Characterization of natural and total artificial heart acceleration

Operator independent left ventricular function monitoring during pharmacological stress echo with the new peak transcutaneous acceleration signal

BACKGROUND

As the myocardium contracts isometrically, it generates vibrations that can be measured with an accelerometer. The vibration peak, peak endocardial acceleration (PEA), is an index of contractility.

OBJECTIVE

To evaluate the feasibility of PEA measured by the cutaneous precordial application of the accelerometer sensor; and to assess the usefulness of PEA monitoring during pharmacological stress echocardiography.

DESIGN

Feasibility study.

SETTING

Stress echo laboratory.

PATIENTS

34 consecutive patients underwent pharmacological stress (26 with dipyridamole; 8 with dobutamine) and PEA monitoring simultaneously.

INTERVENTIONS

A microaccelerometer was positioned in the precordial region and PEA was recorded. Dipyridamole was infused up to 0.84 mg/kg in 10 minutes, and dobutamine up to 40 microg/kg/min in 15 minutes.

RESULTS

A consistent PEA signal was obtained in all patients. Overall mean (SD) baseline PEA was 0.26 (0.15) g (g = 9.8 m/s(2)), increasing to 0.5 (0.36) g at peak stress (+0.24 g, 95% confidence interval (CI) 0.14 to 0.34 g; p < 0.01). PEA increased from 0.26 (0.16) to 0.37 (0.25) g in the dipyridamole group (+0.11 g, 95% CI 0.08 to 0.16 g; p < 0.01), and from 0.29 (0.1) to 0.93 (0.37) g in the dobutamine group (+0.64 g, 95% CI 0.37 to 0.91 g; p < 0.01).

CONCLUSIONS

Using precordial leads this method offers potential for diagnostic application in the short term monitoring of myocardial function. PEA monitoring is feasible during pharmacological stress and documents left ventricular inotropic response quantitatively in a non-invasive and operator independent fashion.

Peak endocardial acceleration reflects heart contractility also in atrial fibrillation

Previous studies demonstrated that peak endocardial acceleration (PEA) in sinus rhythm is related to LV dP/dtmax. Until now, PEA was never evaluated during R-R interval variations in AF. The aim of this study was to establish the behavior of PEA in AF and the relationship of PEA versus LV dP/dtmax. Six sheep (65 +/- 6 kg) were instrumented with a LV Millar catheter and with an accelerometer lead. AF was induced and PEA, LV dP/dtmax, and ECG were monitored. AF persisted for 5 +/- 1.3 minutes. From sinus rhythm to AF, the heart rate went from 92 +/- 3 to 130 +/- 35 beats/min (P < 0.05), LV dP/dtmax from 684 +/- 18 to 956 +/- 344 mmHg/s (P = NS) and PEA from 0.82 +/- 0.06 to 0.94 +/- 0.33 g (P = NS). The correlation between PEA and LV dP/dtmax was significative in sinus rhythm (r = 0.7, P < 0.05) and in AF (r = 0.8, P < 0.05). A positive relationship was found between the preceding interval and PEA (r = 0.4 +/- 0.07, P < 0.05) and LV dP/dtmax (r = 0.61 +/- 0.08, P < 0.05), while a negative one was found between the prepreceding interval and both PEA (r = -0.39 +/- 0.11, P < 0.05) and LV dP/dtmax (r = -0.64 +/- 0.05, P < 0.05). At the onset of AF, LV dP/dtmax and PEA showed similar changes: beat-to-beat correlation between PEA and LV dP/dtmax was high. As for LV dP/dtmax, PEA is positively related to the preceding interval and negatively related to the prepreceding interval. These data confirm that PEA reflects heart contractility also during AF and hold promise for the use of this sensor in therapeutic implantable devices.

An implantable intracardiac accelerometer for monitoring myocardial contractility. The Multicenter PEA Study Group

As the myocardium contracts isometrically, it generates vibrations that are transmitted throughout the heart. These vibrations can be measured with an implantable microaccelerometer located inside the tip of an otherwise conventional unipolar pacing lead. These vibrations are, in their audible component, responsible for the first heart sound. The aim of this study was to evaluate, in man, the clinical feasibility and reliability of intracavity sampling of Peak Endocardial Acceleration (PEA) of the first heart sound vibrations using an implantable tip mounted accelerometer. We used a unidirectional accelerometer located inside the stimulating tip of a standard unipolar pacing lead: the sensor has a frequency response of DC to 1 kHz and a sensitivity of 5 mV/G (G = 9.81 m/s-2). The lead was connected to an external signal amplifier with a frequency range of 0.05-1,000 Hz and to a peak-to-peak detector synchronized with the endocardial R wave scanning the isovolumetric contraction phase. Following standard electrophysiological studies, sensor equipped leads were temporarily inserted in the RV of 15 patients (68 +/- 15 years), with normal regional and global ventricular function, to record PEA at rest, during AAI pacing, during VVI pacing, and during dobutamine infusion (up to 20 micrograms/kg per min). PEA at baseline was 1.1 G +/- 0.5 (heart rate = 75 +/- 14 beats/min) and increased to 1.3 G +/- 0.9 (P = NS vs baseline) during AAI pacing (heart rate = 140 beats/min) and to 1.4 G +/- 0.5 (P = NS vs baseline) during VVI pacing (heart rate = 140 beats/min). Dobutamine infusion increased PEA to 3.7 G +/- 1.1 (P < 0.001 vs baseline), with a heart rate of 121 +/- 13 beats/min. In a subset of three patients, simultaneous hemodynamic RV monitoring was performed to obtain RV dP/dtmax, whose changes during dobutamine and pacing were linearly related to changes in PEA (r = 0.9; P < 0.001). In conclusion, the PEA recording can be consistently and safely obtained with an implantable device. Pharmacological inotropic stimulation, but not pacing induced chronotropic stimulation, increases PEA amplitude, in keeping with experimental studies, suggesting that PEA is an index of myocardial contractility. Acute variations in PEA are closely paralleled by changes in RV dP/dtmax, but are mainly determined by LV events. The clinical applicability of the method using RV endocardial leads and an implantable device offers potential for diagnostic applications in the long-term monitoring of myocardial function in man.