ABSTRACT
BACKGROUND AND OBJECTIVE: Data from electro-anatomical mapping (EAM) systems are playing an increasingly important role in computational modeling studies for the patient-specific calibration of digital twin models. However, data exported from commercial EAM systems are challenging to access and parse. Converting to data formats that are easily amenable to be viewed and analyzed with commonly used cardiac simulation software tools such as openCARP remains challenging. We therefore developed an open-source platform, pyCEPS, for parsing and converting clinical EAM data conveniently to standard formats widely adopted within the cardiac modeling community. METHODS AND RESULTS: pyCEPS is an open-source Python-based platform providing the following functions: (i) access and interrogate the EAM data exported from clinical mapping systems; (ii) efficient browsing of EAM data to preview mapping procedures, electrograms (EGMs), and electro-cardiograms (ECGs); (iii) conversion to modeling formats according to the openCARP standard, to be amenable to analysis with standard tools and advanced workflows as used for in silico EAM data. Documentation and training material to facilitate access to this complementary research tool for new users is provided. We describe the technological underpinnings and demonstrate the capabilities of pyCEPS first, and showcase its use in an exemplary modeling application where we use clinical imaging data to build a patient-specific anatomical model. CONCLUSION: With pyCEPS we offer an open-source framework for accessing EAM data, and converting these to cardiac modeling standard formats. pyCEPS provides the core functionality needed to integrate EAM data in cardiac modeling research. We detail how pyCEPS could be integrated into model calibration workflows facilitating the calibration of a computational model based on EAM data.
Subject(s)
Computer Simulation , Software , Humans , Calibration , Electrocardiography , Models, Cardiovascular , Heart/physiology , Cardiac ElectrophysiologyABSTRACT
INTRODUCTION: Training in clinical cardiac electrophysiology (CCEP) involves the development of catheter handling skills to safely deliver effective treatment. Objective data from analysis of ablation data for evaluating trainee of CCEP procedures has not previously been possible. Using the artificial intelligence cloud-based system (CARTONET), we assessed the impact of trainee progress through ablation procedural quality. METHODS: Lesion- and procedure-level data from all de novo atrial fibrillation (AF) and cavotricuspid isthmus (CTI) ablations involving first-year (Y1) or second-year (Y2) fellows across a full year of fellowship was curated within Cartonet. Lesions were automatically assigned to anatomic locations. RESULTS: Lesion characteristics, including contact force, catheter stability, impedance drop, ablation index value, and interlesion time/distance were similar over each training year. Anatomic location and supervising operator significantly affected catheter stability. The proportion of lesion sets delivered independently and of lesions delivered by the trainee increased steadily from the first quartile of Y1 to the last quartile of Y2. Trainee perception of difficult regions did not correspond to objective measures. CONCLUSION: Objective ablation data from Cartonet showed that the progression of trainees through CCEP training does not impact lesion-level measures of treatment efficacy (i.e., catheter stability, impedance drop). Data demonstrates increasing independence over a training fellowship. Analyses like these could be useful to inform individualized training programs and to track trainee's progress. It may also be a useful quality assurance tool for ensuring ongoing consistency of treatment delivered within training institutions.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Clinical Competence , Education, Medical, Graduate , Humans , Atrial Fibrillation/surgery , Atrial Fibrillation/physiopathology , Atrial Fibrillation/diagnosis , Learning Curve , Electrophysiologic Techniques, Cardiac , Artificial Intelligence , Time Factors , Treatment Outcome , Fellowships and Scholarships , Cardiologists/education , Cardiac Electrophysiology/education , Cardiac CathetersABSTRACT
BACKGROUND AND OBJECTIVE: Simulation of cardiac electrophysiology (CEP) is an important research tool that is increasingly being adopted in industrial and clinical applications. Typical workflows for CEP simulation consist of a sequence of processing stages starting with building an anatomical model and then calibrating its electrophysiological properties to match observable data. While the calibration stages are common and generalizable, most CEP studies re-implement these steps in complex and highly variable workflows. This lack of standardization renders the execution of computational CEP studies in an efficient, robust, and reproducible manner a significant challenge. Here, we propose ForCEPSS as an efficient and robust, yet flexible, software framework for standardizing CEP simulation studies. METHODS AND RESULTS: Key processing stages of CEP simulation studies are identified and implemented in a standardized workflow that builds on openCARP1 Plank et al. (2021) and the Python-based carputils2 framework. Stages include (i) the definition and initialization of action potential phenotypes, (ii) the tissue scale calibration of conduction properties, (iii) the functional initialization to approximate a limit cycle corresponding to the dynamic reference state according to an experimental protocol, and, (iv) the execution of the CEP study where the electrophysiological response to a perturbation of the limit cycle is probed. As an exemplar application, we employ ForCEPSS to prepare a CEP study according to the Virtual Arrhythmia Risk Prediction protocol used for investigating the arrhythmogenic risk of developing infarct-related ventricular tachycardia (VT) in ischemic cardiomyopathy patients. We demonstrate that ForCEPSS enables a fully automated execution of all stages of this complex protocol. CONCLUSION: ForCEPSS offers a novel comprehensive, standardized, and automated CEP simulation workflow. The high degree of automation accelerates the execution of CEP simulation studies, reduces errors, improves robustness, and makes CEP studies reproducible. Verification of simulation studies within the CEP modeling community is thus possible. As such, ForCEPSS makes an important contribution towards increasing transparency, standardization, and reproducibility of in silico CEP experiments.
Subject(s)
Action Potentials , Computer Simulation , Software , Humans , Arrhythmias, Cardiac/physiopathology , Cardiac Electrophysiology , Calibration , Models, Cardiovascular , Heart/physiologyABSTRACT
The field of electrophysiology (EP) has benefited from numerous seminal innovations and discoveries that have enabled clinicians to deliver therapies and interventions that save lives and promote quality of life. The rapid pace of innovation in EP may be hindered by several challenges including the aging population with increasing morbidity, the availability of multiple costly therapies that, in many instances, confer minor incremental benefit, the limitations of healthcare reimbursement, the lack of response to therapies by some patients, and the complications of the invasive procedures performed. To overcome these challenges and continue on a steadfast path of transformative innovation, the EP community must comprehensively explore how artificial intelligence (AI) can be applied to healthcare delivery, research, and education and consider all opportunities in which AI can catalyze innovation; create workflow, research, and education efficiencies; and improve patient outcomes at a lower cost. In this white paper, we define AI and discuss the potential of AI to revolutionize the EP field. We also address the requirements for implementing, maintaining, and enhancing quality when using AI and consider ethical, operational, and regulatory aspects of AI implementation. This manuscript will be followed by several perspective papers that will expand on some of these topics.
Subject(s)
Artificial Intelligence , Cardiac Electrophysiology , Delivery of Health Care , Humans , Biomedical Research , Electrophysiologic Techniques, Cardiac/methodsABSTRACT
BACKGROUND: Biventricular pacing (BVP) has proven efficacy in treating heart failure with reduced ejection fraction (HFrEF) and ventricular dyssynchrony. Conduction system pacing (CSP), encompassing His bundle pacing (HBP) and left bundle area pacing (LBAP), has emerged as a promising alternative, but its benefits are still uncertain. METHODS: PubMed, Scopus and Cochrane databases were searched for randomized controlled trials (RCTs) that compared CSP to BVP for resynchronization therapy in patients with HFrEF and reported the outcomes of (1) paced QRS interval duration; (2) left ventricular ejection fraction (LVEF); and (3) New York Heart Association functional class (NYHA). Heterogeneity was examined with I² statistics. A random-effects model was used for all outcomes. RESULTS: We included 7 RCTs with 408 patients, of whom 200 (49%) underwent CSP. In patients undergoing CSP, there was significantly lower paced QRS duration (MD -13.34; 95% CI -24.32 to -2.36; p=0.02; Figure 1) and NYHA functional class (SMD -0.37; 95% CI -0.69 to -0.05; p=0.02; Figure 2). There was also a significant increase in LVEF in the CSP group (MD 2.06; 95% CI 0.16 to 3.97; p=0.03; Figure 3). No statistical difference was noted for LVESV (SMD -0.51; 95% CI -1.26 to 0.24; p=0.18; I²=83%), threshold for lead capture (MD -0.08; 95% CI -0.42 to 0.27; p=0.66; I²=66%), and procedure time (MD 5.99; 95% CI -15.91 to 27.89; p=0.59; I²=79%). Hospitalizations for HF were only noted in three studies, and no difference was observed between groups (9 vs 7; RR 1.02; 95% CI 0.21 to 4.90; p=0.98; I²=46%). Differences in mortality did not reach statistical significance (3 vs 8; RR 0.45; 95% CI 0.12 to 1.62; p=0.219; I²=0%). In subgroup analysis per CSP technique, there were no significant differences between groups for QRS duration and LVEF. LBAP was the main contributor for the significant difference observed in the NYHA functional class with a trend towards subgroup difference (p interaction=0.06). Although no significant difference was noted for the overall lead threshold, the LBAP subgroup had significantly lower values compared to HBP (p interaction=0.03). CONCLUSION: These findings suggest that CSP may have symptomatic, echocardiographic and electrophysiologic benefits for HFrEF patients requiring resynchronization.
Subject(s)
Heart Failure, Systolic , Cardiac ElectrophysiologyABSTRACT
Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.
Subject(s)
Radiosurgery , Tachycardia, Ventricular , Ventricular Fibrillation , Humans , Female , Male , Tachycardia, Ventricular/surgery , Tachycardia, Ventricular/physiopathology , Adult , Middle Aged , Ventricular Fibrillation/surgery , Ventricular Fibrillation/physiopathology , Radiosurgery/trends , Health Care Surveys , Electrophysiologic Techniques, Cardiac , Recurrence , Treatment Outcome , Practice Patterns, Physicians'/trends , Practice Patterns, Physicians'/statistics & numerical data , Cardiologists/trends , Cardiac Electrophysiology/trendsABSTRACT
Circadian rhythms in physiology and behavior are ≈24-hour biological cycles regulated by internal biological clocks (ie, circadian clocks) that optimize organismal homeostasis in response to predictable environmental changes. These clocks are present in virtually all cells in the body, including cardiomyocytes. Many decades ago, clinicians and researchers became interested in studying daily patterns of triggers for sudden cardiac death, the incidence of sudden cardiac death, and cardiac arrhythmias. This review highlights historical and contemporary studies examining the role of day/night rhythms in the timing of cardiovascular events, delves into changes in the timing of these events over the last few decades, and discusses cardiovascular disease-specific differences in the timing of cardiovascular events. The current understanding of the environmental, behavioral, and circadian mechanisms that regulate cardiac electrophysiology is examined with a focus on the circadian regulation of cardiac ion channels and ion channel regulatory genes. Understanding the contribution of environmental, behavioral, and circadian rhythms on arrhythmia susceptibility and the incidence of sudden cardiac death will be essential in developing future chronotherapies.
Subject(s)
Arrhythmias, Cardiac , Circadian Clocks , Humans , Circadian Rhythm , Myocytes, Cardiac , Death, Sudden, Cardiac/etiology , Cardiac ElectrophysiologyABSTRACT
With the increasing prevalence of arrhythmias, the use of electrophysiology (EP) procedures has increased. Recent advancements in computed tomography (CT) technology have expanded its use in pre-assessments and post-assessments of EP procedures. CT provides high-resolution images, is noninvasive, and is widely available. This article highlights the strengths and weaknesses of cardiac CT in EP.
Subject(s)
Catheter Ablation , Electrophysiologic Techniques, Cardiac , Humans , Cardiac Electrophysiology , Arrhythmias, Cardiac/diagnostic imaging , Arrhythmias, Cardiac/surgery , Tomography, X-Ray Computed/methods , RadiographyABSTRACT
Sports participation in patients with congenital heart disease is an evolving subject. The American Heart Association/American College of Cardiology released a set of guidelines that advise the type and level of sports participation based primarily on anatomical defects with secondary consideration given to hemodynamic effects. Recently, the European Association of Preventive Cardiology/European Society of Cardiology/Association for European Paediatric and Congenital Cardiology offered a contrasting approach to sports participation that is based on hemodynamic and electrophysiological profiles of each patient, regardless of anatomical consideration. These guidelines are drastically different in their approaches but do have some similarities. In this review, we compare both documents, focusing on the aim, population, classification of sports, and the methodology of making recommendations. This review aims to assist practicing cardiologists in integrating the available published data and recommendations when counseling patients for sports participation.
Subject(s)
Cardiologists , Cardiology , Heart Defects, Congenital , Sports , United States/epidemiology , Humans , Child , Cardiac Electrophysiology , American Heart Association , Heart Defects, Congenital/therapyABSTRACT
Hypothyroidism is the most frequent endocrine pathology. Although clinical or overt hypothyroidism has been traditionally associated to low T3 / T4 and high thyrotropin (TSH) circulating levels, other forms exist such as subclinical hypothyroidism, characterized by normal blood T3 / T4 and high TSH. In its different forms is estimated to affect approximately 10% of the population, especially women, in a 5:1 ratio with respect to men. Among its consequences are alterations in cardiac electrical activity, especially in the repolarization phase, which is accompanied by an increased susceptibility to cardiac arrhythmias. Although these alterations have traditionally been attributed to thyroid hormone deficiency, recent studies, both clinical trials and experimental models, demonstrate a fundamental role of TSH in cardiac electrical remodeling. Thus, both metabolic thyroid hormones and TSH regulate cardiac ion channel expression in many and varied ways. This means that the different combinations of hormones that predominate in different types of hypothyroidism (overt, subclinic, primary, central) can generate different forms of cardiac electrical remodeling. These new findings are raising the relevant question of whether serum TSH reference ranges should be redefined. (AU)
Subject(s)
Hypothyroidism , Cardiac Electrophysiology , Triiodothyronine , Thyrotropin , Arrhythmias, CardiacABSTRACT
Hypothyroidism is the most frequent endocrine pathology. Although clinical or overt hypothyroidism has been traditionally associated to low T3 / T4 and high thyrotropin (TSH) circulating levels, other forms exist such as subclinical hypothyroidism, characterized by normal blood T3 / T4 and high TSH. In its different forms is estimated to affect approximately 10% of the population, especially women, in a 5:1 ratio with respect to men. Among its consequences are alterations in cardiac electrical activity, especially in the repolarization phase, which is accompanied by an increased susceptibility to cardiac arrhythmias. Although these alterations have traditionally been attributed to thyroid hormone deficiency, recent studies, both clinical trials and experimental models, demonstrate a fundamental role of TSH in cardiac electrical remodeling. Thus, both metabolic thyroid hormones and TSH regulate cardiac ion channel expression in many and varied ways. This means that the different combinations of hormones that predominate in different types of hypothyroidism (overt, subclinic, primary, central) can generate different forms of cardiac electrical remodeling. These new findings are raising the relevant question of whether serum TSH reference ranges should be redefined. (AU)
Subject(s)
Hypothyroidism , Cardiac Electrophysiology , Triiodothyronine , Thyrotropin , Arrhythmias, CardiacABSTRACT
The introduction of His bundle electrography by Benjamin Scherlag (New York) in 1969, together with programmed stimulation of the heart by Philip Coumel (Paris) in 1967, and Hein Wellens (Amsterdam) in 1972, were decisive turning points on the way to invasive electrophysiology and the development of an independent, now distinctly interventional subspecialty of cardiology. The main topic of the 1970s was bradycardic arrhythmias, promoted by pacemaker therapy, which had been introduced just over 10 years earlier. The recording of the potentials of the bundle of His and other recording locations in the atria and ventricles allowed a differentiated assessment of the excitation process and the refractory periods. High-rate atrial stimulation to determine sinus node recovery time and premature stimulation to determine sinoatrial conduction time were developed to analyze sinoatrial node function. This article describes the introduction of His bundle electrography in a gradually increasing number of centers in Germany and their scientific contribution.