DDD is STILL better than VVI

Transkript

1 DDD is STILL better than VVI 가톨릭의대 노태호

2 VVI(R) 의장점 하나의 lead 시술이용이 시술관련문제발생이적고 가격이저렴, 긴수명 운동시심박출량증가효과가우수 그러나문제는 - absent AV synchrony

3 AV synchrony blood pressure Wu RC and Reynolds DW from Cardiac Pacing. 2005

4 AV synchrony blood pressure Wu RC and Reynolds DW from Cardiac Pacing. 2005

5 AV synchrony cardiac output Wu RC and Reynolds DW from Cardiac Pacing. 2005

6 AV synchrony PCWP Wu RC and Reynolds DW from Cardiac Pacing. 2005

7 A vs V pacing for SSS Andersen HR et al. Lancet 1997;350:1210 freedom from AF

8 CTOPP Connoly SJ et al. N Engl J Med 2000;342:1385 Canadian Trial of Physiologic Pacing cumulative risk of AF

9 MOST Lamas GA et al. N Engl J Med 2002;346:1854 Mode Selection Trial in Sinus-Node Dysfunction

10 A vs V pacing for SSS Andersen HR et al. Lancet 1997;350:1210 overall survival survival from CV death

11 Physiologic pacing 은 VVI 에비해상대적으로 심방세동을예방하고 심부전의발생을감소시키고 CV death 와 total mortality 를감소시킨다.

12 PASE Lamas GA et al. N Engl J Med 1998;338:1079 Pacemaker Selection in the Elderly

13 CTOPP Connoly SJ et al. N Engl J Med 2000;342:1385 Canadian Trial of Physiologic Pacing (n= cumulative risk of stroke or death n= )

14 MOST Lamas GA et al. N Engl J Med 2002;346:1854 Mode Selection Trial in Sinus-Node Dysfunction (n= primary end point: death, non-fatal stroke n= )

15 Physiologic pacing 은 VVI 에비해상대적으로 심방세동의발생을줄이고심부전의발생도약간감소시키는것같지만 CV death 와 total mortality 를감소시키지는못한다.

16 결국, physiologic pacing 은 VVI 의여러장점을고려할때 ( 운동시 CO 증진효과, 간편성, 비용 ) 큰장점도없이과장되어있다.

17 Generators Implanted in Korea 노태호 No of Replacement No of New Implant

18 최근 5 년간한국의 Mode Mix, total % 노태호 year year year year VVI VVI VVI VVI VVIR VVIR VVIR VVIR AAI AAI AAI AAI AAIR AAIR AAIR AAIR VDD VDD VDD VDD DDDRP DDDRP DDDRP DDDRP DDDR DDDR DDDR DDDR DDD DDD DDD DDD TYPE/NO TYPE/NO TYPE/NO TYPE/NO

19 2004 년한국의 Mode Mix 노태호 2005 VVI 24% DDDRP 0% DDDR 14% VVIR 9% AAI 2% AAIR 1% VDD 13% DDD 37%

20 최근 5 년간한국의 Implanting Institutions. 노태호 No of Hosp

21 정말 DDD 가 VVI 보다우수한가?

22 DDD 의생리학적우수성은분명한데 그러면무엇이문제인가?

23 DAVID Wilkoff BL et al. JAMA 2002;288(24):3115 Dual Chamber And VVI Implantable Defibrillator trial Cumulative Probability No. at Risk DDDR VVI Death or First Hospitalization for New or Worsened CHF Dual-Chamber Rate-Responsive Pacing (DDDR) Ventricular Backup Pacing (VVI) Relative Hazard (95% CI), 1.61 ( ) Time, mo

24 MOST substudy Sweeney MO et al. Circulation 2003;107:2932 DDDR VVIR

25 문제가 physiologic pacing 에있나, 아니면 ventricular pacing 에있나? V pacing is a SIDE EFFECT of dual chamber pacing! Managed Ventricular Pacing (MVP) 의출현

26 Atrial Based MVP: A New Algorithm Marquis MVP Download Study (n=181) EnRhythm Clinical Study (n=129) With MVP ON: -Median %VP = 0.1% -Mean %VP = 4.1% -Median relative reduction of VP = 99.9% Sweeney MO et al. J Cardiovasc Electrophysiol 2005;16:1 With MVP ON: -Median %VP = 0.5% -Mean %VP = 8.4% Gillis AM et al. PACE 2006;29:697

27 MVP Mode vs. Traditional Modes DAVID Trial 3 DDDR Mode DAVID Trial 3 VVI Mode GEM III DR Feasibility Study 4 (MVP Mode) Marquis DR MVP Download Study 1 EnRhythm DR Clinical Study 2 Cum %AP 59.3% + 1.5% % 48.7% Not available* Cum %VP 58.9% 3.5% 3.8% 4.1% 8.4% 1 Sweeney MO J Cardiovasc Electrophysiol 2005;16:1 2 Gillis AM et al. PACE 2006;29:697 3 Wilkoff B, et al. on behalf of the DAVID Trial Investigators. JAMA. 2002;288: Sweeney M, et al. GEM III Download Study. PACE 2003;Vol 26(Pt. II):973, Abstract ID #179

28 DDD 는항상 AV synchrony 인가? Interatrial conduction delay Israel CW, Europace 2006;8: 89

29 LA activation to V pacing in DDD Israel CW, Europace 2006;8: 89 LA-EGM: trans-esophageal left-atrial electrogram DDD with short AV interval cannot make AV synchrony

30 요약하면 DDD(R) 이훨씬 physiologic 하다 DDD(R) 이훨씬많이선택되고있다 DDD(R) 은심방세동의발생을억제한다

31 요약하면 중풍과사망에관한견해는일치하지않는다 이유는현재의 DDD(R) 이완전히 physiologic 하지못하기때문이다 우리는이를알고있고개선이가능하다

32 결론적으로 Ideal physiologic pacing system proper sequence of A & V contraction physiologic rate modulation 심방심실의 2 lead 로는구현가능하나 심실내의 single lead 로는이것이불가능하다

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