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心臟植入性電子儀器(CIED)之適應症"Indication for CIED"_20131019南區
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心臟植入性電子儀器(CIED)之適應症"Indication for CIED"_20131019南區

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  • APB: Atrial Premature Beats
    PAF: Paroxysmal Atrial Fibrillation
  • AV indicates atrioventricular
  • AV indicates atrioventricular
  • CSM 頸靜脈按摩
  • CRT indicates cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy defibrillator; GDMT, guideline-directed medical therapy; ICD, implantable
    cardioverter-defibrillator; LV, left ventricular; LVEF, left ventricular ejection fraction; LBBB, left bundle-branch block; MI, myocardial infarction; and NYHA, New York
    Heart Association.


  • 1. 2013 THRS Allied Professional Education Program Cardiovascular Implantable Electronic Device (CIED) 心臟植入性電子儀器之適應症 (Indications for CIED) 高雄榮民總醫院心臟內科 江承鴻 醫師 2013.10.19 (Sat) 1
  • 2. DBT Guideline 2012 ACCF/AHA/HRS Focused Update Incorporated Into the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Developed in Collaboration With the American Association for Thoracic Surgery, Heart Failure Society of America, and Society of Thoracic Surgeons
  • 3. Recommendations & Level of Evidence Class I Class IIa Class IIb Class III Benefit >>> Risk Benefit >> Risk Additional studies with focused objectives needed Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Risk ≥ Benefit No additional studies needed Procedure/ Treatment SHOULD be performed/ administered IT IS REASONABLE to perform procedure/administer treatment Procedure/Treatment MAY BE CONSIDERED Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL Level of Evidence: Level A: Data derived from multiple randomized clinical trials or meta-analyses Multiple populations evaluated; Level B: Data derived from a single randomized trial or nonrandomized studies Limited populations evaluated Level C: Only consensus of experts opinion, case studies, or standard of care Very limited populations evaluated 3
  • 4. Indications for pacing 4
  • 5. Symptomatology + = Reliable Indications Documented Events for Pacing ECG documentation in the medical record is essential ! 5
  • 6. Indications For Pacing • • • • Sick Sinus Syndrome Heart Block Chronic Bifascicular Block Carotid Sinus Hypersensitivity & Neurocardiogenic Syncope • HOCM, DCM 6
  • 7. Sinus Node Dysfunction (Sick Sinus Syndrome) • • • • Sinus Bradycardia Sinus Arrest SA Exit Block Bradycardia-Tachycardia Syndrome • Symptomatic chronotropic incompetence 7
  • 8. Sinus Node Dysfunction • Class I – SND with symptomatic bradycardia, including frequent sinus pauses that produce symptoms (c) – Symptomatic chronotropic incompetence (c) – Symptomatic sinus bradycardia from required drug therapy (c) 8
  • 9. Sinus Node Dysfunction • Class IIa – SND with HR < 40 BPM but the symptoms and bradycardia has not been documented (c) – Syncope of unexplained origin when SND is discovered in EP study (c) • Class IIb – Minimal symptoms with chronic HR < 40 BPM while awake (c) 9
  • 10. Sinus Node Dysfunction • Class III – Without symptoms (c) – Symptoms unrelated to bradycardia (c) – Symptomatic sinus bradycardia due to nonessential medications (c) 10
  • 11. Sinus Node Dysfunction Sinus Bradycardia Inappropriate marked sinus bradycardia • Patient case: • Elderly gentleman denied symptoms. • Family reported that he napped frequently, would fall asleep at the kitchen table during a meal and often fell asleep when friends were visiting. • Patient was proud of his “athletic heart”, particularly as he never exercised.
  • 12. Sinus Node Dysfunction Holter monitor Single APB with marked overdrive suppression of sinus node, mild sinus bradycardia
  • 13. Sinus Node Dysfunction Brady-Tachy Syndrome Marked sinus node suppression post-spontaneous termination of AFib, predisposes to APBs which triggers next episode of PAF
  • 14. Selection of Pacemaker for Sinus Node Dysfunction Sinus Node Dysfunction Evidence for impaired AV conduction or concern over future development of AV block No Yes Desire for rate response No AAI Desire for AV synchrony No Yes AAIR Yes Desire for rate response Desire for rate response No VVI Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 2. Yes VVIR No DDD Yes DDDR 14
  • 15. AV Block • First degree • Second degree - Wenckebach - Mobitz II - 2:1 (high grade) • Third degree - Chronic stable - Asystole 15
  • 16. AV Block • Class I – 3rd & advanced 2nd degree AV block at any level - Bradycardia with symptoms or ventricular arrhythmia due to AV block (c) - Drug therapy results in symptomatic bradycardia (c) - Awake, symptom-free, asystole > 3.0 seconds or escape rate< 40 BPM (c) - Awake, symptom-free, AF with pauses ≧ 5 seconds (c) - Post-AV ablation or post heart surgery (c) - Neuromuscular disease (b) – 2nd degree AV block if symptomatic and not reversible (b) 16
  • 17. AV Block • Class IIa –“Asymptomatic” 3rd degree AV block of HR > 40 BPM (c) –“Asymptomatic” 2nd degree AV block at intraHis or infra-His levels at EP study (b) –1st degree or 2nd degree AV block with symptoms (b) –“Asymptomatic” Mobitz II 2nd degree AV block (b) 17
  • 18. AV Block • Class IIb – Neuromuscular disease, with or without symptoms, as the progression is unpredictable (b) – AV block due to medications or drug toxicity, expected to recur even after drug withdrawn (b) 18
  • 19. AV Block • Class III – Asymptomatic 1st degree AV Block (b) – Asymptomatic Mobitz I 2nd degree AV block at supra-His (AV node) level (c) – AV block due to reversible etiology (b) - Lyme’s disease - Acute inferior wall MI - Drug effect or toxicity 19
  • 20. AV Block - First Degree AV Block •Significant FIRST degree AV Block (PR 400 ms+) will predispose to late diastolic regurgitation, compromised hemodynamics and induce pseudo pacemaker syndrome
  • 21. AV Block - First Degree AV Block A AV V First degree AV Block that induces symptoms c/w pacemaker syndrome (functional retrograde conduction)
  • 22. AV Block - 2nd Degree Wenckebach • Progressive increase in PR interval until a P wave is not conducted • Pause terminated by shortened PR interval
  • 23. AV Block - Mobitz II • No change in PR interval preceding or following blocked P wave • Wide QRS (tri fascicular conduction system disease)
  • 24. AV Block - 2nd Degree Mobitz II Mobitz II 2nd AV Block may be associated with abrupt asystolic complete heart block without a stable escape focus
  • 25. AV Block - 2:1(High Grade) 2nd Degree AVB Narrow QRS - block in AV node (or Bundle of His) Wide QRS - cannot identify level of block
  • 26. 2:1 AV Block Mechanism based on preceding or following rhythms Lead II Lead V1
  • 27. AV Block Chronic Stable Complete Heart Block •75-year-old man referred for “slow pulse”. Denies syncope, presyncope. BUT lacks energy which he attributed to his age! In the presence of a normal sinus node, use the atrial rate as an indicator of the degree of physiologic stress.
  • 28. AV Block Complete in presence of A Fib
  • 29. AV Block Not Always Obvious • What is this rhythm? • Sinus bradycardia • First degree AV Block
  • 30. AV Block Not Always Obvious Baseline Post-Atropine Sinus rate accelerates, unmasks complete heart block, ventricular rate does NOT change, hence top tracing was sinus brady with isorhythmic AV dissociation and CHB
  • 31. Selection of Pacemaker for Atrioventricular Block AV block Chronic atrial tachyarrhythmia, reversion to sinus rhythm not anticipated No Desire for AV synchrony No Yes Desire for rate response No Yes Yes VVI Desire for atrial pacing Desire for rate response No VVIR No Yes Yes VDD VVI VVIR Desire for rate response No Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 1. DDD Yes DDDR 31
  • 32. Neurally Mediated Syndromes • Hypersensitive carotid sinus syndrome • Malignant vasovagal syncope (neurocardiogenic syncope) 32
  • 33. Neurally Mediated Syndromes • Carotid Sinus Massage (CSM) • • • • Check for bruits Always monitor ECG One side at a time Gentle 33
  • 34. Neurally Mediated Syndromes • Class I – Recurrent syncope, CSM > 3 seconds of asystole without vagomimetic medications (c) • Class IIa – Recurrent syncope without clear and provocative cause, CSM > 3 seconds of asystole (c) • Class IIb – Recurrent syncope, tilt table test with marked bradycardia (b) 34
  • 35. Neurocardiogenic Syncope Cardioinhibitory • Tilttest
  • 36. Indications for Cardiac Resynchronization (CRT) Therapy Right Atrial Lead Left Ventricular Lead Right Ventricular Lead 36
  • 37. CRT in Systolic Heart Failure • Class I - LVEF ≦ 35%, sinus rhythm, LBBB with QRS ≧ 150 ms, and NYHA II, III, or ambulatory IV [(a) for NYHA III/IV; (b) for NYHA II]. • Class IIa - LVEF ≦ 35%, sinus rhythm, LBBB with QRS 120 ~ 149 ms, and NYHA II, III, or ambulatory IV (b) - LVEF ≦ 35%, sinus rhythm, non-LBBB with QRS ≧ 150 ms, and NYHA II, III, or ambulatory IV 37
  • 38. CRT in Systolic Heart Failure • Class IIa - AF and LVEF ≦ 35% if a) require ventricular pacing or meet CRT criteria and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT (b) - Patients with LVEF ≦ 35% and undergoing new or replacement device placement with requirement for significant (>40%) ventricular pacing (c) 38
  • 39. CRT in Systolic Heart Failure • Class IIb - LVEF ≦ 30%, ischemic heart failure, sinus rhythm, LBBB QRS with ≧150 ms, & NYHA I. - LVEF ≦ 35%, sinus rhythm, non-LBBB QRS with 120 ~ 149 ms, and NYHA III/ambulatory class IV (b) - LVEF ≦ 35%, sinus rhythm, non-LBBB QRS with ≧ 150 ms, and NYHA II (b) • Class III - NYHA I/II, non-LBBB QRS with <150ms (b) - Comorbidities and/or frailty limit survival with good functional capacity <1 year (c) 39
  • 40. Indications for CRT cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or with implantation of pacing or defibrillation device for special indications LVEF <35% Evaluate general health status Comorbidities and/or frailty limit survival with good functional capacity to <1 y Continue GDMT without implanted device Acceptable noncardiac health Evaluate NYHA clinical status NYHA class I symptoms NYHA class II, III, and ambulatory class IV symptoms Class I LBBB pattern, sinus rhythm, QRS duration ≥150 ms Class IIa LBBB pattern, QRS 120-149 ms OR Non-LBBB pattern, QRS >150 ms OR Class IIb •LVEF <30% •QRS >150 ms •LBBB pattern •Ischemic cardiomyopathy Anticipated to require frequent ventricular pacing (>40%) OR Atrial fibrillation, if ventricular pacing is required or QRS criteria above are met and rate control will result in near 100% ventricular pacing with CRT Class IIb Non-LBBB pattern, QRS 120-149 ms NYHA class IV (stage D) Refractory symptoms or dependence on intravenous inotropes Device not indicated except in selected patients listed for transplantation or with LV assist devices If device already in place, consider deactivation of defibrillation
  • 41. 心房同步 雙心室節律器 (CRT) 中央健康保險局適應症 98.7.1. 修訂 ( 一 ) 應事先審查。 ( 二 ) 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。 ( 三 ) 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。 ( 四 ) 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。
  • 42. Indications for Implantable CardioverterDefibrillators (ICD) Therapy 42
  • 43. ICD (Secondary Prevention) • Class I - Survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after exclude reversible causes (a) - Structural heart disease & spontaneous sustained VT, whether hemodynamically stable or unstable (b) - Syncope of undetermined origin with hemodynamically significant sustained VT or VF induced at EP study (b). 43
  • 44. ICD (Primary Prevention) • Class I - LVEF ≦ 35% due to prior MI, ≧40 days postMI, NYHA II/III (a) - Non-ischemic DCM, LVEF ≦ 35%, NYHA II/III (b) - LVEF < 30% due to prior MI, ≧ 40 days postMI, NYHA I (a) - Non-sustained VT due to prior MI, LVEF ≦ 40%, inducible VF/sustained VT at EP study (b) 44
  • 45. ICD • Class IIa - Unexplained syncope, significant LV dysfunction, non-ischemic DCM (c) - Sustained VT and normal or near-normal ventricular function (c) - HCM & Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more major risk factors for SCD (c) - Long-QT syndrome with syncope and/or VT while receiving beta blockers (b) 45
  • 46. ICD • Class IIa - Non-hospitalized patients awaiting transplantation (c) - Brugada syndrome with syncope (c) - Brugada syndrome with documented VT that has not resulted in cardiac arrest (c) - Catecholaminergic polymorphic VT with syncope and/or documented sustained VT while receiving beta blockers (c) - Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease (c) 46
  • 47. ICD • Class IIb - Non-ischemic heart disease with LVEF ≦ 35%, NYHA I (c) - Long-QT syndrome and risk factors for SCD (b) - Syncope and advanced structural heart disease, failed to define a cause (c) - Familial cardiomyopathy associated with sudden death (c) - LV non-compaction (c) 47
  • 48. ICD • Class III - Do not have a reasonable expectation of survival with an acceptable functional status for at least 1 year (c) - Incessant VT or VF (c) - Psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up (c) - NYHA IV with drug-refractory CHF, not candidates for cardiac transplantation or CRT-D (c) 48
  • 49. ICD • Class III - Syncope of undetermined cause, without inducible ventricular tachyarrhythmias, without structural heart disease (c) - VF / VT is amenable to surgical or catheter ablation (e.g., atrial arrhythmias associated with the WPW syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease) (c) - Ventricular tachyarrhythmias due to a completely reversible disorder, without structural heart disease (e.g., electrolyte imbalance, drugs, or trauma) (b) 49
  • 50. Thanks 50