Biventricular_Pacing_Presentation

Biventricular_Pacing_Presentation - Biventricular Pacing...

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Unformatted text preview: Biventricular Pacing Joanne Olecko Michael Breninford BME 501: Section 29280 Dr. Hsiai, November 28, 2007 Sneider et al., "Radiographic Appearance of Biventricular Pacing for the Treatment of Heart Failure Cascade. Fig. 4, pp. 1449 Topics of Discussion Introduction Biventricular Pacing Defined Clinical Aspects of Biventricular Pacing Biventricular Pacing Technology Concluding Remarks Questions 1 min, MB 2 min, JO 6 min, MB 6 min, JO 1 min, Team 4 min, Class 2 BIVENTRICULAR PACING 3 Biventricular Pacing Device and Leads 4 Biventricular Pacemaker vs. standard pacemaker Pacemaker Symptoms treated Bradycardia Placement of leads 1 or 2 leads: RA (+ RV) A notable Weakness Controller unit RV stimulation, by itself, may lead to cardiac remodeling Biventricular Pacing Device Heart Failure (moderate to severe ) Arrhythmias 2 or 3 leads: LV, RV (+ RA) Lags pacemakers with regards to advanced algorithms and programmability. Shared technology Pulse generator, battery, programmability, etc. rd Typical Pace/sense Many combinations, but further complicated with 3 lead VDD = sensing of RV and RA events, pacing of ventricles DDD = sensing of RV and RA events, pacing of RA and ventricles 5 CLINICAL DISCUSSION 6 Clinical Aspects of Biventricular Pacing Conditions Affecting Cardiac Output Dyssynchronous and Arrhythmic Behavior Result in Low Cardiac Output Increased Contractility Normal Contractility Cardiac Output Contractility Effects of BVP on Hemodynamics Decreased Contractility Results in Improvements Pressure Volume (PV) Loop Cardiac Output and Contractility Increased Ejection Fraction (EF) LV EDV (Preload) FrankStarling Relationship 7 Conditions Affecting Cardiac Output Dilated Cardiomyopathy Left Bundle Branch Block Ventricular Arrhythmias Ventricular Tachycardia Enlarged Left and Right Ventricles Ventricular Fibrillation Asystole (Sudden Cardiac Death) 8 PV Loop Healthy Subject Healthy Subject 240 ct i lit y ESPVR (Active) Key Concepts CO = HR x SV SV = EDV ESV EF = SV/EDV EDPVR (Passive) 200 LV Pressure (mm Hg) 160 120 80 ESV D Co ntr a Contractility C SV 40 A B EDV C n lia mp o c e 40 80 120 160 200 240 9 LV Volume (ml) PV Loop Left Bundle Branch Block Left BundleBranch Block 240 ct i lit y ESPVR (Active) Key Concepts Contractility 200 LV Pressure (mm Hg) Co SV = EDV ESV CO = HR x SV EDV (Vol. Load) C t on lit y ct i ra 160 120 80 ESV D ntr a EDPVR (Passive) ESV (Press. Load) EF = SV/EDV D C C SV SV B lianc mp Co e 40 A B A EDV 40 80 120 160 200 240 10 LV Volume (ml) PV Loop BiV Pacemaker Treatment LBBB Patient treated with BVP 240 ct i lit y ESPVR (Active) Key Concepts Contractility 200 LV Pressure (mm Hg) Co CO = HR x SV SV = EDV ESV Co nt lit ct i ra y ntr a 160 120 80 40 A ESV D EDV (Vol. Load) EDPVR (Passive) ESV (Press. Load) EF = SV/EDV D D C C C SV SV SV B C n lia mp o c e A A B B EDV 40 80 120 160 200 240 11 LV Volume (ml) Summary of Physiological Benefits Reduced Interventricular Dyssynchrony Improved Cardiac Output Increased Stroke Volume Increased Ejection Fraction Increased Systolic Blood Pressure and Pulse Pressure Improved Ventricular Function Without Myocardial Energy Consumption 12 TECHNICAL DISCUSSION 13 Commercial BV Pacing Devices Mfgr. st 1 FDA Approval date Product Name Type of device Medtronic 2001 (w/o ICD) InSync Sentry, Cardiac resynchronization Concerto with and without cardio defibrillator (ICD) Boston Scientific (formerly Guidant) 2002 (w/ ICD) CONTAK Cardiac resynchronization and cardio defibrillator (ICD) Cardiac resynchronization only w/ advanced Arrhythmia/Fibrillation Detection and suppression 14 St Jude Medical 2004 Frontier (II) Primary BVP Requirements LV triggered to contract when RV contracts (or viceversa) or both RV and LV triggered after AV is sensed Avoid conflict with intrinsic conduction a manage crosschamber refractory periods Maximize longevity of device a prolonged battery life 15 15 BVP Device HighLevel Block Diagram Biventricular Pacemaker and ICD Battery Power Supply Circuit Oscillator MCU Timer Circuit Filter Circuit Telemetry Circuit Pulse Output Circuit Pacing Leads Lead Wires Sense Circuit Electrodes Implantable Cardioverter Defibrillator 16 BVP CircuitLevel Block Diagram 17 BVP Core Components Battery Properties Pacemaker Battery: Lithium Iodine Battery Capacity: ~2.0 Ah Max Output Voltage: ~2.75 V Output Voltage Under Load: LithiumIodine Lithium Ion Alkaline ~2.5 V, with 20 A load 18 Biventricular Leads: Voltages & Pulse Timing 19 Leads and Electrodes for Biventricular Pacing 20 Leads for Left Ventricular Sense/Stimulation 21 Pacing Control Algorithm 22 22 CONCLUDING REMARKS 23 Conclusion BVP Offers Significant Benefits in Treating Heart Failure Addresses Dyssynchrony and Atrioventricular Conduction delay and blockage Offers Improvements in Cardiac Output & LV EF as shown by PV Loop Analysis Offers Possible Reversal of Cardiac Remodeling (Controversial) Still a Young Technology (only 6 years old) Some Controversial Claims and Conclusions Mechanism by which BVP improves mechanical LV function in LBBB and CHF are not well understood BVP and Reversal of Cardiac Remodeling is contested Will continue to benefit from advances in Cardiac Imaging and Modeling Pacing and sensing algorithms Moore's law of semiconductors Battery technology Electrode designs Data gathered from past implants 24 24 QUESTIONS 25 Appendix 26 References Clinical Section Iaizzo, P.A. (ed.) (2005) Handbook of Cardiac Anatomy, Physiology, and Devices. Humana Press, Totowa, NJ. pp. 34959. Cascade P.N., Sneider M.B., Koelling T.M., Knight B.P. (2001) Radiographic appearance of biventricular pacing for the treatment of heart failure. AJR Am J Roentgenol. 177, 144750. Panescu D. (2005) Cardiac Resynchronization Therapy. IEEE Eng Med Biol Mag. 24, 226. Voigt A., Barrington W., Ngwu O., Jain S., Saba S. (2006) Biventricular pacing reduces ventricular arrhythmic burden and defibrillator therapies in patients with heart failure. Clin Cardiol. 29, 747. Jarcho J.A. (2006) Biventricular pacing. N Engl J Med. 355, 28894. 27 References Clinical Section, cont. Nelson G.S., Berger R.D., Fetics B.J., Talbot M., Spinelli J.C., Hare J.M., Kass D.A. (2000) Left ventricular or biventricular pacing improves cardiac function at diminished energy cost in patients with dilated cardiomyopathy and left bundlebranch block. Circulation. 102, 30539. Hayes D.L., Wang P.J., SacknerBernstein J., Asivatham S.J. (2004) Resynchronization and Defibrillation for Heart Failure: A Practical Approach. Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN. pp. 39139. Barold S.S. (ed.), Mugica J. (ed.) (2004) The Fifth Decade of Cardiac Pacing. Blackwell Publishing, Elsmford, NY. pp. 63116, 256257. 28 References Clinical Section, cont. Stein K.M. (2007) Biventricular Pacemaker. http://yourtotalhealth.ivillage.com/biventricularpacemaker.html Grayson C.E. (ed.) (2004) Heart Failure: Biventricular Pacing. http://www.medicinenet.com/script/main/art.asp?articlekey=42786&pf=3&page=1 Weinrauch L.A. (2007) Medical Encyclopedia: Dilated cardiomyopathy. http://www.nlm.nih.gov/medlineplus/ency/imagepages/18136.htm Barbara J.D. (2003) Value of Monitoring a Second Precordial Lead for Patients In a Telemetry Unit. General Electric http://www.gehealthcare.com/inen/monitor/products/telemetry/apexpro_moreinfo.html Andersat (2006) EKG lead showing ventricular fibrillation. Ventricular Fibrillation. Wikipedia.org http://en.wikipedia.org/wiki/Image:EKG_VF.jpg 29 References Technical Section Cardiac resynchronization therapy Panescu, Dorin IEEE Engineering in Medicine and Biology Magazine, v 24, n 2, March/April, 2005, p 2226 Biventricular Pacing (Cardiac Resynchronization Therapy) Health Technology Literature Review, Sept 2005, Ministry of Health and LongTerm Care , Canada (ISBN: 1 424900662 ) Timing Cycles for Biventricular Pacing Wang, P. (Div. of Cardiology, New England Med. Center, Boston, MA, USA) Kramer, A. Estes, N.A.M., III Hayes, D.L. Source: Pacing and Clinical Electrophysiology, v 25, n 1, Jan. 2002, p 6275 Cardiac Resynchronization Therapy, p 163 Cheukman Yu, David L. Hayes (Editor), Angelo Auricchio (Editor) Publisher: Blackwell Publishers ISBN: 1405142820 Edition: Hardcover 20060315 Lecture 8: Therapeutic/Prosthetic Devices Pacemakers & Defibrillators Dr. Nitish V. Thakor, Biomedical Instrumentation, JHU Applied Physics Lab http://www.jhu.edu/nthakor/teaching/bmi1/Lecture%208.ppt 30 References Technical Section, cont. Cardiac Pacemakers Step by Step: An Illustrated Guide S. Serge Barold, Roland X. Stroobandt, Alfons F. Sinnaeve Publisher: Futura Publishing Company ISBN: 1405116471 Edition: Paperback 20040101 Cardiac Pacing Electrodes Ken Stokes Proceedings of the IEEE, VOL. 84, NO. 3, March 1996, p457 467 LongTerm Experience with a Preshaped Left Ventricular Pacing Lead JACKY OLLITRAULT, PHILIPPE RITTER, PHILIPPE MABO, STPHANE GARRIGUE, FRANOIS GROSSINELA ,THOMA LAVERGNE Pacing and Clinical Electrophysiology Volume 26 Issue 1 p2 Page 185188, January 2003 Ventricular safety pacing in biventricular pacing Inventor: Berthold Kramm Assignee: Medtronic, Inc. Patent number: 6996437, Filing date: Apr 25, 2002, Issue date: Feb 7, 2006 31 References Glossary Online Medical Dictionaries: http://cancerweb.ncl.ac.uk/omd/ http://www.onlinemedicaldictionary.org/ American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=4741 CHFpatients.com: http://www.chfpatients.com/inotropes.htm NYHA Classification: http://www.hcoa.org/hcoacme/chfcme/chf00070.htm Divers Alert Network: http://www.diversalertnetwork.org/medical/faq/faq.asp?faqid=66 Fairview Health Library: http://www.fairview.org/healthlibrary/content/ca_intracar_car.htm 32 ...
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This note was uploaded on 02/27/2008 for the course BME 501 taught by Professor Yamashiro,hsiai during the Fall '07 term at USC.

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