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心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區
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心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130907北區

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  • 1. 心臟植入性電子儀器(CIED)之適 應症 “Indications for CIED” 亞東紀念醫院 林恆旭 醫師
  • 2. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT)  Indications for intra-cardiac defibrillator (ICD) therapy Ref: • 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy • 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities
  • 3. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT)  Indications for intra-cardiac defibrillator (ICD) therapy
  • 4. Classifications of Bradyarrhythmias There are two types of bradyarrhythmias Sinus node AV node
  • 5. Sinus node dysfunction  Sinus Arrest  Sinus Bradycardia
  • 6. Sinus node dysfunction  Chronotropic Incompetence  Tachybrady syndrome
  • 7. AV node dysfunction  First Degree AV block  Second Degree AV block  Mobitz Type 1 – Wenckebach  Mobitz Type 2  Third Degree AV block – Complete heart block  Bifasicular/Trifasicular block
  • 8. First-Degree AV Block  PR interval > 200 ms  Delayed conduction through the AV Node
  • 9. Second-Degree AV Block – Mobitz I (Wenckebach block)  Progressive prolongation of the PR interval until there is failure to conduct and a ventricular beat is dropped
  • 10. Second-Degree AV Block – Mobitz II  Regularly dropped ventricular beats  2:1 block (2 P-waves for every 1 QRS complex)
  • 11. Third-Degree AV Block Complete Heart Block  No impulse conduction from the atria to the ventricles
  • 12. Fascicular Block Right bundle branch block and left anterior hemiblock Right bundle branch block and left posterior hemiblock Complete left bundle branch block
  • 13. Classifications of Bradyarrhythmias There are two types of bradyarrhythmias Sinus node AV node
  • 14. Indications for Pacing in Persistent Bradycardia
  • 15. Indication for Pacing in Intermittent Documented Bradycardia
  • 16. BBB and Unexplained Syncope CSM: carotid sinus massage; ILR =implantable loop recorder.
  • 17. Indication for Pacing in BBB
  • 18. Indication for Pacing in Undocumented Reflex Syncpe
  • 19. Indication in Unexplained Syncope
  • 20. Common Pacing Indications  Sinus Node Disease (SND), or Sick Sinus Syndrome  High degree AV Block (Mobitz II & 3rd AVB)  Chronotropic Incompetence Epstein et al. “ACC/AHA/HRS Guidelines for Device-Based Therapy.” JACC Vol. 51, No. 21, 2008.
  • 21. Choice of Pacing Mode and Programming
  • 22. Optimal Pacing Mode AVM: AV delay management
  • 23. 現行健保給付規定
  • 24. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT; 心臟再同步化治療)  Indications for intra-cardiac defibrillator (ICD) therapy
  • 25. Indications for CRT in patients with sinus rhythm
  • 26. Indications for CRT in patients with permanent Afib
  • 27. Indications for CRT in patients with conventional pacemaker indications and heart failure
  • 28. 現行健保給付規定  應事先審查。  正常竇房節心律,LVEF<=35%且CLBBB(QRS寬度 >=0.12sec),且NYHA Functional Class III, IV 及經適當藥物治療仍不能改善之病患。  心房顫動之病患, LVEF<=35%且CLBBB(QRS寬度 >=0.12sec),且NYHA Functional Class III, IV 及經適當藥物治療仍不能改善之病患。  心室節律器依賴之病患,LVEF<=35%,NYHA Functional Class III, IV及經適當藥物治療仍 不能改善者。
  • 29. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT)  Indications for intra-cardiac defibrillator (ICD) therapy
  • 30. Class I Recommendations  Level of Evidence: A  With LVEF ≤ 35% due to prior MI who are at least 40 days post-MI and are in NYHA Functional Class II or III  With LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF ≤ 30%, and are in NYHA Functional Class I  Who are survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes
  • 31. Class I Recommendations  Level of Evidence: B  With nonischemic DCM who have an LVEF ≤ 35% and who are in NYHA Functional Class II or III  With nonsustained VT due to prior MI, LVEF < 40%, and inducible VF or sustained VT at electrophysiological study  With structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable  With syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study
  • 32. Class IIa Recommendations  Level of Evidence: B  To reduce SCD in patients with Long QT Syndrome who are experiencing syncope and/or VT while receiving beta blockers
  • 33. Class IIa Recommendations  Level of Evidence: C  With unexplained syncope, significant LV dysfunction, and nonischemic DCM  With sustained VT and normal or near-normal ventricular function  With catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers  For the prevention of SCD in patients with ARVD/C who have one or more risk factors for SCD  With HCM who have one or more major risk factors for SCD  With Brugada syndrome who have had syncope or documented VT that has not resulted in cardiac arrest  With cardiac sarcoidosis, giant cell myocarditis, or Chagas disease  For nonhospitalized patients awaiting transplantation
  • 34. 現行健保給付規定  申報規範:  操作醫院應事先報備作業流程及持續照護計畫。  原則採事後逐案審查,個別醫院如經審查評估不符 治療指引,則改採逐案事前審查。  給付規定:  嚴重心室頻脈、心室顫動導致猝死可能或昏迷。  反覆發作之持續性心室頻脈。  高危險性心臟血管疾病或遺傳性疾病,如:曾經心肌 梗塞併左心室射出分率≦40%,long QT syndrome, short QT syndrome,Brugada syndrome,idiopathic ventricular fibrillation,arrhythmogenic right ventricle dysplasia,catecholaminergic polymorphic ventricular tachycardia,肥厚性心肌 症,擴張性心肌症等,且臨床合併心室快速不整 脈或合併猝死症之家族史者。
  • 35. 現行健保給付規定  心臟整流去顫器結合心房同步雙心室節律器之給 付規定為:符合「心臟整流去顫器」之給付規定, 且合乎「心房同步雙心室節律器」之給付規定者。  已通過同步雙心室節律器事前申請者,於裝置時 突發嚴重心室不整脈者,可改裝ICD或CRTD,以維 護病患安全,並於事後補報。
  • 36. 現行健保給付規定  不宜列入項目:  末期心臟衰竭,無法藥物控制又非心臟移植對象者。  猝死可能經急救後,無意識恢復之患者。  末期疾病患者且存活不足六個月者。  惡性且任何治療無法控制(intractable)之心室頻脈或 心室顫動。  依據「特定醫療技術檢查檢驗醫療儀器施行或使 用管理辦法」,自101.9.1.解除登記列管。配合 將操作醫院、醫師資格等刪除。
  • 37. Thank You

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