibrillation (VF)n nDefibrillationDefibrillationn nBrady pacingBrady pacingn nVVI, VVIR, DDDRVVI, VVIR, DDDRHow it worksn nSensingn nDetectionn nTherapy Auto-Adjusting Sensitivityn nDesigned to sense fine VFPost-sensedsensitivity adjustmentPost-pacedsensitivity adjustmentProgrammed sen
9、sitivityPost-pace blankingMarker Channel TelemetryVPACEVPACEVSENSEVPACEVSENSERectifiedEGMChanging ThresholdPost-PacePost-Sense10x4.5x0.3 mVThree Zone Detectionn nVTn nFVTn nVFVT Detectionn nVentricular sensitivityVentricular sensitivityn nTachy detection interval (TDI)Tachy detection interval (TDI)n
10、 nVT initial NIDVT initial NIDn nVT redetect NIDVT redetect NIDVFFVTVTDetection Status:ONOFFONInterval (ms):320400Initial NID:12/1612Sensitivity (mV):0.3VT Counter Value:123456789101112200 msVSVSVSVSVSTSTSTSTSTSTSTSTSTSTSTSTDVF Detectionn nVentricular sensitivityn nFibrillation detection interval (F
11、DI)n nVF initial NIDn nVF redetection NIDFVT Detection via VF Counter VFVFFVTFVTVTVTDetection Status:Detection Status:ONONONONOFFOFFInterval (ms):Interval (ms):320320260260Initial NID:Initial NID:12/16 12/16 TFTF121110987654321TFTFTFTFTFTFTFTFTFTFVSVSVSVSVSLOOKBACK WINDOW(8 INTERVALS BEFORE NID)FVT
12、Detection via VT Counter VFVFFVTFVTVTVTDetection Status:Detection Status:ONONONONONONInterval (ms):Interval (ms):320320380380500500Initial NID:Initial NID:12/16 12/16 1212121110987654321LOOKBACK WINDOW(8 INTERVALS BEFORE NID)VSVSVSTSTSTSTSTSTSTSTSTSTFTSTFVF Counter:Increased VT Detection Specificity
13、Sinus TachycardiaAtrial TachycardiaAtrial FlutterAtrial FibrillationMorphologyXXXXOnset XStability XTherapiesn nATPn nBurstn nRampn nRamp+n nCardioversionn nDefibrillationBurst Ramp Ramp+ICD Indications, who gets one or notn nClass I: Evidence/general agreement regarding benefit, usefulness, Class I
14、: Evidence/general agreement regarding benefit, usefulness, and effectivenessand effectivenessn nClass II: Conflicting evidence/divergence of opinion regarding Class II: Conflicting evidence/divergence of opinion regarding usefulness/effectivenessusefulness/effectivenessn nIIa: Weight of evidence/op
15、inion in favor of usefulness/effectivenessIIa: Weight of evidence/opinion in favor of usefulness/effectivenessn nIIb: Usefulness/effectiveness less well established by IIb: Usefulness/effectiveness less well established by evidence/opinion.evidence/opinion.n nClass III: Evidence/general agreement re
16、garding lack of Class III: Evidence/general agreement regarding lack of usefulness/effectiveness (harmful in some cases)usefulness/effectiveness (harmful in some cases)Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.2019 Class I Indications for ICD Therapy1. 1. Cardiac arrest due to VF or VT not
17、due to a transient or reversible cause. Cardiac arrest due to VF or VT not due to a transient or reversible cause. (Level of evidence: A)(Level of evidence: A)2. 2. Spontaneous sustained VT. (Level of evidence: B)Spontaneous sustained VT. (Level of evidence: B)3. 3. Syncope of undetermined origin wi
18、th clinically relevant, Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective, not tolerated, or not at EP study when drug therapy is ineffect
19、ive, not tolerated, or not preferred. (Level of evidence: B)preferred. (Level of evidence: B)4. 4. Nonsustained VT with coronary disease, prior MI, LV dysfunction, and Nonsustained VT with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at EP study that is not suppressib
20、le by a inducible VF or sustained VT at EP study that is not suppressible by a Class I antiarrhythmic drug. (Level of evidence: B)Class I antiarrhythmic drug. (Level of evidence: B)Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.2019 Class II Indications1. 1. Cardiac arrest presumed to be due to
21、VF when EP testing is Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditions. precluded by other medical conditions. (Level of evidence: C)(Level of evidence: C)2. 2. Severe symptoms attributable to sustained ventricular Severe symptoms attributable to susta
22、ined ventricular tachyarrhythmias while awaiting cardiac transplantation. (Level tachyarrhythmias while awaiting cardiac transplantation. (Level of evidence: C)of evidence: C)3. 3. Familial or inherited conditions with a high risk for life-Familial or inherited conditions with a high risk for life-t
23、hreatening ventricular tachyarrhythmias such as long QT threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy. (Level of syndrome or hypertrophic cardiomyopathy. (Level of evidence: B)evidence: B)Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.2019 Class
24、 II Indications (cont.)4. 4. Nonsustained VT with coronary artery disease, prior MI, and Nonsustained VT with coronary artery disease, prior MI, and LV dysfunction, and inducible sustained VT or VF at EP study. LV dysfunction, and inducible sustained VT or VF at EP study. (Level of evidence: B)(Leve
25、l of evidence: B)5. 5. Recurrent syncope of undetermined etiology in the presence of Recurrent syncope of undetermined etiology in the presence of ventricular dysfunction and inducible ventricular arrhythmias at ventricular dysfunction and inducible ventricular arrhythmias at EP study, when other ca
26、uses of syncope have been excluded. EP study, when other causes of syncope have been excluded. (Level of evidence: C)(Level of evidence: C)Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.2019 Class III Indications1. 1. Syncope of undetermined cause in a patient without inducible Syncope of undete
27、rmined cause in a patient without inducible ventricular tachyarrhythmias. (Level of evidence: C)ventricular tachyarrhythmias. (Level of evidence: C)2. 2. Incessant VT or VF. (Level of evidence: C)Incessant VT or VF. (Level of evidence: C)3. 3. VF or VT resulting from arrhythmias amenable to surgical
28、 or catheter VF or VT resulting from arrhythmias amenable to surgical or catheter ablation; for example, atrial arrhythmias associated with the Wolff-ablation; for example, atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, right ventricular outflow tract VT, Parkinson-White synd
29、rome, right ventricular outflow tract VT, idiopathic left ventricular tachycardia, or fascicular VT (Level of idiopathic left ventricular tachycardia, or fascicular VT (Level of evidence: C)evidence: C)4. 4. Ventricular tachyarrhythmias due to a transient or reversible disorder Ventricular tachyarrh
30、ythmias due to a transient or reversible disorder (e.g., AMI, electrolyte imbalance, drugs, trauma). (Level of evidence: (e.g., AMI, electrolyte imbalance, drugs, trauma). (Level of evidence: C)C)Gregoratos G. J Am Coll Cardiol. 2019;31:1175-1209.2019 Class III Indications (cont.)5. 5. Significant p
31、sychiatric illnesses that may be aggravated by device Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up. (Level of implantation or may preclude systematic follow-up. (Level of evidence: C)evidence: C)6. 6. Terminal illnesses with pro
32、jected life expectancyTerminal illnesses with projected life expectancy 6 months. (Level of evidence: C) 6 months. (Level of evidence: C)7. 7. Patients with coronary artery disease with LV dysfunction and Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the abs
33、ence of spontaneous or inducible prolonged QRS duration in the absence of spontaneous or inducible sustained or nonsustained VT who are undergoing coronary bypass sustained or nonsustained VT who are undergoing coronary bypass surgery. (Level of evidence: B)surgery. (Level of evidence: B)8. 8. NYHA
34、Class IV drug-refractory congestive heart failure in patients NYHA Class IV drug-refractory congestive heart failure in patients who are not candidates for cardiac transplantation. (Level of evidence: who are not candidates for cardiac transplantation. (Level of evidence: C)C)Gregoratos G. J Am Coll
35、 Cardiol. 2019;31:1175-1209.Implant Proceduren nInsertion of defib leadsInsertion of defib leadsn nTest pacing parameters through analyzer of P / R Test pacing parameters through analyzer of P / R wave, lead impedances, and pacing thresholdwave, lead impedances, and pacing thresholdn nConnect defib
36、leads with defib boxConnect defib leads with defib boxn nTest pacing impedance, threshold through the boxTest pacing impedance, threshold through the boxn nInduce VF, implant success criterion: two Induce VF, implant success criterion: two consecutive times or 3 out of 4 successful consecutive times or 3 out of 4 successful defibrillation, 10 J safety margin.defibrillation, 10 J safety margin.n nTurn of detection, close the woundTurn of detection, close the woundn nFinal programmingFinal programming
