This invention pertains to apparatus and methods for treating cardiac arrhythmias and improving cardiac function.
Tachyarrhythmias are abnormal heart rhythms characterized by a rapid heart rate. Examples of ventricular tachyarrhythmias include ventricular tachycardia (VT) and ventricular fibrillation (VF). Both ventricular tachycardia and ventricular fibrillation can be hemodynamically compromising, and both can be life-threatening. Ventricular fibrillation, however, causes circulatory arrest within seconds and is the most common cause of sudden cardiac death. Cardioversion (an electrical shock delivered to the heart synchronously with an intrinsic depolarization) and defibrillation (an electrical shock delivered without such synchronization) can be used to terminate most tachyarrhythmias, including VT and VF. As used herein, the term defibrillation and cardioversion should be taken to mean an electrical shock delivered either synchronously or not in order to terminate a fibrillation. In electrical defibrillation, a current depolarizes a critical mass of myocardial cells so that the remaining myocardial cells are not sufficient to sustain the fibrillation.
Implantable cardioverter/defibrillators (ICDs) provide electro-therapy by delivering a shock pulse to the heart when fibrillation is detected by the device. The ICD is a computerized device containing a pulse generator that is usually implanted into the chest or abdominal wall. Electrodes connected by leads to the ICD are placed on the heart, or passed transvenously into the heart, to sense cardiac activity and to conduct the impulses from the shock pulse generator. The device delivers a defibrillation shock pulse to the heart in response to a detected tachyarrhythmia by impressing a voltage between shock electrodes in contact with the heart.
The present invention relates to an apparatus and method for preventing post-shock hypotension after termination of ventricular fibrillation. The invention may be incorporated in an ICD or an external defibrillation device. Post-shock cardiac function is improved by delivering a series of electrical stimulation pulses prior to a defibrillation shock while the heart is in fibrillation. In order to avoid delaying an initial defibrillation shock, such pre-shock stimulation therapy is only applied after one or more failed defibrillation attempts, according to the duration of the tachyarrhythmia, or according to the energy level of the defibrillation shock.
It has been found that transient hypotension often occurs following defibrillation shocks. This hypotension may last for seconds, minutes, or even hours and can result in post-shock fatigue in some patients. Some evidence suggests that the likelihood of post-shock hypotension is related to the duration of the fibrillation, and that arterial pressure will quickly return to normal if successful cardioversion occurs within approximately thirty seconds in most patients. Patients who remain in VF for a longer period of time, especially after repeated defibrillation attempts, are more likely to experience transient hypotension after successful cardioversion.
In order to improve post-shock cardiac function, and in some cases increase the likelihood of successful cardioversion, a series of electrical stimulation pulses can be delivered prior to the defibrillation shock. By way of example but not by way of limitation, such pulses may be delivered as a pulse train at a frequency range between 10 and 100 Hz, at an amplitude between 15 and 200 volts, and for a duration of between 100 milliseconds and 2 seconds. Delivering such stimulation pulses while the heart is in fibrillation allows the pulses to be delivered without regard to the intrinsic heart rhythm. Since a patient in VF is in circulatory arrest, however, it is normally considered desirable to delivery defibrillation therapy as soon as possible. In accordance with the present invention, therefore, a series of stimulation pulses are delivered during VF and before a defibrillation shock only after an initial defibrillation shock has failed to cardiovert the patient. In other embodiments, decision algorithms may use additional criteria before delivering pre-shock stimulation therapy such as the duration of the VF, the number of failed defibrillation attempts, and the energy level of defibrillation shock in cases where shocks of increasing magnitude are delivered. By invoking pre-shock stimulation therapy in only these situations, no delay of initial therapy occurs, and the therapy is applied only when it is needed most.
1. Hardware Platform
The present invention may be incorporated into either an external defibrillator or an ICD. The description that follows, however, will principally refer to an ICD configured and programmed to carry out the method of delivering pre-shock stimulation therapy described above. Cardiac rhythm management devices such as ICDs are typically implanted subcutaneously on a patient's chest and have leads threaded intravenously into the heart to connect the device to electrodes used for sensing and delivery of defibrillation shocks. A programmable electronic controller causes defibrillation shocks to be delivered when an arrhythmia is detected. The controller also controls the output of pacing pulses in the case of an ICD with pacemaker functionality. The present invention may be incorporated into an ICD or incorporated into an external defibrillation device. For illustrative purposes, however, a block diagram of an implantable device with cardioversion/defibrillation capability is shown in
The device has a sensing channel for sensing cardiac electrical activity and a stimulation channel for delivering stimulation pulses. The device would normally be implanted such that the ventricles are sensed and stimulated by the respective channels. Each channel in this embodiment utilizes a single lead connected to the device that includes a ring electrode 43a and tip electrode 43b for bipolar sensing and stimulation. In certain embodiments, the device may incorporate a pacemaker functionality in which case the stimulation channel may also be used for delivering paces to the heart in accordance with a pacing algorithm. A MOS switching network 70 controlled by the microprocessor is used to switch the electrodes to the input of a sense amplifier 41 for the sensing channel or to the output of a pulse generator 42 for the stimulation channel. The switching network may also be used to connect only one of either the ring or tip electrode to the pulse generator 42 or sensing amplifier 41 for unipolar sensing or stimulation, in which case the conductive case of the device or can 60 is used as the other electrode. A channel interface 40 which communicates bidirectionally with a port of microprocessor 10 may include an analog-to-digital converter for digitizing sensing signal inputs from the sensing amplifier, registers that can be written to for adjusting the gain and threshold values of the sensing amplifier, and registers for controlling the output of stimulation pulses and/or changing the stimulation pulse amplitude or frequency. A defibrillation shock pulse generator 50 with shock leads 50a and 50b for delivering cardioversion/defibrillation shocks to the ventricles is also interfaced to the controller. In an alternative embodiment, the stimulation channel may use the shock leads rather than the sensing lead for delivering stimulation pulses.
The microprocessor 10 controls the overall operation of the device in accordance with programmed instructions stored in memory. The sensing channel detects a chamber sense, either an atrial sense or ventricular sense, when an electrogram signal (i.e., a voltage sensed by an electrode representing cardiac electrical activity) generated by the channel exceeds a specified detection threshold. The time intervals between such senses are measured in order to detect tachyarrhythmias so that appropriate therapy can be delivered by the device. Upon detection of a tachyarrhythmia warranting intervention (e.g., ventricular fibrillation), the controller causes the delivery of a shock pulse to the heart. As described below with reference to different embodiments, the controller is also programmed to deliver pre-shock stimulation pulses via the stimulation channel when certain criteria are met.
2. Exemplary Decision Algorithms
In an alternative embodiment, once the controller 10 detects a tachyarrhythmia warranting intervention, a command may also be issued to the drug delivery interface 330. The drug delivery interface then actuates a drug delivery apparatus 331 incorporated into the device that delivers a quantity of a pharmacological or neurohumoral agent for improving post-shock cardiac function. (e.g., epinephrine or norepinephrine). The drug delivery apparatus may take a number of forms. One example of such an apparatus is a pump and a drug reservoir located within a header portion of the device, where the pump communicates with an intravenously disposed catheter. The drug delivery interface within the housing communicates with the pump by control wires that pass into the header through a feedthrough. Upon actuation by the drug delivery interface 330, the pump pumps a quantity of drug from a reservoir into the lumen of the catheter.
Although the invention has been described in conjunction with the foregoing specific embodiment, many alternatives, variations, and modifications will be apparent to those of ordinary skill in the art. Such alternatives, variations, and modifications are intended to fall within the scope of the following appended claims.
Number | Name | Date | Kind |
---|---|---|---|
3692027 | Ellinwood, Jr. | Sep 1972 | A |
4003379 | Ellinwood, Jr. | Jan 1977 | A |
4146029 | Ellinwood, Jr. | Mar 1979 | A |
4271192 | Wurtman et al. | Jun 1981 | A |
4281664 | Duggan | Aug 1981 | A |
4299220 | Dorman | Nov 1981 | A |
4417038 | Vogel et al. | Nov 1983 | A |
4470987 | Wurtman et al. | Sep 1984 | A |
4544371 | Dormandy, Jr. et al. | Oct 1985 | A |
4556063 | Thompson et al. | Dec 1985 | A |
4559946 | Mower | Dec 1985 | A |
4651716 | Forester et al. | Mar 1987 | A |
4674518 | Salo | Jun 1987 | A |
4686987 | Salo et al. | Aug 1987 | A |
4693253 | Adams | Sep 1987 | A |
4871351 | Feingold | Oct 1989 | A |
4880005 | Pless et al. | Nov 1989 | A |
4897987 | Spalla | Feb 1990 | A |
4904472 | Belardinelli et al. | Feb 1990 | A |
4924875 | Chamoun | May 1990 | A |
4944299 | Silvian | Jul 1990 | A |
4980379 | Belardinelli et al. | Dec 1990 | A |
4987897 | Funke | Jan 1991 | A |
5002052 | Haluska | Mar 1991 | A |
5014698 | Cohen | May 1991 | A |
5040533 | Fearnot | Aug 1991 | A |
5041107 | Heil, Jr. | Aug 1991 | A |
5042497 | Shapland | Aug 1991 | A |
5058581 | Silvian | Oct 1991 | A |
5087243 | Avitall | Feb 1992 | A |
5113869 | Nappholz et al. | May 1992 | A |
5127404 | Wyborny et al. | Jul 1992 | A |
5137019 | Pederson et al. | Aug 1992 | A |
5190035 | Salo et al. | Mar 1993 | A |
5215083 | Drane et al. | Jun 1993 | A |
5220917 | Cammilli et al. | Jun 1993 | A |
5269301 | Cohen | Dec 1993 | A |
5282836 | Kreyenhagen et al. | Feb 1994 | A |
5284136 | Hauck et al. | Feb 1994 | A |
5305745 | Zacouto | Apr 1994 | A |
5330505 | Cohen | Jul 1994 | A |
5334222 | Salo et al. | Aug 1994 | A |
5342408 | deCoriolis et al. | Aug 1994 | A |
5353800 | Pohndorf et al. | Oct 1994 | A |
5354317 | Alt | Oct 1994 | A |
5366485 | Kroll et al. | Nov 1994 | A |
5368028 | Palti | Nov 1994 | A |
5391190 | Pederson et al. | Feb 1995 | A |
5404877 | Nolan et al. | Apr 1995 | A |
5405362 | Kramer et al. | Apr 1995 | A |
5416695 | Stutman et al. | May 1995 | A |
5417717 | Salo et al. | May 1995 | A |
5431682 | Hedberg | Jul 1995 | A |
5441525 | Shelton et al. | Aug 1995 | A |
5456692 | Smith, Jr. et al. | Oct 1995 | A |
5460605 | Tuttle et al. | Oct 1995 | A |
5464434 | Alt | Nov 1995 | A |
5487752 | Salo et al. | Jan 1996 | A |
5496360 | Hoffmann et al. | Mar 1996 | A |
5499971 | Shapland et al. | Mar 1996 | A |
5501701 | Markowitz et al. | Mar 1996 | A |
5540728 | Shelton et al. | Jul 1996 | A |
5551953 | Lattin et al. | Sep 1996 | A |
5556421 | Prutchi et al. | Sep 1996 | A |
5562711 | Yerich et al. | Oct 1996 | A |
5562713 | Silvian | Oct 1996 | A |
5579876 | Adrian et al. | Dec 1996 | A |
5584868 | Salo et al. | Dec 1996 | A |
5586556 | Spivey et al. | Dec 1996 | A |
5603331 | Heemels et al. | Feb 1997 | A |
5607418 | Arzbaecher | Mar 1997 | A |
5607463 | Schwartz et al. | Mar 1997 | A |
5634899 | Shapland et al. | Jun 1997 | A |
5662689 | Elsberry et al. | Sep 1997 | A |
5676686 | Jensen et al. | Oct 1997 | A |
5690682 | Buscemi et al. | Nov 1997 | A |
5690683 | Haefner et al. | Nov 1997 | A |
5693075 | Plicchi et al. | Dec 1997 | A |
5703125 | Bovy et al. | Dec 1997 | A |
5706829 | Kadri | Jan 1998 | A |
5720770 | Nappholz et al. | Feb 1998 | A |
5725561 | Stroebel et al. | Mar 1998 | A |
5725562 | Sheldon | Mar 1998 | A |
5730125 | Prutchi et al. | Mar 1998 | A |
5749900 | Schroeppel et al. | May 1998 | A |
5782879 | Rosborough et al. | Jul 1998 | A |
5800464 | Kieval | Sep 1998 | A |
5800498 | Obino et al. | Sep 1998 | A |
5814089 | Stokes et al. | Sep 1998 | A |
5817131 | Elsberry et al. | Oct 1998 | A |
5833603 | Kovacs et al. | Nov 1998 | A |
5836935 | Ashton et al. | Nov 1998 | A |
5851220 | Murphy | Dec 1998 | A |
5874420 | Pelleg | Feb 1999 | A |
5876353 | Riff | Mar 1999 | A |
5893881 | Elsberry et al. | Apr 1999 | A |
5899928 | Sholder et al. | May 1999 | A |
5913879 | Ferek-Petric et al. | Jun 1999 | A |
5919210 | Lurie et al. | Jul 1999 | A |
5925066 | Kroll et al. | Jul 1999 | A |
5949659 | Lesche | Sep 1999 | A |
5954761 | Macheck et al. | Sep 1999 | A |
5957861 | Combs et al. | Sep 1999 | A |
5957957 | Sheldon | Sep 1999 | A |
5967986 | Cimochowski et al. | Oct 1999 | A |
5978705 | KenKnight et al. | Nov 1999 | A |
5991668 | Leinders et al. | Nov 1999 | A |
6016443 | Ekwall et al. | Jan 2000 | A |
6016447 | Juran et al. | Jan 2000 | A |
6016448 | Busacker et al. | Jan 2000 | A |
6022322 | Prutchi | Feb 2000 | A |
6035233 | Schroeppel et al. | Mar 2000 | A |
6044297 | Sheldon et al. | Mar 2000 | A |
6049735 | Hartley et al. | Apr 2000 | A |
6070590 | Hoffmann | Jun 2000 | A |
6076015 | Hartley et al. | Jun 2000 | A |
6078834 | Lurie et al. | Jun 2000 | A |
6104949 | Pitts Crick et al. | Aug 2000 | A |
6112116 | Fischell et al. | Aug 2000 | A |
6115636 | Ryan | Sep 2000 | A |
6128526 | Stadler et al. | Oct 2000 | A |
6140740 | Porat et al. | Oct 2000 | A |
6141588 | Cox et al. | Oct 2000 | A |
6154672 | Pendekanti et al. | Nov 2000 | A |
6154675 | Juran et al. | Nov 2000 | A |
6155267 | Nelson | Dec 2000 | A |
6161042 | Hartley et al. | Dec 2000 | A |
6168801 | Heil, Jr. et al. | Jan 2001 | B1 |
6198394 | Jacobsen et al. | Mar 2001 | B1 |
6200265 | Walsh et al. | Mar 2001 | B1 |
6203495 | Bardy | Mar 2001 | B1 |
6206914 | Soykan et al. | Mar 2001 | B1 |
6213942 | Flach et al. | Apr 2001 | B1 |
6221011 | Bardy | Apr 2001 | B1 |
6231516 | Keilman et al. | May 2001 | B1 |
6237398 | Porat et al. | May 2001 | B1 |
6253108 | Rosborough et al. | Jun 2001 | B1 |
6254573 | Haim et al. | Jul 2001 | B1 |
6256233 | Glass | Jul 2001 | B1 |
6259949 | Rosborough et al. | Jul 2001 | B1 |
6261230 | Bardy | Jul 2001 | B1 |
6263241 | Rosborough et al. | Jul 2001 | B1 |
6264606 | Ekwall et al. | Jul 2001 | B1 |
6266563 | KenKnight et al. | Jul 2001 | B1 |
6270457 | Bardy | Aug 2001 | B1 |
6272377 | Sweeney et al. | Aug 2001 | B1 |
6273377 | Sweeney et al. | Aug 2001 | B1 |
6277072 | Bardy | Aug 2001 | B1 |
6277078 | Porat et al. | Aug 2001 | B1 |
6278894 | Salo et al. | Aug 2001 | B1 |
6280380 | Bardy | Aug 2001 | B1 |
6285898 | Ben-Haim | Sep 2001 | B1 |
6298267 | Rosborough et al. | Oct 2001 | B1 |
6298272 | Peterfeso et al. | Oct 2001 | B1 |
6309370 | Haim et al. | Oct 2001 | B1 |
6312378 | Bardy | Nov 2001 | B1 |
6317615 | KenKnight et al. | Nov 2001 | B1 |
6317631 | Ben-Haim et al. | Nov 2001 | B1 |
6331160 | Bardy | Dec 2001 | B1 |
6336903 | Bardy | Jan 2002 | B1 |
6358202 | Arent | Mar 2002 | B1 |
6358203 | Bardy | Mar 2002 | B1 |
6361522 | Scheiner et al. | Mar 2002 | B1 |
6361780 | Ley et al. | Mar 2002 | B1 |
6368284 | Bardy | Apr 2002 | B1 |
6370424 | Prutchi | Apr 2002 | B1 |
6398728 | Bardy | Jun 2002 | B1 |
6411840 | Bardy | Jun 2002 | B1 |
6411844 | Kroll et al. | Jun 2002 | B1 |
6424847 | Mastrototaro et al. | Jul 2002 | B1 |
6440066 | Bardy | Aug 2002 | B1 |
6442413 | Silver | Aug 2002 | B1 |
6443949 | Altman | Sep 2002 | B1 |
6453195 | Thompson | Sep 2002 | B1 |
6459917 | Gowda et al. | Oct 2002 | B1 |
6459929 | Hopper et al. | Oct 2002 | B1 |
6468263 | Fischell et al. | Oct 2002 | B1 |
6473640 | Erlebacher | Oct 2002 | B1 |
6478737 | Bardy | Nov 2002 | B1 |
6501983 | Natarajan et al. | Dec 2002 | B1 |
6511477 | Altman et al. | Jan 2003 | B1 |
6518245 | Anderson et al. | Feb 2003 | B1 |
6519488 | KenKnight et al. | Feb 2003 | B1 |
6556865 | Walcott et al. | Apr 2003 | B1 |
6689117 | Sweeney et al. | Feb 2004 | B1 |
6760621 | Walcott et al. | Jul 2004 | B1 |
6813516 | Ujhelyi et al. | Nov 2004 | B1 |
6892094 | Ousdigian et al. | May 2005 | B1 |
20010000802 | Soykan et al. | May 2001 | A1 |
20020026228 | Schauerte | Feb 2002 | A1 |
20020099328 | Scheiner et al. | Jul 2002 | A1 |
20030004403 | Drinan et al. | Jan 2003 | A1 |
20030045805 | Sheldon et al. | Mar 2003 | A1 |
20030060854 | Zhu | Mar 2003 | A1 |
20030069606 | Girouard et al. | Apr 2003 | A1 |
20030153952 | Auricchio et al. | Aug 2003 | A1 |
20030158584 | Cates et al. | Aug 2003 | A1 |
20030208240 | Pastore et al. | Nov 2003 | A1 |
20030233132 | Pastore et al. | Dec 2003 | A1 |
20040002739 | Cates et al. | Jan 2004 | A1 |
20040093034 | Girouard et al. | May 2004 | A1 |
Number | Date | Country |
---|---|---|
0054138 | Oct 1981 | EP |
0467695 | Jan 1992 | EP |
0545628 | Jun 1993 | EP |
0620420 | Oct 1994 | EP |
1050265 | Nov 2000 | EP |
WO-9725098 | Jul 1997 | WO |
WO-9733513 | Sep 1997 | WO |
WO-9834537 | Aug 1998 | WO |
WO-0004947 | Feb 2000 | WO |
WO-0007497 | Feb 2000 | WO |
WO-0108748 | Feb 2001 | WO |
WO-0130436 | May 2001 | WO |
Number | Date | Country | |
---|---|---|---|
20040002739 A1 | Jan 2004 | US |