心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130914中區

934 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
934
On SlideShare
0
From Embeds
0
Number of Embeds
64
Actions
Shares
0
Downloads
18
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

心臟植入性電子儀器(CIED )之適應症 “Indication for CIED”_20130914中區

  1. 1. Indication for CIED Cardiovascular center, Chia-Yi branch, VGH-TC Liao Ying Chieh
  2. 2. PACEMAKER Pacing against bradycardia
  3. 3. Sick sinus syndrome (SSS) • Degenerative disease • Asymptomatic to syncope • Escape rhythm and symptom • SCD is extremely rare. • Same survival whether treatment or not
  4. 4. • Sinus Bradycardia • Sinus pause • Bradycardia-Tachycardia Syndrome • SA Exit Block • Symptomatic chronotropic incompetence ECG presentation
  5. 5. Treatment consideration • Symptom ? (not specific) • Bradycardia ? • Relationship between symptom and bradycardia • Pacemaker: for symptom, not for survival.
  6. 6. Class I Indication of PPM in SSS • Symptomatic bradycardia (clear relationship) -- irreversible -- due to necessary medication • Symptomatic chonotropic incompetence
  7. 7. Class IIA indication of PPM in SSS • HR < 40/min, with symptom, but the association is not established. • Unexplained syncope + positive provoked test in EP study.
  8. 8. Class IIB indication of PPM in SSS • Minimal symptom, and chronic HR < 40/min
  9. 9. Class III contraindication • No symptom. (Even SSS is diagnosed) • The symptom is documented in the absence of bradycardia.
  10. 10. AV block • First, second (type I, II), third degree. • Supra-his, intra-his, and infra-his. • Advanced AVB and block below his indicated poor prognosis. • Whether symptomatic or not, PPM improved survival in advance AV block.
  11. 11. ECG presentation
  12. 12. AV node Supra-his block Wenckebach phenomenon Affected by endocrine, nerve, and medication His-Purkinje system Intra-his and infra-his block All or none conduction Rarely affected by medication. Level of AV block ◎ ◎ ◎
  13. 13. Degree and level of AV block ADVANCED
  14. 14. Class I indication of PPM in AVB • Type-II 2° or 3° + any of following Symptom, HF, low LVEF, cardiomegaly. intra- or infra- his block. VT/VF, wide QRS, HR <40/min. pause > 3 secs in SR or >5 secs in AF. iatrogenic, neuromuscular disease. happened during exercise
  15. 15. Class IIA indication of PPM in AVB • Pure type-II 2° or 3°AV block. • Type-I 2° AV --- block at “intra- or infra-his” level --- Pacemaker syndrome • 1° AVB --- Pacemaker syndrome
  16. 16. Class IIB indication of PPM in AVB • Type-I 2° or 1° with neuromuscular disease • AV block due to toxin or drug but expected to recur.
  17. 17. Class III contraindication • 1° AV block without symptom • Type-I 2° supra-his AV block without symptom • Reversible cause unlikely to recur
  18. 18. Site of AV block PPM syndrome  IIA No symptom  III IIA At least IIA Mostly I
  19. 19. Chronic Bi-fascicular Block ×× Pre-existed block in 2/3 fascicles
  20. 20. PPM in Chronic Bi-fascicular Block • Class I: Type-II 2° or 3° AV block alternating BBB (LBBB + RBBB) all 3 fascicles are clinically diseased • Class IIa: unexplained syncope H-V interval in EPS>100ms pacing-induced infra-His block in EPS subclinical dysfunction on the 3rd fascicle • Class IIb: Neuromuscular diseases • Class III: no AV block only 1 ° AV block no symptom
  21. 21. Hypersensitivity carotid sinus syndrome Neurocardiac disease • Class I – Recurrent syncope caused by spontaneous carotid sinus stimulation inducing pause > 3 sec • Class IIa – Syncope, cardio-inhibitory pause > 3 sec • Class IIb – Neurocardiogenic syncope with bradycardia, spontaneously or at tilting table test. • Class III – no symptoms – effective avoidance behavior
  22. 22. Indication other than bradycardia ? • Treating PSVT ??  Pace-terminated PSVT if other Tx failed. (IIA) • Preventing Af ??  no such indication. (III) • Preventing VT ??  sustained pause-dependent VT/VF. (I)  high-risk congenital long QT syndrome. (IIA)  others. (III) • HOCM ??  Refractory symptoms + LVOT obstruction. (IIA)
  23. 23. Conclusion of PPM indication • SSS: symptom, correlation to bradycardia. • AV block: advance, intra- and infra-his level. • Bi-fascicular block: diseased third fascicle ? • Neuro-cardiac disease: long pause > 3 secs
  24. 24. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR Therapy on VT/VF
  25. 25. Sudden cardiac death In US 90% SCD are VT/VF
  26. 26. Key to Survive in SCA %Success Time (min) 100 80 90 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 Success rates decrease 7-10% each minute Adapted from text: Cummins RO, 1998. Annals of Emergency Medicine 18: 1269-1275. Recognize cardiac arrest 1 min. Internal emergency response 1 min. Call EMS / dispatch vehicle 1 min. Aid car sent—arrives on scene 6 min. Locate victim and deliver shock 2 min. Total Elapsed Time = 11 min. ICD intervention
  27. 27. Consideration of ICD implantation • VT/VF Risk stratification. Who is at high risk ?
  28. 28. SCD-HeFTMUSTTMADIT-2 Primary prevention of SCD in ICD
  29. 29. Secondary prevention of SCD in ICD • Structurally normal heart CPVT, Brugada, LQT, SQT • Structurally abnormal heart DCM, ICM, HCM, ARVD, infiltrate CM
  30. 30. DCM, ICM, HCM, ARVD, infiltrate CM Class I: Sustained VT/VF Syncope + inducible VT/VF in EP study Class IIA: DCM  syncope + poor LV function HCM  syncope, family Hx of SCD, non-sustain VT, LV wall thick >3cm, BP drop in exercise. ARVD  syncope, Family Hx of SCD, LV involve. Sarcoidosis, Chagas disase, giant cell myocarditis.
  31. 31. Structurally normal heart CPVT, Brugada, LQT, SQT. • Class I: hemodynamic unstable VT/VF or SCD + medication + survival > 1 yr • Class IIa: stable sustain VT syncope.
  32. 32. Contraindication of ICD implantation • Incessant VT/VF, or reversible cause • Syncope in normal heart and negative EP study • Expected survival < 1 year • NYHA Fc IV, except waiting heart transplantation, (IIA) or CRT-D. • Psychiatric illness • Idiopathic VT (can be cured by ablation)
  33. 33. BIVENTRICULAR PACING (CRT) Synchronize the heart
  34. 34. To improve heart failure survival • ACEI • Beta-blocker • CRT (cardiac resynchronize therapy). Lower ejection fraction LVEF <35% LV dyssynchrony, QRS> 120 ms Severe symptom by optimal drug NYHA Fc 3-4
  35. 35. CRT indication in 2008 AHA guideline Class I LVEF <35% + QRS > 0.12s + NYHA-Fc III or IVa Class IIA LVEF <35% + (NYHA-Fc III or IVa) + V pacing LVEF <35% + QRS > 0.12s + (NYHA-Fc III or IVa) +Af COMPANION trial CARE-HF trial
  36. 36. RAFT trial • 1798 P’t, CRT-D vs. ICD • Inclusion: NYHA Fc II ~ III LVEF  30% QRS >120 ms • Follow-up: 40 months • End-point: mortality + HF hospitalization.
  37. 37. MADIT-CRT • 1820 patients, CRT-ICD (1089) vs. ICD (731) • Inclusion: NYHA 1-2 ischemic or NYHA 2 DCM. LVEF < 30%, QRS >130 ms • Follow-up: 2.4 years • End point: mortality or HF events
  38. 38. MADIT-CRT result
  39. 39. Conclusion from MADIT-CRT & RAFT • Extend CRT indication to NYHA Fc II patients. • In NYHA Fc II, benefit is limit to QRS >150 ms, and LBBB morphology. • Benefit in NYHA Fc I is not yet concluded.
  40. 40. THANK YOU FOR ATTENTION QUESTION ?

×