Effect of mitral valvular regurgitation on transthoracic impedance cardiogram

The Usefulness and Limitations of Impedance Cardiography for Cardiac Resynchronization Therapy Device Optimization

Identifying the optimal atrioventricular (AV) or interventricular (VV) delay is beneficial for patients using cardiac resynchronization therapy (CRT) devices. Ultrasonic echocardiography (UCG) has been the most commonly used method; however, it requires high technical knowledge. Impedance cardiography (ICG) can calculate stroke volume by measuring changes in transthoracic electric impedance. This study sought to assess the clinical utility of ICG in comparison with that of UCG for the optimization of CRT devices.Patients who underwent CRT device implantation were retrospectively analyzed. One week after implantation, optimization of AV delay (AVD) was performed in every patient with ICG (AVD-ICG) and UCG (AVD-UCG). VV delay (VVD) was then determined according to the optimal AVD using these two methods.Forty-two patients were enrolled. Average AVD-ICG was significantly shorter than AVD-UCG (128 ± 49 versus 146 ± 41 milliseconds, P = 0.018). Five patients (12%) had the same optimized AVD with two methods, and the difference between AVD-ICG and AVD-UCG was ≤ 20 milliseconds in 19 patients (45%). In the multivariate analysis, the presence of postoperative mitral regurgitation (MR) was an independent predictor of AVD-ICG/AVD-UCG mismatch, defined as a difference over 20 milliseconds (odds ratio = 10.71; 95% confidence interval = 1.72 to 66.72; P = 0.018). The results of optimized VVD were similar using both methods.ICG might be a promising tool for the rapid optimization of CRT devices. However, in patients with moderate-to-severe MR, ICG may not be able to optimize AVD.

Development of a miniature and ASIC based impedance cardiograph

In view of cardiac output monitoring application of impedance cardiography a miniature impedance cardiograph has been developed, which is based on an application specific integrated circuit (analog front end chip AFE4300). Carrier current capability of this chip has been enhanced four times (up to 3.2 milliamperes) for cardiology applications with the help of an external resistance, not provisioned in the original design. Also the sensed signal is externally amplified before feeding to AFE chip to increase resolution in the impedance range of 10-50 Ohms.The AFE chip is interfaced to a Personal Computer with the help of a microcontroller board through a USB cable. Application software programs the AFE chip for sending a carrier current of 3.2 milliamperes (peak to peak) to the subject's body segment through current output ports and sensing the chest impedance through voltage input ports. The chest impedance is read in detector mode and communicated to Laptop through serial peripheral interface of the chip. Chest impedance, change in impedance as a function of time and rate of change of impedance are displayed on the graphic user interface. Fifteen minute data from volunteers have shown consistent recordings, as described in this paper.

Comparison of bioreactance non-invasive cardiac output measurements with cardiac magnetic resonance imaging

Impedance cardiography measurement of cardiac output gained wide interest due to its ease of use and non-invasiveness. However, validation studies of different algorithms yielded diverging results. Bioreactance (BR) as a recent adaption differs fundamentally as the flow signal is derived from phase shifts. Our aim was to assess the accuracy and reproducibility of BR, as compared to the non-invasive gold standard--cardiac magnetic resonance imaging (CMR). We prospectively included 32 stable patients. BR was performed twice in the supine position and averaged over 30 seconds. Mean bias was 0.2 ± 1.8 l/minute (1 ± 28%, percentage error 55%) with limits of agreement ranging from  -3.4 to 3.7 l/minute. Reproducibility was acceptable with a mean bias of 0.1 ± 0.9 l/minute (1 ± 14%, 27%). Low cardiac output was significantly overestimated (-1.1 ± 1.5 l/minute), while high cardiac output was underestimated (1.5 ± 1.7 l/minute), (P=0.001), although reproducibility was unaffected. Bias and weight were moderately correlated in men (r = 0.50, P=0.02). No differences for accuracy were found in nine patients who had an arrhythmia (0.3 ± 1.4 versus 0.1 ± 2.0 l/minute, P=0.76), while clinically relevant differences were found in patients with mild aortic valve disease (1.9 ± 2.2 versus -0.3 ± 1.7 l/minute, P=0.02). Overall, BR showed insufficient agreement with CMR, overestimating low and underestimating high cardiac output states. Reproducibility was acceptable and not negatively affected by the circulatory condition. Consequently, absolute values acquired with BR should be interpreted with caution and must not be used interchangeably in clinical practice.

Assessment of cardiac time intervals by wavelet transform of the impedance cardiogram

BACKGROUND

Impedance cardiography (ICG) is an inexpensive, noninvasive technique for estimating hemodynamic parameters. ICG can be used to obtain the ejection fraction of the left atrium and to monitor systolic time intervals. Traditional ICG technique does not enable unambiguous detection of the left ventricle ejection time (LVET) and the time relationships between specific marker points.

OBJECTIVE

This work aims to approbate a new approach for ICG signal processing using wavelet transform (WT) and to investigate the possibilities of this approach for determination of the parameters which are related to the stroke volume (SV), in particular LVET.

METHODS

Thoracic tetrapolar polyrheocardiography method for simultaneous registration of ECG, ICG and phonocardiograms has been used. A control group consisted of eight healthy men aged 20-25 years. In addition, four patients with essential hypertension participated in the study. Wavelet representation of the ICG data produced local maxima in a two dimensional distribution of the wavelet coefficient. Each extremum point was characterized by the amplitude, scale and time, which determine SV.

RESULTS

LVET was defined as the scale corresponding to the E-wave maximum related to the systolic phase of the cardiac cycle. Also, we defined the initial systolic time interval (ISTI) as the time interval between R peak in the ECG and E-wave maximum on the wavelet plane. During functional test LVET and ISTI values defined by WT demonstrated a proper hemodynamic response to loading for the control group and patients with essential hypertension.

CONCLUSION

The proposed approach demonstrates the ability of ICG-WT technique for adequate assessment of SV parameters, including cardiac time intervals.

Noninvasive measurement of cardiac output: two methods compared in patients with mitral regurgitation

In search for the origin of the less reliable cardiac output (CO) estimations by means of electrical impedance cardiography (EIC), the authors hypothesized that cardiac valve pathology might be one of the reasons. Twenty-six patients were examined by means of echo Doppler (ED) and EIC. The cardiac valve status was obtained by means of echocardiography and color Doppler flow, while CO was obtained by means of both methods. Seventeen patients had no valve pathology (nVP) while nine patients had mild to moderate mitral regurgitation (MVR). The overall correlation between the calculation of CO by means of the two methods was good (r = 0.85, p < 0.001, mean difference and standard deviation: 0.20+/-0.74 L/min), while there was no significant difference between the paired values. After division into an nVP and an MVR population, the results showed an even closer agreement between the CO values in the nVP population (r = 0.88, p < 0.001, mean difference and standard deviation: 0.15+/-0.68 L/min). Furthermore, significant differences were found in the first derivative of the impedance (dZ/dt) signals of these groups. Although the agreement between ED and EIC was slightly lower in the MVR population, EIC reliably estimated CO, even in case of MVR. The impedance signal itself gave an indication for the existence of MVR.

Prediction of pulmonary capillary wedge pressure and assessment of stroke volume by noninvasive impedance cardiography

Early recognition of heart failure is important because early treatment reduces mortality and hospitalization rates. In screening for this disease, there is a need for a simple, safe, and cost-effective method to obtain cardiovascular variables. Therefore we developed a noninvasive impedance cardiographic method to predict the pulmonary capillary wedge pressure (PCWP) from the impedance cardiogram. The impedance cardiographic technique, though, was originally designed for stroke volume (SV) determination. The objectives of this study were to validate both variables by comparison with the paired, invasively obtained equivalents. PCWP, measured with a pulmonary artery catheter, was related to the O/C ratio from the impedance cardiogram. The O/C ratio was calculated as the amplitude of the impedance cardiogram during diastole (O) divided by the maximum height during systole (C). Stroke volume was also calculated from the impedance cardiogram according to the equation of Kubicek (SVIC) and compared with thermodilution (SVTD). Data analysis was performed in 24 stable patients who underwent diagnostic heart catheterization. Linear regression analysis showed that the O/C ratio was strongly related to the invasively measured PCWP over a range of 3 to 30 mm Hg (r = 0.92, standard error of the estimate, 3.2 mm Hg). Between SVIC and SVTD a moderate correlation was established (r = 0.69), but after exclusion of the data from patients with an aortic valve disorder (n = 5), the correlation increased considerably (r = 0.87). No significant differences between SVIC and SVTD were found (mean difference +/- 2 SD = 1.8 +/- 28.8 ml). These preliminary observations suggest that impedance cardiography can predict PCWP and measure SV over a wide range of clinically relevant values. The combined measurement of SV and PCWP by impedance cardiography might be a clinical useful tool in screening for heart failure.

Impedance cardiography using band and regional electrodes in supine, sitting, and during exercise

The electrical impedance and its first derivative (dZ/dt) were measured at 100 kHz on 10 normal males in supine, sitting, and during upright bicycle exercise in order to compare the contribution of regional electrodes to the standard band electrode signal and to evaluate the possible use of spot electrodes for stroke volume (SV) measurements. Simultaneous measurements were made from band electrodes placed around the neck and lower thorax and from spot electrodes which recorded signals from the neck, upper thorax, and lower thorax. The results showed that approximately equal parts of the dZ/dt waveform came from the neck and upper thorax with the lower thorax contribution small but providing important features of the band signal. Changing from supine to sitting showed percentage decreases of 35% and 46% for the band and neck signals, respectively, with an increase of 19% for the upper thorax signal. The percentage increases in SV with upright exercise were 34%, 52%, and 24% for the bands, neck, and upper thorax signals, respectively. Band signal is made up of different signals from various regions of the thorax. Its ability to predict correct changes in SV may result from some "lucky" coincidences. The use of regional electrodes will probably not give the same SV information but may be important in measuring regional activities of the central circulation.

Clinical evaluation of an ensemble-averaging impedance cardiograph for monitoring stroke volume during spontaneous breathing

Simultaneous determination of stroke volume (SV) with an ensemble-averaging impedance cardiograph (AIGG) and the thermodilution technique (TD) was compared in 10 patients scheduled for major vascular surgery. A small, successive increase in SV was achieved by a step-wise infusion of dextran-70 and elevation of the patient's legs. The patients were allowed to breathe normally during the measurement procedures. There was no difference between the ability of AICG and TD to monitor changes in SV and the correlation coefficient for the measurement of changes in SV by the two methods was 0.88. There was no difference between the reproducibility of AICG- (4.6 ml) and TD- (9.2 ml) determined SV or between the coefficient of variation for AICG (4.8%) and TD (9.9%). The mean difference between AICG- and TD-determined SV at the different measurement points (range 1.3-4.2 ml) was well within acceptable limits. In conclusion, the ensemble-averaging impedance cardiograph described in this study was found to be reliable for monitoring changes in SV during uninterrupted, spontaneous breathing.

Noninvasive evaluation of aortic stenosis severity utilizing Doppler ultrasound and electrical bioimpedance

Aortic valve area was calculated noninvasively in 30 patients with aortic stenosis undergoing cardiac catheterization. Continuous wave Doppler ultrasound was employed to estimate the mean transvalvular pressure gradient. The mean left ventricular outflow tract flow velocity and cross-sectional area were determined from pulsed Doppler and two-dimensional ultrasound recordings. Electrical transthoracic bioimpedance cardiography performed simultaneously with the ultrasonic study and repeated at the time of catheterization measured heart rate, systolic ejection period and cardiac output. These noninvasive data permitted calculation of aortic valve area using the Gorlin equation (range 0.21 to 1.75 cm2) and the continuity equation (range 0.25 to 1.9 cm2). Subsequent cardiac catheterization showed valve area to range from 0.21 to 1.75 cm2. The mean Doppler pressure gradient estimate was highly predictive of the gradient measured at catheterization (r = +0.92, SEE = 10). Bioimpedance cardiac output measurements agreed with the average of Fick and indicator dye estimates (r = +0.90, SEE = 0.52). Valve area estimates utilizing continuous wave Doppler ultrasound and electrical bioimpedance were superior (r = +0.91, SEE = 0.12) to estimates obtained utilizing the continuity equation (r = +0.76, SEE = 0.29) and were more reliable in the detection of patients with severe aortic stenosis (9 of 11 versus 6 of 11). These data show that 1) electrical bioimpedance methods accurately estimate cardiac output in the presence of aortic stenosis; 2) the hybridized bioimpedance-Doppler ultrasound method yields accurate estimates of aortic stenosis area; and 3) the speed, accuracy and cost-effectiveness of aortic stenosis evaluation may be improved by this hybridized approach.

The use of impedance cardiography in heart failure

The suitability of the impedance cardiograph for studying patients with cardiac failure in a District General Hospital was assessed over a 12-month period. Over 200 recordings were made from 60 patients. Stroke volume, using the derived formulation of Kubicek and his colleagues, and the Heather Index (a measure of cardiac contractility) were calculated in each case. Serial recordings provided an objective assessment of the efficacy of treatment. An abnormal diastolic O wave was found in the majority of patients. This may indicate an excessive accumulation of blood in the thorax as a result of myocardial dysfunction.

Clinical evaluation of impedance cardiography

We tested the validity of thoracic impedance cardiography for measuring cardiac output in man by comparing absolute values obtained using the non-invasive impedance method with values obtained using the invasive thermodilution method. We also compared per cent changes in cardiac output using impedance cardiography and thermodilution in response to environmental manipulations including cardiac pacing and intravenous administration of ergonovine, dipyridamole, or isoproterenol. Among 19 patients, absolute values for cardiac output, using the impedance and the thermodilution techniques, agreed well (r = 0.85, P less than 0.001). The per cent change in cardiac output by impedance cardiography was positively correlated with the per cent change by thermodilution for the several manipulations (overall r = 0.87, P less than 0.001). Impedance cardiography does appear, in general, to measure cardiac output and stroke volume validly in man, even in situations where heart rate and stroke volume change in opposite directions.