Implantuojamų EKS diagnostinės galimybės Rez. R.Jurgaitienė Pirmieji jų tik greitino ritmą, dabartiniai atlieka įvairiausias širdies darbą gerinančias funkcijas. Pirmasis LT implantuotas 1961m.

Implantuojamų EKS diagnostinės galimybės Pirmasis EKS implantuotas 1958 spalio 8d., Švedijoje. Įlietas į epoksidinę dervą 2V amplitudės 1,5 ms trukmės Pastovaus 70-80 imp./min.dažnio Baterija buvo pakraunama per odą kas savaitę 55mm x16 mm Pirmieji jų tik greitino ritmą, dabartiniai atlieka įvairiausias širdies darbą gerinančias funkcijas. Pirmasis LT implantuotas 1961m.

Šiuolaikiniai EKS gali Parodyti baterijos rezervą Nustatyti sistemos impedanso kitimą Nustatyti spontaninį elektrinį aktyvumą, širdies kameroje, į kurią įvestas elektrodas Stimuliuoti, jei spontaninis elektrinis aktyvumas nepakankamas Automatiškai perjungti stimuliacijos režimą (“Auto Mode Switching”) Automatiškai nustatyti stimuliacijos slenkstį (“Autocapture”) Adaptuoti stimuliacijos dažnį pagal fizinį aktyvumą (“Rate responsive",“Rate adaptive") Monitoruoti (histograma registruojama iki 14 mėn.) : Širdies ritmą Ritmo sutrikimus, ekstrasistoles Stimuliacijos dažnio kitimus Nuosavą ir stimuliuotą širdies veiklą P ir R bangas (diferencinei ritmo sutrikimų diagnostikai) Paciento fizinį aktyvumą (val./parą) Krūtinės ląstos impedansą

EKS duomenys gali atsakyti į klausimus: Kokie EKS parametrai? Koks širdies ritmas ? Kokios širdies aritmijos būna? Kiek aritmijų būna? Koks širdies susitraukimų dažnio svyravimas? Koks skilvelių dažnis prieširdinių aritmijų metu? Ar simptomai susiję su širdies aritmijomis? Koks medikamentinio gydymo efektas? Koks paciento fizinis aktyvumas? Koks skysčių kiekio pokytis krūtinės ląstoje (OptiVol)?

Kokie EKS parametrai? Lead Impedance QuickLinks on the Quick Look screen directly access lifetime chronic lead impedance data which is not cleared. The clinician can tell at a glance if lead impedances are a cause for concern.

Kokie EKS parametrai? Lead Impedance QuickLinks on the Quick Look screen directly access lifetime chronic lead impedance data which is not cleared. The clinician can tell at a glance if lead impedances are a cause for concern.

Paviršiaus EKG ir EKS žymėjimai Fast initial overview at what the patient and pacemaker are doing May alert you to problems with capture or sensing Loss of capture (can be intermittent) Oversensing Undersensing Annotations should match the tracing Rate should be appropriate for what is programmed Rate variations can occur but should be explainable For example: hysteresis, rate response, atrial tracking Žymėjimai tai ką EKS “galvoja” Jie turi sutapti su EKG Galima pastebėti neefektyvią stimuliaciją 7

Paviršiaus EKG Žymėjimai tai ką EKS “galvoja” Jie turi sutapti su EKG Fast initial overview at what the patient and pacemaker are doing May alert you to problems with capture or sensing Loss of capture (can be intermittent) Oversensing Undersensing Annotations should match the tracing Rate should be appropriate for what is programmed Rate variations can occur but should be explainable For example: hysteresis, rate response, atrial tracking Žymėjimai tai ką EKS “galvoja” Jie turi sutapti su EKG Galima pastebėti neefektyvią stimuliaciją 8

Paviršiaus EKG Žymėjimai tai ką EKS “galvoja” Jie turi sutapti su EKG Fast initial overview at what the patient and pacemaker are doing May alert you to problems with capture or sensing Loss of capture (can be intermittent) Oversensing Undersensing Annotations should match the tracing Rate should be appropriate for what is programmed Rate variations can occur but should be explainable For example: hysteresis, rate response, atrial tracking Žymėjimai tai ką EKS “galvoja” Jie turi sutapti su EKG Galima pastebėti neefektyvią stimuliaciją 9

AUTOCAPTURE funkcija – automatinis skilvelių impulso stiprumo parinkimas Point out: The blue bars are the pacemaker output pulses The green bars show backup safety pulses which are delivered in the event of noncapture Two noncapture events occur early in this diagram; this causes the output to increase by 0.25 V After three backup pulses, the increased output finally does capture the heart Two captured beats are enough to launch the threshold search leidžia prailginti EKS veiklos trukmę 10

AUTOCAPTURE Automatinis stimuliacijos slenksčio (skilvelių impulso stiprumo) nustatymas ”Stimuliacijos slenkstis : 0.9 V”

Stimuliacijos slenkstis Paciento aktyvumas Padėties kitimas Paros laikas Gretutinė patologija Hiperkalemija Valgymas Vaistai Ligos progresavimas This graph is just an example but it uses typical values. The patient’s initial pulse amplitude capture threshold was just a bit over 1 V. There were some dips and spikes (thresholds are not static) but notice that the threshold increased to nearly 4 V before it settle back down around 2 V. Had the pacemaker been programmed to 2.5 V, it would have failed to capture the heart for a time period before the threshold stabilized! 12

Stimuliacijos slenkstis ir AUTOCAPTURE Point out: The patient’s threshold was relatively stable for a long period of time, then shot up dramatically The numbers on the side show a 2:1 and then a 3:1 increase in threshold from the baseline Remember, the patient had gastroenteritis but reports no pacemaker-related symptoms 13

Stimuliacijos slenkstis ir AUTOCAPTURE Point out: The first arrow (A) shows the onset of gastroenteritis (the dates help match diagnostic data to events) The (B) arrow shows when the patient received IV fluids during hospitalization. This dramatically increased his capture threshold! (C) shows his release from the hospital and (D) shows today’s visit Of interest: Although this patient’s capture threshold doubled and then tripled in a very short period of time, his pacemaker “never missed a beat.” The AutoCapture™ algorithm adjusted his pacemaker output beat by beat, as he needed it Had a conventional pacemaker been used, even a 3:1 safety margin would not have assured reliable, consistent capture 14

Elektrodo impedansas Impedansas Būklė Unique to the Medtronic Kappa 900, the Initial Interrogation Report automatically includes real-time telemetry reporting the lead status report as well as the measured lead impedance. If a polarity switch were to occur, the Kappa 900 would note it here and in Significant Events on the Quick Look screen. Turi svyruoti gamintojo nustatytose ribose Esant dideliems (>200 Ohms) nuokrypiams nuo normos galima įtarti elektrodo padėties problemą

Koks širdies susitraukimų dažnis? Arrhythmia burden information is crucial to understand to evaluate the risk to the patient. The Arrhythmia Log provides the number of AHR (and VHR) episodes, the time in AHR expressed as an average hours/day and percent of time since last follow up. In addition the duration for the episodes collected is indicated.

Koks širdies ritmas ? Arrhythmia burden information is crucial to understand to evaluate the risk to the patient. The Arrhythmia Log provides the number of AHR (and VHR) episodes, the time in AHR expressed as an average hours/day and percent of time since last follow up. In addition the duration for the episodes collected is indicated.

Koks širdies ritmas ? PV val./parą ? The Atrial Arrhythmia Durations provides even more insight into the arrhythmia burden. Although knowing the total burden is helpful, more specific information regarding the duration of these events is useful in classifying the atrial arrhythmia, evaluating changes in the characteristics of the arrhythmia, evaluating treatment effectiveness, and establishing the risk of complications rising out of the arrhythmia. For example, it can be very useful when considering when to add anticoagulation. The Atrial Arrhythmia Trend – Cardiac Compass is also helpful in evaluating the burden. It can reveal changes in the pattern or durations of atrial arrhythmias. This may be helpful in evaluating the effectiveness of treatment or changes in treatment. The Atrial Arrhythmia Trend – Cardiac Compass provides the hours per day the patient has been in atrial arrhythmias for the last 6 months. This trend is updated automatically, i.e. the data is never cleared. The Cardiac Compass can assist in the assessment of AF disease progression, the efficacy of arrhythmia management (especially if changes are made) and provide more insight into the arrhythmia burden. Note: When comparing Atrial Arrhythmia Trends obtained at different follow-up sessions: The “hours/day” scale may change. The range of this scale depends on the maximum hours/day the patient has spent in an atrial arrhythmia. Do not compare patterns without noting the scale. Changes in the Mode Switch Detection rate will affect the diagnostics. Be aware of possible programming changes when comparing reports between different sessions. Other factors may be reflected in the diagnostics, for example, changes in medications, or patient compliance to treatment. A patient history will assist in comparing data collected at different sessions. Prieširdinės ar skilvelinės aritmijos Aritmijos trukmė (valandos, dienos) Gydymo efektyvumas Sąsaja su nusiskundimais Rizikos vertinimas ir medikamentų (antikoaguliantų) skyrimas

Koks širdies susitraukimų dažnis paros bėgyje? Arrhythmia burden information is crucial to understand to evaluate the risk to the patient. The Arrhythmia Log provides the number of AHR (and VHR) episodes, the time in AHR expressed as an average hours/day and percent of time since last follow up. In addition the duration for the episodes collected is indicated.

Koks skilvelių dažnis prieširdinių aritmijų metu? Arrhythmia burden information is crucial to understand to evaluate the risk to the patient. The Arrhythmia Log provides the number of AHR (and VHR) episodes, the time in AHR expressed as an average hours/day and percent of time since last follow up. In addition the duration for the episodes collected is indicated. Kappa 900 offers a variety of ways to obtain this important data. A fast ventricular response to atrial arrhythmias is thought to be a major contributor to patient complaints. In addition, control of the ventricular response has important clinical consequences. A fast ventricular response to AF contributes to heart failure, and failure to control the ventricular response may be a predictor of cardiomyopathy. The Arrhythmia Log provides the maximum and average ventricular rate during each collected episode, including Atrial High Rate episodes. Only Medtronic provides information to assess ventricular rate control in this manner. The sensor indicated rate is also included. This information provides an indication of the patients activity level at onset of the episode to help identify if exercise induced the event. Another important task is symptom-rhythm correlation. The Arrhythmia Log Time date and time stamps the collected episodes, providing an easy way to compare a patient’s reported symptoms with collected events.

Koks skilvelių dažnis prieširdinių aritmijų metu? Another tool useful in evaluating the ventricular response to atrial arrhythmias is the Ventricular Rate Histogram During Atrial Arrhythmia. Unlike the conventional rate histograms (which are also included in the Kappa 900), this histogram displays the ventricular rate only during atrial arrhythmias. The rates are displayed in rate bins as paced or sensed events. This is a very easy to understand tool providing insight into rate control therapies, and may help gauge the severity of patient symptoms. Didelis skilvelių susitraukimų dažnis dažniausiai sąlygoja pacientų nusiskundimus Didelis skilvelių dažnis dėl PV gali būti ŠN ir kardiomiopatijos priežastimi.

“Auto Mode Switching” “Auto mode switching” funkcija – PV ar PP paroksizmo metu DDD persijungia į VVI (DVI) režimą

Gydymo efektyvumas PV val./parą ? Prieširdinių aritmijų dažnio ir trukmė Gydymo efektyvumas Rizikos vertinimas ir antikoaguliantų skyrimas

AV intervalo automatinė paieška Mažindamas skilvelinės stimuliacijos epizodus EKS taupo baterijas

“Rate responsive",“Rate adaptive“ funkcija “Rate responsive” stimuliacija imituoja sveikos širdies ritmą Sensoriai ( spaudimo bangų,T, pH, pCO2,KD ir kt.) automatiškai padažnina arba paretina dažnį pagal poreikį ŠSD adaptavimas pagal fizinį aktyvumą leidžia pacientui būti aktyvesniam

“Rate responsive",“Rate adaptive“ funkcija Naktis Diena fizinis aktyvumas val./parą Ligonio fizinio aktyvumo vertinimas gydymo eigoje (val./ parą) Kodėl ligonis darosi mažiau aktyvus? Ar gydymas padeda?

OptiVol Skysčio kiekio krūtinės ląstoje monitoravimo sistema Matuojamas elektrinis impedansas CRT-Ds ir IKD OptiVol

Didėjant skysčio kiekiui Elektrinis impedansas mažėja Paankstina ŠN progresavimo nustatymą ir gydymo pradžią Mažina hospitalizacijų dažnį

Koks aritmijos mechanizmas? Pr veikla sutampa su Sk veikla PR trumpas Vagusinė stimuliacija nutraukė tachikardiją 3 prieš. ex . PR ilgėjant atsirado tachikardija Prieširdinė “re-entry” tipo tachikardija

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