Dry electrodes for bioimpedance measurements—design, characterization and comparison

Wearable Devices Based on Bioimpedance Test in Heart-Failure: Design Issues

Heart-failure (HF) is a severe medical condition. Physicians need new tools to monitor the health status of their HF patients outside the hospital or medical supervision areas, to better know the evolution of their patients' main biomarker values, necessary to evaluate their health status. Bioimpedance (BI) represents a good technology for sensing physiological variables and processes on the human body. BI is a non-expensive and non-invasive technique for sensing a wide variety of physiological parameters, easy to be implemented on biomedical portable systems, also called "wearable devices". In this systematic review, we address the most important specifications of wearable devices based on BI used in HF real-time monitoring and how they must be designed and implemented from a practical and medical point of view. The following areas will be analyzed: the main applications of BI in heart failure, the sensing technique and impedance specifications to be met, the electrode selection, portability of wearable devices: size and weight (and comfort), the communication requests and the power consumption (autonomy). The different approaches followed by biomedical engineering and clinical teams at bibliography will be described and summarized in the paper, together with results derived from the projects and the main challenges found today.

Minimization of Parasitic Capacitance between Skin and Ag/AgCl Dry Electrodes

Conventional dry electrodes often yield unstable results due to the presence of parasitic capacitance between the flat electrode surface and the non-uniform skin interface. To address this issue, a gel is typically placed between the electrodes to minimize parasitic capacitance. However, this approach has the drawbacks of being unsuitable for repeated use, limited lifetime due to gel evaporation, and the possibility of developing skin irritation. This is particularly problematic in underserved areas since, due to the cost of disposable wet electrodes, they often sterilize and reuse dry electrodes. In this study, we propose a method to neutralize the effects of parasitic capacitance by attaching high-value capacitors to the electrodes in parallel, specifically when applied to pulse wave monitoring through bioimpedance. Skin capacitance can also be mitigated due to the serial connection, enabling stable reception of arterial pulse signals through bioimpedance circuits. A high-frequency structure simulator (HFSS) was first used to simulate the capacitance when injection currents flow into the arteries through the bioimpedance circuits. We also used the simulation to investigate the effects of add-on capacitors. Lastly, we conducted preliminary comparative analyses between wet electrodes and dry electrodes in vivo with added capacitance values ranging from 100 pF to 1 μF, altering capacitance magnitudes by factors of 100. As a result, we obtained a signal-to-noise ratio (SNR) that was 8.2 dB higher than that of dry electrodes. Performance was also shown to be comparable to wet electrodes, with a reduction of only 0.4 dB using 1 μF. The comparative results demonstrate that the addition of capacitors to the electrodes has the potential to allow for performance similar to that of wet electrodes for bioimpedance pulse rate monitoring and could potentially be used for other applications of dry electrodes.

A novel functional electrical stimulation sleeve based on textile-embedded dry electrodes

BACKGROUND

Functional electrical stimulation (FES) is a rehabilitation technique that enables functional improvements in patients with motor control impairments. This study presents an original design and prototyping method for a smart sleeve for FES applications. The article explains how to integrate a carbon-based dry electrode into a textile structure and ensure an electrical connection between the electrodes and the stimulator for effective delivery of the FES. It also describes the materials and the step-by-step manufacturing processes.

RESULTS

The carbon-based dry electrode is integrated into the textile substrate by a thermal compression molding process on an embroidered conductive matrix. This matrix is composed of textile silver-plated conductive yarns and is linked to the stimulator. Besides ensuring the electrical connection, the matrix improves the fixation between the textile substrate and the electrode. The stimulation intensity, the perceived comfort and the muscle torque generated by the smart FES sleeve were compared to hydrogel electrodes. The results show a better average comfort and a higher average stimulation intensity with the smart FES sleeve, while there were no significant differences for the muscle torque generated.

CONCLUSIONS

The integration of the proposed dry electrodes into a textile is a viable solution. The wearable FES system does not negatively impact the electrodes' performance, and tends to improve it. Additionally, the proposed prototyping method is applicable to an entire garment in order to target all muscles. Moreover, the process is feasible for industrial production and commercialization since all materials and processes used are already available on the market.

Ultraconformal Skin-Interfaced Sensing Platform for Motion Artifact-Free Monitoring

Capable of directly capturing various physiological signals from human skin, skin-interfaced bioelectronics has emerged as a promising option for human health monitoring. However, the accuracy and reliability of the measured signals can be greatly affected by body movements or skin deformations (e.g., stretching, wrinkling, and compression). This study presents an ultraconformal, motion artifact-free, and multifunctional skin bioelectronic sensing platform fabricated by a simple and user-friendly laser patterning approach for sensing high-quality human physiological data. The highly conductive membrane based on the room-temperature coalesced Ag/Cu@Cu core-shell nanoparticles in a mixed solution of polymers can partially dissolve and locally deform in the presence of water to form conformal contact with the skin. The resulting sensors to capture improved electrophysiological signals upon various skin deformations and other biophysical signals provide an effective means to monitor health conditions and create human-machine interfaces. The highly conductive and stretchable membrane can also be used as interconnects to connect commercial off-the-shelf chips to allow extended functionalities, and the proof-of-concept demonstration is highlighted in an integrated pulse oximeter. The easy-to-remove feature of the resulting device with water further allows the device to be applied on delicate skin, such as the infant and elderly.

Assessment of bioimpedance spectroscopy devices: a comparative study and error analysis of gold-plated copper electrodes

Objective. Bioimpedance spectroscopy (BIS) is a non-invasive diagnostic tool to derive fluid volume compartments from frequency dependent voltage drops in alternating currents by extrapolating to the extracellular resistance (R0) and intracellular resistance (Ri). Here we tested whether a novel BIS device with reusable and adhesive single-use electrodes produces results which are (in various body positions) equivalent to an established system employing only single-use adhesive electrodes.Approach. Two BIS devices ('Cella' and the 'Body Composition Monitor' [BCM]) were compared using four dedicated resistance testboxes and by measuring 40 healthy volunteers.Invivocomparisons included supine wrist-to-ankle (WA) reference measurements and wrist-to-wrist (WW) measurements with pre-gelled silver/silver-chloride (Ag/AgCl) electrodes and WW measurements with reusable gold-plated copper electrodes.Main results. Coefficient of variation were <1% for all testbox measurements with both BIS devices. Accuracy was within ±1% of true resistance variability, a threshold which was only exceeded by the Cella device for all resistances in a testbox designed with a lowR0/Riratio.Invivo, WA-BIS differed significantly between BIS devices (p< 0.001). Reusable WW electrodes exhibited larger resistances than WW-BIS with Ag/AgCl electrodes (R0: 738.36 and 628.69 Ω;Ri: 1508.18 and 1390 Ω) and the relative error varied from 7.6% to 31.1% (R0) and -15.6% to 37.3% (Ri).Significance. Both BIS devices produced equivalent resistances measurements but different estimates of body composition bothinsilicoand in WA setupsinvivo, suggesting that the devices should not be used interchangeably. Employing WW reusable electrodes as opposed to WA and WW measurement setups with pre-gelled Ag/AgCl electrodes seems to be associated with measurement variations that are too large for safe clinical use. We recommend further investigations of measurement errors originating from electrode material and current path.

Ulcerated skin evaluation by electrical impedance measurements

In the presented study, the transdermal results from the areas surrounding the ulcerated skin areas were compared with those obtained from healthy skin tissue. The analysis of electrical parameters, such as the slope of the Nyquist plot, min. IM, min. RE, min. f, Imagine part index, Phase index, Real part index, and Magnitude index were conducted. Electrical parameters have been measured in the group without lower leg ulceration and in the group with lower leg ulcers. On the basis of the statistical analysis, it was determined that these parameters may be effective in the evaluation of the skin. In fact, the skin surrounding the ulceration was characterised by different values of electrical parameters as compared with healthy skin tissue. A statistically significant difference was found in the electrical parameters obtained for the healthy leg skin and the skin surrounding the ulceration. This study was to investigate the applicability of electrical parameters in the evaluation of the skin in lower leg ulcers. The electrical parameters can be used as an effective tool in assessing the condition of the skin, both healthy and surrounding the ulcerations. The most useful parameters in assessing skin condition using electrical parameters include min. IM, min. RE, min. f, Imagine part index, Phase index, and Magnitude index.

Validating Adhesive-Free Bioimpedance of the Leg in Mid-Activity and Uncontrolled Settings

OBJECTIVE

Musculoskeletal health monitoring is limited in everyday settings where patient symptoms can substantially change - delaying treatment and worsening patient outcomes. Wearable technologies aim to quantify musculoskeletal health outside clinical settings but sensor constraints limit usability. Wearable localized multi-frequency bioimpedance assessment (MFBIA) shows promise for tracking musculoskeletal health but relies on gel electrodes, hindering extended at-home use. Here, we address this need for usable technologies for at-home musculoskeletal health assessment by designing a wearable adhesive-free MFBIA system using textile electrodes in extended uncontrolled mid-activity settings.

METHODS

An adhesive-free multimodal wearable leg MFBIA system was developed in-lab under realistic conditions (5 participants, 45 measurements). Mid-activity textile and gel electrode MFBIA was compared across multiple compound movements (10 participants). Accuracy in tracking long-term changes in leg MFBIA was assessed by correlating gel and textile MFBIA simultaneously recorded in uncontrolled settings (10 participants, 80+ measurement hours).

RESULTS

Mid-activity MFBIA measurements with textile electrodes agreed highly with (ground truth) gel electrode measurements (average [Formula: see text], featuring <1-Ohm differences (0.618 ± 0.340 Ω) across all movements. Longitudinal MFBIA changes were successfully measured in extended at-home settings (repeated measures r = 0.84). Participant responses found the system to be comfortable and intuitive (8.3/10), and all participants were able to don and operate the system independently.

CONCLUSION

This work demonstrates wearable textile electrodes can be a viable substitute for gel electrodes when monitoring leg MFBIA in dynamic, uncontrolled settings.

SIGNIFICANCE

Adhesive-free MFBIA can improve healthcare by enabling robust wearable musculoskeletal health monitoring in at-home and everyday settings.

Parasitic Effects on Electrical Bioimpedance Systems: Critical Review

Parasitic capacitance represents the main error source in measurement systems based on electrical impedance spectroscopy. The capacitive nature of electrodes' impedance in tetrapolar configuration can give origin to phase errors when electrodes are coupled to parasitic capacitances. Nevertheless, reactive charges in tissue excitation systems are susceptible to instability. Based on such a scenario, mitigating capacitive effects associated with the electrode is a requirement in order to reduce errors in the measurement system. A literature review about the main compensation techniques for parasitic capacitance was carried out. The selected studies were categorized into three groups: (i) compensation in electronic instrumentation; (ii) compensation in measurement processing, and (iii) compensation by negative impedance converters. The three analyzed methods emerged as effective against fixed capacitance. No method seemed capable of mitigating the effects of electrodes' capacitance, that changes in the frequency spectrum. The analysis has revealed the need for a method to compensate varying capacitances, since electrodes' impedance is unknown.

Design and Manufacturing of Equipment for Investigation of Low Frequency Bioimpedance

The purpose of this study was to highlight a method of making equipment for the investigation of low frequency bioimpedance. A constant current with an average value of I = 100 µA is injected into the human body via means of current injection electrodes, and the biological signal is taken from the electrodes of electric potential charged with the biopotentials generated by the human body. The resulting voltage, ΔU is processed by the electronic conditioning system. The mathematical model of the four-electrode system in contact with the skin, and considering a target organ, was simplified to a single equivalent impedance. The capacitive filter low passes down from the differential input of the first instrumentation amplifier together with the isolated capacitive barrier integrated in the precision isolated secondary amplifier and maintains the biological signal taken from the electrodes charged with the undistorted biopotentials generated by the human body. Mass loops are avoided, and any electric shocks or electrostatic discharges are prevented. In addition, for small amplitudes of the biological signal, electromagnetic interferences of below 100 Hz of the power supply network were eliminated by using an active fourth-order Bessel filtering module. The measurements performed for the low frequency of f = 100 Hz on the volunteers showed for the investigated organs that the bioelectrical resistivities vary from 90 Ωcm up to 450 Ωcm, and that these are in agreement with other published and disseminated results for each body zone.

Derivation of Bioimpedance Model Data Utilizing a Compact Analyzer and Two Capacitive Electrodes: A Forearm Example

The paper investigates the impacts of the selected electrical equivalent circuit model, measurement setup, and surrounding environment on the trustworthiness of electrical bioimpedance measurement and obtained model data in the human body. The influence of these constitutive components of the system on finding the model parameters is analyzed and illustrated with examples. The results based on experimental measurements on a forearm near the wrist are provided by employing the model, measurement setup, and novel 16-bit compact wireless impedance analyzer (CIA) according to the outcome of the analysis. The area near the wrist is of interest because of attempts to get cardiac-activity-related impedance changes. It is concluded that a two-electrode system with voltage excitation suits better for determining bioimpedance model parameters in the β dispersion area. The results obtained with the CIA and two capacitive bracelet electrodes on a left forearm were used for the fitting model parameters. Despite the small dimensions of 60 × 60 × 25 mm of the CIA reducing stray capacitance to 8 pF, it provides relative impedance magnitude measurement error below 0.3% and phase error below 0.2 ° in the 10 MHz range. Analysis of the model parameters allowed separation of the electrodes, skin, and internal tissue spectra and revealed the relative significance of model components at different frequencies.

Bioimpedance Measurement of Knee Injuries Using Bipolar Electrode Configuration

Currently, there is no suitable solution for the point-of-care diagnosis of knee injuries. A potential portable and low-cost technique for accessing and monitoring knee injuries is bioimpedance measurement. This study validated the feasibility of the bipolar electrode configuration for knee bioimpedance measurement with two electrodes placed on a fixed pair of knee acupuncture locations called Xiyan. Then, the study collected 76 valid samples to investigate the relationship between bioimpedance and knee injuries, among whom 39 patients have unilateral knee injuries, and 37 individuals have healthy knees. The self-contrast results indicated that knee injuries caused a reduction of bioimpedance of the knee by about 5% on average, which was detectable at around 100 kHz (p ≈ 0.001). Furthermore, the results analyzed by principal component analysis and support vector machines show that the detection sensitivity can reach 87.18% using the leave-one-out cross-validation. We also proposed a low-cost and portable bioimpedance measurement device that meets the needs for measuring knee joint bioimpedance.

Textile-Based Wearable Sensor for Skin Hydration Monitoring

This research describes a wearable skin hydration sensor based on cotton textile to determine the state of hydration within the skin via impedance analysis. The sensor structure comprises a textile substrate, thermoplastic over-layer, conductive patterns, and encapsulant, designed for stable and reliable monitoring of the skin's impedance change in relation to hydration level. The porcine skin with different hydration levels was prepared as a model system of the skin, and the textile-based sensor carefully investigated the porcine skin samples' impedance characteristics. The impedance study reveals that (1) the total impedance of skin decreases as its hydration level increases, and (2) the impedance of the stratum corneum and epidermis layers are more dominantly affected by the hydration level of the skin than the dermis layer. Even after repetitive bending cycles, the impedance data of skin measured by the sensor exhibit a reliable dependence on the skin hydration level, which validates the flexibility and durability of the sensor. Finally, it is shown that the textile-based skin hydration sensor can detect various body parts' different hydration levels of human skin while maintaining a stable conformal contact with the skin. The resulting data are well-matched with the readings from a commercial skin hydration sensor.

Arterial Pulse Localization with Varying Electrode Sizes and Spacings in Wrist-Worn Bioimpedance Sensing

Bioimpedance has emerged as a promising modality to continuously monitor hemodynamic and respiratory physiological parameters through a non-invasive skin-contact approach. Bioimpedance sensors placed at the radial zone of the volar wrist provide sensitive operation to the blood flow of the underlying radial artery. The translation of bioimpedance systems into medical-grade settings for continuous hemodynamic monitoring, however, presents challenges when constraining the necessary sensing components to a minimal form factor while maintaining sufficient accuracy and precision of measurements. Thus, it is important to understand the effects of electrode configuration on bioimpedance signals when reducing them to a wearable form factor. Previous work regarding electrode configurations in bioimpedance does not address wearable constraints, nor do they focus on electrodes viable for wearable applications. In this study, we present empirical evidence of the effects of dry silver electrode sizes and spacings on the specificity and sensitivity of a wrist-worn bioimpedance sensor array. We found that wrist-worn bioimpedance systems for hemodynamic monitoring would benefit from reduced injection electrode spacings (up to a 392% increase in signal amplitude with a 50% decrease in spacing), increased sensing electrode spacings, and decreased electrode surface areas. Clinical Relevance - The work directly contributes towards the development of cuffless continuous blood pressure monitors with applications in clinical and ambulatory settings.

Comfortable Body Surface Potential Mapping by Means of a Dry Electrode Belt

Body Surface Potential Mapping is the spatial high-resolution acquisition of cardiac electrical activity from the thorax surface. The method is used to record more comprehensive cardiac information than conventional ECG measurement approaches. Although Body Surface Potential Mapping is well-known and is technically feasible, it is rarely used in clinical environments. One reason for this is the cumbersome procedure of a measurement. The placement of many adhesive gel electrodes and the contacting with many cables are particularly problematic. These limit both patients and medical staff. Therefore, the goal of this work is to technically simplify Body Surface Potential Mapping so that it would be applicable under clinical conditions. For this purpose, we present a new measurement approach in which only a narrow elastic belt is placed around the thorax to measure the electrical activity of the heart. This belt is equipped with an array of reusable gold-plated dry electrodes. With these dry electrodes, the differential voltages are measured in the horizontal and vertical directions. Afterwards, an approximation of the geometrical potential distribution on the thorax is obtained from these measurements. The results are then visualized as videos or image series or used for further analysis. A subject measurement demonstrates the applicability of this novel approach. It is shown that the obtained Body Surface Potential Maps are very similar to those found in the literature, despite a reduced spatial measurement range. This approach is not only applicable for clinical applications but also suitable for monitoring during physiological training.

System Performance and User Feedback Regarding Wearable Bioimpedance System for Multi-Site Knee Tissue Monitoring: Free-Living Pilot Study With Healthy Adults

Knee-focused wearable devices have the potential to support personalized rehabilitation therapies by monitoring localized tissue alterations related to activities that reduce functional symptoms and pain. However, supporting these applications requires reported data to be reliable and accurate which can be challenging in the unsupervised free-living conditions that wearable devices are deployed. This pilot study has assessed a knee-focused wearable sensor system to quantify 1) system performance (operation, rates of data artifacts, environment impacts) to estimate realistic targets for reliable data with this system and 2) user experiences (comfort, fit, usability) to help inform future designs to increase usability and adoption of knee-focused wearables. Study data was collected from five healthy adult participants over 2 days, with 84.5 and 35.9% of artifact free data for longitudinal and transverse electrode configurations. Small to moderate positive correlations were also identified between changes in resistance, temperature, and humidity with respect to acceleration to highlight how this system can be used to explore relationships between knee tissues and environmental/activity context.

Flexible PCB Failures From Dynamic Activity and Their Impacts on Bioimpedance Measurements: A Wearable Case Study

Wearable health monitoring systems that collect data in free-living environments are becoming increasingly popular. Flexible printed circuits provide a commercially available option that can conform to the shape of a wearable system and support electronic sensing and flexible interconnect. However, repetitive dynamic activity can stress and damage the interconnect of flexible PCBs which degrades data quality. This case study evaluated the performance of flexible PCBs providing interconnect between electrodes and sensing electronics for tissue bioimpedance measurements in a wearable system. Resistance data (1 kHz to 128 kHz) was collected from localized knee tissues of 3 participants using the wearable design with flexible PCBs over 7 days of free-living. From electrical and optical inspection after use trace cracking of the flexible PCBs occurred, degrading tissue resistances reported by the wearable system. Exploration of these results advances understanding of how flexible PCBs perform in free-living conditions for wearable bioimpedance applications.

Human Body-Electrode Interfaces for Wide-Frequency Sensing and Communication: A Review

Several on-body sensing and communication applications use electrodes in contact with the human body. Body-electrode interfaces in these cases act as a transducer, converting ionic current in the body to electronic current in the sensing and communication circuits and vice versa. An ideal body-electrode interface should have the characteristics of an electrical short, i.e., the transfer of ionic currents and electronic currents across the interface should happen without any hindrance. However, practical body-electrode interfaces often have definite impedances and potentials that hinder the free flow of currents, affecting the application's performance. Minimizing the impact of body-electrode interfaces on the application's performance requires one to understand the physics of such interfaces, how it distorts the signals passing through it, and how the interface-induced signal degradations affect the applications. Our work deals with reviewing these elements in the context of biopotential sensing and human body communication.

Localized Bioimpedance Measurements with the MAX3000x Integrated Circuit: Characterization and Demonstration

The commercial availability of integrated circuits with bioimpedance sensing functionality is advancing the opportunity for practical wearable systems that monitor the electrical impedance properties of tissues to identify physiological features in support of health-focused applications. This technical note characterizes the performance of the MAX3000x (resistance/reactance accuracy, power modes, filtering, gains) and is available for on-board processing (electrode detection) for localized bioimpedance measurements. Measurements of discrete impedances that are representative of localized tissue bioimpedance support that this IC has a relative error of <10% for the resistance component of complex impedance measurements, but can also measure relative alterations in the 250 mΩ range. The application of the MAX3000x for monitoring localized bicep tissues during activity is presented to highlight its functionality, as well as its limitations, for multi-frequency measurements. This device is a very-small-form-factor single-chip solution for measuring multi-frequency bioimpedance with significant on-board processing with potential for wearable applications.

Comparison of silver-plated nylon (Ag/PA66) e-textile and Ag/AgCl electrodes for bioelectrical impedance analysis (BIA)

Recently, researchers have adapted Bioelectrical Impedance Analysis (BIA) as a new approach to objectively monitor wounds. They have indicated various BIA parameters associated to specific wound types can be linked to wound healing through trend analysis relative to time. However, these studies are conducted using wet electrodes which have been identified as possessing several shortcomings, such as unstable measurements. Thus, the adaption of e-textile electrodes has become an area of interest in measuring biosignals. E-textile electrodes are known to possess a significantly large polarization impedance (Z_p) that potentially influences these biosignal measurements. In this study we aim to identify the suitability of e-textile electrodes to monitor wounds using BIA methodologies. By adapting suggested methodologies conducted in-vivo from previous studies, we used an ex-vivo model to observe the behaviour of e-textile electrodes relative to time. This was compared to common clinical wet electrodes, specifically Ag/AgCl. The objective of this study was to identify the BIA parameters that can be used to monitor wounds with e-textile electrodes. By analysing the BIA parameters relative to time, we observed the influence ofZ_pon these parameters.

Analog Realization of Fractional-Order Skin-Electrode Model for Tetrapolar Bio-Impedance Measurements

This work compares two design methodologies, emulating both AgCl electrode and skin tissue Cole models for testing and verification of electrical bio-impedance circuits and systems. The models are based on fractional-order elements, are implemented with active components, and capture bio-impedance behaviors up to 10 kHz. Contrary to passive-elements realizations, both architectures using analog filters coupled with adjustable transconductors offer tunability of the fractional capacitors’ parameters. The main objective is to build a tunable active integrated circuitry block that is able to approximate the models’ behavior and can be utilized as a Subject Under Test (SUT) and electrode equivalent in bio-impedance measurement applications. A tetrapolar impedance setup, typical in bio-impedance measurements, is used to demonstrate the performance and accuracy of the presented architectures via Spectre Monte-Carlo simulation. Circuit and post-layout simulations are carried out in 90-nm CMOS process, using the Cadence IC suite.

Textile band electrodes as an alternative to spot Ag/AgCl electrodes for calf bioimpedance measurements

OBJECTIVE

To evaluate the performance of five different types of textiles as band electrodes for calf bioimpedance measurements in comparison with conventional spot Ag/AgCl electrodes.

APPROACH

Calf bioimpedance measurements were performed in 10 healthy volunteers with five different textile materials cut into bands and Ag/AgCl spot electrodes as a baseline. Collected bioimpedance data were analyzed in terms of precision, fit error and presence of measurement artifacts. Each textile material was also evaluated for participant comfort.

MAIN RESULTS

Bioimpedance values for spot electrodes were higher at low frequencies as compared with band electrodes but not at high frequencies. This suggests that spot electrodes have frequency dependent current distributions that adversely impact their use for volume measurements and band electrodes are preferable. The SMP130T-B fabric had the highest precision and the lowest best fit error to the Cole model of the tested textile materials. However, it was the least comfortable textile and most expensive. The Stretch material performed slightly worse than the SMP130T-B fabric, but was half the cost and the most comfortable.

SIGNIFICANCE

These results suggest that there are suitable textile materials for use as dry, band electrodes for calf bioimpedance measurements and that these band electrodes enable greater current uniformity. These textiles could be integrated into a compression sock for remote monitoring of diseases such as Congestive Heart Failure.