QUALI I I VANTAGGI ATTUALI? Princimali innovazioni 1. Compatibilità con la Risonanza Magnetica 2. Controllo remoto 3. Possibilità di monitorare alcuni parametri fisiologici 4. Attacco unico dei cateteri da defibrillazione 5. Stimolazione multisito
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. 1 - RISONANZA MAGNETICA E PM/ICD
Specifically Engineered for the MRI Environment Multiple safety features were designed and incorporated from the ground up: Device verification appears on pacemaker programmer screen One-screen programming clearly outlines necessary steps to scanning and pacing Easily identifiable SureScan radiopaque icon on the device and lead confirms SureScan technology Device contains robust circuitry Dedicated programming mode provides additional security and backup for “Power On Reset” (POR) Hall sensor immune to strong magnetic fields A Lead Designed for Use in the MRI Environment 1 - RISONANZA MAGNETICA E PM/ICD
Monitoraggio Continuo Del Tratto ST Trend deviazioni ST Istograms delle variazioni del tratto ST Registro Episodi ST 3 - MONITORAGGIO DEI PARAMETRI CLINICI
Per correlare gli episodi VT/VF all’ischemia Soglia Positiva Soglia Negativa Intervallo Isoelettrico Q R T Deviazione ST S Segmento ST 3 - MONITORAGGIO DEI PARAMETRI CLINICI Monitoraggio Continuo Del Tratto ST Periodo di riconoscimento
4 - ATTACCO UNICO DEI CATETERI DA DEFIBRILLAZIONE Minor ingombro Minor rischio di decubito
Elettrodi: Prossimale 4 Medio 3 Medio 2 Distale 1 10 vettori di stimolazione Evitare la stimolazione del nervo frenico Scelta della miglior soglia di stimolazione Scelta del sito di stimolazione emodinamicamente ottimale 5 – STIMOLAZIONE MULTISITO Ottimizzazione Della Stimolazione Sinistra
5 – STIMOLAZIONE MULTISITO Ottimizzazione Della Stimolazione Sinistra
N Engl J Med. 2010 Jul 1;363(1):36-44. Epub 2010 May 12. An entirely subcutaneous implantable cardioverter-defibrillator. Bardy GHBardy GH,, Cappato R,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. DEFIBRILLATORE SOTTOCUTANEO
Clin Res Cardiol. 2011 Mar 17. Clinical experience with a novel subcutaneous implantable defibrillator system in a single center. Dabiri Abkenari LDabiri Abkenari L, Theuns DA, Valk SD, Van Belle Y, de Groot NM, Haitsma D, Muskens-Heemskerk A, Szili-Torok T, Jordaens L.Theuns DAValk SDVan Belle Yde Groot NMHaitsma DMuskens-Heemskerk ASzili-Torok TJordaens 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 11-21.6 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. DEFIBRILLATORE SOTTOCUTANEO
The most promising ideas which address the early detection of pacing co- morbidities are: Internal, Chronic Blood Pressure MonitoringInternal, Chronic Blood Pressure Monitoring (Ipertensione) Peak Endocardial Acceleration MonitoringPeak Endocardial Acceleration Monitoring (CAD) Implantable Glucose MonitoringImplantable Glucose Monitoring (Diabete) T-Wave Alternans Monitoring T-Wave Alternans Monitoring (Scompenso, FV, SCD) 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 & activity Core body temperature Continuous remote monitoring COSA CI ASPETTIAMO NEL FUTURO IMMINENTE?
COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 1 Heart 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. Internal, Chronic Blood Pressure Monitoring
Durante 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. COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 2 Peak Endocardial Acceleration Monitoring
COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 3 An 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. Implantable Glucose Monitoring
COSA CI ASPETTIAMO NEL FUTURO IMMINENTE 4 T-Wave Alternans Monitoring T-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.
COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?
COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza?
Optical Techniques for Future Pacemaker Technology Yasuaki Kumamoto, Nicholas Isaac Smith, Katsumasa Fujita, Jun Ando and Satoshi Kawata Osaka University Japan COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza? Lo 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.femtosecondi
COSA CI ASPETTIAMO NEL FUTURO PIU’ LONTANO? Fantascenza? Pacemakers Biologici Terapia Genetica Trapianto Cellulare (es. Tessuto atriale fetale contenente cellule nodali)
COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI: UNA PREMESSA: IL PROBLEMA DELLE INFEZIONI
The time to infection after first pacemaker implantation (n= 44631) and after pacemaker replacements (n= 8380) COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI: UNA PREMESSA: IL PROBLEMA DELLE INFEZIONI
COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI DESIDERATA PERSONALI : 1. MATERIALI PER CATETERI CHE DIMINUISCANO LE ADERENZE E CHE NE FACILITINO L’ESTRAZIONE IN CASO DI INFEZIONE O MALFUNZIONAMENTO. 1. STANDARDIZZAZIONE DEI PROGRAMMATORI E DEI SISTEMI DI MONITORAGGIO REMOTO. 1. 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.
«Caro, devo dirti che mi pare un argomento un pò troppo di "nicchia".» COSA CI ASPETTIAMO NEL FUTURO IMMINENTE CONCLUSIONI 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.
POST-MORTEM CARDIAC DEVICE RETRIEVAL FOR RE-USE IN THIRD WORLD NATIONS: VIEWS OF THE GENERAL PUBLIC AND PATIENT POPULATION David 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 of Pennsylvania, Philadelphia, PA Conclusions: As the prevalence of cardiovascular disease increases throughout the world, innovative methods of delivering healthcare to underserved nations must be explored. An overwhelming majority of funeral directors have the desire and ability to perform post-mortem cardiac device removal for philanthropic reuse in underserved nations if given the opportunity. Heart Rhythm 2009 UN’ULTIMA CONSIDERAZIONE
La felicità non sta nell'assenza dei contrasti, ma nell'armonia dei contrasti. Roberto Benigni