A modified Lewis ECG lead system for ambulatory monitoring of atrial arrhythmias.

BACKGROUND: When using a reduced ECG lead system with three leads or less, the analysis of atrial activity during arrhythmias can become problematic due to low signal amplitude and noise. Long ago, Sir Thomas Lewis proposed a lead system for atrial activity enhancement in which two electrodes are placed directly on the chest, however, these leads are sensitive to arm movement artifacts. In this study, a modified Lewis lead system is proposed that is better suited for ambulatory applications since the electrodes are placed in areas with less muscle. MATERIALS AND METHODS: The proposed modification is compared to the original Lewis leads as well as to the ES lead of the EASI system. Forty-one healthy volunteers and 10 patients with atrial fibrillation participated. RESULTS: The modified Lewis lead has nearly 3 times as large atrial amplitude as the original Lewis leads, and is associated with the largest amplitude of atrial activity when compared to the amplitude of electromyographic activity in healthy volunteers. CONCLUSION: The results suggest that the proposed modification of the Lewis lead system has potential to improve ambulatory monitoring of atrial arrhythmias.

Cardiac signal estimation based on the arterial and venous pressure signals of a hemodialysis machine.

Continuous cardiac monitoring is usually not performed during hemodialysis treatment, although a majority of patients with kidney failure suffer from cardiovascular disease. In the present paper, a method is proposed for estimating a cardiac pressure signal by combining the arterial and the venous pressure sensor signals of the hemodialysis machine. The estimation is complicated by the periodic pressure disturbance caused by the peristaltic blood pump, with an amplitude much larger than that of the cardiac pressure signal. Using different techniques for combining the arterial and venous pressure signals, the performance is evaluated and compared to that of an earlier method which made use of the venous pressure only. The heart rate and the heartbeat occurrence times, determined from the estimated cardiac pressure signal, are compared to the corresponding quantities determined from a photoplethysmographic reference signal. Signals from 9 complete hemodialysis treatments were analyzed. For a heartbeat amplitude of 0.5 mmHg, the median absolute deviation between estimated and reference heart rate was 1.3 bpm when using the venous pressure signal only, but dropped to 0.6 bpm when combining the pressure signals. The results show that the proposed method offers superior estimation at low heartbeat amplitudes. Consequently, more patients can be successfully monitored during treatment without the need of extra sensors. The results are preliminary, and need to be verified on a separate dataset.

Changes in high-frequency QRS components are more sensitive than ST-segment deviation for detecting acute coronary artery occlusion.

OBJECTIVES: This study describes changes in high-frequency QRS components (HF-QRS) during percutaneous transluminal coronary angioplasty (PTCA) and compares the ability of these changes in HF-QRS and ST-segment deviation in the standard 12-lead electrocardiogram (ECG) to detect acute coronary artery occlusion. BACKGROUND: Previous studies have shown decreased HF-QRS in the frequency range of 150-250 Hz during acute myocardial ischemia. It would be important to know whether the high-frequency analysis could add information to that available from the ST segments in the standard ECG. METHODS: The study population consisted of 52 patients undergoing prolonged balloon occlusion during PTCA. Signal-averaged electrocardiograms (SAECG) were recorded prior to and during the balloon inflation. The HF-QRS were determined within a bandwidth of 150-250 Hz in the preinflation and inflation SAECGs. The ST-segment deviation during inflation was determined in the standard frequency range. RESULTS: The sensitivity for detecting acute coronary artery occlusion was 88% using the high-frequency method. In 71% of the patients there was ST elevation during inflation. If both ST elevation and depression were considered, the sensitivity was 79%. The sensitivity was significantly higher using the high-frequency method, p<0.002, compared with the assessment of ST elevation. CONCLUSIONS: Acute coronary artery occlusion is detected with higher sensitivity using high-frequency QRS analysis compared with conventional assessment of ST segments. This result suggests that analysis of HF-QRS could provide an adjunctive tool with high sensitivity for detecting acute myocardial ischemia.

Non-invasive assessment of the atrial cycle length during atrial fibrillation in man: introducing, validating and illustrating a new ECG method.

OBJECTIVES: Atrial fibrillation (AF) in man has previously been shown to include a wide variety of atrial activity. Assessment of the characteristics of this arrhythmia with a commonly applicable tool may therefore be important in the choice and evaluation of different therapeutic strategies. As the AF cycle length has been shown to correlate locally with atrial refractoriness and globally with the degree of atrial organization, with, in general, shorter cycle length during apparently random AF compared to more organized AF, we have developed a new method for non-invasive assessment of the AF cycle length using the surface and the esophagus (ESO) ECG. METHODS AND RESULTS: From the frequency spectrum of the residual ECG, created by suppression of the QRST complexes, the dominant atrial cycle length (DACL) was derived. By comparison with multiple intracardiac simultaneously acquired right and left AF cycle lengths in patients with paroxysmal AF, we found that the DACL in lead V1, ranging from 130 to 185 ms, well represented a spatial average of the right AF cycle lengths, whereas the DACL in the ESO ECG, ranging from 140 to 185 ms, reflected both the right and the left AF cycle length, where the influence from each structure depended on the atrial anatomy of the individual, as determined by MRI. In patients with chronic AF, the method was capable of following changes in the AF cycle length due to administration of D,L-sotalol and 5 min of ECG recording was sufficient for the DACL to be reproducible. CONCLUSIONS: We conclude that this new non-invasive method, named 'Frequency Analysis of Fibrillatory ECG' (FAF-ECG), is capable of assessing both the magnitude and the dynamics of the atrial fibrillation cycle length in man.

Identification of patients prone to hypotension during hemodialysis based on the analysis of cardiovascular signals.

Intradialytic hypotension (IDH) is a major complication during hemodialysis treatment, and therefore it is highly desirable to identify, at an early stage during treatment, whether the patient is prone to IDH. Heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity (BRS) were analyzed during the first 30 min of treatment to assess information on the autonomic nervous system. Using the sequential floating forward selection method and linear classification, the set of features with the best discriminative power was selected, resulting in an accuracy of 92.1%. Using a classifier based on the HRV features only, thereby avoiding that continuous blood pressure has to be recorded, accuracy decreased to 90.2%. The results suggest that an HRV-based classifier is useful for determining whether a patient is prone to IDH at the beginning of the treatment.

Biexponential pulmonary clearance of 99mTc-DTPA induced by detergent aerosol.

We measured the pulmonary clearance of technetium-99m-labeled diethylenetriamine pentaacetatic acid (99mTc-DTPA) for 3 h after perturbation of the surfactant system by administration of the detergent dioctyl sodium sulfosuccinate in aerosol. Forty-two rabbits were anesthetized with pentobarbital sodium. Tracheostomies were performed, and the rabbits were mechanically ventilated. Increasing concentrations of detergent (0.125-2%) or vehicle were given for 5 min, and clearance measurements were performed immediately or 60 min after detergent administration. No animals developed respiratory distress. After vehicle, the clearance was monoexponential with a half-life of 153 min. Detergent induced a biexponential clearance with a rapidly clearing additional pool of radioactivity with a half-life of 5-15 min. The relative amount of radioactivity clearing rapidly increased with detergent concentration. The detergent effect was partly reversible. We conclude that detergent induces a biexponential clearance of 99mTc-DTPA by accelerating the transfer of tracer across the alveolocapillary barrier in a proportion of lung units in a dose-related manner.

Vectorcardiographic loop alignment and morphologic beat-to-beat variability.

The measurement of subtle morphologic beat-to-beat variations in the electrocardiogram is complicated by the presence of respiration-induced movements of the heart. A statistical signal model is developed which accounts for such movements by means of scaling, rotation, and time synchronization of vectorcardiographic loops. The maximum-likelihood estimator of the parameters describing these three transformations is presented and is extended to the case of multiple loop alignment. The performance of the method is assessed by measuring morphologic variability before and after loop alignment. It is shown that the effects of respiration on morphologic variability can be considerably reduced by the new method. Measurements on morphologic variability were typically reduced by a factor of 0.53 after loop alignment. The results show also that beat-to-beat measurements are strongly dependent on the selected sampling rate and that a rate of 1 kHz is too low.

Signal-to-noise ratio enhancement of cardiac late potentials using ensemble correlation.

An optimal one-weight "filter" is presented for the purpose of improving the signal-to-noise ratio of averaged ECG recordings in the analysis of late potentials. Based on a simple statistical model, the filter is estimated from the ensemble correlation of available beats. The correlation estimator is found by a maximum likelihood procedure in which the observed signal is assumed to have a Gaussian distribution. The performance of the optimal filter is studied in relation to an ensemble with individual or subaveraged beats.

Spatiotemporal QRST cancellation techniques for analysis of atrial fibrillation.

A new method for QRST cancellation is presented for the analysis of atrial fibrillation in the surface electrocardiogram (ECG). The method is based on a spatiotemporal signal model which accounts for dynamic changes in QRS morphology caused, e.g., by variations in the electrical axis of the heart. Using simulated atrial fibrillation signals added to normal ECGs, the results show that the spatiotemporal method performs considerably better than does straightforward average beat subtraction (ABS). In comparison to the ABS method, the average QRST-related error was reduced to 58 percent. The results obtained from ECGs with atrial fibrillation agreed very well with those from simulated fibrillation signals.

Maximum likelihood analysis of cardiac late potentials.

This study presents a new time-domain method for the detection of late potentials in individual leads. Basic statistical properties of the ECG samples are modeled in order to estimate the amplitude and duration of late potentials. The signal model accounts for correlation in both time and across the ensemble of beats. Late potentials are modeled as a colored process with unknown amplitude which is disturbed by white, Gaussian noise. Maximum likelihood estimation is applied to the model for estimating the amplitude of the late potentials. The resulting estimator consists of an eigenvector-based filter followed by a nonlinear operation. The performance of the maximum likelihood procedure was compared to that obtained by traditional time-domain analysis based on the vector magnitude. It was found that the new technique yielded a substantial improvement of the signal-to-noise ratio in the function used for endpoint determination. This improvement leads to a prolongation of the filtered QRS duration in cases with late potentials.

Automatic detection of ST-T complex changes on the ECG using filtered RMS difference series: application to ambulatory ischemia monitoring.

A new detector is presented which finds changes in the repolarization phase (ST-T complex) of the cardiac cycle. It operates by applying a detection algorithm to the filtered root mean square (rms) series of differences between the beat segment (ST segment or ST-T complex) and an average pattern segment. The detector has been validated using the European ST-T database, which contains ST-T complex episodes manually annotated by cardiologists, resulting in sensitivity/positive predictivity of 85/86%, and 85/76%, for ST segment deviations and ST-T complex changes, respectively. The proposed detector has a performance similar to those which have a more complicated structure. The detector has the advantage of finding both ST segment deviations and entire ST-T complex changes thereby providing a wider characterization of the potential ischemic events. A post-processing stage, based on a cross-correlation analysis for the episodes in the rms series, is presented. With this stage subclinical events with repetitive pattern were found in around 20% of the recordings and improved the performance to 90/85%, and 89/76%, for ST segment and ST-T complex changes, respectively.

Vectorcardiographic loop alignment and the measurement of morphologic beat-to-beat variability in noisy signals.

The measurement of subtle morphologic beat-to-beat variability in the electrocardiogram (ECG)/vectorcardiogram (VCG) is complicated by the presence of noise which is caused by, e.g., respiration and muscular activity. A method was recently presented which reduces the influence of such noise by performing spatial and temporal alignment of VCG loops. The alignment is performed in terms of scaling, rotation and time synchronization of the loops. Using an ECG simulation model based on propagation of action potentials in cardiac tissue, the ability of the method to separate morphologic variability of physiological origin from respiratory activity was studied. Morphologic variability was created by introducing a random variation in action potential propagation between different compartments. The results indicate that the separation of these two activities can be done accurately at low to moderate noise levels (less than 10 microV). At high noise levels, the estimation of the rotation angles was found to break down in an abrupt manner. It was also shown that the breakdown noise level is strongly dependent on loop morphology; a planar loop corresponds to a lower breakdown noise level than does a nonplanar loop.

Characterization of atrial fibrillation using the surface ECG: time-dependent spectral properties.

Time-frequency analysis is considered for characterizing atrial fibrillation in the surface electrocardiogram (ECG). Variations in fundamental frequency of the fibrillatory waves are tracked by using different time-frequency distributions which are appropriate to short- and long-term variations. The cross Wigner-Ville distribution is found to be particularly useful for short-term analysis due to its ability to handle poor signal-to-noise ratios. In patients with chronic atrial fibrillation, substantial short-term variations exist in fibrillation frequency and variations up to 2.5 Hz can be observed within a few seconds. Although time-frequency analysis is performed independently in each lead, short-term variations in fibrillation frequency often exhibit a similar pattern in the leads V1, V2 and V3. Using different techniques for short- and long-term analysis, it is possible to reliably detect subtle long-term changes in fibrillation frequency, e.g., related to an intervention, which otherwise would have been obscured by spontaneous variations in fibrillation frequency.

Clustering ECG complexes using hermite functions and self-organizing maps.

An integrated method for clustering of QRS complexes is presented which includes basis function representation and self-organizing neural networks (NN's). Each QRS complex is decomposed into Hermite basis functions and the resulting coefficients and width parameter are used to represent the complex. By means of this representation, unsupervised self-organizing NN's are employed to cluster the data into 25 groups. Using the MIT-BIH arrhythmia database, the resulting clusters are found to exhibit a very low degree of misclassification (1.5%). The integrated method outperforms, on the MIT-BIH database, both a published supervised learning method as well as a conventional template cross-correlation clustering method.

Time course of ECG depolarization and repolarization changes during ischemia in PTCA recordings.

OBJECTIVES: In this work we studied the temporal evolution of changes in the electrocardiogram (ECG) as a consequence of the induced ischemia during prolonged coronary angioplasty, comparing the time course of indexes reflecting depolarization and those reflecting repolarization. METHODS: We considered both local (measured at specific points of the ECG) and global (obtained from the Karhunen-Loève transform) indexes. In particular, the evolution of Q, R and S wave amplitudes during ischemia was analyzed with respect to classical indexes such as ST level. As a measurement of sensitivity we used an Ischemic Changes Sensor (ICS), which reflects the capacity of an index to detect changes in the ECG. RESULTS: The results showed that, in leads with low-amplitude ST-T complexes, the S wave amplitude was more sensitive in detecting ischemia than was the commonly used index ST60. It was found that in such leads the S wave amplitude initially exhibited a delayed response to ischemia when compared to ST60, but its performance was better from the second minute of occlusion. The global indexes describing the ST-T complex were, in terms of the ICS, superior to the S wave amplitude for ischemia detection. CONCLUSIONS: Ischemic ECG changes occur both at repolarization and depolarization, with alterations in the depolarization period appearing later in time. Local indexes are less sensitive to ischemia than global ones.

Time-varying digital filtering of ECG baseline wander.

Time-varying filtering techniques are applied to the problem of baseline correction by letting the cut-off frequency of a linear filter be controlled by the low-frequency properties of the ECG signal. The time-varying filter is implemented as a bank of linear low-pass filters, in which each filter has a slightly differing cut-off frequency. Sampling rate decimation and interpolation are employed because the design of a filter for baseline reduction can be treated as a narrowband filtering problem. All filters have a linear phase response to reduce, for example, ST-segment distortion. The performance of the technique presented is studied on ECG signals with different types of simulated baseline wander. The results are compared with the performance of time-invariant linear filtering and cubic spline interpolation. The results show that an improvement in performance can be achieved when using time-varying filtering, especially at low heart rates or during episodes with excessive base-line wander.

Sampling rate and the estimation of ensemble variability for repetitive signals.

The measurement of ensemble variability in time-aligned event signals is studied in relation to sampling rate requirements. The theoretical analysis is based on statistical modelling of time misalignment in which the time resolution is limited by the length of the sampling interval. For different signal-to-noise ratios (SNRs), the sampling rate is derived which limits the misalignment effect to less than 10% of the noise effect. Each signal is assumed to be corrupted by additive noise. Using a normal QRS complex with a high SNR (approximately equal to 30 dB), a sampling rate of approximately 3 kHz is needed for accurate ensemble variability measurements. This result is surprising since it implies that the Nyquist rate is far too low for accurate variability measurements. The theoretical results are supplemented with results obtained from an ECG database of 94 subjects for which the ensemble variability is computed at different sampling rates using signal interpolation. The ensemble variability is substantially reduced (40%) when increasing the rate from 1 to 3 kHz, thus corroborating the results suggested by the theoretical analysis.

Effects of digital resolution on characterisation of cardiac late potentials.

The effects of amplitude resolution in the signal-averaged ECG are studied in relation to the analysis of cardiac late potentials. The statistical properties of ECG signals from 22 patients after myocardial infarction were investigated in terms of amplitude distribution and noise level for the material. It was found that unbiased averaging could be achieved using a resolution greater than 10 microV. The noise levels of the bandpass-filtered individual X, Y and Z leads (range of 1-10 microV) and the vector magnitude were also investigated. Marked intra-lead differences in noise level were found, indicating that analysis based on individual leads is preferable. The effects of quantisation noise on the vector magnitude were negligible for amplitude resolutions below 5 microV. However, the additional noise contribution at 5 microV could be compensated by a moderate increase in acquisition time. The sensitivity to noise was considered when determining the endpoint of the filtered QRS complex using the vector magnitude.

Detection of autonomic modulation in permanent atrial fibrillation.

A new signal processing method for the detection of cyclic variations in atrial fibrillation frequency is presented. The objective was to investigate whether or not respiration, through the autonomic nervous system, modulates the fibrillation frequency in patients with permanent atrial fibrillation. A group of eight patients with permanent atrial fibrillation, atrioventricular block III and a permanent pacemaker were studied during rest, rhythm-controlled respiration, with each breath lasting for 8 s (i.e. a breathing frequency of 0.125 Hz), and rhythm-controlled respiration after full vagal blockade by atropine. Using the new method, a spectral peak could be detected, in two of the patients, at the breathing frequency during rhythm-controlled respiration then disappeared after injection of atropine.

Detection of body position changes using the surface electrocardiogram.

A method for detecting body position changes that uses the surface vectorcardiogram (VCG) is presented. Such changes are often manifested as sudden shifts in the electrical axis of the heart and can erroneously be interpreted as acute ischaemic events. Axis shifts were detected by analysing the rotation angles obtained from the alignment of successive VCG loops to a reference loop. Following the rejection of angles originating from noise events, the detection of body position changes was performed on the angle series using a Bayesian approach. On a database of ECG recordings from normal subjects performing a predefined sequence of body position changes, a detection rate of 92% and a false alarm rate of 7% was achieved.