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Electrode modelling and simulation of diagnostic and pulmonary vein isolation in atrial fibrillation
(2022)
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.
Background: A disturbed synchronization of the ventricular contraction can cause a highly developed systolic heart failure in affected patients, which can often be explained by a diseased left bundle branch block (LBBB). If medication remains unresponsive, the concerned patients will be treated with a cardiac resynchronization therapy (CRT) system. The aim of this study was to integrate His bundle pacing into the Offenburg heart rhythm model in order to visualize the electrical pacing field generated by His bundle pacing.
Methods: Modelling and electrical field simulation activities were performed with the software CST (Computer Simulation Technology) from Dessault Systèms. CRT with biventricular pacing is to be achieved by an apical right ventricular electrode and an additional left ventricular electrode, which is floated into the coronary vein sinus. This conventional type of biventricular pacing leads to a reduction of the left ventricular ejection fraction. Furthermore, the non-responder rate of the CRT therapy is about one third of the CRT patients.
Results: His bundle pacing represents a physiological alternative to conventional cardiac pacing and cardiac resynchronization. An electrode implanted in the His bundle emits a stronger electrical pacing field than the electrical pacing field of conventional cardiac pacemakers. The pacing of the His bundle was performed by the Medtronic Select Secure 3830 electrode with pacing voltage amplitudes of 3 V, 2 V and 1.5 V in combination with a pacing pulse duration of 1 ms.
Conclusions: Compared to conventional cardiac pacemaker pacing, His bundle pacing is capable of bridging LBBB conduction disorders in the left ventricle. The His bundle pacing electrical field is able to spread via the physiological pathway in the right and left ventricles for CRT with a narrow QRS-complex in the surface ECG.
The visualization of heart rhythm disturbance and atrial fibrillation therapy allow the optimization of new cardiac catheter ablations. With the simulation software CST (Computer Simulation Technology, Darmstadt) electromagnetic and thermal simulations can be carried out to analyze and optimize different heart rhythm disturbance and cardiac catheters for pulmonary vein isolation. Another form of visualization is provided by haptic, three-dimensional print models. These models can be produced using an additive manufacturing method, such as a 3D printer. The aim of the study was to produce a 3D print of the Offenburg heart rhythm model with a representation of an atrial fibrillation ablation procedure to improve the visualization of simulation of cardiac catheter ablation.
The basis of 3D printing was the Offenburg heart rhythm model and the associated simulation of cryoablation of the pulmonary vein. The thermal simulation shows the pulmonary vein isolation of the left inferior pulmonary vein with the cryoballoon catheter Arctic Front AdvanceTM from Medtronic. After running through the simulation, the thermal propagation during the procedure was shown in the form of different colors. The three-dimensional print models were constructed on the base of the described simulation in a CAD program. Four different 3D printers are available for this purpose in a rapid prototyping laboratory at the University of Applied Science Offenburg. Two different printing processes were used: 1. a binder jetting printer with polymer gypsum and 2. a multi-material printer with photopolymer. A final print model with additional representation of the esophagus and internal esophagus catheter was also prepared for printing.
With the help of the thermal simulation results and the subsequent evaluation, it was possible to make a conclusion about the propagation of the cold emanating from the catheter in the myocardium and the surrounding tissue. It could be measured that already 3 mm from the balloon surface into the myocardium the temperature drops to 25 °C. The simulation model was printed using two 3D printing methods. Both methods as well as the different printing materials offer different advantages and disadvantages. While the first model made of polymer gypsum can be produced quickly and cheaply, the second model made of photopolymer takes five times longer and was twice as expensive. On the other hand, the second model offers significantly better properties and was more durable overall. All relevant parts, especially the balloon catheter and the conduction, are realistically represented. Only the thermal propagation in the form of different colors is not shown on this model.
Three-dimensional heart rhythm models as well as virtual simulations allow a very good visualization of complex cardiac rhythm therapy and atrial fibrillation treatment methods. The printed models can be used for optimization and demonstration of cryoballoon catheter ablation in patients with atrial fibrillation.
Spinal cord stimulation (SCS) is the most commonly used technique of neurostimulation. It involves the stimulation of the spinal cord and is therefore used to treat chronic pain. The existing esophageal catheters are used for temperature monitoring during an electrophysiology study with ablation and transesophageal echocardiography. The aim of the study was to model the spine and new esophageal electrodes for the transesophageal electrical pacing of the spinal cord, and to integrate them in the Offenburg heart rhythm model for the static and dynamic simulation of transesophageal neurostimulation. The modeling and simulation were both performed with the electromagnetic and thermal simulation software CST (Computer Simulation Technology, Darmstadt). Two new esophageal catheters were modelled as well as a thoracic spine based on the dimensions of a human skeleton. The simulation of directed transesophageal neurostimulation is performed using the esophageal balloon catheter with an electric pacing potential of 5 V and a trapezoidal signal. A potential of 4.33 V can be measured directly at the electrode, 3.71 V in the myocardium at a depth of 2 mm, 2.68 V in the thoracic vertebra at a depth of 10 mm, 2.1 V in the thoracic vertebra at a depth of 50 mm and 2.09 V in the spinal cord at a depth of 70 mm. The relation between the voltage delivered to the electrodes and the voltage applied to the spinal cord is linear. Virtual heart rhythm and catheter models as well as the simulation of electrical pacing fields and electrical sensing fields allow the static and dynamic simulation of directed transesophageal electrical pacing of the spinal cord. The 3D simulation of the electrical sensing and pacing fields may be used to optimize transesophageal neurostimulation.
Hintergrund: Die Pulmonalvenenisolation (PVI) mit Hilfe von Kryoballonkathetern ist eine anerkannte Methode zur Behandlung von Vorhofflimmern (AF). Diese Methode bietet eine kürzere Behandlungsdauer als die klassische Therapie durch die Hochfrequenzablation (HF). Ziel dieser Studie war es, verschiedene Kryoballonkatheter, HF-Katheter und Ösophaguskatheter in ein Herzrhythmusmodell zu integrieren und mittels statischer und dynamischer Simulation elektrische und thermische Felder bei PVI unter Vorhofflimmern zu untersuchen.
Methodik: Die Modellierung und Simulation erfolgte mit der elektromagnetischen und thermischen Simulationssoftware CST (CST Darmstadt). Zwei Kryoballons, ein HF-Ablationskatheter und ein Ösophaguskatheter wurden auf der Grundlage der technischen Handbücher der Hersteller Medtronic und Osypka modelliert. Der 23 mm Kryoballon und ein kreisförmiger Mappingkatheter wurden in das Offenburger Herzrhythmusmodell integriert, insbesondere die left inferior pulmonary vein (LIPV) zur Simulation der thermischen Feldausbreitung während einer PVI. Die Simulation einer PVI mit HF-Energie wurde mit dem integrierten HF-Ablationskatheter in der Nähe der LIPV durchgeführt. Der im Herzrhythmusmodell platzierte TO8 Ösophaguskatheter ermöglichte die Ableitung linksatrialer elektrischer Felder bei AF und die Analyse thermischer Felder während PVI.
Ergebnisse: Elektrische Felder konnten bei Sinusrhythmus und AF mit einem AF-Fokus in der LIVP statisch und dynamisch im Herzen und Ösophagus simuliert werden. Bei einer simulierten 20 Sekunden Applikation eines Kryoballon-Katheters bei -50°C wurde eine Temperatur von -24°C in einer Tiefe von 0,5 mm im Myokard gemessen. In einer Tiefe von 1 mm betrug die Temperatur -3°C, bei 2 mm Tiefe 18°C und bei 3 mm Tiefe 29°C. Unter der 15 sekündigen Anwendung eines HF-Katheters mit einer 8-mm-Elektrode und einer Leistung von 5 W bei 420 kHz betrug die Temperatur an der Spitze der Elektrode 110°C. In einer Tiefe von 0,5 mm im Myokard betrug die Temperatur 75°C, in einer Tiefe von 1 mm 58°C, in einer Tiefe von 2 mm 45°C und in einer Tiefe von 3 mm 38°C. Im Ösophagus konnte bei den meisten Simulationen eine konstante Temperatur von 37°C gemessen und die Gefahr einer Ösophagus-Fistel ausgeschlossen werden. Bei Kryoablation der LIPV wurde eine Abkühlung des Ösophagus auf 30°C gemessen.
Schlussfolgerungen: Die Herzrhythmussimulation elektrischer und thermaler Felder ermöglichen mit Anwendung unterschiedlicher Herzkatheter eine statische und dynamische Simulation von PVI durch Kryoablation, HF-Ablation und Temperaturanalyse im Ösophagus. Unter Einbeziehung von MRT- oder CT-Daten können elektrische und thermale Simulationen möglicherweise zur Optimierung von PVIs genutzt werden.
Hintergrund: Richtung und Stärke des elektrischen Feldes (E-Feld) der biventrikulären (BV) Stimulation und elektrische interventrikuläre Desynchronisation sind bei Patienten mit Herzinsuffizienz und verbreitertem QRS Komplex von Bedeutung für den Erfolg der kardialen Resynchronisationstherapie (CRT). Das 3D Herzrhythmusmodell (HRM) ermöglicht die
Simulation von CRT und Hochfrequenz (HF) Ablation. Das Ziel der Studie besteht in der Integration von Schrittmacher- und Ablationselektroden in das HRM zur E-Feld Simulation der BV Stimulation und thermischen Feld (T-Feld) Simulation der HF Ablation von Vorhofflimmern (AF).
Methoden: Es wurden fünf multipolare linksventrikuläre (LV) Elektroden, eine epikardiale LV Elektrode, vier bipolare rechtsatriale (RA) Elektroden, zwei rechtsventrikuläre (RV) Elektroden und ein HF Ablationskatheter mit CST (Computer Simulation Technology, Darmstadt) modelliert und das HRM (Schalk et al: Clin Res Cardiol 106, Suppl 1, April 2017, P1812) um den Koronarvenensinus (CS) erweitert (HRM-CS). E-Feld Simulationen bei vorhofsynchroner BV Stimulation und bei RA Stimulation mit RV und LV Ableitung erfolgten mit den Elektroden Select Secure 3830, Capsure VDD-2 5038 und Attain OTW 4194 im HRM+CS (Fig.). F-Feld Simulationen der HF Ablation von AF bei CRT wurden mit integriertem Ablationskatheter AlCath G FullCircle (Biotronik) simuliert.
Ergebnisse: HRM-CS ermöglichte 3D E-Feld Simulationen bei vorhofsynchroner bipolarer BV Stimulation und bei bipolarer RA Stimulation mit bipolarer RV und LV Ableitung. RV und LV Stimulation erfolgten zeitgleich bei einer Amplitude von 3 V an der LV Elektrode und 1 V an der RV Elektrode mit einer Impulsbreite von jeweils 0,5 ms. Die von der BV Stimulationen erzeugten Fernpotentiale konnten von der RA Elektrode wahrgenommen werden. Das Fernpotential an der RA Elektrodenspitze betrug 32,86 mV und in 1 mm Abstand von der RA Elektrodenspitze ergab sich ein Fernpotential von 185,97 mV. HRM-CS ermöglichte 3D T-Feld Simulationen der HF Ablation von AF bei CRT. Das T-Feld bei HF Ablation des AV-Knotens wurde mit einer anliegenden Leistung von 5 W bei 420 kHz an der distalen 8 mm Ablationselektrode simuliert. Die Temperatur an der Katheterspitze betrug nach 5 s Ablationsdauer 88,66 °C, in 1 mm Abstand von der Katheterspitze im Myokard 42,17 °C und in 2 mm Abstand 37,49 °C.
Schlussfolgerungen: HRM-CS und Elektrodenmodelle ermöglichen die 3D Simulationen von E-Feldern bei vorhofsynchroner BV Stimulation, RA Stimulation mit RV und LV Wahrnehmung und von T-Feldern bei HF Ablation. E-Feld Simulationen von RA, RV und LV Stimulation und Sensing können möglicherweise zur Vorhersage von CRT Respondern genutzt werden.