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Potyagaylo D, van Dam PM, Kuniewicz M, Dolega-Dolegowski D, Pregowska A, Atkinson A, Dobrzynski H, Proniewska K. Interactive teaching of medical 3D cardiac anatomy: atrial anatomy enhanced by ECG and 3D visualization. Front Med (Lausanne) 2024; 11:1422017. [PMID: 39036097 PMCID: PMC11258796 DOI: 10.3389/fmed.2024.1422017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
The most commonly applied way of teaching students to convey the foundations of human anatomy and physiology involves textbooks and lectures. This way of transmitting knowledge causes difficulties for students, especially in the context of three-dimensional imaging of organ structures, and as a consequence translates into difficulties with imagining them. Even despite the rapid uptake of knowledge dissemination provided by online materials, including courses and webinars, there is a clear need for learning programs featuring first-hand immersive experiences tailored to suit individual study paces. In this paper, we present an approach to enhance a classical study program by combining multi-modality data and representing them in a Mixed Reality (MR)-based environment. The advantages of the proposed approach have been proven by the conducted investigation of the relationship between atrial anatomy, its electrophysiological characteristics, and resulting P wave morphology on the electrocardiogram (ECG). Another part of the paper focuses on the role of the sinoatrial node in ECG formation, while the MR-based visualization of combined micro-computed tomography (micro-CT) data with non-invasive CineECG imaging demonstrates the educational application of these advanced technologies for teaching cardiac anatomy and ECG correlations.
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Affiliation(s)
- Danila Potyagaylo
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Krakow, Poland
| | - Peter M. van Dam
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
- Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Agnieszka Pregowska
- Institute of Fundamental Technological Research, Polish Academy of Sciences, Warsaw, Poland
| | - Andrew Atkinson
- Division of Cardiovascular and Endocrine Sciences, University of Manchester, Manchester, United Kingdom
| | - Halina Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
- Division of Cardiovascular and Endocrine Sciences, University of Manchester, Manchester, United Kingdom
| | - Klaudia Proniewska
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Krakow, Poland
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
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van der Schaaf I, Kloosterman M, Gorgels APM, Loh P, van Dam PM. CineECG for visualization of changes in ventricular electrical activity during ischemia. J Electrocardiol 2024; 83:50-55. [PMID: 38325009 DOI: 10.1016/j.jelectrocard.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND CineECG offers a visual representation of the location and direction of the average ventricular electrical activity throughout a single cardiac cycle, based on the 12‑lead ECG. Currently, CineECG has not been used to visualize ventricular activation patterns during ischemia. PURPOSE To determine the changes in ventricular activity during acute ischemia with the use of CineECG, and relating this to changes in the ECG. METHODS Continuous ECG's during percutaneous coronary intervention with prolonged balloon inflation from the STAFF III database were analyzed with CineECG at baseline and every 10 s throughout the first 150 s of balloon inflation. The CineECG direction was determined for the initial QRS-complex, terminal QRS-complex, ST-segment and T-wave. Changes in the CineECG were quantified by calculating the Δangle between the direction at baseline and the direction at every 10 s of inflation. Additionally, the root mean square amplitude (rmsA) of the ST-segment was computed. RESULTS 94 patients were included. At start inflation, the median Δangle was 14.7° [7.5-33.4], 21.8° [11.4-34.2], 20.6° [8.0-43.9], and 23.5° [11.8-48.0] for the initial QRS-complex, terminal QRS-complex, ST-segment and T-wave, respectively. Meanwhile, the median rmsA increased from 0.039 mV [0.027-0.058] at baseline to 0.045 mV [0.033-0.075] at start of inflation. CONCLUSIONS CineECG was able to detect immediate changes in ventricular electrical activity during induced ischemia, while changes in the ST-segment of the ECG were still subtle. Therefore, CineECG might support the early detection of acute ischemia, even before distinct ECG changes become visible.
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Affiliation(s)
- I van der Schaaf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands.
| | - M Kloosterman
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - A P M Gorgels
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands; Hartkliniek Maastricht, Victor de Stuersstraat 15, 6217 KP Maastricht, the Netherlands
| | - P Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - P M van Dam
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; ECG Excellence, Weijland 38, 2415 BC Nieuwerbrug, the Netherlands
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Locati ET, Van Dam PM, Ciconte G, Heilbron F, Boonstra M, Vicedomini G, Micaglio E, Ćalović Ž, Anastasia L, Santinelli V, Pappone C. Electrocardiographic temporo-spatial assessment of depolarization and repolarization changes after epicardial arrhythmogenic substrate ablation in Brugada syndrome. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:473-487. [PMID: 38045442 PMCID: PMC10689926 DOI: 10.1093/ehjdh/ztad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/16/2023] [Accepted: 08/25/2023] [Indexed: 12/05/2023]
Abstract
Aims In Brugada syndrome (BrS), with spontaneous or ajmaline-induced coved ST elevation, epicardial electro-anatomic potential duration maps (epi-PDMs) were detected on a right ventricle (RV) outflow tract (RVOT), an arrhythmogenic substrate area (AS area), abolished by epicardial-radiofrequency ablation (EPI-AS-RFA). Novel CineECG, projecting 12-lead electrocardiogram (ECG) waveforms on a 3D heart model, previously localized depolarization forces in RV/RVOT in BrS patients. We evaluate 12-lead ECG and CineECG depolarization/repolarization changes in spontaneous type-1 BrS patients before/after EPI-AS-RFA, compared with normal controls. Methods and results In 30 high-risk BrS patients (93% males, age 37 + 9 years), 12-lead ECGs and epi-PDMs were obtained at baseline, early after EPI-AS-RFA, and late follow-up (FU) (2.7-16.1 months). CineECG estimates temporo-spatial localization during depolarization (Early-QRS and Terminal-QRS) and repolarization (ST-Tpeak, Tpeak-Tend). Differences within BrS patients (baseline vs. early after EPI-AS-RFA vs. late FU) were analysed by Wilcoxon signed-rank test, while differences between BrS patients and 60 age-sex-matched normal controls were analysed by the Mann-Whitney test. In BrS patients, baseline QRS and QTc durations were longer and normalized after EPI-AS-ATC (151 ± 15 vs. 102 ± 13 ms, P < 0.001; 454 ± 40 vs. 421 ± 27 ms, P < 0.000). Baseline QRS amplitude was lower and increased at late FU (0.63 ± 0.26 vs. 0.84 ± 13 ms, P < 0.000), while Terminal-QRS amplitude decreased (0.24 ± 0.07 vs. 0.08 ± 0.03 ms, P < 0.000). At baseline, CineECG depolarization/repolarization wavefront prevalently localized in RV/RVOT (Terminal-QRS, 57%; ST-Tpeak, 100%; and Tpeak-Tend, 61%), congruent with the AS area on epi-PDM. Early after EPI-AS-RFA, RV/RVOT localization during depolarization disappeared, as Terminal-QRS prevalently localized in the left ventricle (LV, 76%), while repolarization still localized on RV/RVOT [ST-Tpeak (44%) and Tpeak-Tend (98%)]. At late FU, depolarization/repolarization forces prevalently localized in the LV (Terminal-QRS, 94%; ST-Tpeak, 63%; Tpeak-Tend, 86%), like normal controls. Conclusion CineECG and 12-lead ECG showed a complex temporo-spatial perturbation of both depolarization and repolarization in BrS patients, prevalently localized in RV/RVOT, progressively normalizing after epicardial ablation.
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Affiliation(s)
- Emanuela T Locati
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Peter M Van Dam
- Cardiology Department, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kopernika 7e, 31-034 Kraków, Poland
| | - Giuseppe Ciconte
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Francesca Heilbron
- Milano Bicocca University, Istituto Auxologico, Via Thomas Mann 8, 20162 Milan, Italy
| | - Machteld Boonstra
- Cardiology Department, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, Netherlands
| | - Gabriele Vicedomini
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Emanuele Micaglio
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Žarko Ćalović
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Luigi Anastasia
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Vincenzo Santinelli
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
| | - Carlo Pappone
- Arrhythmology-Electrophysiology Department, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
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Frosted R, Paludan-Müller C, Vad OB, Olesen MS, Bundgaard H, van Dam P, Christensen AH. CineECG analysis provides new insights into Familial ST-segment Depression Syndrome. Europace 2023; 25:euad116. [PMID: 37140072 PMCID: PMC10228618 DOI: 10.1093/europace/euad116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/04/2023] [Indexed: 05/05/2023] Open
Abstract
AIMS Familial ST-segment Depression Syndrome (Fam-STD) is a novel inherited cardiac disease associated with arrhythmias and sudden cardiac death. This study aimed at investigating the cardiac activation pathway in patients with Fam-STD, modelling the electrocardiogram (ECG) phenotype, and performing in-depth ST-segment analyses. METHODS AND RESULTS CineECG analysis of patients with Fam-STD and age- and sex-matched controls. The groups were compared using the CineECG software which included the trans-cardiac ratio and the electrical activation pathway. We simulated the Fam-STD ECG phenotype by adjusting action potential duration (APD) and action potential amplitude (APA) in specific cardiac regions. High-resolution ST-segment analyses were performed per lead by dividing the ST-segment into nine 10 ms subintervals. Twenty-seven Fam-STD patients (74% females, mean age 51.6 ± 6.2 years) and 83 matched controls were included. Among Fam-STD patients, electrical activation pathway analysis in the anterior-basal orientation showed significantly abnormal direction toward the basal areas of the heart starting from QRS 60-89 ms until Tpeak-Tend (all P < 0.001). Simulations with shortened APD and reduced APA in the left ventricle basal regions recapitulated the Fam-STD ECG phenotype. Detailed ST-segment analyses showed significant differences in all nine 10 ms subintervals (all P < 0.01), with the most prominent findings during the 70-79/80-89 ms intervals. CONCLUSION CineECG analyses indicated abnormal repolarization with basal directions, and the Fam-STD ECG phenotype was simulated by reducing APD and APA in the left ventricle basal regions. Detailed ST-analysis showed amplitudes consistent with the proposed diagnostic criteria for Fam-STD patients. Our findings provide new insight into the electrophysiological abnormalities of Fam-STD.
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Affiliation(s)
- Rasmus Frosted
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital—Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 11, 2730 Herlev, Denmark
| | - Christian Paludan-Müller
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Oliver Bundgaard Vad
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Morten Salling Olesen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Laboratory for Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Peter van Dam
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- ECG Excellence BV, Weijland 38, 2415 BC Nieuwerbrug, The Netherlands
| | - Alex Hørby Christensen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital—Herlev-Gentofte Hospital, Borgmester Ib Juuls Vej 11, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Boonstra M, Kloosterman M, van der Schaaf I, Roudijk R, van Dam P, Loh P. ECG-based techniques to enhance clinical practice in cardiac genetic disease management. J Electrocardiol 2023; 76:55-60. [PMID: 36436475 DOI: 10.1016/j.jelectrocard.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/10/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Inherited cardiomyopathies are associated with a broad spectrum of potentially lethal phenotypes characterized by structural and electrical myocardial remodeling. Increased awareness and genetic cascade screening lead to more genotype-positive, yet phenotype-negative individuals to be evaluated and followed up. The predictive value of genetic testing is hampered by incomplete penetrance and high variability in disease onset, progression and severity. CLINICAL CHALLENGES Dilated cardiomyopathy usually manifests with symptoms of heart failure and ventricular arrhythmias (VA) develop in advanced disease. In arrhythmogenic cardiomyopathy (ACM), electrical remodeling can precede structural and functional changes and life-threatening VA can be the first disease manifestation. Early signs and symptoms may be subtle and go unnoticed. Physicians are in great need of appropriate screening and risk-stratification strategies. Task Force Criteria (TFC) were established to standardize the clinical diagnosis of ACM but risk-stratification remains challenging. Accurate prediction of disease progression in variation carriers is currently beyond the capabilities of diagnostic tests. PROPOSED DIAGNOSTIC TECHNIQUES We propose three ECG-based techniques; isopotential mapping, inverse ECG and CineECG, to enhance risk-stratification in ACM. With the use of isopotential mapping abnormal spatio-temporal activation and repolarization may be identified. Furthermore, by combining subject specific ≥12‑lead ECG data with cardiothoracic imaging using inverse ECG techniques, the direct link between ECG and cardiac anatomy can be obtained. CONCLUSION New ECG techniques may prove more sensitive to detect early de- and repolarization abnormalities in yet asymptomatic variation carriers. Early electrical signs of disease progression may be identified prior to symptoms. Furthermore, individualized risk-stratification may be enhanced.
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Affiliation(s)
- Machteld Boonstra
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Manon Kloosterman
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Iris van der Schaaf
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rob Roudijk
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Peter van Dam
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Loh
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Al-Zaiti S, Macleod R, Dam PV, Smith SW, Birnbaum Y. Emerging ECG methods for acute coronary syndrome detection: Recommendations & future opportunities. J Electrocardiol 2022; 74:65-72. [PMID: 36027675 DOI: 10.1016/j.jelectrocard.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 12/13/2022]
Abstract
Despite being the mainstay for the initial noninvasive assessment of patients with symptomatic coronary artery disease, the 12‑lead ECG remains a suboptimal diagnostic tool for myocardial ischemia detection with only acceptable sensitivity and specificity scores. Although myocardial ischemia affects the configuration of the QRS complex and the STT waveform, current guidelines primarily focus on ST segment amplitude, which constitutes a missed opportunity and may explain the suboptimal diagnostic performance of the ECG. This possible opportunity and the low cost and ease of use of the ECG provide compelling motivation to enhance the diagnostic accuracy of the ECG to ischemia detection. This paper describes numerous computational ECG methods and approaches that have been shown to dramatically increase ECG sensitivity to ischemia detection. Briefly, these emerging approaches can be conceptually grouped into one of the following four approaches: (1) leveraging novel ECG waveform features and signatures indicative of ischemic injury other than the classical ST-T amplitude measures; (2) applying body surface potentials mapping (BSPM)-based approaches to enhance the spatial coverage of the surface ECG to detecting ischemia; (3) developing an inverse ECG solution to reconstruct anatomical models of activation and recovery pathways to detect and localize injury currents; and (4) exploring artificial intelligence (AI)-based techniques to harvest ECG waveform signatures of ischemia. We present recent advances, shortcomings, and future opportunities for each of these emerging ECG methods. Future research should focus on the prospective clinical testing of these approaches to establish clinical utility and to expedite potential translation into clinical practice.
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Affiliation(s)
- Salah Al-Zaiti
- Department of Acute & Tertiary Care, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Robert Macleod
- Department of Biomedical Engineering, University of Utah, Salt Lake, UT, USA
| | - Peter Van Dam
- Department of Cardiology, University Medical Center Utrecht, the Netherlands
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and University of Minnesota, Minneapolis, MN, USA
| | - Yochai Birnbaum
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
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