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

Reconstruction of retrospective cardiac activity--numerical study in a single cell and in a linear strand

Although computational modeling of the prospective electrical activity in the cardiac tissue is well established and robust, the retrospective extrapolation of this activity has not been explored to date. Here, we establish an algorithm for the backward-in-time extrapolation of electrical activity from measurements taken in the present. Using minimal human cardiac kinetic models and a modified Newton-Raphson algorithm, we demonstrate the feasibility of past activity reconstruction in a single cell and in a linear strand. In a single cell, reconstruction of state variables' shape, the action potential morphology, and the time of stimulation was successful for up to 1300 ms poststimulation and for data with signal-to-noise ratio levels higher than 40 dB. For linear strands, the action potential morphology was reconstructed for 500 ms poststimulation, and the reconstructed conduction velocity remained unaffected for signal-to-noise ratio levels higher than 50 dB. Moreover, tissue restitution properties due to various pacing rates were successfully reconstructed by the backward-in-time algorithm. These preliminary results demonstrate that past cardiac activity may be reconstructed from measurements in the present. We envision that this methodology could be implemented in future clinical applications, for example to trace the location and timing of ectopic foci during ablation procedures.

Orthogonal field calibration analysis for myocardial electrode arrays used in defibrillation studies

Mapping the myocardial electric field during a defibrillation pulse requires the recording of potential differences between electrodes. The field is then calculated from these quantities and the corresponding calibration matrix. One straightforward calibration technique involves alignment of a known electric field along each of the orthogonal axes of an electrode array and recording the resulting potential differences. However, no results have been reported to support the efficacy of this technique. This study performs a detailed error analysis including a one-to-one comparison to a precision calibration technique, and quantitatively establishes the efficacy of the orthogonal field technique.

Construction and validation of a plunge electrode array for three-dimensional determination of conductivity in the heart

The heart's response to electrical shock, electrical propagation in sinus rhythm, and the spatiotemporal dynamics of ventricular fibrillation all depend critically on the electrical anisotropy of cardiac tissue. Analysis of the microstructure of the heart predicts that three unique intracellular electrical conductances can be defined at any point in the ventricular wall; however, to date, there has been no experimental confirmation of this concept. We report the design, fabrication, and validation of a novel plunge electrode array capable of addressing this issue. A new technique involving nylon coating of 24G hypodermic needles is performed to achieve nonconductive electrodes that can be combined to give moderate-density multisite intramural measurement of extracellular potential in the heart. Each needle houses 13 silver wires within a total diameter of 0.7 mm, and the combined electrode array gives 137 sites of recording. The ability of the electrode array to accurately assess conductances is validated by mapping the potential field induced by a point current source within baths of saline of varying concentration. A bidomain model of current injection in the heart is then used to test an approximate relationship between the monodomain conductivities measured by the array, and the full set of bidomain conductivities that describe cardiac tissue.

A percutaneous catheter-based system for the measurement of potential gradients applicable to the study of transthoracic defibrillation

BACKGROUND

The local electric (E) field or potential gradient produced by a shock reliably predicts VF termination. In this study we evaluated a multiple electrode, catheter-based device for closed-chest 3D measurements of E field from transthoracic defibrillation shocks.

METHODS

Catheters with multiple electrodes on the tip were placed in intracardiac locations in anesthetized swine. An empirically derived calibration matrix and custom microprocessor was used to transform simultaneously measured voltages into orthogonal E field vector components. E fields produced in six intracardiac locations by 30 and 300 J shocks were compared in eight animals. Correlations were determined for measured current and E field at various shock strengths at two different transthoracic impedances in five additional animals. VF was induced in 12 animals and E field measured during defibrillation attempts.

RESULTS

The E field measurements resulting for 30 J transthoracic shocks were not significantly different among different intracardiac sites. At 300 J, however, significant differences were observed between sites with the greatest intensities recorded in the coronary sinus and right ventricle. Within animals, the variability of the measurement at each site was small, ranging from 2.8 +/- 1.6% to 5.7 +/- 4.5%. Significant correlations (P < 0.001) between measured E field and peak current were observed at native impedance (34 +/- 4 Omega, r = 0.81) and at adjusted impedance (76 +/- 4 Omega, r = 0.78) with transthoracic shocks of 200, 300, and 360 J. In VF studies, the probability of defibrillation was closely fit by a sigmoidal dose response curve in the coronary sinus E field with an approximate threshold of 4.7 V/cm with 50% defibrillation success at 9.3 V/cm.

CONCLUSIONS

The measured intracardiac E field variability within animals and at a specific site was small, exhibiting a median value of 5.1%, contrasted to median variabilities across animals of 5-11% suggesting the capacity of this measurement system to provide subject specific information on the distribution of E fields. The measured E field magnitudes across animals in the coronary sinus were linearly correlated with applied shock current with a very strong linear relation to effective shock voltage observed in vitro in a saline tank. When evaluated as a predictor of shock success, the observed values were consistent with previously reported critical fields. This technique may be of value in evaluating waveforms for transthoracic defibrillation as well as electrode size, placement, and composition.

Calibrated current divider network for precision current delivery during high-voltage transthoracic defibrillation

The design of a calibrated resistive-network current divider for precision current delivery during transthoracic defibrillation shocks is presented together with test results. The current divider presents a constant 50-ohm load to the defibrillator and thus maintains a constant pulse shape. Current is selected before the shock by setting three rheostats using a computer-generated calibration table. Following each shock, the data acquisition and display software updates the calibration table based on the measured value of transthoracic resistance. Over a range of 15-27 A, the root-mean-square (rms) error for delivered versus selected current was 0.48% for a 45-ohm resistive load, and 0.71% for a 100-ohm load. These test results were confirmed by animal experiments. Over 3 dogs, the rms error was 0.49% from 15-27 A and not greater than 1.5% over the entire 8-44 A range.

Optical Action Potential Upstroke Morphology Reveals Near-Surface Transmural Propagation Direction

The analysis of surface-activation patterns and measurements of conduction velocity in ventricular myocardium is complicated by the fact that the electrical wavefront has a complex 3D shape and can approach the heart surface at various angles. Recent theoretical studies suggest that the optical upstroke is sensitive to the subsurface orientation of the wavefront. Our goal here was to (1) establish the quantitative relationship between optical upstroke morphology and subsurface wavefront orientation using computer modeling and (2) test theoretical predictions experimentally in isolated coronary-perfused swine right ventricular preparations. We show in numerical simulations that by suitable placement of linear epicardial stimulating electrodes, the angle φ of wavefronts with respect to the heart surface can be controlled. Using this method, we developed theoretical predictions of the optical upstroke shape dependence on φ. We determined that the level V F * at which the rate of rise of the optical upstroke reaches the maximum linearly depends on φ. A similar relationship was found in simulations with epicardial point stimulation. The optical mapping data were in good agreement with theory. Plane waves propagating parallel to myocardial fibers produced upstrokes with V F *<0.5, consistent with theoretical predictions for φ>0. Similarly, we obtained good agreement with theory for plane waves propagating in a direction perpendicular to fibers ( V F *>0.5 when φ<0). Finally, during epicardial point stimulation, we discovered characteristic saddle-shaped V F * maps that were in excellent agreement with theoretically predicted changes in φ during wavefront expansion. Our findings should allow for improved interpretation of the results of optical mapping of intact heart preparations.

Do clinically relevant transthoracic defibrillation energies cause myocardial damage and dysfunction?

Sufficiently strong defibrillation shocks will cause temporary or permanent damage to the heart. Weak defibrillation shocks do not cause any damage to the heart but also do not defibrillate. A relevant and practical question is what range of shock energies is most likely to defibrillate while not causing damage to the heart. This question is most difficult to answer in the pre-hospital defibrillation setting where the patients' size and shape vary, placement of the defibrillation patches vary, and the etiology of their arrhythmia varies. Unlike internal defibrillators, which are tested at implantation, efficacy of an external defibrillator is determined only once, when it is most needed. This review discusses shock damage and dysfunction caused by monophasic waveforms as well as biphasic waveforms. Evidence is presented suggesting that for perfused hearts, the threshold for damage is well above any shock size delivered clinically. For non-perfused hearts, both in humans and animals, evidence is presented that monophasic shocks of up to 5 J/kg do not cause any more cardiac damage/dysfunction than that associated with smaller shocks and that much of this damage is caused by the ischemic period itself rather than the shock. Although many patients can be defibrillated with 150 J (2.2 J/kg) biphasic shocks, some patients may require biphasic shocks up to 360 J (5 J/kg) to be defibrillated. Studies still need to be performed comparing the efficacy and damaging effects of 360 J biphasic shocks to 150 J biphasic shocks. Until those studies are completed, it seems reasonable to use the same 360 J (5 J/kg) energy limit for biphasic shocks as for monophasic shocks.

Simplified calibration of single-plunge bipolar electrode array for field measurement during defibrillation

In an earlier study, the authors presented a calibration technique for a triaxial bipolar electrode array (EA) that used 72 data points collected during a global sweep of the electric field vector relative to the EA axes. Although necessary for the initial characterization of the EAs, this data requirement has to be significantly reduced for the technique to become a practical tool. Therefore, in the present study, an analysis is performed to determine the relation between the number of data points used in the calibration and the mean root-mean-square error. The analysis shows that 18 data points can produce results nearly identical to those obtained with the 72-point calibration, thus reducing the required amount of data fourfold.