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最佳起搏模式和部位最佳起搏模式和部位上海交通大学附属第一人民医院上海交通大学附属第一人民医院 上海市第一人民医院上海市第一人民医院 心内科心内科 孙宝贵孙宝贵最佳起搏模式和部位？最佳起搏模式和部位？心脏起搏器（1958）心动过缓房内 房内传导同步房室 房室顺序 异常室内 室内激动 合适的起搏器类型合适的起搏器类型合理的起搏方式合理的起搏方式最佳的起搏部位最佳的起搏部位最佳起搏模式和部位最佳起搏模式和部位？一一.单腔起搏单腔起搏二二.双腔起搏双腔起搏三三.三腔起搏三腔起搏四四.起搏部位起搏部位五五.频率反应频率反应一一.单腔起搏单腔起搏优点：优点：植入简单，价格便宜，植入简单，价格便宜，电能消耗少电能消耗少部位：部位：心室？心房？心室？心房？评价：评价：心室心室VVI非生理非生理心房心房AAI较生理较生理（变时性）（变时性）一一.单腔起搏单腔起搏心房心房 VS VS 心室心室八十年代始：八十年代始：19,92719,927例例VVIVVI起搏起搏2 2年年AF为为25%25%30%30%CtoppCtopp：AAIAAI起搏起搏HFHF和和AFAF发生少发生少我们的结果我们的结果：VVIVVI：AFAF4 4年为年为33%33%，5 5年为年为41%41%，6 6年为年为52%52%AAIAAI：AF10%AF 50%of pacemaker recipients have an 50%of pacemaker recipients have an inappropriate sinus mechanism to exertion inappropriate sinus mechanism to exertion and emotional stimuliand emotional stimuliSick-Sinus Syndrome patients frequently have sinus function deterioration over time The problem can be precipitated or exacerbated by the need for antianginal or antiarrhythmic medication11555RestingRestingRateRateOnset Onset ActivityActivityPlateauPlateauSlow ReturnSlow ReturnTo BaselineTo BaselineEnd End ActivityActivityRapidRapidRiseRiseTimeTimeHRHR(min(min-1-1)Benditt,David G.,Rate Adaptive Pacing;Blackwell Publishing 1993.p.57,fig 4.10Heart-Rate Response in the Healthy HeartMyths and RealityAge:Myth:Old patients dont need rate adaptive pacingReality:Older pacemaker patients require the same heart rate support as younger patientsMyths and RealityWomen:Myth:Women dont need rate adaptive pacingReality:Women require more aggressive heart rate support than menChronotropic IncompetencePatients with chronotropic incompetence cannot achieve an appropriate and normal heart rate response to daily activitiesVVI and DDD pacing will not helpThe answer is“rate adaptive pacing”Australia 3 26 0 68 Hong Kong 19 21 13 43India 63 7 9 11Japan 20 15 25 24China 57 8 30 5Canada 20 31 8 35USA 0 23 0 74 Belgium 1 21 3 66France 8 18 14 53 World Survey of Cardiac Pacing 2001%VVI VVIR DDD DDDRA rate adaptive sensor:Must accurately emulate changes in cardiac output in a linear fashion in response to physical and emotional stimuliShould measure and respond to sympathetic tone or circulating catecholamines levels Sensors for Rate Adaptive PacingSpecial LeadpHpHTemperatureTemperatureOxygen SaturationOxygen SaturationRV dP/dtRV dP/dtRV Stroke VolumeRV Stroke VolumeSensors for Rate Adaptive PacingStandard LeadActivityRespiratory RateMinute VentilationQT IntervalPaced Depolarization Integral(PDI)How do we overcome sensor deficiencies?Use Dual Sensors演讲完毕，谢谢观看！