REVEAL+XT+植入式心电事件记录仪应用1例课件.pptx

1、REVEAL 案例分享案例分享超越晕厥的超越晕厥的应用应用 病例病例资料资料 男，57岁，因阵发性心悸一年，晕厥一次入院。患者2010年10月无明显诱因下出现胸闷心悸，伴有头晕，持续10分钟左右可自行缓解，未引起重视也未予以治疗，近1年中共发作5次，无规律性，与体位改变无关。2011年10月患者在走路时突然出现胸闷不适，随机头晕，黑朦，神志不清后摔倒在地，持续5分钟左右自行清醒，当时无肢体抽搐、口吐白沫、大小便失禁，醒后伴头部外伤流血。反复查动态心电图示：窦性心律，偶发室性早搏。心脏彩超提示左室舒张功能减退。头颅CT正常。2011年12月，门诊心脏超声报告未见明显异常。晕厥查因不确定。与患者沟

2、通后，患者决定接受Reveal XT植入REVEAL的系统组成的系统组成 植入性心电监测仪 患者助手 2090程控仪 CareLink 远程管理 REVEAL LINQ 的小型化程度突破性技术体积缩小87%，1.2 cc,2.5 g 植入更简单洛仑兹图+P波分析2分钟房颤专区59分钟储存MR 兼容 1.5 T和条件性 3 T*Under the following usage scenarios:Average of 1 auto-detected episode per day Average of 1 patient-activated episode per month Less tha

3、n or equal to 6 months shelf life(between device manufacture and insertion)Note:Under maximum shelf storage time(12 months),longevity is reduced by approximately 3 months.4Medtronic Confidential.Internal Use Only.无需导管室条件，免标测X无需标测最佳植入位置：距离胸骨左缘2CM，第4肋间，45度角植入式心电事件检测器植入式心电事件检测器Reveal LINQ 被预先放置在植入工具中.小

4、于一厘米 切口提高了精度，也保证了美观使用过的医生认为植入工具简单易用，非常容易掌握.7开创无囊袋皮下注射术，植入简单REVEAL XT常规植常规植入部位入部位 1 起搏器位置，近锁骨(最高近锁骨下 3 cm):n=6,7.2%2 乳头右上方（乳头上方 2cm）:n=51,61.4%3 乳头左上方:n=3,3.6%4 乳头右方:n=11,13.3%5 乳房下缘以下,14.5%通过比较向量检测结果，以下的位置比较理想 （P波：1-3mV R波：5-15mV）植入后出现心悸及黑朦症状，ICM记录到事件，如下图：CL 220-230MSHR 260BPM考虑SVT可能 遂建议患者行电生理检查，证实室

5、上速，给予射频消融治疗 术后患者未再出现心悸及晕厥晕厥原因待查卒中原因监测AF消融术后监测其他心律失常监测ICM临床应用范畴IN SERTA BLE C A RD IA C M O N ITO RIN G SYSTEMDi agnost i c yi el d wi t h I CM vs.convent i onal t est i ng i n unexpl ai ned syncopeRAST:Krahn,Ci r cul at i on.2001(Hol ter +ti l t tabl e+EP testi ng)syncope(90%)SyncopeKr ahn AD,et al.

6、Ci r cul at i on.2001;104:46-51.Pati ent fow di agram show s hi gher di agnosti c yi el d w i th Reveal m oni tori ngUnexpl ai ned Syncopen=6030m oni tori ng3i n f ol l ow-up14di agnosed6di agnosed24undi agnosed13undi agnosed30conventi onal6IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMDi agnost i

7、 c yi el d w i th I CM vs.convent i onal t est i ng i n unexpl ai ned syncopeEaSyAS:Farw el l,Eur Heart J.2006w i thout paci ng i ndi cat i on r esul t i ng f r om car ot i d si nus m assage and t i l t test i ngI CM pati ents r ecei ved an ECG di agnosi s t han by convent i onal t esti ng(43%vs.6%;

8、HR 6.53 95%CI 3.73-11.4;p 0.001)t i m es f aster i n I CM pat i ent s(p 0.001)Farw el l DJ,et al.Eur Heart J.2006;27:351-356.Syncope0.0002004006008001,0000.250.500.751.00Ti m esConventi onalI LR6.5 ti m es m ore I CM pati ents di agnosed6.1 ti m es m ore I CM pati ents treatedI LRConventi onalTotalP

9、acem aker16319Li f estyl e m odifcati on12113Drug therapy 81 9Drug cessati on 21 3Aw ai ti ng therapy 20 2RF abl ati on 10 1I CD 01 1Ti l t trai ni ng 10 1Psychi atry ref erence 10 1Total437507IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMCi r cul at i on.2012;125:2566-2571.I CM-gui ded pacem aker

10、 ther apy f or neur al l y m edi at ed syncopeI SSUE 3:Bri gnol e,Ci r cul at i on.2012Purpose:To assess the ef fecti veness of paci ng ther apy at preventi ng syncope recurr ence i n pati ents w i th neur al l y m edi ated syncope(NM S)M ethods:Resul ts:89 pts experi enced asystol i c syncope w i t

11、hi n 12 m onthsI m pl i cati ons:i ntervent i on t hat i m proves outcom es i ncr eased and shoul d i m pact gui del i nesSyncope32%absol ute reducti on i n syncoperecurrence w i th I PG therapy8IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMReduced ti m e t o di agnosi s and treatm ent wi t h rem

12、ot e m oni t ori ng i n I CM pat i entsDrak-Hernandez,Rev Esp Car di ol.2013f ol l ow ed w i th the Car eLi nk Netw ork or conventi onal on-si te f ol l ow-updi agnosi s(56 days vs.260 days,p 0.001)and ti m e to i ni ti ati on of speci f i c treatm ent(73 days vs.260 days,p 0.001)Rev Esp Car di ol.2

13、013;66:943-948.Syncope0Conventi onal M oni tori ngTi m e f rom I CM i m pl ant to treatm entRem ote M oni tori ng2004006008001000P .001*Rem ote M oni tori ng reduced ti m e to treatm ent by 187 days9IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMI CM s m or e cost-ef f ect i ve m et hod t o di agno

14、se unexpl ai ned syncopeRAST:Krahn,J Am Col l Car di ol.2003OBJECTI VES:W e sought t o assess t he cost i m pl i cati ons of tw o i nvesti gati on st r ategi es i n pat i ent s w i t h unexpl ai ned syncope.BACKGROUND:Establ i shi ng a di agnosi s i n pati ents w i th unexpl ai ned syncope i m m edi

15、 at e,pr ol onged m oni t or i ng as an al t er nati ve t o conventi onal di agnosti c st r ategi es has not been st udi ed.M ETHODS:w i th an ext er nal l oop r ecor der,ti l t and el ectr ophysi ol ogi c(EP)testi ng,or pr ol onged m oni t ori ng w i th an i m pl antabl e l oop r ecor der w i th on

16、e-year m oni t or i ng.I f pati ent s r em ai ned undi agnosed af t er t hei r assi gned str at egy,they w er e of f er ed a cr ossover t o the al t er nat e str at egy.Cost anal ysi s of the tw o t esti ng str at egi es w as perf or m ed.RESULTS:Fourt een of 30 pati ents w ho w er e bei ng m oni to

17、r ed w er e di agnosed cr ossover,a di agnosi s w as obt ai ned i n 1 of 5 pati ents under goi ng conventi onal t esti ng,com par ed w i th 8 of 21 pati ents w ho com pl et ed m oni t or i ng(20%vs.38%,dol l ar s per di agnosi s.Convent i onal t esti ng f ol l ow ed by m oni t or i ng w as associ at

18、ed CO NCLUSI ONS:A str at egy of pr i m ary m oni t or i ng i s m or e cost-ef f ecti ve than convent i onal test i ng i n est abl i shi ng a di agnosi s i n recurr ent unexpl ai ned syncope.Kr ahn AD,et al.J Am Col l Car di ol.2003;42:495-501.Unexpl ai ned Syncopen=6030m oni tori ng14di agnosed6di

19、agnosed$2,731/pati ent$5,852/di agnosi s$1,683/pati ent$8,414/di agnosi s24undi agnosed16undi agnosed30conventi onalSyncopeI CM s reduced cost/di agnosi s by 30%10IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMSyncopeBenef i t s wi t h I CM vs convent i onal t est i ng i n unexpl ai ned syncopeEaSy

20、AS:Farw el l,Eur opean Heart J.2004BACKGROUND:Syncope i s a com m on,di sabl i ng sym ptom.The m ost usef ul dat a f or di agnosi ng and m anagi ng syncope i s the r ecor di ng of physi cal par am et er s such as the ECG and bl ood pr essur e duri ng a spontaneous event.I m pl ant abl e l oop r ecor

21、 der s(I LR)pr ovi de an opportuni ty to r ecor d ECG data f r om a spontaneous event.The pur pose of the East bour ne Syncope Assessm ent St udy(EaSyAS)w as t o i nvesti gat e the i m pact of I LRs on an unsel ect ed popul at i on of syncopal pat i ent s present i ng acutel y to our i nst i t ut i

22、on.M ETHO DS:Al l pati ents pr esenti ng acut el y w i th r ecur r ent,unexpl ai ned syncope over a 16-m onth peri od,w er e r andom i sed af t er a basi c cl i ni cal w orkup t o r ecei ve the Reveal Pl us I LR or conventi onal i nvesti gat i on.Al l pati ents w er e f ol l ow ed up f or at l east

23、6 m onths(m ean 276 134 days)f ol l ow i ng r andom i sati on.The pr i m ary out com e m easur e w as t i m e t o ECG di agnosi s.RESULTS:Four hundr ed tw enty-one pati ents pr esent ed,201 w er e el i gi bl e,m edi an age syncopes(I Q r ange 2 6).Thi rty-thr ee per cent of I LR pati ents and 4%of c

24、onventi onal p 0:0001).I LR pati ents had f ew er post-r andom i sati on i nvesti gati ons and f ew er hospi tal days,r esul ti ng i n a savi ng of costs,406 ver sus 1210(m ean di f f er ence 809,95%CI CO NCLUSI O NS:LR si gni f i cantl y i ncr eased the r at e of di agnosi s i n an unsel ect ed W e

25、stern popul ati on w i th r ecur r ent syncope.Ther e w as a si gni f i cant decr ease i n the r at es of hospi t al i sat i on and i nvest i gat i on i n pat i ent s recei vi ng an I LR.Farw el l DJ,et al.EHJ 2004;25:1257-1263.ProcedureRevealControlDi f f erence i n cost()(95%CI)Com puted tom ograp

26、hy head48-5.30(-13.86 to 1.29)M agneti c resonance i m agi ng11-0.05(-3.06 to 2.91)El ectroencephal ogram02-2.04(-4.80 to 0.72)Carti d doppl er35-2.19(-8.14 to 2.89)Echo1215-8.54(-25.31 to 6.54)24-hr Hol ter411-7.34(-15.08 to-0.37)ELR:R Test528-29.84(-43.49 to-18.04)El ectrophysi ol ogi c study01-6.

27、12(-17.90 to 5.65)I nvesti gati ons34.095.461.43(-92.92 to 35.16)Hospi tal i sati on3791090-747.30(-2728.48 to-72.75)Total costs4061210808.72(-2766.22 to-123.42)Costs i ncurred post-random i zati on13IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMI CM s f or Stroke Preventi onB BACACK KG G RORO U U

28、 N N D D11(cryptogeni c str oke)23-5pr om pts a change f r om anti pl atel et to anti coagul ati on m edi cati on f or str oke r educti on(Am eri can and Eur opean str oke gui del i nes).6-8 TRENDS 09,TRENDS 10,ASSERT 12,SO S AF 14 S ST TR RO O K KE EAF burden detecti on i s hi ghl y rel i abl e,w i

29、 th accur acy of 98.5%.XPECT 10I n cryptogeni c stroke,I CM s provi de superi or di agnosti c yi el d(17-30%)vs.standard m oni tori ng(1.7-3.0%),i denti f y 8.8 ti m es m ore AF at 3 year s.RI TTER 14,CRYSTAL AF 14Cl i ck on references i n bl ue above to l i nk to study reference pages18IN SERTA BLE

30、 C A RD IA C M O N ITO RIN G SY STEM98.5%AF det ect i on accur acy wi t h Reveal XTXPECT:Hi ndri cks,Ci r c Ar r hyt hm El ect r ophysi ol.2010O bj ecti ve:Reveal XTM ethods:saf ety eval uati onResul ts:StrokeHi ndri cks G,e al.Ci r c Ar r hyt hm El ect rophysi ol.2010;3:141-147.XTdetected7319PPV79.

31、3%XT non-detected3111NPV 97.4%Sensi ti vi ty96.1%85.4%100%100%80%80%60%60%40%40%20%20%0%0%AF Burden(Hol ter%)AF Burden(I CM%)r=0.976AF Burden(%ti m e i n AF)w as accuratel ym easured i n l arge m aj ori ty of pati ents.IN SERTA BLE C A RD IA C M O N ITO RIN G SY STEMStrokeSuper i or AF di agnost i c

32、 yi el d wi t h I CM vs.st andar d m oni t or i ng i n crypt ogeni c st r okeCRYSTAL AF:Bernstei n,I SC Lat e Br eaki ng.2014vs.standard m oni tori ng i nci dence (HR 8.78 95%CI 3.47-22.19,p 0.0001)Hazard Rati o(95%CI)=8.78(3.47,22.19)l og-rank p-val ue 0.00010000202030104060801006612121818242430303

33、636ControlI CMNo.at Ri skControl 220 194 167 114 72 36 7 I CM 221 191 173 102 57 29 8 M onths si nce random i zati on%Subj ects w i th AF detectedLat e Br eaki ng Cl i ni cal Tr i alDetecti on of AF at 3 Years14IN SERTA BLE C A RD IA C M O N ITO RIN G SYSTEMThe rel at i onshi p between AT/AF and st

34、r oke i n devi ce pat i entsTRENDS:Gl otzer,Ci r c Ar r hyt hm El ect r ophysi ol.20092 scor e of 2.2+1.2 f ol l ow ed f or 1.4 yr ssec)occurr ed i n 24%of ptsw as associ ated w i th hi gher TE r ate(2.4)and i ncr eased ri sk of TE event(HR 2.2 0.96,StrokeCi r c Ar r hyt hm El ect rophysi ol.2009;2:

35、474-480.TE Rates for the O veral l Study Group(Unadj usted)Subset(95%CI),%Excl udi ng TI As (95%CI),%1.1(0.8 1.6)0.5(0.3 0.9)(5.5 h)1.1(0.4 2.8)1.1(0.4 2.8)(5.5 h)2.4(1.2 4.5)1.8(0.9 3.8)Hazard Rati os for Throm boem bol i c Events Associ ated w i th AT/AF Burden Adj usted for Stroke Ri sk Factors a

36、nd Anti throm boti c TherapyCat egoryVari abl e(95%CI)*P Val uebur den0.98(0.34,2.82)0.97Hi gh bur den vs.2.20(0.96,5.05)0.06bur den;that i s,hi gh corr esponds to a burden of 5.5 hour s,l ow corr esponds to a burden of 20 seconds to 190 bpm f or 6 m i n)w i thi n f i r st 3 m onths p 0.001)r ate of

37、 stroke or system i c em bol i sm w as 4.89(95%CI,1.96 to 10.07)Subcl i ni cal atri al tachyarrhythm i as presentSubcl i ni cal atri al tachyarrhythm i as presentCum ul ati ve HazardCum ul ati ve HazardSubcl i ni cal atri al tachyarrhythm i as absentSubcl i ni cal atri al tachyarrhythm i as absent00

38、.00.000.020.040.060.080.20.40.60.81.00.5101.52.02.52.52.01.51.00.50Years of Fol l ow-Up2.52.01.51.00.500.000.300.250.200.150.100.050.5101.52.02.500.00.20.40.60.81.0Ri sk of Cl i ni cal AFRi sk of I schem i c Stroke or System i c Em bol i smHeal ey JS,et al.N Engl J M ed.2012;366:120-129.17IN SERTA B

39、LE C A RD IA C M O N ITO RIN G SY STEMStrokeI CM det ect ed AF bur den i s associ at ed wi t h an i ncr eased r i sk of st r okeSOS AF:Bori ani,Eur Heart J.2014OBJECTI VE:The ai m of thi s study w as t o assess the associ ati on betw een m axi m um dai l y at ri al f i bri l l at i on(AF)burden and

40、ri sk of i schaem i c st roke.BACKGROUND:Car di ac i m pl ant ed el ectr oni c devi ces(CI EDs)enhance detect i on of AF,pr ovi di ng a com prehensi ve m easure of AF burden.DESI GN,SETTI NG,AND PATI ENTS:A pool ed anal ysi s of i ndi vi dual pati ent data f r om f i ve pr ospect i ve studi es w as

41、perf or m ed.Pati ents w i thout per m anent AF,pr evi ousl y i m pl ant ed w i th CI EDs,w er e i ncl uded i f they had at l east 3 m onths of f ol l ow-up.A t otal of 10,016 pati ent s(m edi an age 70 year s)m et t hese cr i ter i a.The r i sk of i schaem i c str oke associ at ed w i th pr e-speci

42、 f i ed cut-of f poi nts of AF bur den(5 m i n,1,6,12,and 23 h,respect i vel y)w as assessed.RESULTS:Dur i ng a m edi an f ol l ow-up of 24 m onths,43%of 10,016 pati ents exper i enced at l east 1 day w i t h at l east 5 m i n of AF bur den and f or them the m edi an ti m e t o t he m axi m um AF bu

43、r den w as 6 m onths CHADS2 scor e and anti coagul ants at basel i ne dem onstr at ed t hat AF bur den w as an i ndependent pr edi ct or of i schaem i c str oke.Am ong the thr eshol ds of AF bur den that w e eval uat ed,1 h w as associ at ed w i th the CONCLUSI ONS:Devi ce-det ect ed AF bur den i s

44、associ ated w i th an i ncr eased r i sk of i schaem i c str oke i n a r el ati vel y unsel ect ed popul ati on of CI EDs pati ents.Thi s f i ndi ng m ay add t o the basi s f or t i m el y and cl i ni cal l y appr opri ate deci si on-m aki ng on ant i coagul at i on t reat m ent.Eur Heart J.2014;35:

45、508-516.TotalEventsHR for AF burden 1 h vs.1 h(95%CI)P-val ueStr oke8,122442.09(1.10,3.96)0.0239Str oke+TI A8,122692.05(1.24 3.39)0.0051Adj usti ng f or CHADS2 score Str oke8,122441.90(1.00,3.61)0.0487 Str oke+TI A8,122691.89(1.14,3.12)0.0135Tabl e 3 Cox regressi on anal ysi s perform ed on 8,122 pa

46、ti ents w i thout oral anti coagul ati on at basel i ne,adj usted for the CHADS2 score21IN SERTA BLE C A RD IA C M O N ITO RIN G SYSTEMI CM s f or Post-AF Abl ati on M oni tori ngA AF F A AB BL LA AT TI I O O N NAF bur den detecti on i s hi ghl y rel i abl e,w i th accur acy of 98.5%.XPECT 10W i th

47、AF m or e l i kel y asym ptom ati c(79%),I CM s gui de ef f ecti ve post-abl ati on m anagem ent.DI SCERN 13,UNM ASKI NG 11,PO KUSHALO V 13B BACACK KG G RORO U UN N D D one year1 asym ptom ati c pati ents to hel p gui de l ong-term tr eatm ent deci si ons1 1Cl i ck on references i n bl ue above to l

48、 i nk to study reference pagesIN SER TA BLE C A RD IA C M O N ITO RIN G SY STEMAF Abl ati onI CM s assess AF cat het er abl at i on and AAD ef f i cacyPokushal ov,Ci r c Ar r hyt hm El ect r ophysi ol.2013BACKGRO UND:w hether an earl y r e-abl ati on w as superi or to anti arrhythm i c dr ug(AAD)the

49、r apy i n pati ents w i th previ ous f ai l ed pul m onary vei n i sol ati on.M ETHO DS AND RESULTS:Pati ents w i th paroxysm al atri al f i bri l l ati on(AF)el i gi bl e f or AAD ther apy or re-abl ati on after a previ ousl y f ai l ed i ni ti al pul m onary vei n i sol ati on procedure w er e el

50、i gi bl e f or thi s study and w er e f ol l ow ed up f or 3 year s to assess rhythm by m eans of an i m pl anted cardi ac m oni tor.Af ter the bl anki ng peri od post-abl ati on,154 pati ents had sym ptom ati c AF recurr ences At the end of f ol l ow-up,61(79%)pati ents i n the AAD gr oup and 19(25