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Die drei großen Hersteller von Cochlea-Implantat (CI)-Systemen ermöglichen es klinischen Audiologen, die Mikrofoneigenschaften der meisten CI-Sprachprozessoren zu prüfen. Dazu können bei diesen Sprachprozessoren Monitorkopfhörer angeschlossen und das/die Mikrofon(e) inklusive eines Teils der Signalvorverarbeitung abgehört werden. Präzise Angaben dazu, mit welchen Stimuli, bei welchem Pegel und nach welchem Kriterium diese Prüfung stattfinden soll, machen die CI-Hersteller nicht. Auf Basis dieser Prüfung soll der Audiologe dann über die Funktion der Mikrofone und damit darüber entscheiden, ob der betreffende Sprachprozessor an den Hersteller eingeschickt wird oder nicht.
Zur Objektivierung der CI-Sprachprozessor-Mikrofon-Prüfung haben wir eine Testbox entwickelt, mit der alle abhörbaren aktuellen CI-Sprachprozessoren der drei großen Hersteller geprüft werden können. Die Box wurde im 3D-Druck-Verfahren hergestellt. Der zu prüfende Sprachprozessor wird in die Messbox eingehängt und über einen darin verbauten Lautsprecher mit definierten Prüfsignalen (Sinustöne unterschiedlicher Frequenz) beschallt. Das Mikrofonsignal wird über das Kabel der Monitorkopfhörer herausgeführt und mit einer Shifting- and Scaling-Schaltung in einen Spannungsbereich transformiert, der für die AD-Wandlung mit einem Mikrokontroller (ATmega1280 verbaut auf einem Arduino Mega) geeignet ist. Derselbe Mikrokontroller übernimmt über einen eigens gebauten DA-Wandler die Ausgabe der Sinustöne über den Lautsprecher. Signalaufnahme und –wiedergabe erfolgen mit jeweils 38,5 kHz Samplingrate. Der für jede Frequenz über mehrere Perioden des Prüfsignals ermittelte Effektivwert wird mit dem Effektivwert, der mit einem neuwertigen Referenzprozessor für diese Frequenz gemessen wurde, verglichen. Die Messergebnisse werden graphisch auf einem Display ausgegeben.
Derzeit läuft eine erste Datenerhebung mit in der Klinik subjektiv auffällig gewordenen CI-Sprachprozessoren, die anschließend in der Messbox untersucht werden. So sollen realistische Schwellen für kritische Abweichungen von den Referenz-Effektivwerten ermittelt werden. Im weiteren Verlauf sollen dann Hit und False Alarm-Raten der subjektiven Prüfung bestimmt werden.
Das normalhörende auditorische System ist in der Lage, interaurale Zeit- bzw. Phasendifferenzen zur verbesserten Signaldetektion im Störgeräusch zu nutzen. Dieses Phänomen wird häufig als binaurale Entmaskierung bezeichnet und ist sowohl bei einfachen Signalen wie Sinustönen, als auch bei Sprachsignalen im Störgeräusch wirksam. Vorangegangene Studien haben gezeigt, dass binaurale Entmaskierung eingeschränkt auch bei bilateralen CI-Trägern beobachtbar ist (Zirn et al., 2016).
Aktuelle Ergebnisse zeigen, dass die binaurale Entmaskierung sensitiv gegenüber der bilateralen CI-Anpassung ist. So lässt sich der Effekt durch tonotopen Abgleich und Herausstellen eines apikalen Feinstrukturkanals modulieren. Steigerungen der binauralen Entmaskierung um bis zu 1,5 dB sind auf diese Weise gegenüber der konventionellen CI-Anpassung möglich. Allerdings variiert der Einfluss der CI-Anpassung interindividuell erheblich.
BiCI users’ sensitivity to interaural phase differences for single- and multi-channel stimulation
(2016)
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.
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.
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.
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.
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.
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.
Introduction: To simplify AV delay (AVD) optimization in cardiac resynchronization therapy (CRT), we reported that the hemodynamically optimal AVD for VDD and DDD mode CRT pacing can be approximated by individually measuring implant-related interatrial conduction intervals (IACT) in oesophageal electrogram (LAE) and adding about 50ms. The programmer-based St Jude QuickOpt algorithm is utilizing this finding. By automatically measuring IACT in VDD operation, it predicts the sensed AVD by adding either 30ms or 60ms. Paced AVD is strictly 50ms longer than sensed AVD. As consequence of those variations, several studies identified distinct inaccuracies of QuickOpt. Therefore, we aimed to seek for better approaches to automate AVD optimization.
Methods: In a study of 35 heart failure patients (27m, 8f, age: 67±8y) with Insync III Marquis CRT-D systems we recorded telemetric electrograms between left ventricular electrode and superior vena cava shock coil (LVtip/SVC = LVCE) simultaneously with LAE. By LVCE we measured intervals As-Pe in VDD and Ap-Pe in DDD operation between right atrial sense-event (As) or atrial stimulus (Ap), resp., and end of the atrial activity (Pe). As-Pe and Ap-Pe were compared with As-LA an Ap-LA in LAE, respectively.
Results: End of the left atrial activity in LVCE could clearly be recognized in 35/35 patients in VDD and 29/35 patients in DDD operation. We found mean intervals As-LA of 40.2±24.5ms and Ap-LA of 124.3±20.6ms. As-Pe was 94.8±24.1ms and Ap-Pe was 181.1±17.8ms. Analyzing the sums of As-LA + 50ms with duration of As-Pe and Ap-LA + 50ms with duration of Ap-Pe, the differences were 4.7±9.2ms and 4.2±8.6ms, resp., only. Thus, hemodynamically optimal timing of the ventricular stimulus can be triggered by automatically detecting Pe in LVCE.
Conclusion: Based on minimal deviations between LAE and LVCE approach, we proposed companies to utilize the LVCE in order to automate individual AVD optimization in CRT pacing.
Introduction: Patient selection for cardiac resynchronization therapy (CRT) requires quantification of left ventricular conduction delay (LVCD). After implantation of biventricular pacing systems, individual AV delay (AVD) programming is essential to ensure hemodynamic response. To exclude adverse effects, AVD should exceed individual implant-related interatrial conduction times (IACT). As result of a pilot study, we proposed the development of a programmer-based transoesophageal left heart electrogram (LHE) recording to simplify both, LVCD and IACT measurement. This feature was implemented into the Biotronik ICS3000 programmer simultaneously with 3-channel surface ECG.
Methods: A 5F oesophageal electrode was perorally applied in 44 heart failure CRT-D patients (34m, 10f, 65±8 yrs., QRS=162±21ms). In position of maximum left ventricular deflection, oesophageal LVCD was measured between onsets of QRS in surface ECG and oesophageal left ventricular deflection. Then, in position of maximum left atrial deflection (LA), IACT in VDD operation (As-LA) was calculated by difference between programmed AV delay and the measured interval from onset of left atrial deflection to ventricular stimulus in the oesophageal electrogram. IACT in DDD operation (Ap-LA) was measured between atrial stimulus and LA..
Results: LVCD of the CRT patients was characterized by a minimum of 47ms with mean of 69±23ms. As-LA and Ap-LA were found to be 41±23ms and 125±25ms, resp., at mean. In 7 patients (15,9%), IACT measurement in DDD operation uncovered adverse AVD if left in factory settings. In this cases, Ap-LA exceeded the factory AVD. In 6 patients (13,6%), IACT in VDD operation was less than or equal 10ms indicating the need for short AVD.
Conclusion: Response to CRT requires distinct LVCD and AVD optimization. The ICS3000 oesophageal LHE feature can be utilized to measure LVCD in order to justify selection for CRT. IACT measurement simplifies AV delay optimization in patients with CRT systems irrespective of their make and model.
In-vivo and in-vitro comparison of implant-based CRT optimization - What provide new algorithms?
(2011)
Introduction: In cardiac resynchronization therapy (CRT), individual AV delay (AVD) optimization can effectively increase hemodynamics and reduce non-responder rate. Accurate, automatic and easily comprehensible algorithms for the follow-up are desirable. QuickOpt is the first attempt of a semi-automatic intracardiac electrogram (IEGM) based AVD algorithm. We aimed to compare its accuracy and usefulness by in-vitro and in-vivo studies.
Methods: Using the programmable ARSI-4 four-chamber heart rhythm and IEGM simulator (HKP, Germany), the QuickOpt feature of an Epic HF system (St. Jude, USA) was tested in-vitro by simulated atrial IEGM amplitudes between 0.3 and 3.5mV during both, manual and automatic atrial sensing between 0.2 and 1.0mV. Subsequently, in 21 heart failure patients with implanted biventricular defibrillators, QuickOpt was performed in-vivo. Results of the algorithm for VDD and DDD stimulation were compared with echo AV delay optimization.
Results: In-vitro simulations demonstrated a QuickOpt measuring accuracy of ± 8ms. Depending on atrial IEGM amplitude, the algorithm proposed optimal AVD between 90 and 150ms for VDD and between 140 and 200ms for DDD operation, respectively. In-vivo, QuickOpt difference between individual AVD in DDD and VDD mode was either 50ms (20pts) or 40ms (1pt). QuickOpt and echo AVD differed by 41 ± 25ms (7 – 90ms) in VDD and by 18 ± 24ms (17-50ms) in DDD operation. Individual echo AVD difference between both modes was 73 ± 20ms (30-100ms).
Conclusion: The study demonstrates the value of in-vitro studies. It predicted QuickOpt deficiencies regarding IEGM amplitude dependent AVD proposals constrained to fixed individual differences between DDD and VDD mode. Consequently, in-vivo, the algorithm provided AVD of predominantly longer duration than echo in both modes. Accepting echo individualization as gold standard, QuickOpt should not be used alone to optimize AVD in CRT patients.
Non-responder rate in cardiac resynchronization therapy (CRT) could be partly decreased by individualized parameter optimization excluding adverse hemodynamic timing. In heart failure patients with sinus rhythm, an atrial kick enables the completion of atrial contraction and may significantly enhance the ventricular filling. Compared to that, exclusion of atrial kick is a sign of suboptimal atrioventricular timing. However, the recognition of atrial kick by echocardiography will be negatively affected in patients requiring a very short or long AV delays.
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.
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.
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.