제세동기, CRT삽입환자에서 보이는 심전도¹€진배... · 보이는 심전도 ......

Kyung Hee Medical Center

Cardiology Division

심박동기, 제세동기, CRT삽입환자에서 보이는 심전도

경희의대 김진배


Cardiology Division

Introduction

A pacemaker is really a

system that has two parts:

a small metal titanium can

containing the electronic

circuitry and a long-lasting

battery, called a pulse

generator and an insulated

wire, called a lead.

박동기란?


Cardiology Division

Introduction

박동기 가 환자의 심박동을 감지하고 반응하는 양식으로 이러한 양식을 표현해 주는 기호가 존재한다.

환자의 심박동에 따라 조율 방식이 바뀌는 기능이 있는 심박동기가 존재한다.

조율 방식


Cardiology Division

The NASPE/BPEG Generic (NBG) Code

Category Chamber(s) Paced

Chamber(s) Sensed

Response to Sensing

Programmability Rate Modulation

Antitachyarrhythmia Function(s)

Position I II III IV V

O = None

A = Atrium

V = Ventricle

D = Dual (A+V)

O = None

A = Atrium

V = Ventricle

D = Dual (A+V)

O = None

T = Triggered

I = Inhibited

D = Dual (T+I)

O = None

P = Simple Programmable

M = Multiprogrammable

C = Communicating

R = Rate Modulation

O = None

P = Pacing

(antitachyarrhythmia)

S = Shock

D = Dual (P+S)

Manufacturer’s Designation Only

S = Single (A or V)

S = Single (A or V)

Note: Positions I through III are used exclusively for antibradyarrhythmia function


Cardiology Division

Common Pacemaker Modes

Pacing Sensing Response

to Sensing

Programmability

& Rate Response

V V I

- Ventricular pacing

- Ventricular sensing

- Inhibited when sensing a ventricular event


Cardiology Division

Common Pacemaker Modes

Pacing Sensing Response

to Sensing

Programmability

& Rate Response

D D D

- Dual (Atrial & Ventricular) pacing

- Dual (Atrial & Ventricular) sensing

- Dual (Inhibited & Triggered) response to sensing


Cardiology Division

Case


Cardiology Division

QRS morphology Apex Vs Septal pacing


Cardiology Division

Apex Vs Septal pacing


Cardiology Division

ECG before pacemaker implantation


Cardiology Division

83 M Hypertension

Syncope


Cardiology Division

What is the mechanism of

bradycardia?

1. SA block

2. type II AV block with junctional escape rhythm

3. complete AV block with junctional escape rhythm

4. complete AV block with idioventricular escape rhythm

5. cannot be defined

정답: 3


Cardiology Division

Rhythm strip after temporary pacemaker

VVI pacing


Cardiology Division

Pacemaker Fusion and Pseudofusion

SAN

AVN

V

A

Cardiac pacemakers step by step 2004


Cardiology Division

49 M s/p ICD implantation d/t Brugada SD

Chest discomfort ICD 삽입전


Cardiology Division

ECG at OPD

2012-05-03


Cardiology Division

ECG strip

2012-05-03


Cardiology Division

What make the change of QRS

morphology ?

1. pseudo-fusion

2. fusion

3. spontaneous idioventricular rhythm

4. multiple PVC’s

5. Cannot be defined

정답: 2


Cardiology Division

Telemetry monitoring

after mode change

2012-05-04


Cardiology Division

What is the pacing mode ?

1. DDD VVI

2. VVI AAI

3. AAI VVI

4. DDD AAI


정답: 4


Cardiology Division

63 F VVI with sick sinus syndrome

Both knee joint pain


Cardiology Division

24hr Holter monitoring


Cardiology Division

What is the mechanism of pacing

interval change ?

1. Sensing failure

2. Pacing failure

3. Oversensing

4. Hysteresis


정답: 4


Cardiology Division

Hysteresis

환자의 자발적인 박동이 감지될 경우 escape interval을 길게 설정



Cardiology Division

65 F DDDR with complete AV block

Chest discomfort


Cardiology Division

VVI 30 bpm

2012-05-04


Cardiology Division

What is the mechanism of ST change ?

1. LVH with strain

2. Apical HCMP

3. Myocardial ischemia

4. Myocardial infarction


정답: 5


Cardiology Division

박동기 삽입전 심전도

2010-04-21


Cardiology Division

Memory effect of myocardium

Sss

s

Sss Cardiac pacemakers step by step 2004


Cardiology Division

70 M, s/p CAB

Stable angina, CAOD(3VD) Preop ECG


Cardiology Division

Immediate postop


Cardiology Division

Pacing with temporary pacemaker

What is the ECG finding ?


Cardiology Division

Pacing with temporary pacemaker


Cardiology Division

Mode change of pacemaker

AV sequential pacing VVI

Sensing failure pacemaker off


Cardiology Division

ECG (POD#1)


Cardiology Division

Sensing failure



Cardiology Division

ㅁㅁㅁ

ㅁㅁㅁ ㅁㅁㅁ



Cardiology Division

58 F DDD with complete AV block (’06)

Palpitation, chest discomfort

2012-02-22


Cardiology Division

Medical history

2012-02-22

‘00, 본원에서 VVI implantation d/t tachybradycardia syndrome

‘02년부터 Follow up loss

’06년, OO 대 병원 심장내과 follow up 중 AV block발생 DDD로 upgrade

AF으로 Propafenon, digoxin, aspirin 복용하며 follow up중 증상 발현되어 본원 내원.


Cardiology Division 2012-02-22

Chest PA and lateral


Cardiology Division

What is the mechanism of wide QRS

tachycardia?

1. Ventricular tachycardia

2. SVT with aberrant conduction

3. sinus tachycardia with pacing rhythm

4. Use dependency


정답: 5


Cardiology Division

Pacemaker interrogation

2012-02-22

• Lower rate = 60 bpm

• Max tracking rate = 130 bpm


Cardiology Division

Mode change

2012-02-22 DDD DDIR


Cardiology Division

VVI 30 bpm

2012-02-22


Cardiology Division

ECG on HD #2

2012-02-23


Cardiology Division

70 F, CHF, Idiopathic DCMP (EF = 28%)

dyspnea Preop CRT

2011-11-16


Cardiology Division

Chest PA and lateral after CRT-D

2011-11-17


Cardiology Division

ECG after CRT-D

2011-11-17 QRS duration 150 120 ms


Cardiology Division

ECG (VVI 30 bpm)

2012-05-04


Cardiology Division

LV only pacing

2012-05-04


Cardiology Division

RV only pacing

2012-05-04


Cardiology Division

Take home massage !!

1.증상이 없더라도 규칙적으로 박동기 작동을 심전도로 확인하고 기록

2.환자의 history상 pacemaker indication확인

3. lead 위치를 chest x ray로 확인

4. pacing mode을 확인

5. 환자의 underlying rhythm을 확인

6. pacemaker interrogation하여 function확인


Cardiology Division

Thank you for your attention !

도움 주신 분들

원주의대 안민수 선생님

힘찬 병원 이병호 선생님

경희대 윤명기 선생님

경희대 김상호 선생님

국군 수도 병원 김성순 선생님

제세동기, CRT삽입환자에서 보이는 심전도¹€진배... · 보이는 심전도 ......

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Transcript of 제세동기, CRT삽입환자에서 보이는 심전도¹€진배... · 보이는 심전도 ......