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Schrittmacher- & ICD-Patienten im Herzsport
Dr. med. Stefan Steiner
Bad Nauheim 7.März 2015
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http://www.spiegel.de/sport/fussball/daniel-engelbrecht-profi-mit-defibrillator-bei-stuttgarter-kickers-a-1003242.html
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http://www.sport1.de/fussball/2-bundesliga/2015/01/sebastian-neumann-
vom-vfr-aalen-wird-defibrillator-eingesetzt
http://www.kicker.de/news/fussball/2bundesliga/startseite/619674/artikel_h
erz-op-aalens-neumann-kaempft-um-seine-karriere.html
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http://www.dfb.de/news/detail/meyer-ueber-defibrillatoren-im-
sport-einzelfall-sehr-genau-ueberpruefen-111052/
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Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators
Herzschr Elektrophys 2012 · 23:87–93
Lam
pert R
, Cannom
D, O
lshansky B
. Safe
ty of sports participation in patie
nts with
ICD
: a Surve
y of Heart R
hyth
m S
ociety M
embers.
J C
ardiovasc E
lectroph
ysiol (20
06
) 17:11–15
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Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators
Herzschr Elektrophys 2012 · 23:87–93
Lam
pert R
, Cannom
D, O
lshansky B
. Safe
ty of sports participation in patie
nts with
ICD
: a Surve
y of Heart R
hyth
m S
ociety M
em
bers.
J C
ardiovasc E
lectroph
ysiol (20
06
) 17:11–15
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Lampert R, Cannom D, Olshansky B. Safety of sports participation in patients with ICD: a Survey of Heart Rhythm Society Members.
J Cardiovasc Electrophysiol (2006) 17:11–15
Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators Herzschr Elektrophys 2012 · 23:87–93
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Vorgesehene Themen
Systeme/Systemwahl – Indikationen
Interventions-Frequenzen
Implantation & Zugang
Prinzipielle „Probleme“
Vorsichts-Maßnahmen für Tasche/Elektrode
Guidelines
Aktuelle Empfehlungen – „diskutiert“
Notfälle
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Was wofür?
Normaler Herzrhythmus
nix!
Schrittmacher
Ventrikuläre Tachyarrhythmie
Bradykardie
ICD
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Schrittmacher (SM)
Implantierbarer Cardioverter/Defibrillator
(ICD)
3 - Kammer -ICD = „CRT-D″
(Rechtes Atriumund beide Ventrikel)
1 - Kammer -ICD (Rechter Ventrikel)
3 - Kammer -SM = „CRT-P″
(Rechtes Atrium und beide Ventrikel)
1 - Kammer - SM (Rechtes Atrium oder Ventrikel)
2 - Kammer – ICD (Rechtes Vorhof und Ventrikel)
2 - Kammer – SM (Rechtes Atrium und Ventrikel)
S-ICD (subcutan)
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Schrittmacher - Indikation?
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Schrittmacher - Indikation?
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Sick - Sinus - Syndrom SM - Indikationen
I
Eindeutiger Zusammenhang mit der Symptomatik und:
- Sinusknotenfunktionsstörung mit HF < 40/min oder Pausen >3 / 4s
- Chronotrope Inkompetenz [C]
IIa Vermuteter Zusammenhang der
Symptomatik mit einer Sinusknotenfunktionsstörung [C]
IIb HF < 40/min oder Pausen >3 / 4s und EF↓ [C]
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Erworbener AV- Block Klasse I - SM - Indikationen
Klasse Symptomatisch Asymptomatisch
I AV-Block III.°
[C]
AV-Block II.° [B]
perm. AV-Block III.° [C]
Häufiger AV-Block III.° [B]
Häufiger AV-Block II.°, Typ Mobitz & breite QRS [B]
AV-Knoten-Ablation [C]
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Indikation ICD Synkope
Dokumentierte VT oder Induzierbare VT & EF <40% (ESC!)
I A
Überlebtes Kammerflimmern/VT ohne reversible Ursache
I A
Chron. Myokardinfarkt (>40d) NYHA II-III, EF 35%
I A
DCM, optimale Medikation NYHA II-III, EF 35%
I B
Chron. Myokardinfarkt (>40d) asymptomatisch, EF 30%
I B
DCM, optimale Medikation asymptomatisch, EF 35% >9mon
I
B
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3 - Kammer - Stimulation „Kardiale Resynchronisationstherapie“ (CRT)
Schrittmacher- Stimulation bei ungenügender Wirkung der optimalen, maximalen
medikamentösen Therapie der
Herzinsuffizienz
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3 - Kammer - Stimulation „Kardiale Resynchronisationstherapie“ (CRT)
Schrittmacher- Stimulation bei ungenügender Wirkung der optimalen, maximalen
medikamentösen Therapie der
Herzinsuffizienz
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Kardiale Dys-Synchronie
Atrio- ventrikulär
Inter- ventrikulär
Intra- ventrikulär
Cazeau, et al. PACE 2003; 26[Pt. II]: 137–143
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Indikation CRT - 1-
NYHA III/IV SR, EF 35%, QRS 120ms Optimale med. Therapie
I A
NYHA II SR, EF 35%, QRS 150ms Optimale med. Therapie
I A
NYHA III/IV AF, EF 35%, QRS 130ms AV-Knoten-Ablation
IIa B
NYHA III/IV AF, EF 35%, QRS 130ms BAA SM-Abhängigkeit
IIa
C
Cave: Lebenserwartung, NYHA IV-Pat. „should be ambulatory“ , LSB höchste Evidenz
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Indikation CRT 2-
Klasse-I-Schrittmacher-Indikation
NYHA III/IV EF 35%, QRS 120ms
I B
NYHA III/IV EF 35%, QRS <120ms
IIa B
NYHA II EF 35%, QRS <120ms
IIa
C
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Welche Stimulations - Frequenz ?
- „Starr-frequent“
(Inhibierung durch Eigenrhythmus)
- Messung der Sinus-knoten-Frequenz
- Frequenzanpassung (Rate - Response)
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Stimulations-Frequenz bei AV-Block Der Sinusknoten ist die beste rate-response
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PMT
?
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Vorhofflimmer-Risiko bei/durch Sport
F. Bisbal · L. Mont: Arrhythmias in the athlete Herzschr Elektrophys 2012 · 23:76–81 DOI 10.1007/s00399-012-0182-1
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„Routine-Kontrolle“ Aktuell stationärer Aufenthalt wegen
kardialer Dekompensation
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Geschafft – AMS!
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Oversense durch Muskelpotenziale
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Therapie-Möglichkeiten eines ICD Antibradykarde
Therapie
„Schrittmacher“
Schock
ATP = Überstimulation
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Überstimulation (Overdrive, ATP)
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Überstimulation (Overdrive, ATP)
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Elektroden-Anlage V. subclavia/ceph.(/jug.) rechtes Atrium
Ventrikel
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V. subclavia
V. cephalica
V. jugularis
epikardial
sc. getunnelt
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J. Kuschyk, M. Borggrefe : Herzschrittmachertherapie + Elektrophysiologie 2011/1: 21-26
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Wie werden Elektroden fixiert? „Passiv“ z. B. Anker
„Aktiv“ z.B. Schraube
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Aus:
Subclavian Crush
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Elektroden - Defekte
Maisel WH, Kramer DB. Implantable cardioverter-defibrillator lead performance. Circulation. 2008; 117:2721. doi: 10.1161/CIRCULATIONAHA.108.776807.
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S-ICD
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Therapie-Möglichkeiten eines S-ICD Antibradykarde
Therapie
„Schrittmacher“
Schock
ATP = Überstimulation
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Kontakt-Sportarten
•
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http://www.stuttgarter-nachrichten.de/inhalt.kickers-spieler-engelbrecht-mein-defibrillator-ist-mein-schutzengel.97d787a6-99a1-4a20-b936-eb9f37c826c6.html
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http://www.faz.net/aktuell/sport/fussball/bundesliga-nachwuchs-
fussballprofi-mit-defibrillator-13349130.html#aufmacherOverl
ay
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Probleme bei/durch Sport für ICD-Patienten – eminence-based
1. 2,5-faches Risiko bez. SCD für gefährdete Patienten Katecholamine , Azidose, Dehydratation, Ischämie, E´lyt-Verschiebungen
2. Gefahr durch Synkope 3. Verschlechterung der DFT/Schock-Effektifität 4. Verschlechterung der Grunderkrankung durch Sport
(ARVCM - DCM) 5. Elektroden-/Aggregat-/Taschen-Problem durch
exzessive Armbewegungen, Traumata 6. Inadäquate Schocks ggf. mit Induktion von VT/ VF
ST, T-Wave-Double-Count, Noise (Elektrodenbruch, ZF, Header, EMI)
Frei nach: Hein Heidbuchel, Francois Carre´: Exercise and competitive sports in patients with an implantable cardioverter-defibrillator
European Heart Journal doi:10.1093/eurheartj/ehu130
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Bethesda
36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities Barry J. Maron, Douglas P. Zipes; Journal of the American College of Cardiology Vol. 45, No. 8, 2005
??
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Lampert R, Cannom D, Olshansky B. Safety of sports participation in patients with ICD: a Survey of Heart Rhythm Society Members.
J Cardiovasc Electrophysiol (2006) 17:11–15
Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators Herzschr Elektrophys 2012 · 23:87–93
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Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators
Herzschr Elektrophys 2012 · 23:87–93
Lam
pert R
, Cannom
D, O
lshansky B
. Safe
ty of sports participation in patie
nts with
ICD
: a Surve
y of Heart R
hyth
m S
ociety M
em
bers.
J C
ardiovasc E
lectroph
ysiol (20
06
) 17:11–15
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Aus: R. Lampert,· B. Olshansky: Sports participation in patients with implantable cardioverter–defibrillators
Herzschr Elektrophys 2012 · 23:87–93
Lam
pert R
, Cannom
D, O
lshansky B
. Safe
ty of sports participation in patie
nts with
ICD
: a Surve
y of Heart R
hyth
m S
ociety M
embers.
J C
ardiovasc E
lectroph
ysiol (20
06
) 17:11–15
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Rachel Lampert, MD; Brian Olshansky et al:
Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators
Results of a Prospective, Multinational Registry, Circulation 2013;127:2021-2030
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Lead survival based on time since lead implantation
Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-DefibrillatorsClinical Perspective
Circulation. 2013;127:2021-2030
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Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-DefibrillatorsClinical Perspective
Circulation. 2013;127:2021-2030
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Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-DefibrillatorsClinical Perspective
Circulation. 2013;127:2021-2030
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Lampert R et al. Safety of Sports for Athletes With Implantable Cardioverter-DefibrillatorsClinical Perspective
Circulation. 2013;127:2021-2030
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Anforderungen an die Programmierung bei Sportlern
• SM-Sensing bipolar (Myopotenziale) • Grund-Erkrankung? Grund-Arrhythmie (TAA - Sensortyp des SM)?:
– Herzgesund: Max. Sensor-Frequenz , obere Grenz-Frequenz
– CHF, KHK: Max. Sensor-Frequenz , obere Grenz-Frequenz
– CRT: Max. Sensor-Frequenz , obere Grenz-Frequenz
• Vermeidung inadäquater Schocks (TAA)
Erkennungs-Frequenz , Erkennungs-Dauer
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VVI bei Sinusrhythmus Optimale Systemwahl?
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Schön: AAI ! - oder?
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DDD! Schlecht - oder?
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Schön: AAI ! - oder?
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Schön: DDD ! - oder?
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Empfehlung zu Sportarten unabhängig von der Grunderkrankung
Nach:
C.W.Israel: Sport bei Schrittmacherpatienten
Herzschritt Elektophys 2012; 23:94-106
Kontraindiziert: Mögliche EMI
Todesfolge bei Bewusstlosigkeit
denkbar: Segelflug, Drachensegeln, Fliegen
Motorsport Tauchen
Bergsteigen, free climbing
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Empfehlung zu Sportarten unabhängig von der Grunderkrankung
Nach:
C.W.Israel: Sport bei Schrittmacherpatienten
Herzschritt Elektophys 2012; 23:94-106
Abzuraten:
• Kampf-Sportarten • Kontakt-/Ball-Sportarten mit Thorax-Schlägen: Rugby, Eishockey, Abfahrt-Ski, Squash, Tennis • Tauchen > 10 m Tiefe • Höhenaufenthalt > 7000 m • Gewichtheben •bei ipislat. Implantat:
(Tisch-)Tennis, Badminton, Speer-, Diskus-, Hammer- Werfen, Kugelstoßen, Bogenschießen, Schießen, Hockey, Billard, Golf, Kegeln, Kricket
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Empfehlung zu Sportarten unabhängig von der Grunderkrankung
Nach:
C.W.Israel: Sport bei Schrittmacherpatienten
Herzschritt Elektophys 2012; 23:94-106
Weniger empfehlenswert: Fußball, Handball, Basketball
Volleyball, Baseball
Empfehlenswert: Wandern, Walking, Joggen,
Langlauf, Mittelstreckenlauf Schwimmen
Ballett, Tanzen, Gymnastik Ski-Langlauf, Radfahren
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Notfälle
Immer vorrangig: Den Patienten schützen !
Sturz verhindern Verletzungen vermeiden Keine Angst vor Schocks
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Andere ICB, LAE, Aortensyndrome
Notfälle (???)
Bewusstloser Patient -auch in Ruhe-
System-Problem Asystolie
Kammerflimmern
Electrical Storming Therapien aufgebraucht?
Überhaupt ICD-Träger?
Klassische CPR - aber:
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Defibrillation - CPR
http://www.reanimation-online.de/inhalt/defi.htm
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Inadäquat technisch Elektrodenproblem
Notfälle (???)
Schock +/- Synkope
Inadäquat medizinisch TAA, ST
Adäquate VT/VF-Therapie
Stationäre Abklärung
Magnet ?
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Intermitt. Exitblock Elektrodenproblem
Notfälle (???)
Bewusstloser Patient -in Ruhe wieder ansprechbar-
Oversense Muskelpotenziale
Adäquate VT/VF-Therapie
Abklärung
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Exitblock Elektrodenproblem
Notfälle (???)
Patient ansprechbar- Symptomatisch auch in Ruhe
Laufende VT Therapien aufgebraucht
Systemproblem
Klassische Erste Hilfe Stationäre Abklärung
Andere
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Intermitt. Exitblock Elektrodenproblem
Notfälle (???)
Patient ansprechbar- Symptomatisch nur unter Belastung
Oversense Muskelpotenziale
Hämodynamische Probleme Programmierung/Systemwahl
Abklärung
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Und die Moral von der Geschicht, …
• Bitte Pat. mit implantiertem Aggregat behandeln wie einen Pat. ohne –zunächst, … • CPR einleiten ohne zu zögern (keine Angst vor internen
Schocks!!!!)
• Pat. vor Verletzungen schützen
• Bei erforderlicher externer Defibrillation möglichst Patches anterior-posterior kleben
• Großzügig Magnet nutzen!! Monitoring!!!
• Piepsen/Vibrationen/Erhitzung/Zucken bis zum Beweis des Gegenteils ernst nehmen
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„Sollten Ihnen meine Aussagen klar sein,
dann müssen Sie mich missverstanden
haben.“ Alan Greenspan (geb. 06.03.1926)
– ehem. US-Notenbankchef