Improved signal processing techniques for the analysis of high resolution serosal slow wave activity in the stomach

Translation of an existing implantable cardiac monitoring device for measurement of gastric electrical slow-wave activity

BACKGROUND

Despite evidence that slow-wave dysrhythmia in the stomach is associated with clinical conditions such as gastroparesis and functional dyspepsia, there is still no widely available device for long-term monitoring of gastric electrical signals. Actionable biomarkers of gastrointestinal health are critically needed, and an implantable slow-wave monitoring device could aid in the establishment of causal relationships between symptoms and gastric electrophysiology. Recent developments in the area of wireless implantable gastric monitors demonstrate potential, but additional work and validation are required before this potential can be realized.

METHODS

We hypothesized that translating an existing implantable cardiac monitoring device, the Reveal LINQ™ (Medtronic), would present a more immediate solution. Following ethical approval and laparotomy in anesthetized pigs (n = 7), a Reveal LINQ was placed on the serosal surface of the stomach, immediately adjacent to a validated flexible-printed-circuit (FPC) electrical mapping array. Data were recorded for periods of 7.5 min, and the resultant signal characteristics from the FPC array and Reveal LINQ were compared.

KEY RESULTS

The Reveal LINQ device recorded slow waves in 6/7 subjects with a comparable period (p = 0.69), signal-to-noise ratio (p = 0.58), and downstroke width (p = 0.98) to the FPC, but with reduced amplitude (p = 0.024). Qualitatively, the Reveal LINQ slow-wave signal lacked the prolonged repolarization phase present in the FPC signals.

CONCLUSIONS & INFERENCES

These findings suggest that existing cardiac monitors may offer an efficient solution for the long-term monitoring of slow waves. Translation toward implantation now awaits.

High-resolution in vivo monophasic gastric slow waves to quantify activation and recovery profiles

BACKGROUND

Gastric bio-electrical slow waves are, in part, responsible for coordinating motility. Spatial dynamics about the recovery phase of slow wave recordings have not been thoroughly investigated due to the lack of suitable experimental techniques.

METHODS

A high-resolution multi-channel suction electrode array was developed and applied in pigs to acquire monophasic gastric slow waves. Signal characteristics were verified against biphasic slow waves recorded by conventional surface contact electrode arrays. Monophasic slow wave events were categorized into two groups based on their morphological characteristics, after which their amplitudes, activation to recovery intervals, and gradients were quantified and compared. Coverage of activation and recovery maps for both electrode types were calculated and compared.

KEY RESULTS

Monophasic slow waves had a more pronounced recovery phase with a higher gradient than biphasic slow waves (0.5 ± 0.1 vs. 0.3 ± 0.1 mV·s^-1 ). Between the 2 groups of monophasic slow waves, there was a significant difference in amplitude (1.8 ± 0.5 vs. 1.1 ± 0.2 mV), activation time gradient (0.8 ± 0.2 vs. 0.3 ± 0.1 mV·s^-1 ), and recovery time gradient (0.5 ± 0.1 vs. 0.3 ± 0.1 mV·s^-1 ). For the suction and conventional contact electrode arrays, the recovery maps had reduced coverage compared to the activation maps (4 ± 6% and 43 ± 11%, respectively).

CONCLUSIONS AND INFERENCES

A novel high-resolution multi-channel suction electrode array was developed and applied in vivo to record monophasic gastric slow waves. Slow wave recovery phase analysis could be performed more efficiently on monophasic signals compared with biphasic signals, due to the more identifiable recovery phases.

Wet-printing of PEDOT:PSS Microelectrodes for Gastric Slow Wave Recording

Bioelectrical slow waves are fundamental to maintaining the normal motility of the gastrointestinal tract. Slow wave abnormalities are associated with several major digestive disorders. High-resolution electrical mapping arrays have been used to investigate pathological slow wave abnormalities. However, conventional electrode substrate materials are opaque with high mechanical modulus, which leads to non-compliance and sub-par contact with the organ, without additional manipulations. Here we developed highly conformal and transparent conducting polymer electrode arrays using the extrusion wet-printing technique. The performance of electrodes for the electrophysiological recording of the gastric slow wave was validated using in a pig model, against a previously validated reference array over 100 s recording window. The conducting polymer electrodes registered comparable frequency to the reference array ( 3.31±0.20 cpm vs. 3.27±0.07 cpm, p = 0.067), with lower amplitude ( 372±237 vs. ), and signal to noise ratio ( 10.92±7.83 vs. [Formula: see text]). Further adjustments to the deposition parameters and contact material will improve the performance of the conducting polymer array for future experimental applications. Clinical Relevance- These conducting polymer electrodes provide better compliance and minimized mechanical mismatch to the gut tissue thus allowing long-term monitoring and stimulation of the gut. This could be potentially extended to other organs as well.

Quantification of Gastric Slow Wave Velocity using Bipolar High-Resolution Recordings

OBJECTIVE

Gastric bio-electrical slow waves are, in part, responsible for coordinating motility. High-resolution (HR) in vivo recordings can be used to capture the wavefront velocity of the propagating slow waves. A standard marking-and-grouping approach is typically employed along with manual review. Here, a bipolar velocity estimation (BVE) method was developed, which utilized local directional information to estimate the wavefront velocity in an efficient manner.

METHODS

With this approach, unipolar in vivo HR recordings were used to construct bipolar recordings in different directions. Then, the local directionality of the slow wave was extracted by calculating time delay information. The accuracy of the method was verified using synthetic data and then validated with in vivo HR pig experimental recordings.

RESULTS

Against ventilator noise amplitude of 0% - 70% of the average slow wave amplitude, the direction and speed error increased from 4.4 and 0.9 mm/s to 8.6 and 1.4 mm/s. For signals added with high-frequency noise with signal-to-noise ratios of 60 dB - 12 dB, the error increased from 8.0 and 1.0 mm/s to 9.8 and 1.2 mm/s. For experimental signals, the BVE algorithm resulted in 19.2 1.7 of direction error and 2.0 0.2 mm/s of speed error, when compared to the standard marking-and-grouping method.

CONCLUSION

Gastric slow wave wavefront velocities were estimated rapidly using the BVE algorithm with minimal errors.

SIGNIFICANCE

The BVE algorithm enables the ability to estimate wavefront velocities in HR recordings in an efficient manner.

The influence of interstitial cells of Cajal loss and aging on slow wave conduction velocity in the human stomach

Loss of interstitial cells of Cajal (ICC) has been associated with gastric dysfunction and is also observed during normal aging at ~13% reduction per decade. The impact of ICC loss on gastric slow wave conduction velocity is currently undefined. This study correlated human gastric slow wave velocity with ICC loss and aging. High-resolution gastric slow wave mapping data were screened from a database of 42 patients with severe gastric dysfunction (n = 20) and controls (n = 22). Correlations were performed between corpus slow wave conduction parameters (frequency, velocity, and amplitude) and corpus ICC counts in patients, and with age in controls. Physiological parameters were further integrated into computational models of gastric mixing. Patients: ICC count demonstrated a negative correlation with slow wave velocity in the corpus (i.e., higher velocities with reduced ICC; r2  = .55; p = .03). ICC count did not correlate with extracellular slow wave amplitude (p = .12) or frequency (p = .84). Aging: Age was positively correlated with slow wave velocity in the corpus (range: 25-74 years; r2  = .32; p = .02). Age did not correlate with extracellular slow wave amplitude (p = .40) or frequency (p = .34). Computational simulations demonstrated that the gastric emptying rate would increase at higher slow wave velocities. ICC loss and aging are associated with a higher slow wave velocity. The reason for these relationships is unexplained and merit further investigation. Increased slow wave velocity may modulate gastric emptying higher, although in gastroparesis other pathological factors must dominate to prevent emptying.

A Novel High-Density Electromyography Probe for Evaluating Anorectal Neurophysiology: Design, Human Feasibility Study, and Validation with Trans-Sacral Magnetic Stimulation

Fecal incontinence (FI) substantially impairs quality of life and imparts a major socioeconomic burden. Anal sphincter injury and possibly pudendal nerve damage are considered common causes, however, current clinical methods for evaluating their function remain suboptimal. Electromyography (EMG) and pudendal nerve terminal latencies have been applied with some success, but are not considered standard practice due to uncertain accuracy and clinical value. In this study we developed and applied a novel anorectal high-density (HD) EMG probe in humans and pigs to acquire quantitative electrophysiological metrics of the anorectum. In the human trial we assessed somatic pathways and showed that EMG amplitude was greater for tight voluntary squeezes than light voluntary squeezes (0.03 ± 0.02 mV vs. 0.05 ± 0.03 mV). In a porcine model we applied trans-sacral magnetic stimulation to evoke extrinsically activated involuntary pathways and the resulting motor evoked potentials (MEP) were captured using the HD-EMG probe. The mean MEP amplitude at 50% magnetic stimulation intensity output (MSO) was significantly lower that the MEP amplitude at 85, 95 and 100% MSO (1.52 ± 0.50 mV vs. 3.10 ± 0.60 mV). In conclusion, the use of HD-EMG probe in conjunction with trans-sacral magnetic stimulation, for spatiotemporal mapping of anorectal EMG and MEP activity is anticipated to achieve new insights into FI and could offer improved diagnostic and prognostic biomarkers for anorectal dysfunction.

Intsy: a low-cost, open-source, wireless multi-channel bioamplifier system

OBJECTIVE

Multi-channel electrical recordings of physiologically generated signals are common to a wide range of biomedical fields. The aim of this work was to develop, validate, and demonstrate the practical utility of a high-quality, low-cost 32/64-channel bioamplifier system with real-time wireless data streaming capability.

APPROACH

The new 'Intsy' system integrates three main off-the-shelf hardware components: (1) Intan RHD2132 bioamplifier; (2) Teensy 3.2 microcontroller; and (3) RN-42 Bluetooth 2.1 module with a custom LabView interface for real-time data streaming and visualization. Practical utility was validated by measuring serosal gastric slow waves and surface EMG on the forearm with various contraction force levels. Quantitative comparisons were made to a gold-standard commercial system (Biosemi ActiveTwo).

MAIN RESULTS

Intsy signal quality was quantitatively comparable to that of the ActiveTwo. Recorded slow wave signals had high SNR (24  ±  2.7 dB) and wavefront propagation was accurately mapped. EMG spike bursts were characterized by high SNR (⩾10 dB) and activation timing was readily identified. Stable data streaming rates achieved were 3.5 kS s^-1 for wireless and 64 kS s^-1 for USB-wired transmission.

SIGNIFICANCE

Intsy has the highest channel count of any existing open-source, wireless-enabled module. The flexibility, portability and low cost ($1300 for the 32-channel version, or $2500 for 64 channels) of this new hardware module reduce the entry barrier for a range of electrophysiological experiments, as are typical in the gastrointestinal (EGG), cardiac (ECG), neural (EEG), and neuromuscular (EMG) domains.

High-resolution mapping of gastric slow-wave recovery profiles: biophysical model, methodology, and demonstration of applications

Slow waves play a central role in coordinating gastric motor activity. High-resolution mapping of extracellular potentials from the stomach provides spatiotemporal detail on normal and dysrhythmic slow-wave patterns. All mapping studies to date have focused exclusively on tissue activation; however, the recovery phase contains vital information on repolarization heterogeneity, the excitable gap, and refractory tail interactions but has not been investigated. Here, we report a method to identify the recovery phase in slow-wave mapping data. We first developed a mathematical model of unipolar extracellular potentials that result from slow-wave propagation. These simulations showed that tissue repolarization in such a signal is defined by the steepest upstroke beyond the activation phase (activation was defined by accepted convention as the steepest downstroke). Next, we mapped slow-wave propagation in anesthetized pigs by recording unipolar extracellular potentials from a high-resolution array of electrodes on the serosal surface. Following the simulation result, a wavelet transform technique was applied to detect repolarization in each signal by finding the maximum positive slope beyond activation. Activation-recovery (ARi) and recovery-activation (RAi) intervals were then computed. We hypothesized that these measurements of recovery profile would differ for slow waves recorded during normal and spatially dysrhythmic propagation. We found that the ARi of normal activity was greater than dysrhythmic activity (5.1 ± 0.8 vs. 3.8 ± 0.7 s; P < 0.05), whereas RAi was lower (9.7 ± 1.3 vs. 12.2 ± 2.5 s; P < 0.05). During normal propagation, RAi and ARi were linearly related with negative unit slope indicating entrainment of the entire mapped region. This relationship was weakened during dysrhythmia (slope: -0.96 ± 0.2 vs -0.71 ± 0.3; P < 0.05).NEW & NOTEWORTHY The theoretical basis of the extracellular gastric slow-wave recovery phase was defined using mathematical modeling. A novel technique utilizing the wavelet transform was developed and validated to detect the extracellular slow-wave recovery phase. In dysrhythmic wavefronts, the activation-to-recovery interval (ARi) was shorter and recovery-to-activation interval (RAi) was longer compared with normal wavefronts. During normal activation, RAi vs. ARi had a slope of -1, whereas the weakening of the slope indicated a dysrhythmic propagation.

Ambulatory gastric mucosal slow wave recording for chronic experimental studies

Dysrhythmic bioelectric slow wave activity have been implicated in major functional motility disorders such as gastroparesis and chronic unexplained nausea and vomiting, but its correlation to symptoms is still unclear. For patients with severe gastroparesis, high-frequency gastric stimulation is offered as a therapy in some centers. Temporary gastric electrical stimulation has also been proposed an approach to screen patients who would benefit from the implantation of a permanent stimulator. In this study we introduced novel methods for recording slow wave activity from the gastric mucosa during the entire temporary stimulation phase of 5 days, in 3 patients. An ambulatory recording system was applied to record 3 channels of mucosal slow wave activity, as well as three axis accelerometer data to monitor when the patient was mobile. Techniques were developed to detect large movements and these time periods were excluded from analyses of mucosal slow waves. The frequency and amplitude of the slow waves was calculated in a 5 min segment, with 75% overlap, for the entire duration. In feasibility studies, the slow wave frequency and amplitude for the patients were 3.0±0.96 cpm and 1.43±1.75 mV. Large variations in slow wave amplitude were seen in comparsion to slow wave frequency, which were concordant with previous studies. The use of the ambulatory system will allow for investigation of pathophysiology, correlation of electrophysiology data to patient symptoms and to determine the effects of post-prandial and noctural slow wave patterns. We anticipate that future use of slow wave information alongside patient symptoms may allow improved selection of patients for stimulaton techniques.

High-resolution electrical mapping of porcine gastric slow-wave propagation from the mucosal surface

BACKGROUND

Gastric motility is coordinated by bioelectrical slow waves, and gastric dysrhythmias are reported in motility disorders. High-resolution (HR) mapping has advanced the accurate assessment of gastric dysrhythmias, offering promise as a diagnostic technique. However, HR mapping has been restricted to invasive surgical serosal access. This study investigates the feasibility of HR mapping from the gastric mucosal surface.

METHODS

Experiments were conducted in vivo in 14 weaner pigs. Reference serosal recordings were performed with flexible-printed-circuit (FPC) arrays (128-192 electrodes). Mucosal recordings were performed by two methods: (i) FPC array aligned directly opposite the serosal array, and (ii) cardiac mapping catheter modified for gastric mucosal recordings. Slow-wave propagation and morphology characteristics were quantified and compared between simultaneous serosal and mucosal recordings.

KEY RESULTS

Slow-wave activity was consistently recorded from the mucosal surface from both electrode arrays. Mucosally recorded slow-wave propagation was consistent with reference serosal activation pattern, frequency (P≥.3), and velocity (P≥.4). However, mucosally recorded slow-wave morphology exhibited reduced amplitude (65-72% reduced, P<.001) and wider downstroke width (18-31% wider, P≤.02), compared to serosal data. Dysrhythmias were successfully mapped and classified from the mucosal surface, accorded with serosal data, and were consistent with known dysrhythmic mechanisms in the porcine model.

CONCLUSIONS & INFERENCES

High-resolution gastric electrical mapping was achieved from the mucosal surface, and demonstrated consistent propagation characteristics with serosal data. However, mucosal signal morphology was attenuated, demonstrating necessity for optimized electrode designs and analytical algorithms. This study demonstrates feasibility of endoscopic HR mapping, providing a foundation for advancement of minimally invasive spatiotemporal gastric mapping as a clinical and scientific tool.

Acute Slow Wave Responses to High-Frequency Gastric Electrical Stimulation in Patients With Gastroparesis Defined by High-Resolution Mapping

BACKGROUND AND AIMS

High-frequency gastric electrical stimulation (GES) has emerged as a therapy for gastroparesis, but the mechanism(s) of action remain unclear. There is a need to refine stimulation protocols for clinical benefit, but a lack of accurate techniques for assessing mechanisms in clinical trials, such as slow wave modulation, has hindered progress. We thereby aimed to assess acute slow wave responses to GES in gastroparesis patients using high-resolution (HR) (multi-electrode) mapping, across a range of stimulation doses achievable by the Enterra stimulation device (Medtronic Inc., MN, USA).

MATERIALS AND METHODS

Patients with medically refractory gastroparesis (n = 8) undergoing device implantation underwent intraoperative HR mapping (256 electrodes). Baseline recordings were followed by four protocols of increasing stimulation intensity, with washout periods. Slow wave patterns, frequency, velocity, amplitude, and dysrhythmia rates were quantified by investigators blinded to stimulation settings.

RESULTS

There was no difference in slow wave pattern, frequency, velocity, or amplitude between baseline, washout, and stimulation periods (all p > 0.5). Dysrhythmias included ectopic pacemakers, conduction blocks, retrograde propagation, and colliding wavefronts, and dysrhythmia rates were unchanged with stimulation off vs. on (31% vs. 36% duration dysrhythmic; p > 0.5). Symptom scores and gastric emptying were improved at 5.8 month follow-up (p < 0.05).

CONCLUSIONS

High-frequency GES protocols achievable from a current commercial device did not acutely modulate slow wave activity or dysrhythmias. This study advances clinical methods for identifying and assessing therapeutic GES parameters, and can be applied in future studies on higher-energy protocols and devices.

A novel retractable laparoscopic device for mapping gastrointestinal slow wave propagation patterns

BACKGROUND

Gastric slow waves regulate peristalsis, and gastric dysrhythmias have been implicated in functional motility disorders. To accurately define slow wave patterns, it is currently necessary to collect high-resolution serosal recordings during open surgery. We therefore developed a novel gastric slow wave mapping device for use during laparoscopic procedures.

METHODS

The device consists of a retractable catheter constructed of a flexible nitinol core coated with Pebax. Once deployed through a 5-mm laparoscopic port, the spiral head is revealed with 32 electrodes at 5 mm intervals. Recordings were validated against a reference electrode array in pigs and tested in a human patient.

RESULTS

Recordings from the device and a reference array in pigs were identical in frequency (2.6 cycles per minute; p = 0.91), and activation patterns and velocities were consistent (8.9 ± 0.2 vs 8.7 ± 0.1 mm s^-1; p = 0.2). Device and reference amplitudes were comparable (1.3 ± 0.1 vs 1.4 ± 0.1 mV; p = 0.4), though the device signal-to-noise ratio was higher (17.5 ± 0.6 vs 12.8 ± 0.6 dB; P < 0.0001). In the human patient, corpus slow waves were recorded and mapped (frequency 2.7 ± 0.03 cycles per minute, amplitude 0.8 ± 0.4 mV, velocity 2.3 ± 0.9 mm s^-1).

CONCLUSION

In conclusion, the novel laparoscopic device achieves high-quality serosal slow wave recordings. It can be used for laparoscopic diagnostic studies to document slow wave patterns in patients with gastric motility disorders.

Time-Delay Mapping of High-Resolution Gastric Slow-Wave Activity

GOAL

Analytic monitoring of electrophysiological data has become an essential component of efficient and accurate clinical care. In the gastrointestinal (GI) field, recent advances in high-resolution (HR) mapping are now providing critical information about spatiotemporal profiles of slow-wave activity in normal and disease (dysrhythmic) states. The current approach to analyze GI HR electrophysiology data involves the identification of individual slow-wave events in the electrode array, followed by tracking and clustering of events to create a spatiotemporal map. This method is labor and computationally intensive and is not well suited for real-time clinical use or chronic monitoring.

METHODS

In this study, an automated novel technique to assess propagation patterns was developed. The method utilized time delays of the slow-wave signals which was computed through cross correlations to calculate velocity. Validation was performed with both synthetic and human and porcine experimental data.

RESULTS

The slow-wave profiles computed via the time-delay method compared closely with those computed using the traditional method (speed difference: 7.2% ± 2.6%; amplitude difference: 8.6% ± 3.5%, and negligible angle difference).

CONCLUSION

This novel method provides rapid and intuitive analysis and visualization of slow-wave activity.

SIGNIFICANCE

This techniques will find major applications in the clinical translation of acute and chronic HR electrical mapping for motility disorders, and act as a screening tool for detailed detection and tracking of individual propagating wavefronts, without the need for comprehensive standard event-detection analysis.

Iterative Covariance-Based Removal of Time-Synchronous Artifacts: Application to Gastrointestinal Electrical Recordings

OBJECTIVE

The aim of this study was to develop, validate, and apply a fully automated method for reducing large temporally synchronous artifacts present in electrical recordings made from the gastrointestinal (GI) serosa, which are problematic for properly assessing slow wave dynamics. Such artifacts routinely arise in experimental and clinical settings from motion, switching behavior of medical instruments, or electrode array manipulation.

METHODS

A novel iterative Covariance-Based Reduction of Artifacts (COBRA) algorithm sequentially reduced artifact waveforms using an updating across-channel median as a noise template, scaled and subtracted from each channel based on their covariance.

RESULTS

Application of COBRA substantially increased the signal-to-artifact ratio (12.8 ± 2.5 dB), while minimally attenuating the energy of the underlying source signal by 7.9% on average ( -11.1 ± 3.9 dB).

CONCLUSION

COBRA was shown to be highly effective for aiding recovery and accurate marking of slow wave events (sensitivity = 0.90 ± 0.04; positive-predictive value = 0.74 ± 0.08) from large segments of in vivo porcine GI electrical mapping data that would otherwise be lost due to a broad range of contaminating artifact waveforms.

SIGNIFICANCE

Strongly reducing artifacts with COBRA ultimately allowed for rapid production of accurate isochronal activation maps detailing the dynamics of slow wave propagation in the porcine intestine. Such mapping studies can help characterize differences between normal and dysrhythmic events, which have been associated with GI abnormalities, such as intestinal ischemia and gastroparesis. The COBRA method may be generally applicable for removing temporally synchronous artifacts in other biosignal processing domains.

Extending the automated gastrointestinal analysis pipeline: Removal of invalid slow wave marks in gastric serosal recordings

Gastric contractions are governed by a bioelectrical event known as slow waves. High-resolution electrical mapping has recently been applied to study complex gastric slow wave spatiotemporal propagations in detail. As these methods are translated to clinical and experimental applications, it is evident that efficient and automated methods are a necessity for analysis. Despite automated methods to detect slow wave events, manual review and correction remains necessary due to the presence of experimental noise in the recordings. Manual deletion of invalid slow wave events is time consuming and inefficient. We have therefore developed an algorithm to eliminate invalid markers of slow waves, via the use of frequency and morphological analysis. The techniques were validated with experimental data using serosal gastric slow wave recordings from animals and humans with a sensitivity of 90% and specificity of 85%. It is anticipated these methods will facilitate analyzing high-resolution slow wave mapping data and accelerate clinical translation of electrical mapping to clinical and diagnostic gastroentrology.

Detection of the Recovery Phase of in vivo gastric slow wave recordings

Gastric motility is coordinated by bio-electrical events known as slow waves. Abnormalities in slow waves are linked to major functional and motility disorders. In recent years, the use of high-resolution (HR) recordings have provided a unique view of spatiotemporal activation profiles of normal and dysrhythmic slow wave activity. To date, in vivo studies of gastric slow wave activity have primarily focused on the activation phase of the slow wave event. In this study, the recovery phase of slow waves was investigated through the use of HR recording techniques. The recovery phase of the slow wave event was detected through the use of the signal derivative, computed via a wavelet transform. The activation to recovery interval (ARi) metric was computed as a difference between the recovery time and activation time. The detection method was validated with synthetic slow wave signals of varying morphologies with the addition of synthetic ventilator and high frequency noise. The methods was then applied to HR experimental porcine gastric slow wave recordings. Ventilator noise more than 10% of the slow wave amplitude affected the estimation of the ARi metric. Signal to noise ratio below 3 dB affected the ARi metric, but with minor deviation in accuracy. Experimental ARi values ranged from 3.7-4.7 s from three data sets, with significant differences across them.

The impact of surgical excisions on human gastric slow wave conduction, defined by high-resolution electrical mapping and in silico modeling

BACKGROUND

Gastric contractions are coordinated by slow waves, generated by interstitial cells of Cajal (ICC). Gastric surgery affects slow wave conduction, potentially contributing to postoperative gastric dysfunction. However, the impact of gastric cuts on slow waves has not been comprehensively evaluated. This study aimed to define consequences of surgical excisions on gastric slow waves by applying high-resolution (HR) electrical mapping and in silico modeling.

METHODS

Patients undergoing gastric stimulator implantation (n = 10) underwent full-thickness stapled excisions (25 × 15 mm, distal corpus) for histological evaluation, enabling HR mapping (256 electrodes; 36 cm(2) ) over and adjacent to excisions. A biophysically based in silico model of bidirectionally coupled ICC networks was developed and applied to investigate the underlying conduction mechanisms and importance of excision orientation.

KEY RESULTS

Normal gastric slow waves propagated aborally (3.0 ± 0.2 cpm). Excisions induced complete conduction block and wavelets that rotated around blocks, then propagated rapidly circumferentially distal to the blocks (8.5 ± 1.2 vs normal 3.6 ± 0.4 mm/s; p < 0.01). This 'conduction anisotropy' homeostatically restored antegrade propagating gastric wavefronts distal to excisions. Excisions were associated with complex dysrhythmias in five patients: retrograde propagation (3/10), ectopics (3/10), functional blocks (2/10), and collisions (1/10). Simulations demonstrated conduction anisotropy emerged from bidirectional coupling within ICC layers and showed transverse incision length and orientation correlated with the degree of conduction distortion.

CONCLUSIONS & INFERENCES

Orienting incisions in the longitudinal gastric axis causes least disruption to electrical conduction and motility. However, if transverse incisions are made, a homeostatic mechanism of gastric conduction anisotropy compensates by restoring aborally propagating wavefronts. Complex dysrhythmias accompanying excisions could modify postoperative recovery in susceptible patients.

Recent progress in gastric arrhythmia: pathophysiology, clinical significance and future horizons

Gastric arrhythmia continues to be of uncertain diagnostic and therapeutic significance. However, recent progress has been substantial, with technical advances, theoretical insights and experimental discoveries offering new translational opportunities. The discoveries that interstitial cells of Cajal (ICC) generate slow waves and that ICC defects are associated with dysmotility have reinvigorated gastric arrhythmia research. Increasing evidence now suggests that ICC depletion and damage, network disruption and channelopathies may lead to aberrant slow wave initiation and conduction. Histological and high-resolution (HR) electrical mapping studies have now redefined the human 'gastric conduction system', providing an improved baseline for arrhythmia research. The application of HR mapping to arrhythmia has also generated important new insights into the spatiotemporal dynamics of arrhythmia onset and maintenance, resulting in the emergence of new provisional classification schemes. Meanwhile, the strong associations between gastric functional disorders and electrogastrography (EGG) abnormalities (e.g. in gastroparesis, unexplained nausea and vomiting and functional dyspepsia) continue to motivate deeper inquiries into the nature and causes of gastrointestinal arrhythmias. In future, technical progress in EGG methods, new HR mapping devices and software, wireless slow wave acquisition systems and improved gastric pacing devices may achieve validated applications in clinical practice. Neurohormonal factors in arrhythmogenesis also continue to be elucidated and a deepening understanding of these mechanisms may open opportunities for drug design for treating arrhythmias. However, for all translational goals, it remains to be seen whether arrhythmia can be corrected in a way that meaningfully improves organ function and symptoms in patients.

Multi-channel wireless mapping of gastrointestinal serosal slow wave propagation

BACKGROUND

High-resolution (HR) extracellular mapping allows accurate profiling of normal and dysrhythmic slow wave patterns. A current limitation is that cables traverse the abdominal wall or a natural orifice, risking discomfort, dislodgement or infection. Wireless approaches offer advantages, but a multi-channel system is required, capable of recording slow waves and mapping propagation with high fidelity.

METHODS

A novel multi-channel (n = 7) wireless mapping system was developed and compared to a wired commercial system. Slow wave signals were recorded from the porcine gastric and intestinal serosa in vivo. Signals were simultaneously acquired using both systems, and were filtered and processed to map activation wavefronts. For validation, the frequency and amplitude of detected events were compared, together with the speed and direction of mapped wavefronts.

KEY RESULTS

The wireless device achieved comparable signal quality to the reference device, and slow wave frequencies were identical. Amplitudes of the acquired gastric and intestinal slow wave signals were consistent between the devices. During normal propagation, spatiotemporal mapping remained accurate in the wireless system, however, during ectopic dysrhythmic pacemaking, the lower sampling resolution of the wireless device led to reduced accuracy in spatiotemporal mapping.

CONCLUSIONS & INFERENCES

A novel multichannel wireless device is presented for mapping slow wave activity. The device achieved high quality signals, and has the potential to facilitate chronic monitoring studies and clinical translation of spatiotemporal mapping. The current implementation may be applied to detect normal patterns and dysrhythmia onset, but HR mapping with finely spaced arrays currently remains necessary to accurately define dysrhythmic patterns.

A system and method for online high-resolution mapping of gastric slow-wave activity

High-resolution (HR) mapping employs multielectrode arrays to achieve spatially detailed analyses of propagating bioelectrical events. A major current limitation is that spatial analyses must currently be performed "off-line" (after experiments), compromising timely recording feedback and restricting experimental interventions. These problems motivated development of a system and method for "online" HR mapping. HR gastric recordings were acquired and streamed to a novel software client. Algorithms were devised to filter data, identify slow-wave events, eliminate corrupt channels, and cluster activation events. A graphical user interface animated data and plotted electrograms and maps. Results were compared against off-line methods. The online system analyzed 256-channel serosal recordings with no unexpected system terminations with a mean delay 18 s. Activation time marking sensitivity was 0.92; positive predictive value was 0.93. Abnormal slow-wave patterns including conduction blocks, ectopic pacemaking, and colliding wave fronts were reliably identified. Compared to traditional analysis methods, online mapping had comparable results with equivalent coverage of 90% of electrodes, average RMS errors of less than 1 s, and CC of activation maps of 0.99. Accurate slow-wave mapping was achieved in near real-time, enabling monitoring of recording quality and experimental interventions targeted to dysrhythmic onset. This work also advances the translation of HR mapping toward real-time clinical application.

Automated classification and identification of slow wave propagation patterns in gastric dysrhythmia

The advent of high-resolution (HR) electrical mapping of slow wave activity has significantly improved the understanding of gastric slow wave activity in normal and dysrhythmic states. One of the current limitations of this technique is it generates a vast amount of data, making manual analysis a tedious task for research and clinical development. In this study we present new automated methods to classify, identify, and locate patterns of interest in gastric slow wave propagation. The classification method uses a similarity metric to classify slow wave propagations, while the identification algorithm uses the divergence and mean curvature of the slow wave propagation to identify and regionalize patterns of interest. The methods were applied to synthetic and experimental datasets and were also compared to manual analysis. The methods classified and identified patterns of slow wave propagation in less than 1 s, compared to manual analysis which took up to 40 min. The automated methods achieved 96% accuracy in classifying AT maps, and 95% accuracy in identifying the propagation pattern with a mean spatial error of 1.5 mm in comparison to manual methods. These new methods will facilitate the efficient translation of gastrointestinal HR mapping techniques to clinical practice.

The bioelectrical basis and validity of gastrointestinal extracellular slow wave recordings

  Gastrointestinal extracellular recordings have been a core technique in motility research for a century. However, the bioelectrical basis of extracellular data has recently been challenged by claims that these techniques preferentially assay movement artifacts, cannot reproduce the underlying slow wave kinetics, and misrepresent the true slow wave frequency. These claims motivated this joint experimental-theoretical study, which aimed to define the sources and validity of extracellular potentials. In vivo extracellular recordings and video capture were performed in the porcine jejunum, before and after intra-arterial nifedipine administration. Gastric extracellular recordings were recorded simultaneously using conventional serosal contact and suction electrodes, and biphasic and monophasic extracellular potentials were simulated in a biophysical model. Contractions were abolished by nifedipine, but extracellular slow waves persisted, with unchanged amplitude, downstroke rate, velocity, and downstroke width (P>0.10 for all), at reduced frequency (24% lower; P=0.03). Simultaneous suction and conventional serosal extracellular recordings were identical in phase (frequency and activation-recovery interval), but varied in morphology (monophasic vs. biphasic; downstroke rate and amplitude: P<0.0001). Simulations demonstrated the field contribution of current flow to extracellular potential and quantified the effects of localised depolarisation due to suction pressure on extracellular potential morphology. In sum, these results demonstrate that gastrointestinal extracellular slow wave recordings cannot be explained by motion artifacts, and are of a bioelectrical origin that is highly consistent with the underlying biophysics of slow wave propagation. Motion suppression is shown to be unnecessary as a routine control in in vivo extracellular studies, supporting the validity of the extant gastrointestinal extracellular literature.

Mapping and modeling gastrointestinal bioelectricity: from engineering bench to bedside

A key discovery in gastrointestinal motility has been the central role played by interstitial cells of Cajal (ICC) in generating electrical slow waves that coordinate contractions. Multielectrode mapping and multiscale modeling are two emerging interdisciplinary strategies now showing translational promise to investigate ICC function, electrophysiology, and contractions in the human gut.

Automated algorithm for GI spike burst detection and demonstration of efficacy in ischemic small intestine

We present a novel, fully-automated gastrointestinal spike burst detection algorithm. Following pre-processing with SALPA (Wagenaar and Potter, J. Neurosci. Methods 120:113-120, 2002) and a Savitzky-Golay filter to remove unwanted low and high frequency components, candidate spike waveforms are detected utilizing the non-linear energy operator. Candidate waveforms are classified as spikes or artifact by a support vector machine. The new method achieves highly satisfactory performance with >90% sensitivity and positive prediction value. We also demonstrate an application of the new method to detect changes in spike rate and spatial propagation patterns upon induction of mesenteric ischemia in the small intestine. Spike rates were observed to transiently increase 10-20 fold for a duration of ≈600 s, relative to baseline conditions. In ischemic conditions, spike activity propagation patterns included retrograde-longitudinal wavefronts with occasional spontaneous conduction blocks, as well as self-terminating concentric-circumferential wavefronts. Longitudinal and circumferential velocities were 6.8-8.0 cm/s and 18.7 cm/s, respectively.

Experimental and Automated Analysis Techniques for High-resolution Electrical Mapping of Small Intestine Slow Wave Activity

BACKGROUND/AIMS

Small intestine motility is governed by an electrical slow wave activity, and abnormal slow wave events have been associated with intestinal dysmotility. High-resolution (HR) techniques are necessary to analyze slow wave propagation, but progress has been limited by few available electrode options and laborious manual analysis. This study presents novel methods for in vivo HR mapping of small intestine slow wave activity.

METHODS

Recordings were obtained from along the porcine small intestine using flexible printed circuit board arrays (256 electrodes; 4 mm spacing). Filtering options were compared, and analysis was automated through adaptations of the falling-edge variable-threshold (FEVT) algorithm and graphical visualization tools.

RESULTS

A Savitzky-Golay filter was chosen with polynomial-order 9 and window size 1.7 seconds, which maintained 94% of slow wave amplitude, 57% of gradient and achieved a noise correction ratio of 0.083. Optimized FEVT parameters achieved 87% sensitivity and 90% positive-predictive value. Automated activation mapping and animation successfully revealed slow wave propagation patterns, and frequency, velocity, and amplitude were calculated and compared at 5 locations along the intestine (16.4 ± 0.3 cpm, 13.4 ± 1.7 mm/sec, and 43 ± 6 µV, respectively, in the proximal jejunum).

CONCLUSIONS

The methods developed and validated here will greatly assist small intestine HR mapping, and will enable experimental and translational work to evaluate small intestine motility in health and disease.

Comparison of filtering methods for extracellular gastric slow wave recordings

BACKGROUND

Extracellular recordings are used to define gastric slow wave propagation. Signal filtering is a key step in the analysis and interpretation of extracellular slow wave data; however, there is controversy and uncertainty regarding the appropriate filtering settings. This study investigated the effect of various standard filters on the morphology and measurement of extracellular gastric slow waves.

METHODS

Experimental extracellular gastric slow waves were recorded from the serosal surface of the stomach from pigs and humans. Four digital filters: finite impulse response filter (0.05-1 Hz); Savitzky-Golay filter (0-1.98 Hz); Bessel filter (2-100 Hz); and Butterworth filter (5-100 Hz); were applied on extracellular gastric slow wave signals to compare the changes temporally (morphology of the signal) and spectrally (signals in the frequency domain).

KEY RESULTS

The extracellular slow wave activity is represented in the frequency domain by a dominant frequency and its associated harmonics in diminishing power. Optimal filters apply cutoff frequencies consistent with the dominant slow wave frequency (3-5 cpm) and main harmonics (up to ≈ 2 Hz). Applying filters with cutoff frequencies above or below the dominant and harmonic frequencies was found to distort or eliminate slow wave signal content.

CONCLUSIONS & INFERENCES

Investigators must be cognizant of these optimal filtering practices when detecting, analyzing, and interpreting extracellular slow wave recordings. The use of frequency domain analysis is important for identifying the dominant and harmonics of the signal of interest. Capturing the dominant frequency and major harmonics of slow wave is crucial for accurate representation of slow wave activity in the time domain. Standardized filter settings should be determined.

Automated classification of spatiotemporal characteristics of gastric slow wave propagation

Gastric contractions are underpinned by an electrical event called slow wave activity. High-resolution electrical mapping has recently been adapted to study gastric slow waves at a high spatiotemporal detail. As more slow wave data becomes available, it is becoming evident that the spatial organization of slow wave plays a key role in the initiation and maintenance of gastric dsyrhythmias in major gastric motility disorders. All of the existing slow wave signal processing techniques deal with the identification and partitioning of recorded wave events, but not the analysis of the slow wave spatial organization, which is currently performed visually. This manual analysis is time consuming and is prone to observer bias and error. We present an automated approach to classify spatial slow wave propagation patterns via the use of Pearson cross correlations. Slow wave propagations were grouped into classes based on their similarity to each other. The method was applied to high-resolution gastric slow wave recordings from four pigs. There were significant changes in the velocity of the gastric slow wave wavefront and the amplitude of the slow wave event when there was a change in direction to the slow wave wavefront during dsyrhythmias, which could be detected with the automated approach.

A miniature bidirectional telemetry system for in vivo gastric slow wave recordings

Stomach contractions are initiated and coordinated by an underlying electrical activity (slow waves), and electrical dysrhythmias accompany motility diseases. Electrical recordings taken directly from the stomach provide the most valuable data, but face technical constraints. Serosal or mucosal electrodes have cables that traverse the abdominal wall, or a natural orifice, causing discomfort and possible infection, and restricting mobility. These problems motivated the development of a wireless system. The bidirectional telemetric system constitutes a front-end transponder, a back-end receiver and a graphical userinter face. The front-end module conditions the analogue signals, then digitizes and loads the data into a radio for transmission. Data receipt at the backend is acknowledged via a transceiver function. The system was validated in a bench-top study, then validated in vivo using serosal electrodes connected simultaneously to a commercial wired system. The front-end module was 35 × 35 × 27 mm3 and weighed 20 g. Bench-top tests demonstrated reliable communication within a distance range of 30 m, power consumption of 13.5 mW, and 124 h operation when utilizing a 560 mAh, 3 V battery. In vivo,slow wave frequencies were recorded identically with the wireless and wired reference systems (2.4 cycles min−1), automated activation time detection was modestly better for the wireless system (5% versus 14% FP rate), and signal amplitudes were modestly higher via the wireless system (462 versus 3 86μV; p<0.001). This telemetric system for slow wave acquisition is reliable,power efficient, readily portable and potentially implantable. The device will enable chronic monitoring and evaluation of slow wave patterns in animals and patients.0967-3334/

Abnormal initiation and conduction of slow-wave activity in gastroparesis, defined by high-resolution electrical mapping

BACKGROUND & AIMS

Interstitial cells of Cajal (ICC) generate slow waves. Disrupted ICC networks and gastric dysrhythmias are each associated with gastroparesis. However, there are no data on the initiation and propagation of slow waves in gastroparesis because research tools have lacked spatial resolution. We applied high-resolution electrical mapping to quantify and classify gastroparesis slow-wave abnormalities in spatiotemporal detail.

METHODS

Serosal high-resolution mapping was performed using flexible arrays (256 electrodes; 36 cm(2)) at stimulator implantation in 12 patients with diabetic or idiopathic gastroparesis. Data were analyzed by isochronal mapping, velocity and amplitude field mapping, and propagation animation. ICC numbers were determined from gastric biopsy specimens.

RESULTS

Mean ICC counts were reduced in patients with gastroparesis (2.3 vs 5.4 bodies/field; P < .001). Slow-wave abnormalities were detected by high-resolution mapping in 11 of 12 patients. Several new patterns were observed and classified as abnormal initiation (10/12; stable ectopic pacemakers or diffuse focal events; median, 3.3 cycles/min; range, 2.1-5.7 cycles/min) or abnormal conduction (7/10; reduced velocities or conduction blocks; median, 2.9 cycles/min; range, 2.1-3.6 cycles/min). Circumferential conduction emerged during aberrant initiation or incomplete block and was associated with velocity elevation (7.3 vs 2.9 mm s(-1); P = .002) and increased amplitudes beyond a low base value (415 vs 170 μV; P = .002).

CONCLUSIONS

High-resolution mapping revealed new categories of abnormal human slow-wave activity. Abnormalities of slow-wave initiation and conduction occur in gastroparesis, often at normal frequency, which could be missed by tests that lack spatial resolution. Irregular initiation, aberrant conduction, and low amplitude activity could contribute to the pathogenesis of gastroparesis.

Rapid high-amplitude circumferential slow wave propagation during normal gastric pacemaking and dysrhythmias

BACKGROUND

Gastric slow waves propagate aborally as rings of excitation. Circumferential propagation does not normally occur, except at the pacemaker region. We hypothesized that (i) the unexplained high-velocity, high-amplitude activity associated with the pacemaker region is a consequence of circumferential propagation; (ii) rapid, high-amplitude circumferential propagation emerges during gastric dysrhythmias; (iii) the driving network conductance might switch between interstitial cells of Cajal myenteric plexus (ICC-MP) and circular interstitial cells of Cajal intramuscular (ICC-IM) during circumferential propagation; and (iv) extracellular amplitudes and velocities are correlated.

METHODS

An experimental-theoretical study was performed. High-resolution gastric mapping was performed in pigs during normal activation, pacing, and dysrhythmia. Activation profiles, velocities, and amplitudes were quantified. ICC pathways were theoretically evaluated in a bidomain model. Extracellular potentials were modeled as a function of membrane potentials.

KEY RESULTS

High-velocity, high-amplitude activation was only recorded in the pacemaker region when circumferential conduction occurred. Circumferential propagation accompanied dysrhythmia in 8/8 experiments was faster than longitudinal propagation (8.9 vs 6.9 mm s(-1) ; P = 0.004) and of higher amplitude (739 vs 528 μV; P = 0.007). Simulations predicted that ICC-MP could be the driving network during longitudinal propagation, whereas during ectopic pacemaking, ICC-IM could outpace and activate ICC-MP in the circumferential axis. Experimental and modeling data demonstrated a linear relationship between velocities and amplitudes (P < 0.001).

CONCLUSIONS & INFERENCES

The high-velocity and high-amplitude profile of the normal pacemaker region is due to localized circumferential propagation. Rapid circumferential propagation also emerges during a range of gastric dysrhythmias, elevating extracellular amplitudes and organizing transverse wavefronts. One possible explanation for these findings is bidirectional coupling between ICC-MP and circular ICC-IM networks.

The gastrointestinal electrical mapping suite (GEMS): software for analyzing and visualizing high-resolution (multi-electrode) recordings in spatiotemporal detail

Background

Gastrointestinal contractions are controlled by an underlying bioelectrical activity. High-resolution spatiotemporal electrical mapping has become an important advance for investigating gastrointestinal electrical behaviors in health and motility disorders. However, research progress has been constrained by the low efficiency of the data analysis tasks. This work introduces a new efficient software package: GEMS (Gastrointestinal Electrical Mapping Suite), for analyzing and visualizing high-resolution multi-electrode gastrointestinal mapping data in spatiotemporal detail.

Results

GEMS incorporates a number of new and previously validated automated analytical and visualization methods into a coherent framework coupled to an intuitive and user-friendly graphical user interface. GEMS is implemented using MATLAB®, which combines sophisticated mathematical operations and GUI compatibility. Recorded slow wave data can be filtered via a range of inbuilt techniques, efficiently analyzed via automated event-detection and cycle clustering algorithms, and high quality isochronal activation maps, velocity field maps, amplitude maps, frequency (time interval) maps and data animations can be rapidly generated. Normal and dysrhythmic activities can be analyzed, including initiation and conduction abnormalities. The software is distributed free to academics via a community user website and forum (http://sites.google.com/site/gimappingsuite).

Conclusions

This software allows for the rapid analysis and generation of critical results from gastrointestinal high-resolution electrical mapping data, including quantitative analysis and graphical outputs for qualitative analysis. The software is designed to be used by non-experts in data and signal processing, and is intended to be used by clinical researchers as well as physiologists and bioengineers. The use and distribution of this software package will greatly accelerate efforts to improve the understanding of the causes and clinical consequences of gastrointestinal electrical disorders, through high-resolution electrical mapping.

Gastrointestinal extracellular electrical recordings: fact or artifact?

Extracellular electrical recordings underpin an important literature of basic and clinical motility science. In the November 2011 edition of Neurogastroenterology and Motility, Sanders and colleagues reported that contraction artifacts could be recorded from in vitro murine gastric tissues using extracellular electrodes, and that true extracellular bioelectrical activity could not be detected when the contractions were suppressed. The authors interpret their findings to mean that previous extracellular studies have generally assayed contraction artifacts, rather than bioelectrical activity, and suggest that movement suppression is an obligatory control for extracellular experiments. If their interpretation is correct, these claims would be significant, requiring a reinterpretation of many studies, and posing major challenges for future in vivo and especially clinical work. However, a demonstration that motion artifacts can be recorded from murine in vitro tissue does not necessarily mean that other extracellular studies also represented artifacts. This viewpoint evaluates a recently published by Sanders and colleagues in light of the competing literature, and finds a considerable volume of evidence to support the veracity of GI extracellular electrical recordings. It is reasoned from biophysical principles, technical considerations, and experimental studies that motion artifacts cannot explain GI extracellular electrical recordings in general, and that bioelectrical fact and artifact can be readily and reliably distinguished in most contexts. Calls for obligatory motion suppression for extracellular studies are therefore not supported. However, the artifacts recorded by Sanders and colleagues nevertheless serve as a reminder that educated caution is needed when recording, filtering and interpreting extracellular data.

An improved method for the estimation and visualization of velocity fields from gastric high-resolution electrical mapping

High-resolution (HR) electrical mapping is an important clinical research tool for understanding normal and abnormal gastric electrophysiology. Analyzing velocities of gastric electrical activity in a reliable and accurate manner can provide additional valuable information for quantitatively and qualitatively comparing features across and within subjects, particularly during gastric dysrhythmias. In this study, we compared three methods of estimating velocities from HR recordings to determine which method was the most reliable for use with gastric HR electrical mapping. The three methods were 1) simple finite difference (FD) 2) smoothed finite difference (FDSM), and 3) a polynomial-based method. With synthetic data, the accuracy of the simple FD method resulted in velocity errors almost twice that of the FDSM and the polynomial-based method, in the presence of activation time error up to 0.5 s. With three synthetic cases under various noise types and levels, the FDSM resulted in average speed error of 3.2% and an average angle error of 2.0° and the polynomial-based method had an average speed error of 3.3% and an average angle error of 1.7°. With experimental gastric slow wave recordings performed in pigs, the three methods estimated similar velocities (6.3-7.3 mm/s), but the FDSM method had a lower standard deviation in its velocity estimate than the simple FD and the polynomial-based method, leading it to be the method of choice for velocity estimation in gastric slow wave propagation. An improved method for visualizing velocity fields is also presented.