心臟植入性電子儀器(CIED)之適

應症 “Indications for CIED”

亞東紀念醫院 林恆旭 醫師

Outline

Indications for pacing

Indications for cardiac resynchronization therapy (CRT)

Indications for intra-cardiac defibrillator (ICD) therapy

Ref: • 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy • 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

Outline

Indications for pacing

Indications for cardiac resynchronization therapy (CRT)

Indications for intra-cardiac defibrillator (ICD) therapy

Classifications of Bradyarrhythmias

There are two types of bradyarrhythmias

Sinus node

AV node

Sinus node dysfunction

Sinus Arrest

Sinus Bradycardia

Sinus node dysfunction

Chronotropic Incompetence

Tachybrady syndrome

AV node dysfunction

First Degree AV block

Second Degree AV block

Mobitz Type 1 – Wenckebach

Mobitz Type 2

Third Degree AV block – Complete heart

block

Bifasicular/Trifasicular block

First-Degree AV Block

PR interval > 200 ms

Delayed conduction through the AV Node

Second-Degree AV Block –

Mobitz I (Wenckebach block)

Progressive prolongation of the PR interval until there is failure to conduct and a ventricular beat is dropped

Second-Degree AV Block –

Mobitz II

Regularly dropped ventricular beats 2:1 block (2 P-waves for every 1 QRS complex)

Third-Degree AV Block Complete Heart Block

No impulse conduction from the atria to the ventricles

Fascicular Block

Right bundle branch block and left anterior hemiblock

Right bundle branch block and left posterior hemiblock

Complete left bundle branch block

Classifications of Bradyarrhythmias

There are two types of bradyarrhythmias

Sinus node

AV node

Indications for Pacing in Persistent Bradycardia

Indication for Pacing in Intermittent Documented Bradycardia

BBB and Unexplained Syncope

CSM: carotid sinus massage;

ILR =implantable loop recorder.

Indication for Pacing in BBB

Indication for Pacing in Undocumented Reflex Syncpe

Indication in Unexplained Syncope

Common Pacing Indications

Sinus Node Disease (SND), or Sick Sinus

Syndrome

High degree AV Block (Mobitz II & 3rd AVB)

Chronotropic Incompetence

Epstein et al. “ACC/AHA/HRS Guidelines for Device-Based Therapy.” JACC Vol. 51, No. 21, 2008.

Choice of Pacing Mode and Programming

Optimal Pacing Mode

AVM: AV delay management

現行健保給付規定

Outline

Indications for pacing

Indications for cardiac resynchronization therapy (CRT; 心臟再同步化治療)

Indications for intra-cardiac defibrillator (ICD) therapy

Indications for CRT in patients with sinus rhythm

Indications for CRT in patients with permanent Afib

Indications for CRT in patients with conventional pacemaker indications

and heart failure

現行健保給付規定

應事先審查。

正常竇房節心律，LVEF<=35%且CLBBB(QRS寬度>=0.12sec)，且NYHA Functional Class III, IV及經適當藥物治療仍不能改善之病患。

心房顫動之病患， LVEF<=35%且CLBBB(QRS寬度>=0.12sec)，且NYHA Functional Class III, IV及經適當藥物治療仍不能改善之病患。

心室節律器依賴之病患，LVEF<=35%，NYHA Functional Class III, IV及經適當藥物治療仍不能改善者。

Outline

Indications for pacing

Indications for cardiac resynchronization therapy (CRT)

Indications for intra-cardiac defibrillator (ICD) therapy

Class I Recommendations

Level of Evidence: A

With LVEF ≤ 35% due to prior MI who are at least 40 days post-MI and are in NYHA Functional Class II or III

With LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF ≤ 30%, and are in NYHA Functional Class I

Who are survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes

Class I Recommendations

Level of Evidence: B

With nonischemic DCM who have an LVEF ≤ 35% and who are in NYHA Functional Class II or III

With nonsustained VT due to prior MI, LVEF < 40%, and inducible VF or sustained VT at electrophysiological study

With structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable

With syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study

Class IIa Recommendations

Level of Evidence: B

To reduce SCD in patients with Long QT Syndrome who are experiencing syncope and/or VT while receiving beta blockers

Class IIa Recommendations Level of Evidence: C

With unexplained syncope, significant LV dysfunction, and nonischemic DCM

With sustained VT and normal or near-normal ventricular function

With catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers

For the prevention of SCD in patients with ARVD/C who have one or more risk factors for SCD

With HCM who have one or more major risk factors for SCD

With Brugada syndrome who have had syncope or documented VT that has not resulted in cardiac arrest

With cardiac sarcoidosis, giant cell myocarditis, or Chagas disease

For nonhospitalized patients awaiting transplantation

現行健保給付規定 申報規範：

操作醫院應事先報備作業流程及持續照護計畫。

原則採事後逐案審查，個別醫院如經審查評估不符治療指引，則改採逐案事前審查。

給付規定： 嚴重心室頻脈、心室顫動導致猝死可能或昏迷。 反覆發作之持續性心室頻脈。 高危險性心臟血管疾病或遺傳性疾病，如：曾經心肌梗塞併左心室射出分率≦40%，long QT syndrome，short QT syndrome，Brugada syndrome，idiopathic ventricular fibrillation，arrhythmogenic right ventricle dysplasia，catecholaminergic polymorphic ventricular tachycardia，肥厚性心肌症，擴張性心肌症等，且臨床合併心室快速不整脈或合併猝死症之家族史者。

現行健保給付規定

心臟整流去顫器結合心房同步雙心室節律器之給付規定為：符合「心臟整流去顫器」之給付規定，且合乎「心房同步雙心室節律器」之給付規定者。

已通過同步雙心室節律器事前申請者，於裝置時突發嚴重心室不整脈者，可改裝ICD或CRTD，以維

護病患安全，並於事後補報。

現行健保給付規定

不宜列入項目：

末期心臟衰竭，無法藥物控制又非心臟移植對象者。

猝死可能經急救後，無意識恢復之患者。

末期疾病患者且存活不足六個月者。

惡性且任何治療無法控制(intractable)之心室頻脈或心室顫動。

依據「特定醫療技術檢查檢驗醫療儀器施行或使用管理辦法」，自101.9.1.解除登記列管。配合將操作醫院、醫師資格等刪除。

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