Patent Application
20080228093
The present invention relates generally to medical devices and, more particularly, to cardiac devices and methods used for classification of cardiac events based on morphological analysis of cardiac signals.
When functioning normally, the heart produces rhythmic contractions and is capable of pumping blood throughout the body. However, due to disease or injury, the heart rhythm may become irregular resulting in diminished pumping efficiency. Arrhythmia is a general term used to describe heart rhythm irregularities arising from a variety of physical conditions and disease processes. Cardiac rhythm management systems, such as implantable pacemakers and cardiac defibrillators, have been used as an effective treatment for patients with serious arrhythmias. These systems typically include circuitry to sense electrical signals from the heart and a pulse generator for delivering electrical stimulation pulses to the heart. Leads extending into the patient's heart are connected to electrodes that contact the myocardium for sensing the heart's electrical signals and for delivering stimulation pulses to the heart in accordance with various therapies for treating the arrhythmias.
Cardiac rhythm management systems may pace the heart by stimulating the heart tissue to produce a contraction of the tissue. Pacemakers deliver a series of low energy pace pulses timed to assist the heart in producing a contractile rhythm that maintains cardiac pumping efficiency. Detecting if a pacing pulse “captures” the heart and produces a contraction allows the cardiac rhythm management system to adjust the energy level of pace pulses to correspond to the optimum energy expenditure that reliably produces capture. A pace pulse must exceed a minimum energy value, or capture threshold, to produce a contraction. It is desirable for a pace pulse to have sufficient energy to stimulate capture of the heart without expending energy significantly in excess of the capture threshold.
Cardiac rhythm management systems may also detect and terminate abnormal tachyarrhythmias using a variety of tiered therapies. These tiered therapies range from the delivery of anti-tachyarrhythmia pacing (ATP) to high energy shocks to terminate tachyarrhythmia or fibrillation. To effectively deliver these treatments, the CRM device must first identify the type of arrhythmia that is occurring.
Detecting various cardiac events, such as capture or a tachyarrhythmia event, may be accomplished by analyzing the morphology of a cardiac signal, such as an electrogram (EGM) or electrocardiogram (ECG). The morphological analysis may involve determining the presence and/or location of cardiac signal features in the cardiac signal. This type of analysis is simplified when the cardiac signal features used to detect the cardiac events are relatively consistent and can be discriminated from other signal features and from noise.
There is a need for methods and systems that enhance detection of cardiac signal features used to classify various cardiac events. The present invention fulfills these and other needs.
The present invention is directed to methods and devices used to classify cardiac events based on morphological analysis of sensed signals. One embodiment of the invention involves a method for classifying a cardiac event. The method includes sensing a signal comprising a cardiac signal component and a noise signal component. The sensed signal is processed to preferentially alter morphology of the cardiac signal component. The altered morphology of the cardiac signal component enhances detection of one or more features of the cardiac signal component. The one of more features of the cardiac signal component are detected and the cardiac event is classified using the detected features.
In certain implementations, processing the sensed signal involves processing the sensed signal using adaptable signal processing parameters. The signal processing parameters may be automatically determined or may be manually determined by a physician. For example, the signal processing parameters may be selected to accentuate one or more desirable features of the cardiac signal component or to mitigate one or more undesirable features of the cardiac signal component.
According to one aspect, the signal processing parameters may be determined to enhance a correlation coefficient between beats from cardiac episodes and a template.
Another aspect of the invention involves detecting one or more undesirable features of the cardiac signal component and determining signal processing parameters that mitigate the undesirable features of the cardiac signal component. For example, the undesirable features may be detected using a gradient analysis or using a curvature analysis.
The undesirable features may be detected and/or the signal processing parameters enhanced based on signals produced using a pacing protocol (e.g., AAI pacing to simulate a tachyarrhythmia episode) and/or may be based on stored cardiac signals.
According to various applications, the cardiac events classified using the altered cardiac signal component may include cardiac pacing responses and/or tachyarrhythmia episodes.
Another embodiment of the invention is directed to a medical system used to classify cardiac events. The system includes sensing circuitry configured to sense a signal comprising a cardiac signal component and a noise component. Signal processing circuitry is configured to process the sensed signal to preferentially alter morphology of the cardiac signal component of the sensed signal. The altered cardiac signal component enhances detection of one or more features of the cardiac signal component. A feature detector is configured to detect the one or more features of the cardiac signal component. A cardiac event processor configured to classify a cardiac event using the detected features.
A filter may be used to alter the cardiac signal component. In one example, the filter includes a high pass corner frequency of about 3 Hz and a low pass corner frequency of about 100 Hz. The system may additionally include a noise filter configured to filter the sensed signal to reduce the noise component of the sensed signal.
Parameters of the signal processing circuitry may be derived from population data or may be based on individual characteristics of a patient. The parameters of the signal processing circuitry can be automatically adapted by the device or programmed by a physician.
According to one implementation, the signal processing circuitry comprises a bank of signal processing units. Each of the signal processing units may have associated signal processing parameters and/or may be optimized to recognize or classify a particular type cardiac event.
The above summary of the present invention is not intended to describe each embodiment or every implementation of the present invention. Advantages and attainments, together with a more complete understanding of the invention, will become apparent and appreciated by referring to the following detailed description and claims taken in conjunction with the accompanying drawings.
While the invention is amenable to various modifications and alternative forms, specifics thereof have been shown by way of example in the drawings and will be described in detail below. It is to be understood, however, that the intention is not to limit the invention to the particular embodiments described. On the contrary, the invention is intended to cover all modifications, equivalents, and alternatives falling within the scope of the invention as defined by the appended claims.
In the following description of the illustrated embodiments, references are made to the accompanying drawings forming a part hereof, and in which are shown by way of illustration, various embodiments by which the invention may be practiced. It is to be understood that other embodiments may be utilized, and structural and functional changes may be made without departing from the scope of the present invention.
Detection of various cardiac events and/or conditions, including cardiac pacing response events and/or tachyarrhythmia events may be accomplished through morphological analysis of the cardiac signal produced by the heart. The cardiac signal may be acquired via implanted electrodes coupled to a pacemaker, defibrillator, or other type of cardiac rhythm management system. Various types of cardiac events are associated with consistently occurring cardiac signal features that can be used to classify the type of cardiac event.
Detection of cardiac signal features used to classify cardiac events may be made more difficult due to morphological characteristics of the cardiac signal. For example, undesirable cardiac signal features that occur close in time to a feature used for event identification are problematic. These undesirable features cause variation in discriminating the feature used for event identification. For example, if cardiac event identification is based on the amplitude and timing of a cardiac signal peak, a cardiac signal exhibiting a single sharp peak is desirable. The presence of a double peak or a flattened peak may lead to variation in determining the peak coordinates and corresponding inaccuracy in event identification.
The flow graph of
A signal sensed via implantable or patient-external sensors, such as cardiac electrodes, pressure sensors, respiration sensors, accelerometers, or other sensors, generally includes a noise component superimposed on the cardiac signal component. For example, if the sensed signal is related to cardiac activity, the resultant composite signal is thus not necessarily an accurate representation of cardiac activity because the noise signal component is also present in the composite signal. For purposes of this discussion, noise signals are signals from sources other than the cardiac activity of the heart. Noise sources may include environmental noise, such as 60 Hz power line noise, myopotentials from skeletal muscle, motion artifacts, and/or other noise sources. Much effort has previously been directed to removing noise from the cardiac signal to achieve the “pure” cardiac signal component without noise or with a reduced level of noise. Reduction of noise is one technique used to facilitate morphological analysis of sensed signals to classify cardiac events. For example, increasing the signal to noise ratio of the sensed signal by filtering the noise component can enhance feature detection.
Noise reduction approaches attempt to reveal the cardiac signal from a signal that combines the cardiac signal with signal components from unwanted sources. The approaches of the present invention are directed to preferentially modifying the cardiac signal component of the sensed signal to enhance signal feature detection rather than to achieve the reduction of noise in the sensed signal. Modification of the cardiac signal component as illustrated by various embodiments herein may be accomplished with or without the process of noise reduction. For example, the signal processing techniques of the present invention may be applied to change the shape of the cardiac signal component to enhance detection of signal features present in the cardiac signal component of a sensed signal.
Signal processing for feature enhancement of the cardiac signal in accordance with embodiments of the invention may be achieved by processing the signal sensed via cardiac electrodes using one or more signal processors. The graphs of
Signals processed to enhance feature detection lead to more accurate identification of cardiac events.
After processing, the cardiac signals 306 exhibit altered morphology that enhances positive peak detection, as illustrated in
A system capable of processing signals to enhance feature detection may be implemented in a cardiac rhythm management (CRM) device such as an implantable cardiac defibrillator, pacemaker or resynchronization device. Although the present system is described in conjunction with device having a microprocessor-based architecture, it will be understood that the CRM device may be implemented in any logic-based integrated circuit architecture, if desired. Furthermore, methods of the present invention may be implemented in a patient-external device or a system that incorporates both patient-external and implantable components.
Referring now to
The lead system 402 includes implantable electrodes used to detect electric cardiac signals produced by the heart and to provide electrical energy to the heart under certain predetermined conditions to treat cardiac arrhythmias. The lead system 402 may include one or more electrodes used for pacing, sensing, and/or defibrillation. In the embodiment shown in
The lead system 402 may include intracardiac leads 404, 405, 406 inserted into a patient's heart and electrically coupled to the cardiac myocardium. The intracardiac leads 404, 405, 406 include various electrodes positionable within the heart for sensing electrical activity of the heart and for delivering electrical stimulation energy to the heart, for example, pacing pulses and/or defibrillation shocks to treat various arrhythmias of the heart.
As illustrated in
The right ventricular lead system 404 illustrated in
In one configuration, the RV-tip electrode 412 referenced to the can electrode 409 may be used to implement unipolar pacing and/or sensing in the right ventricle 419. Bipolar pacing and/or sensing in the right ventricle may be implemented using the RV-tip 412 and RV-ring 411 electrodes. In yet another configuration, the RV-ring 411 electrode may optionally be omitted, and bipolar pacing and/or sensing may be accomplished using the RV-tip electrode 412 and the RV-coil 414, for example. The RV-coil 414 and the SVC-coil 416 are defibrillation electrodes.
The left ventricular lead 406 includes an LV distal electrode 413 and an LV proximal electrode 417 located at appropriate locations in or about the left ventricle and used for pacing and/or sensing the electrical signals of the left ventricle. The left ventricular lead 406 may be guided into the right atrium of the heart via the superior vena cava. From the right atrium, the left ventricular lead 406 may be deployed into the coronary sinus ostium, the opening of the coronary sinus 450. The lead 406 may be guided through the coronary sinus 450 to a coronary vein of the left ventricle. This vein is used as an access pathway for leads to reach the surfaces of the left ventricle which are not directly accessible from the right side of the heart. Lead placement for the left ventricular lead 406 may be achieved via subclavian vein access and a preformed guiding catheter for insertion of the LV electrodes 413, 417 adjacent to the left ventricle.
Unipolar pacing and/or sensing in the left ventricle may be implemented, for example, using the LV distal electrode referenced to the can electrode 409. The LV distal electrode 413 and the LV proximal electrode 417 may be used together as bipolar sense and/or pace electrodes for the left ventricle. Pacing delivered to the heart via the left ventricular lead 406 and the right ventricular lead 404 may be used to provide cardiac resynchronization therapy such that the ventricles of the heart are paced substantially simultaneously, or in phased sequence, to provide enhanced cardiac pumping efficiency for patients suffering from chronic heart failure.
The right atrial lead 405 includes a RA-tip electrode 456 and an RA-ring electrode 454 positioned at appropriate locations in the right atrium for sensing and pacing the right atrium. In one configuration, the RA-tip 456 referenced to the can electrode 409, for example, may be used to provide unipolar pacing and/or sensing in the right atrium. In another configuration, the RA-tip electrode 456 and the RA-ring electrode 454 may be used to provide bipolar pacing and/or sensing.
Circuitry 575 used to classify cardiac events and to control the delivery of therapy is enclosed within the housing of the device 400.
The CRM device circuitry 575 is typically powered by an electrochemical battery (not shown). A memory 545 stores data and program commands used to implement cardiac event identification according to the embodiments of the present invention as well as other operations such as therapy delivery. Data and program commands may be transferred between the device circuitry 575 and a patient-external device 555 via telemetry-based communications circuitry 550.
The circuitry 575 includes a therapy control processor 565 capable of controlling the delivery of pacing pulses and/or defibrillation shocks to the right ventricle, left ventricle, right atrium and/or left atrium. The pacing pulse generator 530 is configured to generate pacing pulses for treating bradyarrhythmia, for example, or for synchronizing the contractions of contralateral heart chambers using biatrial and/or biventricular pacing. Furthermore, under control of the therapy control processor 565, the cardioversion/defibrillation pulse generator 535 may be used to generate high energy shocks to terminate tachyarrhythmia episodes.
The pacing pulses and/or defibrillation shocks are delivered via multiple cardiac electrodes 505 disposed at various locations within, on, or about the heart and electrically coupled to the heart. In certain configurations, multiple electrodes may provide multiple sensing and/or stimulation sites within a single heart chamber. The electrodes 505 are coupled to switch matrix circuitry 525 that is used to selectively couple the electrodes 505 to the sense circuitry 510 and the therapy pulse generators 530, 535.
Cardiac electrical activity may be sensed from the electrode sites of the patient's heart are sensed via electrodes 505 and sense circuitry 510. Other types of signals, e.g., heart sound signals, pressure signals, respiration signals, and/or other types of signals may be sensed using various sensors 506 in conjunction with sense circuitry 510. Sensed signals acquired using the sensors 505, 506 and sense circuitry 510 are processed by signal processing circuitry 515 to enhance cardiac signal features used for cardiac event detection. The type of processing applied via the signal processing circuitry 515 may be based on the type of cardiac event being identified. For example, in one situation, the morphology of the cardiac signal component of the sensed signal may be altered to enhance a first set of features to facilitate detection of the cardiac pacing responses. In a second situation, the morphology of the cardiac signal component of the sensed signal may be altered to enhance a second set of features to facilitate detection of tachyarrhythmia or to identify a type of tachyarrhythmia.
Altering the morphology of the cardiac signal component of the sensed signal may be accomplished by filtering the signal to remove certain frequency components. For example, high pass, low pass or band pass filtering may be applied. Additionally or alternatively, the cardiac signal morphology may be altered by changing data acquisition parameters such as A/D converter resolution or sample frequency. The signal acquired via the electrodes 505 or sensors 506 and sense circuitry 510 may also be filtered to remove or reduce the noise component from the sensed signal.
The cardiac signal that has been modified to enhance feature detection is analyzed by cardiac event processor 560. During this analysis, cardiac signal features present in the processed signal are used to classify various cardiac events. In one scenario, cardiac signal features present in a processed electrogram (EGM) signal are used by the cardiac event processor 560 to classify the cardiac response to pacing. For example, the presence or absence of cardiac signal peaks within cardiac response detection windows may be used to determine whether or not the pacing pulse produced capture or some other pacing response such as noncapture, fusion or pseudofusion, or noncapture with intrinsic activation.
In another implementation, the cardiac signal modified by the signal processing circuitry 515 may be used to classify cardiac tachyarrhythmia episode types. Features extracted from the processed signal of cardiac episode beats may be compared to template features that are representative of various types of tachyarrhythmia. The amplitude, timing, and/or other characteristics of the processed signal features of episode beats are compared to corresponding template features. If the episode beat features and template features are sufficiently similar, then the cardiac event processor 560 identifies the cardiac episode as the type of tachyarrhythmia represented by the template.
In some implementations, the parameters of the signal processing circuitry 515 may be selected based on population data. For example, a fixed filter configuration may be chosen to process the signal, where the fixed filter provides a desired morphology of signal features across the general patient population. In one capture application, a filter with a high pass corner frequency of about 3 Hz and a low pass corner frequency of about 100 Hz produces negative and positive signal peaks that occur with a desired amplitude and timing. Determination of the cardiac pacing response may involve sensing for the presence of positive and/or negative peaks within detection windows. For most patients, these signal processing parameters produce cardiac signals that provide accurate cardiac pacing response determination based on the location and timing of the cardiac signal peaks.
As illustrated in
For example, as illustrated in
Due to disease state, patient pathophysiology, sensor characteristics and/or lead implant characteristics, the uniform parameter settings described above may result in sub-optimal feature detection for certain patients. In some embodiments, the signal processing parameter settings may be programmable via an external device programmer or other remote device management system. For example, in one scenario, a physician or other health care provider may select the parameters for signal processing and observe changes in the cardiac signal processed using the selected parameters. Through observation of the cardiac signal, the physician may determine if the selected parameters produce a desired improvement in cardiac signal morphology to achieve enhanced feature detection. In another scenario, the physician may determine if the modified parameters produce a desired effect, e.g., more accurate capture detection and/or identification of tachyarrhythmia episodes.
In some embodiments, selection of the individualized parameter settings may be performed automatically by the device. For example, the device implement a process wherein the parameter settings are automatically incrementally changed and the signal produced using each of the parameter setting is analyzed. This process may continue until one or more undesirable features are reduced in the cardiac signal until desirable features are accentuated, or until optimal parameter settings are determined. For example, in one implementation, the device may identify an undesirable feature in the signal and then automatically step through the available signal processing parameter settings to determine whether, or the degree to which, each setting removes or sufficiently reduces the undesirable feature. If it is not possible to eliminate the undesirable signal feature from the cardiac signal, an optimal parameter setting which provides the greatest reduction of the undesirable feature is selected. In other implementations, desirable features may be accentuated through the use of automatic modification of the signal processing parameters. For example, the device may step through available signal processing parameter settings to determine an optimal parameter setting that produces a sharp signal peak.
Methods to reduce undesirable features, accentuate desirable features, and/or to determine optimal parameter settings for signal processing may be implemented in firmware, software or a combination of both firmware and software. The automated parameter selection process may be performed on demand, periodically, and/or when degradation of cardiac event identification is detected. For example, if capture detection cannot be achieved or is intermittent, the signal processing parameter settings used for capture detection may be tested and readjusted.
The flow graph of
The presence of undesirable features in the cardiac signal may be determined using various techniques. Several exemplary techniques are described herein, but any technique that detects the presence of an undesirable feature or analyzes the comparative strength of desirable and undesirable features may be used.
A technique using gradient analysis for determining the presence of undesirable features is described in the context of a cardiac signal used for capture detection.
In accordance with one embodiment, the presence of a multiple peaks in a cardiac signal may be detected using a gradient analysis. In this process, the gradient 740 of the cardiac signal 710 is determined. The cardiac signal gradient 740 is graphically illustrated in
If one or more additional zero crossings are detected in the cardiac signal gradient 740 at locations close to the location of the main peak zero crossing, as illustrated in
Another method for detecting undesirable features in the cardiac signal such as the multiple peaks illustrated in
Modification of cardiac signal processing parameters to enhance feature detection in accordance with embodiments of the invention may be applied to improve discrimination of tachyarrhythmia events. In morphology based arrhythmia detection, feature points of cardiac signal are extracted, and the correlation with features from a template is calculated. If the correlation coefficient is higher than a predetermined threshold, the beat is classified as the type of beat represented by the template.
In one implementation, the detected beat signal is compared to a template representative of supraventricular rhythm (SVR). If the beat signal is correlated to the SVR template, the beat is classified as SVR and therapy is withheld. If the beat signal is not correlated to the SVR template, the beat is classified as a ventricular tachyarrhythmia beat and therapy may be delivered. According to this approach, feature points 1-8 are extracted from the cardiac signal 810, as illustrated in
In accordance with the approaches of the present invention, signal processing parameters may be determined that eliminate the undesirable morphology or curvature that occur in regions 820 and 830. The above-described gradient or curvature based methods may be used to detect the undesirable inflection points. For example, inflection points may be detected using the gradient approach as points where the gradient is zero.
There are also other approaches to detect undesirable features or enhance desirable features in the cardiac signal component, such as using energy or power of the signal. For example, for the capture detection example, it may be possible to integrate the positive and negative deflections and choose the signal processing parameters which produce the smallest integral as the optimal parameter.
Determination of the signal processing parameters may be performed based on patient population data or may be individualized for a particular patient. As previously discussed, the signal processing parameters may be automatically or manually determined. In one approach, the signal processing parameters may be determined during template creation and/or update. In another approach, the signal processing parameters may be determined based on the patient's stored episode data. In another approach, the signal processing parameters may be selected by a physician and uploaded to the device. In yet another approach, the physician could run a pacing or exercise protocol to simulate tachyarrhythmia with the device adjusting the signal processing parameters during the simulated tachyarrhythmia to enhance tachyarrhythmia detection.
Various modifications and additions can be made to the embodiments discussed hereinabove without departing from the scope of the present invention. Accordingly, the scope of the present invention should not be limited by the particular embodiments described above, but should be defined only by the claims set forth below and equivalents thereof.
