IMPLANTABLE DEVICE FOR THE IMPLANTABLE DEVICE FOR THE TREATMENT OF ATRIAL FIBRILLATREATMENT OF ATRIAL FIBRILLA

TIONTION

Cooper JM,Katcher MS,Orlov MVCooper JM,Katcher MS,Orlov MV

NEJM,2002,346(26) :2062-68

Atrial fibrillation is a commAtrial fibrillation is a common arrhythmiaon arrhythmia

Common symptoms:Common symptoms:• palpitationspalpitations• DyspneaDyspnea• fatiguefatigue

Associated complications:Associated complications:• StrokeStroke• heart failureheart failure• deathdeath

Cooper JM ,et al.NEJM,2002,346(26) :2062-68

Common Common ApproachesApproaches

Rate control plus anticoagulRate control plus anticoagulationation

Rhythm control with antiarrRhythm control with antiarrythmic medicationsythmic medications

Pacemaker and defibrilPacemaker and defibrillatorlator Cooper JM ,et al.NEJM,2002,346(26) :2

062-68

Ventricular pacing during artrial fibrillation

Symptomatic bradycardiaSymptomatic bradycardia-----permanent pacemake-----permanent pacemake

rsrs The atrioventricular node is bomdardThe atrioventricular node is bomdard

ed with electrial impulsesed with electrial impulses The factors influences on Ventricular The factors influences on Ventricular

raterate• intrinsic conduction-system diseaseintrinsic conduction-system disease• takeing rate-controlling pharmacolotakeing rate-controlling pharmacolo

gic agentsgic agents• with high a vagal tonewith high a vagal tone

Cooper JM ,et al.NEJM,2002,346(26) :2062-68

Ablation of atrioventricular noAblation of atrioventricular node de

plus implantation of pacemakeplus implantation of pacemaker(1)r(1)

• decreases the incidence of palpitdecreases the incidence of palpitations ,dyspnea,et alations ,dyspnea,et al

• increases exercise tolerance increases exercise tolerance • elminates rate-controlling medielminates rate-controlling medi

cationscations• improves the cardiovascular heimproves the cardiovascular he

modynamicmodynamic Cooper JM ,et al.NEJM,2002,346(26) :2062-68

Ablation of atrioventricular Ablation of atrioventricular node node

plus implantation of pacemplus implantation of pacemakeraker

• No effect on the fibrillation in tNo effect on the fibrillation in the atriahe atria

• No effect on the associated risk No effect on the associated risk of thromboembolismof thromboembolism

Cooper JM ,et al.NEJM,2002,346(26) :2062-68

适应证适应证

症状严重的、药物无效或不能耐受药物治症状严重的、药物无效或不能耐受药物治

疗的慢性房颤和房扑患者疗的慢性房颤和房扑患者

一般均有不同类型的基础病一般均有不同类型的基础病

Prevention of atrial fibrillation with atrial pacing

The mechanism of atrial paThe mechanism of atrial pacingcing

Allows coordinated contraction of the cAllows coordinated contraction of the chambershambers

Lowers average atrial pressureLowers average atrial pressure Deacreases any stretch-related changesDeacreases any stretch-related changes Prevents pauses and reduces the risk of Prevents pauses and reduces the risk of

the atrial fibrillation associated with inthe atrial fibrillation associated with increased vagal tone and braycardiacreased vagal tone and braycardia

Supress ectopic atrial beatsSupress ectopic atrial beats

The Mode Selection The Mode Selection TrialTrial

Number of patientsNumber of patients: More than 2000 patient: More than 2000 patients with the SSSs with the SSS

Two groupsTwo groups: ventricular pacemaker,dual-ch: ventricular pacemaker,dual-chamber pacemakeramber pacemaker

The primary end pointsThe primary end points: mortality,stroke: mortality,stroke ResultResult: no difference with respect to the pri: no difference with respect to the pri

mary end point;50% decrease in the likehoomary end point;50% decrease in the likehood of a first episode of atrial fibillation and a rd of a first episode of atrial fibillation and a reduction in kisk of progression to chronic ateduction in kisk of progression to chronic atrial fibillation with dual-chamber pacingrial fibillation with dual-chamber pacing

Press release of NASP,Natick,Mass,May,2001

Alternative single-site and dual-site atrial paceng

房间传导阻滞（房间传导阻滞（ Interartrial Conduction Interartrial Conduction BlockBlock ））

一般人群房间传导阻滞发生一般人群房间传导阻滞发生 1%1% ，缓—速综合征，缓—速综合征

患者发生率患者发生率 32%32%

诊断标准：右房与左房间传导超过诊断标准：右房与左房间传导超过 100ms100ms

体表心电图：体表心电图：• PP 波增宽波增宽• PP 波时限≥波时限≥ 120ms120ms• ⅠⅠ 导联导联 PP 波常有明显切迹，切迹间双峰间距波常有明显切迹，切迹间双峰间距＞＞ 0.040.04• ⅡⅡ 、Ⅲ 导联、Ⅲ 导联 PP 波双向，先负后正波双向，先负后正

Synchronized atrial activatiSynchronized atrial activationon Usual single-site of atrial pacing:Usual single-site of atrial pacing:

• interatrial septuminteratrial septum• coronary sinuscoronary sinus• Bachmann’bundleBachmann’bundle• …………

Dual-site of atrial pcingDual-site of atrial pcing• the right atrial appendagethe right atrial appendage• interatrial septuminteratrial septum

• Dual-atrial pacingDual-atrial pacing• the right atrial appendage the right atrial appendage • coronary sinuscoronary sinus

Patients in whom the the atrial lPatients in whom the the atrial lead was placed at Bachmann’budlead was placed at Bachmann’budle or on the interatrial septum had a e or on the interatrial septum had a lower incidence of parxymal and chlower incidence of parxymal and chronic atrial fibrillation than those in ronic atrial fibrillation than those in whom the lead was posisioned in thwhom the lead was posisioned in the traditional right atrial appendage.e traditional right atrial appendage.

Bailin SJ,et al.JCE,2001;142:1047-55

双房同步起搏双房同步起搏

双心房＋右心室起搏，是三腔人工心脏起搏器的双心房＋右心室起搏，是三腔人工心脏起搏器的

一种。一种。

用于防治与房间传导阻滞有关的某些快速性房性用于防治与房间传导阻滞有关的某些快速性房性

心律失常心律失常

冠状窦起搏的最佳位电多选择在冠状窦中部冠状窦起搏的最佳位电多选择在冠状窦中部

双房同步起搏方式双房同步起搏方式

单腔起搏器单腔起搏器：仅有房间传导阻滞及快速房性心律：仅有房间传导阻滞及快速房性心律

失常，选用双极失常，选用双极 AATAAT 方式方式

双腔双腔 DDDDDD起搏器起搏器：同时合并缓慢性心律失常或：同时合并缓慢性心律失常或

房室传导阻滞，选用房室传导阻滞，选用 DDD(RDDD(R ）方式）方式

Chorus 6234Chorus 6234或或 70347034 （（ ela corpela corp ）：）：

AAT(AAT( 房间水平房间水平 )+DDD)+DDD （房室间水平）（房室间水平）

Overdrive atrial pacing

The mechanism of overdrive atrial The mechanism of overdrive atrial pacingpacing

The atrial pacing predominate over the intThe atrial pacing predominate over the intrinsic atrial activity to reduce the initiatiorinsic atrial activity to reduce the initiation of atrial fibrillationn of atrial fibrillation

Supresses prematrue atrial beatsSupresses prematrue atrial beats Influnces the pattern of atrial depolarizatiInflunces the pattern of atrial depolarizati

onon Lowers the incidence of atrial arrhythmiaLowers the incidence of atrial arrhythmia Decrease the number of days during whicDecrease the number of days during whic

h atrial fibrillation occurredh atrial fibrillation occurred

High-frequency pacing

and electrical cardioversion

Antitachycardia deviceAntitachycardia device(1)(1)

The Metrix Atrioverter,InConThe Metrix Atrioverter,InControltrol

The Jewel AF device,MedtronThe Jewel AF device,Medtronicic

The GEM AT Ⅲ,MedtronicThe GEM AT Ⅲ,Medtronic

Antitachycardia deviceAntitachycardia device(2)(2)

The device was progremmed to detect artThe device was progremmed to detect artrial fibillation,and adminster a shock to rrial fibillation,and adminster a shock to restore sinus rythemestore sinus rythem

To deliver rapid atrial pacing to treat atriTo deliver rapid atrial pacing to treat atrial arrhythmiasal arrhythmias

The over efficacy of thr device in teminatThe over efficacy of thr device in teminating atrial fibrillation was 90%,1/3 episodeing atrial fibrillation was 90%,1/3 episodes requiring more than one shocks requiring more than one shock

Safty:no instence of ventricular proarrytSafty:no instence of ventricular proarrythmiahmia

The GEM AT The GEM AT Ⅲ,MedtronicⅢ,Medtronic

The shocks for atrial fibrillation caThe shocks for atrial fibrillation can be activeed by the patientn be activeed by the patient

To be programmed to occur automTo be programmed to occur automatically in the early morning while atically in the early morning while the patent is sleepthe patent is sleep

To ensure that the shock is delivereTo ensure that the shock is delivered within 24 hours after the onset of d within 24 hours after the onset of atrial fibrillationatrial fibrillation

Conclution and fultuConclution and fulturere

The ideal patient population foThe ideal patient population for this invasive antiarrhythmic sr this invasive antiarrhythmic strategy has not been definedtrategy has not been defined

25% patients who receive an i25% patients who receive an implantable defibrillator for vemplantable defibrillator for ventricular arrhythmias also havntricular arrhythmias also have paroxymal artrial fibrillatione paroxymal artrial fibrillation