(Circulation. 1997;96:3672-3680.)
© 1997 American Heart Association, Inc.
Articles |
Hemodynamic Evaluation of the Heart With a Nonfluoroscopic Electromechanical Mapping Technique
From the Cardiovascular System Laboratory, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Correspondence to Shlomo A. Ben-Haim, MD, DSc, Cardiovascular System Laboratory, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron St, PO Box 9649, 31096 Haifa, Israel. E-mail sol{at}biomed.technion.ac.il
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Abstract |
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Background Clinical cardiac volumetric measurement techniques are essential for assessing cardiac performance but produce significant inaccuracies in extrapolation of the volume of a three-dimensional (3D) object from two-dimensional images and lack the ability to associate cardiac electrical and mechanical activities. In this study, we tested the accuracy of cardiac volumetric measurements using a new catheter-based system.
Methods and Results The system uses magnetic technology to accurately locate a special catheter at a frequency of 125 Hz and is currently used in the field of electrophysiology, in which activation maps are superimposed on the 3D geometry of the cardiac chamber. The mapping procedure is based on sequentially acquiring the location of the tip and local electrogram while in contact with the endocardium. The 3D geometry of the chamber is reconstructed in real time, and its volume could be calculated at every time step (8 ms). The volumetric measurements of the system were found to be highly accurate for simple phantoms (mean±SEM deviation, 2.3±1.1%), left ventricular casts (9.6±1.3%), and a dynamic test jig. In addition, left ventricular volumes of 12 swine were measured. Intraobserver and interobserver variabilities were found to be minimal (ejection fraction, 6.5±1.9% and 7.1±2.0%; stroke volume, 4.5±1.0% and 11.3±2.4%). Comparison with the thermodilution method for measuring stroke volume showed an average deviation of 8.1±2.2%. Typical pressure-volume loops were also obtained.
Conclusions The new mapping image provides, for the first time, simultaneous information regarding cardiac mechanics, hemodynamics, and electrical properties. Furthermore, all this information is achieved without the use of fluoroscopy, contrast medium, or complicated image processing.
Key Words: hemodynamics • mechanics • mapping • cardiac volume
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Introduction |
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Volumetric measurements of the chambers of the heart during the different stages of the cardiac cycle are essential for the calculation of specific parameters such as EF and SV. These parameters play a major role in the assessment of patients with a variety of cardiac disorders in the determination of the diagnosis and prognosis and guidance of the management of these patients.1,2 Consequently, a variety of interventional and noninterventional techniques have been developed to measure these volumes, such as echocardiography,3–5 angiocardiography,6,7 isotope-scanning techniques,8,9 computed tomography,10 and MRI.11
Although widely used, currently used clinical methods, such as conventional echocardiography and angiocardiography, are limited by the appreciable inaccuracies that result from extrapolation of the volume of a 3D object from 2D measurements, geometric assumption regarding the shape of the ventricle, position and orientation of the imaging planes, and problematic edge detection. These limitations can result in significant inaccuracies and interobserver variabilities.12,13
Moreover, at present, none of the methods discussed above have the ability to associate between the electrical activity of the heart and its regional and global (volumetric changes) mechanics. With the growing interest in evaluation of the electromechanical coupling of the heart and with new data available regarding the importance of the hemodynamic effect of single-site or multisite pacing, a single method that could combine information on both the cardiac mechanics and electrical functions could provide valuable information for both basic and clinical cardiology.
A new method is presented for in vivo measurement of cardiac volumes using a computerized nonfluoroscopic, catheter-based mapping system that enables the generation of 3D electromechanical maps. The new method is currently used in the field of electrophysiology, in which activation maps are superimposed on the anatomy of the chamber.14,15 The method is based on the use of a new locatable catheter connected to an endocardial mapping and navigation system. The system uses magnetic technology to accurately determine the location and orientation of the catheter and simultaneously records the intracardiac local electrogram from its tip. The 3D geometry of the chamber, from which the volume can be calculated, is reconstructed in real time from the set of endocardial sites that were sampled. The electrophysiological information is color coded and superimposed on the electromechanical map.
The overall objective of the present study was to test the possible role of this new mapping method in evaluating cardiac mechanics. Several stages were undertaken in the process of testing the accuracy of the volumetric measurements of this technique. First, simple objects with known volumes were tested. We then studied the accuracy of the volumetric measurements of LV casts and a custom-built dynamic test jig. Finally, the accuracy and reproducibility of in vivo LV volume measurements were studied.
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Methods |
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System Components
The navigation and mapping system is composed of a miniature passive magnetic field sensor, an external ultralow magnetic field emitter (location pad), and a processing unit (NOGA, Biosense).
The locatable catheter (NAVI-STAR, Cordis-Webster) is similar to a regular electrophysiological 8F deflectable-tip catheter; just proximal to the tip electrode lies the location sensor, totally embedded within the catheter.
The locator pad is located beneath the operating table and generates ultralow magnetic fields (5x10-6 to 5x10-5 T) that contain the information necessary to resolve the location and orientation of the sensor in 6 df. The accuracy of the location capabilities of the system has been tested before and was shown to be 0.16 and 0.73 mm for both in vitro and in vivo studies, respectively.15
Mapping Procedure
Two locatable catheters were introduced into the heart. The
first catheter was inserted into the coronary sinus or RV apex
and served as a reference catheter. A mapping catheter was then
inserted into the mapped chamber. The location of the tip of the
mapping catheter while inside the heart was recorded relative to
the fixed intracardiac reference catheter. This relative location
determination enabled correction for motion of the animal as well as of
the heart within the animal (ie, respiration). Through movement of the
catheter inside the heart, the system continuously analyzed its
end-diastolic location and presented it to the
user, thus enabling navigation without the use of fluoroscopy (Fig 1
).
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The mapping procedure is based on dragging the mapping catheter randomly over the endocardium and sequentially acquiring the location of the tip while in contact with the endocardium. The set of points collected comprises an irregularly sampled data set of location points that are members of the endocardial surface. Chamber geometry is then reconstructed, in real time, using the set of sampled location points. The endocardial surface is presented as a set of polygons (triangles) whose vertices are the sampled points. The LAT at each site is determined as the time difference between a selected fiducial point on the body-surface ECG and the steepest negative intrinsic deflection (minimum dV/dt) in the unipolar intracardiac electrogram (filtered at 0.5 to 400 Hz) recorded from the tip of the mapping catheter. The activation map is color coded and superimposed on the 3D chamber geometry. The center of mass of the reconstructed chamber is automatically calculated from the set of the surface points. The volume of the chamber can be calculated from the sum of the volumes of all tetrahedrons constructed when connecting the center of mass to all triangles forming the reconstructed surface.
At each site, the spatial coordinates of the tip of the catheter were recorded at a frequency of 125 Hz. Hence, the movement of each endocardial site throughout the cardiac cycle could be tracked and analyzed. This enabled the creation of a dynamically beating image of the 3D map from which the volume at each time step (8 ms) could be calculated.
Phantom Volumetric Measurements
To test the accuracy of the reconstruction algorithm, two
objects with known volumes were used: an ellipsoid with a volume of 83
mL and a tennis ball with a volume of 158 mL. Each object was mapped
using up to 70 sampled points, and the volume of the reconstructed
object was compared with the actual volume. The procedure was carried
out five times for each object.
Volumetric Measurements of LV Casts
At this stage, we tested the accuracy of the volumetric
measurements of six casts of the swine LV. The casts were made using
polyester from six postmortem pig hearts. Each cast was mapped using
the locatable catheter, which sequentially acquired points from the
cast surface. The procedure was carried out twice for each cast. The
volume calculated by the system was then compared with the actual
volume of the cast.
Volumetric Measurements of a Specially Built Test Jig
A cylinder-shaped, dynamic test jig was used to study the in
vitro accuracy of the volumetric measurements of the system. The
maximal and minimal volumes and the calculated EF were measured by the
system and compared with the actual volumes of the test jig (maximal
volume, 547.3 mL; minimal volume, 377 mL; SV, 169 mL; EF, 31%).
Animal Studies
Studies were performed on healthy male pigs weighing 30 to 40
kg. The experimental protocol was approved by the Animal Use and Care
Committee of the Technion Faculty of Medicine. All animals were
anesthetized with pentobarbital (30 mg/kg), intubated,
and placed on a Harvard large-animal mechanical respirator. Vascular
access was obtained using vascular cutdown of the jugular veins,
carotid artery, and femoral vein and artery as needed.
In some of the experiments, a 5F solid-state pressure catheter (Millar Instruments) was positioned in the LV for simultaneous pressure recording. A 6F Swan-Ganz thermodilution catheter was advanced from the jugular vein to be positioned in the pulmonary artery.
The protocol used in our studies consisted of taking the first three points using fluoroscopy (two at the base near the aortic and mitral valves and one at the apex). EDV and ESV were calculated as the maximal and minimal volumes throughout the cardiac cycle. SV was calculated as the difference between the EDV and the ESV, and EF was calculated as SV divided by EDV.
Procedure
Twelve animals were studied. The LV was mapped twice during
sinus rhythm by the same observer, who was blinded to the volumetric
results to determine intraobserver variability. After acquisition of
the first map, the user immediately proceeded to acquire the second
map. Points were rejected from the according to the following criteria:
(1) premature beat or a beat after a premature beat, (2) cycle length
that deviated >15% of the average cycle length, (3)
end-diastolic location stability (measured as the
difference in end-diastolic location between two
consecutive beats) that was >2 mm, and (4) LAT stability (defined
as the difference between the LATs of two consecutive beats) that was
>2 ms.
In all pigs, thermodilution cardiac output measurements were acquired with a cardiac output computer in the standard way. Four measurements of cardiac output were obtained and averaged immediately. SV was calculated by dividing the average thermodilution cardiac output by the heart rate and later compared with the calculated SV measured by the new method.
In eight of the pigs studied, the LV was also mapped by a second observer, immediately after completion of the second map, and interobserver variability was determined.
To ensure hemodynamic stability among the three maps that were obtained, both heart rate and SV measurements were monitored throughout the experiment. No animals were eliminated from experimentation because of failure to meet the criteria of the experiments.
Statistical Analysis
Results are reported as mean±SEM. The volumetric measurements
of the casts by the mapping technique were compared with their actual
volume by simple linear regression analysis. In the animal
studies, intraobserver and interobserver variabilities for
determination of EDV, ESV, SV, and EF were calculated as the difference
between the two measurements expressed as a percentage of the average
value. Simple linear regression and r values were used to
study the correlation between SV calculated by the new method and SV
derived from thermodilution measurements. SEE values were calculated in
the usual manner.
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Results |
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Phantom Measurements
Initially, the accuracy of the reconstruction algorithm was tested with known phantoms. As can be seen from Table 1
, the calculated volume of the
reconstructed objects was very close to the actual volume, with the
average deviation being 3.2±0.4% and 2.3±1.1% for the tennis ball
and ellipsoid, respectively. Fig 2
illustrates a typical graph of the volume of the reconstructed object
as a function of the number of points sampled. Both curves reached a
plateau value after 40 to 60 points.
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, Calculated
ellipsoid volume; 
, calculated tennis ball volume.
Volumetric Measurements of LV Casts
At this stage, the volumetric measurements of the reconstructed
images of six LV casts were compared with their actual volumes. The
volumetric measurements highly correlated with the actual volume of the
cast (r=.94, y=0.89x+2.4), with an
average deviation of 9.6±1.3% (Table 2).
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Volumetric Measurements of a Specially Built Test Jig
A custom-built dynamic test jig was used to test the in vitro
accuracy of the new mapping method in determining dynamic volume
changes of a moving object. As can be seen from Table 3, the volume measurements of the system
(maximal and minimal volumes) and the calculated
hemodynamic parameters (SV and EF) were
highly accurate, with an average deviation of 1.4±0.3%, 0.7±0.3%,
6.0±0.4%, and 5.2±0.9% for maximal volume, minimal volume, SV, and
EF, respectively.
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Animal Studies
From our initial experience, we found that after acquisition of
the first three points under fluoroscopic guidance, the remainder of
the mapping procedure could be achieved without the use of fluoroscopy.
We also noted that the mapping procedure could be achieved relatively
quickly, during an average of 15 to 20 minutes. No complications were
noted.
Typical end-diastolic and end-systolic
electromechanical maps of the swine LV are presented in Fig 3. All maps showed a similar activation
pattern during sinus rhythms, with the earliest site of activation (the
red area in the map) located in the superior septum. The activation
then spread to the remainder of the ventricle, with the posterolateral
areas and atrioventricular ring being activated
last (blue and purple areas). Total activation time of this ventricle
was 55 ms. The measured volumes of the LV shown in this figure were
EDV, 61.0 mL; ESV, 33.2 mL; SV, 27.9 mL; and EF, 46%. Fig 4 represents the relation between
the calculated parameters and the number of points sampled
during a typical procedure. Note that the EDV initially increased
significantly and then reached a plateau at 
50 points. In contrast,
the EF reached its final value after 10 points.
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) of the swine LV calculated
by the mapping method as a function of the number of sampled
points.
As described above, the volume of the ventricle could be calculated at
time steps of 8 ms. This enabled continuous determination of the volume
throughout the cardiac cycle (during both the systolic and
diastolic periods). A typical plot of the LV volume during
the cardiac cycle is presented in Fig 5 (top left). Fig 5 (top right) plots the
intraventricular pressure recorded
simultaneously. Using the information presented in
both plots, we could now determine the relationship between pressure
and volume throughout the cardiac cycle. Thus, typical PV curves, as
presented in Fig 5 (bottom), could be obtained.
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Volumetric Measurements
To determine intraobserver and interobserver variabilities, each
heart was mapped three times. In this group, mean EDV and ESV were
51.5±3.2 and 29.6±1.5 mL, respectively, with mean calculated SV and
EF of 21.8±2.3 mL and 42.0±2.0%, respectively. Intraobserver
variability (Table 4) was found to be
relatively small (EDV, 8.0±1.5%; ESV, 12.2±3.1%; SV, 4.5±1.0%;
EF, 6.5±1.9%). Similarly, interobserver variability (Table 5) was relatively small (EDV, 5.9±1.7%;
ESV, 7.5±1.1%; SV, 11.3±2.4%; EF, 7.1±2.0%).
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Comparison with Thermodilution Measurements
SV was calculated with the system as EDV-ESV and later correlated
with SV measurements using the thermodilution technique. The average
error between the two methods was found to be 8.1±2.2%. Fig 6 depicts the linear regression plot. SV
measurements highly correlated with those determined by thermodilution,
with r value of .93, slope of 0.95, y intercept
of -0.12 mL, and SEE of 1.7 mL.
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Discussion |
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We presented the volumetric accuracy data for a new catheter-based method for studying cardiac mechanical, hemodynamic, and electrophysiological functions. The new method samples the location of a special catheter throughout the cardiac cycle at a plurality of endocardial sites and reconstructs a dynamic 3D electromechanical map of the chamber. For the volumetric measurements of the new method to be correct, three conditions must be met: (1) the location of each sampled site must be highly accurate, (2) the number of sites sampled should be adequate to represent the entire chamber, and (3) the reconstruction algorithm should be accurate and reproducible.
To test the accuracy and repeatability of the volumetric measurements of the new method, several steps were undertaken. First, the location accuracy of the new method has been shown in both in vivo and in vitro studies to be <1 mm.15 To further evaluate the precision of the reconstruction algorithm, the accuracy of volumetric measurements of simple phantoms and LV casts was tested and found to be highly accurate (2.3±1.1% and 3.2±0.4% deviation for the phantom study and 9.6±1.3% for the LV cast study). To test the volumetric accuracy of moving objects, we used a cylinder-shaped dynamic test jig. We again found that the volumetric measurements were accurate, with the error ranging from 0.7% to 5%.
The final stage of the study demonstrated that in closed-chest anesthetized pigs, measurement of the LV volumes and hemodynamic parameters could be achieved with excellent reproducibility and a high degree of precision. Both intraobserver and interobserver variabilities were found to be very low. In addition, we observed an excellent correlation with SV measured with thermodilution, which was previously established as an accurate method for determining SV.16 Interestingly, we noted that EF reached stable values after a relatively small number of sites were sampled, whereas absolute volume determination (EDV, ESV) required sampling of more points. This finding is not surprising because both EDV and ESV increase simultaneously when more points are sampled, therefore resulting in a relatively constant determination of EF.
Comparison With Other Imaging Modalities
Quantitative determination of LV volumes has long been a
cornerstone of diagnostic cardiology.
However, common clinical modalities, such as angiographic methods,
echocardiography, and radionuclide angiography, may
produce significant inaccuracies that result from various assumptions
regarding the geometry of the chamber.
Angiocardiographic methods for determining LV may produce significant inaccuracies in determining absolute volumes due to the extrapolation of the volume from 2D images, using geometric assumptions about the ellipsoid nature of the ventricle. Image distortion, varying spatial orientation of the ventricle, and lack of sharpness of ventricular borders may limit the accuracy of these volumetric measurements even further. Several studies have shown that ventriculography tends to overestimate LV volumes.6,12 This may be due to inclusion of areas contained within the trabeculae carneae cordis, to the fact that from any viewing angle the angiographic silhouette creates a maximal area, and to hemodynamic effects of the contrast medium. These limitations may result in lack of precision. For instance, three groups of investigators examined biplane angiographic estimates of SV and compared them with cardiac output measurements based on either the Fick method or the indicator dye dilution method; these different studies reported variation of up to 50%,17 30%,18 and 37%.19
Echocardiography has the advantages of being noninvasive and of not using hazardous radiation. Consequently, various 2D echocardiographic approaches for measuring LV volumes have been described.3,4 Nevertheless, all of these methods make some assumptions regarding the cavity shape and geometric location among the different tomographic imaging planes. Thus, the operator has no means of localizing the image plane in 3D space and must rely solely on image content to position images for volume calculation.
In addition, the in vivo beating heart displays a complicated series of motions in all dimensions in the thoracic cavity during the cardiac cycle. The heart shows variable twist motions, contractions along its long axis, and changes in its relation with the thoracic wall. Because all the techniques described use 2D imaging planes, they face common problems in selecting the appropriate areas or diameters for measurements due to the through-plane motion of the measured area.
The method described in the present study, despite obvious limitations, may bring a unique value to the 3D evaluation of cardiac mechanics because of two conceptual advantages. First, the 3D geometry of the chamber is reconstructed, and thus the volume can be calculated without extrapolation based on geometric assumptions from 2D measurements. Second, the dynamic of the chamber is based on the actual motion of each endocardial point sampled and does not rely on the imaging plane.
The reproducibility of the volumetric measurements of the new method as
quantified by intraobserver variability (SV, 4.5%; EF, 6.5%) and
interobserver variability (SV, 11.3%; EF, 7.1%) was found to be
relatively small and may be comparable to or even better than other
techniques. For example, Baur et al20 compared
intraobserver and interobserver variabilities for
echocardiography and MRI. Intraobserver variability
was relatively low for both techniques (in most instances, <5%),
whereas interobserver variability was considerably larger (10%). In
addition, biological variability, defined as the difference in
volumetric measurements between beats, was the largest source of error
in echocardiography and ranged up to 19% for SV.
This type of variability is decreased in MRI, radionuclide angiography,
and the present technique because the results are averaged over
several beats. Gopal et al21 assessed cardiac
function by 3D echocardiography and compared it
with conventional echocardiography. Interobserver
variability was found to be 10.2%, 26.1%, and 33.3% for 3D
echocardiography, quantitative 2D
echocardiography using an apical biplane summation
of disk algorithm, and visual estimation, respectively. In a similar
study, these authors found an interobserver variability of cardiac
volumes that ranged from 5% to 8% for 3D
echocardiography and 6% to 9% for MRI in normal
subjects.22 Similar results were found in other
studies comparing quantitative 3D echocardiography
with radionuclide angiography23 and
MRI24 and observer variabilities found for
cine–computed tomography10 and radionuclide
angiography.8 The results of the phantom and cast
studies may also be comparable to other
methods.9,25,26 For example, Krebs et
al25 found a correlation (r=.97)
similar to that of our study for measurement of LV cast volume using a
multiplanar transesophageal echo probe, which was
significantly better than that for biplane angiography
(r=.88).
Possible Clinical Advantages and Uses
The new method described in this study may offer a number of
possible clinical advantages. The ability to accurately determine
global hemodynamic parameters, without the
use of fluoroscopy, contrast medium, and image processing, may overcome
some of the shortcomings of angiocardiographic volumetric measurements.
This applies especially to contrast material injection, which can be
hazardous and lead to various complications such as renal failure,
heart failure due to the injection of hyperosmotic solution, allergic
reaction, and so on.27 Moreover, as discussed
above, the ability to present accurate 3D information regarding
cardiac mechanics may overcome some of the limitations of cardiac
hemodynamic evaluation during ventriculography.
The ability to accurately determine LV volume throughout the cardiac cycle simultaneously with intracavitary pressure recordings enables determination of the PV relation (PV loop). In the past 20 years, PV relation analysis has evolved as a dominant approach to estimate cardiac systolic and diastolic abnormalities and is better able to separate chamber function into primary systolic and diastolic functions.28,29 Numerous studies have expanded the usefulness of this approach by defining relations among ventricular PV data, myocardial energetics, and different hemodynamic and pharmacological conditions.30,31
The present study has shown that PV loops can be obtained with the use of the new technique. Nevertheless, these should be regarded as average PV loops because they lack the ability to represent beat-to-beat changes in PV relations due to the sequential nature of the mapping procedure.
The ability to supply valuable information regarding the 3D geometry and mechanics of the chamber, combine PV information, and associate mechanical and electrical data may provide a powerful clinical and research tool. Hence, substantial information may be added with respect to systolic and diastolic function of the LV in both health and disease. Of special interest may be the evaluation of LV diastolic function because it may contribute significantly to LV dysfunction in a large number of patients. Furthermore, by altering ventricular filling times through the introduction of a premature beat or a pause, after fixed pacing periods, Starling's filling effect on LV systolic and diastolic performance might be examined.
Another important application of the new method would be to study the relationship between abnormal electrical activation sequences and the resulting mechanical events. This would allow better understanding of the role of electromechanical coupling in LV performance and the influence of various conductive disorders on cardiac mechanics and may bring a unique value to the evaluation of the effects of pacing.
The use of pacing to alter the hemodynamic state in patients with cardiomyopathies is an emerging technique in cardiovascular medicine.32–34 Dual-chamber pacing changes the temporal relation between the atrial and ventricular contraction and the sequence of ventricular activation, and both factors probably contribute substantially to the hemodynamic benefit achieved with pacing. Such benefit has been shown to occur in patients with hypertrophic obstructive cardiomyopathy,32,33 in which RV apical pacing may reduce the dynamic pressure gradient over the LV outflow tract, probably by altering the activation sequence of the septum. Other preliminary studies have also shown significant improvement in functional class with pacing in patients with dilated cardiomyopathy.34 Recent work may suggest that the position of the pacing electrode and the resulting activation sequence also have important hemodynamic consequences, even in structurally normal hearts.35
Limitations of the New Method
In contrast to conventional volumetric measurement techniques,
which sample the endocardial surface simultaneously and in
a regular sequence, the acquisition of the spatial location of the
endocardial sites that forms the basis for the 3D reconstruction of the
dynamic geometry of the chamber by the new method is sequential and
irregular. Hence, a major prerequisite of the new mapping method is
that the rhythm be monomorphic and stable throughout the mapping
procedure. Also, the fact that the data used in a single reconstruction
are recorded over several heartbeats limits the temporal resolution
of the method.
In addition, because the geometry of the reconstructed image is highly dependent on the sampled sites, failure to collect data points from the entire ventricle will result in underestimation of the true volume. Inability to collect data points from specific areas in the ventricles may result from user variabilities or the mechanical relations between the catheter and the geometry of the chamber.
By introducing filtering criteria for the acceptance of sampled points and sampling the first points with fluoroscopy, we were able to achieve accurate and reproducible measurements with different users. However, with regard to the number of points that must be acquired, speed of acquisition, and volumetric measurement accuracy, the results of the present study should be restricted to the animal model used and still must be verified clinically. For example, in coronary artery disease patients with dilated hearts or aneurysms, additional sampled points may be required to accurately determine LV volumes.
Conclusions
The present study has presented a new method for the
3D assessment of LV mechanical properties. The study has shown through
several stages that the new method is capable of highly accurate and
reproducible determination of LV volumes in both in vitro and in vivo
studies.
The ability to provide accurate information regarding the 3D mechanics of the LV without the use of fluoroscopy, contrast medium, complicated image processing, or extrapolation of the volume from 2D images may provide an important clinical advantage. Furthermore, the ability to accurately combine detailed information regarding the mechanical and electrical functions of the heart in a spatially oriented fashion may provide a useful tool for both basic and clinical cardiology.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This work was supported by a grant from Biosense. We thank Ruth Singer for editing the manuscript.
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Footnotes |
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Dr Ben-Haim is one of the founders of Biosense, Inc.
Received April 28, 1997; revision received July 24, 1997; accepted August 2, 1997.
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