Transcript Cooper JM ,et al.NEJM,2002,346(26) :2062

IMPLANTABLE DEVICE FOR THE
TREATMENT OF ATRIAL
FIBRILLATION
Cooper JM,Katcher MS,Orlov MV
NEJM,2002,346(26) :2062-68
Atrial fibrillation is a common
arrhythmia
Common symptoms:
• palpitations
• Dyspnea
• fatigue
 Associated complications:
• Stroke
• heart failure
• death

Cooper JM ,et al.NEJM,2002,346(26) :2062-68
Common Approaches
 Rate
control plus anticoagulation
 Rhythm control with antiarrythmic
medications
Pacemaker and defibrillator
Cooper JM ,et al.NEJM,2002,346(26) :2062-68
Ventricular pacing
during artrial fibrillation
Symptomatic bradycardia
-----permanent pacemakers
 The
atrioventricular node is bomdarded
with electrial impulses
 The factors influences on Ventricular rate
• intrinsic conduction-system disease
• takeing rate-controlling pharmacologic
agents
• with high a vagal tone
Cooper JM ,et al.NEJM,2002,346(26) :2062-68
Ablation of atrioventricular node
plus implantation of pacemaker(1)
• decreases the incidence of
palpitations ,dyspnea,et al
• increases exercise tolerance
• elminates rate-controlling medications
• improves the cardiovascular
hemodynamic
Cooper JM ,et al.NEJM,2002,346(26) :2062-68
Ablation of atrioventricular node
plus implantation of pacemaker
•
•
No effect on the fibrillation in the atria
No effect on the associated risk of
thromboembolism
Cooper JM ,et al.NEJM,2002,346(26) :2062-68
适应证

症状严重的、药物无效或不能耐受药物治
疗的慢性房颤和房扑患者

一般均有不同类型的基础病
Prevention of
atrial fibrillation
with atrial pacing
The mechanism of atrial pacing
 Allows coordinated contraction of the chambers
 Lowers average atrial pressure
 Deacreases any stretch-related changes
 Prevents pauses and reduces the risk of the
atrial fibrillation associated with increased vagal
tone and braycardia
 Supress ectopic atrial beats
The Mode Selection Trial




Number of patients: More than 2000 patients with
the SSS
Two groups: ventricular pacemaker,dual-chamber
pacemaker
The primary end points: mortality,stroke
Result: no difference with respect to the primary end
point;50% decrease in the likehood of a first episode
of atrial fibillation and a reduction in kisk of
progression to chronic atrial fibillation with dualchamber pacing
Press release of NASP,Natick,Mass,May,2001
Alternative single-site and
dual-site atrial paceng
房间传导阻滞（Interartrial Conduction Block）

一般人群房间传导阻滞发生1%，缓—速综合征患
者发生率32%

诊断标准：右房与左房间传导超过100ms

体表心电图：
• P波增宽
• P波时限≥120ms
• Ⅰ导联P波常有明显切迹，切迹间双峰间距＞0.04
• Ⅱ、Ⅲ 导联P波双向，先负后正
Synchronized atrial activation
 Usual
•
•
•
•
single-site of atrial pacing:
interatrial septum
coronary sinus
Bachmann’bundle
……
 Dual-site of atrial pcing
• the right atrial appendage
• interatrial septum
• Dual-atrial pacing
• the right atrial appendage
• coronary sinus
Patients in whom the the atrial lead was
placed at Bachmann’budle or on the
interatrial septum had a lower incidence of
parxymal and chronic atrial fibrillation than
those in whom the lead was posisioned in
the traditional right atrial appendage.
Bailin SJ,et al.JCE,2001;142:1047-55
双房同步起搏

双心房＋右心室起搏，是三腔人工心脏起搏器的
一种。

用于防治与房间传导阻滞有关的某些快速性房性
心律失常

冠状窦起搏的最佳位电多选择在冠状窦中部
双房同步起搏方式

单腔起搏器：仅有房间传导阻滞及快速房性心律
失常，选用双极AAT方式

双腔DDD起搏器：同时合并缓慢性心律失常或房
室传导阻滞，选用DDD(R）方式

Chorus 6234或7034（ela corp）：
AAT(房间水平)+DDD（房室间水平）
Overdrive atrial pacing
The mechanism of overdrive atrial
pacing
 The atrial pacing predominate over the intrinsic
atrial activity to reduce the initiation of atrial
fibrillation
 Supresses prematrue atrial beats
 Influnces the pattern of atrial depolarization
 Lowers the incidence of atrial arrhythmia
 Decrease the number of days during which atrial
fibrillation occurred
High-frequency pacing
and electrical cardioversion
Antitachycardia device(1)
The Metrix Atrioverter,InControl
The Jewel AF device,Medtronic
The GEM AT Ⅲ,Medtronic
Antitachycardia device(2)
 The device was progremmed to detect artrial
fibillation,and adminster a shock to restore sinus
rythem
 To deliver rapid atrial pacing to treat atrial
arrhythmias
 The over efficacy of thr device in teminating
atrial fibrillation was 90%,1/3 episodes requiring
more than one shock
 Safty:no instence of ventricular proarrythmia
The GEM AT Ⅲ,Medtronic
 The shocks for atrial fibrillation can be
activeed by the patient
 To be programmed to occur automatically
in the early morning while the patent is
sleep
 To ensure that the shock is delivered within
24 hours after the onset of atrial
fibrillation
Conclution and fulture
The ideal patient population for this
invasive antiarrhythmic strategy has
not been defined
25% patients who receive an
implantable defibrillator for ventricular
arrhythmias also have paroxymal artrial
fibrillation