Bridging noninvasive and interventional electroanatomical imaging: role of magnetocardiography

Clinical magnetocardiography: the unshielded bet-past, present, and future

Magnetocardiography (MCG), which is nowadays 60 years old, has not yet been fully accepted as a clinical tool. Nevertheless, a large body of research and several clinical trials have demonstrated its reliability in providing additional diagnostic electrophysiological information if compared with conventional non-invasive electrocardiographic methods. Since the beginning, one major objective difficulty has been the need to clean the weak cardiac magnetic signals from the much higher environmental noise, especially that of urban and hospital environments. The obvious solution to record the magnetocardiogram in highly performant magnetically shielded rooms has provided the ideal setup for decades of research demonstrating the diagnostic potential of this technology. However, only a few clinical institutions have had the resources to install and run routinely such highly expensive and technically demanding systems. Therefore, increasing attempts have been made to develop cheaper alternatives to improve the magnetic signal-to-noise ratio allowing MCG in unshielded hospital environments. In this article, the most relevant milestones in the MCG's journey are reviewed, addressing the possible reasons beyond the currently long-lasting difficulty to reach a clinical breakthrough and leveraging the authors' personal experience since the early 1980s attempting to finally bring MCG to the patient's bedside for many years thus far. Their nearly four decades of foundational experimental and clinical research between shielded and unshielded solutions are summarized and referenced, following the original vision that MCG had to be intended as an unrivaled method for contactless assessment of the cardiac electrophysiology and as an advanced method for non-invasive electroanatomical imaging, through multimodal integration with other non-fluoroscopic imaging techniques. Whereas all the above accounts for the past, with the available innovative sensors and more affordable active shielding technologies, the present demonstrates that several novel systems have been developed and tested in multicenter clinical trials adopting both shielded and unshielded MCG built-in hospital environments. The future of MCG will mostly be dependent on the results from the ongoing progress in novel sensor technology, which is relatively soon foreseen to provide multiple alternatives for the construction of more compact, affordable, portable, and even wearable devices for unshielded MCG inside hospital environments and perhaps also for ambulatory patients.

Predictive value of unshielded magnetocardiographic mapping to differentiate atrial fibrillation patients from healthy subjects

BACKGROUND

P-wave duration, its dispersion and signal-averaged ECG, are currently used markers of vulnerability to atrial fibrillation (AF). However, since tangential atrial currents are better detectable at the body surface as magnetic than electric signals, we investigated the accuracy of magnetocardiographic mapping (MCG), recorded in unshielded clinical environments, as predictor of AF occurrence.

METHODS

MCG recordings, in sinus rhythm (SR), of 71 AF patients and 75 controls were retrospectively analyzed. Beside electric and magnetic P-wave and PR interval duration, two MCG P-wave subintervals, defined P-dep and P-rep, were measured, basing on the point of inversion of atrial magnetic field (MF). Eight parameters were calculated from inverse solution with "Effective Magnetic Dipole (EMD) model" and 5 from "MF Extrema" analysis. Discriminant analysis (DA) was used to assess MCG predictive accuracy to differentiate AF patients from controls.

RESULTS

All but one (P-rep) intervals were significantly longer in AF patients. At univariate analysis, three EMD parameters differed significantly: in AF patients, the dipole-angle-elevation angular speed was lower during P-dep (p < 0.05) and higher during P-rep (p < 0.001) intervals. The space-trajectory during P-rep and the angle-dynamics during P-dep were higher (p < 0.05), whereas ratio-dynamics P-dep was lower (p < 0.01), in AF. At DA, with a combination of MCG and clinical parameters, 81.5% accuracy in differentiating AF patients from controls was achieved. At Cox-regression, the angle-dynamics P-dep was an independent predictor of AF recurrences (p = 0.037).

CONCLUSIONS

Quantitative analysis of atrial MF dynamics in SR and the solution of the inverse problem provide new sensitive markers of vulnerability to AF.

Percutaneous method for single-catheter multiple monophasic action potential recordings during magnetocardiographic mapping in spontaneously breathing rodents

To test the feasibility of a novel method to combine magnetocardiographic (MCG) estimate of ventricular repolarization (VR) and multiple monophasic action potential (MultiMAP) recording in spontaneously breathing rodents with percutaneous sub-xyphoid epicardial placement of a MCG-compatible amagnetic catheter (AC), ten Wistar rats (WRs) and ten guinea pigs (GPs) were studied. Under fluoroscopic control, the AC was moved until four stable MAPs were recorded (fixed inter-electrode distance of 1.2 mm). 36-channel DC-SQUID (sensitivity 20 fT Hz(-½)) were used for MCG mapping. MAPs, differentially amplified (BW: DC-500 Hz), were digitized at 1 kHz. AC pacing provided local ventricular effective refractory period (VERP) estimate. MAP duration (MAPd) was measured at 50% and 90% levels of repolarization. Simultaneous MCG mapping and MultiMAP recording were successful in all animals. Average MAPd50% and MAPd90% were shorter in WRs than in GPs (26.4 ± 2.9 ms versus 110.6 ± 14.3 ms and 60.7 ± 5.4 ms versus 127.7 ± 15.3 ms, respectively). VERP was 51 ± 4.8 ms in WRs and 108.4 ± 12.9 ms in GPs, respectively. The MAP amplitude was 16.9 ± 4.5 in WRs and 16.2 ± 4.2 in GPs. MAP and MCG parameters of VR were in good agreement. All animals survived the procedure. Two also survived a second invasive study; one was followed up until natural death at 52 months. Percutaneous MultiMAP recording is minimally invasive, usually avoids animal sacrifice, is compatible with simultaneous surface MCG mapping and might be used for experimental validation of MCG VR abnormality, to study the arrhythmogenic potential of new drugs and/or animal models of ventricular arrhythmias.

Identification of ischemic heart disease via machine learning analysis on magnetocardiograms

Ischemic heart disease (IHD) is predominantly the leading cause of death worldwide. Early detection of IHD may effectively prevent severity and reduce mortality rate. Recently, magnetocardiography (MCG) has been developed for the detection of heart malfunction. Although MCG is capable of monitoring the abnormal patterns of magnetic field as emitted by physiologically defective heart, data interpretation is time-consuming and requires highly trained professional. Hence, we propose an automatic method for the interpretation of IHD pattern of MCG recordings using machine learning approaches. Two types of machine learning techniques, namely back-propagation neural network (BNN) and direct kernel self-organizing map (DK-SOM), were applied to explore the IHD pattern recorded by MCG. Data sets were obtained by sequential measurement of magnetic field emitted by cardiac muscle of 125 individuals. Data were divided into training set and testing set of 74 cases and 51 cases, respectively. Predictive performance was obtained by both machine learning approaches. The BNN exhibited sensitivity of 89.7%, specificity of 54.5% and accuracy of 74.5%, while the DK-SOM provided relatively higher prediction performance with a sensitivity, specificity and accuracy of 86.2%, 72.7% and 80.4%, respectively. This finding suggests a high potential of applying machine learning approaches for high-throughput detection of IHD from MCG data.

From 3D to 4D imaging: is that useful for interventional cardiac electrophysiology?

Three-dimensional electroanatomical imaging is increasingly used in interventional cardiac electrophysiology, to guide catheter ablation of cardiac arrhythmias. At the same time, there is a growing interest for non-invasive methods, such as magnetocardiographic mapping (MCG), to localize the arrhythmogenic substrates, to test their reproducibility and to plan the most appropriate interventional approach. So far electroanatomical imaging has relayed on static mathematical modeling of the heart and more recently on direct merging with three-dimensional rendering of cardiac anatomy from multidetector computer tomography or magnetic resonance imaging. Merging electrophysiological information with static anatomical structures, can surely be a source of uncertainty for MCG-based pre-interventional localization of the arrhythmogenic substrate and causes mismatch between the real-time imaging of moving catheters and the static geometry of the cardiac chambers reconstructed with invasive electroanatomical imaging. The implementation of recent realistic numerical models of the beating heart in a breathing thorax can improve accuracy and fill the gap between non-invasive and interventional electroanatomical imaging.