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S-ICD
subcutaneous implantable cardioverter-defibrillator
AA Hendriks
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Inhoud
• verschil T-ICD / S-ICD
• selectie patiënten voor S-ICD
• vector bepaling
• procedure /techniek
• complicaties
• sensing
• therapie
• programming
• trouble shoot
• literatuur
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ICD
• Wat doet een ICD
• voorkomen van plotse hartdood
• geeft therapie op VT en VF
• Indicaties
• primaire preventie
• secundaire preventie
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Transvenous ICD vs S-ICD
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Verschil
• transveneuze ICD
• leads endovasculair met
risico’s van dien
• perforatie, pneumothorax,
dislokatie, infectie, lead
fracture
• brady of resynchronisatie
functie
• mogelijkheid tot ATP
• subcutane (S-) ICD
• plaatsing onder de huid
• geen endovasculaire
leads
• geen brady of
resynchronisatie functie
• geen mogelijkheid tot
ATP
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S-ICD patient selectie
• jonge patiënten met lang levensverwachting
• meerdere wissels (infectie risico)
• actieve patiënten
• geen dislocatie risico > minder restricties
• weinig co-morbiditeiten (harfalen, bradycardieen)
• niet als recidiverende monomorfe VT (ATP indicatie)
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CRM-110712-AB MAR20138
Duurzaam
Less Biomechanical Stress
• Not exposed to the dynamics and
force of cardiac motion (~100,000
flexes/day)
• Not exposed to clavicular crush
forces
• polyurethane body > resistant voor
slijtage
• geen inner coils
• multistrand cable-core design > bestand
tegen breuken
• designed to withstand the forces
associated with cardiopulmonary
resuscitation (CPR) forces
Unique Construction
The Subcutaneous Electrode is designed to provide
strength and durability
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S-ICD patient selectie
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CRM-110712-AB MAR201310
Sensing
• Three sensing vectors provide different perspectives of patient’s cardiac rhythm for optimal sensing
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CRM-110712-AB MAR201311
Screening
A 3-lead surface ECG is used to assess the appropriateness of surface signals that correlate with device detection
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vector bepaling
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Houding / exercise
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S-ICD
• movie
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Techniek
• plaatsing S-ICD: incisie 9-10 cm
• linkerzijde van de borstkast ter hoogte van de 5e
intercostaal ruimte
• plaatsing electrode: sternaal, incisie 1-2cm
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Stap 1
• after the patient has been properly prepped and
draped, an incision is made to place the pulse
generator at the mid-axillary like between the 5th
and 6th intercostal spaces
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Stap 2, 3
• The electrode is positioned through two
subcutaneous tunnels from the pocket to the
xiphoid incision and from the xiploid incision to the
superior site
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Stap 4
• The pulse generator is connected to subcutaneous
electrode and secured in the pocket
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Na implantatie
• defibrillation threshold test (DFT)
• programming VT discriminator zone, VF zone
• adviezen: tav wondgenezing (douchen, ontsteking,
wijken wond etc.)
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Optimale plaatsing
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Esthetisch
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Complicaties
• T-wave oversensing
• > inappropriate shock
• inappropriate shock rate
• S-ICD 2x > TV-ICD
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Complicaties
• Migratie
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Complicaties
• lead/device malposition /displacement
• haematoma
• Infection (but without bacteraemia)
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CRM-110712-AB MAR201325
Surface ECG
Intracardiac signal
Subcutaneous ECG
similar to a surface ECG
Far-Field sensing
Sinus RhythmVentricular
Tachycardia
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CRM-110711-AB MAR2013
STATIC MORPHOLOGY
Compare morphology & width to NSR Template
DYNAMIC MORPHOLOGY
Compare beat-to-beat morphology
QRS WIDTH
Compare QRS Width with NSR Template
SHOCK ZONE
Heart rate within Shock Zone?
INSIGHT™ DISCRIMINATION
Heart rate within Conditional Shock Zone?
NO
YES
POOR MATCH
MONOMORPHIC
“T” (Tachy)
“S” (Sensed)
“S” (Sensed)
“T” (Tachy)
“T” (Tachy)
“S” (Sensed)
WIDE QRS
NARROW QRS
POLYMORPHIC
GOOD MATCH
NO
YES
INSIGHT™ Rhythm Discrimination
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CRM-110711-AB MAR2013
Dynamic morphology Analysis
• Dynamic analysis quickly identifies shockable polymorphic rhythms
• Consecutive detections are compared to each other, not the NSR Template
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CRM-110711-AB MAR201328
Static Wave Form Morphology
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CRM-110711-AB MAR201329
QRS Width Analysis
• If Dynamic morphology analysis indicates similar beats,
QRS width is used to label detections:
– Normal: QRS Width narrower than the NSR Template
– VT: QRS Width wider than the NSR Template
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S-ICD therapie
• Biphasic shock
• 80J (delivered)
• Up to 5 shocks per episode
• Charge time to 80J ≤ 10 sec
• Post-shock pacing
• Full featured episode storage
• Battery longevity: 5 years
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Programming S-ICD
• TV-ICD 100 programmeerbare features i.t.t. S-ICD < 10
• sensing vector
• zones
• pacing after shock on/off
• polarity of next shock and time delay to shock (smart charge) can
be manually reset
• but will automatically adjust during operation
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Bewijs?
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inappropriate shocks
• first results: inappropriate shock rates of 20% at 3
years
• introduction of dual-zone programming cuts the
inappropriate shock rate at 3 years to 11.7%
• dual-zone programming as compared to single
zone programming: 70% reduction in in-
appropriate shocks for SVT
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What to do in case of inappropriate shock
• interrogate, chest X-ray
• optimizing the sensing vector
• adding a conditional zone (if not present)
• modifying the detection rate
• storing a baseline template during exercise testing
• (addition of anti- arrhythmic drugs)
• (ablation )
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Take-home message
• elegante procedure voor de ‘ongecompliceerde’
jonge patient
• minder complicaties, minder lange termijn risico’s
• CAVEAT inappropriate shocks ihkv T-wave
oversensing
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• movie echte patient