An optimized lead system for long-term esophageal electrocardiography

Feasibility of transesophageal phrenic nerve stimulation

BACKGROUND

Every year, more than 2.5 million critically ill patients in the ICU are dependent on mechanical ventilation. The positive pressure in the lungs generated by the ventilator keeps the diaphragm passive, which can lead to a loss of myofibers within a short time. To prevent ventilator-induced diaphragmatic dysfunction (VIDD), phrenic nerve stimulation may be used.

OBJECTIVE

The goal of this study is to show the feasibility of transesophageal phrenic nerve stimulation (TEPNS). We hypothesize that selective phrenic nerve stimulation can efficiently activate the diaphragm with reduced co-stimulations.

METHODS

An in vitro study in saline solution combined with anatomical findings was performed to investigate relevant stimulation parameters such as inter-electrode spacing, range to target site, or omnidirectional vs. sectioned electrodes. Subsequently, dedicated esophageal electrodes were inserted into a pig and single stimulation pulses were delivered simultaneously with mechanical ventilation. Various stimulation sites and response parameters such as transdiaphragmatic pressure or airway flow were analyzed to establish an appropriate stimulation setting.

RESULTS

Phrenic nerve stimulation with esophageal electrodes has been demonstrated. With a current amplitude of 40 mA, similar response figures of the diaphragm activation as compared to conventional stimulation with needle electrodes at 10mA were observed. Directed electrodes best aligned with the phrenic nerve resulted in up to 16.9 % higher amplitude at the target site in vitro and up to 6 cmH20 higher transdiaphragmatic pressure in vivo as compared to omnidirectional electrodes. The activation efficiency was more sensitive to the stimulation level inside the esophagus than to the inter-electrode spacing. Most effective and selective stimulation was achieved at the level of rib 1 using sectioned electrodes 40 mm apart.

CONCLUSION

Directed transesophageal phrenic nerve stimulation with single stimuli enabled diaphragm activation. In the future, this method might keep the diaphragm active during, and even support, artificial ventilation. Meanwhile, dedicated sectioned electrodes could be integrated into gastric feeding tubes.

A Band-Pass Instrumentation Amplifier Based on a Differential Voltage Current Conveyor for Biomedical Signal Recording Applications

Recently, due to their abundant benefits, current-mode instrumentation amplifiers have received considerable attention in medical instrumentation and read-out circuit for biosensors. This paper is focused on the design of current-mode instrumentation amplifiers for portable, implantable, and wearable electrocardiography and electroencephalography applications. To this end, a CMOS differential voltage second-generation current conveyor (DVCCII) based on a linear transconductor is presented. A new band-pass instrumentation amplifier, based on the designed DVCCII, is also implemented in this paper. The concept of the proposed differential voltage current conveyor and instrumentation amplifier is validated numerically and their predicted performance is presented. The simulation results of the presented circuits were tested for 0.18 μm TSMC CMOS technology in a post layout simulation level using the Cadence Virtuoso tool with a ±0.9 V power supply, and demonstrated that the designed DVCCII has a wide dynamic range of ±400 mV and ±0.85 mA and a power consumption of 148 μW. The layout of the DVCCII circuit occupies a total area of 0.378 μm2. It is shown that the designed DVCCII benefits from good linearity over a wide range of input signals and provides a low input impedance at terminal X. Two versions of the proposed band-pass instrumentation amplifier using pseudo resistances were designed with different specifications for two different applications, namely for EEG and ECG signals. Numerical analyses of both designs show proper outputs and frequency responses by eliminating the undesired artifact and DC component of the EEG and ECG input signals.

Multichannel Esophageal Heart Rate Monitoring of Preterm Infants

OBJECTIVE

Autonomic dysregulation in preterm infants requires continuous monitoring of vital signs such as heart rate over days to months. Unfortunately, common surface electrodes are prone to electrocardiography (ECG) signal artifacts and cause serious skin irritations during long-term use. In contrast, esophageal ECG is known to be very sensitive due to the proximity of electrodes and heart and insensitive to external influences. This study addresses if multichannel esophageal ECG qualifies for heart rate monitoring in preterm infants.

METHODS

We recorded esophageal leads with a multi-electrode gastric feeding tube in a clinical study with 13 neonates and compared the heartbeat detection performance with standard surface leads. A computationally simple and versatile ECG wave detection algorithm was used.

RESULTS

Multichannel esophageal ECG manifested heartbeat sensitivity and positive predictive value greater than 98.5% and significant less false negative (FN) ECG waves as compared to surface ECG due to site-typical electrode motion artifacts. False positive bradycardia as indicated with more than 13 consecutive FN ECG waves was equally expectable in esophageal and surface channels. No adverse events were reported for the multi-electrode gastric feeding tube.

CONCLUSION

Heart rate monitoring of preterm infants with multiple esophageal electrodes is considered as feasible and reliable. Less signal artifacts will improve the detection of bradycardia, which is crucial for immediate interventions, and reduce alarm fatigue.

SIGNIFICANCE

Due to the possibility to integrate the multichannel ECG into a gastric feeding tube and meanwhile omit harmful skin electrodes, the presented system has great potential to facilitate future intensive care of preterm infants.

Efficient Thermobonding Process Forming a Polyurethane Based Diagnostic Catheter with Liquid Crystal Polymer. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019;2019:6163-6166. [PMID: 31947250 DOI: 10.1109/embc.2019.8857913]

Diagnostic and therapeutic catheters play an inevitable role in minimal invasive medical procedures. Unfortunately, standard catheters show a limited transducer density and high production efforts. We propose a novel catheter design and manufacturing method using a liquid crystal polymer (LCP)-based flexible printed circuit board (FPCB) and a thermoplastic polyurethane (TPU) elastomer tube. Both components are bond together with a low cost, additive free lamination process at a re-flow temperature of 250° C. The lamination process is improved with a laser welding seam and LCP-integrated microholes preventing delamination. Standardized Mechanical tests were conducted to characterize the bonding. A Peel strength of up to 8.5 N in the radial direction and a non plastic elongation in the axial direction of 10% provide evidence that the thermobonding process is suitable for the production of flexible and mechanically durable medical catheters featuring high electrode densities.

Advanced Cardiac Signal Recording

Implantable loop recorders allow prolonged and continuous single-lead electrocardiogram recording, with the pivotal addition of remote monitoring. They have significantly shortened time to electrocardiographic diagnosis and appropriate therapy of many bradyarrhythmias/tachyarrhythmias and proved helpful in arrhythmia burden definition, offering invaluable information in the diagnostic workup for syncope and atrial fibrillation. Advanced cardiac signal recording is also possible by transesophageal catheters. They have been used to orient diagnosis during wide and narrow QRS complex tachycardias and also to perform minimally invasive pacing. Intracardiac electrophysiologic study remains, however, essential for diagnosis of several arrhythmias in the perspective of curative catheter ablation.

A Baseline Wander Tracking System for Artifact Rejection in Long-Term Electrocardiography

Long-term electrocardiogram (ECG) signals might suffer from relevant baseline disturbances during physical activity. Motion artifacts in particular are more pronounced with dry surface or esophageal electrodes which are dedicated to prolonged ECG recording. In this paper we present a method called baseline wander tracking (BWT) that tracks and rejects strong baseline disturbances and avoids concurrent saturation of the analog front-end. The proposed algorithm shifts the baseline level of the ECG signal to the middle of the dynamic input range. Due to the fast offset shifts, that produce much steeper signal portions than the normal ECG waves, the true ECG signal can be reconstructed offline and filtered using computationally intensive algorithms. Based on Monte Carlo simulations we observed reconstruction errors mainly caused by the non-linearity inaccuracies of the DAC. However, the signal to error ratio of the BWT is higher compared to an analog front-end featuring a dynamic input ranges above 15 mV if a synthetic ECG signal was used. The BWT is additionally able to suppress (electrode) offset potentials without introducing long transients. Due to its structural simplicity, memory efficiency and the DC coupling capability, the BWT is dedicated to high integration required in long-term and low-power ECG recording systems.

Graphics-processor-unit-based parallelization of optimized baseline wander filtering algorithms for long-term electrocardiography

Long-term electrocardiogram (ECG) often suffers from relevant noise. Baseline wander in particular is pronounced in ECG recordings using dry or esophageal electrodes, which are dedicated for prolonged registration. While analog high-pass filters introduce phase distortions, reliable offline filtering of the baseline wander implies a computational burden that has to be put in relation to the increase in signal-to-baseline ratio (SBR). Here, we present a graphics processor unit (GPU)-based parallelization method to speed up offline baseline wander filter algorithms, namely the wavelet, finite, and infinite impulse response, moving mean, and moving median filter. Individual filter parameters were optimized with respect to the SBR increase based on ECGs from the Physionet database superimposed to autoregressive modeled, real baseline wander. A Monte-Carlo simulation showed that for low input SBR the moving median filter outperforms any other method but negatively affects ECG wave detection. In contrast, the infinite impulse response filter is preferred in case of high input SBR. However, the parallelized wavelet filter is processed 500 and four times faster than these two algorithms on the GPU, respectively, and offers superior baseline wander suppression in low SBR situations. Using a signal segment of 64 mega samples that is filtered as entire unit, wavelet filtering of a seven-day high-resolution ECG is computed within less than 3 s. Taking the high filtering speed into account, the GPU wavelet filter is the most efficient method to remove baseline wander present in long-term ECGs, with which computational burden can be strongly reduced.