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

3,144 views

Published on

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

No Downloads
Views
Total views
3,144
On SlideShare
0
From Embeds
0
Number of Embeds
90
Actions
Shares
0
Downloads
37
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”_20130907北區

  1. 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. 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. 3. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT)  Indications for intra-cardiac defibrillator (ICD) therapy
  4. 4. Classifications of Bradyarrhythmias There are two types of bradyarrhythmias Sinus node AV node
  5. 5. Sinus node dysfunction  Sinus Arrest  Sinus Bradycardia
  6. 6. Sinus node dysfunction  Chronotropic Incompetence  Tachybrady syndrome
  7. 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. 8. First-Degree AV Block  PR interval > 200 ms  Delayed conduction through the AV Node
  9. 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. 10. Second-Degree AV Block – Mobitz II  Regularly dropped ventricular beats  2:1 block (2 P-waves for every 1 QRS complex)
  11. 11. Third-Degree AV Block Complete Heart Block  No impulse conduction from the atria to the ventricles
  12. 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. 13. Classifications of Bradyarrhythmias There are two types of bradyarrhythmias Sinus node AV node
  14. 14. Indications for Pacing in Persistent Bradycardia
  15. 15. Indication for Pacing in Intermittent Documented Bradycardia
  16. 16. BBB and Unexplained Syncope CSM: carotid sinus massage; ILR =implantable loop recorder.
  17. 17. Indication for Pacing in BBB
  18. 18. Indication for Pacing in Undocumented Reflex Syncpe
  19. 19. Indication in Unexplained Syncope
  20. 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. 21. Choice of Pacing Mode and Programming
  22. 22. Optimal Pacing Mode AVM: AV delay management
  23. 23. 現行健保給付規定
  24. 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. 25. Indications for CRT in patients with sinus rhythm
  26. 26. Indications for CRT in patients with permanent Afib
  27. 27. Indications for CRT in patients with conventional pacemaker indications and heart failure
  28. 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. 29. Outline  Indications for pacing  Indications for cardiac resynchronization therapy (CRT)  Indications for intra-cardiac defibrillator (ICD) therapy
  30. 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. 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. 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. 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. 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. 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. 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. 37. Thank You

×