P-wave Variability and Atrial Fibrillation.

The analysis of P-wave template has been widely used to extract indices of Atrial Fibrillation (AF) risk stratification. The aim of this paper was to assess the potential of the analysis of the P-wave variability over time in patients suffering from atrial fibrillation. P-wave features extracted from P-wave template together with novel indices of P-wave variability have been estimated in a population of patients suffering from persistent AF and compared to those extracted from control subjects. We quantify the P-wave variability over time using three algorithms and we extracted three novel indices: one based on the cross-correlation coefficients among the P-waves (Cross-Correlation Index, CCI), one associated to variation in amplitude of the P-waves (Amplitude Dispersion Index, ADI), one sensible to the phase shift among P-waves (Warping Index, WI). The control group resulted to be characterized by shorter P-wave duration and by a less amount of fragmentation and variability, respect to AF patients. The parameter CCI shows the highest sensitivity (97.3%) and a good specificity (95%).

Regulatory frameworks for mobile medical applications.

A mobile application (app) is a software program that runs on mobile communication devices such as a smartphone. The concept of a mobile medical app has gained popularity and diffusion but its reference regulatory context has raised discussion and concerns. Theoretically, a mobile app can be developed and uploaded easily by any person or entity. Thus, if an app can have some effects on the health of the users, it is mandatory to identify its reference regulatory context and the applicable prescriptions.

An optically coupled sensor for the measurement of currents induced by MRI gradient fields into endocardial leads.

OBJECT: The gradient fields generated during magnetic resonance imaging (MRI) procedures have the potential to induce electrical current on implanted endocardial leads. Whether this current can result in undesired cardiac stimulation is unknown. MATERIALS AND METHODS: This paper provides a detailed description of how to construct an optically coupled sensor for the measurement of gradient-field-induced currents into endocardial leads. The system is based on a microcontroller that works as analog-to-digital converter and sends the current signal acquired from the lead to an optical high-speed, light-emitting diode transmitter. A plastic fiber guides the light outside the MRI chamber to a photodiode receiver and then to an acquisition board connected to a PC laptop. RESULTS: The performance of the system has been characterized in terms of power consumption (8 mA on average), sampling frequency (20.5 kHz), measurement range (-12.8 to 10.3 mA) and resolution (22.6 µA). Results inside a 3 T MRI scanner are also presented. CONCLUSIONS: The detailed description of the current sensor could permit more standardized study of MRI gradient current induction in pacemaker systems. Results show the potential of gradient currents to affect the pacemaker capability of triggering a heartbeat, by modifying the overall energy delivered by the stimulator.

Impact of capped and uncapped abandoned leads on the heating of an MR-conditional pacemaker implant.

PURPOSE: To assess the risk of radiofrequency (RF)-induced heating in patients with MR-conditional pacemaker (PM) systems, in the presence of another lead abandoned from a previous implant. METHODS: Four commercial pacemaker leads were placed beside a MR-conditional PM system, inside a human trunk simulator. The phantom has been exposed to the RF generated by a 64 MHz body bird-cage coil (whole-body specific absorption rate [SAR] = 1 W/kg) and the induced heating was measured at the tip of the abandoned lead and of the MR-conditional implant. Configurations that maximize the coupling between the RF field and the leads have been tested, as well as realistic implant positions. RESULTS: Abandoned leads showed heating behaviors that strongly depend on the termination condition (abandoned-capped or saline exposed) and on the lead path (left or right positioning). Given a whole-body SAR = 1 W/kg, a maximum temperature rise of 17.6°C was observed. The presence of the abandoned lead modifies the RF-heating profile of the MR-conditional implant: either an increase or a decrease in the induced heating at its lead tip can occur, mainly depending on the relative position of the two leads. Variations ranging from -63% to +69% with respect to the MR-conditional system alone were observed. CONCLUSION: These findings provide experimental evidence that the presence of an abandoned lead poses an additional risk for the patient implanted with a MR-conditional PM system. Our results support the current PM manufacturers' policy of conditioning the MR compatibility of their systems to the absence of abandoned leads (including leads from MR-conditional implants). From a clinical point of view, in such cases, the decision whether to perform the exam shall be based upon a risk/benefit evaluation, as in the case of conventional PM systems.

Wrong detection of ventricular fibrillation in an implantable cardioverter defibrillator caused by the movement near the MRI scanner bore.

The static magnetic field generated by MRI systems is highly non-homogenous and rapidly decreases when moving away from the bore of the scanner. Consequently, the movement around the MRI scanner is equivalent to an exposure to a time-varying magnetic field at very low frequency (few Hz). For patients with an implanted cardiac stimulators, such as an implantable cardioverter/defibrillator (ICD), the movements inside the MRI environment may thus induce voltages on the loop formed by the leads of the device, with the potential to affect the behavior of the stimulator. In particular, the ICD's detection algorithms may be affected by the induced voltage and may cause inappropriate sensing, arrhythmia detections, and eventually inappropriate ICD therapy.We performed in-vitro measurements on a saline-filled humanshaped phantom (male, 170 cm height), equipped with an MRconditional ICD able to transmit in real-time the detected cardiac activity (electrograms). A biventricular implant was reproduced and the ICD was programmed in standard operating conditions, but with the shock delivery disabled. The electrograms recorded in the atrial, left and right ventricle channels were monitored during rotational movements along the vertical axis, in close proximity of the bore. The phantom was also equipped with an accelerometer and a magnetic field probe to measure the angular velocity and the magnetic field variation during the experiment. Pacing inhibition, inappropriate detection of tachyarrhythmias and of ventricular fibrillation were observed. Pacing inhibition began at an angular velocity of about 7 rad/s, (dB/dt of about 2 T/s). Inappropriate detection of ventricular fibrillation occurred at about 8 rad/s (dB/dt of about 3 T/s). These findings highlight the need for a specific risk assessment of workers with MR-conditional ICDs, which takes into account also effects that are generally not considered relevant for patients, such as the movement around the scanner bore.

Electromagnetic immunity of implantable pacemakers exposed to wi-fi devices.

The purpose of this study is to evaluate the potential for electromagnetic interference (EMI) and to assess the immunity level of implantable pacemakers (PM) when exposed to the radiofrequency (RF) field generated by Wi-Fi devices. Ten PM from five manufacturers, representative of what today is implanted in patients, have been tested in vitro and exposed to the signal generated by a Wi-Fi transmitter. An exposure setup that reproduces the actual IEEE 802.11b/g protocol has been designed and used during the tests. The system is able to amplify the Wi-Fi signal and transmits at power levels higher than those allowed by current international regulation. Such approach allows one to obtain, in case of no EMI, a safety margin for PM exposed to Wi-Fi signals, which otherwise cannot be derived if using commercial Wi-Fi equipment. The results of this study mitigate concerns about using Wi-Fi devices close to PM: none of the PM tested exhibit any degradation of their performance, even when exposed to RF field levels five times higher than those allowed by current international regulation (20 W EIRP). In conclusion, Wi-Fi devices do not pose risks of EMI to implantable PM. The immunity level of modern PM is much higher than the transmitting power of RF devices operating at 2.4 GHz.

Radiofrequency identification and medical devices: the regulatory framework on electromagnetic compatibility. Part I: medical devices.

Radiofrequency identification (RFID) technology has acheived significant success and has penetrated into various areas of healthcare. Several RFID-based applications are used in various modalities with the ultimate aim of improving patient care. When a wireless technology is used in a healthcare environment, attention must be paid to the potential risks deriving from its use; one of the most important being electromagnetic interference with medical devices. In this paper, the regulatory framework concerning the electromagnetic compatibility between RFID and medical devices is analyzed to understand whether and how the application of the current standards allows for the effective control of the risks of electromagnetic interference.

Radiofrequency identification and medical devices: the regulatory framework on electromagnetic compatibility. Part II: active implantable medical devices.

The number and the types of electromagnetic emitters to which patients with active implantable medical devices (AIMD) are exposed to in their daily activities have proliferated over the last decade. Radiofrequency identification (RFID) is an example of wireless technology applied in many fields. The interaction between RFID emitters and AIMD is an important issue for patients, industry and regulators, because of the risks associated with such interactions. The different AIMDs refer to different standards that address the electromagnetic immunity issue in different ways. Indeed, different test setups, immunity levels and rationales are used to guarantee that AIMDs are immune to electromagnetic nonionizing radiation. In this article, the regulatory framework concerning electromagnetic compatibility between RFID systems and AIMDs is analyzed to understand whether and how the application of the current AIMD standards allows for the effective control of the possible risks associated with RFID technology.

Daily distribution of atrial arrhythmic episodes in sick sinus syndrome patients: implications for atrial arrhythmia monitoring.

AIMS: Disorders such as paroxysmal atrial fibrillation (AF) and atrial tachyarrhythmias (AT) are difficult to investigate because of their intermittent, and sometimes asymptomatic, nature. The aim of this study was to investigate the daily temporal distribution of AT/AF episodes--onset and occurrence--by analysing data from 250 pacemaker-implanted, brady-tachy syndrome patients who have been enrolled in the Burden II Study. METHODS AND RESULTS: Data were analysed accounting for the mode switch list which includes date, time, and duration of each mode switch episode. Chi-squared tests for goodness of fit were used to determine whether AT/AF episode were uniformly distributed. The population analysed in the present study suggests the occurrence of a circadian rhythm of paroxysmal AF episodes, similar to that described for other cardiovascular diseases, with clustering of events in the morning from 08:00 and (to a lesser degree) in the afternoon (03:00 to 18:00). The relative risk of AT/AF onset is 13% higher during daytime, 40% lower at night (P < 0.000001). CONCLUSION: The use of monitoring devices based on daily electrocardiogram (ECG) recording could be optimized with these data, thus increasing the probability to detect AT/AF episodes.

On the resolution of ECG acquisition systems for the reliable analysis of the P-wave.

The analysis of the P-wave on surface ECG is widely used to assess the risk of atrial arrhythmias. In order to provide reliable results, the automatic analysis of the P-wave must be precise and reliable and must take into account technical aspects, one of those being the resolution of the acquisition system. The aim of this note is to investigate the effects of the amplitude resolution of ECG acquisition systems on the P-wave analysis. Starting from ECG recorded by an acquisition system with a less significant bit (LSB) of 31 nV (24 bit on an input range of 524 mVpp), we reproduced an ECG signal as acquired by systems with lower resolution (16, 15, 14, 13 and 12 bit). We found that, when the LSB is of the order of 128 µV (12 bit), a single P-wave is not recognizable on ECG. However, when averaging is applied, a P-wave template can be extracted, apparently suitable for the P-wave analysis. Results obtained in terms of P-wave duration and morphology revealed that the analysis of ECG at lowest resolutions (from 12 to 14 bit, LSB higher than 30 µV) could lead to misleading results. However, the resolution used nowadays in modern electrocardiographs (15 and 16 bit, LSB <10 µV) is sufficient for the reliable analysis of the P-wave.

Role of the lead structure in MRI-induced heating: In vitro measurements on 30 commercial pacemaker/defibrillator leads.

MRI-induced heating on endocardial leads is a serious concern for the safety of patients with implantable pacemakers or cardioverter-defibrillator. The lead heating depends on many factors and its amount is largely variable. In this study, we investigated the role of those structural properties of the lead that are reported on the accompanying documents of the device: (1) fixation modality (active vs. passive); (2) number of electrodes (unipolar vs. bipolar); (3) length; (4) tip surface; and (5) tip and ring resistance. In vitro temperature and specific absorption rate measurements on 30 leads (27 pacemakers, three implantable cardioverter-defibrillator leads) exposed to the radiofrequency field typical of a 1.5 T MRI scanner are presented. The data show that each lead has its own attitude to radiofrequency-induced heating and that the information that is available in the accompanying documents of the pacemaker is not sufficient to explain such attitude. Even if combined with that of the implant geometry, this information is still not sufficient to estimate the amount of heating due to the exposure to the radiofrequency field during MRI examination.

RFID in healthcare environment: electromagnetic compatibility regulatory issues.

Several wireless technology applications (RFID, WiFi, GSM, GPRS) have been developed to improve patient care, reaching a significant success and diffusion in healthcare. Given the potential development of such a technology, care must be paid on the potential risks deriving from the use of wireless device in healthcare, among which one of the most important is the electromagnetic interference with medical devices. The analysis of the regulatory issues concerning the electromagnetic compatibility of medical devices is essential to evaluate if and how the application of the current standards allows an effective control of the possible risks associated to the electromagnetic interference on medical devices.

P-wave characteristics after electrical external cardioversion: predictive indexes of relapse.

Atrial fibrillation (AF) is the most common arrhythmia in the western countries and accounts for hundred thousand strokes per year. Electrocardiographic characteristics of AF have been demonstrated to help identify patients at risk of developing AF. Prolonged and highly fragmented P-waves have been observed in patients prone to AF, and time-domain. Morphological characteristics of the P-wave from surface ECG recordings turned out to significantly distinguish patients at risk of AF. The aim of this study is to evaluate the morphological and time-domain characteristics of the P-wave in patients with AF relapse after cardioversion, respect to patients without. 14 patients who underwent successful electrical cardioversion for persistent AF were enrolled. Five minute ECG recordings were performed for each subject, immediately post-successful cardioversion. ECG signals were acquired by using a 16-lead mapping system for high-resolution biopotential measurements (sample frequency 2 kHz, 31 nV resolution, 0-400 Hz bandwidth). From the 16 recordings, a standard 12-lead ECG was derived and analyzed in terms of signal-averaged P-wave. Time-domain and mor-phological characteristics were estimated from the averaged P-waves of each lead. Time-domain features were quantified as: maximum P-wave duration in any of the 12 leads (Pmax), minimum P-wave duration in any of the leads (Pmin), P-wave dispersion (Pdisp=Pmax-Pmin), and Pindex (standard devia-tion of P-wave duration in any of the 12 leads). Morphological characteristics were extracted from a Gaussian function-based model of the P-wave as: average model order (Nav), maximum number of zero-crossing (PCmax), and maximum and average number of maxima and minima (FCImax and FCIav) in any of the leads. The results obtained so far indicate that the morphological and time-domain characteristics distinguish between patients with AF relapse and patients without.

Numerical model for estimating RF-induced heating on a pacemaker implant during MRI: experimental validation.

MRI may cause tissue heating in patients implanted with pacemakers (PMs) or cardioverters/defibrillators. As a consequence, these patients are often preventatively excluded from MRI investigations. The issue has been studied for several years now, in order to identify the mechanisms involved in heat generation, and define safety conditions by which MRI may be extended to patients with active implants. In this sense, numerical studies not only widen the range of experimental measurements, but also model a realistic patient's anatomy on which it is possible to study individually the impact of the many parameters involved. In order to obtain reliable results, however, each and every numerical analysis needs to be validated by experimental evidence. Aim of this paper was to design and validate through experimental measurements, an accurate numerical model, which was able to reproduce the thermal effects induced by a birdcage coil on human tissues containing a metal implant, specifically, a PM. The model was then used to compare the right versus left pectoral implantation of a PM, in terms of power deposited at the lead tip. This numerical model may also be used as reference for validating simpler models in terms of computational effort.

Effect of high-pass filtering on ECG signal on the analysis of patients prone to atrial fibrillation.

The aim of this study was to assess the effect of filtering techniques on the time-domain analysis of the ECG. Multi-lead ECG recordings obtained from chronic atrial fibrillation (AF) patients after successful external cardioversion have been acquired. Several high-pass filtering techniques and three cut-off frequency values were used: Bessel and Butterworth four-pole and two-pole bidirectional and unidirectional filters, at 0.01, 0.05 and 0.5 Hz low cut-off frequency. As a reference, a beat-by-beat linear piecewise interpolation was used to remove baseline wander, on each P-wave. Results show that ECG filtering affects the estimation of P-wave duration in a manner that depends upon the type of filter used: particularly, the bidirectional filters caused negligible variation of P-wave duration, while unidirectional ones provoked an increase higher than 8%.

A novel, user-friendly step counter for home telemonitoring of physical activity.

Step counting is an important index of motion in telemonitoring. We have developed a wearable system based on a device with a force-sensing resistor. This is affixed at the calf gastrocnemius level to monitor the muscular expansion related to the gait. The gastrocnemius expansion measurement unit (GEMU) was tested on three subjects at Level 2 of the Tinetti test of unbalance, who performed five repetitions of 100 steps at two different speeds (normal and slow). The mean error was less than 0.5%. The GEMU also performed better than an accelerometer unit, which is normally considered to be the best solution for this disability. The system can be integrated into a routine home-care application based on a GSM home-care unit.

In vitro investigation of pacemaker lead heating induced by magnetic resonance imaging: role of implant geometry.

PURPOSE: To evaluate the effect of the geometry of implantable pacemakers (PMs) on lead heating induced by magnetic resonance imaging (MRI). MATERIALS AND METHODS: In vitro experiments were conducted with two different setups, using fluoroptic probes to measure the temperature increase. The first experiment consisted of a rectangular box filled with a gelled saline and a pacemaker with its leads. This box was exposed in an MRI birdcage coil to a sinusoidal 64-MHz field with a calibrated whole-body specific absorption rate (WB-SAR) of 1 W/kg. The highest SAR and temperature increase (3000 W/kg, 12 degrees C) occurred for the implant configuration having the largest area. The second experimental setup consisted of a human-shaped torso filled with gelled saline. In this setup the PM and its lead were exposed to a real MRI scanner, using clinical sequences with WB-SAR up to 2 W/kg. RESULTS: We found that higher heating occurs for configurations with longer exposed lead lengths and that right chest PMs showed the highest temperature and local SAR (11.9 degrees C, 2345 W/kg), whereas the left chest PMs were less heated (6.3 degrees C, 1362 W/kg). Implant geometry, exposed lead length, and lead area must be considered in the wide variation of temperature increases induced by MRI. CONCLUSIONS: The amount of MRI-induced lead tip heating depends strongly on implant geometry, particularly the lead area, exposed lead length, and position of the implant in the phantom. Critical lead tip heating was found for the longer leads. Therefore, to minimize MRI-induced lead tip heating, the PM lead should be as short as possible.

Time-domain and morphological analysis of the P wave. Part II: effects of atrial pacing on P-wave features.

BACKGROUND: The aim of this study was to compare time-domain and morphological descriptors of paced and spontaneous P wave in patients prone to atrial fibrillation (AF). METHODS: Nineteen patients (nine women, aged 72 +/- 10 years) affected by paroxysmal AF and implanted with dual-chamber pacemakers (PM) were studied. Two 5-minute recordings were performed during spontaneous and paced rhythm. Electrocardiogram (ECG) signals were acquired using a 32-lead mapping system. Patients were grouped into two classes: no previous AF and previous AF groups, according to the number of AF episodes in the 6 months before the analysis. RESULTS AND CONCLUSION: During atrial pacing P wave appeared prolonged and morphologically more complex with respect to sinus rhythm. We also found that in patients at lower risk for AF, the atrial pacing changes the atrial activation to a greater extent than in patients at higher risk for AF. Finally, all time-domain and morphological descriptors of the P wave except one succeed in discriminating "no previous AF" and "previous AF" patients in spontaneous rhythm, while no significant differences have been observed during pacing for any parameters.

Time-domain and morphological analysis of the P-wave. Part I: Technical aspects for automatic quantification of P-wave features.

INTRODUCTION: Time-domain and morphological analysis of P-wave from surface electrocardiogram has been extensively used to identify patients prone to atrial arrhythmias, especially atrial fibrillation (AF). However, since no standard procedure exists for P-wave preprocessing, standardization of cut-off values for P-wave duration and morphological features is difficult. This study is a methodological investigation of P-wave preprocessing procedures for automatic time-domain and morphological analysis. METHODS: We compared, on simulated and real data, the P-wave template obtained applying three alignment algorithms with that obtained without alignment, in terms of template error, shift error, P-wave duration, and morphological parameters. We also proposed automatic algorithms for estimation of P-wave duration. RESULTS: We found that alignment is necessary for a reliable extraction of P-wave template by the averaging procedure, in order to perform time-domain and morphological analysis. On simulated and real data, the error on P-wave duration can be as high as 30 ms on a template obtained without alignment; if alignment procedure is performed, the error on P-wave duration is negligible. Analogously, morphological features are correctly estimated only on a P-wave template obtained with P-waves alignment. We also found that the proposed algorithm for the automatic estimation of the P-wave duration gave reliable results.

Complexity of MRI induced heating on metallic leads: experimental measurements of 374 configurations.

BACKGROUND: MRI induced heating on PM leads is a very complex issue. The widely varying results described in literature suggest that there are many factors that influence the degree of heating and that not always are adequately addressed by existing testing methods. METHODS: We present a wide database of experimental measurements of the heating of metallic wires and PM leads in a 1.5 T RF coil. The aim of these measurements is to systematically quantify the contribution of some potential factors involved in the MRI induced heating: the length and the geometric structure of the lead; the implant location within the body and the lead path; the shape of the phantom used to simulate the human trunk and its relative position inside the RF coil. RESULTS: We found that the several factors are the primary influence on heating at the tip. Closer locations of the leads to the edge of the phantom and to the edge of the coil produce maximum heating. The lead length is the other crucial factor, whereas the implant area does not seem to have a major role in the induced temperature increase. Also the lead structure and the geometry of the phantom revealed to be elements that can significantly modify the amount of heating. CONCLUSION: Our findings highlight the factors that have significant effects on MRI induced heating of implanted wires and leads. These factors must be taken into account by those who plan to study or model MRI heating of implants. Also our data should help those who wish to develop guidelines for defining safe medical implants for MRI patients. In addition, our database of the entire set of measurements can help those who wish to validate their numerical models of implants that may be exposed to MRI systems.