U.S. patent application number 12/131750 was filed with the patent office on 2008-09-25 for electrophysiology therapy catheter.
Invention is credited to Graydon E. Beatty, Jeffrey R. Budd, John A. Hauck.
Application Number | 20080234564 12/131750 |
Document ID | / |
Family ID | 37833351 |
Filed Date | 2008-09-25 |
United States Patent
Application |
20080234564 |
Kind Code |
A1 |
Beatty; Graydon E. ; et
al. |
September 25, 2008 |
Electrophysiology therapy catheter
Abstract
A mapping catheter is positioned in a heart chamber, and active
electrode sites are activated to impose an electric field within
the chamber. The blood volume and wall motion modulates the
electric field, which is detected by passive electrode sites on the
preferred catheter. Electrophysiology measurements, as well as
geometry measurements, are taken from the passive electrodes and
used to display a map of intrinsic heart activity.
Inventors: |
Beatty; Graydon E.;
(Bloomington, MN) ; Budd; Jeffrey R.; (Shoreview,
MN) ; Hauck; John A.; (Shoreview, MN) |
Correspondence
Address: |
ST. JUDE MEDICAL, ATRIAL FIBRILLATION DIVISION
14901 DEVEAU PLACE
MINNETONKA
MN
55345-2126
US
|
Family ID: |
37833351 |
Appl. No.: |
12/131750 |
Filed: |
June 2, 2008 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11734191 |
Apr 11, 2007 |
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12131750 |
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09547945 |
Apr 12, 2000 |
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11734191 |
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09005105 |
Jan 9, 1998 |
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09547945 |
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08387832 |
May 26, 1995 |
6240307 |
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PCT/US93/09015 |
Sep 23, 1993 |
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09005105 |
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07950448 |
Sep 23, 1992 |
5297549 |
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08387832 |
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07949690 |
Sep 23, 1992 |
5311866 |
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07950448 |
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Current U.S.
Class: |
600/374 |
Current CPC
Class: |
A61B 5/287 20210101;
A61B 5/053 20130101; A61B 5/0538 20130101; A61B 5/1076
20130101 |
Class at
Publication: |
600/374 |
International
Class: |
A61B 5/042 20060101
A61B005/042 |
Claims
1-3. (canceled)
4. A catheter assembly for mapping the electrical activity of a
heart chamber, comprising: a lead body having a proximal end and a
distal end for insertion into the heart chamber; and a deployable
array of electrodes located at the distal end of the lead body,
wherein the deployable array includes a plurality of limbs, each
limb carrying one or more electrodes adapted to measure voltage on
a surface of the heart chamber.
5. The catheter assembly of claim 4, wherein the deployable array
further includes at least one active electrode.
6. The catheter assembly of claim 4, wherein each limb carries two
electrodes.
7. The catheter assembly of claim 6, wherein at least one electrode
on each limb is a ring electrode.
8. The catheter assembly of claim 4, further comprising: a handle
coupled to the proximal end of the lead body, wherein the handle is
configured to manipulate the position of the deployable array of
electrodes.
9. The catheter assembly of claim 4 wherein at least one electrode
is a passive electrode.
10. The catheter assembly of claim 9, wherein each passive
electrode is configured to sense electrophysiological data.
11. The catheter assembly of claim 10, wherein each passive
electrode is configured to sense an impedance.
12. The catheter assembly of claim 4, wherein the each of the
plurality of limbs is connected to the distal end of the lead body
at a proximal end of the limb.
13. The catheter assembly of claim 12, wherein the limbs in the
plurality of limbs are connected at a distal end of the plurality
of limbs.
14. A method for mapping electrical activity in a heart chamber,
comprising: inserting a catheter having a plurality of limbs into
the heart chamber; deploying the limbs of the catheter to place a
plurality of passive electrodes onto a surface of the heart
chamber; determining the position of the plurality of electrodes;
measuring electrical activity on the surface of the heart chamber
using the plurality of electrodes; and creating a
electrophysiologic map of the measured electrical activity.
15. The method of claim 14, wherein the deploying step further
comprises deploying an active electrode into the heart chamber.
16. The method of claim 14, wherein the deploying step further
comprises deploying the limbs of the catheter to place a plurality
of passive electrodes at precisely spaced intervals onto the
surface of the heart chamber.
17. The method of claim 14, wherein the measuring step further
comprises receiving electrophysiological data from the surface of
the heart chamber.
18. The method of claim 17, wherein the measuring step further
comprises measuring an impedance at the surface of the heart
chamber.
19. The method of claim 14, wherein the deploying step further
comprises deploying the limbs of the catheter such that the limbs
are connected at a proximal end of the plurality of limbs.
20. The method of claim 19, wherein the deploying step further
comprises deploying the limbs of the catheter such that the limbs
are connected at a distal end of the plurality of limbs.
21. The method of claim 14, wherein the creating step further
comprises creating a three-dimensional dynamic electrophysiologic
map of the measured electrical activity.
Description
CROSS REFERENCED TO RELATED CASES
[0001] This is a Divisional Application of U.S. Ser. No.
09/005,105, filed Jan. 9, 1998, entitled "Electrophysiology Mapping
System;" which was a Continuation-In-Part of U.S. Ser. No.
08/387,832, officially filed May 26, 1995 and entitled "Endocardial
Mapping System and Catheter Probe"; which is a national stage
application based upon international application PCT/US93/09015,
filed Sep. 23, 1993; which in turn is a Continuation-In-Part of
both U.S. Ser. No. 07/950,448, filed Sep. 23, 1992 (now U.S. Pat.
No. 5,291,549) and U.S. Ser. No. 07/949,690, also filed Sep. 23,
1992 (now U.S. Pat. No. 5,311,866). The parent application, Ser.
No. 08/387,832, is incorporated by reference herein.
FIELD OF THE INVENTION
[0002] The parent invention relates to electrophysiology apparatus
which is used to measure and to visualize electrical activity
occurring in a patient's heart. The system can display both a
visual map of the underlying electrical activity originating in a
chamber of a patient's heart and the location of a therapy catheter
located within a heart chamber. The electrophysiology apparatus
includes several subsystems including: a therapy catheter system, a
measurement catheter system and a computer based signal
acquisition, control and display system.
BACKGROUND OF THE INVENTION
[0003] Many cardiac tachyarrhythmias are caused by conduction
defects which interfere with the normal propagation of electrical
signals in a patient's heart. These arrhythmias may be treated
electrically, pharmacologically or surgically. The optimal
therapeutic approach to treat a particular tachyarrhythmia depends
upon the nature and location of the underlying conduction defect.
For this reason electrophysiologic mapping is used to explore the
electrical activity of the heart during a tachyarrhythmic episode.
The typical electrophysiologic mapping procedure involves
positioning an electrode system within the heart. Electrical
measurements are made which reveal the electrical propagation of
activity in the heart. If ablation is the indicated therapy then a
therapy catheter is positioned at the desired location within the
heart and energy is delivered to the therapy catheter to ablate the
tissue.
[0004] There are numerous problems associated with these
electrophysiologic diagnostic and therapeutic procedures. First the
testing goes on within a beating heart. The motion of the
diagnostic catheter and treatment catheter can injure the heart and
provoke bouts of arrhythmia which interfere with the collection of
diagnostic information. During the delivery of ablation therapy it
is common to use fluoroscopic equipment to visualize the location
of the catheters. Many physicians are concerned about routine
occupational exposure to X-rays. In addition, the traditional
mapping techniques do not provide a high resolution view of the
electrical activity of the heart which makes it difficult to
precisely locate the source of the arrhythmia.
SUMMARY
[0005] The electrophysiology apparatus of the invention is
partitioned into several interconnected subsystems. The measurement
catheter system introduces a modulated electric field into the
heart chamber. The blood volume and the moving heart wall surface
modify the applied electric field. Electrode sites within the heart
chamber passively monitor the modifications to the field and a
dynamic representation of the location of the interior wall of the
heart is developed for display to the physician. Electrophysiologic
signals generated by the heart itself are also measured at
electrode sites within the heart and these signals are low pass
filtered and displayed along with the dynamic wall representation.
This composite dynamic electrophysiologic map may be displayed and
used to diagnose the underlying arrhythmia.
[0006] A therapy catheter system can also be introduced into the
heart chamber. A modulated electrical field delivered to an
electrode on this therapy catheter can be used to show the location
of the therapy catheter within the heart. The therapy catheter
location can be displayed on the dynamic electrophysiologic map in
real time along with the other diagnostic information. Thus the
therapy catheter location can be displayed along with the intrinsic
or provoked electrical activity of the heart to show the relative
position of the therapy catheter tip to the electrical activity
originating within the heart itself. Consequently the dynamic
electrophysiology map can be used by the physician to guide the
therapy catheter to any desired location within the heart.
[0007] The dynamic electrophysiologic map is produced in a
step-wise process. First,the interior shape of the heart is
determined. This information is derived from a sequence of
geometric measurements related to the modulation of the applied
electric field. Knowledge of the dynamic shape of the heart is used
to generate a representation of the interior surface of the
heart.
[0008] Next, the intrinsic electrical activity of the heart is
measured. The signals of physiologic origin are passively detected
and processed such that the magnitude of the potentials on the wall
surface may be displayed on the wall surface representation. The
measured electrical activity may be displayed on the wall surface
representation in any of a variety of formats. Finally, a location
current may be delivered to a therapy catheter within the same
chamber. The potential sensed from this current may be processed to
determine the relative or absolute location of the therapy catheter
within the chamber.
[0009] These various processes can occur sequentially or
simultaneously several hundred times a second to give a continuous
image of heart activity and the location of the therapy device.
BRIEF DESCRIPTION OF THE DRAWINGS
[0010] An exemplary and illustrative form of the invention is shown
in the drawings and identical reference numerals refer to
equivalent structure throughout.
[0011] FIG. 1 is a schematic block diagram of the electrophysiology
apparatus;
[0012] FIG. 2 is a block diagram representing the partitioning of
the electrophysiology apparatus;
[0013] FIG. 3 is a diagram of an illustrative balloon electrode set
implementation of the measurement catheter and a therapy
catheter;
[0014] FIG. 4 is a schematic diagram of an illustrative basket
electrode set implementation of the measurement catheter;
[0015] FIG. 5 is a flow chart showing the wall surface generation
process;
[0016] FIG. 6 is a schematic diagram of a row of electrodes of the
balloon catheter and their use in measuring distance to the heart
chamber wall;
[0017] FIG. 7 is a screen display representing the motion of the
cardiac wall surface;
[0018] FIG. 8 is a schematic block diagram of the portion of the
electrophysiology apparatus which implements the body orientation
generation process;
[0019] FIG. 9 is a flow charting showing the body orientation
generation process;
[0020] FIG. 10 is a flow chart showing the wall electrogram
generation process;
[0021] FIG. 11 is a representative screen display showing wall
electrogram information;
[0022] FIG. 12 is a representative screen display showing wall
electrogram information;
[0023] FIG. 13 is a representative screen display showing wall
electrogram information;
[0024] FIG. 14 is a flow chart showing the site electrogram
generation process; and
[0025] FIG. 15 is a flow chart showing the movable electrode
location process.
[0026] FIG. 16 is a schematic block diagram of the therapy catheter
system;
[0027] FIG. 17 is a schematic diagram of the laser delivery
embodiment of the therapy catheter;
[0028] FIG. 18 is a schematic diagram of a microwave delivery
embodiment of the therapy catheter;
[0029] FIG. 19 is a schematic diagram of a chemical delivery
embodiment of the therapy catheter; and
[0030] FIG. 20 is a schematic diagram of the angioplasty catheter
embodiment of the therapy catheter.
DETAILED DESCRIPTION
[0031] FIG. 1 shows the electrophysiologic apparatus 10 connected
to a patient 12. In a typical procedure a monitoring catheter
system 14 is placed in the heart 16 to generate a display of the
electrical activity of the heart 16. After diagnosis a therapy
catheter 18 may be inserted into the heart to perform ablation or
other corrective treatment.
[0032] The monitoring catheter 14 has a proximal end 20 which may
be manipulated by the attending physician, and a distal end 22
which carries a monitoring catheter electrode set 44. In general
the distal end 22 of the monitoring catheter 14 will be relatively
small and will float freely in the heart chamber. The therapy
catheter 18 has a distal end 24 which carries a therapy catheter
electrode set 46. The therapy catheter also has proximal end 26
which can be manipulated by the attending physician.
[0033] The electrode sets located on the catheters are coupled to
an interface system 28, through appropriate cables. The cable 30
connects the monitoring catheter electrode set 44 to the interface
system 28 while cable 32 connects the therapy catheter electrode
set 46 to the interface system 28. The interface system 28 contains
a number of subsystems which are controlled by a computer 34. The
data collected by the interface system 28 is manipulated by the
computer 34 and displayed on a display device 36. Surface
electrodes represented by electrode 40 may also be coupled to the
electrophysiology apparatus 10 for several purposes via an
appropriate cable 42. A therapy generator 38 is connected to the
therapy catheter electrode 60 and to the therapy surface ground 70,
through the interface system 28. The skin surface electrode cable
42 couples the ECG surface electrodes 74 to the ECG system 39,
which may be a subsystem of interface system 28.
[0034] FIG. 2 is a schematic diagram showing an illustrative
segmentation of the electrode sets and their electrical connections
to subsystems in the electrophysiology apparatus 10. For example
the monitoring electrode set 44 contains a subset of passive
electrodes 48 which are connected to a signal conditioner 50. The
monitoring electrode set 44 also contains a subset of active
electrodes 52 which are connected to a signal generator 54 through
a switch 59. The signal generator 54 is controlled by the computer
34. In operation, the signal generator 54 generates a burst of
(4800 Hz for example) signals which are supplied to the active
electrode set 52. This energy sets up an electric field within the
heart 16 chamber. The electrical potentials present on the passive
electrode set 48 represent the summation of the underlying
electrophysiological signals generated by the heart and the field
induced by the burst. The signal conditioner 50 separates these two
components. The preferred technique is to separate the signals
based upon their frequency.
[0035] The high pass section 56 of the signal conditioner extracts
the induced field signals as modulated by the blood volume and the
changing position of the chamber walls 125. First, the signals are
amplified with a gain of approximately 500 from passive electrodes
48 with amplifier 151. Next, the signals are high pass filtered at
roughly 1200 Hz by filter 153. Then the 4800 Hz signal is extracted
by demodulator 155. Finally, the individual signals are converted
to digital format by the analog to digital converter 157 before
being sent to the computer 34.
[0036] The low pass section 58 of the signal conditioner 50
extracts physiologic signals. First, signal drift is reduced with a
0.01 Hz high pass filter 143. Next, a programmable gain amplifier
145 amplifies the signals. Then a low pass filter 147 removes
extraneous high frequency noise and the signal from the induced
field. Finally, the physiologic signals are converted to digital
format by the analog to digital converter 149 before being sent to
the computer 34.
[0037] The therapy catheter electrode set 46 includes at least one
therapy delivery electrode 60, and preferably one or more
monitoring electrodes 62, and one or more locator electrodes 68.
The therapy delivery electrode 60 cooperates with the ground
electrode 70, which is generally a skin patch electrode, to deliver
ablation energy to the heart. These electrodes are coupled to the
ablation energy generator 38 which is shown as an RF current
source. A locator electrode 68 is provided which is preferably
proximate the delivery electrode 60, but can be a separate
electrode site located near the distal end 24 of the therapy
catheter 18. This electrode site is coupled with an active
electrode 52 through a switch 59 to the signal generator 54. In
use, the electric field coupled to the therapy catheter 18 permits
the physician to track and visualize the location of the locator
electrode 68 on the display device 36. The therapy catheter
electrode set 46 can also be used to monitor the physiologic
signals generated at the chamber wall 125 by a low pass signal
conditioner 141 which is similar to the low pass section 58 of the
signal conditioner 50. These digitized signals are then sent to the
computer 34.
[0038] At least one electrode pair 119 of surface electrodes 40 are
also coupled to the signal generator 54 through switch 59. Each
electrode 89 and 115 are placed opposite each other on the body
surface with the heart 16 in-between them. The induced field is
sensed by passive electrodes 48 and conditioned by the high pass
section 56 of the signal conditioner 50. This field helps the
computer 34 align or orient the passive electrodes 48 to the body
for better visualization of the heart on the monitor 36.
[0039] The ECG subsystem 39 accepts signals from standard ECG skin
electrodes 74. It also contains a low pass section similar to the
low pass section 58 of signal conditioner 50. In general, the
passive electrode set 48 and active electrode set 52 will reside on
a single catheter, however it should be recognized that other
locations and geometries are suitable as well. Both basket and
balloon devices are particularly well suited to this
application.
[0040] FIG. 3 shows an electrode configuration on a balloon
catheter 94 which has an inflatable balloon 96 which underlies an
array or set of passive electrodes 48 typified by passive electrode
72. These passive electrodes 48 can be organized into rows,
typified by row 123, and columns, typified by column 121. A pair of
active excitation electrodes 52 are typified by proximal electrode
92 and distal electrode 98. The balloon catheter 94 configuration
can be quite small in comparison with the basket catheter 80
configuration. This small size is desirable both for insertion into
and for use in a beating heart 16.
[0041] FIG. 3 also shows a movable, reference or therapy catheter
system 18. This catheter is shown lying along the interior surface
125 of the heart 16. A pair of electrodes shown as delivery
electrode 60 and reference electrode 62 are located a fixed
distance apart on the catheter body 64. This auxiliary catheter may
be used to supply ablation energy to the tissue during therapy.
This therapy catheter 18 may be used with either the basket
catheter 80 configuration or the balloon catheter 94
configuration.
[0042] FIG. 4 shows an electrode configuration on a basket catheter
80. The limbs of the basket 80, typified by limb 82 carry multiple
passive electrode sites typified by electrode 84. A pair of active
excitation electrodes are shown on the central shaft 86 of the
basket 80 as indicated by excitation electrode 88. The basket
catheter 80 electrodes lie gently against the interior surface 125
of the heart 16 urged into position by the resilience of the limbs.
The basket catheter 80 permits unimpeded flow of blood through the
heart during the mapping procedure which is very desirable. This
form of catheter also places the electrodes into contact with the
heart chamber wall 125 for in-contact mapping of the physiologic
potentials of the heart 16.
[0043] Returning to FIG. 1 and FIG. 2 these figures show one
illustrative partitioning of system functions. In use, the signal
generator 54 can generate a 4800 Hz sinusoidal signal burst on the
active electrode set 52 which creates an electric field in the
heart. The changing position of the chamber walls 125 and the
amount of blood within the heart determines the signal strength
present at the passive electrode sites 48. For purposes of this
disclosure the chamber geometry is derived from the electric field
as measured at the passive electrode sites 48 which may, or may not
be in contact with the walls 125 of the heart. In the case of the
basket electrodes 84 which lie on the heart surface 125 the field
strength is inversely proportional to the instantaneous physical
wall location and the distance from the active electrodes 52 to
these walls. In the case of the balloon catheter the potentials on
the passive set of electrodes 72 are related to the wall location,
but a set of computationally intensive field equations must be
solved to ascertain the position of the wall. In general, both the
basket and balloon approach can be used to generate the dynamic
representation of the wall surface.
[0044] The computer 34 operates under the control of a stored
program which implements several control functions and further
displays data on a display device 36. The principal software
processes are the wall surface generation process (WSGP); the body
orientation generation process (BOGP); the wall electrogram
generation process (WEGP); the site electrogram generation process
(SEGP); and the movable electrode location process (MELP).
Wall Surface Generation Process
[0045] FIG. 5 is a flow chart describing the method used to
generate the "wall surface" of the interior of the heart 16. The
step-wise processes are presented with certain physical parameters
which are either known in advance by computation or are measured.
This knowledge or information is shown in block 53, block 55 and
block 57. The WSGP process begins at block 41 with the insertion of
the monitoring catheter 14 in the heart 16. This catheter 14 places
an array of electrodes 44 in a heart 16 chamber. This array must
have both passive measurement electrode sites 48 and active
interrogation electrode sites 52 located in a known position. The
process enters a measurement and display loop at block 43 where an
interrogation pulse burst is generated by the signal generator 54
seen in FIG. 2. These pulses are generated first with the current
source at site 92 and the current sink at site 98 and second with
the current source at site 98 and the sink at site 92 as seen in
FIG. 3. At block 45 the signal conditioner 50 uses information on
the frequency and timing of the interrogation current from block 53
to demodulate the signals and analog to digital convert the signals
received at the passive measurement electrodes 48. At block 47 the
information from block 55 is used. This information includes both
the current strength of the interrogation pulse and the location of
the interrogation source and sink electrodes. Impedance is voltage
divided by current. The voltage offset caused by the location of
the current source can be reduced by the two measurements of
opposite polarity. This information is used to determine the
impedance which the chamber and the blood contained in that chamber
imposes on the field generated by the interrogation current. The
knowledge from block 57 is used next. Block 49 determines how the
heart chamber tissue, which has roughly three times the impedance
of blood, in combination with the type of electrode array affects
the field generated by the interrogation electrodes.
[0046] In a system as shown as the basket in FIG. 4 the blood
effects the impedance directly as the field is propagated from the
interrogation electrodes to the measurement electrodes. In general,
if a point current course is used within a chamber the inverse of
the measured voltage is proportional to the square root of the
distance from the source. With the distance from each electrode 84
to both excitation electrodes 88 computed from the measured voltage
and the known location of the electrodes 84 relative to each other,
the locations of each electrode 84 can be determined.
[0047] In a system as shown in FIG. 3 the impedance of the field
generated within the blood volume is modulated by the position of
the walls 125, with their higher impedance, with respect to the
location relative to the measurement electrodes. Using this
knowledge and the measurements from block 47 the distance from the
interrogation electrodes to the heart chamber wall 125 is
determined at a point normal to the field generated by the active
interrogation electrodes 52.
[0048] The passive electrodes 48 on the balloon catheter 94 can be
positioned in rows 123 and columns 121 with the columns in a line
from the top of the balloon 96 near active electrode 92 to the
bottom of the balloon 96 near active electrode 98. In a preferred
embodiment three configurations are possible: 8 rows and 8 columns,
7 rows and 9 columns, and 6 rows and 10 columns. In each such
embodiment the measurements from any row 123 are treated
independently. Using the 8 row, 8 column embodiment as an example,
8 measurements of distance are taken for any selected row of
electrodes, giving a total of 64 measurements.
[0049] FIG. 6 is a schematic drawing of the embodiment required to
measure the distance 129 from the centroid 127 of the balloon 96
through the passive electrode 131 to the heart chamber wall 125.
The passive electrode 131 is one of eight electrodes on a row of
electrodes 123. Starting with electrode 131 and labeling it as
electrode A, the other electrodes on the row 123 are labeled B, C,
D, E, F, G and H by proceeding around the balloon 96 in a clockwise
direction. The measurements of impedance "I" at these electrodes
are thus labeled I.sub.A, I.sub.B, I.sub.C, I.sub.D, I.sub.E,
I.sub.F, I.sub.G and I.sub.H. To compute the distance 129 in the
direction of electrode 131 the following equation is computed:
ln ( D A ) = c 0 + c 1 * ln ( I A ) + c 2 * ln ( I B ) + c 3 * ln (
I c ) + c 4 * ln ( I D ) + c 5 * ln ( I E ) + c 4 * ln ( I F ) + c
3 * ln ( I G ) + c 2 * ln ( I H ) ##EQU00001##
where D.sub.A is the desired distance 129 and c0 through c5 are
optimized parameters. A typical vector of these parameters is (c0,
c1, c2, c3, c4, c5)=(3.26, -0.152, -0.124, -0.087, -0.078,
-0.066).
[0050] Once the distance 129 in the direction of electrode 131 is
determined then the computation can be redone by shifting this
direction clockwise one electrode, relabeling electrodes A through
H and solving the above equation again. Once the distances for this
row of electrodes 123 are determined then the next row distances
are determined in the same way until the distances at all 64
electrodes are determined.
[0051] Returning to FIG. 5, with multiple wall locations in space
determined by this method, a model of the chamber wall 125 shape
can be created in block 51. Various techniques for creating a shape
are possible, including cubic spline fits, and best fit of an
ellipsoid. The positions of the active electrodes 52 and the
passive electrodes 48 relative to the heart 16 chamber walls are
also determined at this point. The loop continues as the method
moves back to block 43. This loop continues at a rate fast enough
to visualize the real-time wall motion of the heart chamber, at
least at twenty times per second.
[0052] There are numerous display formats or images which can be
used to present the dynamic endocardial wall surface to the
physician. It appears that one of the most useful is to unfold the
endocardial surface and project it onto a plane. Wire grid shapes
representing a perspective view of the interior of the heart
chamber are useful as well. It appears that each individual
physician will develop preferences with respect to preferred output
image formats. In general, different views of the endocardial
surface will be available or may be used for diagnosis of arrythmia
and the delivery of therapy. One distinct advantage of the present
invention is that the image of the heart wall is not static or
artificial. In this system the image is a measured property of the
heart wall, and is displayed in motion.
[0053] FIG. 7 shows two separate frames of the dynamic
representation of the heart wall. Wire frame 71 shows the heart at
systole while wire frame 73 shows the heart at diastole. Path arrow
75 and path arrow 77 represent the dynamic cycling through several
intermediate shapes between the systole and diastole
representation. These views are useful as they indicate the
mechanical pumping motion of the heart to the physician.
Body Orientation Generation Process
[0054] FIG. 8 is a schematic drawing of the apparatus required to
perform the body orientation generation process. It shows a patient
12 with at least one pair 119 of skin electrodes 40 attached to the
body surface in a stationary position on the body and in a known
configuration. These electrodes are typified by example surface
electrodes 89 and 115 each of which could be an ECG electrode 74,
an RF generation current sink electrode 70, or another electrode
specifically dedicated to the BOGP. Ideally, electrode 89 and 115
are opposite one another on the body with the heart 16 directly in
between them. This pair of electrodes is attached to the signal
generator 54 through the switch 59 via an appropriate cable 117.
The distal end 22 of monitoring catheter 14 is situated in the
heart 16 where the passive electrodes 48 can measure the signals
generated across the electrode 89 and electrode 115.
[0055] FIG. 9 is a flow chart describing the method used to align
the wall surface representation of the WSGP to the body
orientation. The process begins at step 101 where the monitoring
catheter 14 with a set of passive electrodes 48 is inserted into
heart 16 chamber and a pair of surface electrodes 119 are attached
at a known position on the body 12. The process begins cycling at
step 102 where the signal generator 54 generates a signal across
the skin electrode 89 and skin electrode 115. At step 103 the
voltage created by the signal generator 54 is measured from passive
electrode 48 by the high pass section 56 of the signal conditioner
50 by using the information from block 110 which includes the
frequency and timing of the field generated by the signal generator
54. This voltage information is stored in an array "Y".
[0056] At step 104 a regression analysis is performed which creates
a vector which lines up with the field generated in step 103. This
regression method is the same whether a basket catheter as shown in
FIG. 4 or a balloon catheter as shown in FIG. 3 is used. The
location of each passive electrode 48.is provided to the method by
block 110. This information comes from different sources in each
case however. In the case of a basket catheter 80 these three
dimensional electrode locations come from the WSGP. In the case of
the balloon catheter 94 these three dimensional electrode locations
are known a priori. In each case they are saved in an array "X".
The regression to compute the orientation vector uses the standard
regression equation for the computation of a slope:
b=.SIGMA.xy/.SIGMA.x.sup.2
where "X" is the array of electrode locations, "Y" is the array of
measured voltages and "b" is the orientation vector. If more than
one pair of skin electrodes are used then an orthogonal set of
orientation vectors can be created and any rotation of the
monitoring catheter 14 relative to the body 12 can be detected.
[0057] In step 105 the information on the location of the chamber
walls 125 from the WSGP 109 can be used to create a three
dimensional model of the heart 16 chamber as seen in FIG. 7. By
combining this model with the computed orientation from step 104
and the known location of the skin electrodes 108 this
representation can be shown in a known orientation relative to the
body in step 106. In step 107 a specific orientation such as
typical radiological orientations RAO (right anterior oblique), LAO
(left anterior oblique), or AP (anterior/posterior) can be
presented. By repeatedly showing this view a dynamic representation
can be presented which matches the view shown on a standard
fluoroscopic display. Thus such an image can be presented without
the need for using ionizing radiation.
Wall Electrogram Generation Process
[0058] FIG. 10 is a flow chart describing the wall electrogram
generation process (WEGP). This process begins at block 61 when a
monitoring catheter 14 with an array of passive measurement
electrodes 48 is placed in a heart chamber 16 and deployed. The
process enters a loop at block 63. The frequency of the
interrogation pulses generated by the signal generator 54 is
provided by block 85. With this knowledge the low pass filter
section 58 of the signal conditioner 50 measures the voltage at
frequencies lower than the generated interrogation pulses.
Typically the highest frequency of the biopotentials is 100 Hz but
can be as high as 250 Hz.
[0059] In the case of a basket system as seen in FIG. 4 the
measurements are contact voltages from the chamber wall 125 tissue
contacting the electrodes 84.
[0060] In the case of a balloon system as seen in FIG. 3 the
measurements are measurements of the field generated throughout the
blood volume by the tissue on the chamber wall 125. At step 65, a
model of the array boundary and the chamber wall 125 boundary is
created from the information in block 87. This information includes
the location of the passive electrodes 48 on the array and the
chamber wall 125 locations from the WSGP.
[0061] In the case of a basket system as seen in FIG. 4, the array
boundary and the chamber wall 125 boundary are the same since they
are in contact. The locations are determined in three-dimensional
space of the sites on the chamber wall where potentials are
measured.
[0062] In the case of the balloon system as seen in FIG. 3, the
array boundary and the chamber wall 125 boundary are different.
During step 65, locations are generated in three-dimensional space
of the sites on the chamber wall where potentials are to be
determined.
[0063] At step 66, the potentials are projected on to the sites on
the chamber wall specified in step 65. In the case of a basket
system as seen in FIG. 4, the measured potentials are assigned to
these sites.
[0064] In case of a balloon system as seen in FIG. 3, a three
dimensional technique such as those typically used in field theory
is used to generate a representation of the three dimensional field
gradients in the blood volume of the heart chamber. Two examples of
appropriate techniques are a spherical harmonics solution to
Laplace's equation, and boundary element analysis. A more detailed
description of spherical harmonics is given in the parent
disclosure which is incorporated by reference herein.
[0065] For the boundary element method in the mapping system of the
invention, the voltage is measured at the passive electrodes 48 on
the probe or balloon catheter 94. From the voltage at the
electrodes on the probe and the knowledge that the probe is
nonconducting, the voltage and normal current at a previously
selected set of nodes on the endocardial surface 125 are determined
by the boundary element method in the following manner.
[0066] It is known that the voltage in the blood pool between the
probe and the endocardium satisfies Laplace's equation that states
that the net current flow across any specific boundary is zero. To
find the voltage and/or normal current on the endocardium, one must
find the solution of Laplace's equation in the blood pool and
calculate the values of this solution on the endocardium. Standard
finite element and finite difference methods can be used to find
the solution to Laplace's equation, but they have large
computational overhead for generating and keeping track of a
three-dimensional grid in the whole blood pool. In the mapping
system of the invention, Laplace's equation is solved by the
boundary element method, a specialized finite element method that
permits one to restrict the calculations to the two-dimensional
probe and endocardial surfaces (and not have to deal with
calculations over the blood pool between these two surfaces). In
order to create an accurate map of the endocardial voltage and/or
normal current based on the voltage information from a limited
number of electrodes on the probe, the system uses a higher-order
version of the boundary element method. This system currently uses
bicubic splines to represent the probe and endocardial surfaces and
bilinear elements and bicubic splines to represent the voltage and
the normal current on these surfaces.
[0067] The boundary element method consists of creating and solving
a set of linear equations for the voltage and the normal current on
the endocardium based on the voltage measurements at the electrodes
on the probe. Each of the elements in the matrices that are
involved in this set consists of two-dimensional integrals, which
are calculated by numerical and analytical integration.
[0068] Using Laplace's equation with data given on the probe is a
so-called "ill-posed" problem. For such problems, all solution
procedures, including the boundary element method, are ill
conditioned, that is, small errors in the measured voltage on the
probe surface can result in large errors in the calculated voltage
and/or normal current on the endocardium. To minimize the errors on
the endocardium, options for regularization or constraints have
been included in the software code. For example: the user can
choose parameters that cause the code to add equations for known or
expected values of the voltage and/or normal current on the
endocardium. This capability is often but not exclusively used to
add equations that take into account the voltage and/or normal
current of the map of the previous instant(s) in time (the previous
"frame(s)"). This process uses historical data from the previous
frame to constrain the values subsequently computed.
[0069] The solution of the set of the boundary element equations
and regularizing equations (if any) is normally accomplished by
singular value decomposition but there is an option to solve the
linear system by decomposition (Gaussian elimination) or direct or
inherent methods. When singular value decomposition is used, there
is an option to turn off the influence of high-frequency errors
(that is, do a type of regularization) by setting various small
singular values to zero, the result of which can be an increase in
the accuracy of the calculated voltage and normal current on the
endocardium.
[0070] In block 67, a large number of points are calculated on the
three-dimensional chamber surface 125. In the case of a basket
catheter as seen in FIG. 4, this is done through interpolation
using bilinear or bicubic splines. In the case of a balloon
catheter as seen in FIG. 3, this can be done either by using the
model, such as the boundary element method or spherical harmonics
to generate more points. Alternatively, bilinear or bicubic splines
can be used to interpolate between a smaller number of points.
[0071] In block 69 a representation of the electrical potentials on
the surface 125 are used to display the patterns. These types of
displays include color maps, maps of iso-potential lines, maps of
potential gradient lines and others. The electro-physiologic
information is reconstructed on the dynamic wall surface 125. In
general the measured electrical activity is positioned by the WSGP
at the exact location which gives rise to the activity. The high
resolution of the system creates an enormous amount of information
to display. Several techniques may be used to display this
information to the physician. For example the electrogram data can
be shown in false color gray-scale on a two dimensional wall
surface representation. In this instance areas of equal potential
areas are shown in the same color. Also a vectorized display of
data can be shown on a wire grid as shown in FIG. 11 where the
distance between any two dots typified by dot pair 91 and 93
represent a fixed potential difference. The more active electrical
areas show clusters of dots. In a dynamic display the dot movement
highlights areas of greater electrical activity. In FIG. 12
gradient lines typified by line 135 represent the change in
potential over the chamber wall surface. Those areas with the
largest change per unit area have the longest gradient lines
oriented in the direction of steepest change. In FIG. 13
iso-potential lines typified by line 95 represent equal electrical
potential. In this representation the closeness of lines represents
more active electrical areas.
Site Electrogram Generation Process
[0072] FIG. 14 is a flow chart of the site electrogram generation
process (SEGP). This process is used to extract and display a time
series representation of the electrical activity at a physician
selected site. FIG. 13 shows a site 97 that has been selected and a
time series electrogram 99 is shown on the display device 36 along
with the dynamic wall representation. Returning to FIG. 14 this
process begins at block 76 when a catheter with an array with both
passive measurement electrodes 48 and active electrodes 52 is
placed in a heart chamber and deployed. The process enters a loop
at 78. The inputs to the method include the wall locations from
block 37. Then the wall electrogram generator 35 provides the
electrical potentials on this surface at 79. The user will use the
display 36 to determine a location of interest in block 33 which
will then be marked on the display device 36 at step 81. The
voltage from this location will be collected at block 83. This
voltage will be plotted in a wave-form representation 99 in block
31. The loop continues at this point at a rate sufficient to
display all of the frequencies of such a time series electrogram
99, at least 300 points per second.
[0073] The false color and vectorized display images may direct the
physician to specific sites on the endocardial surface for further
exploration. The system may allow the physician to "zoom" in on an
area to show the electrical activity in greater detail. Also the
physician may select a site on the endocardial wall 125 and display
a traditional time series electrogram 99 originating at that
site.
Movable Electrode Location Process
[0074] FIG. 15 is a flow-chart of the movable electrode location
process (MELP). It begins at block 11 when a catheter with an array
of passive measurement electrodes 48 and active electrodes 52 is
placed in a heart 16 chamber and deployed. At block 13 a second
catheter 18 with at least one electrode is introduced into the same
chamber. The process enters a loop at block 15 where the signal
generator 54 generates a carrier current between the movable
location electrode 68 and an active electrode 52. At block 17 the
high pass section 56 of signal conditioner 50, using the frequency
and timing information of the location signal from block 29,
produces measured voltages from the passive measurement electrodes
48. At block 19 the information from block 27 is used to determine
the location of the electrode 68 where the location current is
generated. This information includes the strength of the generated
location current, the impedances of blood and tissue, the location
of the active electrode 52 in use and the location of all the
passive measurement electrodes 48. One method for using this
information would entail performing a three dimensional
triangulation of the point source location signal using four
orthogonal passive electrode 48 sites. The implementation of step
19 is the same both for the case of a basket system as seen in FIG.
3 and for the case of a balloon system as seen in FIG. 4. In this
preferred implementation, two data sets are acquired closely spaced
in time such that they are effectively instantaneous relative to
the speed of cardiac mechanical activity. Alternatively, the data
sets could be acquired simultaneously, by driving signals at two
different frequencies, and separating them electronically by well
known filtering means.
[0075] The first data set is acquired by driving the current
carrier from the location electrode 68 to a first sink or active
electrode as typified by electrode 98. This electrode is at a known
location on the body of the monitoring catheter 14 relative to the
array of passive electrodes 48. The location of this first sink
electrode is ideally displaced distally from the centroid 127 of
the array of electrodes by at least 25 millimeters. A second data
set is then acquired by driving the current from the location
electrode 68 to a second active electrode 92, located ideally at
least 25 millimeters proximally from the centroid 127 of the array
of electrodes.
[0076] The location algorithm is performed by minimizing the
following equation:
i = 1 n ( k ( R -> i - R -> L ) 0.5 - v pi 1 - b 1 - k ( R
-> i - R -> S 1 ) 0.5 ) 2 + ( k ( R -> i - R -> L ) 0.5
- v pi 2 - b 2 - k ( R -> i - R -> S 2 ) 0.5 ) 2
##EQU00002##
Where n is the number of array electrodes, where k, b.sub.1 and
b.sub.2 are fitting parameters, V.sub.pi are the potentials
measured from each i.sup.th electrode 72, R.sub.i is a vector from
the origin (centroid of the array of electrodes 96) to the i.sup.th
probe electrode 72, R.sub.L is the "location vector", or three
dimensional location to be solved for in the minimization, and
R.sub.s1, R.sub.s2 are the location vectors of the active sink
electrodes (eg. 92 and 98) which are known at locations on the axis
of the array of passive electrodes 48.
[0077] Additional data sets could be incorporated, following the
same logic as above. Each additional squared parenthetical term
requires the probe data set Vpi, another `b` fitting term, and the
particular active sink electrode 52 vector R.sub.s used during the
acquisition of that data set. If the sink electrode 52 is far
enough away, for example using a right leg patch electrode, the
fourth term in the squared expression for that data set may be
deleted as R.sub.s becomes very large.
[0078] It is also noted that the method does not require two data
sets. The first squared expression in the above expression
(requiring only data set V.sub.pi1) may be sufficiently
accurate.
[0079] The non-linear least squares minimization may be performed
on the above summation by any of several well-known methods. The
Levenberg-Marquardt method has been used in practice to accomplish
this with efficient and robust results. Nominal values for k and b
are 70 and 0 respectively, when normalizing the potential values
obtained as if the current source were 1 ampere. The number of
parameters in the minimization for the above expression are six: k,
b.sub.1, b.sub.2, and the x, y, and z coordinates of vector R.sub.L
(assuming a Cartesian coordinate system with origin at the center
of the array of electrodes 96).
[0080] At step 21 a model of the heart 16 chamber wall is generated
from the information provided from the WSGP 25. Such a model can be
represented on a display 36 in a manner typified in FIG. 6. Once
this surface is rendered, within this surface a second figure
representing the distal end of the monitoring catheter 14 can be
presented. In this way, the full three dimensional geometry of the
chamber and the array catheter can be presented.
[0081] In step 23 this geometry is updated repeatedly to provide a
dynamic view of the chamber, the monitoring catheter 18, along with
a representation of the distal end 24 of the therapy catheter 18.
If this is then combined with the electrical potentials generated
by the WEGP, the therapy catheter can be moved to an electrical
site of interest represented by a point in three dimensional
space.
Calibration Process
[0082] Calibration of the system to insure that physical dimensions
are accurately scaled is not a necessity for use of the system in a
diagnostic or therapeutic setting. However, the availability of
heart geometry in real time can permit various hemodynamic
measurements to be made and displayed to the physician as well.
These measurements include systolic time intervals, stroke volume
and cardiac output. Calibration, where desired, requires at least
two electrodes 60 and 62 a known distance apart placed along the
inner-surface of the heart chamber 16, as shown in FIG. 3. In
general the two electrode sites will each be coupled to the
location signal generator 54. The MELP of FIG. 15 can be calibrated
by scaling the calculations 50 the distance between computed
locations match the known distance apart of the two electrodes 60
and 62. Since the electrodes 60 and 62 are positioned on the
chamber wall 125, the WSGP of FIG. 5 can be calibrated by scaling
the distance measured by the WSGP in the direction of electrodes 60
and 62 to the calibrated distances measured by MELP. Finally, since
the electrodes are contacting the chamber wall and providing
electrograms, the WEGP of FIG. 10 and SEGP of FIG. 14 can be
calibrated to those measurements by computing the voltages at the
same locations on the chamber wall 125 where electrodes 60 and 62
are located. These computed voltages can then be scaled to match
the physically measured voltages from electrodes 60 and 62.
Therapy Catheter
[0083] FIG. 16 is a schematic diagram of the therapy catheter
system. The therapy catheter 18 has both a distal end 24 and a
proximal end 26. A handle 163 is on the proximal end 26 which
allows the user to manipulate the distal end 24 and position it in
the heart 16. Referring to FIG. 1, this handle also permits the
therapy catheter 18 to connect to the interface system 28 of the
electrophysiologic apparatus 10 through the cable 32. The location
current is generated by the signal generator 54 through the switch
59 and subsequently through the wire 177 of cable 32 which is
connected directly to the locator electrode 68. The therapy
catheter system also includes a therapy generator 38 which is
connected to the therapy catheter handle 163 via therapy supply
line 161. The therapy supply line 161 extends through the handle
163, through the catheter body 64, to the therapy deployment
apparatus 60 at the distal end 24 of the catheter. The locator
electrode 68 is in close proximity to the therapy deployment
apparatus 60 in order to determine its location within the heart
16.
[0084] FIG. 17 shows an embodiment of the therapy catheter 18 using
laser energy to supply the therapy. This laser catheter 165
includes the location wire 177 which connects the interface system
28 to the locator electrode 68 at the catheter's distal end 24. In
this instance the therapy supply line 161 is a fiber optic cable
167 and the therapy deployment apparatus 60 is a fiber optic
terminator 169 which directs the laser energy to the site of
therapy delivery.
[0085] FIG. 18 shows an embodiment of the therapy catheter 18 using
microwave energy to supply the therapy. This microwave catheter 171
includes the location wire 177 which connects the interface system
28 to the locator electrode 68 at the catheter's distal end 24. In
this instance the therapy supply line 161 is a microwave wave guide
173 and the therapy deployment apparatus 60 is a microwave emitter
175 which directs the microwave energy to the site of therapy
delivery.
[0086] FIG. 19 shows an embodiment of the therapy catheter 18 using
a chemical to supply the therapy. This chemical deliver catheter
181 includes the location wire 177 which connects the interface
system 28 to the locator electrode 68 at the catheter's distal end
24. In this instance the therapy supply line 161 is a chemical
filled lumen 183. This lumen extends to the distal end 24 of the
chemical delivery catheter 181 where a needle 185 is used to infuse
the chemical into the heart chamber wall 125. During introduction
of the chemical delivery catheter 181 into the heart chamber the
needle 185 is withdrawn into the catheter body through withdrawal
action 187. Once the location of the distal end 24 is determined to
be at the site of interest the chemical delivery needle 185 can be
deployed through the reverse of withdrawal action 187. Potential
chemicals to be used in the therapeutic delivery process include
formaldehyde and alcohol.
[0087] Each of the therapy catheters 18 shown in FIG. 17 through
FIG. 19 as well as the radio frequency catheter shown in FIG. 2 can
be miniaturized and inserted into the coronary arterial tree. The
location signal generated at locator electrode 68 can still be
sensed by the passive electrodes 48 even though the signal is
coming from the epicardium of the heart 16 rather than from within
the heart chamber. Thus the movable electrode location process of
FIG. 15 can be used in this instance to help determine the location
of the distal end 24 of the therapy catheter 18 in the coronary
arterial tree and whether it is close to a site of abnormal
electrical activity. Assuming that a site of ischemia will commonly
be a site of abnormal electrical activity, the MELP will also
enable more rapid location of potential sites for angioplasty.
[0088] FIG. 20 shows an embodiment of the therapy catheter 18 using
balloon inflation to supply the therapy. This angioplasty catheter
191 includes the location wire 177 which connects the interface
system 28 to the locator electrode 68 at the catheter's distal end
24. In this instance the therapy supply line 161 is an inflation
media supply lumen 193 and the therapy deployment apparatus 60 is
an angioplasty balloon 195. In use, a site of interest would be
determined after viewing the wall electrogram generated by the WEGP
of FIG. 10. Next the angioplasty therapy catheter 191 would be
positioned in the coronary arterial tree and its position
determined relative to the site of interest. Next, when the distal
end 24 of the angioplasty catheter 191 was at the proper location
the balloon 195 would be deployed to open the artery. Finally, the
electrical activity of the site would be reviewed to determine
whether the underlying tissue 125 was now receiving a proper blood
supply and thus was no longer electrically abnormal.
* * * * *