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Transthoracic impedance cardiography (ICG) is a non-invasive method for determination of hemodynamic parameters. The basic principle of transthoracic ICG is the measurement of electrical conductivity of the thorax over the time. The aim of the study was the analysis of hemodynamic parameters from healthy individuals and the evaluation of various hemodynamic monitoring devices. Fourteen men (mean age 25 ± 4.59 years) and twelve women (mean age 24 ± 3.5 years) were measured during the cardiovascular engineering laboratory at Offenburg University of Applied Sciences, Offenburg, Germany. The ICG recordings were measured with the devices CardioScreen 1000, CardioScreen 2000 and TensoScreen with the corresponding Software Cardiovascular Lab 2.5 (Medis Medizinische Messtechnik GmbH, Illmenau, Germany). In order to create identical frame conditions, all measurements were recorded in the same position and for the same duration. Various positions were simulated from horizontal lying position to vertical standing position. Altogether, more than 30 hemodynamic parameters were measured.
In contrast to conventional aortic valve replacement, the Transcatheter Aortic Valve Implantation (TAVI) is a new highly specialist alternative to surgical valve replacement for patients with symptomatic severe aortic stenosis and high operative risk. The procedure was performed in a minimally invasive way and was introduced at the university heart centre, Freiburg – Bad Krozingen in 2008. The results have been getting better and better over the years. The aim of the investigation is the analysis of electrocardiogram conduction time and the electrocardiography changes recorded hours and days after the procedure depending on artificial heart valve models, which may lead to pacemaker implantation, even the analysis of the effectiveness of treatment.
Cardiac contractility modulation (CCM) is a device-based therapy for the treatment of systolic left ventricular chronic heart failure. Unlike other device-based therapies for heart failure, CCM delivers non-excitatory pacing signals to the myocardium. This leads to an extension of the action potential and to an improved contractility of the heart. The modeling and simulation was done with the electromagnetic simulation software CST. Three CCM electrodes were inserted into the Offenburg heart rhythm model and subsequently simulated the electric field propagation in CCM therapy.
In addition, simulations of CCM have been performed with electrodes from other device-based therapies, such as cardiac resynchronization therapy (CRT) and implantable cardioverter / defibrillator (ICD) therapy. At the same distance to the simulation electrode, the electric field is slightly stronger in CCM therapy than in CCM therapy with additionally implanted CRT or ICD electrodes. In addition, there is a change in the electric field propagation at the electrodes of the CRT and the shock electrode of the ICD.
By simulating several different therapy procedures on the heart, it is possible to check how they affect their behavior during normal operation. CCM heart rhythm model simulation allows the evaluation the individual electrical pacing and sensing field during CCM.
Abstract: Electric field of biventricular (BV) pacing, left ventricular (LV) electrode position and electrical interventricular desynchronization are important parameters for successful cardiac resynchronization therapy (CRT) in patients with heart failure, sinus rhythm and reduced LV ejection fraction. The aim of the study was to evaluate electric pacing field of transesophageal left atrial (LA) pacing and BV pacing with 3D heart rhythm simulation. Bipolar right atrial (RA), right ventricular (RV), LV electrodes and multipolar hemispherical esophageal LA electrodes were modeled with CST (Computer Simulation Technology, Darmstadt). Electric pacing field were simulated with bipolar RA and RV pacing with Solid S (Biotronik) electrode, bipolar LV pacing with Attain 4194 (Medtronic) electrode and bipolar LA pacing with TO8 (Osypka) esophageal electrode. 3D heart rhythm model with esophagus allowed electric pacing field simulation of 4-chamber pacing with bipolar intracardiac RA, RV, LV pacing and bipolar transesophageal LA pacing. The pacing amplitudes were 3V RA pacing amplitude, 50V LA pacing amplitude, 1.5V RV pacing amplitude and 3V LV pacing amplitude with 0.5ms pacing pulse duration. The atrioventricular delay between RA pacing and BV pacing was 140ms atrioventricular pacing delay and simultaneous RV and LV pacing. Electric pacing fields were simulated during the different pacing modes AAI, VVI, DDD and DDD0V. The intracardiac far-field pacing potentials were evaluated with intracardiac electrodes and a distance of 1mm from the electrodes with RA electrode 1.104V, RV electrode 0.703V and LV electrode 1.32V. The transesophageal far-field pacing potential was evaluated with transesophageal electrode and a distance of 10mm from the elelctrode with LA electrode 6.076V. Heart rhythm model simulation with esophagus allows evaluation of electric pacing fields in AAI, VVI, DDD, DDD0V and DDD0D pacing modes. Electric pacing field of RA, RV and LV pacing in combination with LA pacing may additional useful pacing mode in CRT non-responders.
Pulmonary vein isolation (PVI) is a common therapy in atrial fibrillation (AF). The cryoballoon was invented to isolate the pulmonary vein in one step and in a shorter time than a point-by-point radiofrequency (RF) ablation. The aim of the study was to model two cryoballoon catheters, one RF catheter and to integrate them into a heart rhythm model for the static and dynamic simulation of PVI by cryoablation and RF ablation in AF. The modeling and simulation were carried out using the electromagnetic and thermal simulation software CST (CST, Darmstadt). Two cryoballons and one RF ablation catheter were modeled based on the technical manuals of the manufacturers Medtronic and Osypka. The PVI especially the isolation of the left inferior pulmonary vein using a cryoballoon catheter was performed with a -50 °C heatsource and an exponential signal. The temperature at the balloon surface was -50 °C after 20 s ablation time, -24 °C from the balloon 0,5 mm in the myocardium, at a distance of 1 mm -3 °C, at 2 mm 18 °C and at a distance of 3mm 29 °C. PVI with RF energy was simulated with an applied power of 5 W at 420 kHz at the distal 8 mm ablation electrode. The temperature at the tip electrode was 110 °C after 15 s ablation time, 75 °C from the balloon at 0,5 mm in the myocardium, at a distance of 1 mm 58 °C, at 2 mm 45 °C and at a distance of 3 mm 38 °C. Virtual heart rhythm and catheter models as well as the simulation of the temperature allow the simulation of PVI in AF by cryo ablation and RF ablation. The 3D simulation of the temperature profile may be used to optimize RF and cryo ablation.
The high frequency (HF) catheter ablation is the gold standard for the therapy of many cardiac tachyarrhythmias, such as atrioventricular node re-entry tachycardia (AVNRT), atrioventricular re-entry tachycardia (AVRT) or atrial flutter (AFL). The aim of the study was to simulate the HF ablation of AVNRT, AVRT, AFL and its heat propagation in reference to the supplied power with different electrode material and electrode size. The modeling and simulation were performed with the thermal and electromagnetic simulation software CST® (Computer Simulation Technology, Darmstadt). The modeling and simulation were carried out using ablation catheters with 4 mm tip electrode and 8 mm tip electrode with different electrode materials. Both electrode types were made of platinum and gold respectively. For the measurement of the heat propagation in the heart tissue, the catheters were integrated in the Offenburg heart rhythm model. The HF ablation procedures were performed with the 4 mm platinum tip electrode, with an application duration of 45 seconds and a power output of 40 watts. The HF ablation of the atrioventricular node slow pathway produced a maximum temperature of 66.33 °C. The Kent bundle HF ablation in the left atrium achieved a maximum temperature of 67.14 °C. The HF ablation of the right atrial isthmus resulted 65.96 °C. The 8 mm distal platinum tip electrode and a power output of 60 watts reached 72.85 °C. The 8 mm distal gold tip electrode and a power output of 60 watt reached 64.66 °C, due to the improved thermal conductivity of gold. Virtual heart and ablation electrode models allow the static and dynamic simulation of HF ablation with different electrode material and electrode size. The 3D simulation of the temperature profile may be used to optimize the AVNRT, AVRT and AFL HF ablation.
Transcatheter aortiv valve implantation is a new safe strategy treatment for patients with symptomatic severe aortic stenosis and high operative risk. The aim of the study was to compare the pre-and post- muiscatheter aortiv valve implantation procedures to determine the atrioventricuktr conduction time as a potential predictor of permanent pacemaker therapy requirement after transcatheter aortiv valve implantation. The transcatheter aortiv valve implantation patients were divided into groups without pacemaker and with dual or single chamber pacemEtker with diffent atrioventrieular conduction time disturbance before and after transcatheter aortiv valve implantation. In heart failure, patients without permanent pacemaker therapy after transcatheter aortiv valve implantation, atrioventricular conduction time was prolonged after transcatheter aortiv valve implantation. In patients with permanent dual chamber pacemaker therapy after transcatheter aortiv valve implantation, atrioventricular conduction time was normalised with dual chaniber atrioventrieuku pacing mode. Atrioventricular conduction time may be a useful parameter to evaluate the risk of post-procedural atrioventricular conduction block and permanent pacemaker therapy in transcatheter north, valve implantation patients.
Cardiac resynchronization therapy is an established therapy for heart failure patients with sinus rhythm, reduced left ventricular ejection fraction and prolongation of QRS duration. The aim of the study was to evaluate ventricular desynchronization with electrical interventricular delay (IVD) to left ventricular delay (LVD) ratio in atrial fibrillation heart failure patients. IVD and LVD were measured by transesophageal posterior left ventricular ECG recording. In atrial fibrillation heart failure patients with prolonged QRS duration, the mean IVD-to-LVD-ratio was 0.84 +/- 0.42 with a range from 0.17 to 2.2 IVD-to-LVD-ratio. IVD-to-LVD-ratio correlated with QRS duration. IVD-to-LVD-ratio may be a useful parameter to evaluate electrical ventricular desynchronization in atrial fibrillation heart failure patients.
Cardiac resynchronization therapy with atrioventricular and interventricular pacing delay optimized biventricular pacing is an established therapy for heart failure patients with sinus rhythm and reduced left ventricular ejection fraction. The aim of the study was to evaluate atrioventricular and interventricular pacing delay optimization in cardiac resynchroniza-tion therapy by transthoracic impedance cardiography in biventricular pacing with different left ventricular electrode po-sition. In biventricular pacing heart failure patients with lateral, posterolateral and anterolateral left ventricular electrode position, the mean optimal atrioventricular sening delay was 108.6 ± 20.3 ms and the mean optimal interventricular pac-ing delay -12.3 ± 25.9 ms. Transthoracic impedance cardiography may be a useful technique to optimize atrioventricular and interventricular pacing delay in biventricular pacing with different left ventricular electrode position.
Cardiac resynchronization therapy with atrioventricular and interventricular delay optimized biventricular pacing is an established therapy for symptomatic heart failure patients with prolongation of QRS duration, left bundle branch block and reduced left ventricular ejection fraction. The aim of the investigation was to evaluate right atrial, right ventricular and left ventricular electrical signals of implantable electronic cardiac devices with and without signal averaging technique with novel LabVIEW software. Electrical interatrial conduction delay and inter-ventricular conduction delay may be useful parameters to evaluate electrical atrial and ventricular desynchronization in heart failure patients.
Transcatheter aortic valve implantation is a therapy for patients with reduced left ventricular ejection fraction and symptomatic aortic stenosis. The aim of the study was to compare the pre-and post- transcatheter aortic valve implantation procedures to determine the QRS and QT ventricular conduction times as a potential predictor of permanent pacemaker therapy requirement after transcatheter aortic valve implantation. QRS and QT ventricular conduction times were prolonged after transcatheter aortic valve implantation in heart failure patients with permanent dual chamber pacemaker therapy after transcatheter aortic valve implantation. QRS and QT ventricular conduction times may be useful parameters to evaluate the risk of post-procedural ventricular conduction block and permanent pacemaker therapy in transcatheter aortic valve implantation.
Cardiac resynchronization therapy (CRT) is an established therapy for heart failure patients and improves quality of life in patients with sinus rhythm, reduced left ventricular ejection fraction (LVEF), left bundle branch block and wide QRS duration. Since approximately sixty percent of heart failure patients have a normal QRS duration they do not benefit or respond to the CRT. Cardiac contractility modulation (CCM) releases nonexcitatoy impulses during the absolute refractory period in order to enhance the strength of the left ventricular contraction. The aim of the investigation was to evaluate differences in cardiac index between optimized and nonoptimized CRT and CCM devices versus standard values. Impedance cardiography, a noninvasive method was used to measure cardiac index (CI), a useful parameter which describes the blood volume during one minutes heart pumps related to the body surface. CRT patients indicate an increase of 39.74 percent and CCM patients an improvement of 21.89 percent more cardiac index with an optimized device.
Cardiac resynchronization therapy is an established therapy for heart failure patients. The aim of the study was to evaluate electrical left cardiac atrioventricular delay and interventricular desynchronization in sinus rhythm cardiac resynchronization therapy responder and non-responder. Cardiac electrical desynchronization were measured by surface ECG and focused transesophageal bipolar left atrial and left ventricular ECG before implantation of cardiac resynchronization therapy defibrillators. Preoperative electrical cardiac desynchronization was 195.7 ± 46.7 ms left cardiac atrioventricular delay and 74.8 ± 24.5 ms interventricular delay in cardiac resynchronization therapy responder. Cardiac resynchronization therapy responder New York Heart Association class improved during long term biventricular pacing. Transesophageal left cardiac atrioventricular delay and interventricular delay may be additional useful parameters to improve patient selection for cardiac resynchronization therapy.
Background: The electrical field (E-field) of the biventricular (BV) stimulation is important for the success of cardiac resynchronization therapy (CRT) in patients with cardiac insufficiency and widened QRS complex. The 3D modeling allows the simulation of CRT and high frequency (HF) ablation.
Purpose: The aim of the study was to model different pacing and ablation electrodes and to integrate them into a heart model for the static and dynamic simulation of atrial and BV stimulation and high frequency (HF) ablation in atrial fibrillation (AF).
Methods: The modeling and simulation was carried out using the electromagnetic simulation software CST (CST Darmstadt). Five multipolar left ventricular (LV) electrodes, one epicardial LV electrode, four bipolar right atrial (RA) electrodes, two right ventricular (RV) electrodes and one HF ablation catheter were modeled. Selected electrodes were integrated into the Offenburg heart rhythm model for the electrical field simulation. The simulation of an AV node ablation at CRT was performed with RA, RV and LV electrodes and integrated ablation catheter with an 8 mm gold tip.
Results: The right atrial stimulation was performed with an amplitude of 1.5 V with a pulse width of 0.5. The far-field potentials generated by the atrial stimulation were perceived by the right and left ventricular electrode. The far-field potential at a distance of 1 mm from the right ventricular electrode tip was 36.1 mV. The far-field potential at a distance of 1 mm from the left ventricular electrode tip was measured with 37.1 mV. The RV and LV stimulation were performed simultaneously at amplitude of 3 V at the LV electrode and 1 V at the RV electrode with a pulse width of 0.5 ms each. The far-field potentials generated by the BV stimulations could be perceived by the RA electrode. The far-field potential at the RA electrode tip was 32.86 mV. AV node ablation was simulated with an applied power of 5 W at 420 kHz and 10 W at 500 kHz at the distal 8 mm ablation electrode.
Conclusions: Virtual heart and electrode models as well as the simulations of electrical fields and temperature profiles allow the static and dynamic simulation of atrial synchronous BV stimulation and HF ablation at AF. The 3D simulation of the electrical field and temperature profile may be used to optimize the CRT and AF ablation.
The electrical field (E-field) of the biventricular (BV) stimulation is important for the success of cardiac resynchronization therapy (CRT) in patients with cardiac insufficiency and widened QRS complex.
The aim of the study was to model different pacing and ablation electrodes and to integrate them into a heart model for the static and dynamic simulation of BV stimulation and HF ablation in atrial fibrillation (AF).
The modeling and simulation was carried out using the electromagnetic simulation software CST. Five multipolar left ventricular (LV) electrodes, four bipolar right atrial (RA) electrodes, two right ventricular (RV) electrodes and one HF ablation catheter were modelled. A selection were integrated into the heart rhythm model (Schalk, Offenburg) for the electrical field simulation. The simulation of an AV node ablation at CRT was performed with RA, RV and LV electrodes and integrated ablation catheter with an 8 mm gold tip.
The BV stimulation were performed simultaneously at amplitude of 3 V at the LV electrode and 1 V at the RV electrode with a pulse width of 0.5 ms each. The far-field potential at the RA electrode tip was 32.86 mV and 185.97 mV at a distance of 1 mm from the RA electrode tip. AV node ablation was simulated with an applied power of 5 W at 420 kHz at the distal ablation electrode. The temperature at the catheter tip was 103.87 °C after 5 s ablation time and 37.61 °C at a distance of 2 mm inside the myocardium. After 15 s, the temperature was 118.42 °C and 42.13 °C.
Virtual heart and electrode models as well as the simulations of electrical fields and temperature profiles allow the static and dynamic simulation of atrial synchronous BV stimulation and HF ablation at AF and could be used to optimize the CRT and AF ablation.
Spectral analysis of signal averaging electrocardiography in atrial and ventricular tachyarrhythmias
(2017)
Background: Targeting complex fractionated atrial electrograms detected by automated algorithms during ablation of persistent atrial fibrillation has produced conflicting outcomes in previous electrophysiological studies. The aim of the investigation was to evaluate atrial and ventricular high frequency fractionated electrical signals with signal averaging technique.
Methods: Signal averaging electrocardiography (ECG) allows high resolution ECG technique to eliminate interference noise signals in the recorded ECG. The algorithm uses automatic ECG trigger function for signal averaged transthoracic, transesophageal and intracardiac ECG signals with novel LabVIEW software (National Instruments, Austin, Texas, USA). For spectral analysis we used fast fourier transformation in combination with spectro-temporal mapping and wavelet transformation for evaluation of detailed information about the frequency and intensity of high frequency atrial and ventricular signals.
Results: Spectral-temporal mapping and wavelet transformation of the signal averaged ECG allowed the evaluation of high frequency fractionated atrial signals in patients with atrial fibrillation and high frequency ventricular signals in patients with ventricular tachycardia. The analysis in the time domain evaluated fractionated atrial signals at the end of the signal averaged P-wave and fractionated ventricular signals at the end of the QRS complex. The analysis in the frequency domain evaluated high frequency fractionated atrial signals during the P-wave and high frequency fractionated ventricular signals during QRS complex. The combination of analysis in the time and frequency domain allowed the evaluation of fractionated signals during atrial and ventricular conduction.
Conclusions: Spectral analysis of signal averaging electrocardiography with novel LabVIEW software can utilized to evaluate atrial and ventricular conduction delays in patients with atrial fibrillation and ventricular tachycardia. Complex fractionated atrial electrograms may be useful parameters to evaluate electrical cardiac arrhythmogenic signals in atrial fibrillation ablation.
Heart rhythm model and simulation of electrophysiological studies and high-frequency ablations
(2017)
Background: Target of the study was to create an accurate anatomic CAD heart rhythm model, and to show its usefulness for cardiac electrophysiological studies and high-frequency ablations. The method is more careful for the patients’ health and has the potential to replace clinical studies due to its high efficiency regarding time and costs.
Methods: All natural heart components of the new HRM were based on MRI records, which guaranteed electronic functionality. The software CST was used for the construction, while CST’s material library assured genuine tissue properties. It should be applicable to simulate different heart rhythm diseases as well as various diffusions of electromagnetic fields, caused by electrophysiological conduction, inside the heart tissue.
Results: It was achievable to simulate sinus rhythm and fourteen different heart rhythm disturbance with different atrial and ventricular conduction delays. The simulated biological excitation of healthy and sick HRM were plotted by simulated electrodes of four polar right atrial catheter, six polar His bundle catheter, ten polar coronary sinus catheter, four polar ablation catheter and eight polar transesophageal left cardiac catheter. Accordingly, six variables were rebuilt and inserted into the anatomic HRM in order to establish heart catheters for ECG monitoring and HF ablation. The HF ablation catheters made it possible to simulate various types of heart rhythm disturbance ablations with different HF ablation catheters and also showed a functional visualisation of tissue heating. The use of tetrahedral meshing HRM made it attainable to store the results faster accompanied by a higher degree of space saving. The smart meshing function reduced unnecessary high resolutions for coarse structures.
Conclusions: The new HRM for EPS simulation may be additional useful for simulation of heart rhythm disturbance, cardiac pacing, HF ablation and for locating and identification of complex fractioned signals within the atrium during atrial fibrillation HF ablation.
Heart rhythm model and simulation of electrophysiological studies and high-frequency ablations
(2017)
Background: The simulation of complex cardiologic structures has the potential to replace clinical studies due to its high efficiency regarding time and costs. Furthermore, the method is more careful for the patients’ health than the conventional ways. The aim of the study was to create an anatomic CAD heart rhythm model (HRM) as accurate as possible, and to show its usefulness for cardiac electrophysiological studies (EPS) and high-frequency (HF) ablations.
Methods: All natural heart components of the new HRM were based on MRI records, which guaranteed electronic functionality. The software CST (Computer Simulation Technology, Darmstadt) was used for the construction, while CST’s material library assured genuine tissue properties. It should be applicable to simulate different heart rhythm diseases as well as various diffusions of electromagnetic fields, caused by electrophysiological conduction, inside the heart tissue.
Results: It was achievable to simulate normal sinus rhythm and fourteen different heart rhythm disturbance with different atrial and ventricular conduction delays. The simulated biological excitation of healthy and sick HRM were plotted by simulated electrodes of four polar right atrial catheter, six polar His bundle catheter, ten polar coronary sinus catheter, four polar ablation catheter and eight polar transesophageal left cardiac catheter (Fig.). Accordingly, six variables were rebuilt and inserted into the anatomic HRM in order to establish heart catheters for ECG monitoring and HF ablation. The HF ablation catheters made it possible to simulate various types of heart rhythm disturbance ablations with different HF ablation catheters and also showed a functional visualisation of tissue heating. The use of tetrahedral meshing HRM made it attainable to store the results faster accompanied by a higher degree of space saving. The smart meshing function reduced unnecessary high resolutions for coarse structures.
Conclusions: The new HRM for EPS simulation may be additional useful for simulation of heart rhythm disturbance, cardiac pacing, HF ablation and for locating and identification of complex fractioned signals within the atrium during atrial fibrillation HF ablation.
Background: Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy for heart failure (HF) patients (P) with sinus rhythm, reduced left ventricular (LV) ejection fraction (EF) and electrical ventricular desynchronization. The aim of the study was to evaluate electrical interventricular delay (IVD) and left ventricular delay (LVD) in right ventricular (RV) pacemaker pacing before upgrading to CRT BV pacing.
Methods: HF P (n=11, age 69.0 ± 7.9 years, 1 female, 10 males) with DDD pacemaker (n=10), DDD defibrillator (n=1), RV pacing, New York Heart Association (NYHA) class 3.0 ± 0.2 and 24.5 ± 4.9 % LVEF were measured by surface ECG and transesophageal bipolar LV ECG before upgrading to CRT defibrillator (n=8) and CRT pacemaker (n=3). IVD was measured between onset of QRS in the surface ECG and onset of LV signal in the transesophageal ECG. LVD was measured between onset and offset of LV signal in the transesophageal ECG. CRT atrioventricular (AV) and BV pacing delay were optimized by impedance cardiography.
Results: Interventricular and intraventricular desynchronization in RV pacemaker pacing were 228.2 ± 44.8 ms QRS duration, 86.5 ± 32.8ms IVD, 94.4 ± 23.8ms LVD, 2.6 ± 0.8 QRS-IVD-ratio with correlation between IVD and QRS-IVD-ratio (r=-0.668 P=0.0248) and 2.3 ± 0.7 QRS-LVD-ratio. The LVEF-IVD-ratio was 0.3 ± 0.1 with correlation between IVD and LVEF-IVD-ratio (r=-0.8063 P=0.00272) and with correlation between QRS duration and LVEF-IVD-ratio (r=-0.7251 P=0.01157). Optimal sensing and pacing AV delay were 128.3 ± 24.8 ms AV delay after atrial sensing (n=6) and 173.3 ± 40.4 ms AV delay after atrial pacing (n=3). Optimal BV pacing delay was -4.3 ± 11.3 ms between LV and RV pacing (n=7). During 30.4 ± 29.6 month CRT follow-up, the NYHA class improved from 3.1 ± 0.2 to 2.2 ± 0.3.
Conclusions: Transesophageal electrical IVD and LVD in RV pacemaker pacing may be additional useful ventricular desynchronization parameters to improve P selection for upgrading RV pacemaker pacing to CRT BV pacing.
Cardiac resynchronization therapy (CRT) with biventricular (BV) pacing is an established therapy in approximately two-thirds of symptomatic heart failure (HF) patients (P) with left bundle branch block (LBBB). The aim of this study was to evaluate left atrial (LA) conduction delay (LACD) and left ventricular (LV) conduction delay (LVCD) using pre-implantational transesophageal electrocardiography (ECG) in sinus rhythm (SR) CRT responder (R) and non-responder (NR).
Methods: SR HF P (n=52, age 63.6±10.4 years; 6 females, 46 males) with New York Heart Association (NYHA) class 3.0±0.2, 24.4±7.1 % LV ejection fraction and 171.2±37.6 ms QRS duration (QRSD) were measured by bipolar filtered transesophageal LA and LV ECG recording with hemispherical electrodes (HE) TO catheter (Osypka AG, Rheinfelden, Germany). LACD was measured between onset of P-wave in the surface ECG and onset of LA deflection in the LA ECG. LVCD was measured between onset of QRS in the surface ECG and onset of LV deflection in the LV ECG.
Results: There were 78.8 % SR CRT R (n=41) with 171.2±36.9 ms QRSD, 73.3±25.7 ms LACD, 80.0±24.0 ms LVCD and 2.3±0.5 QRSD-LVCD-ratio. SR CRT R QRSD correlated with LACD (r=0.688, P<0.001) and LVCD (r=0.699, P<0.001). There were 21.2 % SR CRT NR (n=11) with 153.4±22.4 ms QRSD (P=0.133), 69.8±24.8 ms LACD (n=6, P=0.767), 54.2±31.0 ms LVCD (P<0.0046) and 3.9±2.5 QRSD-LVCD-ratio (P<0.001). SR CRT NR QRSD not corre-lated with IACD (r=-0.218, P=0.678) and IVCD (r=0.042, P=0.903). During a 22.8±21.3 month CRT follow-up, the CRT R NYHA class improved from 3.1±0.3 to 1.9±0.3 (P<0.001). In CRT NR, NYHA class not improved (2.9±0.4 to 2.9±0.2, P=1) during 11.2±9.8 months BV pacing.
Conclusions: Transesophageal LA and LV ECG with HE can be utilized to analyse LACD and LVCD in HF P. Pre-implantational LVCD and QRSD-LVCD-ratio may be additional useful parameters to improve P selection for SR CRT.
Capture threshold (CT) for transesophageal left atrial (LA) pacing (TLAP) and transesophageal left ventricular (LV) pacing (TLVP) with conventional cylindrical electrodes (CE) are higher than TLAP feeling threshold (FT). Purpose of the study was to evaluate focused TLAP CT and FT for supraventricular tachycardia (SVT) initiation and focused TLVP CT for cardiac resynchronisation therapy (CRT) simulation.
Methods: SVT initiation in patients (P) with palpitations (n=49, age 47 ± 17 years) was analysed during spontaneous rhythm and during focused bipolar TLAP with atrial constant current stimulus output, distal CE and three or seven 6 mm hemispherical electrodes (HE) (TO, Osypka AG, Rheinfelden, Germany). CRT simulation in heart failure P (n=75, age 62 ± 11 years) was evaluated by focused bipolar TLAP and/or TLVP with ventricular constant voltage stimulus output and different pacing mode.
Results: Focused electrical pacing field between CE and HE (n=28) allowed low threshold TLAP with 8.0 ± 2.6 mA CT at 9.9 ms stimulus duration (SD) which was lower than 9.2 ± 4.5 mA FT at 9.9 ms SD. Focused electrical pacing field between HE and HE (n=21) allowed low threshold TLAP with 8.1 ± 2.2 mA CT at 9.9 ms SD which was lower than 9.8 ± 5.0 mA FT at 9.9 ms SD. SVT initiation by programmed AAI TLAP was possible in 23 P and not possible in 26 P. CRT simulation was evaluated with TLAP and TLVP with VAT, D00 and V00 pacing mode and 95.5 ± 10.9 V TLVP CT at 4.0 ms SD.
Conclusions: Programmed focused AAI TLAP allowed initiation of SVT with very low CT and high FT and focused electrical pacing field between CE-HE and HE-HE.CRT simulation with focused TLAP and/or TLVP with VAT, D00 and V00 pacing mode may be a useful technique to detect responders to CRT.
Cardiac resynchronisation therapy (CRT) with biventricular pacing (BV) is an established therapy for heart failure (HF) patients with interventricular conduction delay (IVCD). The aim of the study was to evaluate transesophageal IVCD and left ventricular (LV) pacing with directed electrical pacing field (EPF) in HF patients.
Methods: HF patients were analysed with bipolar transesophageal LV electrocardiogram recording and LV pacing with constant voltage stimulus output, 4 ms stimulus duration, distal cylindrical electrode (CE) and seven 6 mm hemispherical electrodes (HE) with 15 mm electrode distance (TO, Dr. Osypka, Rheinfelden, Germany).
Results: LV electrocardiogram recording with HE-HE and CE-HE evaluated a mean IVCD of 79.9 ± 36.7 ms. Directed EPF with CE-HE and HE-HE allowed LV VAT (n=12) and LV D00 pacing (n=5) with a mean effective capture output of 97.35 ± 6.64 V. In 15 responders with IVCD of 87 ± 33 ms arterial pulse pressure (PP) increased from 65 ± 24 mmHg to 79 ± 27 mmHg (p < 0.001). EPF was simulated with finite element method.
Conclusions: Transesophageal LV electrocardiography and directed EPF pacing with CE and HE allowed the evaluation of IVCD and PP to select patients for BV pacing.
Termination of atrial flutter (AFL) is not possible in all AFL patients (P) with transesophageal left atrial pacing (TLAP) with undirected electrical pacing field (EPF) and high atrial pacing threshold. Purpose of the study was to evaluate bipo-lar transesophageal left atrial electrocardiography (TLAE) and TLAP with directed EPF for evaluation and termination of AFL with and without simultaneous transesophageal echocardiography (TEE).
Methods: AFL P were analysed using either a TO electrode with one cylindrical (CE) and three or seven hemispherical electrodes (HE) or TEE electrode with four HE (Osypka, Rheinfelden, Germany). Burst TLAP cycle length was between 200msand 50ms.
Results: AFL cycle length was 233±30 ms with mean ventricular cycle length of 540±149 ms. AFL could be terminated by rapid bipolar TLAP with directed EPF using HE-HE and CE-HE with induction of atrial fibrillation (AF), induction of AF and spontaneous conversion to sinus rhythm and direct conversion to sinus rhythm. Directed EPF was simulated with finite element method.
Conclusions: AFL can be evaluated by bipolar TLAE. AFL can be terminated with rapid TLAP with directed EPF with and without simultaneous TEE. Bipolar TLAE with rapid TLAP is a safe, simple and useful method for evaluation and termination of AFL.
ECG simulators, available on the market, imitate the electric activity of the heart in a simplified manner. Thus, they are suitable for education purposes but not really for testing algorithms to recognize complex arrhythmias needed for pacemakers and implantable defibrillators. Especially certain discrimination between various morphologies of atrial and ventricular fibrillation needs simulators providing native electrograms of different patients’ heart rhythm events. This explains the necessity to develop an ECG simulator providing high-resolution native intracardiac and surface electrograms of in-vivo rhythm events. In this paper we demonstrate an approach for an ECG simulator based on a consumer multichannel soundcard and a corresponding software application for a laptop computer. This Live-ECG Simulator is able to handle invasive electrogram recordings from electrophysiological studies and send the data to a modified external soundcard for subsequent digital to analog conversion. The hardware is completed with an electronic circuit providing level adjustment to adapt the output amplitude to the input conditions of several cardiac implants.
Responder-rate in cardiac resynchronization therapy (CRT) of patients in sinus rhythm (SR) or atrial fibrillation (AF) mainly depends on accurat selection, optimal position of the left ventricular electrode and individualization of hemodynamical parameters of the implanted biventricular pacing system during follow-up. High resolution esophageal left heart electrocardiography offers a quick and semi-invasive approach to the electrical activity of left atrium and left ventricle. It was used in 62 heart failure patients in sinus rhythm and 11 in atrial fibrillation after implantation of CRT systems to compare the semi-invasive interventricular conduction delay (IVCDE) with QRS width. In all of the patients, guideline decision for CRT was linked with IVCDE of about 40ms and up. From logical point of view, IVCDE provides the minimal target interval for the left ventricular electrode placement in order to exclude non-responders. Esophageal measurement of interatrial conduction intervals in VDD and DDD pacing was utilized to individualize the AV delay and to exclude adverse hemodynamic effects.
New frontiers of supraventricular tachycardia and atrial flutter evaluation and catheter ablation
(2012)
Radiofrequency catheter ablation (RFCA) has revolutionized treatment for tachyarrhythmias and has become first-line therapy for some tachycardias. Although developed in the 1980s and widely applied in the 1990s, the technique is still in development. Transesophageal atrial pacing (TAP) can used for initiation and termination of supraventricular tachycardia (SVT).
Methods: The paroxysmal SVT include a wide spectrum of disorders including, in descending order of frequency, atrial flutter, atrioventricular (AV) nodal reentry, Wolff-Parkinson-White syndrome, and atrial tachycardia. While not life-threatening in most cases, they may cause important symptoms, such as palpitations, chest discomfort, breathlessness, anxiety, and syncope, which significantly impair quality of life. Medical therapy has variable efficacy, and most patients are not rendered free of symptoms. Research over the past several decades has revealed fundamental mechanisms involved in the initiation and maintenance of all of these arrhythmias. Knowledge of mechanisms has in turn led to highly effective surgical and catheter-based treatments. The supraventricular arrhythmias and their treatment are described in this report. SVT initiation was analysed with programmed TAP in 49 patients with palpitations (age 47 ± 17 years, 24 females, 25 males).
Results: In comparison to antiarrhythmic drug therapy the radiofrequency catheter ablation in patients suffering from atrial flutter, atrioventricular nodal reentry, atrioventricular reentry and atrial tachycardia is the better choice in most cases. TAP SVT initiation was possible in 23 patients before RFCA. Atrial cycle length of SVT was 320 ± 59 ms. We initiated AV nodal reentrant tachycardia (AVNRT, n=15), atrial tachycardia (AT, n=6) and AV reentrant tachycardia with Kent pathway conduction (AVRT, n=2) before RFCA.
Conclusions: Radiofrequency catheter ablation is a successful and safe method to cure most patients with paroxysmal supraventricular tachycardias. TAP allowed initiation and termination of SVT especially in outpatients.
Cardiac resynchronization therapy (CRT) with biventricular pacing is an established therapy for heart failure (HF) patients (P) with ventricular desynchronization and reduced left ventricular (LV) ejection fraction. The aim of this study was to evaluate electrical right atrial (RA), left atrial (LA), right ventricular (RV) and LV conduction delay with novel telemetric signal averaging electrocardiography (SAECG) in implantable cardioverter defibrillator (ICD) P to better select P for CRT and to improve hemodynamics in cardiac pacing.
Methods: ICD-P (n=8, age 70.8 ± 9.0 years; 2 females, 6 males) with VVI-ICD (n=4), DDD-ICD (n=3) and CRT-ICD (n=1) (Medtronic, Inc., Minneapolis, MN, USA) were analysed with telemetric ECG recording by Medronic programmer 2090, ECG cable 2090AB, PCSU1000 oscilloscope with Pc-Lab2000 software (Velleman®) and novel National Intruments LabView SAECG software.
Results: Electrical RA conduction delay (RACD) was measured between onset and offset of RA deflection in the RAECG. Interatrial conduction delay (IACD) was measured between onset of RA deflection and onset of far-field LA deflection in the RAECG. Interventricular conduction delay (IVCD) was measured between onset of RV deflection in the RVECG and onset of LV deflection in the LVECG. Telemetric SAECG recording was possible in all ICD-P with a mean of 11.7 ± 4.4 SAECG heart beats, 97.6 ± 33.7 ms QRS duration, 81.5 ± 44.6 ms RACD, 62.8 ± 28.4 ms RV conduction delay, 143.7 ± 71.4 ms right cardiac AV delay, 41.5 ms LA conduction delay, 101.6 ms LV conduction delay, 176.8 ms left cardiac AV delay, 53.6 ms IACD and 93 ms IVCD.
Conclusions: Determination of RA, LA, RV and LV conduction delay, IACD, IVCD, right and left cardiac AV delay by telemetric SAECG recording using LabView SAECG technique may be useful parameters of atrial and ventricular desynchronization to improve P selection for CRT and hemodynamics in cardiac pacing.
Cardiac resynchronization therapy with biventricular pacing is an established therapy for heart failure patients with electrical left ventricular desynchronization. The aim of this study was to evaluate left atrial conduction delay, intra left atrial conduction delay, left ventricular conduction delay and intra left ventricular conduction delay in heart failure patients using novel signal averaging transesophageal left heart ECG software.
Methods: 8 heart failure patients with dilated cardiomyopathy (DCM), age 68 ± 9 years, New York Heart Association (NYHA) class 2.9 ± 0.2, 24.8 ± 6.7 % left ventricular ejection fraction, 188.8 ± 15.5 ms QRS duration and 8 heart failure patients with ischaemic cardiomyopathy (ICM), age 67 ± 8 years, NYHA class 2.9 ± 0.3, 32.5 ± 7.4 % left ventricular ejection fraction and 167.6 ± 19.4 ms QRS duration were analysed with transesophageal and transthoracic ECG by Bard LabDuo EP system and novel National Intruments LabView signal averaging ECG software.
Results: The electrical left atrial conduction delay was 71.3 ± 17.6 ms in ICM versus 72.3 ± 12.4 ms in DCM, intra left atrial conduction delay 66.8 ± 8.6 ms in ICM versus 63.4 ± 10.9 ms in DCM and left cardiac AV delay 180.5 ± 32.6 ms in ICM versus 152.4 ± 30.4 ms in DCM. The electrical left ventricular conduction delay was 40.9 ± 7.5 ms in ICM versus 42.6 ± 17 ms in DCM and intra left ventricular conduction delay 105.6 ± 19.3 ms in ICM versus 128.3 ± 24.1 ms in DCM.
Conclusions: Left heart signal averaging ECG can be utilized to analyse left atrial conduction delay, intra left atrial conduction delay, left ventricular conduction delay and intra left ventricular conduction delay to improve patient selection for cardiac resynchronization therapy.