心臟起搏器培訓(xùn)資料：起搏器程控隨訪

1、起搏器程控隨訪 美敦力三步隨訪 2 | Title 什么是起搏器的程控隨訪？ 定期在單位時間 內(nèi)，通過外部程控 儀對病人體內(nèi)起搏 器系統(tǒng)工作的有效 性、合理性進(jìn)行評 價；必要時結(jié)合起 搏器的診斷功能， 對每一個病人的不 同情況做出參數(shù)調(diào) 整。 3 | Title 隨訪的內(nèi)容和目的 近期隨訪 觀察傷口變化 了解導(dǎo)線固定情況 程控起搏參數(shù) 了解患者對起搏的反應(yīng) 對患者進(jìn)行測試 4 | Title 隨訪的內(nèi)容和目的 遠(yuǎn)期隨訪 癥狀是否改善 生活質(zhì)量是否提高 術(shù)后心功能是否改善 對血流動力學(xué)的影響 起搏后有無心律失常 了解起搏后各種并發(fā)癥 5 | Title 如何才能將一次起搏器的程控隨訪做完整？ 病

2、史及臨床評估 詢問并打印起搏器相關(guān)參數(shù) n評價起搏器電池狀態(tài) n測試起搏器各項參數(shù) n回顧起搏器的診斷信息 優(yōu)化起博功能 6 | Title 程控隨訪的主要步驟 隨訪前準(zhǔn)備工作 第一步：評估電池狀態(tài) 第二步：測量3項重要參數(shù) 第三步：分析診斷圖表與數(shù)據(jù) 結(jié)束隨訪 7 | Title 隨訪前準(zhǔn)備工作 患者體位：坐位或仰臥位 器材：程控儀、心電圖機(jī)、電極貼片 記錄心電圖 普通心電圖 磁頻心電圖 詢問起搏器 打印起搏器參數(shù)及診斷數(shù)據(jù)、圖表 8 | Title 第一步：評價起搏器電池狀態(tài) 9 | Title 第一步：評價起搏器電池狀態(tài) 1、心電圖+磁鐵頻率心電圖 電池狀態(tài)良好： 程控頻率+DOO 85

3、bpm 電池狀態(tài) ERI: VVI 65bpm+VOO 65bpm ERI: Elective Replacement Indicator 擇期更換指示 EOL：End of life 電池耗竭 10 | Title 第一步：評價起搏器電池狀態(tài) 普通心電圖磁頻心電圖 電池狀態(tài)良好程控頻率DOO/VOO 85bpm 電池ERIVVI 65bpm VOO 65bpm ERI：Elective Replacement Indicator（擇期更換指示） 1、通過心電圖評估 11 | Title 100 min-1100 min-1100 min-185 min-185 min-1 TMT 放置磁鐵

4、脈寬下降 25% 磁頻心電圖 (單腔模式) TMT：Threshold Margin Test 12 | Title 100 min-1100 min-1100 min-185 min-185 min-1 TMT 放置磁鐵 100 ms100 ms100 ms 脈寬下降 25% 100 ms 磁頻磁頻 ECG (雙腔模式雙腔模式) 13 | Title 第一步：評價起搏器電池狀態(tài) 2、詢問起搏器，直接觀察程控儀顯示的電 池電壓狀態(tài) -正常時 2.590.05V 14 | Title 病例 15 | Title 病例 16 | Title 病例 17 | Title ERI = Electron

5、ic Replacement Indicator RRT = Recommended Replacement Time （更多用） 關(guān)于ERI 18 | Title 何時出現(xiàn)ERI 植入后 環(huán)境溫度穩(wěn)定 隨電量減少電壓也降低，觸發(fā)ERI 植入前 環(huán)境溫度變化極大 低溫使電壓降低，觸發(fā)ERI 19 | Title 出現(xiàn)ERI的表現(xiàn) 重大事件窗出現(xiàn)提示 起搏狀態(tài)改變 20 | Title 出現(xiàn)ERI意味著什么？ 真耗竭：電池電量耗竭 ERI不能被清除 假耗竭：電池電量并未耗竭 如果起搏器的溫度恢復(fù)正常范圍（室溫）后， ERI可以被清除 21 | Title 如何清除ERI 僅假耗竭的起搏器可以清除

6、ERI提示信息 清除ERI的方法 清除ERI提示信息 修改低限頻率：65 bpm 60（或醫(yī)生需要的數(shù) 值） 修改起搏模式及相關(guān)參數(shù) 點擊“Program” 22 | Title ERI與起搏器更換 ERI與起搏器更換 ERI不等于電池沒電 廠家保證95%的起搏器在出現(xiàn)ERI后至少可以 繼續(xù)工作3個月 出現(xiàn)ERI（電池電量真耗竭）應(yīng)立即更換立即更換 ERI = Electronic Replacement Indicator 23 | Title 重要的第一步 電池是起搏器的唯一能源，通常都最先檢查 應(yīng)從多角度評估電池狀態(tài) 普通心電圖、磁頻心電圖 起搏器提示 電池電壓 電池內(nèi)阻 24 | Ti

7、tle 第二步：測量三個重要數(shù)據(jù) 起搏閾值(V/ms) P/R波幅度(mV) 起搏環(huán)路阻抗() 25 | Title 1、起搏閾值（v/ms） 測量起搏閾值時應(yīng)明確輸出脈沖的振幅和 脈寬； 雙腔起搏器閾值測試的方法： 分別用AAI(病竇)和VVI方式測試 DDD方式： 測心房時，提高下限頻率且AV=350ms 測心室時，縮短AV間期至持續(xù)的VP出現(xiàn) 26 | Title 27 | Title 28 | Title 病例8 5.0v/0.4ms 29 | Title 2、P/R波幅度（mV） 美敦力起搏器提供了自動感知測試； 測試雙腔導(dǎo)線感知的兩種方法： 分別用AAI和VVI方式測試； DDD方

8、式: 測P波時,要將下限頻率降低到自身竇率以下； 測R波時，在維持上述的參數(shù)設(shè)置之外，另將AV間期 延長至350ms或持續(xù)的R波出現(xiàn)； 30 | Title 自動感知測試方法推薦 31 | Title 起搏環(huán)路阻抗（） 起搏器詢問后，直接在QuickLook界面上直接讀 ?。?也可利用Battery and lead impedance measurement 再測量； 32 | Title 測試起搏阻抗 33 | Title 程控隨訪第二步的關(guān)鍵點 測試方法的有效性 測試結(jié)果的準(zhǔn)確性 熟知各測試數(shù)據(jù)的正常范圍 有自動測試功能的起搏器，也需定期隨訪， 評估分析儲存的測試數(shù)據(jù) 34 | Titl

9、e 第三步：回顧起搏器的診斷信息 起搏器的診斷功能：應(yīng)用己經(jīng)植入人體的起搏器 及其導(dǎo)線，以診斷數(shù)據(jù)和圖表的形式，記錄和存 貯患者心律情況及起搏器工作狀況，幫助醫(yī)生制 定治療方案，是一個特殊的“Holter”功能。 35 | Title 診斷圖表總覽 36 | Title Heart Rate Histograms-Atrial 37 | Title Heart Rate Histograms-Ventricular 38 | Title A-V Conduction Histogram 39 | Title Sensor Indicated Profile 40 | Title High Ra

10、te Episodes 41 | Title High Rate Episodes 42 | Title Arrhythmia Management Rate-Control Assessment* V Rate During AT/AF Details Available on-screen or in initial interrogation report Histogram displays percent of V-beats paced or sensed that fall into each rate bin Only V-beats during mode switch in

11、cluded Clinical Questions/Concerns Do ventricular rates recorded during atrial tachyarrhythmias suggest that medications need to be modified to control ventricular response? Is modification of the AV node an alternative option? Is conducted AF response ON? If not, would it be useful to try? Printed

12、Report Version On-Screen Display * The information collected may help with assessment of rate-control, rhythm- control, and risk for stroke in patients with atrial tachyarrhythmias. 43 | Title Arrhythmia Management Rhythm-Control Assessment* Cardiac Compass Details Lists AT/AF observations (if any)

13、Vertical lines reflect cumulative daily burden levels (hrs/day) Includes MS episodes (or, if MS = OFF, AHR episodes) regardless of duration Clinical Questions/Concerns? Are previously undiagnosed episodes present? Do episode date/times correlate to patient symptoms? Has rhythm-control therapy increa

14、sed the amount of time spent in sinus rhythm? Are pharmacologic or other therapy adjustments needed? Are atrial tachyarrhythmias affecting HF status or frequency of VT/VF? Printed Report Version On-Screen Display * The information collected may help with assessment of rate-control, rhythm- control,

15、and risk for stroke in patients with atrial tachyarrhythmias. 44 | Title Arrhythmia Management Risk for Stroke Assessment* Clinical Questions/Concerns Is there an increased risk for stroke due to episodes of long duration? Do daily burden levels suggest that the patient may be at a higher risk for s

16、troke? Does patient have other contributing risk factors? Should anticoagulation therapy be modified or initiated? * The information collected may help with assessment of rate-control, rhythm- control, and risk for stroke in patients with atrial tachyarrhythmias. 45 | Title Arrhythmia Management Atr

17、ial and Ventricular High Rate Episode Log VHR Count: Number of episodes in which consecutive V-V intervals exceeded high rate detection criteria. (nominal at least 5 intervals 180 bpm) AHR Count: Number of episodes in which consecutive A-A intervals (includes refractory) exceeded trigger criteria. A

18、trial Episode Trigger Options: Mode switch (4 of 7 A-A intervals faster than detection rate) AHR criteria (nominal 4 of 7 intervals within a 5 second window must be faster than 180 bpm) 46 | Title Arrhythmia Management Atrial and Ventricular High Rate Episode Log AHR Episode Details: Date and time s

19、tamps for up to 16 recorded events Durations start after detection criteria are met; termination occurs after 5 consecutive AP-AP intervals or 7 A-A intervals slower than the upper tracking rate (nominal 130 bpm) Max A rate is computed as the faster of the trigger detection rate or mean atrial inter

20、val + 25 ms (converted to a rate) Max V rate is computed as the minimum of slower of two most recent V-V intervals or current minimum V rate Average V rate is computed only if the AHR episode duration 10 sec; computed as the number of V- event/(episode duration/60) Sensor rate is taken at the beginn

21、ing of the episode EGM/trend notification, if available (up to 48 seconds, multiple episodes) 47 | Title Arrhythmia Management Atrial and Ventricular High Rate Episode Log VHR Episode Details: Date and time stamps for up to 16 recorded events Durations start after detection criteria are met; termina

22、tion occurs after programmed number of consecutive V-V intervals are slower than detection rate (nominal 5 beats) Max V rate is computed as the minimum of slower of two most recent V-V intervals or current minimum V rate Average V rate is computed as the number of V-event/(episode duration/60) Max A

23、 rate is computed as the faster of the trigger detection rate or mean atrial interval + 25 ms (converted to a rate) Sensor rate is taken at the beginning of the episode EGM/trend notification, if available (up to 48 seconds, multiple episodes) 48 | Title Capture Management Trend-Atrial 49 | Title Ca

24、pture Management Trend-Ventricular 50 | Title Capture Management Trend-Ventricular 51 | Title Sensitivity Trend P Wave 52 | Title Sensitivity Trend R Wave 53 | Title Lead Impedence - Atrial 54 | Title Lead Impedence - Ventricular 55 | Title Clinician selected. 56 | Title 57 | Title Clinician selecte

25、d. 58 | Title 59 | Title 程控隨訪必須做的第三步 通過分析診斷圖表，調(diào)整起搏參數(shù)，使病人 得到最優(yōu)化的治療（如起搏模式的改變、 AV間期的延長、極性的變化等）； 通過特殊的“Holter”，對病人心律失常的發(fā) 生和進(jìn)展進(jìn)行評估并給予合理的治療方案。 60 | Title 起搏器常規(guī)三步隨訪步驟起搏器常規(guī)三步隨訪步驟 第一步：先檢測起搏器的電池狀態(tài) 第二步：測試起搏閾值、感知、導(dǎo)線阻抗 第三步：看“Holter”診斷報告，了解病人病情與起搏 參數(shù)的合理性 調(diào)整起搏參數(shù)，優(yōu)化起搏功能 61 | Title 常見需優(yōu)化的起搏設(shè)置與功能 起搏模式 起搏輸出 起搏、感知極性 AV間期的調(diào)整 特殊功能的開啟 MVP、SearchAV、頻率驟降、竇性優(yōu)先、模式 轉(zhuǎn)換、頻率應(yīng)答、睡眠功能、單腔滯后 62 | Title 結(jié)束程控隨訪 打印隨訪報告 數(shù)據(jù)存盤 記錄普通心電圖 63 | Title 起搏器的隨訪間隔 急性期急性期 中期中期 鄰近更換鄰近更換 出院前； 12周時 64 | Title 2090程控儀升級后如何存盤及打印報告？ 存貯介質(zhì)指示器位于程控儀左上角 65 | Title 指示器的不同狀態(tài) 未插入U盤（或拔出U盤后） 默認(rèn)的存儲、讀取介質(zhì)是軟盤，軟盤標(biāo)志為綠色 插入U盤 存儲、讀取介質(zhì)自動變?yōu)閁盤，U盤標(biāo)