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,*,ICD,植入术后管理,-,如何减少,ICD,不适当电击,沈法荣,浙江医院心内科,2011.03.05,南京,ICD植入术后管理-如何减少ICD不适当电击沈法荣,ICD,不适当电击,除了由于发生恶性室性心律失常必须进行电治疗外的其它电击治疗均称为,ICD,不适当电击,ICD,不适当电击包括：,误放电、不必要,的电击,ICD不适当电击除了由于发生恶性室性心律失常必须进行电治疗外,ICD,疗法对患者的影响,基础疾病,：,心肌缺血、心功能恶化、电风暴等,生活质量的影响,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,心理的影响,Shock!,ICD疗法对患者的影响基础疾病：心肌缺血、心功能恶化、电风暴,减少不适当电击的益处,1-4,改善患者的生活质量,( Improved patient quality of life);,增加,ICD,的依从性,(Increased ICD acceptance);,延长,ICD,使用寿命,( Improved ICD longevity);,减少患者由于放电就诊，随访次数以及电击后住院治疗，减轻,ICD,植入后医生工作负担,( Fewer calls to physicians, requests for emergency vehicles, ER visits, and hospitalizations for post-shock care).,1,Wathen MS, et al. PainFREE Rx II Study.,Circulation,. 2004;110:2591-2596.,2,Sears SE Jr, et al. Understanding ICD shocks.,Clin Cardiol,. March 2003;26(3):107-111.,3,Irvine J, et al. Quality of life in the Canadian ICD Study (CIDS).,Am Heart J.,August,2002;144(2):282-289.,4,Ahmad M, et al. Patients attitudes toward ICD shocks.,PACE,. June 2000;23(6):934-938.,减少不适当电击的益处 1-4改善患者的生活质量( Impro,引起不适当电击的常见原因,MADIT II.,J Am Coll Cardiol,. April 2008;51(14):1357-1365.,Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial.,Heart,Rhythm Society Conference. 2004.,误放电,(,窦性、,SVT/AF,、干扰,),或反复放电,不必要的电击,引起不适当电击的常见原因MADIT II. J Am Col,如何减少,ICD,不适当电击？,1,、减少,误放电,2,、减少,不必要,的电击,如何减少ICD不适当电击？,1,、减少误放电,干扰引起,(1),、电极导线断裂占,48%,；,在,990,例患者中，,ICD,除颤导线植入后,5,年和,8,年时，无故障率分别为,85%,和,60%,。植入,10,年后，,ICD,除颤导线的年故障率达,20% (P,机壳,RV,线圈, SVC,线圈,SVC,线圈,机壳,每日测量,RV,机壳、,RVSVC,和,SVC,机壳的阻抗,基于这些测量,计算电击向量的阻抗值,(,如,: RVSVC,和机壳,),单线圈导线测量,RV,机壳,1、减少误放电干扰引起(1)、电极导线断裂占48%；2 G,1,、减少误放电,干扰引起,(2),、,T,波过感知占,48%,；,处理：程控感知灵敏度、,Decay-delay,、程控极性、药物和重新植入,ICD,导线或起搏导线,(3),、电磁干扰,EMI,占,4%、,肌电干扰及导线断裂,2,Gunderson BD, Gillberg JM, Swerdlow CD. Importance of Oversensing in Inappropriate Detection of Ventricular Fibrillation by Chronically-Implanted ICDs.,Heart Rhythm,. 2004;1:S244. Abstract.,1,Poster: Poole JE, et al. Analysis of ICD Shock Electrograms in the SCD-HeFT Trial. H,eart Rhythm,. 2004.,3,Abstract: Patel AS, et al. Modification to Lead Integrity Alert Improves Performance. HRS Conference 2009.,1、减少误放电干扰引起2 Gunderson BD, Gi,9,VT/VF,识别功能障碍,-,T,波过感知,2.0mV,1.5mV,2004-06-14,2004-11-11,术后测试：阈值：,0.5V,（,0.42ms,）、,R,波：,9mV,、,DFT,：,15J,处理：,程控感知灵敏度,Decay-delay,程控极性,药物,重新植入,ICD,导线或起搏导线,9VT/VF识别功能障碍- T波过感知2.0mV 1.5mV,10,NF-VEGM,FF-VEGM,电磁干扰,(EMI),过感知,肌电干扰过感知,电极断裂致过感知,Low Frequency,AEGM,NF-VEGM,NF-VEGM,FF-VEGM,10NF-VEGMFF-VEGM电磁干扰 (EMI)过感知肌,11,导线完整性损坏,50%,以上导线断裂或绝缘破损者有,ICD,放电！,11导线完整性损坏50%以上导线断裂或绝缘破损者有ICD放电,1,、减少误放电,-,窦性、,SVT/AF,误放电,窦性心律,处理：,窦速被,ICD,误识别为,VT-,Onset,、形态学,窦速被误识别为,VF-,在,VF,区中设置,FVT,区，并扩大,SVT,鉴别的范围,1、减少误放电- 窦性、SVT/AF误放电窦性心律处理：,窦速,室速,Onset,窦速室速Onset,1,、减少误放电,- SVT/AF,三次误放电,房颤,房颤,处理：稳定性、形态学标准,在,VF,区中设置,FVT,区，并扩大,SVT,鉴别的范围,1、减少误放电- SVT/AF 三次误放电房颤房颤处理：,ICD,的识别,识别,再识别,基本指标,加强指标,频率,持续时间,猝发指标（,onset,）,稳定性指标（,stability,）,形态学指标,联合指标,心内斜率参数,QRS,宽度,1,、减少误放电,-,窦性、,SVT/AF,猝发性指标：鉴别窦速和室速；,稳定性指标：鉴别伴有快速心室率的心房颤动与室速；,EGM,宽度：通过心室,EGM,形态，区分宽和窄的心动过速波形，减少由于窦速或房颤引起的不恰当的治疗；,ICD,的再识别：在任何一次治疗发放后的识别过程，通过监测可能发现三个可能的结局：,1,）快速性心律失常终止；,2,）再识别原来的心律失常；,3,）再识别一个不同的心律失常，包括,VT,的加速。,PR Logic,Wavelet,、,Mophyology,联合指标,Wavelet,波形鉴别能较少,78.2%,的误治疗,Morphology,Rhythm ID,运算法则，当敏感性保持,100%,时，特异性高达,94%,ICD的识别识别再识别基本指标加强指标频率持续时间猝发指标（,ATP for SVTs,在,the PainFREE,SM,Rx II Study,表明，,ATP,治疗能减少,66%,的由于诊断为,SVT,造成的电击治疗。,Percent of Inappropriately Detected SVT Episodes with Avoided Shock after ATP Therapy,Effective in terminating,1:1 SVTs,(27/68),(78/119),(67/69),*Poster: Wathen M, et al., Ventricular Antitachycardia Pacing by Implantable Cardioverter Defibrillators Reduces Shocks for Inappropriately Detected Supraventricular Tachycardia. HRS Conference 2004.,ATP for SVTs在the PainFREESM Rx,1,、减少误放电,-,不恰当治疗,：反复放电,三天内共放电,64,次,-ICD,风暴现象,ICD,电风暴现象（,electrical storm,）,指在,24,小时内有,2,至,3,次以上的室速或室颤发生并使,ICD,放电治疗，两次室速或室颤的间隔时间大于,5,分钟；,国外报道发生率为,14%,20%,；,常发生于,ICD,术后早期或,1,年内；,处理：,困难,药物（奎尼丁、胺碘酮、索他洛尔、,B、,镇静等）；,血运重建；,提高起搏频率；,射频,心理干预等,1、减少误放电- 不恰当治疗：反复放电三天内共放电64次I,1,、减少误放电,-,不恰当治疗,：反复放电,ATP,加速,VT,成功,CD,第一,CD,失败,再次,CD,成功,ATP,“,诱发,”,VF,反复放电：,ATP,加速,VT,；,ATP,诱发,VF,；,首次放电失败，再次放电；,ICD,设置不当：非持续性,VT,放电或,VT,不必要放电；,心律失常：室上性、室性；,外界电磁干扰等,1、减少误放电-不恰当治疗：反复放电ATP加速VT成功CD,PREPARE Study,1,Wilkoff BL, et al. PREPARE. Study,J Am Coll Cardiol,. 2008;52:541-550.,2,Peterson B, et al. Medtronic data on file. 2008.,电击治疗减少了,63%*,1,2,P=0.003,1,、减少误放电,-,非持续性室上速,NSVT,PREPARE Study1 Wilkoff BL, et,PREPARE Study: Percent of Patients Shocked,1,Wilkoff BL, et al. PREPARE Study.,J Am Coll Cardiol,. 2008;52:541-550.,Paepare,组病人明显减少了电击治疗*,1,只有,3.6%,病人有电击误治疗,1,、减少误放电,-,非持续性室上速,NSVT,PREPARE Study: Percent of Pati,2,减少不必要的电击,2减少不必要的电击,22,RR 30,HR 218,RR 28,HR 217,室速：,ATP？CV？DC？,22RR 30RR 28室速：ATP？CV？DC？,PainFREE,TM,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,VT,1,2,ATP,对,“,慢,”,VT,有很高的疗效,(,周长,300 ms; ,10%,in CL),n=4,2%,n=2,1%,NS,晕厥,FVT,n=2,0.7%,n=2,0.7%,NS,死亡（总）,心脏性猝死,32 (10%),1 (0.3%),24 (7%),2 (0.6%),NS,NS,PainFREE II,Wathen M, Sweeney M, DeGroot P.,Circulation,. 2001; 104: 796-801.,Schaumann A, et al.,Circulation,. 1998; 97: 66-74.,Peinado R, et al.,Am J Cardiol.,1998; 82: 1422-1425 Bansch D, et al.,J Am Coll Cardiol. 1998,. 31: 608-615.,PainFREE,TM,临床研究,-,结论,3,- ATP不增加额外的晕厥或室性心律失常加速的危险性Pain,PainFREE Rx II,（,2004,）,有,ICD,适应证的患者,与电击相比，,FVT,经验性的,ATP,治疗,:,非常有效,安全性相同,提高生活质量,“在大多数,ICD,患者中,ATP,可能是,FVT,治疗的首选”,PainFREE,TM,临床研究总结,Wathen M, Sweeney M, DeGroot P.,Circulation,. 2001; 104: 796-801.,Wathen MS, et al. Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks for spontaneous rapid ventricular tachycardia in patients with,implantable cardioverter defibrillators: PainFREE RxII Trial Results. Circulation 2004;110:2591-2596.,PainFREE Rx,（,2001,）,CAD,患者,Fast VT,是常见的,ATP,成功终止,3/4 FVT,事件,ATP,没有增加晕厥或加速的风险,PainFREE Rx II （2004）PainFREET,独特的快速心律失常识别区,Optional VT Zone,Fast VT Zone,VF Zone,FVT,区,via VF,区,先诊断,VF,， 再鉴别出,FVT,，,确保不遗漏,VF,的诊断，给与正确的治疗,独特的快速心律失常识别区Optional VT ZoneFa,ATP Reduces Shocks!,1-4,ATP Successfully terminated 92% of MVTs,2,Monomorphic VTs represent 91% of all true VT/VFs,1,ATP Reduces Shocks!1-4ATP Suc,Automatically delivers ATP while the capacitor charges with NO DELAY to definitive therapy.,Designed to treat EVERY fast ventricular arrhythmia with ATP,ATP During Charging,3,VF Zone,240 ms,(250 bpm),320 ms,(188 bpm),ATP During Charging,Shock,Automatically delivers ATP w,ATP During Charging,3,If,ATP During Charging,therapy is successful, no shock is delivered.,ATP During Charging is a feature in EnTrust,and Virtuoso,ICDs and Concerto,CRT-D.,ATP During Charging3If ATP Du,EnTrust,临床研究结果 *,222,位患者,用,ATP During Charge,治疗,71,个,VF,区的自发事件,-,ATP,成功终止,53,个事件,ATP,治疗有效率,70% *,自动转换到,ATP BC,减少充电,36,次,在,ATP During Charging,治疗组合事件中没有晕厥或头昏报道,识别到第一次放电的平均时间,4.9,*EnTrust Clinical Study Results presented at HRS (May 2005) by Jrg O. Schwab.,* 95% posterior credible interval = (57.74%, 80.50%),ATP Before/During Charging-,临床研究,EnTrust 临床研究结果 *222位患者*EnTrust,3 x Burst,3 x Ramp,治疗顺序,事件,1,事件,2,事件,3,事件,4,2 x Shock,减少无效,ATP,治疗的延误时间,ATP,优化,3 x Burst3 x Ramp 治疗顺序事件 1事,小 结,ICD,术后如何减少不适当电击？,减少误放电：,（干扰、窦速,/SVT/AF,、,NSVT,）；,减少不必要的电击：,ATP,、,ATP During Charging,小 结ICD术后如何减少不适当电击？,谢谢！,谢谢！,