6 EVOLUZIONE DEGLI ICDThis slide shows the rapid rate at which devices shrunk in size over the years.
7 QUALI I I VANTAGGI ATTUALI? Princimali innovazioni Compatibilità con la Risonanza MagneticaControllo remotoPossibilità di monitorare alcuni parametri fisiologiciAttacco unico dei cateteri da defibrillazioneStimolazione multisito
8 1 - RISONANZA MAGNETICA E PM/ICD Si stima che oltre il 75% dei pazienti portatori di pacemaker avranno la necessità di sottoporsi a MRI nel corso della vita del loro device.
10 1 - RISONANZA MAGNETICA E PM/ICD Specifically Engineered for the MRI EnvironmentMultiple safety features were designed and incorporated from the ground up:Device verification appears on pacemaker programmer screenOne-screen programming clearly outlines necessary steps to scanning and pacingEasily identifiable SureScan radiopaque icon on the device and lead confirms SureScan technologyDevice contains robust circuitryDedicated programming mode provides additional security and backup for “Power On Reset” (POR)Hall sensor immune to strong magnetic fieldsA Lead Designed for Use in the MRI Environment
16 3 - MONITORAGGIO DEI PARAMETRI CLINICI Monitoraggio Continuo Del Tratto STIstograms delle variazioni del tratto STTrend deviazioni STRegistro Episodi ST
17 3 - MONITORAGGIO DEI PARAMETRI CLINICI Monitoraggio Continuo Del Tratto STPer correlare gli episodi VT/VF all’ischemiaIntervallo IsoelettricoQRTDeviazione STSSegmento STPeriodo di riconoscimentoSoglia PositivaSoglia Negativa
18 4 - ATTACCO UNICO DEI CATETERI DA DEFIBRILLAZIONE Minor rischio di decubitoMinor ingombro
19 5 – STIMOLAZIONE MULTISITO Ottimizzazione Della Stimolazione SinistraElettrodi:Prossimale 4Medio 3Medio 2Distale 110 vettori di stimolazioneEvitare la stimolazione del nervo frenicoScelta della miglior soglia di stimolazioneScelta del sito di stimolazione emodinamicamente ottimale
20 5 – STIMOLAZIONE MULTISITO Ottimizzazione Della Stimolazione Sinistra
21 DEFIBRILLATORE SOTTOCUTANEO N Engl J Med Jul 1;363(1): Epub 2010 May 12.An entirely subcutaneous implantable cardioverter-defibrillator.Bardy GH,, Cappato R,CONCLUSIONS:In small, nonrandomized studies, an entirely subcutaneous ICD consistently detected and converted ventricular fibrillation induced during electrophysiological testing. The device also successfully detected and treated all 12 episodes of spontaneous, sustained ventricular tachyarrhythmia.
22 DEFIBRILLATORE SOTTOCUTANEO Clin Res Cardiol Mar 17.Clinical experience with a novel subcutaneous implantable defibrillator system in a single center.Dabiri Abkenari L, Theuns DA, Valk SD, Van Belle Y, de Groot NM, Haitsma D, Muskens-Heemskerk A, Szili-Torok T, Jordaens L.BACKGROUND:Implantable cardioverter-defibrillators (ICDs) reduce mortality in both primary and secondary prevention, but are associated with substantial short- and long-term morbidity. A totally subcutaneous ICD (S-ICD) system has been developed. We report the initial clinical experience of the first 31 patients implanted at our hospital.METHODS:All patients had an ICD indication according to the ACC/AHA/ESC guidelines. The first 11 patients were part of the reported CE trial. The implantation was performed without fluoroscopy. The device was implanted subcutaneously in the anterior axillary line, with a parasternal lead tunneled from the xiphoid to the manubrial-sternal junction. Ventricular fibrillation (VF) was induced to assess detection accuracy and defibrillation efficacy using 65 J shocks.RESULTS:Post-implant, 52 sustained episodes of VF were induced. Sensitivity was 100% and induced conversion efficacy was 100% (with standard polarity in 29 patients). Mean time to therapy was 13.9 ± 2.5 s (range s). Late procedure-related complications were observed in 2 of the first 11 implantations (lead migration). During follow-up, spontaneous ventricular arrhythmias occurred in four patients, with accurate detection of all episodes. Inappropriate therapy was observed in five patients. Recurrences were prevented with reprogramming.CONCLUSIONS:The S-ICD system can be implanted without the use of fluoroscopy by using anatomical landmarks only. Episodes of VF were accurately detected using subcutaneous signals, and all induced and clinical episodes were successfully converted. The S-ICD system is a viable alternative to conventional ICD systems for selected patients.
26 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE? The most promising ideas which address the early detection of pacing co-morbidities are:Internal, Chronic Blood Pressure Monitoring (Ipertensione)Peak Endocardial Acceleration Monitoring (CAD)Implantable Glucose Monitoring (Diabete)T-Wave Alternans Monitoring (Scompenso, FV, SCD)
27 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE? RV pressure sensor measures:- Systolic and diastolic pressure- Estimated pulmonary artery diastolic pressure- RV dp/dt (positive & negative)Heart rate & activityCore body temperature• Continuous remote monitoring
28 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 1 Internal, Chronic Blood Pressure MonitoringHeart disease is the primary cause of death in the United States. Hypertension is a contributing factor to heart disease that could be more effectively monitored and treated with the assistance of an implanted blood pressure sensor. In conjunction with a pacemaker, a blood pressure sensor would improve long-term management of heart failure and save lives. Many current blood-pressure monitoring technologies require catheters or other invasive entry to the body. Unlike an implantable system, the current methods are cumbersome and introduce a potential entryway for infection.
29 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 2 Peak Endocardial Acceleration MonitoringDurante la fase di contrazione isovolumetrica il miocardio genera delle vibrazioni responsabili del primo tono cardiaco; studi recenti hanno dimostrato come il picco di queste vibrazioni (PEA: Peak Endocardial Acceleration) rifletta la contrattilità miocardica e quindi rappresenti un indice ben correlato al dP/dt del ventricolo sinistro.Monitoring refers to the chronic monitoring of left ventricular ejection fraction (LVEF). It is hypothesized that once PEA drops to a certain level, the onset of cardiomyopathy is indicated. With proper forewarning the physician could administer drugs to stem the progression to CHF.
30 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 3 Implantable Glucose MonitoringAn implantable glucose monitoring system is the future in diabetes treatment. The monitor could be attached to the pacemaker of diabetics, and implanted into the patient during the pace maker surgical procedure. The immediate project goals of the glucose sensor is to supply continuous information on glucose levels and an alarm system which will warn the patient when glucose levels fall outside a desired range. In the distant future companies will also develop closed loop systems which deliver insulin based on the readings they gather. A continuous feedback of glucose levels will enable diabetic patients to avoid hypoglycemia and realize the benefits of more closely controlled blood sugar.
31 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 4 T-Wave Alternans MonitoringT-wave alternans are recurrent discrepancies in the electrocardiogram signal of a stress test patient. It has been proposed that these discrepancies, slight flutters of the T-wave signal repeated once every 3-5 cycles, correlate with an increased risk for myocardial infarct (MI). The altered signal, it is hypothesized, results from an electrical impedence caused by coronary artery blockage. In order to pick up the discrepency in the signal, however, a special millivolt capacitor system must be used.
32 COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?
33 COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?
34 COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?Optical Techniques forFuture Pacemaker TechnologyYasuaki Kumamoto, Nicholas Isaac Smith,Katsumasa Fujita, Jun Ando and Satoshi KawataOsaka UniversityJapanLo studio ha evidenziato gli effetti intracellulari di irradiazione laser concentrata, a frequenza quasi infrarossa, della durata di alcuni femtosecondi, che si sono concretizzati nella contrazione delle cellule cardiache di alcuni ratti da laboratorio.
35 COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?Pacemakers BiologiciTerapia GeneticaTrapianto Cellulare (es. Tessuto atriale fetale contenente cellule nodali)
36 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI:UNA PREMESSA: IL PROBLEMA DELLE INFEZIONI
37 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI:UNA PREMESSA: IL PROBLEMA DELLE INFEZIONIThe time to infection after first pacemaker implantation (n= 44631) and after pacemaker replacements (n= 8380)
38 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONIDESIDERATA PERSONALI :MATERIALI PER CATETERI CHE DIMINUISCANO LE ADERENZE E CHE NE FACILITINO L’ESTRAZIONE IN CASO DI INFEZIONE O MALFUNZIONAMENTO.STANDARDIZZAZIONE DEI PROGRAMMATORI E DEI SISTEMI DI MONITORAGGIO REMOTO.AMPIA E CAPILLARE DIFFUSIONE DEI DATI CLINICI INVIATI DAI DISPOSITIVI E LORO FRUIBILITA’ DA PARTE DI TUTTI I CLINICI INTERESSATI ATTRAVERSO RETI E DATA BASE.
39 COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI«Caro,devo dirti che mi pare un argomento un pò troppo di "nicchia".»DESIDERATA PERSONALI :AMPIA E CAPILLARE DIFFUSIONE DEI DATI CLINICI INVIATI DAI DISPOSITIVI E LORO FRUIBILITA’ DA PARTE DI TUTTI I CLINICI INTERESSATI ATTRAVERSO RETI E DATA BASE.
41 UN’ULTIMA CONSIDERAZIONE POST-MORTEM CARDIAC DEVICE RETRIEVAL FORRE-USE IN THIRD WORLD NATIONS: VIEWS OF THEGENERAL PUBLIC AND PATIENT POPULATIONDavid C. Lange, BA, James N.. Kirkpatrick, MD, Hakan Oral,MD, Edward B. Goldman, JD, Kim A. Eagle, MD and Timir S.Baman, MD. University of Michigan, Ann Arbor, MI, University ofPennsylvania, Philadelphia, PAConclusions: As the prevalence of cardiovascular diseaseincreases throughout the world, innovative methods of deliveringhealthcare to underserved nations must be explored. Anoverwhelming majority of funeral directors have the desireand ability to perform post-mortem cardiac device removalfor philanthropic reuse in underserved nations if given theopportunity.Heart Rhythm 2009
42 La felicità non sta nell'assenza dei contrasti, ma nell'armonia dei contrasti. Roberto Benigni