长PR间期引起ICD误放电.pptVIP

长PR间期引起ICD误放电 天津胸科医院 许静 病例资料 患者 男性 53岁 98年、02年先后2次下壁、前壁心肌梗死 02年行CABG治疗 08年再次心内膜下心肌梗死合并心肾功能不全住院治疗并行血液透析20余天 住院期间先后2次室速伴晕厥行电复律 UCG：LA45mm、LV76mm、LVEF26%、PAP48mmHg、二尖瓣反流中度、 EKG：窦性心律、室内阻滞、间歇Ⅰ-Ⅱ°AVB、阵发室速 患者住院窦律及室速发作EKG Ⅱ Ⅰ Ⅲ avR avL avF V1 V2 V3 V4 V5 Ⅰ Ⅱ Ⅲ avR avL avF V1 V2 V3 V4 V5 频率143次/分 器械选择 1.CRT-D：心功能差，间断AVB，室内阻滞，首选 2.双腔-ICD：间断AVB;室速发作频率慢(140次/分) 3.单腔-ICD 於2008年3月3日植入Medtronic Marquis DR 7274双腔-ICD ICD干预时的监护EKG 事件腔内心电图（一） R-R间期440ms A-V间期 240ms AV/RR=54% 50% ICD初始设置及事件回顾 调整PR Logic R-R间期400ms A-V间期 280ms AV/RR=70% 66% 事件腔内心电图（二） 再次调整PR Logic R-R间期450ms A-V间期 320ms AV/RR=71% 75% 事件腔内心电图（三） 讨 论 既往的文献报道，ICD误放电率大约是16-21%。常见的误识别原因有SVT、AF、AL及一些折返性心动过速，另外T波等的误感知也可导致误识别从而激活抗心动过速治疗，不适当的治疗不仅严重影响病人的生活质量，同时也增加病人的死亡率 目前Sc-ICD鉴别SVT与VT的标准包括：突发性、QRS宽度、稳定性及波形识别。 Dc-ICD多采用房室关系 Summary of Main Studies Comparing Single- versus Dual-Chamber ICDs or Detection Algorithms Study Year Population Randomization n Primary Endpoint m Main Findings Detect Supraventricular Tachycardia study 2006 Dc-ICD recipients Sc vs Dc mode detection 400 Inappropriately detected SVT arrhythmias 6 Reduction of inappropriately detected SVT arrhythmias with Dc-ICD (32.3% vs 46.5%) No reduction of the proportion of inappropriate shocks PINAPP 2004 Dc-ICD recipients Sc vs Dc mode detection 60 Delivery of inappropriate ICD therapies for atrial arrhythmias 12 No differences in the absolute number of misclassified episodes of SVT and inappropriate therapies 1 + 1 Trial 2004 Dc-ICD recipients with slow VTs Sc vs Dc mode detection 100 Inappropriate ICD therapies, VTs above the TDI, and VTs with a therapy delay 2 minutes 12 Moderate superiority of Dc-ICD for the combined primary end-point No significant differences in the rate of inappropriate therapies Low sensitivity of Dc-ICDs for true VTs (94%) Deisenhofer et al) 2001 Sc and Dc-ICD recipients True Sc vs Dc ICDs 92 Inappropriate ICD therapies and complications 7.6 No significant differences in the proportion of inappropriate therapi