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起搏器常见故障与处理.ppt
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起搏器常见故障与处理.ppt介绍

起搏器常见故障与处理大连医科大学附属第一医院高连君(2009 年1月11 ,哈尔滨)狭义的概念起搏系统(包括起搏器、电极导线)的机械故障需要更换起搏器或电极导线广义的概念包括起搏系统以外的因素及起搏参数设置不当导致的起搏器功能异常需通过分析起搏心电图后调整起搏参数予以解决起搏故障的原因起搏脉冲发生器故障起搏电极导线故障心肌组织病变其他(技术或医源性原因)起搏器故障心电图间歇起搏起搏停止感知功能障碍起搏频率改变特殊功能丧失起搏器故障检查程序病史:症状、心梗史、服药史、外力外伤、声、强磁场、电击体检:特殊心音、心杂音、摩擦音、腹肌或隔肌抽动、埋植部位跳动辅助检查:心电图、Holter 、胸片、超声、磁铁试验、程控试验起搏系统:起搏器型号、类型、植入日期、是否顺利、年限和指标导线型号、植入日期、类型(单双极、心房心室、主动、被动、部位)起搏参数:植入时测试参数、近期程控参数(时间、原因、变化)步骤与要求认识和判断由起搏系统故障和故障假象致的ECG 异常分析能够提供起搏系统异常的各种数据和相关资料了解和掌握各型起搏器的功能参数找出起搏器系统异常的原因并制定可能的解决方案解决故障的步骤定义问题(什么问题?)找出问题的原因(什么原因?)解决问题(如何解决?)验证解决方案(解决了吗?)故障分类1、感知不良2 、过分感知3 、无夺获4 、无输出5 、故障假象1.感知不良有自身激动波(P或QRS) ,但起搏器未能识别或感知感知不良有自身激动波(P或QRS) ,但起搏器未能识别或感知原因灵敏度设置不当导线移位导线故障:绝缘破裂;导体断裂导线成熟(电极头端的纤维化)原信号改变患者女性,65 岁,因SSS 植入DDDR 起搏器患者女性,65 岁,因SSS 植入DDDR 起搏器患者女性,65 岁,因SSS 植入DDDR 起搏器电极脱位是最常见的并发症之一发生率为2%~8%其中90 %发生在一周内表现为起搏或/和感知失灵早期脱位发生在术24 ~48h ,晚期脱位可发生于术后一个月,应及早复位2.过分感知感知到不适当的信号(生理或非生理)原因感知灵敏度设置导线故障连接器连接不良受到干扰3. 无夺获起搏脉冲后无去极化迹象常见原因1、导线移位2 、输出低3 、导线成熟4 、连接器连接不良5 、导线故障不常见原因Twiddler 综合症电极异常-- 例如,高钾血症心肌梗塞药物治疗电池耗竭传出阻滞4.无输出心电图上没有起搏信号(起搏器发出脉冲,但未经导线传出)可能原因连接器连接不良导线故障电池耗竭电路故障5.故障假象不能“常规解释”的心电图表现似乎为起搏器故障,但实际代表了正常的起搏器功能需认真分析加以鉴别磁铁作用时间间期变化A-A 对V-V 时间间期高限频率行为假文氏现象;2:1 阻滞电路重新设置电池耗竭起搏器介导心动过速的介入治疗频率反应磁铁作用放磁铁时起搏器将以磁铁频率非同步起搏高限频率行为假文氏现象引起的频率变化高限频率行为2:1 阻滞作用引起的频率骤降电路重置和电池耗竭在受到电磁干扰时可能会重置(射频电流,除颤,引起反转至备份模式)将发生频率和模式变化重新设置至以前的参数到达择期更换指标后转为“备份模式”起搏器介导心动过速的介入程序频率适应性起搏起搏器特殊功能ON 引起的频率变化滞后频率骤降反应模式转换睡眠功能新的自动功能…滞后感知事件之后出现滞后频率频率骤降反应在频率偶尔发生骤降时,以高频发放起搏脉冲模式转换起搏器从跟踪(DDDR) 转换到非跟踪(DDIR) 模式睡眠功能房室间期/不应期变化安全起搏空白期频率适应性房室间期延迟传感器- 可变的室后房不应期(PVARP) 室性早搏反应非竞争性心房起搏(NCAP) 心室安全起搏为防止由于交叉感知引起的心室脉冲发放抑制而设计在心房起搏事件后产生一个心室起搏110 毫秒频率适应性房室间期延迟室性早搏反应室早后室后房不应期将延长到400 毫秒起搏模式变化电池耗竭(转为支持或后备模式)电路重新设置模式转换噪音反转起搏器介导的心动过速(PMT) 快速心房跟踪高频心房跟踪心室上快速性心律不齐心房过感知困惑的病例辛某,女,25 岁,扩张型心肌病,病窦,于2007 年1月植入双腔起搏器(DDDR )。2007 年3月程控发现心室阈值升高,2006 年11 月Holter 示心室起搏障碍诊断:起搏器系统故障分析原因:导线脱位?连接异常?起搏器本身故障?处置:重新测试结果:心房与心室导线阈值、阻抗、感知均正常更换起搏器诊断:起搏器系统故障?分析原因:导线脱位?连接异常?起搏器本身故障?处置:重新测试结果:心房与心室导线阈值、阻抗、感知均正常更换起搏器验证后:仍不明确徐某,女,44 岁,Ⅲ° 房室阻滞,于2007 年7月植入双腔起搏器。2008 年10 日因头晕症状发作,程控发现心房心室阻抗增高诊断:导线断裂?故障处理总结解决故障排除问题的四个步骤鉴别由起搏系统故障和故障假象引起的心电图异常分析引起起搏器异常的原因利用帮助排除起搏系统异常的数据和资源制定解决异常的方案规律随访了解与掌握起搏器新的或特殊的功能与参数有时很难…CorePace Module 4: Troubleshooting If a pacemaker is oversensing, you will see signals on the marker channel that do not correspond to the ECG pattern. In this example, the pacemaker recorded a ventricular pulse on the marker channel. However, no activity was demonstrated on the ECG strip. Pauses or intervals longer than the programmed lower rate will occur in single chamber systems. Dual chamber systems may show tracking at the upper rate with atrial oversensing. This ECG exhibits oversensing that may be attributed to: Lead insulation failure (a decrease in lead impedance will be seen) Make-and-break fracture A lead connection problem (Note: The information below transitions into the next slide.) Insulation failure 梐common cause of oversensing 梠ccurs when myopotentials are detected at the site of the insulation break. Lead fracture is another common cause of oversensing. As the frayed ends of conductor wires 搈ake and break ?contact, the pacemaker senses these 搈ake and break ?signals, which results in oversensing. Oversensing may also occur if the lead is loose in the connector block. CorePace Module 4: Troubleshooting Interference falls under two categories: Electromagnetic interference (EMI) Skeletal myopotentials (noncardiac signals) Oversensing may occur when EMI signals are incorrectly interpreted as P- orR-waves. Sources of EMI are often found in hospitals and include surgical/therapeutic equipment, such as: Electrocautery Transthoracic defibrillation Lithotripsy RF ablation TENS units MRI is generally contraindicated for pacemaker patients. Exposure to a magnetic field may produce high-rate pacing that results in ventricular fibrillation and may damage the circuitry of the device. Concomitant devices, such as ICDs, should be tested to ensure that oversensing between the two devices does not occur. The most common type of myopotential interference is the inappropriate inhibition of pacing pulses as a result of the sensing of myopotentials. Myopotential oversensing is of greater concern with unipolar devices than bipolar devices. CorePace Module 4: Troubleshooting This ECG strip shows loss of atrial capture, followed by a scheduled ventricular pace. Following the ventricular pulse, the marker channel recorded an intrinsicP-wave. CorePace Module 4: Troubleshooting In addition to lead dislodgment, lead perforation should be considered as a potential cause of noncapture with acute implants. A poor connection at the connector block usually occurs because the lead has been inadequately secured at implant. The poor connection may be viewed radiographically. As a lead matures and becomes surrounded by fibrotic tissue, the threshold of stimulation decreases, which may result in noncapture. CorePace Module 4: Troubleshooting Twiddler 抯syndrome can be identified radiographically. Hyperkalemia, an electrolyte abnormality, is defined by a high serum potassium level and is commonly caused by kidney disease. Hyperkalemia may affect the stimulation threshold If a myocardial infarction occurs near the tip of the lead, an increase in the stimulation threshold and/or noncapture may occur. Drug therapy may affect capture thresholds and result in significant changes from the patient 抯baseline. If the delivered voltage is significantly reduced, advanced stages of battery depletion may result in noncapture. Exit block occurs when the stimulation threshold exceeds the pacemaker 抯maximum output. CorePace Module 4: Troubleshooting When the pacemaker problem is no output, the marker channel shows pacing markers 桝P or VP 梐lthough no artifact appears on the ECG. No output is defined as the failure to pace. Impulses are generated from the IPG, but is not transferred to the lead. CorePace Module 4: Troubleshooting A poor connection at the connector block can result in a lack of output, which can prevent the pacemaker from delivering a pacing pulse. In addition to lead dislodgment, lead perforation should be considered with acute implants as a potential cause of noncapture. Battery depletion can result in a lack of output, which can prevent the pacemaker from delivering a pacing pulse. At generator replacement procedures, (and sometimes at initial implants) the 

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