logging in or signing up 20.%20%E6%A9%9F%E6%A2%B0%E7%B6%AD%E7%94% 5034 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 42 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: July 18, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript ?????? : ?????? ????? ???????? ???? ?????(pacemaker) : ?????(pacemaker) ??????????(pacemaker)? : ??????????(pacemaker)? ???????????????,????(pulse generator )???(electrode)???(lead)??????,????????????,???????????,?????????????????,??????????? ??????? : ??????? ??????????????????????(???)???????,??????????,?????????????60-100????????????????????????????????????? ?????????? : ?????????? ??????????????????,??X-???????????,???????????,???????????????3???????,?????,????????3?4?????,??????????,????????????,??X-?????????????????????????,?????????????????,????????????????????,??????????????????,????????????,?????1-3????? ?????????????? : ?????????????? (?)???????,??????(?)???????,??????(?)?????????????????????????(?)?????????,??????(?)???????,???????????????????????????,?????,????????????????????????,?????????????,??????????????????(?)??????????????????,????????????,??????????? ???????? : ???????? ???????,??????:(?)????,?????(VVI)?(?)????,?????(VVIR)?(?)????,?????(AAI)?(?)????,?????(AAIR)?(?)????????,?????(VDD)?(?)?????,?????(DDD)?(?)?????,?????(DDDR)?(?)???????,?????(CRT-DDDR) ????????????????? : ????????????????? ?????????(Atrial pacemaker) : ?????????(Atrial pacemaker) ??????????????? P?????spike ????QRS?? ?????(AAI)??????(AAIR) ??????????(Sick Sinus Syndrome)??? ?????????(ventricular pacemaker) : ?????????(ventricular pacemaker) ????????????? QRS?????spike QRS???????? ????,?????(VVI) ????,?????(VVIR) ???????????? ?????????? (Dual chamber pacemaker) : ?????????? (Dual chamber pacemaker) ????????????? ??????? ???????????? : ???????????? 1.????,????????????????? 2.?????(?18???????),???????? 3.??????,????????????????????,???????????,??????????????? 4.???????4-6??,???????????? 5.?????????????????????,??????????????? 6.???????????????????,???????????????,????????? 7.?????,?????????,????????????????????,??????,?????????,30???????????????????????? ???: : ???: 1.?????????????????????????,???????????????????,???????????????????????????????,?????????? 2.?????,?????????????,?????????,30?????????????? 3.?????,?????????????70?,??6??,??????????????? 4.?????,????500??????????,?????10??,????????????????(??????)? Slide 14: 5.????????,????????????,??????????????,???????????????10??,???????? 6.????????????????????,?????????2????????,??????????????????,??????????????? 7.??????????,???????????????,???????????????? 8.?????????2???????,??????,?????????? 9.????????,???????????? 10.????????????,???24????????X?????????,???????????????,???????????????????????X????,???X????????????,???????,?????????????? ????(?) : ????(?) ????:?????????????;???????????????,?????????????,?????????,???????7-10?;?????????,????????????????,?????????1.??????????????????:(1)???(???)(2)????????(????)(3)??????(3??×3??)(4)????????(10???)(5)????(1???) ????(?) : ????(?) ????:?????????????????????????????,???????????????(?:?????),????????????????,????????,???????????????????????????,?????????????????????????,???????????,?????????????????????????????????5????????????????????,???????????????????,????????????? ????(?) : ????(?) ?????????: 1.????:??????????,???????????????,????????????????????????????????????????????????????????????????????????????????????,????????????????????????????????????????????,????????,?????,??????????????????????????????,??????????,?????????????? ????(?) : ????(?) 2.??????????????????????????,???????????????????????????? 3.?????????:??????????????,???????????,????????????????????,???????????????:(1)??:????????????????? (2) ????????? (3)????? (4)???????(5)???????(6)???? (7)?????????(8)??????? (9)?????( 10)??????????????? ????(?) : ????(?) ??????: 1.?????????????????,???????????????????,?????????????,???????????????5?/????????,??????2.??????????????????(???????)???????????????????????????????????5?(2~3??)????????????????????,???????????3.??????????????????,??????????????????????????????????????????????????????????????????,??????3????????????????,?????????????????4.?????,?????? ????(?) : ????(?) 5.?????????????? 6.????????,??????? 7.??????????????,????????38?,???????;??????????????????????,??????,????????? 8.???????????????6-10?,?????????????????????????????,?????????????????????????????????????,??????????????? 9.?????????????????????????????????????????,??????????????,?????? 10.??????????????,??????????? ???????? : ???????? (?)?:???????????????:????????,????????????????????????????????????????????,???????????????????????????,????????????????? ???????? : ???????? (?) ?:????????????? ?:????????????,??????1-2???,??????????????,????????????,?????????????????????????,?????????????,?????????????? ???????? : ???????? (?) ?:?????????? ?:??????????,??????;?????????????(?????????),???????,???????? ???????? : ???????? (?) ?:????????????????? ?:?????????????,????????,??????? ???????? : ???????? (?) ?:??????????????????? ?:?????????,????????,?????????????,?????????????????????????? ???????????? : ???????????? ???????????? : ???????????? ?? ??chronic heart failure ????,??? 30% ????????,?????????????????????;?????interventricular conductiondelay,????????????,???????????????????????interventricular conduction delay ( IVCD ),??????????????,??????????????? ?????????????,?biventricular pacing,????? ( ???leftventricular free wall ) ????,?????cardiac resynchronization therapy ( CRT ) Cardiac dyssynchrony : Cardiac dyssynchrony Cardiac dyssynchrony ???:??????????????atrial-ventricular dyssynchrony,?AV block ?,???????? pacemaker ??????? ???????? ???????????????????????????? ? ventricular dyssynchrony? Ventricular dyssynchrony : Ventricular dyssynchrony Ventricular dyssynchrony ??? cardiac output ??????: ??loss of segment contribution to global ejection fraction. ??decreased diastolic filling time. ??prolonged and increased mitral regurgitation. ??reverse remodeling. Slide 31: ??????????????????? Purkinje system,???????????,?? ??????????????????????? ???????????,??????????? ???paradoxical septal motion ?delayed LV lateral wall motion,???????????? ????????????,?????????? ?????????,???????diastolic filling time,??????filling volume,?? ???????? ??????????,???????mitral annulus ?????????mitral regurgitation ??????3?????mechanism Remodeling : Remodeling ??mechanism ??? ventricular dyssynchrony,???biventricular pacing ????remodeling,heart failure ????progressive LV dilation ?loss of contractile function,????remodeling? Remodeling ???????????????,??study ??biventricular pacing ???remodeling,??????????????? ??? ( indication ) : ??? ( indication ) ??????????????,?????????,?????????: ??Chronic heart failure, NYHA class III or IV? ??QRS duration >140 ms? ??LV ejection fraction ?35%? ?????????? 6 ????,????????? ?? Journal ????LV end-diastolic dimension ?55 ????6 ???????450 m???????,????? medical treatment ??????,??? ?????????? bradycardia ??????????? Slide 34: ???? ???? : ???? ????????????????,?? pacemaker ? 3 ? leads ( ??? ),pacemaker ????????????????,? lead ?? left or right subclavian vein ????,1 ? lead ?? right atrium,1 ??? right ventricular apex;??????? lead ?? coronary sinus ?,????? lateral cardiac vein ( ??left ventricle free wall ),????? latest activation site of LV ( ?left ventricle ?????? )? ???????? lead ?? coronary sinus ???? site,?????? preformed angulation lead,??????? guide wire system,???????????????? ?????study : ?????study randomized, single-blinded, cross-over study???? 131 ???,sinus rhythm ?atrial fibrillation ????,??? 6?9?12 ??,?? 6-minute walking distance, peak oxygen uptake, quality of life ( QoL ) by the Minnesota score, NYHA class, echocardiography and LVEF by radionuclide technique???:6-minute walking distance ? pacing ???? 23%,???????,???????????????????? 12 ??12? ??MUSTIC-1(MUltiste STimulation In Cardiomyopathy ??MUSTIC-2 : ??MUSTIC-2 randomized, control study??? 76 ???,?? NYHA class III heart failure ??interventricular conduction delay? ? 3 ??? cardiac resynchronization ???;sinus rhythm group ??inactive pacing,atrial fibrillation group ??ventricule-inhibited pacing? ??:85% ???????biventricular pacing,?clinical improvement ????12 ??? ??PATH-CHF ( The PAcing Therapies in Congestive Heart Failure ) : ??PATH-CHF ( The PAcing Therapies in Congestive Heart Failure ) ??? 41 ???,?? biventricular pacing and left ventricle pacing,??? 3 ?12 ?? ?? 6-minute walking distance, peak oxygen uptake, quality of life and NYHA class? ??:cardiac resynchronization therapy ?????????????,? biventricular pacing ?left ventricle pacing ?clinical outcome ???? ??MIRACLE (Multicenter InSync Randomized Clinical Evaluation ) : ??MIRACLE (Multicenter InSync Randomized Clinical Evaluation ) Randomized and double-blind study???? 453 ???,?? pacemaker,??????pacing,????????? 3 ?? 6 ??,???? NYHA class, quality of life and 6-minute walking distance? ??:????? pacing group ?????????? control group?????????????????? ???? ( Adverse events ) : ???? ( Adverse events ) ?MIRACLE Study ??????,? 6 ??????,?? 7% ? adverse events ?? ? 2002 ? Abraham ???? study ? ,????????? 8%?????,0.3% ????,6% ?????????,0.3% ????????????? 6%LV lead ???,1% ???? lead ??? ?? : ?? ???? study ???? cardiac resynchronization therapy ?: ??reduce the degree of ventricular dyssynchrony ??recovery of diastolic filling time. ??decrease the magnitude of mitral regurgitation. ??reverse remodeling. ???? left ventricle ejection fraction ?cardiac function,??NYHA class??????? quality of life ????? ?? : ?? cardiac resynchronization therapy????????? pacemaker ????,??????? survival rate ?chronic heart failure ?? interventricular conduction delay ????,cardiac resynchronization therapy ?????? heart function ?????????????? Slide 43: ??????????????? Cardiac vein stenosis PTCA with 3.5 mm balloon Final result ??????????(AICD) : ??????????(AICD) Defibrillators and sudden death : Defibrillators and sudden death In ischemic heart disease, ventricular tachyarrhythmias are the leading cause of sudden death In nonischemic HF, bradyarrhythmias are the leading cause of sudden death The evidence for benefit is less clear for patients with nonischemic cardiomyopathy Slide 46: MULTICENTER AUTOMATIC DEFIBRILLATOR IMPLANTATION TRIAL-II (MADIT-II) 1997-2001 A trial designed to evaluate the effect of prophylactic ICD therapy on survival in patients with prior MI and LVD Supported by a research grant from Guidant Corp. Slide 47: MADIT-II Trial started July 8, 1997 Trial stopped November 20, 2001 by DSMB because ICD saved lives 1,232 patients enrolled from 76 centers in U.S. and Europe Slide 48: MADIT-II: Eligibility Chronic CAD with prior MI EF<0.30 No requirement for NSVT or EPS No upper age limitation Slide 49: (probability of survival) 0.78 0.69 P=0.007 Kaplan-Meier Survival by Treatment Group Slide 50: MADIT-II: Mortality by Rx Group CONV DEFIB (n=490) (n=742) no. of patients [%] Deaths 97 [19.8%] 105 [14.2%] --------------------------------- Hazard Ratio (ICD:CONV) 0.69 (31% ? mortality) (95% CI) (0.51, 0.93) P-value 0.016 Slide 51: Similar HR for: AF vs. NSR Single vs. Dual chamber ICD Slide 52: MADIT-II: CONCLUSION In coronary patients with LVEF <0.30, prophylactic ICD therapy is associated with 31% reduction in mortality. This improved survival is on top of optimal medical Rx. Randomized implantable defibrillator trials : Randomized implantable defibrillator trials ICM, ischemic cardiomyopathy; NICM, nonischemic cardiomyopathy; N/A, data not available; ?, decreased; ?, no change ????????? : ????????? ????????(intra-aortic balloon pump,IABP), ?????????(extracorporeal membrane oxygenation,ECMO) ?????(ventricular assist device,VAD) ????????(IABP) : ????????(IABP) ????????????,??????,?????,??????????;??????,????,???????????,???????? ?????????,??????????? ??,??????????????????????????????,???????????,????????,?????? ????????(IABP) : ????????(IABP) ????????,?????(???T ????????)????(???????????????)?????????(???????????,?????????????,IABP ????????,??????????????,???????T ?????????,?????????????),?????????????,??????,????????,Q ?????,?????????????? IABP ????? : IABP ????? ????????(?????90mmHg,????????20mmHg,????????1.8 l/min/m2?????????) ???????????,???????,?????????????,????????????? ????????????,???????,?????????????,????? Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Refractory unstable angina Cardiogenic shock Postoperative hemodynamic compromise AMI with MR or VSD Intractable ventricular tachycardia as a result of myocardial ischemia Patients with left main coronary stenosis or severe three vessel disease undergoing anesthesia for cardiac surgery High risk PTCA Maintenance of vessel patency after PTCA of a total occlusion Indications Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Anatomic abnormality of femoral-iliac artery Iliac or aortic atherosclerotic disease impairing blood flow run off Moderate or severe AR Aortic dissection or aneurysm Patent ductus Bypass grafting to femoral arteries or aorta Bleeding diathesis Sepsis Contraindications Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Position: 1 to 2 cm below the top of the aortic arch Inflation: at the aortic dicrotic notch (T wave on ECG) Deflation: immediately before systole (at or before the R wave) Slide 61: Intraaortic Balloon Counterpulsation Slide 62: Intraaortic Balloon Counterpulsation IABP : IABP ?IABP ?????,???????????(??40%),??????(??70%),??????????(??40%),?????????(??20%), ????????,?????????,????????(??40%),??????????? ??????????? : ??????????? ?????? > 2 L/min/m2 ?????? < 20 mmHg ??? > 100 mmHg ??? > 30ml/HR ????????? ???? ?????????(ECMO) : ?????????(ECMO) ?????????,????????,??????,??????????,???????????,?????? ?????,???????????,??????????????,??????????????? ?10 ??????????????????,?????????????,????????????????????????,???????????????,?????????????????????????? ??? : ??? 50?????,?????????,???????????????,???????????????????3?4?????????????????????????????????????????????????,????????????????????????????????????,?????????????????(???????)???,?????,??????????,????????????????,?????,??????????? ??? : ??? 69?????,????????????????,?????????????????,??????????????????????????????????,?????????????????????????????????????(???????)??,??????????????,??????????????,?????????,?????????????,?????????????????3??????????????,???????2?????????,????????,???????????????????????? ??? : ??? 57?????,???????????????????????????????,????????????????,????????????????,????,????,???????????,????????????????????,????????????????,??????????????????????????????????????????,????????????,????????? ???????????? : ???????????? ??,??????(????????????;ECMO)?????????,?????????????????????,??????????????????????,??????????????,????????????????????????????,???????????????,???????????????????,?????????????? ????????? : ????????? ???????????????,?????????????,?????????????,?????????????????????:(1)??????,(2)?????????,(3)??????????,(4) ???????,(5)????????????????????????????????????,?????????(???????????),??????????????????????,??????????????????????????????,???????,??????????????????????? ???????????? : ???????????? ?????????????????????????????????????????????????????????????????,????????????????????????????????????,?????????????????????????????,???????????????????,?????????????,?????????????????????????????????????????????????????? ?????????(ECMO) : ?????????(ECMO) ?????????(roller pump)????(centrifugal pump)??,??????????????????,??????????,?????????????1????????????,?????????? ?????????????(activated clotting time,ACT)?150?200???,????????50,000/mm3?100,000/mm3??,????12g/dl ?????40%???????????????(membrane oxygenator)????????? ECMO???? : ECMO???? ????????????????????????????????????????????????ECMO),??????????????,?80% ?ECMO ????????,????????,?????????????? ????????VAD ????ECMO???? : ????ECMO???? 1.???: A.?ECMO??? B.??PRBC 2 unit C.????: D.VV mode: FiO2: 1.0, gas flow: 10L/min E.VA mode:FiO2:1.0, gas flow: blood flow = 1:1 ????ECMO???? : ????ECMO???? 2.?ABG: A. Pulse oximeter???,???SaO2???????????;???SaO2?????ECMO?SaO2? B. VV mode:????????,FiO2: 1.0,gas flow: 10L/min? C. VA mode:??????,??ECMO SaO2????,???ECMO ABG? D. ???ABG:????? ????ECMO???? : ????ECMO???? ACT: A. Heparin dose: 5c.c./250c.c. 5%G/W to keep ACT level(??????ACT level) B. ACT?????: ACT???????bed side,??????????? ????2c.c.???????????,??????????????,?????start,?????? ???????????,??????????????????,??ACT????????? ????ECMO???? : ????ECMO???? ????:?B-I ointment cover??,?????????????? ?????????(?CVP???????,ECMO??????????)? ??????pale?cyanosis?swelling?pulseless?????????,?????????? ????????????port,??????,???Kelly??,??port,????,??Kelly,????????Bio-pump???????,????????,??????ECMO??,?????? ???Propofol??????,?????tube??Heparin? Keep Hct?30%(Hct?,oxygenator?clot,?Hct?,O2 delivery??,?????????);Platelet>75000/mm3? ????ECMO???? : ????ECMO???? ?????chest care? Q6H?urine stick??????,?????????;??????????,??ECMO??? ECMO machine dysfunction?,???????????? ????pump head??????,????????????,????????????,??: A. ??????kinking,?????? B. ????????,???????? C. ?CVP?????,?????????????? ??????????etc? D. ?14????????ECMO????,????? ????ECMO???? : ????ECMO???? ??ECMO??:pre-pump?post-pump A. Pre-pump??:?????????????,???pump-head????????,??????30mmHg???;????,??????,??????????? B. Post-pump??(pre-oxygenator):??oxygenator(???)?????,??????300mmHg???;????????oxygenator??????????????? Flow?????????????? ???????????? : ???????????? ???????????????????????????,?????????????????????????????1960??????????????(bridge to recovery):???????????????? (FDA)???1994??????????????????????(bridge to transplant):?????????????????,??????????????? (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; REMATCH trial) : (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; REMATCH trial) (1998~2001) ????????????????????????????? ???????????????????????????????????????????????????????????(destination therapy)?????????????????2?,??????????,?????????????(Heartmate)???????????????,??????????????????????2??3?,?????????????????????????????? (Ann Thorac Surg 2003; 75:S86-92 & N Engl J Med. 2001; 345:1435-43)??????????(FDA)??2003???????????,????????????????????????????,??????????????? REMATCH: LVAD support superior to medical management for transplant-ineligible CHF patients : REMATCH: LVAD support superior to medical management for transplant-ineligible CHF patients Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure Slide 83: Kaplan-Meier estimates of survival at 1 and 2 years REMATCH 11/12/01 Rose EA et al. N Engl J Med 2001;345(20):1435-43. ???????????? : ???????????? ????????????ThoraTec?BerlinHeart Excor,?????????????,?????,???????????????????????????? ????????????Heartmate ? Novacor,??????????????,????????,???????????????????????,????????????? ???????????? : ???????????? ???????????????????????????????,???????????????????????????,????????????,???????????????? ????????????????,???????????,????????????????????????????????,??????????????????????DeBakey, Jarvik 2000, BerlinHeart Incor ????? : ????? ?????,??????,????????????????????????????????????,???????????,???????,??????,????????????????????????????????????Lion heart, Abiocor ?????(VAD) : ?????(VAD) ?????(VAD)???????????????,????????,?????????????????????????,???????????,????????????,?IABP????????,?????????? ?????,??????,????????????????????? ?????(VAD) : ?????(VAD) ??????????????????20%??????(5),?????????(? > 20mmHg)????????(? > 5 Wood Units)????????(?RVEF < 10%)?,????????????,?????????????????????,??????????????????????,??????,?????????????????????? ?????(VAD) : ?????(VAD) ???????????????????,???????(fill-to-empty mode)????(automatic mode),??????????????,??????,???????????,??????????,????????????????????????????,??????????,??????,?????????? ?????(VAD) : ?????(VAD) ???????(fixed-rate mode),???????????,????????????????????????? ?????(VAD) : ?????(VAD) ???????(synchronous mode),?IABP???????????,???????????R??????????,?????VAD?,??1:2?1:3,????????,????????VAD???????? ?????(VAD) : ?????(VAD) ???????HeartMate ?Novacor ????????? ??Thoractec VAD?????????????? HeartMate ??????? : HeartMate ??????? ???????????????????????,??????????,???????????,??????????????,??????????????,?????????????????,????????????????????????(25mm porcine xenograft),????????????,??????????????,????????????83ml,????????,?????10?,?????12 ????????,??????????,????????? ????????33 ??,????????????8.5 ??,??????? Novacor ????? : Novacor ????? ??????????????(22mm Carpentier-Edward porcine xenograft),?????????,????????,????????????,??????????70 ml,????????12?;?HeartMate ??????????????? Thoractec VAD : Thoractec VAD ?????,?????(????????)?????????????,????????,?????????????????,?????????????,??????????,??????????65 ml,????????7???????????????????(Bjork-Shiley concavo-convex tilting discvalve)????,?????warfarin????? Ventricular Assist Devices and Cardiac transplantation : Ventricular Assist Devices and Cardiac transplantation For patients with end-stage HF refractory to optimal pharmacologic and adjunctive device therapy, cardiac transplantation remains the gold standard of treatment 2700 heart transplants/year in the USA 1-year survival: 80% Bridging to cardiac transplantation with a ventricular assist device may provide superior overall and posttransplant survival compared with those bridged with only inotropes Slide 97: Left ventricular assist device (LVAD) LVAD is implanted in the LV where, via a graft, the blood is deviated to the pump and is then ejected through an outflow graft into the ascending aorta VAD????? : VAD????? ????HeartMate?????????????????287???????????222 ???????????,??100%?????? ?????????,VAD????????,?????VAD?????????????VAD ??????????????????? ???????????? : ???????????? ?? ???????????????????????1966??? 1980?????????????:?????,???cyclosporin,?????????????? 1990??????????????????,???????????????,??????????????? ????????????????? : ????????????????? 1.????????(???????????)?????? ???????????????????????,???????????? 2.???????:???????,???????,?????????,?????????????????? 3.??????:??????????????????,???????????????? ????????????????? : ????????????????? ?????????(??????????????????),???????????????????????????????????:????????????????????????????????14????????????? ??????????????? : ??????????????? 1.???:????????65 mmHg??????????????? 2.????????:???,???,???????? 3.??????????:???,???????? 4.?????? 5.?????????? 6.???????????????????(?????????) 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20.%20%E6%A9%9F%E6%A2%B0%E7%B6%AD%E7%94% 5034 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 42 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: July 18, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript ?????? : ?????? ????? ???????? ???? ?????(pacemaker) : ?????(pacemaker) ??????????(pacemaker)? : ??????????(pacemaker)? ???????????????,????(pulse generator )???(electrode)???(lead)??????,????????????,???????????,?????????????????,??????????? ??????? : ??????? ??????????????????????(???)???????,??????????,?????????????60-100????????????????????????????????????? ?????????? : ?????????? ??????????????????,??X-???????????,???????????,???????????????3???????,?????,????????3?4?????,??????????,????????????,??X-?????????????????????????,?????????????????,????????????????????,??????????????????,????????????,?????1-3????? ?????????????? : ?????????????? (?)???????,??????(?)???????,??????(?)?????????????????????????(?)?????????,??????(?)???????,???????????????????????????,?????,????????????????????????,?????????????,??????????????????(?)??????????????????,????????????,??????????? ???????? : ???????? ???????,??????:(?)????,?????(VVI)?(?)????,?????(VVIR)?(?)????,?????(AAI)?(?)????,?????(AAIR)?(?)????????,?????(VDD)?(?)?????,?????(DDD)?(?)?????,?????(DDDR)?(?)???????,?????(CRT-DDDR) ????????????????? : ????????????????? ?????????(Atrial pacemaker) : ?????????(Atrial pacemaker) ??????????????? P?????spike ????QRS?? ?????(AAI)??????(AAIR) ??????????(Sick Sinus Syndrome)??? ?????????(ventricular pacemaker) : ?????????(ventricular pacemaker) ????????????? QRS?????spike QRS???????? ????,?????(VVI) ????,?????(VVIR) ???????????? ?????????? (Dual chamber pacemaker) : ?????????? (Dual chamber pacemaker) ????????????? ??????? ???????????? : ???????????? 1.????,????????????????? 2.?????(?18???????),???????? 3.??????,????????????????????,???????????,??????????????? 4.???????4-6??,???????????? 5.?????????????????????,??????????????? 6.???????????????????,???????????????,????????? 7.?????,?????????,????????????????????,??????,?????????,30???????????????????????? ???: : ???: 1.?????????????????????????,???????????????????,???????????????????????????????,?????????? 2.?????,?????????????,?????????,30?????????????? 3.?????,?????????????70?,??6??,??????????????? 4.?????,????500??????????,?????10??,????????????????(??????)? Slide 14: 5.????????,????????????,??????????????,???????????????10??,???????? 6.????????????????????,?????????2????????,??????????????????,??????????????? 7.??????????,???????????????,???????????????? 8.?????????2???????,??????,?????????? 9.????????,???????????? 10.????????????,???24????????X?????????,???????????????,???????????????????????X????,???X????????????,???????,?????????????? ????(?) : ????(?) ????:?????????????;???????????????,?????????????,?????????,???????7-10?;?????????,????????????????,?????????1.??????????????????:(1)???(???)(2)????????(????)(3)??????(3??×3??)(4)????????(10???)(5)????(1???) ????(?) : ????(?) ????:?????????????????????????????,???????????????(?:?????),????????????????,????????,???????????????????????????,?????????????????????????,???????????,?????????????????????????????????5????????????????????,???????????????????,????????????? ????(?) : ????(?) ?????????: 1.????:??????????,???????????????,????????????????????????????????????????????????????????????????????????????????????,????????????????????????????????????????????,????????,?????,??????????????????????????????,??????????,?????????????? ????(?) : ????(?) 2.??????????????????????????,???????????????????????????? 3.?????????:??????????????,???????????,????????????????????,???????????????:(1)??:????????????????? (2) ????????? (3)????? (4)???????(5)???????(6)???? (7)?????????(8)??????? (9)?????( 10)??????????????? ????(?) : ????(?) ??????: 1.?????????????????,???????????????????,?????????????,???????????????5?/????????,??????2.??????????????????(???????)???????????????????????????????????5?(2~3??)????????????????????,???????????3.??????????????????,??????????????????????????????????????????????????????????????????,??????3????????????????,?????????????????4.?????,?????? ????(?) : ????(?) 5.?????????????? 6.????????,??????? 7.??????????????,????????38?,???????;??????????????????????,??????,????????? 8.???????????????6-10?,?????????????????????????????,?????????????????????????????????????,??????????????? 9.?????????????????????????????????????????,??????????????,?????? 10.??????????????,??????????? ???????? : ???????? (?)?:???????????????:????????,????????????????????????????????????????????,???????????????????????????,????????????????? ???????? : ???????? (?) ?:????????????? ?:????????????,??????1-2???,??????????????,????????????,?????????????????????????,?????????????,?????????????? ???????? : ???????? (?) ?:?????????? ?:??????????,??????;?????????????(?????????),???????,???????? ???????? : ???????? (?) ?:????????????????? ?:?????????????,????????,??????? ???????? : ???????? (?) ?:??????????????????? ?:?????????,????????,?????????????,?????????????????????????? ???????????? : ???????????? ???????????? : ???????????? ?? ??chronic heart failure ????,??? 30% ????????,?????????????????????;?????interventricular conductiondelay,????????????,???????????????????????interventricular conduction delay ( IVCD ),??????????????,??????????????? ?????????????,?biventricular pacing,????? ( ???leftventricular free wall ) ????,?????cardiac resynchronization therapy ( CRT ) Cardiac dyssynchrony : Cardiac dyssynchrony Cardiac dyssynchrony ???:??????????????atrial-ventricular dyssynchrony,?AV block ?,???????? pacemaker ??????? ???????? ???????????????????????????? ? ventricular dyssynchrony? Ventricular dyssynchrony : Ventricular dyssynchrony Ventricular dyssynchrony ??? cardiac output ??????: ??loss of segment contribution to global ejection fraction. ??decreased diastolic filling time. ??prolonged and increased mitral regurgitation. ??reverse remodeling. Slide 31: ??????????????????? Purkinje system,???????????,?? ??????????????????????? ???????????,??????????? ???paradoxical septal motion ?delayed LV lateral wall motion,???????????? ????????????,?????????? ?????????,???????diastolic filling time,??????filling volume,?? ???????? ??????????,???????mitral annulus ?????????mitral regurgitation ??????3?????mechanism Remodeling : Remodeling ??mechanism ??? ventricular dyssynchrony,???biventricular pacing ????remodeling,heart failure ????progressive LV dilation ?loss of contractile function,????remodeling? Remodeling ???????????????,??study ??biventricular pacing ???remodeling,??????????????? ??? ( indication ) : ??? ( indication ) ??????????????,?????????,?????????: ??Chronic heart failure, NYHA class III or IV? ??QRS duration >140 ms? ??LV ejection fraction ?35%? ?????????? 6 ????,????????? ?? Journal ????LV end-diastolic dimension ?55 ????6 ???????450 m???????,????? medical treatment ??????,??? ?????????? bradycardia ??????????? Slide 34: ???? ???? : ???? ????????????????,?? pacemaker ? 3 ? leads ( ??? ),pacemaker ????????????????,? lead ?? left or right subclavian vein ????,1 ? lead ?? right atrium,1 ??? right ventricular apex;??????? lead ?? coronary sinus ?,????? lateral cardiac vein ( ??left ventricle free wall ),????? latest activation site of LV ( ?left ventricle ?????? )? ???????? lead ?? coronary sinus ???? site,?????? preformed angulation lead,??????? guide wire system,???????????????? ?????study : ?????study randomized, single-blinded, cross-over study???? 131 ???,sinus rhythm ?atrial fibrillation ????,??? 6?9?12 ??,?? 6-minute walking distance, peak oxygen uptake, quality of life ( QoL ) by the Minnesota score, NYHA class, echocardiography and LVEF by radionuclide technique???:6-minute walking distance ? pacing ???? 23%,???????,???????????????????? 12 ??12? ??MUSTIC-1(MUltiste STimulation In Cardiomyopathy ??MUSTIC-2 : ??MUSTIC-2 randomized, control study??? 76 ???,?? NYHA class III heart failure ??interventricular conduction delay? ? 3 ??? cardiac resynchronization ???;sinus rhythm group ??inactive pacing,atrial fibrillation group ??ventricule-inhibited pacing? ??:85% ???????biventricular pacing,?clinical improvement ????12 ??? ??PATH-CHF ( The PAcing Therapies in Congestive Heart Failure ) : ??PATH-CHF ( The PAcing Therapies in Congestive Heart Failure ) ??? 41 ???,?? biventricular pacing and left ventricle pacing,??? 3 ?12 ?? ?? 6-minute walking distance, peak oxygen uptake, quality of life and NYHA class? ??:cardiac resynchronization therapy ?????????????,? biventricular pacing ?left ventricle pacing ?clinical outcome ???? ??MIRACLE (Multicenter InSync Randomized Clinical Evaluation ) : ??MIRACLE (Multicenter InSync Randomized Clinical Evaluation ) Randomized and double-blind study???? 453 ???,?? pacemaker,??????pacing,????????? 3 ?? 6 ??,???? NYHA class, quality of life and 6-minute walking distance? ??:????? pacing group ?????????? control group?????????????????? ???? ( Adverse events ) : ???? ( Adverse events ) ?MIRACLE Study ??????,? 6 ??????,?? 7% ? adverse events ?? ? 2002 ? Abraham ???? study ? ,????????? 8%?????,0.3% ????,6% ?????????,0.3% ????????????? 6%LV lead ???,1% ???? lead ??? ?? : ?? ???? study ???? cardiac resynchronization therapy ?: ??reduce the degree of ventricular dyssynchrony ??recovery of diastolic filling time. ??decrease the magnitude of mitral regurgitation. ??reverse remodeling. ???? left ventricle ejection fraction ?cardiac function,??NYHA class??????? quality of life ????? ?? : ?? cardiac resynchronization therapy????????? pacemaker ????,??????? survival rate ?chronic heart failure ?? interventricular conduction delay ????,cardiac resynchronization therapy ?????? heart function ?????????????? Slide 43: ??????????????? Cardiac vein stenosis PTCA with 3.5 mm balloon Final result ??????????(AICD) : ??????????(AICD) Defibrillators and sudden death : Defibrillators and sudden death In ischemic heart disease, ventricular tachyarrhythmias are the leading cause of sudden death In nonischemic HF, bradyarrhythmias are the leading cause of sudden death The evidence for benefit is less clear for patients with nonischemic cardiomyopathy Slide 46: MULTICENTER AUTOMATIC DEFIBRILLATOR IMPLANTATION TRIAL-II (MADIT-II) 1997-2001 A trial designed to evaluate the effect of prophylactic ICD therapy on survival in patients with prior MI and LVD Supported by a research grant from Guidant Corp. Slide 47: MADIT-II Trial started July 8, 1997 Trial stopped November 20, 2001 by DSMB because ICD saved lives 1,232 patients enrolled from 76 centers in U.S. and Europe Slide 48: MADIT-II: Eligibility Chronic CAD with prior MI EF<0.30 No requirement for NSVT or EPS No upper age limitation Slide 49: (probability of survival) 0.78 0.69 P=0.007 Kaplan-Meier Survival by Treatment Group Slide 50: MADIT-II: Mortality by Rx Group CONV DEFIB (n=490) (n=742) no. of patients [%] Deaths 97 [19.8%] 105 [14.2%] --------------------------------- Hazard Ratio (ICD:CONV) 0.69 (31% ? mortality) (95% CI) (0.51, 0.93) P-value 0.016 Slide 51: Similar HR for: AF vs. NSR Single vs. Dual chamber ICD Slide 52: MADIT-II: CONCLUSION In coronary patients with LVEF <0.30, prophylactic ICD therapy is associated with 31% reduction in mortality. This improved survival is on top of optimal medical Rx. Randomized implantable defibrillator trials : Randomized implantable defibrillator trials ICM, ischemic cardiomyopathy; NICM, nonischemic cardiomyopathy; N/A, data not available; ?, decreased; ?, no change ????????? : ????????? ????????(intra-aortic balloon pump,IABP), ?????????(extracorporeal membrane oxygenation,ECMO) ?????(ventricular assist device,VAD) ????????(IABP) : ????????(IABP) ????????????,??????,?????,??????????;??????,????,???????????,???????? ?????????,??????????? ??,??????????????????????????????,???????????,????????,?????? ????????(IABP) : ????????(IABP) ????????,?????(???T ????????)????(???????????????)?????????(???????????,?????????????,IABP ????????,??????????????,???????T ?????????,?????????????),?????????????,??????,????????,Q ?????,?????????????? IABP ????? : IABP ????? ????????(?????90mmHg,????????20mmHg,????????1.8 l/min/m2?????????) ???????????,???????,?????????????,????????????? ????????????,???????,?????????????,????? Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Refractory unstable angina Cardiogenic shock Postoperative hemodynamic compromise AMI with MR or VSD Intractable ventricular tachycardia as a result of myocardial ischemia Patients with left main coronary stenosis or severe three vessel disease undergoing anesthesia for cardiac surgery High risk PTCA Maintenance of vessel patency after PTCA of a total occlusion Indications Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Anatomic abnormality of femoral-iliac artery Iliac or aortic atherosclerotic disease impairing blood flow run off Moderate or severe AR Aortic dissection or aneurysm Patent ductus Bypass grafting to femoral arteries or aorta Bleeding diathesis Sepsis Contraindications Intraaortic Balloon Counterpulsation : Intraaortic Balloon Counterpulsation Position: 1 to 2 cm below the top of the aortic arch Inflation: at the aortic dicrotic notch (T wave on ECG) Deflation: immediately before systole (at or before the R wave) Slide 61: Intraaortic Balloon Counterpulsation Slide 62: Intraaortic Balloon Counterpulsation IABP : IABP ?IABP ?????,???????????(??40%),??????(??70%),??????????(??40%),?????????(??20%), ????????,?????????,????????(??40%),??????????? ??????????? : ??????????? ?????? > 2 L/min/m2 ?????? < 20 mmHg ??? > 100 mmHg ??? > 30ml/HR ????????? ???? ?????????(ECMO) : ?????????(ECMO) ?????????,????????,??????,??????????,???????????,?????? ?????,???????????,??????????????,??????????????? ?10 ??????????????????,?????????????,????????????????????????,???????????????,?????????????????????????? ??? : ??? 50?????,?????????,???????????????,???????????????????3?4?????????????????????????????????????????????????,????????????????????????????????????,?????????????????(???????)???,?????,??????????,????????????????,?????,??????????? ??? : ??? 69?????,????????????????,?????????????????,??????????????????????????????????,?????????????????????????????????????(???????)??,??????????????,??????????????,?????????,?????????????,?????????????????3??????????????,???????2?????????,????????,???????????????????????? ??? : ??? 57?????,???????????????????????????????,????????????????,????????????????,????,????,???????????,????????????????????,????????????????,??????????????????????????????????????????,????????????,????????? ???????????? : ???????????? ??,??????(????????????;ECMO)?????????,?????????????????????,??????????????????????,??????????????,????????????????????????????,???????????????,???????????????????,?????????????? ????????? : ????????? ???????????????,?????????????,?????????????,?????????????????????:(1)??????,(2)?????????,(3)??????????,(4) ???????,(5)????????????????????????????????????,?????????(???????????),??????????????????????,??????????????????????????????,???????,??????????????????????? ???????????? : ???????????? ?????????????????????????????????????????????????????????????????,????????????????????????????????????,?????????????????????????????,???????????????????,?????????????,?????????????????????????????????????????????????????? ?????????(ECMO) : ?????????(ECMO) ?????????(roller pump)????(centrifugal pump)??,??????????????????,??????????,?????????????1????????????,?????????? ?????????????(activated clotting time,ACT)?150?200???,????????50,000/mm3?100,000/mm3??,????12g/dl ?????40%???????????????(membrane oxygenator)????????? ECMO???? : ECMO???? ????????????????????????????????????????????????ECMO),??????????????,?80% ?ECMO ????????,????????,?????????????? ????????VAD ????ECMO???? : ????ECMO???? 1.???: A.?ECMO??? B.??PRBC 2 unit C.????: D.VV mode: FiO2: 1.0, gas flow: 10L/min E.VA mode:FiO2:1.0, gas flow: blood flow = 1:1 ????ECMO???? : ????ECMO???? 2.?ABG: A. Pulse oximeter???,???SaO2???????????;???SaO2?????ECMO?SaO2? B. VV mode:????????,FiO2: 1.0,gas flow: 10L/min? C. VA mode:??????,??ECMO SaO2????,???ECMO ABG? D. ???ABG:????? ????ECMO???? : ????ECMO???? ACT: A. Heparin dose: 5c.c./250c.c. 5%G/W to keep ACT level(??????ACT level) B. ACT?????: ACT???????bed side,??????????? ????2c.c.???????????,??????????????,?????start,?????? ???????????,??????????????????,??ACT????????? ????ECMO???? : ????ECMO???? ????:?B-I ointment cover??,?????????????? ?????????(?CVP???????,ECMO??????????)? ??????pale?cyanosis?swelling?pulseless?????????,?????????? ????????????port,??????,???Kelly??,??port,????,??Kelly,????????Bio-pump???????,????????,??????ECMO??,?????? ???Propofol??????,?????tube??Heparin? Keep Hct?30%(Hct?,oxygenator?clot,?Hct?,O2 delivery??,?????????);Platelet>75000/mm3? ????ECMO???? : ????ECMO???? ?????chest care? Q6H?urine stick??????,?????????;??????????,??ECMO??? ECMO machine dysfunction?,???????????? ????pump head??????,????????????,????????????,??: A. ??????kinking,?????? B. ????????,???????? C. ?CVP?????,?????????????? ??????????etc? D. ?14????????ECMO????,????? ????ECMO???? : ????ECMO???? ??ECMO??:pre-pump?post-pump A. Pre-pump??:?????????????,???pump-head????????,??????30mmHg???;????,??????,??????????? B. Post-pump??(pre-oxygenator):??oxygenator(???)?????,??????300mmHg???;????????oxygenator??????????????? Flow?????????????? ???????????? : ???????????? ???????????????????????????,?????????????????????????????1960??????????????(bridge to recovery):???????????????? (FDA)???1994??????????????????????(bridge to transplant):?????????????????,??????????????? (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; REMATCH trial) : (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; REMATCH trial) (1998~2001) ????????????????????????????? ???????????????????????????????????????????????????????????(destination therapy)?????????????????2?,??????????,?????????????(Heartmate)???????????????,??????????????????????2??3?,?????????????????????????????? (Ann Thorac Surg 2003; 75:S86-92 & N Engl J Med. 2001; 345:1435-43)??????????(FDA)??2003???????????,????????????????????????????,??????????????? REMATCH: LVAD support superior to medical management for transplant-ineligible CHF patients : REMATCH: LVAD support superior to medical management for transplant-ineligible CHF patients Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure Slide 83: Kaplan-Meier estimates of survival at 1 and 2 years REMATCH 11/12/01 Rose EA et al. N Engl J Med 2001;345(20):1435-43. ???????????? : ???????????? ????????????ThoraTec?BerlinHeart Excor,?????????????,?????,???????????????????????????? ????????????Heartmate ? Novacor,??????????????,????????,???????????????????????,????????????? ???????????? : ???????????? ???????????????????????????????,???????????????????????????,????????????,???????????????? ????????????????,???????????,????????????????????????????????,??????????????????????DeBakey, Jarvik 2000, BerlinHeart Incor ????? : ????? ?????,??????,????????????????????????????????????,???????????,???????,??????,????????????????????????????????????Lion heart, Abiocor ?????(VAD) : ?????(VAD) ?????(VAD)???????????????,????????,?????????????????????????,???????????,????????????,?IABP????????,?????????? ?????,??????,????????????????????? ?????(VAD) : ?????(VAD) ??????????????????20%??????(5),?????????(? > 20mmHg)????????(? > 5 Wood Units)????????(?RVEF < 10%)?,????????????,?????????????????????,??????????????????????,??????,?????????????????????? ?????(VAD) : ?????(VAD) ???????????????????,???????(fill-to-empty mode)????(automatic mode),??????????????,??????,???????????,??????????,????????????????????????????,??????????,??????,?????????? ?????(VAD) : ?????(VAD) ???????(fixed-rate mode),???????????,????????????????????????? ?????(VAD) : ?????(VAD) ???????(synchronous mode),?IABP???????????,???????????R??????????,?????VAD?,??1:2?1:3,????????,????????VAD???????? ?????(VAD) : ?????(VAD) ???????HeartMate ?Novacor ????????? ??Thoractec VAD?????????????? HeartMate ??????? : HeartMate ??????? ???????????????????????,??????????,???????????,??????????????,??????????????,?????????????????,????????????????????????(25mm porcine xenograft),????????????,??????????????,????????????83ml,????????,?????10?,?????12 ????????,??????????,????????? ????????33 ??,????????????8.5 ??,??????? Novacor ????? : Novacor ????? ??????????????(22mm Carpentier-Edward porcine xenograft),?????????,????????,????????????,??????????70 ml,????????12?;?HeartMate ??????????????? Thoractec VAD : Thoractec VAD ?????,?????(????????)?????????????,????????,?????????????????,?????????????,??????????,??????????65 ml,????????7???????????????????(Bjork-Shiley concavo-convex tilting discvalve)????,?????warfarin????? Ventricular Assist Devices and Cardiac transplantation : Ventricular Assist Devices and Cardiac transplantation For patients with end-stage HF refractory to optimal pharmacologic and adjunctive device therapy, cardiac transplantation remains the gold standard of treatment 2700 heart transplants/year in the USA 1-year survival: 80% Bridging to cardiac transplantation with a ventricular assist device may provide superior overall and posttransplant survival compared with those bridged with only inotropes Slide 97: Left ventricular assist device (LVAD) LVAD is implanted in the LV where, via a graft, the blood is deviated to the pump and is then ejected through an outflow graft into the ascending aorta VAD????? : VAD????? ????HeartMate?????????????????287???????????222 ???????????,??100%?????? ?????????,VAD????????,?????VAD?????????????VAD ??????????????????? ???????????? : ???????????? ?? ???????????????????????1966??? 1980?????????????:?????,???cyclosporin,?????????????? 1990??????????????????,???????????????,??????????????? ????????????????? : ????????????????? 1.????????(???????????)?????? ???????????????????????,???????????? 2.???????:???????,???????,?????????,?????????????????? 3.??????:??????????????????,???????????????? ????????????????? : ????????????????? ?????????(??????????????????),???????????????????????????????????:????????????????????????????????14????????????? ??????????????? : ??????????????? 1.???:????????65 mmHg??????????????? 2.????????:???,???,???????? 3.??????????:???,???????? 4.?????? 5.?????????? 6.???????????????????(?????????)