心臟植入性電子儀器(CIED )之歷史”CIED Overview “_20130914中區

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心臟植入性電子儀器(CIED )之歷史”CIED Overview “_20130914中區

  1. 1. History and Overview of Cardiac Implantable Electronic Devices Allied Professional Training, THRS 07th, 14th, 21st, Sep, 2013
  2. 2. Contents  Brief of cardiac pacing  Overview of battery and generator  Lead technology  Pacemaker Mode and NBG code
  3. 3. ECG history 王叔和 (201- 280BC) : 脈經 Hippocrates (460 – 375 BC): “Those who suffer from frequent and strong faints without any manifest cause die suddenly” Dr. William Harvey (1578-1657) 1774AD : first external electric stimulation of heart 1882AD :Dr.Von Ziemssen decscribed 42 (46) y/o female with chest tumor, Stimulated her heart using electric current and could change her heart rate at will
  4. 4. 1887AD : The physiologist Augustus Desire’ recorded the first human surface electrocardiogram Willem Einthoven (1860 – 1927),He initially indicated the four observed deflections with the characters A, B, C, D but later adopted the middle characters of the alphabeth: P, Q, R, S and T 1942:The extremity bipolar electrode system (the standard electrocardiogram lead system) was expanded in 1933 by F. N. Wilson who introduced the unipolar chest wall electrode ECG history
  5. 5. Cardiac Pacing 1928: Mark Lidwell: Pacing to save life of a infant in cardiac arrest 1932: Hyman Pacemaker “artificial pacemaker” 1940 Hoop pacemaker 1950 Zoll Pacemaker : 1st catheter electrode 1957 Bakken’s Pacemaker
  6. 6. History of Pacemaker 1958, Siemens-Elema In 1994 Siemens sold its entire pacemaker business to the American company St. Jude Medical Arne Larsson
  7. 7. Indications and CIED Products • Pacemaker • Single chamber pacemaker • Dual chamber pacemaker Bradycardia • ICD (Implantable cardiovertor defibrillator) • Single chamber ICD • Dual Chamber ICD Ventricular Tachycardia/Ventricular Fibrillation • CRT-P • CRT-D Congestive Heart Failure
  8. 8. Pacemaker
  9. 9. Modern Pacemaker  Fully programmable dual chamber pacing  Rate response to activity and metabolic changes  Telemetry of pacer function  Incorporated algorithms to respond to change in intrinsic rhythms  Store patients arrhythmic events
  10. 10. Pacing System +
  11. 11. Fundamentals of Electricity  Ohm’s Law U = I X R U = Voltage (Volt, V) I = Current (Ampere, A) R = Resistance ( Ohm, ) 6 V I = 6 / 3 = 2 A 12 V I = 12 / 6 = 2 A 3 6
  12. 12. Pacing Impedance Insulation Defect <250 Ohm Normal Pacing Impedance 300 Ohm~1500 Ohm Lead fracture >1500 Ohm
  13. 13. Battery Energy  Energy, W= U X I X t W = U x I x t W= U2 x t R I = U R 2X output voltage 4X Energy
  14. 14. Pacemaker Components Connector Electric component Battery
  15. 15. Lithium Battery Battery Technology Li-I battery 3,0 [V] [Ah] Lithiumiodine Phase 1 Phase 2 Phase 3 30 µA 2,0 1.8 V 1,0 0 1 2 3 4
  16. 16. A Specialized Battery – Quasar (QMR)  Uses Lithium on the anode and both Silver Vanadium Oxide (SVO) and polycarbonmonofluoride (CFx) on the cathode  SVO for fast movement of ions  Lithium and CFx to approximate pacer battery characteristic  Current collector- collect ions formed by chemical reaction & transport them to battery terminal & to the device
  17. 17. Battery Capacity and Longevity
  18. 18. How pacemaker works  Pacing : Amplitude (V), Pulse width (ms) Capture Noncapture Pulse Width (ms) PulseAmplitude(V)
  19. 19. How Pacemaker works  Sensing T-wave P- or R-wave Myopotentials 8 mV 0,2 mV1 mV Band pass filter
  20. 20. How Pacemaker Works  Sensing- Choosing sensitivity 23 Sensitivity 5.0 mV Sensitivity 1.0 mV Sensitivity 10.0 mV
  21. 21. 24 Considerations in Sensitivity Programming  To make the device more sensitive (to pick up signals it might be missing), lower the mV setting  To make the device less sensitive (to avoid detecting non- cardiac signals), increase the mV setting  Sensitivity should  Pick up low-amplitude cardiac signals  Avoid very low-amplitude non-cardiac signals
  22. 22. Timing Cycles  Base rate (Lower rate limit)  Refractory Absolute Refractory Period Relative or Noise Sampling Period Alert Period
  23. 23. I II III IV V Chamber(s) Paced Chamber(S) Sensed Mode(s) of Response Progammable Functions Antitachyca rdia Functions V=Ventricle V=Ventricle T=Triggered R=Rate Modulable O=None A=Atrium A=Atrium I=Inhibited C=Cpmmunicating P=Paced D=Dual (A&V) D=Dual (A&V) D=Dual M=Multiprogramm able S=Shocks O=None O=None O=None P=Simple Programmable D=Dual O= None THE NBG CODE
  24. 24. 27 Mode Selection Considerations  Status of Atrial Rhythm  Intrinsic vs. Paced  Presence of Atrial Tachyarrhythmias:  Acute/Chronic  Status of AV Conduction  Normal Slowed Blocked  Presence of Chronotropic Incompetence Single Chamber ? Dual Chamber ? Rate Modulation?
  25. 25. Pacing Lead  Unipolar-Large Antenna • Large spike • More sensitive to interference • Pectoral muscle stimulation • More susceptible to EMI • Smaller lead diameter  Bipolar • Small spike • More sensitive to intrinsic cardiac signals • No myopotential inhibition • EMI protected • Less crosstalk Cathod “-” Anode “+” Anode “+” Cathod “-” Unipolar Bipolar
  26. 26. Pacing Lead  Passive lead  Tined lead  Active lead  Screwed lead
  27. 27. 31SJM internal use ONLY Steroid Delivery  MCRD steroid  (Monolithic Controlled Release Delivery)  < 1 mg Dexamethasone Sodium Phosphate 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 4 8 12 16 20 52 l l l ll l l l l l l lll ll l ll l l l Amplitude (Volt) Weeks With steroid
  28. 28. Myocardial and Epicardial Leads  Leads applied directly to the heart  Fixation mechanisms include:  Epicardial stab-in  Myocardial screw-in  Suture-on
  29. 29. Magnet Reed Switch Magnet are need for test: Asynchronous mode DOO/AOO/VOO Magnet rate could indicate battery longevity, eg. Magnet rate is 99 at BOL, 85 at ERI
  30. 30. SJM internal use ONLY Magnet for Troubleshooting  When a magnet is applied:  Pacing rate increases  Newer device 98.5 ppm (5000 series devices)  Older SJM devices (pre Affinity) programmed rate  BOL = magnet rate = 98.6 ppm / 2.75 volts  ERI = magnet rate = 86.3 ppm / 2.5 volts  EOL = magnet rate = 68.0 ppm / 2.2 volts  Device reverts to asynchronous mode  DDD >> DOO  VVI >> VOO  AAI >> AOO  AV delay decreases 125  If you don’t get any pacing?  Could be an ICD or the pacer is at EOS  Check CXR for ID
  31. 31. ICD
  32. 32. History of the AICD  1969 - Dr. Mirowski and Dr. Morton Mower begin collaborating and develop the first experimental model Milestones
  33. 33. History of AICD Therapy  1975 - The first device is implanted and tested in an animal  1980 - The first patient is implanted with an AICD device Milestones
  34. 34. Whats Inside an ICD?
  35. 35. ICD Leads-DF1 and IS-1 Two DF-1, One IS-1 DF-1 (Shock)IS-1 (Pace/ Sense)
  36. 36. 40 DF4 Development History  Project began in 2004  Originally designed on Epic+ device  Built on Atlas II+ HF, Promote (non-RF), and Riata ST for testing  Extensive testing done on this system  No failures at two times maximum voltage (1500V)  First submissions September 2007
  37. 37. Dual Coil Lead Proximal Shock Electrode Distal Shock Electrode Hot Can Single Coil Lead Cold Can
  38. 38. Dual coil v.s. Single coil Dual Coil Single Coil Pro Lower DFT Higher DFT Con Difficult to remove May easier to remove
  39. 39. ICD Modules Special Functions Measurements Electrogram and Data Storage Reversion Classification Sensing Induction Therapy
  40. 40. PVT Detection - Fixed Gain/ Sensitivity NSR
  41. 41. Automatic Sensitivity Control (ASC) Automatic Sensitivity Tracking GAIN FILTER COMP THRESHOLD Sensed EventFrom Sense/Pace Leads Threshold adjusts + and - to adapt to the signal
  42. 42. Defib with slow VT and Fast VT Tach B (Fast VT) (ATP and CV Shocks) Treatment 375 ms (160 bpm) Sinus Tach A (Slow VT) (ATP and CV Shocks) Fib (Shock) Non-Treatment Treatment Treatment 500 ms (120 bpm) 300 ms (200 bpm) >500 ms (<120 bpm) No therapy SVT discrimination, VT therapy deliver when VT indicated VF therapy deliver
  43. 43. AF/AFl + Morphology, Stability ( AVA) VT/ VF Treat VT w/ 1:1 retro AF + VT AFl + VT Treat AF/AFl Inhibit ST, AT, 1:1 SVT Inhibit Treat Isolated VT + Morphology Onset Sinus Tach AV Int Atrial CL Ventricular CL Dual Chamber Sensing: Rate Branch + Additional SVT Criteria
  44. 44. Therapy Anti-tachycardia pacing (ATP)
  45. 45. Therapy High Voltage shock  Uses of High Voltage Therapy  To terminate:  Ventricular Tachycardia  Ventricular Fibrillation Thanks, I needed that!
  46. 46. Q: How do you manage a patient with multiple shocks?  Appropriate therapy  Ischemia  CHF  Electrolytes  Beta blockers  Procainamide  Amiodarone  Inappropriate Therapy  Noise  EMI  Inappropriate programming  Increased rate cutoff settings for 1 zone, 2 zone and 3 zone programming  Longer detection intervals for 2 zone and 3 zone programming  Optimized SVT discriminator settings for VR, DR and CRT-D  ATP as the first therapy in all zones (including ATP while charging in VF zone)  VT and SVT override settings programmed to off epoisodes of sustained VT/VF in 24 hrs = “Storm”
  47. 47. Magnet in ICD  Off Detection, No therapy will be delivered
  48. 48. CRT (Cardiac Resynchronization Therapy)
  49. 49. 53 Ventricular Resynchronization with CRT Pacing @ left lateral free wall in addition to right side Symmetric lateral and septal wall conduction & contraction More efficient pump
  50. 50. 54 Synchrony More work done with less effort & increased efficiency!
  51. 51. 55 Coronary Sinus approach Right Atrial Lead Right Ventricular Lead Left Lateral Free wall LV Lead Optimal LV Lead Placement
  52. 52. Venograms and LV Lead Placement LAO AP RAO Align to CS OS/ Middle Vein Anterior Lateral Posterior Right Basal Mid Apical
  53. 53. Final LV Lead Position RAO Good lateral position
  54. 54. Final LV Lead Position LAO Good lateral position
  55. 55. CIED revolution MRI conditional Device Leadless pacemaker ……

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