Newer data on the configuration and variability ranges of body surface maps in a sample of normal subjects

Varied onset of heart ventricular depolarization in different age groups of healthy volunteers

Group mean isopotential maps of initial parts of ventricular depolarization (QRS complex) in 4 age groups (10, 14, 19 and 22 years) of young healthy subjects, females and males, were analyzed using different increments between isopotential lines. It was found that the increment 0.1 mV masks some features of the maps, which are seen only by smaller increment (0.02 mV): the time of appearance of maximum and minimum on the anterior chest, smaller voltage values of the extrema as usually published, minimum dominating over maximum in the youngest groups. Therefore, the often applied criterion for the QRS onset – the increasing maximum on the anterior chest – should be reconsidered at least when it concerns the isopotential maps of children.

The opposite polarity of the PQ segment compared to the P wave isointegral maps

The aim of our work was to study the opposite polarity of the PQ segment to the P wave body surface potential maps in different groups of patients. We constructed isointegral maps (IIM) in 26 healthy controls (C), 16 hypertensives (HT), 26 patients with arterial hypertension and left ventricular hypertrophy (LVH) and 15 patients with myocardial infarction (MI). We analyzed values and positions of map extrema and compared the polarity of maps using the correlation coefficient. The IIM P maxima appeared mainly over the precordium, the minima mainly in the right subclavicular area. The highest maxima were in the MI group, being significantly higher than in the HT and LVH groups. No differences concerning any values of other extrema were significant. The IIM PQ maxima were distributed over the upper half of the chest; the minima mainly over the middle sternum. A statistically significant opposite polarity between the IIM P and IIM PQ was found in 80 % of cases. The opposite polarity of the P wave and the PQ segment was proved in isointegral body surface maps. The extrema occurred in areas not examined by the standard chest leads. This has to be considered for diagnostic purposes.

Aspects of left ventricular morphology outperform left ventricular mass for prediction of QRS duration

BACKGROUND

The knowledge of the case-specific normal QRS duration in each individual is needed when determining the onset, severity and progression of the heart disease. However, large interindividual variability even of the normal QRS duration exists. The aims of the study were to develop a model for prediction of normal QRS complex duration and to test it on healthy individuals.

METHODS

The study population of healthy adult volunteers was divided into a sample for development of a prediction model (n = 63) and a testing sample (n = 30). Magnetic resonance imaging data were used to assess anatomical characteristics of the left ventricle: the angle between papillary muscles (PM(A)), the length of the left ventricle (LV(L)) and left ventricular mass (LV(M)). Twelve-lead electrocardiogram (ECG) was used for measurement of the QRS duration. Multiple linear regression analysis was used to develop a prediction model to estimate the QRS duration. The accuracy of the prediction model was assessed by comparing predicted with measured QRS duration in the test set.

RESULTS

The angle between PM(A) and the length of the LV(L) were statistically significant predictors of QRS duration. Correlation between QRS duration and PM(A) and LV(L) was r = 0.57, P = 0.0001 and r = 0.45, P = 0.0002, respectively. The final model for prediction of the QRS was: QRS(Predicted)= 97 + (0.35 x LV(L)) - (0.45 x PM(A)). The predicted and real QRS duration differed with median 1 ms.

CONCLUSIONS

The model for prediction of QRS duration opens the ability to predict case-specific normal QRS duration. This knowledge can have clinical importance, when determining the normality on case-specific basis.

P-wave body surface potential distribution in rats

The aim of this study was to investigate body surface potential distribution during the P wave in Wistar rats. We performed body surface potential mapping by means of a 64-channel synchronous electrocardiotopography. The positive area covered the caudal part of the thorax, and the negative one covered the cranial part of the thorax. During the P wave, we observed 1 maximum and 1 minimum on the body surface. The dynamics of the P-wave body surface potential distribution in rats was characterized by minor movement of the positive and negative areas, and a counterclockwise shift of the extrema on the ventral body surface. The obtained results are discussed in comparison with those in dogs and humans.

Geometrical aspects of the interindividual variability of multilead ECG recordings

The electrocardiogram (ECG) as measured from healthy subjects shows a considerable interindividual variability. This variability is caused by geometrical as well as by physiological factors. In this study, the relative contribution of the geometrical factors is estimated. In addition a method aimed at correcting for these factors is described. First, a measure (RV) for quantifying the overall variability is presented, and for healthy individuals its value is estimated as 0.52. Next, based on a simulation study using the individual (heart-lung-torso) geometry of 25 subjects, the variability caused by geometrical factors is estimated as 0.40, indicating that in healthy subjects the RV for healthy individuals resulting from electrophysiology is of the order of 0.33. In an evaluation of the correction procedure, applied to realistic, simulated body surface potentials, it is shown that RV caused by geometrical factors can be reduced from 0.40 to 0.06. When applying the correction procedure to measured ECG data no reduction of the RV value could be demonstrated. These results indicate that the involved procedure of the inverse computation of a cardiac equivalent source, at the present time, is of insufficient quality to cash in on the substantial reduction of RV values from 0.52 down to 0.33 that might be obtainable.

Body surface potential field representation fidelity: analysis of map estimation procedures

The first part of this study analyzed the spatial-temporal error distribution of the Lux-type limited lead system. Quantitative new evidence is reported that the 32-lead anterior subset estimates the further 160 leads with an average amplitude error less than 38.5 microV. The spatial error distribution revealed 8 sites where the error is the highest, primarily on the anterior side, independent of the clinical classification. The second part of the study examined inter-lead-system conversion strategies for interpolating the Lux-192 lead maps from the Montreal-63 data. The methodology based on the Laplacian interpolation yielded an average amplitude error of 143.7 microV and an average correlation of 0.87 for pattern fidelity. In this specific case a modified linear interpolation surpassed the Laplacian method. A presented example illustrates that even in cases when the fidelity of the signal information is heavily compromised the diagnostic information may remain less influenced.

Lead system transformation of body surface map data

Multicenter application of body surface map data (multilead electrocardiographic [ECG] data) is hampered by the fact that the centers involved in body surface mapping use lead systems differing in lead placement as well as in the number of leads. In this study, the performance of two methods for converting multilead ECGs from one lead system to another is evaluated in their application to the major lead systems presently in use throughout the world. The first method is based on Laplacian interpolation, and the second method is derived from the correlations between the signals in an extensive lead system. Through analyzing the representation errors, it was found that, for lead systems incorporating over 60 leads, both methods work well, yielding errors comparable to interbeat differences in individuals. For lead systems incorporating fewer leads, the correlation method is to be preferred.

Body surface potential mapping of a patient with Wolff-Parkinson-White syndrome with two accessory pathways and two atrial pacemaker complexes

As part of an ongoing research protocol, a patient with Wolff-Parkinson-White syndrome underwent body surface potential mapping and electrophysiologic studies before radiofrequency ablation therapy. Careful analysis of the body surface potential mapping data made it possible to distinguish four different map sequences representing four different cardiac complexes. Analysis of these maps is consistent with two accessory pathways, with the additional pathology of two distinct atrial pacemaker sites. A right anterosuperior pathway was found to conduct continuously. The second pathway is consistent with a right inferior pathway conducting intermittently. The analysis demonstrates the type of information that can be extracted from body surface potential maps, even in the presence of complex pathologies.

A model study of the sensitivity of body surface potential distribution to variations of electrode placement

The effect of electrode displacement as one of the sources of reproducibility errors in body surface potential maps was studied using a realistic computer model of the cardiac electric field. A uniform dipole layer model of the cardiac generator and a realistic geometry of the torso, heart, and lungs was adopted for the simulation of surface potentials during ventricular activation. The effect of systematic electrode displacement in terms of longitudinal shifts and variations of longitudinal size (height) of the mapped area was studied. The map reconstruction error of three different limited lead systems and the variability of maps measured on all points of the mapping grid, as well as maps reconstructed from limited lead systems, were investigated and quantified. A mean relative error of map reconstruction of less than 3.5% was found for longitudinal shifts from -4.4 to +1.7 cm, and for longitudinal size changes from 65 to 108% of the initial area. For vertical displacements of electrodes between the limits of +/- 2.0 cm for full grid maps and +/- 1.4 cm if limited lead systems were used, the mean relative error of the maps remained under 5%.

Characterizing His-Purkinje system signals observed at the body surface. A model study

A computer model of the His-Purkinje system (HPS), based on human geometry, has been developed and used in conjunction with an atrial model and an inhomogeneous torso model to calculate electrocardiograms (ECGs) and isofield potential and magnetic maps. The calculated electric potential maximum for penetrating His bundle (HB) activity is 0.6 microV, somewhat smaller than reported by others. A calculated ECG of combined atrial and HPS activity indicates that atrial repolarization contributes to the ramp pattern observed in the PR segment. Simulated isofield distributions indicate two features that should be present in serial-measured HPS maps: (1) maps preceding HB activity should be included to illustrate the nature of the onset of HB activity and (2) maps should show a change in the location and magnitude of the extrema commensurate with the change in direction and magnitude of the source current circumscribed by the anatomy of the HB and bundle branches.

Trauma triage in western Sydney: results of a pilot study

A pilot study of the effectiveness of prehospital triage of trauma patients was carried out in a western Sydney between February and July 1988. Triage guidelines were developed to identify seriously injured persons at the incident site who might warrant admission to a Level 3 Trauma Service Hospital (Trauma Centre), as part of the NSW Department of Health trauma services plan. The study results were based on 64% of ambulance trauma transports for which a triage decision was provided. Of trauma transports studied, 3.7% had injuries serious enough to warrant admission to Level 3 Trauma Service Hospital. Ambulance officers correctly triaged 77% of these cases in the field. However, 62% of trauma transports triaged 'severe' or 'critical' did not have injuries serious enough to warrant admission to a Level 3 Trauma Service Hospital. Nevertheless, the triage guidelines compared favourably with similar instruments used elsewhere. Based on the performance of the triage guidelines it was concluded that the introduction of a regionalized trauma service in metropolitan NSW with local bypass is possible.

Diagnostic features of body surface potential maps in patients with myocardial ischemia and normal resting 12-lead electrocardiograms

Body surface maps recorded from 35 ischemic patients with normal resting 12-lead electrocardiograms were compared with those obtained from 36 age- and sex-matched normal subjects. From instantaneous maps of each subject 187 variables were derived relating to the configuration (80 variables) and magnitude (104 variables) of the potential distribution and duration of the electrocardiographic intervals (3 variables). By using stepwise discriminant analysis we selected 3 variables whose linear combination enabled us to correctly allocate 91% of the study population (jacknife procedure; specificity 92%, sensitivity 91%). To substantiate the validity of the results the discriminant function was tested on a new independent population consisting of 27 ischemic patients and 54 normal subjects from another laboratory. A proper allocation was obtained in 86% of the cases (specificity 87%, sensitivity 85%). The large number of correctly classified ischemic patients and the repeatability of the results indicate that the adopted criteria are good markers of ischemic heart disease.

Diagnostic body surface potential map patterns in left ventricular hypertrophy during PQRST

Body surface potential maps were recorded from 117 thoracic sites and 3 limb electrodes in 173 normal subjects older than 30 years of age and 122 patients with clinically "pure" left ventricular (LV) hypertrophy. Typical LV hypertrophy map patterns were identified at successive instants during the PQRST waveform by removing from sequential LV hypertrophy maps the corresponding normal variability range at each electrode site. The presence in individual patients of 1 or more patterns typical in time and location of LV hypertrophy allowed retrospective assignment to the LV hypertrophy group. The most consistent discriminant patterns were excessive negative voltages in the anterior torso with reciprocal excess of positive voltages in the upper right chest during the second half of the P wave, excessive negative voltages in the lower right anterior torso at mid-QRS and excessive negative voltages in the left precordium with reciprocal excess of positive voltages in the upper right chest throughout ST-T. Best classification results were achieved with ST-T features, followed by features from the P wave, the QRS waveform and the PR segment. Cumulative use of ST-T and P features yielded a specificity of 94% with a sensitivity of 88%. Little improvement was obtained by the addition of QRS and PR information. The discriminant map criteria were applied to body surface potential maps from 169 new subjects (77 normal subjects ages 20 to 30 years and 92 patients with complicated LV hypertrophy). Little modification in specificity (93%) and sensitivity (90%) was observed. The performance of commonly used standard lead criteria was also tested.(ABSTRACT TRUNCATED AT 250 WORDS)