Noninvasive Classification of Ventricular Preexcitation with Unshielded Magnetocardiography and Transesophageal Atrial Pacing and Follow-Up

Clinical magnetocardiography: the unshielded bet-past, present, and future

Magnetocardiography (MCG), which is nowadays 60 years old, has not yet been fully accepted as a clinical tool. Nevertheless, a large body of research and several clinical trials have demonstrated its reliability in providing additional diagnostic electrophysiological information if compared with conventional non-invasive electrocardiographic methods. Since the beginning, one major objective difficulty has been the need to clean the weak cardiac magnetic signals from the much higher environmental noise, especially that of urban and hospital environments. The obvious solution to record the magnetocardiogram in highly performant magnetically shielded rooms has provided the ideal setup for decades of research demonstrating the diagnostic potential of this technology. However, only a few clinical institutions have had the resources to install and run routinely such highly expensive and technically demanding systems. Therefore, increasing attempts have been made to develop cheaper alternatives to improve the magnetic signal-to-noise ratio allowing MCG in unshielded hospital environments. In this article, the most relevant milestones in the MCG's journey are reviewed, addressing the possible reasons beyond the currently long-lasting difficulty to reach a clinical breakthrough and leveraging the authors' personal experience since the early 1980s attempting to finally bring MCG to the patient's bedside for many years thus far. Their nearly four decades of foundational experimental and clinical research between shielded and unshielded solutions are summarized and referenced, following the original vision that MCG had to be intended as an unrivaled method for contactless assessment of the cardiac electrophysiology and as an advanced method for non-invasive electroanatomical imaging, through multimodal integration with other non-fluoroscopic imaging techniques. Whereas all the above accounts for the past, with the available innovative sensors and more affordable active shielding technologies, the present demonstrates that several novel systems have been developed and tested in multicenter clinical trials adopting both shielded and unshielded MCG built-in hospital environments. The future of MCG will mostly be dependent on the results from the ongoing progress in novel sensor technology, which is relatively soon foreseen to provide multiple alternatives for the construction of more compact, affordable, portable, and even wearable devices for unshielded MCG inside hospital environments and perhaps also for ambulatory patients.

From 3D to 4D imaging: is that useful for interventional cardiac electrophysiology?

Three-dimensional electroanatomical imaging is increasingly used in interventional cardiac electrophysiology, to guide catheter ablation of cardiac arrhythmias. At the same time, there is a growing interest for non-invasive methods, such as magnetocardiographic mapping (MCG), to localize the arrhythmogenic substrates, to test their reproducibility and to plan the most appropriate interventional approach. So far electroanatomical imaging has relayed on static mathematical modeling of the heart and more recently on direct merging with three-dimensional rendering of cardiac anatomy from multidetector computer tomography or magnetic resonance imaging. Merging electrophysiological information with static anatomical structures, can surely be a source of uncertainty for MCG-based pre-interventional localization of the arrhythmogenic substrate and causes mismatch between the real-time imaging of moving catheters and the static geometry of the cardiac chambers reconstructed with invasive electroanatomical imaging. The implementation of recent realistic numerical models of the beating heart in a breathing thorax can improve accuracy and fill the gap between non-invasive and interventional electroanatomical imaging.

A novel method for reducing pain sensation at transesophageal atrial stimulation

Transesophageal atrial stimulation (TAS) is widely used in evaluation and treatment of supraventricular arrhythmias. It can yield important information in most situations, where invasive atrial stimulation is usually done, but is safe, rapid, inexpensive and can often be performed in an outpatient setting. However, in clinical practice TAS pacing usually causes patients some degree of discomfort and/or pain. The aim of the study was to evaluate the possibility and methods to obtain successful atrial capture using multiple electrical pulses in order to reduce pain sensation during the procedure. The study was performed in 17 patients aged 22 to 54 years, special experimental arrangement was used. We elaborated a novel method of combining very short electric pulses (splitting the impulse) from different locations which resulted in desired current density and pulse length in target tissue. As the result the stimulation could be less painful for patient than routinely used single 10ms current pulse.