Порог дефибрилляции

[AlexAV]

Коллеги. Если у кого-то имеется опыт имплантаций кардиовертер-дефибрилляторов, хотелось бы услышать мнение по поводу проверки порога дефибрилляции. Делает ли это кто-нибудь? Лично я не проверяю, так как категория пациентов, которым имплантируют КВДФ, достаточно тяжёлая и лишний раз рисковать смысла не вижу.

[angio]

Скажите, а насколько это необходимо? Неужели стандартных программ pacing -> shok может не хватить.

[dav1972]

В последнюю пару лет перестали. Точно не проводим у пациентов с низкой фракцией выброса (разумеется, таких большинство).

[dav1972]

Сообщение от angio

Скажите, а насколько это необходимо? Неужели стандартных программ pacing -> shok может не хватить.

Почему Вы уверены, что не может быть такой ситуации?
Для ситуаций с высоким порогом даже разработаны соответствующие протоколы действий (репозиционирование электрода, установка дополнительного подкожного электрода)

[AlexAV]

Так мы вообще тестов не проводим и вы тоже "пару лет назад перестали проводить". А как быть у "пропущенных и упущенных" пациентов с высоким порогом?
Просто существует точка зрения, что порог дефибрилляции при вызванной ФЖ будет не таким же, как при спонтанной ФЖ у пациента. Кроме того, наткнулся тут на статью в PACE про проверку порога дефибрилляции. Ссылку выложу позже.

[AlexAV]

Pacing Clin Electrophysiol. 2011 Nov 29. doi: 10.1111/j.1540-8159.2011.03275.x. [Epub ahead of print]
Brain Natriuretic Peptide and Biomarkers of Myocardial Ischemia Increase after Defibrillation Threshold Testing.
Francis CK, Kuo YH, Azzam I, Selim S, Patel N, Beri R, Goldman D, Girgis I, Daniels S.
Source

Robert Wood Johnson Medical School, New Brunswick, New Jersey Jersey Shore University Medical Center, Neptune, New Jersey University of Kentucky Medical School, Lexington, Kentucky Hartford Hospital, Hartford, Connecticut.
Abstract

Background: During implantable cardioverter defibrillator insertion, induced ventricular fibrillation followed by test shocks (defibrillation threshold testing [DFT]) is utilized to confirm effective device function. The effect of DFT on ventricular function is uncertain. Brain natriuretic peptide (BNP) is a marker of ventricular dysfunction and hemodynamic stress. We hypothesized that DFT causes increased BNP levels. Methods: BNP, creatine kinase, creatine kinase-MB (CK-MB), and troponin I (cTnI) were measured in 31 patients (mean age 71.4 years; 12 women) at preinsertion (T1), at 2-4 hours (T2), and at 8-12 hours (T3) after DFT. Biomarker levels were compared in patients receiving one shock (Group A) or two shocks (Group B). Results: After DFT all biomarkers increased above baseline levels but did not reach levels diagnostic for myocardial infarction. From T1 to T2, elevations in CK-MB and cTnI occurred in the highest proportion of patients (CK-MB 90% and cTnI 84%). From T1 to T3, elevation in BNP and cTnI were most prevalent (BNP 83% and cTnI 90%). Significant increases were measured in BNP levels from T1 to T3 (P = 0.0003), CK-MB levels from T1 to T2 (P < 0.0001), and cTnI levels from T1 to T2 (P < 0.0001) and from T1 to T3 (P < 0.0001). CK-MB levels did not increase significantly from T1 to T3 (P = 0.51). Conclusions: BNP levels rise progressively after DFT accompanied by early CK-MB increases and sustained increases in cTnI. These data suggest that DFT is associated with hemodynamic stress and left ventricular dysfunction, as evidenced by increases in BNP. (PACE 2011;1-6).

©2011, The Authors. Journal compilation ©2011 Wiley Periodicals, Inc.

[AlexAV]

Am Heart J. 2011 Aug;162(2):390-7. Epub 2011 Jul 7.
Defibrillation testing during implantable cardioverter-defibrillator implantation in Italian current practice: the Assessment of Long-term Induction clinical ValuE (ALIVE) project.
Stefano B, Pietro RR, Maurizio G, Maurizio L, Renato M, Maurizio L, Pietro R, Alessandro P, Gianluca B, Monica M, Sergio C, Massimo S.
Source

Fatebenefratelli Hospital, Rome, Italy. [Ссылки доступны только зарегистрированным пользователям ]
Abstract
BACKGROUND:

Clinical practice with regard to defibrillation threshold (DFT) testing during implantable cardioverter-defibrillator (ICD) implantation varies considerably, even among experienced implanting centers. International guidelines do not as yet mandate DFT testing.
OBJECTIVE:

The objective of this project is to assess current clinical decision making regarding DFT testing during ICD implantation.
METHODS:

The ALIVE project collected data on DFT testing from a multicenter network of Italian clinicians sharing a common system for the collection, management, analysis, and reporting of clinical and diagnostic data from patients with Medtronic (Minneapolis, MN) implantable devices.
RESULTS:

Data on 2,082 consecutive patients implanted with a Medtronic ICD in 111 Italian centers, over the period 2007 to 2010, were analyzed. Defibrillation threshold testing was performed in 33% of cases (678/2,082). The main reasons for performing the test were physician's clinical practice ("I always perform DFT") (80%) and secondary prevention implantation (12%). The main reasons for not performing DFT testing were centers' practice (44%), primary prevention (31%), and device replacement (15%). In 22 patients, ventricular fibrillation induction was not achieved; 656 patients completed DFT testing: 633 patients (96%) performed a single test, 19 patients (3%) performed a second induction test, and 4 patients (0.6%) underwent an additional induction test.
CONCLUSIONS:

The preliminary results of the ALIVE project show that a great number of implant procedures are performed without DFT testing in the common practice of the participating centers. We also measured an inhomogeneous, center-dependent DFT testing behavior, which suggests the importance of defining a common guideline for ICD implant testing. Follow-up data on our patients will provide more information on the clinical value of the test.

[AlexAV]

J Am Coll Cardiol. 2008 Aug 12;52(7):551-6.
No benefit from defibrillation threshold testing in the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial).
Blatt JA, Poole JE, Johnson GW, Callans DJ, Raitt MH, Reddy RK, Marchlinski FE, Yee R, Guarnieri T, Talajic M, Wilber DJ, Anderson J, Chung K, Wong WS, Mark DB, Lee KL, Bardy GH; SCD-HeFT Investigators.
Source
Department of Cardiology, University of Washington, Box 356422, 1959 NE Pacific Street, Seattle, Washington 98195, USA. [Ссылки доступны только зарегистрированным пользователям ]
Abstract
OBJECTIVES:
This study investigated whether defibrillation threshold (DFT) testing during implantable cardioverter-defibrillator (ICD) implantation predicts clinical outcomes.
BACKGROUND:
Defibrillation testing is often performed during insertion of ICDs to confirm shock efficacy. There are no prospective data to suggest that this procedure improves outcomes when modern ICDs are implanted for primary prevention of sudden death.
METHODS:
The analysis included the 811 patients who were randomized to the ICD arm of the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) and had the device implanted. The DFT testing protocol in SCD-HeFT was designed to limit shock testing in a primary prevention heart failure population.
RESULTS:
Baseline DFT data were available for 717 patients (88.4%). All 717 patients had a DFT of < or =30 J, the maximum output of the device in this study. The DFT was < or =20 J in 97.8% of patients. There was no survival difference between patients with a lower DFT (< or =10 J, n = 547) and a higher DFT (>10 J, n = 170) (p = 0.41). First shock efficacy was 83.0% for the first clinical ventricular tachyarrhythmia event; there were no differences in shock efficacies when the cohort was subdivided by baseline DFT.
CONCLUSIONS:
Low baseline DFTs were obtained in patients with stable, optimally treated heart failure during ICD implantation for primary prevention of sudden death. First shock efficacy for ventricular tachyarrhythmias was high regardless of baseline DFT testing results. Baseline DFT testing did not predict long-term mortality or shock efficacy in this study.

[dav1972]

Спасибо за ссылки! Одобрялка, к сожалению, не работает!

Теперь появилась уверенность, что мои действия (имплантация без DFT-теста) имеют довольно весомую обоснованность!

У больных с очень низкой фракцией меня еще сильно смущала потенциальная возможность тромбоэмболий.