IBHRE国际心律失常考官委员会英文资料：03 Basic CRT Programming 29Dec09.ppt

Basic CRT ProgrammingAgenda●What is a CRT device?●LV Pulse Pacing Configuration: VectSelect™●LV Output Setting●Bi-V Triggered Pacing●AV & VV Optimization3What is Cardiac Rhythm Management (CRM) ??1. Pacemaker (Brady – Heart Rhythm too slow)Single-Chamber Pacemaker Dual-Chamber Pacemaker 2. Implantable Cardioverter Defibrillator (ICD/ AICD/ Tachy – Heart Rhythm too fast)Single-Chamber ICD Dual-Chamber ICD3. Cardiac Resynchronization Therapy (CRT/ BiV/ Heart Failure)Bi-Ventricular Pacemaker (CRT-P) Bi-Ventricular ICD (CRT-D)Interventricular Conduction Delay in Heart FailureLeft Bundle Branch Block (LBBB)What is a CRT Device?What is CRT?Cardiac Resynchronization TherapyBi-Ventricular Pacing Therapy (BiV)What is a CRT device?●CRT = Cardiac Resynchronization Therapy●CRT-P: Resynchronization device for Heart failure patients with 3 chambers pacing (RA RV LV)●CRT-D: Resynchronization device for Heart failure with 3 chambers pacing and defibrillation back-up (RA RV LV)Bi-V Pacemaker / CRT-P+Bi-V PacemakerBi-V PacemakerPacing Lead (RV)Pacing Lead (RV)Pacing Lead (RA)Pacing Lead (RA)LV LeadLV LeadBi-V ICD / CRT-D+CRT-DCRT-DShocking Lead (RV)Shocking Lead (RV)Pacing Lead (RA)Pacing Lead (RA)LV LeadLV LeadHow a CRT works?LV Pulse Pacing Configuration: VectSelect™Lead PositioningCoronarySinusRightVentricularApexRightAtrialApendageAnatomy – Nervus PhrenicusPhrenic nervePhrenic nerve●Phrenic nerve stimulation is not uncommon due to the close proximity of the LV lead to the phrenic nerve along the left lateral wall of the heart.Parameters●CRT-P features the VectSelect™ Programmable LV Pulse ConfigurationsUnipolarPace LV tip to canBipolarPace LV tip to LV ringPace LV tip to RV ringPace LV ring to RV Ring(-)(-)(-)(-) (+) (+) (+)(-)CRT-PBipolar LV lead (Independent output device)18CRT-D features the VectSelect™ Programmable LV Pulse Configurations○Bipolar1.LV-Tip to LV-ring 2.LV-tip to RV-coil3.LV-ring to RV-coil ●Benefits○May reduce phrenic nerve stim○Increased flexibility○May reduce the need for lead repositioning○Different thresholdsVectSelect™ Programmable LV Pulse Configuration in CRT-DCRT-DBipolar LV leadDedicated ICD leadPace LV tip to LV ring or RV coilPace LV ring to RV coil(-) (+)(-) (+) (+)(-)Evaluating Sensing and Pacing Thresholds●If a bipolar LV lead is implanted, testing of alternate pacing configurations* may be performed to: ○Determine if another configuration provides lower pacing thresholds, and/or○Resolve phrenic nerve or diaphragmatic stimulation*Possible configurations available dependent on pulse generator used Electronic Repositioning™  LV Output SettingOutput Setting in CRT DevicesOutput Setting in LV:Full safety margin in LV may not be necessary due to1.Potential phrenic nerve stimulation (increase PW instead of amplitude may help)2.Patient may not be pacemaker dependent3.Already have RV lead to support the ventricle4.Expect patient to be 100% BiV pacing, therefore, try to minimize battery consumption to prolong device longevityQRS Axis of RV, LV & BiV PacingQRS axis and pacingRV Apex PacingLV PacingBV PacingLead ILead ILead ILead AVFLead AVFLead AVFExperience with the VIGOR CHF demonstrates the relationship between BV, RV, and LV axes and their distribution.Although the patient population axes are variable, for a given individual, the BiV axis is always superior and in between the RV and LV pacing axes.• Mean Pacing Axes Observed in VIGOR CHF Clinical Trial• ResultsLeads I & III Show Best the Changes Lead IIIIILead III++--BiV Pacing: a sum of LV and RV Apex pacing so the vector is around -11512-Lead Patterns for BiV PacingRV Apex Pacing Lead ILead IIIIIII++--LV Pacing Lead ILead IIIIIII++--Application of QRS Axis in Tied Output Device: Frontier PacemakerTied Output Devices: Frontier Pacemaker●LV and RV channels are electrically tied together in the header or an adapter●LV and RV pace/sense output functions not separately programmable● Modified header provides an extra port for the LV lead●Sensing includes both the RV and LV leadsBiV to RV Apex onlyBiV to LV onlyBi-V Triggered PacingAF with Rapid Ventricular Response: No BiV pacing is possibleAF with Rapid Ventricular Response: No BiV pacing is possibleParametersTriggered Mode●CRT-P or CRT-D Triggered Auto Mode SwitchThe NBG CodePositionIIIIIIIVVCategoryChamber(s) pacedChamber(s) sensedResponse to sensingRate ModulationMultisite PacingLettersO= NoneA=AtriumV=VentricleD=DualS=Single*O= NoneA=AtriumV=VentricleD=DualS=Single*O=NoneT=TriggeredI=InhibitedD=DualO=NoneR=Rate ModulationO=NoneA=AtriumV=VentricleD=Dual* Manufacturer’s designation onlyTriggered Mode●During triggered pacing and AMS the device will pace Bi-V “Simultaneously” indicated by the VSt or BiSt markerTriggered Mode●During triggered pacing and AMS the device will only trigger to the AMS Max Trigger RatePermanently Programmed Triggered Mode●The device can only trigger to the Max triggering rateAV & VV OptimizationTarget for ResynchronizationAtrio-Atrio-ventricularventricularInter-Inter-ventricularventricularIntra-Intra-ventricularventricularHow to synchronize?Pacing @ Mid Left Lateral Free Wall& Optimized V-V TimingSymmetric Lateral and Septal Conduction and ContractionMore Efficient PumpVentricular Resynchronization with CRTAV & VV Optimization●Importance of AV delay ○Assists with optimizing preload○Optimized atrial-ventricular conduction○Reduced diastolic mitral regurgitation○Improved contribution of atrial kick○Increase diastolic filling time○Maximum effective preload●Importance of VV timing○Assists with contractility by optimizing the interventricular conduction delay Target for ResynchronizationTiming Cycle Optimization is neededCardiac ResynchronizationImprove Intraventricular SynchronyImprove Atrioventricular SynchronyImprove Interventricular SynchronyBiventricular PacingDCM with Biventricular PacingDilated CardiomyopathyCourtesy of A. Auricchio, University of Magdeburg, GermanySource: Mark H. Schoenfeld. Contemporary Pacemaker and Defibrillator Device Therapy: Challenges Confronting the General Cardiologist. Circulation 2007;115;638-653Optimal AV Delay•Can it be defined?“The shortest possible AV delay which allows complete ventricular filling, thereby optimizing stroke volume and minimizing pre-systolic mitral regurgitation” What is the ideal timing●Optimal AV interval which allows complete ventricular filling and ventricular pacing occurs just after full mitral valve closure○Too long: Active filling starts during the passive filling (diastole)○Too short: Ventricular contraction before active filling is completeParameters●Paced AV Delay & Sensed AV DelayProgramming VV Timing OptimizationHow to access the heart●The echocardiographic examination with the transducer in the parasternal long-axis position. ●Transducer in the Apical position Echocardiography●The 4-chamber viewMotion Mode (M-Mode)•2-D image of a parasternal short axis view.•The red line represents the user defined “sampling line” for the display of motion (m-mode)•Note that the line sampled cuts through (or displays) in order from top to bottom: •RV freewall•IVS •LV posterior wallQuickOpt●It takes about one minute to do the echo of 30-60 minutes, by just pressing one buttonStart manual testStart auto testQuickOpt: Automatic. Quick OptTHANK YOU& Good Luck in your Exam !!。