Rapid construction of a patient-specific torso model from 3D ultrasound for non-invasive imaging of cardiac electrophysiology.

One of the main limitations in using inverse methods for non-invasively imaging cardiac electrical activity in a clinical setting is the difficulty in readily obtaining high-quality data sets to reconstruct accurately a patient-specific geometric model of the heart and torso. This issue was addressed by investigation into the feasibility of using a pseudo-3D ultrasound system and a hand-held laser scanner to reconstruct such a model. This information was collected in under 20 min prior to a catheter ablation or pacemaker study in the electrophysiology laboratory. Using the models created from these data, different activation field maps were computed using several different inverse methods. These were independently validated by comparison of the earliest site of activation with the physical location of the pacing electrodes, as determined from orthogonal fluoroscopy images. With an estimated average geometric error of approximately 8 mm, it was also possible to reconstruct the site of initial activation to within 17.3 mm and obtain a quantitatively realistic activation sequence. The study demonstrates that it is possible rapidly to construct a geometric model that can then be used non-invasively to reconstruct an activation field map of the heart.

Design of a measurement system for electrophysiological cardiac surgery.

The treatment of cardiac arrhythmias by surgical removal of abnormal electrical pathways across the atrio-ventricular ring or re-entrant circuits within the myocardium is dependent on the ability to accurately locate the abnormality by measuring and displaying the activation front of muscle depolarisation as it spreads across the surface of the heart. The localisation of the aberration requires induction of the arrhythmia, simultaneous measurement of activity from many (100-200) sites over the surface of the heart, attachment of fiducial markers to this data, and display of the activation sequence in the form of an isochronous map. An instrument has been built at Green Lane Hospital to provide the necessary measurement, control, and analysis facilities required by this procedure. The purpose built measurement system is a multiprocessor unit which incorporates up to 512 programmable intracardiac amplifiers, two multifunction cardiac pacing stimulators, a versatile real time data display, a patient safety isolation system, and digital storage for eight seconds of electrocardiographic data. Signals are acquired from a mesh of bipolar electrodes attached to either a 'sock' or a 'band' which is placed on the heart during open heart surgery. The analysis of data is carried out on a personal computer, connected to the measurement system via a serial command link and a high speed parallel data link. Corrective surgery is now being carried out on a routine basis for some types of arrhythmias.

Gas-mixing efficiency in a mathematical model of the lung.

Non-uniform composition of gas in the lungs may arise because of uneven dilution of alveolar with inspired gas by convection (bulk flow) or because of the finite rates of molecular diffusion in the small air-spaces. Such non-uniformity represents 'mixing inefficiency' which may be expressed by the difference between the effective dead-space ('ventilatory dead-space', VDV) and the actual airway dead-space ('Fowler dead-space', VDF). This expression of mixing inefficiency does not distinguish between convective and diffusive mechanisms. We show, from simulated gas wash-out of an asymmetrical, two-compartment model of the lung, that a third dead-space ('wash-out dead-space', VDW) enables this distinction to be made: VDV-VDW reveals convective, and VDW-VDF diffusive, mixing inefficiency. The position of the branch point subtending the two compartments greatly affects the outcome, however. When the branch point is relatively peripheral, inefficiency is mainly diffusive; when it is relatively central, inefficiency is mainly convective. These findings indicate how mixing efficiency may be measured more selectively than at present in real lungs.

Recovery of ventilation distributions by gas wash-out of a mechanical pump.

A method for deriving virtually continuous distributions of ventilation in the lungs from multiple-breath wash-out of inert, insoluble gases has been tested using a mechanical pump in which two parallel compartments, simulating lung regions, could be differentially ventilated to any desired, and known, extent. With more than moderate non-uniformity, bimodal distributions were always recovered from wash-out data, and with high reproducibility. In a substantial proportion of wash-out experiments ventilation was recovered in regions of very low and very high turnover in addition to the expected modes. These spurious modes may be abolished by various computational devices, none entirely satisfactory. Simultaneous wash-out and wash-in of two or three gases of similar diffusivity give essentially identical solutions. When the pump is operated with the two cylinders out of phase, emptying patterns derived from gas wash-out correspond quite well with those expected from the pump setting. These results help to identify and clarify some of the errors which affect physiological wash-out studies.

Data acquisition from a multiplex, quadrupole mass spectrometer.

Although various methods have been used to correct the output of a respiratory mass spectrometer for the delay and rise time in its response, thereby reducing the error in measured gas concentrations, there are additional considerations in the case of a multiplex mass spectrometer. The measured signal from the detector is a series of discrete samples of the concentration of several different gases rather than a continuous monitor of a single gas concentration as generated by other types of mass spectrometer. If the time constant of the mass spectrometer is of the same order as the interval between samples of a gas in the multiplex mode, correction techniques based on continuous-time analysis would not be as valid as those based on discrete-time analysis. Such correction techniques were compared to the use of a simple time shift. For multibreath gas washout analysis with simulated worst-case 'square wave breathing' it was found that, because of the complex nature of the response of the mass spectrometer, a simple time shift provided a reduction in error nearly equal to that of an additional first order response correction, and that such further corrections may be unnecessary or even invalid under some circumstances.

The effects of cardiopulmonary bypass upon pulmonary gas exchange.

Cardiac output, venous admixture, physiological dead space, blood gas tensions, inspired gas distribution, and other respiratory variables were measured in 10 patients breathing both air and oxygen before and on five occasions up to 10 days after coronary artery vein-graft operations under cardiopulmonary bypass with moderate hypothermia. Cardiac output was unchanged at 8 hours but fell 8 percent by 22 hours. Thereafter it progressively increased and at 10 days was higher than before the operation. Venous admixture rose to a maximum at 28 to 48 hours, postoperatively, but the increase was inversely related to the magnitude of preoperative admixture. The part played by airway and alveolar closure in determining venous admixture is discussed. While admixture increased, the nitrogen-clearance curve improved, presumably due to progressive "dropout" of the worst-ventilated regions. Physiological dead space fell to a minimum at 28 hours after operation; this was attributed to a fall in the end-inspiratory position consequent upon a reduction in both functional residual capacity and tidal volume. There was an increase in ventilation after operation, and this persisted at 10 days; it appeared to be due to reflex stimulation from the lungs and chest wall.

The effects of posture on venous admixture and respiratory dead space in health.

Alveolar-arterial PO2 difference ([A-a]PO2), venous admixture, and physiologic dead space were measured in 24 healthy men and women 23 to 72 years of age in the sitting and supine positions, breathing air, breathing O2, and breathing O2 in deep breaths. In the supine (but not the sitting) position, (A-a)PO2 and venous admixture, breathing both air and O2, were more highly correlated with the difference between closing volume and expiratory reserve volume than with age. The change in (A-a)PO2 and venous admixture from sitting to lying was related to the change in closing volume minus expiratory reserve volume, during both air and O2 breathing. These results confirm previous work on the contribution of gravity-dependent airway closure to the air-breathing venous admixture. They further indicate that the same mechanism is important when O2 is breathed, and it may account for most of the alveoli that close during O2 breathing because of critically low ventilation perfusion ratios. Physiologic dead space in the supine position may be predicted by subtracting 12.5% from the normal sitting value for the same tidal volume and respiratory frequency.