Optimization of cardiac defibrillation by three-dimensional finite element modeling of the human thorax

Can Mobile Videocall Assist Laypersons' Use of Automated External Defibrillators? A Randomized Simulation Study and Qualitative Analysis

Objective

To investigate the feasibility of mobile videocall guidance to facilitate AED use by laypersons. Design, setting, and participants. A total of 90 laypersons were randomized into three groups: the mobile video call-guided, voice call-guided, and non-guided groups. Participants were exposed to simulated cardiac arrest to use an AED, and guided by video calls, voice calls, or were not guided. We recorded the simulation experiments as a videoclip, and other researchers who were blinded to the simulation assessed the performance according to the prespecified checklist after simulations. Outcomes measure and analysis. We compared the performance score and time intervals from AED arrival to defibrillation among the three groups and analyzed the common errors.

Results

There was no significant difference among the three groups in terms of baseline characteristics. Performance scores in the checklist for using AED were higher in the mobile video call-guided group, especially in the category of "Power on AED" and "Correctly attaches pads" than in the other groups. However, the time interval to defibrillation was significantly longer in the mobile video call-guided group.

Conclusions

Mobile video call guidance might be an alternative method to facilitate AED use by laypersons. Therefore, further well-designed research is needed to evaluate the feasibility of this approach in OHCA.

Accuracy of instructional diagrams for automated external defibrillator pad positioning

INTRODUCTION

Correct defibrillation pad positioning optimises the chances of successful defibrillation. AEDs have pictoral representation to guide untrained bystanders in correct pad positioning. There is a wide variation in this pictoral guidance and evidence suggests that correct anatomical pad placement is poor. We reviewed all currently available diagrams and assessed the resultant pad placement achieved by untrained bystanders following these instructions.

METHODS

Twenty untrained bystanders were presented with a total of 27 different pad placement diagrams (including one designed by the researchers) in a random sequence and were asked to apply them to the chest of an adult manikin. The lateral/medial and cranial/caudal position in relation to the optimal position recommended by the European Resuscitation Council guidelines was then measured for each pair of pads.

RESULTS

Overall, the sternal pad was placed an average of 6.0 mm cranial to, and 3.2 mm medial to, the optimal position. The apical pad was placed an average of 78.2 mm caudal to, and 59.3 mm medial to, the optimal position. The pad position diagram we designed and assessed out performed existing diagrams.

CONCLUSION

All current defibrillation pad diagrams fail to achieve accurate defibrillation pad placement. A clearer, more effective diagram, such as the one we designed, is urgently needed to ensure bystander defibrillation is effective as possible.

Effect of ventricular myocardium characteristics on the defibrillation threshold

Myocardium characteristics differ markedly among individuals and play an important role in defibrillation threshold. The accuracy of simulation models used in most published studies are still have room to be improved and most of them only discussed the effect of myocardial anisotropy on defibrillation threshold. In our manuscript, a rabbit ventricular finite-element (FE) volume conductor model with high precision was constructed. Ventricular myocardium characteristics include cardiomyocyte coupling and the degree of myocardial anisotropy, which are represented as the value and the ratio of anisotropic conductivity, respectively. Quantitative analysis was performed simultaneously in terms of cardiomyocyte coupling and the degree of myocardial anisotropy. Based on this, the combined effects of these two factors were further discussed. The electric field distributions of shocks and the defibrillation thresholds under different myocardial characteristics were simulated on this model. The simulation results revealed that as the degree of myocardial anisotropy increases, defibrillation threshold increases, and cardiomyocyte decoupling (decrease in electrical conductivity) can considerably increase the defibrillation threshold.

Absence of Rapid Propagation through the Purkinje Network as a Potential Cause of Line Block in the Human Heart with Left Bundle Branch Block

Background: Cardiac resynchronization therapy is an effective device therapy for heart failure patients with conduction block. However, a problem with this invasive technique is the nearly 30% of non-responders. A number of studies have reported a functional line of block of cardiac excitation propagation in responders. However, this can only be detected using non-contact endocardial mapping. Further, although the line of block is considered a sign of responders to therapy, the mechanism remains unclear.

Methods: Herein, we created two patient-specific heart models with conduction block and simulated the propagation of excitation based on a cellmodel of electrophysiology. In one model with a relatively narrow QRS width (176 ms), we modeled the Purkinje network using a thin endocardial layer with rapid conduction. To reproduce a wider QRS complex (200 ms) in the second model, we eliminated the Purkinje network, and we simulated the endocardial mapping by solving the inverse problem according to the actual mapping system.

Results: We successfully observed the line of block using non-contact mapping in the model without the rapid propagation of excitation through the Purkinje network, although the excitation in the wall propagated smoothly. This model of slow conduction also reproduced the characteristic properties of the line of block, including dense isochronal lines and fractionated local electrocardiograms. Further, simulation of ventricular pacing from the lateral wall shifted the location of the line of block. By contrast, in the model with the Purkinje network, propagation of excitation in the endocardial map faithfully followed the actual propagation in the wall, without showing the line of block. Finally, switching the mode of propagation between the two models completely reversed these findings.

Conclusions: Our simulation data suggest that the absence of rapid propagation of excitation through the Purkinje network is the major cause of the functional line of block recorded by non-contact endocardial mapping. The line of block can be used to identify responders as these patients loose rapid propagation through the Purkinje network.

New conducted electrical weapons: Finite element modeling of safety margins

Introduction-We have previously published on the ventricular fibrillation (VF) risk with TASER^® X26 conducted electrical weapon (CEW). Our risk model accounted for realistic body mass index distributions, modeled the effects of partial or oblique dart penetration, and used epidemiological CEW statistics. As new CEWs have become available to law enforcement, their cardiac safety profile was not quantified. Therefore, we applied our VF probability model to evaluate their cardiac risk. Methods and Results-An eXperimental Rotating-Field (XRF) waveform CEW and the X2 CEW are new 2-shot electrical weapon models designed to target a precise amount of delivered charge per pulse, 64 μC and 62 μC, respectively. They can deploy 1 or 2 probe pairs, delivered by 2 separate cartridges. New Smart Probes (SP), which carry 11.5 mm long CEW darts, can be used with XRF and X2 CEWs. Finite element modeling (FEM) was used to approximate the current and charge densities produced by XRF and X2 CEWs in tissues located in the vicinity of darts, including accounting for the effects of fat, anisotropic skeletal muscles, sternum, ribs, and lungs. Using our previous cardiac risk probabilistic model, the new XRF and X2 CEWs operated with 11.5 mm SPs, had an estimated overall theoretical VF risk of less than 1 in 1 300 000 and 1 in 1 490 000 cases, respectively. We also found that the XRF and X2 CEWs had increased cardiac safety margins with respect to those previously reported for the X26 CEWs when all three CEW models were operated with 9 mm CEW darts. Lastly, the cardiac risk of these new CEWs (<; 0.76 ppm) was found to be much lower than reported levels of CEW non-cardiac fatal injuries (e.g. falls and burns, > 7.2 ppm). Conclusions-While not risk-free, the new TASER XRF and X2 CEWs offer increased cardiac safety margins and extremely low cardiac risk profiles.

Current distribution in tissues with conducted electrical weapons operated in drive-stun mode

INTRODUCTION

The TASER® conducted electrical weapon (CEW) is best known for delivering electrical pulses that can temporarily incapacitate subjects by overriding normal motor control. The alternative drive-stun mode is less understood and the goal of this paper is to analyze the distribution of currents in tissues when the CEW is operated in this mode.

METHODS AND RESULTS

Finite element modeling (FEM) was used to approximate current density in tissues with boundary electrical sources placed 40 mm apart. This separation was equivalent to the distance between drive-stun mode TASER X26™, X26P, X2 CEW electrodes located on the device itself and between those located on the expended CEW cartridge. The FEMs estimated the amount of current flowing through various body tissues located underneath the electrodes. The FEM simulated the attenuating effects of both a thin and of a normal layer of fat. The resulting current density distributions were used to compute the residual amount of current flowing through deeper layers of tissue. Numerical modeling estimated that the skin, fat and skeletal muscle layers passed at least 86% or 91% of total CEW current, assuming a thin or normal fat layer thickness, respectively. The current density and electric field strength only exceeded thresholds which have increased probability for ventricular fibrillation (VFTJ), or for cardiac capture (CCTE), in the skin and the subdermal fat layers.

CONCLUSION

The fat layer provided significant attenuation of drive-stun CEW currents. Beyond the skeletal muscle layer, only fractional amounts of the total CEW current were estimated to flow. The regions presenting risk for VF induction or for cardiac capture were well away from the typical heart depth.

Tailor-made heart simulation predicts the effect of cardiac resynchronization therapy in a canine model of heart failure

Despite extensive studies on clinical indices for the selection of patient candidates for cardiac resynchronization therapy (CRT), approximately 30% of selected patients do not respond to this therapy. Herein, we examined whether CRT simulations based on individualized realistic three-dimensional heart models can predict the therapeutic effect of CRT in a canine model of heart failure with left bundle branch block. In four canine models of failing heart with dyssynchrony, individualized three-dimensional heart models reproducing the electromechanical activity of each animal were created based on the computer tomographic images. CRT simulations were performed for 25 patterns of three ventricular pacing lead positions. Lead positions producing the best and the worst therapeutic effects were selected in each model. The validity of predictions was tested in acute experiments in which hearts were paced from the sites identified by simulations. We found significant correlations between the experimentally observed improvement in ejection fraction (EF) and the predicted improvements in ejection fraction (P<0.01) or the maximum value of the derivative of left ventricular pressure (P<0.01). The optimal lead positions produced better outcomes compared with the worst positioning in all dogs studied, although there were significant variations in responses. Variations in ventricular wall thickness among the dogs may have contributed to these responses. Thus CRT simulations using the individualized three-dimensional heart models can predict acute hemodynamic improvement, and help determine the optimal positions of the pacing lead.

A multi-criteria evaluation method for assessing the defibrillation outcome of different electrode placements in swine

Compared with clinical and experimental approaches, numerical modeling of defibrillation offers a great opportunity to optimize the defibrillation strategy in a more individualized way. Through numerical simulation of the shock-induce electric field distribution, the outcome of a certain defibrillation shock could be predicted according to several different metrics. In this paper, we propose a novel evaluation method, in which four defibrillation criteria are assigned with separate weighting factors to quantitatively assess the efficiency of a certain defibrillation shock. Three anatomically realistic finite element models of swine were constructed for the evaluation study of 8 electrode pairs in different placements. In addition, corresponding animal experiments were performed to determine the defibrillation threshold of 8 electrode placements. Both computational and experimental results suggest that the clinical recommended anterior-lateral position is the most efficient electrode displacement for transthoracic defibrillation in swine. In conclusion, the good agreement between stimulations and experiments indicates that the present multi-criteria evaluation method would be potentially useful for optimizations of cardiac defibrillation outcome.

Cardiac fibrillation risks with TASER conducted electrical weapons

The TASER(®) conducted electrical weapon (CEW) delivers electrical pulses that can temporarily incapacitate subjects. We analyzed the cardiac fibrillation risk with TASER CEWs. Our risk model accounted for realistic body mass index distributions, used a new model of effects of partial or oblique dart penetration and used recent epidemiological CEW statics.

Transmural and apicobasal gradients in repolarization contribute to T-wave genesis in human surface ECG

The cellular basis of the T-wave morphology of surface ECG remains controversial in clinical cardiology. We examined the effect of action potential duration (APD) distribution on T-wave morphology using a realistic model of the human ventricle and torso. We developed a finite-element model of the ventricle consisting of ∼26 million elements, including the conduction system, each implemented with the ion current model of cardiomyocytes. This model was embedded in a torso model with distinct organ structures to obtain the standard ECG leads. The APD distribution was changed in the transmural direction by locating the M cells in either the endocardial or epicardial region. We also introduced apicobasal gradients by modifying the ion channel parameters. Both the transmural gradient (with M cells on the endocardial side) and the apicobasal gradient produced positive T waves, although a very large gradient was required for the apicobasal gradient. By contrast, T waves obtained with the transmural gradient were highly symmetric and, therefore, did not represent the true physiological state. Only combination of the transmural and the moderate apicobasal gradients produced physiological T waves in surface ECG. Positive T waves in surface ECG mainly originated from the transmural distribution of APD with M cells on the endocardial side, although the apicobasal gradient was also required to attain the physiological waveform.

Medical safety of TASER conducted energy weapon in a hybrid 3-point deployment mode

INTRODUCTION

TASER conducted energy weapons (CEW) deliver electrical pulses that can temporarily incapacitate subjects. The goal of this paper is to analyze the distribution of TASER CEW currents in the heart and surrounding organs and to understand theoretical chances of triggering cardiac arrhythmias, of capturing the vagus and phrenic nerves and producing electroporation of skeletal muscle structures. The CEW operates in either probe mode or drive-stun (direct contact) mode. There is also a hybrid mode in which current is passed from a single probe to either or both of 2 drive-stun electrodes on the weapon, presumed to be in direct contact with the skin.

METHODS AND RESULTS

The models analyzed herein describe strength-duration thresholds for myocyte excitation and ventricular fibrillation (VF) induction. Finite element modeling (FEM) was used to approximate current density in the heart for worst-case TASER electrode placement. The FEMs theoretically estimated that maximum TASER CEW current densities in the heart and in neighboring organs are at safe levels. A 3-point deployment mode was compared to probe-mode deployment. The margins of safety for the 3-point deployment were estimated to be as high as or higher than for the probe-mode deployment.

CONCLUSION

Numerical modeling estimated that TASER CEWs were expected to be safe when deployed in 3-point mode. In drive-stun, probe-mode or 3-point deployments, the CEWs had high theoretically approximated safety margins for cardiac capture, VF, phrenic or vagus nerve capture and skeletal muscle damage by electroporation.

Estimating the measuring sensitivity of unipolar and bipolar ECG with lead field method and FDM models

New portable electrocardiogram (ECG) measurement systems are emerging into market. Some use nonstandard bipolar electrode montage and sometimes very small interelectrode distances to improve the usability of the system. Modeling could provide a straightforward method to test new electrode systems. The aim of this study was to assess whether modeling the electrodes' measuring sensitivity with lead field method can provide a simple tool for testing a number of new electrode locations. We evaluated whether the actual ECG signal strength can be estimated by lead fields with two realistic 3D finite difference method (FDM) thorax models. We compared the modeling results to clinical body surface potential map (BSPM) data from 236 normal patients and studied 117 unipolar and 42 bipolar leads. In the case of unipolar electrodes the modeled measuring sensitivities correlated well with the clinical data (r=0.86, N=117, p<0.05). In the case of bipolar electrodes the correlation was moderate (r=0.62 between Model 1 and clinical data, r=0.71 between Model 2 and clinical data, N=42 and p<0.05 for both). Based on this we can conclude that lead field analysis based on realistic thorax models provides a good initial prediction for designing new electrode montages and measurement systems.

Transthoracic atrial defibrillation energy thresholds are correlated to uniformity of current density distributions

Previous studies have shown that successful defibrillation depends on the uniformity of current density in the heart and the percentage of total current reaching the heart. This study uses an anatomically-realistic finite element computer model of the human torso for external atrial defibrillation to (1) examine the defibrillation energy thresholds and current density distributions for common clinical paddle placements and (2) investigate the effects of electrode shifts on these defibrillation parameters. The model predicts atrial defibrillation threshold (AD FT) energy by requiring a voltage gradient of 5 V/cm over at least 95% of atrial myocardium. This study finds that variation in electrode placement by only a few centimeters increases ADFTs by up to 46% with a corresponding change of 38% between the average current density in the left and right atria and 34% between the heterogeneity indices of atrial current density distributions. Additionally, the heterogeneity index, or degree of uniformity, is linearly correlated to the ADFT (R2=0.9). We suggest that uniformity of current density distribution, in addition to minimum current density, may be an important parameter to use for predicting successful defibrillation when testing new electrode placements.

DefibViz: a visualization tool for the assessment of electrode parameters on transthoracic defibrillation thresholds

DefibViz is a software application developed for defibrillation simulation and visualization. It exploits both surface techniques and methods for the interactive exploration of volumetric datasets for the analysis of transthoracic defibrillation simulation results. DefibViz\ has a graphical user interface for the specification of the shape, size, position, and applied voltage of a defibrillator's electrodes. An option is provided for using 3-D slice plane widgets, which operate on the volumetric datasets, such that the distribution of the voltage gradient induced by an electric shock can be visually inspected in various tissues throughout the myocardium and torso. One goal of DefibViz is to enhance understanding of how electrode parameters relate to the change of the voltage gradient distribution throughout the heart, which may help lead to optimal defibrillator design. DefibViz; is significant, in that, it is built by using an open-source graphics and visualization framework providing a platform for subsequent modifiability and extensibility. Moreover, it integrates simulation and visualization techniques, which previously required the running of several independent software executables, into an enhanced, seamless, and comprehensive software application.

Image based modeling of defibrillation in children

Volume imaging, defibrillation electrode models, and finite element modeling are employed in patient-specific procedural modeling in pediatric patients with cardiac arrhythmias. Due to variable size and anatomy, these patients may not be well-served by devices designed for adult defibrillation. A pipeline for rapid creation of image based models that can be interactively interrogated to determine optimal defibrillation scenarios and preliminary proof-of-concept work are presented. This approach has potential clinical applications for therapy planning and broad applications for finite element modeling in anatomical models. Clinical studies investigating the effects of body size, habitus, and anatomical variation on myocardial voltage gradients are planned.

Cardiac current density distribution by electrical pulses from TASER devices

TASERs deliver electrical pulses that can temporarily incapacitate subjects. The goal of this paper is to analyze the distribution of TASER currents in the heart and understand their chances of triggering cardiac arrhythmias. The models analyzed herein describe strength-duration thresholds for myocyte excitation and ventricular fibrillation induction. Finite element modeling is used to compute current density in the heart for worst-case TASER electrode placement. The model predicts a maximum TASER current density of 0.27 mA/cm(2) in the heart. It is conclude that the numerically simulated TASER current density in the heart is about half the threshold for myocytes excitation and more than 500 times lower than the threshold required for inducing ventricular fibrillation. Showing a substantial cardiac safety margin, TASER devices do not generate currents in the heart that are high enough to excite myocytes or trigger VF.

A computer modeling tool for comparing novel ICD electrode orientations in children and adults

BACKGROUND

Use of implantable cardiac defibrillators (ICDs) in children and patients with congenital heart disease is complicated by body size and anatomy. A variety of creative implantation techniques has been used empirically in these groups on an ad hoc basis.

OBJECTIVE

To rationalize ICD placement in special populations, we used subject-specific, image-based finite element models (FEMs) to compare electric fields and expected defibrillation thresholds (DFTs) using standard and novel electrode configurations.

METHODS

FEMs were created by segmenting normal torso computed tomography scans of subjects ages 2, 10, and 29 years and 1 adult with congenital heart disease into tissue compartments, meshing, and assigning tissue conductivities. The FEMs were modified by interactive placement of ICD electrode models in clinically relevant electrode configurations, and metrics of relative defibrillation safety and efficacy were calculated.

RESULTS

Predicted DFTs for standard transvenous configurations were comparable with published results. Although transvenous systems generally predicted lower DFTs, a variety of extracardiac orientations were also predicted to be comparably effective in children and adults. Significant trend effects on DFTs were associated with body size and electrode length. In many situations, small alterations in electrode placement and patient anatomy resulted in significant variation of predicted DFT. We also show patient-specific use of this technique for optimization of electrode placement.

CONCLUSION

Image-based FEMs allow predictive modeling of defibrillation scenarios and predict large changes in DFTs with clinically relevant variations of electrode placement. Extracardiac ICDs are predicted to be effective in both children and adults. This approach may aid both ICD development and patient-specific optimization of electrode placement. Further development and validation are needed for clinical or industrial utilization.

Simultaneous double external DC shock techniques for atrial fibrillation: a simulation study

The success rate of direct current cardioversion (DCC), the most common method to convert atrial fibrillation (AF) to sinus rhythm (SR), depends on various factors including AF duration, prior anti-arrhythmic therapy, electrode position and size, transthoracic impedance, and the use of biphasic versus monophasic shocks. Recent, small clinical studies have reported using quadruple electrodes to deliver higher energy, in order to increase DCC success rates in refractory patients. This study aims to computationally model and compare double shock defibrillation with conventional single shock DCC, based on the two parameters, defibrillation threshold (DFT) and heterogeneity index (HI). DFT is the energy required to achieve a voltage gradient of 5 V/cm over 95% of the atrial myocardium. HI, calculated as the (95(th)-5(th))/50(th) percentile of atrial electric field magnitudes, is a measure of non-uniformity. The electric field distributions in the myocardium were generated for over five thousand different conventional and quadruple electrode placements with electrodes of two different sizes. Results show that there is a significant decrease in DFT (p0.01) and HI (p0.01) with increase in electrode size and quantity.

Finite element computer modeling of transthoracic atrial defibrillation

Placement of external electrodes can significantly affect the success rate of transthoracic atrial defibrillation, but studies have not led to agreement on optimal electrode placements. This study aims to (1) develop an anatomically realistic, finite element model of the human torso for external atrial defibrillation, (2) investigate model parameters of skeletal muscle conductivity and anisotropy and the presence of subcutaneous fat, and (3) investigate clinical defibrillation parameters of electrode size, shape, and location. The model predicts atrial defibrillation threshold (ADFT) energy by requiring a voltage gradient of 5 V/cm over at least 95% of atrial myocardium. The model compares favorably with a clinical study of 301 patients that reported an anterior-posterior electrode position required approximately 20% less energy than an anterior-anterior position. Results indicate that a change in electrode size has a different effect for different electrode placements. This study finds that variation in electrode placement by only a few centimeters can change ADFTs by up to 51%. This is the first computer model of transthoracic atrial defibrillation to our knowledge. Our computer model is not limited to a few empirically selected electrode placements as in clinical studies and can test any location, size, and number of electrode placements.

Finite element modelling and simulations in cardiovascular mechanics and cardiology: A bibliography 1993–2004

The paper gives a bibliographical review of the finite element modelling and simulations in cardiovascular mechanics and cardiology from the theoretical as well as practical points of views. The bibliography lists references to papers, conference proceedings and theses/dissertations that were published between 1993 and 2004. At the end of this paper, more than 890 references are given dealing with subjects as: Cardiovascular soft tissue modelling; material properties; mechanisms of cardiovascular components; blood flow; artificial components; cardiac diseases examination; surgery; and other topics.

An Epicardial Subxiphoid Implantable Defibrillator Lead:. Superior Effectiveness After Failure of Standard Implants

A single epicardial implantable lead using the subxiphoid approach is described in this article. It consists of a single halo-shaped coil that is implanted under the inferior surface of the heart, including the right and left inferior ventricular surfaces. It has been implanted in four patients who could not be defibrillated with a transvenous system, even with the adjunct use of subcutaneous leads or left chest wall patch. Three of the patients had progressive heart failure due to ischemic myocardiopathy; the fourth patient had a dilated idiopathic myocardiopathy. The approach is simple and appears to be effective due to its ability to encompass the left and right ventricles. This vector seems to significantly lower the threshold for defibrillation, and may offer substantial benefit in the setting of high defibrillation thresholds with conventional leads, or when conventional systems are inadequate to achieve consistent defibrillation.

Measurement of thoracic current flow in pigs for the study of defibrillation and cardioversion

Although defibrillation has been in clinical use for more than 50 years, the complete current flow distribution inside the body during a defibrillation procedure has never been directly measured. This is due to the lack of appropriate imaging technology to noninvasively monitor the current flow inside the body. The current density imaging (CDI) technique, using a magnetic resonance (MR) imager, provides a new approach to this problem [Scott et al. (1991)]. CDI measures the local magnetic field generated by the current and calculates the current density by computing its curl. In this study, CDI was used to measure current density at all points within a postmortem pig torso during an electrical current application through defibrillation electrodes. Furthermore, current flow information was visualized along the chest wall and within the chest cavity using streamline analysis. As expected, some of the highest current densities were observed in the chest wall. However, current density distribution varied significantly from one region to another, possibly reflecting underlying heterogeneous tissue conductivity and anisotropy. Moreover, the current flow analysis revealed many complex and unexpected current flow patterns that have never been observed before. This study has, for the first time, noninvasively measured the volume current measurement inside the pig torso.

Estimation of current density distribution under electrodes for external defibrillation

BACKGROUND

Transthoracic defibrillation is the most common life-saving technique for the restoration of the heart rhythm of cardiac arrest victims. The procedure requires adequate application of large electrodes on the patient chest, to ensure low-resistance electrical contact. The current density distribution under the electrodes is non-uniform, leading to muscle contraction and pain, or risks of burning. The recent introduction of automatic external defibrillators and even wearable defibrillators, presents new demanding requirements for the structure of electrodes.

METHOD AND RESULTS

Using the pseudo-elliptic differential equation of Laplace type with appropriate boundary conditions and applying finite element method modeling, electrodes of various shapes and structure were studied. The non-uniformity of the current density distribution was shown to be moderately improved by adding a low resistivity layer between the metal and tissue and by a ring around the electrode perimeter. The inclusion of openings in long-term wearable electrodes additionally disturbs the current density profile. However, a number of small-size perforations may result in acceptable current density distribution.

CONCLUSION

The current density distribution non-uniformity of circular electrodes is about 30% less than that of square-shaped electrodes. The use of an interface layer of intermediate resistivity, comparable to that of the underlying tissues, and a high-resistivity perimeter ring, can further improve the distribution. The inclusion of skin aeration openings disturbs the current paths, but an appropriate selection of number and size provides a reasonable compromise.

Calibrated single-plunge bipolar electrode array for mapping myocardial vector fields in three dimensions during high-voltage transthoracic defibrillation

Mapping of the myocardial scalar electric potential during defibrillation is normally performed with unipolar electrodes connected to voltage dividers and a global potential reference. Unfortunately, vector potential gradients that are calculated from these data tend to exhibit a high sensitivity to measurement errors. This paper presents a calibrated single-plunge bipolar electrode array (EA) that avoids the error sensitivity of unipolar electrodes. The EA is triaxial, uses a local potential reference, and simultaneously measures all three components of the myocardial electric field vector. An electrode spacing of approximately 500 microm allows the EA to be direct-coupled to high-input-impedance, isolated, differential amplifiers and eliminates the need for voltage dividers. Calibration is performed with an electrolytic tank in which an accurately measured, uniform electric field is produced. For each EA, unique calibration matrices are determined which transform potential difference readings from the EA to orthogonal components of the electric field vector. Elements of the matrices are evaluated by least squares multiple regression analysis of data recorded during rotation of the electric field. The design of the electrolytic tank and electrode holder allows the electric field vector to be rotated globally with respect to the electrode axes. The calibration technique corrects for both field perturbation by the plunge electrode body and deviations from orthogonality of the electrode axes. A unique feature of this technique is that it eliminates the need for mechanical measurement of the electrode spacing. During calibration, only angular settings and voltages are recorded. For this study, ten EAs were calibrated and their root-mean-square (rms) errors evaluated. The mean of the vector magnitude rms errors over the set of ten EAs was 0.40% and the standard deviation 0.07%. Calibrated EAs were also tested for multisite mapping in four dogs during high-voltage transthoracic shocks.

Optimization of the defibrillation current density in the heart region by a two-layer segmented electrode

Transthoracic defibrillation is a procedure applying high intensity electrical current through the thorax region by electrodes, in order to simultaneously activate most of the myocardial cells, thus enforcing them to reinstate a normal rhythm. A solution is proposed for analysis and synthesis of the current density distribution field in the heart region. In an attempt to reach uniform excitation of the greatest possible quantity of myocardial cells, a field image is searched for, with the J-vector uniformity distribution as a criterion. The finite element method and the method of approximating functions are used, as well as nonlinear programming. This approach resulted in designing a two-layer defibrillation electrode, with the layer applied to to the thorax divided in three different resistivity regions.

A software implementation for detailed volume conductor modelling in electrophysiology using finite difference method

There is an evolving need for new information available by employing patient tailored anatomically accurate computer models of the electrical properties of the human body. Because construction of a computer model can be difficult and laborious to perform sufficiently well, devised models have varied greatly in the level of anatomical accuracy incorporated in them. This has restricted the validity of conducted simulations. In the present study, a versatile software package was developed to transform anatomic voxel data into accurate finite difference method volume conductor models conveniently and in a short time. The package includes components for model construction, simulation, visualisation and detailed analysis of simulation output based on volume conductor theory. Due to the methods developed, models can comprise more anatomical details than the prior computer models. Several models have been constructed, for example, a highly detailed 3-D anatomically accurate computer model of the human thorax as a volume conductor utilising the US National Library of Medicine's (NLM) Visible Human Man (VHM) digital anatomy data. Based on the validation runs the developed software package is readily applicable in analysis of a wide range of bioelectric field problems.

Defibrillation efficacy of different electrode placements in a human thorax model

The objective of this study was to measure the defibrillation threshold (DFT) associated with different electrode placements using a three-dimensional anatomically realistic finite element model of the human thorax. Coil electrodes (Endotak DSP, model 125, Guidant/CPI) were placed in the RV apex along the lateral wall (RV), withdrawn 10 mm away from the RV apex along the lateral wall (RVprox), in the RV apex along the anterior septum (RVseptal), and in the SVC. An active pulse generator (can) was placed in the subcutaneous prepectoral space. Five electrode configurations were studied: RV-->SVC, RVprox-->SVC, RVSEPTAL-->SVC, RV-->Can, and RV-->SVC + Can. DFTs are defined as the energy required to produce a potential gradient of at least 5 V/cm in 95% of the ventricular myocardium. DFTs for RV-->SVC, RVprox-->SVC, RVseptal-->SVC, RV-->Can, and RV-->SVC + Can were 10, 16, 7, 9, and 6 J, respectively. The DFTs measured at each configuration fell within one standard deviation of the mean DFTs reported in clinical studies using the Endotak leads. The relative changes in DFT among electrode configurations also compared favorably. This computer model allows measurements of DFT or other defibrillation parameters with several different electrode configurations saving time and cost of clinical studies.

Impact of transvenous lead position on active-can ICD defibrillation: a computer simulation study

Optimizing lead placement in transvenous defibrillation remains central to the clinical aspects of the defibrillation procedure. Studies involving superior vena cava (SVC) return electrodes have found that left ventricular (LV) leads or septal positioning of the right ventricular (RV) lead minimizes the voltage defibrillation threshold (VDFT) in endocardial lead-->SVC defibrillation systems. However, similar studies have not been conducted for active-can configurations. The goal of this study was to determine the optimal lead position to minimize the VDFT for systems incorporating an active can. This study used a high resolution finite element model of a human torso that includes the fiber architecture of the ventricular myocardium to find the role of lead positioning in a transvenous LEAD-->can defibrillation electrode system. It was found that, among single lead systems, posterior positioning of leads in the right ventricle lowers VDFTs appreciably. Furthermore, a septal location of leads resulted in lower VDFTs than free-wall positioning. Increasing the number of leads, and thus the effective lead surface area in the right ventricle also resulted in lower VDFTs. However, the lead configuration that resulted in the lowest VDFTs is a combination of mid-cavity right ventricle lead and a mid-cavity left ventricle lead. The addition of a left ventricular lead resulted in a reduction in the size of the low gradient regions and a change of its location from the left ventricular free wall to the septal wall.

Finite element analysis of defibrillation fields in a human torso model for ventricular defibrillation

In order to optimize defibrillation electrode systems for ventricular defibrillation thresholds (DFTs), a Finite Element Torso model was built from fast CT scans of a patient who had large cardiac dimensions (upper bound of normal) but no heart disease. Clinically used defibrillation electrode configurations, i.e. Superior Vena Cava (SVC) to Right Ventricle (RV) (SVC-RV), left pectoral Can to RV (Can-RV) and Can + SVC-RV, were analyzed. The DFTs were calculated based on 95% ventricular mass having voltage gradient > 5 V/cm and these results were also compared with clinical data. The low voltage gradient regions with voltage gradient < 5 V/cm were identified and the effect of electrode dimension and location on DFTs were also investigated for each system. A good correlation between the model results and the clinical data supports the use of Finite Element Analysis of a human torso model for optimization of defibrillation electrode systems. This correlation also indicates that the critical mass hypothesis is the primary mechanism of defibrillation. Both the FEA results and the clinical data show that Can + SVC-RV system offers the lowest voltage DFTs when compared with SVC-RV and Can-RV systems. Analysis of the effect of RV, SVC and Can electrode dimensions and locations can have an important impact on defibrillation lead designs.

Detailed model of the thorax as a volume conductor based on the visible human man data

A large number of computerized conductivity models of the human thorax have been created to study bioelectric phenomena in human beings. Devised models have varied greatly in the level of anatomical detail incorporated thus restricting the accuracy and validity of conducted simulations. This paper introduces a highly detailed anatomically accurate three-dimensional computer model of the conductive anatomy of the human thorax for calculating electric fields generated by equivalent bioelectric sources and different externally applied sources. The anatomy of the devised model is based on high resolution colour cryosection images of the US National Library of Medicine's Visible Human Man data set and is comprised of more anatomical detail than prior computer models. The model is based on the finite difference method and is readily applicable for the analysis of a wide range of biomedical field problems, such as electrocardiography, impedance cardiography, tissue stimulations, and especially, in development of measurement systems.

A generalized activating function for predicting virtual electrodes in cardiac tissue

To fully understand the mechanisms of defibrillation, it is critical to know how a given electrical stimulus causes membrane polarizations in cardiac tissue. We have extended the concept of the activating function, originally used to describe neuronal stimulation, to derive a new expression that identifies the sources that drive changes in transmembrane potential. Source terms, or virtual electrodes, consist of either second derivatives of extracellular potential weighted by intracellular conductivity or extracellular potential gradients weighted by derivatives of intracellular conductivity. The full response of passive tissue can be considered, in simple cases, to be a convolution of this "generalized activating function" with the impulse response of the tissue. Computer simulations of a two-dimensional sheet of passive myocardium under steady-state conditions demonstrate that this source term is useful for estimating the effects of applied electrical stimuli. The generalized activating function predicts oppositely polarized regions of tissue when unequally anisotropic tissue is point stimulated and a monopolar response when a point stimulus is applied to isotropic tissue. In the bulk of the myocardium, this new expression is helpful for understanding mechanisms by which virtual electrodes can be produced, such as the hypothetical "sawtooth" pattern of polarization, as well as polarization owing to regions of depressed conductivity, missing cells or clefts, changes in fiber diameter, or fiber curvature. In comparing solutions obtained with an assumed extracellular potential distribution to those with fully coupled intra- and extracellular domains, we find that the former provides a reliable estimate of the total solution. Thus the generalized activating function that we have derived provides a useful way of understanding virtual electrode effects in cardiac tissue.

Simulated internal defibrillation in humans using an anatomically realistic three-dimensional finite element model of the thorax

INTRODUCTION

Determination of the optimal electrode configuration during implantable cardioverter defibrillator (ICD) implantation remains largely an empirical process. This study investigated the feasibility of using a finite element model of the thorax to predict clinical defibrillation metrics for internal defibrillation in humans. Computed defibrillation metrics from simulations of three common electrode configurations with a monophasic waveform were compared to pooled metrics for similar electrode and waveform configurations reported in humans.

METHODS AND RESULTS

A three-dimensional finite element model was constructed from CT cross-sections of a human thorax. Myocardial current density distributions for three electrode configurations (epicardial patches, right ventricular [RV] coil/superior vena cava [SVC] coil, RV coil/SVC coil/subcutaneous patch) and a truncated monophasic pulse with a 65% tilt were simulated. Assuming an inexcitability threshold of 25 mA/cm2 (10 V/cm) and a 75% critical mass criterion for successful defibrillation, defibrillation metrics (interelectrode impedance, defibrillation threshold current, voltage, and energy) were calculated for each electrode simulation. Values of these metrics were within 1 SD of sample-size weighted means for the corresponding metrics determined for similar electrode configurations and waveforms reported in human clinical studies. Simulated myocardial current density distributions suggest that variations in current distribution and uniformity partially explain differences in defibrillation energy requirements between electrode configurations.

CONCLUSION

Anatomically realistic three-dimensional finite element modeling can closely simulate internal defibrillation in humans. This may prove useful for characterizing patient-specific factors that influence clinically relevant properties of current density distributions and defibrillation energy requirements of various ICD electrode configurations.

Electrical defibrillation optimization: an automated, iterative parallel finite-element approach

To date, optimization of electrode systems for electrical defibrillation has been limited to hand-selected electrode configurations. In this paper we present an automated approach which combines detailed, three-dimensional (3-D) finite-element torso models with optimization techniques to provide a flexible analysis and design tool for electrical defibrillation optimization. Specifically, a parallel direct search (PDS) optimization technique is used with a representative objective function to find an electrode configuration which corresponds to the satisfaction of a postulated defibrillation criterion with a minimum amount of power and a low possibility of myocardium damage. For adequate representation of the thoracic inhomogeneities, 3-D finite-element torso models are used in the objective function computations. The CPU-intensive finite-element calculations required for the objective function evaluation have been implemented on a message-passing parallel computer in order to complete the optimization calculations in a timely manner. To illustrate the optimization procedure, it has been applied to a representative electrode configuration for transmyocardial defibrillation, namely the subcutaneous patch-right ventricular catheter (SP-RVC) system. Sensitivity of the optimal solutions to various tissue conductivities has been studied. Results for the optimization of defibrillation systems are presented which demonstrate the feasibility of the approach.

Numerical analysis of electrical defibrillation. The parallel approach

Numerical modeling offers a viable tool for studying electrical defibrillation, allowing the behavior of field quantities to be observed easily as the different system parameters are varied. One numerical technique, namely the finite-element method, has been found particularly effective for modeling complex thoracic anatomies. However, an accurate finite-element model of the thorax often requires a large number of elements and nodes, leading to a large set of equations that cannot be solved effectively with the computational power of conventional computers. This is especially true if many finite-element solutions need to be achieved within a reasonable time period (eg, electrode configuration optimization). In this study, the use of massively parallel computers to provide the memory and reduction in solution time for solving these large finite-element problems is discussed. Both the uniform and unstructured grid approaches are considered. Algorithms that allow efficient mapping of uniform and unstructured grids to data-parallel and message-passing parallel computers are discussed. An automatic iterative procedure for electrode configuration optimization is presented. The procedure is based on the minimization of an objective function using the parallel direct search technique. Computational performance results are presented together with simulation results.