Multifunctional catheters combining intracardiac ultrasound imaging and electrophysiology sensing.

A family of 3 multifunctional intracardiac imaging and electrophysiology (EP) mapping catheters has been in development to help guide diagnostic and therapeutic intracardiac EP procedures. The catheter tip on the first device includes a 7.5 MHz, 64-element, side-looking phased array for high resolution sector scanning. The second device is a forward-looking catheter with a 24-element 14 MHz phased array. Both of these catheters operate on a commercial imaging system with standard software. Multiple EP mapping sensors were mounted as ring electrodes near the arrays for electrocardiographic synchronization of ultrasound images and used for unique integration with EP mapping technologies. To help establish the catheters' ability for integration with EP interventional procedures, tests were performed in vivo in a porcine animal model to demonstrate both useful intracardiac echocardiographic (ICE) visualization and simultaneous 3-D positional information using integrated electroanatomical mapping techniques. The catheters also performed well in high frame rate imaging, color flow imaging, and strain rate imaging of atrial and ventricular structures. The companion paper of this work discusses the catheter design of the side-looking catheter with special attention to acoustic lens design. The third device in development is a 10 MHz forward-looking ring array that is to be mounted at the distal tip of a 9F catheter to permit use of the available catheter lumen for adjunctive therapy tools.

Semi-automatic segmentation of fetal cardiac cavities: progress towards an automated fetal echocardiogram.

OBJECTIVE: To develop a novel application of a tool for semi-automatic volume segmentation and adapt it for analysis of fetal cardiac cavities and vessels from heart volume datasets. METHODS: We studied retrospectively virtual cardiac volume cycles obtained with spatiotemporal image correlation (STIC) from six fetuses with postnatally confirmed diagnoses: four with normal hearts between 19 and 29 completed gestational weeks, one with d-transposition of the great arteries and one with hypoplastic left heart syndrome. The volumes were analyzed offline using a commercially available segmentation algorithm designed for ovarian folliculometry. Using this software, individual 'cavities' in a static volume are selected and assigned individual colors in cross-sections and in 3D-rendered views, and their dimensions (diameters and volumes) can be calculated. RESULTS: Individual segments of fetal cardiac cavities could be separated, adjacent segments merged and the resulting electronic casts studied in their spatial context. Volume measurements could also be performed. Exemplary images and interactive videoclips showing the segmented digital casts were generated. CONCLUSION: The approach presented here is an important step towards an automated fetal volume echocardiogram. It has the potential both to help in obtaining a correct structural diagnosis, and to generate exemplary visual displays of cardiac anatomy in normal and structurally abnormal cases for consultation and teaching.

Quantitative assessment of regional peak myocardial acceleration during isovolumic contraction and relaxation times by tissue Doppler imaging.

OBJECTIVE: To examine regional wall acceleration and its relation to relaxation. STUDY DESIGN: 8 sheep were examined by tissue Doppler ultrasound imaging (VingMed Vivid FiVe) in apical four chamber views to evaluate the left ventricular wall divided into six segments and the mitral annulus in two segments. Peak myocardial acceleration during isovolumic periods (pIVA) derived from tissue Doppler echocardiography was analysed during isovolumic contraction (ICT) and relaxation times (IRT) in each segment. INTERVENTIONS: After scanning at baseline, haemodynamic status was changed by administration of blood, dobutamine, and metoprolol. Changes of pIVA during IRT and ICT were compared over the four haemodynamic conditions in parallel with their peak positive and negative dP/dt measured with a high frequency manometer tipped catheter. RESULTS: pIVA of the basal lateral segment during ICT correlated most strongly with peak positive dP/dt (r = 0.96, p < 0.0001) and there was good correlation between pIVA of the mitral valve annulus in the septum during IRT and peak negative dP/dt (r = 0.80, p < 0.0001). pIVA differed significantly between the four haemodynamic conditions during ICT in all segments (p < 0.05); pIVA during IRT did not differ significantly between the four conditions. CONCLUSIONS: pIVA of the basal lateral wall during ICT correlated most strongly with peak positive dP/dt, and pIVA of the septal mitral valve annulus during IRT correlated well with peak negative dP/dt.

Flow in the early embryonic human heart: a numerical study.

Computational fluid dynamic (CFD) experimentation provides a unique medium for detailed examination of flow through complex embryonic heart structures. The purpose of this investigation was to demonstrate that streaming blood flow patterns exist in the early embryonic heart and that fluid surface stresses change significantly with anomalous alterations in fetal heart lumen shape. Stages 10 and 11 early human embryo hearts were digitized as calibrated two-dimensional (2D) cross-sectional sequential images. A 3D surface was constructed from the stacking of these 2D images. CFD flow solutions were obtained (steady and pulsatile flow). Particle traces were placed in the inlet and outlet portions of these two stages. Sections of the embryonic heart were artificially reshaped. CFD flow solutions were obtained and surface stress changes analyzed. Streaming was shown to exist, with particles released on one or the other side of the cardiac lumen tending not to cross over and mix with particles released from the opposite side of the cardiac lumen. Shear stress changes (stage 10) occur in the altered lumens. Streaming exists in steady and pulsatile flow scenarios in the embryonic heart models. There are differences in local shear stress distributions with surface shape anomalies of the fetal heart lumen. These observations may help shed light on the potential role of fluid dynamic factors in determining patterns of abnormal heart development.

Use of tissue velocity imaging in the diagnosis of fetal cardiac arrhythmias.

BACKGROUND: Precise diagnosis of cardiac arrhythmias in the fetus is crucial for a managed therapeutic approach. However, many technical, positional, and gestational age-related limitations may render conventional methods, such as M-mode and Doppler flow methodologies, or newer techniques, such as fetal electrocardiography or magnetocardiography, difficult to apply, or these techniques may be unsuitable for the diagnosis of fetal arrhythmias. METHODS AND RESULTS: In this prospective study, we describe a novel method based on raw scan-line tissue velocity data acquisition and analysis. The raw data are available from high-frame-rate 2D tissue velocity images and allow simultaneous sampling of right and left atrial and ventricular wall velocities to yield precise temporal analysis of atrial and ventricular events. Using this timing data, a ladder diagram-like "fetal kinetocardiogram" was developed to diagram and diagnose arrhythmias and to provide true intervals. This technique was feasible and fast, yielding diagnostic results in all 31 fetuses from 18 to 38 weeks of gestation. Analysis of various supraventricular and ventricular arrhythmias was readily obtained, including arrhythmias that conventional methods fail to diagnose. CONCLUSIONS: The fetal kinetocardiogram opens a new window to aid in the diagnosis and understanding of fetal arrhythmias, and it provides a tool for studying the action of antiarrhythmic drugs and their effects on electrophysiological conduction in the fetal heart.

Surface integration of velocity vectors from 3D digital colour Doppler: an angle independent method for laminar flow measurements.

BACKGROUND: The study was designed to test the angle independence of a dynamic three-dimensional digital colour Doppler method for laminar flow measurement. The technique acquired three-dimensional data by rotational acquisition and used surface integration of Doppler vector velocities and flow areas in time and space for flow computation. METHOD: A series of pulsatile flows (peak flow 55-180 ml/s) through a curved tube were studied with reference flow rates obtained using an ultrasonic flow meter. Colour Doppler imaging was performed at three angles to the direction of flow (20 degrees, 30 degrees, 40 degrees), using a multiplane transoesophageal probe controlled by an ATL HDI5000 system. Integration of digital velocity vectors over a curved three-dimensional surface across the tube for each of the 11 flow rates at each angle was performed off-line to compute peak flow. RESULTS: Peak flow rates correlated closely (r=0.99) with the flow meter with the mean difference from the reference being -0.8+/-2 x 4 ml/s, 0.9+/-2.6 ml/s, 1.0+/-2 x 3 ml/s for 20 degrees, 30 degrees and 40 degrees respectively. Comparison of the three angle groups showed no significant differences (P=0.15, ANOVA). When sampled obliquely, the flow area on the curved surface increased while the velocities measured decreased. CONCLUSION: Surface integration of velocity vectors to compute three-dimensional Doppler flow data is less angle dependent than conventional Doppler methods.

Quantification of aortic regurgitation by real-time 3-dimensional echocardiography in a chronic animal model: computation of aortic regurgitant volume as the difference between left and right ventricular stroke volumes.

BACKGROUND: The accuracy of conventional 2-dimensional echocardiographic and Doppler techniques for the quantification of valvular regurgitation remains controversial. In this study, we examined the ability of real-time 3-dimensional (RT3D) echocardiography to quantify aortic regurgitation by computing aortic regurgitant volume as the difference between 3D echocardiographic-determined left and right ventricular stroke volumes in a chronic animal model. METHODS: Three to 6 months before the study, 6 sheep underwent surgical incision of one aortic valve cusp to create aortic regurgitation. During the subsequent open chest study session, a total of 25 different steady-state hemodynamic conditions were examined. Electromagnetic (EM) flow probes were placed around the main pulmonary artery and ascending aorta and balanced against each other to provide reference right and left ventricular stroke volume (RVSV and LVSV) data. RT3D imaging was performed by epicardial placement of a matrix array transducer on the volumetric ultrasound system, originally developed at the Duke University Center for Emerging Cardiovascular Technology. During each hemodynamic steady state, the left and right ventricles were scanned in rapid succession and digitized image loops stored for subsequent measurement of end-diastolic and end-systolic volumes. Left and right ventricular stroke volumes and aortic regurgitant volumes were then calculated and compared with reference EM-derived values. RESULTS: There was good correlation between RT3D left and right ventricular stroke volumes and reference data (r = 0.83, y = 0.94x + 2.6, SEE = 9.86 mL and r = 0.63, y = 0.8x - 1.0, SEE = 5.37 mL, respectively). The resulting correlation between 3D- and EM-derived aortic regurgitant volumes was at an intermediate level between that for LVSV and that for RVSV (r = 0.80, y = 0.88x + 7.9, SEE = 10.48 mL). RT3D tended to underestimate RVSV (mean difference -4.7 +/- 5.4 mL per beat, compared with -0.03 +/- 9.7 mL per beat for the left ventricle). There was therefore a small overestimation of aortic regurgitant volume (4.7 +/- 10.4 mL per beat). CONCLUSION: Quantification of aortic regurgitation through the computation of ventricular stroke volumes by RT3D is feasible and shows good correlation with reference flow data. This method should also be applicable to the quantification of other valvular lesions or single site intracardiac shunts where a difference between right and left ventricular cavity stroke volumes is produced.

Evaluation of systolic and diastolic ventricular performance of the right ventricle in fetuses with ductal constriction using the Doppler Tei index.

Fetal ductal constriction (DC) can depress right ventricular (RV) function. However, noninvasive assessment of fetal RV function remains difficult. We evaluated RV and left ventricular (LV) performance in fetuses with DC using the Doppler-derived Tei index. The Tei index measures the ratio of total time spent in isovolumic contraction and relaxation (isovolumic time) to the ejection time. Tricuspid inflow and RV outflow Doppler traces for the derivation of RV Tei indexes and mitral inflow and LV outflow traces for LV Tei indexes were measured in 78 fetuses of pregnant women who received indomethacin and 70 normal fetuses (gestational ages ranging from 20 to 39 weeks). DC occurred in 23 fetuses, defined as pulsatility index <1.9. In fetuses with DC, the RV isovolumic time was prolonged and RV ejection time was shortened, and the RV Tei index was high compared with those in fetuses that received indomethacin without DC and normal fetuses. Also, the RV Tei index clearly separated the fetuses with DC from normal and fetuses that received indomethacin without DC (0.74 +/- 0.14 vs 0.35 +/- 0.07 and 0.37 +/- 0.06, respectively; p <0.0001). The LV Tei index was not affected by DC. Serial study in 7 fetuses with DC showed that the RV Tei index decreased from 0.69 +/- 0.12 to 0.38 +/- 0.04 (p = 0.0002) after discontinuation of indomethacin coincident with ductal relaxation, although it remained elevated in 2 cases at the time of ductal relaxation. Thus, the Tei index is a useful and sensitive indicator for detecting abnormal RV performance in fetuses with DC.

Accuracy of three-dimensional quantification of left ventricular function using magnetic sensor acquisition: a dynamic in vitro model.

OBJECTIVE: To evaluate the accuracy of a three-dimensional (3D) magnetic position sensor system in the quantification of ventricular stroke volumes in a dynamic model. METHODS: A latex balloon model of the left ventricle was suspended in a water bath connected to a pump producing 10 different pulsatile stroke volumes (15-65 ml/beat). Scanning was performed using a 5.0 mHz transducer mounted with a Flock of Birds (FOB) magnetic receiver (GE System Five). The probe was scanned to sweep continuously across and over the balloon volume over 3-7 seconds. Digital loops were stored on magneto-optical disks and reviewed retrospectively using 3D Echopac software (GE) based on Simpson's method and compared with a two-dimensional (2D) biplane area-length method (1/2 L x R) measurements at end systole and end diastole. Both 3D and 2D derived stroke volumes were compared with the reference stroke volume calculated by direct measurement of balloon capacity. RESULTS: There was an improved correlation between 3D stroke volume and reference stroke volume (y = 0.91x + 0.41, r = 0.97, SEE = 2.83 ml, P = 0.0001) compared to 2D stroke volume and reference stroke volume (y = 0.49x + 8.68, r = 0.87, SEE = 3.87 ml, P = 0.0011, difference between 2D and 3D P < 0.003). CONCLUSION: 3D magnetic FOB scanning is practical, accurate and should facilitate assessment of left ventricular function.

Graphical and stereolithographic models of the developing human heart lumen.

Scaled physical models can be useful in analyzing stage-specific hemodynamics in the embryonic human heart to address correlations between early physical stressors and myocardial wall responses. We generated models of the cardiac blood space from reconstructions of four digitized human embryo images from Carnegie Collection at the Armed Forces Institute of Pathology. From physical scale models manufactured by stereolithography, compliant sleeves can be created for flow dynamics studies. This novel use of Carnegie collection images and graphical modeling software provides tools for broadening our understanding of normal and aberrant heart formation.

Dipyridamole stress ultrasonic myocardial tissue characterization in patients with Kawasaki disease.

Dipyridamole stress integrated backscatter (IBS) was used for evaluation of myocardial ischemia or damage in 31 children with coronary artery lesions caused by Kawasaki disease, in comparison with thallium-201 myocardial imaging. All patients underwent echocardiography at rest and after dipyridamole stress at the anterior interventricular septum, posterior wall (PW), and inferior wall (INF). At rest, no significant difference was seen in cyclic variation (CV) of IBS in the regions with normal or abnormal distribution on Tl-201 imaging. But in the regions showing abnormal distribution after stress, CV decreased significantly. A delayed study after stress showed the recovery of CV to the level at rest in all patients. Sensitivity of abnormal cyclic variation integrated backscatter was 75% in the PW and 91% in the INF, and specificity was 91% in the PW and 90% in the INF, compared with the results of thallium-201 imaging. Dipyridamole stress IBS can provide sensitive detection of myocardial ischemia or damage in Kawasaki disease.

Noninvasive assessment of left ventricular isovolumic contraction and relaxation with continuous wave Doppler aortic regurgitant velocity signals: an in vivo validation study.

The purpose of this study was to provide fundamental in vivo validation of a method with the use of aortic regurgitant (AR) jet signals recorded with continuous wave (CW) Doppler for assessing left ventricular (LV) isovolumic contraction and relaxation. Preliminary studies have suggested that analysis of CW Doppler AR velocity signals permits the estimation of LV positive and negative dP/dt. We studied 19 hemodynamically different states in 6 sheep with surgically induced chronic aortic regurgitation. CW AR velocity spectra and high-fidelity LV and aortic pressures were recorded simultaneously. Rates of LV pressure rise and fall (RPR and RPF) were calculated by determining the time interval between points at 1 m/s and 2.5 m/s in the deceleration and acceleration slopes of the CW Doppler AR velocity envelope (corresponding to a pressure change of 21 mm Hg). RPR and RPF calculated by CW Doppler analysis for each state were compared with the peak positive dP/dt and negative dP/dt, obtained from the corresponding high-fidelity LV pressure curve, respectively. The LV peak positive and negative dP/dt derived by catheter ranged from 817 to 2625 mm Hg/s and from 917 to 2583 mm Hg/s, respectively. Multiple regression analysis showed that Doppler RPR correlated well with catheter peak positive dP/dt (r = 0.93; mean differences, -413 +/- 250 mm Hg/s). There was also good correlation and agreement between Doppler RPF and the catheter peak negative dP/dt (r = 0.89; mean difference, -279 +/- 239 mm Hg/s). Both Doppler-determined RPR and RPF underestimated their respective LV peak dP/dt. CW Doppler AR spectra can provide a reliable noninvasive estimate of LV dP/dt and could be helpful in the serial assessment of ventricular function in patients with aortic regurgitation.

Validation of a digital color Doppler flow measurement method for pulmonary regurgitant volumes and regurgitant fractions in an in vitro model and in a chronic animal model of postoperative repaired tetralogy of Fallot.

OBJECTIVES: The purpose of this study was to validate a digital color Doppler (DCD) automated cardiac flow measurement method for quantifying pulmonary regurgitation (PR) in an in vitro and a chronic animal model of the right ventricular outflow tract of postoperative tetralogy of Fallot (TOF). BACKGROUND: There has been no reliable ultrasound method that can accurately quantitate PR. METHODS: We developed an in vitro model of mild pulmonary stenosis and wide-open PR that mimics the patterns of flow seen in patients with postoperative TOF. Thirteen different forward and regurgitant stroke volumes (RSVs) across the noncircular shaped cross-sectional outflow tract flow area were estimated using the DCD method in two orthogonal planes. In six sheep with surgically created PR, 24 different hemodynamic states with PR strictly quantified by electromagnetic probes were also studied. RESULTS: The RSVs and regurgitant fractions (RFs) obtained by the DCD method using average values from two orthogonal planes correlated well with reference values (RSV: r = 0.99, mean difference = 0.02 +/- 0.39 ml/beat for in vitro model; r = 0.97, mean differences = 1.79 +/- 1.84 ml/beat for animal model, RF: r = 0.98, mean difference = -1.10 +/- 4.34% for in vitro model; r = 0.94, mean difference = 2.73 +/- 6.75% for animal model). However, the DCD method using a single plane had limited accuracy for estimating pulmonary RFs and RSVs. CONCLUSIONS: The DCD method using average values from two orthogonal planes provides accurate estimation of RSVs and RFs and should have clinical importance for serially quantifying PR in patients with postoperative TOF.

In vitro validation of tissue Doppler left ventricular regional wall velocities by using a novel balloon phantom.

To investigate the validity and accuracy of tissue Doppler imaging (TDI) using a novel balloon phantom, validation of TDI myocardial velocity measurements has been carried out indirectly from conventional M-mode images. However it is not a true and independent gold standard. We described a new TDI validation method by using a specially developed left ventricular balloon model mounted in a water bath and constructed using two pear-shaped balloons. It was connected to a pulsatile flow pump at 8 stroke volumes (50-85 ml/beat). The displacement and velocity of the balloon walls were recorded simultaneously by video imaging and TDI on a GE-Vingmed System Five with a 5 MHz phased array probe at the highest frame rates available. Conventional M-mode and 2-D imaging verified that our balloon model mimicked the shape and wall motion of left ventricle. There was a good correlation and agreement between the maximum video excursion of the anterior and posterior walls of the phantom and the results of the temporal integration of digital distance data by TDI (Anterior wall: r = 0.97, SEE = 0.24 mm, mean +/- s = 0.04 +/- 0.24 mm; Posterior wall: r = 0.95, SEE = 0.22 mm, mean +/- s = 0.03 +/- 0.24 mm). Analysis of the velocity profile by the TDI method showed that the velocity at each measured point was correlated well with the velocity obtained from the video images (Anterior wall: r = 0.97, SEE = 0.30 mm, mean +/- s = -0.04 +/- 0.28 mm; Posterior wall: r = 0.97, SEE = 0.30 mm, mean +/- s = 0.04 +/- 0.28 mm). Our balloon model provided a new independent method for the validation of TDI data. This study demonstrated that the present TDI system is reliable for measuring wall motion distance and velocity.

Quantification of flow volume with a new digital three-dimensional color Doppler flow approach: an in vitro study.

OBJECTIVE: The quantification of flow stroke volume is important for evaluation of patients with cardiac dysfunction and cardiovascular disease. Three-dimensional digital color Doppler flow imaging allows the acquisition of flow data in an orientation approximately parallel to flow and analysis of the Doppler flow velocities perpendicular to flow (cross-sectional flow calculation). This in vitro study assessed the applicability of this method for quantifying cardiac output in a funnel-shaped tube model similar to mitral inflow or the left ventricular outflow tract. METHODS: A new digital three-dimensional color Doppler method was used to acquire Doppler flow information. Raw scan line data with digital velocity assignments were obtained on a conventional Doppler color flow imaging system with a 180 degrees rotating multiplanar transesophageal probe connected to a computer workstation. Nine stroke volumes (20-60 mL) with flow rates ranging from 1.5 to 5.28 L/min in a funnel-shaped pulsatile laminar flow model were studied. Three-dimensional flow rates were compared with standard-of-reference measurements of flow obtained from timed collection in a graduated cylinder and with an ultrasonic flow meter. RESULTS: Within the funnel tube, the flow volumes that were calculated from the first, second, and third depths and the average of all 3 depths correlated well with the actual flow rate (r = 0.97-0.99). Results from the middle and second levels and from the average of all 3 depths provided the closest fit to the actual flow rates (r = 0.99; y = 0.96x + 0.14; and r = 0.98; y = 1.14x - 0.43, respectively). CONCLUSIONS: Although a work in progress, this digital three-dimensional color Doppler flow measurement method is feasible, accurate, and simple, and it may offer in vivo evaluation of blood volume flow given a favorable orientation between the valve orifice and the scanning device.

Impact of harmonic imaging and transducer frequency on 'ventricular volume' measurements using real-time three-dimensional echocardiography: studies in an in vitro model.

AIMS: Harmonic imaging has increased the yield of quantifiable scans in two-dimensional echocardiography. Although real-time three-dimensional echocardiography avoids geometric assumptions in volume analysis, accurate measurement can be limited by image quality. This study compared volumes from a balloon model mimicking the left ventricle, scanned with and without harmonic imaging, using real time three-dimensional echocardiography. METHODS: Two balloons separated by ultrasound gel were suspended in a water bath. To mimic different chamber volumes, 12 volumes of water within the inner balloon (40-180ml) were scanned using a 3.5MHz probe at fundamental frequency and using a 2.5MHz probe with and without harmonic imaging. RESULTS: Scanning at 3.5MHz, the long axis (B) scans did not significantly underestimate the balloon volume but the 'short axis' (C) scans did (mean difference from actual volumes -0.7-1.4ml, P=0.14 - 3.9 +/- 1.2 ml,P < 0.0001 for B and C scans, respectively). Scanning at 2.5MHz both B and C scans significantly underestimated even more the true volume, C scans to a greater extent (mean difference -6.9 +/- 2.4ml and -11.2 +/- 4.0ml for B and C scans respectively,P < 0.0001 in both cases). However with harmonic imaging, transmitting at 1.7MHz and receiving at 2-4MHz, there was no significant difference of either B or C scans from the reference values (mean difference of B scans -1.2 +/- 1.9ml, P=0.06 and C scans -0.6 +/- 2.2ml, P=0.4). CONCLUSION: The enhanced resolution provided by harmonic imaging improves accuracy of volume analysis by real-time three-dimensional echocardiography.