A multi-variate predictability framework to assess invasive cardiac activity and interactions during atrial fibrillation

Objective: This study introduces a predictability framework based on the concept of Granger causality (GC), in order to analyze the activity and interactions between different intracardiac sites during atrial fibrillation (AF). Methods: GC-based interactions were studied using a three-electrode analysis scheme with multi-variate autoregressive models of the involved preprocessed intracardiac signals. The method was evaluated in different scenarios covering simulations of complex atrial activity as well as endocardial signals acquired from patients. Results: The results illustrate the ability of the method to determine atrial rhythm complexity and to track and map propagation during AF. Conclusion: The proposed framework provides information on the underlying activation and regularity, does not require activation detection or postprocessing algorithms and is applicable for the analysis of any multielectrode catheter. Significance: The proposed framework can potentially help to guide catheter ablation interventions of AF

Impact of atherosclerotic plaque composition on coronary microembolization during percutaneous coronary interventions

BACKGROUND: Cardiac marker release after percutaneous coronary interventions (PCI) reflects myocardial necrosis which is usually the result of periprocedural (micro)embolization of atherothrombotic debris and associated with impaired left ventricular function and adverse outcome. METHODS: In this prospective study, we examined 55 patients treated by direct stenting of single de-novo lesions to assess the relationship between plaque composition, as determined by preinterventional intravascular ultrasound (IVUS) with radiofrequency data (IVUS-RF) analysis (so-called Virtual Histology) versus coronary microembolization, as determined by serial measurement of cardiac markers. IVUS was performed with an electronic system and 20-MHz IVUS catheters. Serum creatine kinase (CK) and cardiac troponin I (CTnI) were determined before PCI and after 6, 12, and 24 hours. RESULTS: Plaques had a volume of 99 +/- 63 mm(3) and were composed of fibrous (61 +/- 9%) and fibro-fatty tissue (27 +/- 12%), dense calcium (4 +/- 3%), and necrotic core (NC) (8 +/- 6%). NC volume per se, volume per 10 mm of segment length, and volume % were correlated (r = 0.64, 0.66, and 0.52 respectively; all P 10.8 mm(3)) had a particularly high increase in markers (P < 0.001). In contrast, total plaque volume and plaque components other than NC had no relation with cardiac markers (ns). CONCLUSIONS: Patients with large NC in culprit lesions may experience more myocardial injury from peri-interventional microembolization. IVUS-RF assessment before PCI has the potential to identify lesions at particular high risk which may help to tailor PCI

OCT for the Identification of Vulnerable Plaque in Acute Coronary Syndrome

AbstractAfter 2 decades of development and use in interventional cardiology research, optical coherence tomography (OCT) has now become a core intravascular imaging modality in clinical practice. Its unprecedented spatial resolution allows visualization of the key components of the atherosclerotic plaque that appear to confer “vulnerability” to rupture—namely the thickness of the fibrous cap, size of the necrotic core, and the presence of macrophages. The utility of OCT in the evaluation of plaque composition can provide insights into the pathophysiology of acute coronary syndrome and the healing that occurs thereafter. A brief summary of the principles of OCT technology and a comparison with other intravascular imaging modalities is presented. The review focuses on the current evidence for the use of OCT in identifying vulnerable plaques in acute coronary syndrome and its limitations

Rotor detection in atrial fibrillation

Atrial fibrillation (AF) is one of the most common arrhythmias in the clinical practice. Catheter ablation method was developed more than 20 years ago as an approach to terminate this rhythm disorder. Since its outbreak, this technique obtained international acceptance among the clinicians, and technological advances in this field increased its safety while reducing the procedure duration. However, there is no perfect AF treatment procedure described yet, since the understanding of the driving and sustaining AF mechanisms remains poor, with pulmonary vein isolation being the most common ablation strategy. Several theories try to explain the initiating and maintenance mechanisms of the AF, ranging from multiple wavelets propagating at random in the atria to ectopic focus fired from the pulmonary veins. Alternatively, spatiotemporal stable sources (rotors) have been proposed as the maintenance mechanism of AF. The most representative characteristic of a rotor is the re-entry spiral-like propagation pattern that the electrical wavefront exhibits as it propagates. The assessment of its presence and posterior ablation of the sites where rotors anchor might improve the success of AF ablation. Technical solutions emerged focusing on the rotor assessment problem. They base their methods on the reconstruction of the atrial activity using multi-electrode catheters and phase maps, in which they detect singularity points, the sites where rotors spin. The ablation of these sites showed promising results, but the difficulty to reproduce the results by other authors increased the controversy on this technique. In this Thesis we address the rotor detection problem in the time domain as opposed to current methods based on the phase domain of the signals. We develop a new method to identify local activation times (LATs) in unipolar electrograms (EGMs) recorded with multi-electrode catheters. We propose a new filtering scheme to enhance the activation component of the EGM while considerably reducing the presence of noise in the signal. This signal processing method reects the real activity of the tissue in contact with the electrode. It opposes the Hilbert transform (HT) used to extract the phase component of the signal, that do not correlate well with the temporal activations. With the EGM LATs we perform a spatial interpolation translating the electrode positions of the catheter into a regular 2D grid. This way we generate isochronal maps revealing the electrical wavefronts in the atrium. What is more, this step guarantees compatibility with multi-electrode catheters, not restricting the method to specific models. With the isochronal maps, we develop a new rotor detection algorithm based on the optical flow of the wavefront dynamics, and a rotation pattern match. Additionally, we develop a new method based on Granger's causality to estimate the directionality of the wavefronts, that provides an additional indicator for rotational patterns. We validate the methods using in silico and real AF signals. We implement these methods into a system that can assess the presence of rotational activation sites in the atrium. Our system is able to operate in realtime with multi-electrode catheters of different topologies in contact with the atrial wall. We integrate signal acquisition and processing in our system, allowing direct acquisition of the signals without requiring signal exportation from a recording device, which delays the clinical procedure. We address the computational time handicap by designing parallelizable signal processing steps. We employ multi-core processors and GPU based code to distribute the computations and minimize the processing times, achieving near real-time results. The results presented in this Thesis provide a new technical solution to detect the presence of rotational activity (rotors) in AF patients in real-time. Although the presence of rotational activity is itself controversial, we individually validate each of the steps of the procedure and obtain evidence of the presence of rotational activity in AF patients. The system has been also found useful to characterize the atrial sites where rotational activity was found in terms of spatial and voltage distribution. The results of this Thesis provide a new alternative to existing methods based on phase analysis and open a new research line in the detection of the mechanisms sustaining AF.La fibrilación auricular (FA) es una de las arritmias más comunes en la práctica clínica. Para tratar de terminar esta fibrilación en pacientes se desarrollo el método de ablación con catéter hace ya más de 20 años. Desde su puesta en marchar esta técnica ha ido ganando aceptación internacional por parte de la comunidad médica, y los avances tecnológicos desarrollados en esta línea han aumentado la seguridad y disminuido la duración del procedimiento. Sin embargo todavía no existe un tratamiento perfecto para tratar la FA, debido en parte a que el conocimiento de los mecanismos que inician y sostienen la fibrilación son limitados. Como método de ablación el aislamiento de las venas pulmonares prevalece como el más empleado en la práctica, pero se hace necesario el desarrollo de nuevos métodos para hacer frente al problema de la FA. Distintas teorías tratan de explicar los mecanismos de inicio y mantenimiento de la FA, desde unas basadas en la propagación de múltiples frentes de onda aleatorios en las aurículas, hasta las que basan su hipótesis en focos ectópicos disparados principalmente desde las venas pulmonares, entre otras teorías. Recientemente, una de estas teorías basada en fuentes espacio-temporalmente estables (rotores) se propuso como mecanismo de mantenimiento de la FA. La característica más representativa de un rotor es su patrón de reentrada en forma de espiral que realiza el frente de onda eléctrico en el tejido auricular. La evaluación de la presencia de rotores y la posterior de los sitios en los que se encuentren puede mejorar el éxito de la ablación en pacientes con FA. En vista de esta tendencia por la búsqueda de rotores se desarrollaron soluciones técnicas para la evaluación de zonas que alberguen actividad rotacional. Sus técnicas se basan en la reconstrucción de la actividad auricular empleando catéteres multi-electrodo y detectando puntos de singularidad en mapas de phase, esto es la posición en la aurícula en la que el rotor gira. La ablación de estos puntos mostró resultados prometedores, pero la dificultad por replicar los resultados por parte de otros autores incremento la controversia con respecto a esta técnica. En esta Tesis abordamos el problema de la detección de rotores en el dominio del tiempo, oponiéndonos a las técnicas actuales basadas en el dominio de la fase de las señales. Para ello hemos desarrollado un nuevo para identificar tiempos de activación local en electrogramas unipolares registrados con catéteres multi-electrodo. Para ello proponemos un nuevo método de filtrado para realzar la activación del electrograma reduciendo considerablemente la presencia de ruido en la señal. Con este procesado de la señal extraemos y reflejamos la actividad real del tejido en contacto con el electrodo. Al mismo tiempo nos oponemos a la transformada de Hilbert empleada para calcular la componente de fase de la señal, que es sabido no tiene una buena correlación con las activaciones temporales. Con los electrogramas y los tiempos de activación locales aplicamos una interpolación espacial logrando trasladar la posición de los electrodos en el catéter a una rejilla regular en 2D. Mediante este paso generamos mapas isócronos que reconstruyen los frentes de onda eléctricos que se propagan en la aurícula. Además, la interpolación nos permite garantizar una compatibilidad con otros catéteres multi-electrodos, no restringiendo el uso de nuestro método a modelos específicos. Con los mapas isócronos hemos desarrollado un nuevo algoritmo de detección de rotores basado en el flujo óptico de la dinámica del frente de onda que hacemos coincidir con un patrón de rotación. Adicionalmente hemos desarrollado un nuevo método basad en la causalidad propuesta por Granger para estimar la dirección de los frentes de propagación, que sirve como indicador adicional para encontrar patrones de activación rotacional. Hemos validado todos y cada uno de los métodos empleando señales in silico así como señales reales de pacientes con FA. En la parte de aplicación, hemos implementado los métodos en un sistema que evalúa la presencia de actividad rotacional en la aurícula. Nuestro sistema opera en tiempo real siendo compatible con catéteres multi-electrodo de diferentes topologías asegurando contacto con la pared auricular. Para evitar sobreextender el procedimiento clínico, hemos integrado las partes de adquisición y procesado de señal conjuntamente, lo que nos permite un registro de las señales directo sin viii necesidad de requerir un exportado adicional desde un sistema de registro. Para hacer frente al objetivo de presentar los resultados en tiempo real hemos diseñado todos los pasos de procesado de señal para que sean paralelizables. Para ello empleamos procesadores multinúcleo y código para ejecutar en tarjetas gráficas (GPUs) para distribuir las computaciones y minimizar el tiempo de procesado, logrando resultados en quasi tiempo real. Hemos empleado el sistema de detección de rotores para estudiar la distribución espacial y de voltaje de los sitios que muestran actividad rotacional en la aurícula. Aunque la presencia de actividad rotacional es en sí misma controvertida, hemos validad individualmente todos y cada uno de los pasos descritos obteniendo evidencia de la presencia de actividad rotacional en pacientes con FA.Programa Oficial de Doctorado en Multimedia y ComunicacionesPresidente: Pablo Laguna Lasaosa.- Secretario: Pablo Martínez Olmos.- Vocal: Batiste Andreu Martínez Climen

Focal Spot, Winter 1984/85

https://digitalcommons.wustl.edu/focal_spot_archives/1039/thumbnail.jp

From Molecules to the Masses : Visual Exploration, Analysis, and Communication of Human Physiology

Det overordnede målet med denne avhandlingen er tverrfaglig anvendelse av medisinske illustrasjons- og visualiseringsteknikker for å utforske, analysere og formidle aspekter ved fysiologi til publikum med ulik faglig nivå og bakgrunn. Fysiologi beskriver de biologiske prosessene som skjer i levende vesener over tid. Vitenskapen om fysiologi er kompleks, men samtidig kritisk for vår forståelse av hvordan levende organismer fungerer. Fysiologi dekker en stor bredde romlig-temporale skalaer og fordrer behovet for å kombinere og bygge bro mellom basalfagene (biologi, fysikk og kjemi) og medisin. De senere årene har det vært en eksplosjon av nye, avanserte eksperimentelle metoder for å detektere og karakterisere fysiologiske data. Volumet og kompleksiteten til fysiologiske data krever effektive strategier for visualisering for å komplementere dagens standard analyser. Hvilke tilnærminger som benyttes i visualiseringen må nøye balanseres og tilpasses formålet med bruken av dataene, enten dette er for å utforske dataene, analysere disse eller kommunisere og presentere dem. Arbeidet i denne avhandlingen bidrar med ny kunnskap innen teori, empiri, anvendelse og reproduserbarhet av visualiseringsmetoder innen fysiologi. Først i avhandlingen er en rapport som oppsummerer og utforsker dagens kunnskap om muligheter og utfordringer for visualisering innen fysiologi. Motivasjonen for arbeidet er behovet forskere innen visualiseringsfeltet, og forskere i ulike anvendelsesområder, har for en sammensatt oversikt over flerskala visualiseringsoppgaver og teknikker. Ved å bruke søk over et stort spekter av metodiske tilnærminger, er dette den første rapporten i sitt slag som kartlegger visualiseringsmulighetene innen fysiologi. I rapporten er faglitteraturen oppsummert slik at det skal være enkelt å gjøre oppslag innen ulike tema i rom-og-tid-skalaen, samtidig som litteraturen er delt inn i de tre høynivå visualiseringsoppgavene data utforsking, analyse og kommunikasjon. Dette danner et enkelt grunnlag for å navigere i litteraturen i feltet og slik danner rapporten et godt grunnlag for diskusjon og forskningsmuligheter innen feltet visualisering og fysiologi. Basert på arbeidet med rapporten var det særlig to områder som det er ønskelig for oss å fortsette å utforske: (1) utforskende analyse av mangefasetterte fysiologidata for ekspertbrukere, og (2) kommunikasjon av data til både eksperter og ikke-eksperter. Arbeidet vårt av mangefasetterte fysiologidata er oppsummert i to studier i avhandlingen. Hver studie omhandler prosesser som foregår på forskjellige romlig-temporale skalaer og inneholder konkrete eksempler på anvendelse av metodene vurdert av eksperter i feltet. I den første av de to studiene undersøkes konsentrasjonen av molekylære substanser (metabolitter) ut fra data innsamlet med magnetisk resonansspektroskopi (MRS), en avansert biokjemisk teknikk som brukes til å identifisere metabolske forbindelser i levende vev. Selv om MRS kan ha svært høy sensitivitet og spesifisitet i medisinske anvendelser, er analyseresultatene fra denne modaliteten abstrakte og vanskelige å forstå også for medisinskfaglige eksperter i feltet. Vår designstudie som undersøkte oppgavene og kravene til ekspertutforskende analyse av disse dataene førte til utviklingen av SpectraMosaic. Dette er en ny applikasjon som gjør det mulig for domeneeksperter å analysere konsentrasjonen av metabolitter normalisert for en hel kohort, eller etter prøveregion, individ, opptaksdato, eller status på hjernens aktivitetsnivå ved undersøkelsestidspunktet. I den andre studien foreslås en metode for å utføre utforskende analyser av flerdimensjonale fysiologiske data i motsatt ende av den romlig-temporale skalaen, nemlig på populasjonsnivå. En effektiv arbeidsflyt for utforskende dataanalyse må kritisk identifisere interessante mønstre og relasjoner, noe som blir stadig vanskeligere når dimensjonaliteten til dataene øker. Selv om dette delvis kan løses med eksisterende reduksjonsteknikker er det alltid en fare for at subtile mønstre kan gå tapt i reduksjonsprosessen. Isteden presenterer vi i studien DimLift, en iterativ dimensjonsreduksjonsteknikk som muliggjør brukeridentifikasjon av interessante mønstre og relasjoner som kan ligge subtilt i et datasett gjennom dimensjonale bunter. Nøkkelen til denne metoden er brukerens evne til å styre dimensjonalitetsreduksjonen slik at den følger brukerens egne undersøkelseslinjer. For videre å undersøke kommunikasjon til eksperter og ikke-eksperter, studeres i neste arbeid utformingen av visualiseringer for kommunikasjon til publikum med ulike nivåer av ekspertnivå. Det er naturlig å forvente at eksperter innen et emne kan ha ulike preferanser og kriterier for å vurdere en visuell kommunikasjon i forhold til et ikke-ekspertpublikum. Dette påvirker hvor effektivt et bilde kan benyttes til å formidle en gitt scenario. Med utgangspunkt i ulike teknikker innen biomedisinsk illustrasjon og visualisering, gjennomførte vi derfor en utforskende studie av kriteriene som publikum bruker når de evaluerer en biomedisinsk prosessvisualisering målrettet for kommunikasjon. Fra denne studien identifiserte vi muligheter for ytterligere konvergens av biomedisinsk illustrasjon og visualiseringsteknikker for mer målrettet visuell kommunikasjonsdesign. Særlig beskrives i større dybde utviklingen av semantisk konsistente retningslinjer for farging av molekylære scener. Hensikten med slike retningslinjer er å heve den vitenskapelige kompetansen til ikke-ekspertpublikum innen molekyler visualisering, som vil være spesielt relevant for kommunikasjon til befolkningen i forbindelse med folkehelseopplysning. All kode og empiriske funn utviklet i arbeidet med denne avhandlingen er åpen kildekode og tilgjengelig for gjenbruk av det vitenskapelige miljøet og offentligheten. Metodene og funnene presentert i denne avhandlingen danner et grunnlag for tverrfaglig biomedisinsk illustrasjon og visualiseringsforskning, og åpner flere muligheter for fortsatt arbeid med visualisering av fysiologiske prosesser.The overarching theme of this thesis is the cross-disciplinary application of medical illustration and visualization techniques to address challenges in exploring, analyzing, and communicating aspects of physiology to audiences with differing expertise. Describing the myriad biological processes occurring in living beings over time, the science of physiology is complex and critical to our understanding of how life works. It spans many spatio-temporal scales to combine and bridge the basic sciences (biology, physics, and chemistry) to medicine. Recent years have seen an explosion of new and finer-grained experimental and acquisition methods to characterize these data. The volume and complexity of these data necessitate effective visualizations to complement standard analysis practice. Visualization approaches must carefully consider and be adaptable to the user's main task, be it exploratory, analytical, or communication-oriented. This thesis contributes to the areas of theory, empirical findings, methods, applications, and research replicability in visualizing physiology. Our contributions open with a state-of-the-art report exploring the challenges and opportunities in visualization for physiology. This report is motivated by the need for visualization researchers, as well as researchers in various application domains, to have a centralized, multiscale overview of visualization tasks and techniques. Using a mixed-methods search approach, this is the first report of its kind to broadly survey the space of visualization for physiology. Our approach to organizing the literature in this report enables the lookup of topics of interest according to spatio-temporal scale. It further subdivides works according to any combination of three high-level visualization tasks: exploration, analysis, and communication. This provides an easily-navigable foundation for discussion and future research opportunities for audience- and task-appropriate visualization for physiology. From this report, we identify two key areas for continued research that begin narrowly and subsequently broaden in scope: (1) exploratory analysis of multifaceted physiology data for expert users, and (2) communication for experts and non-experts alike. Our investigation of multifaceted physiology data takes place over two studies. Each targets processes occurring at different spatio-temporal scales and includes a case study with experts to assess the applicability of our proposed method. At the molecular scale, we examine data from magnetic resonance spectroscopy (MRS), an advanced biochemical technique used to identify small molecules (metabolites) in living tissue that are indicative of metabolic pathway activity. Although highly sensitive and specific, the output of this modality is abstract and difficult to interpret. Our design study investigating the tasks and requirements for expert exploratory analysis of these data led to SpectraMosaic, a novel application enabling domain researchers to analyze any permutation of metabolites in ratio form for an entire cohort, or by sample region, individual, acquisition date, or brain activity status at the time of acquisition. A second approach considers the exploratory analysis of multidimensional physiological data at the opposite end of the spatio-temporal scale: population. An effective exploratory data analysis workflow critically must identify interesting patterns and relationships, which becomes increasingly difficult as data dimensionality increases. Although this can be partially addressed with existing dimensionality reduction techniques, the nature of these techniques means that subtle patterns may be lost in the process. In this approach, we describe DimLift, an iterative dimensionality reduction technique enabling user identification of interesting patterns and relationships that may lie subtly within a dataset through dimensional bundles. Key to this method is the user's ability to steer the dimensionality reduction technique to follow their own lines of inquiry. Our third question considers the crafting of visualizations for communication to audiences with different levels of expertise. It is natural to expect that experts in a topic may have different preferences and criteria to evaluate a visual communication relative to a non-expert audience. This impacts the success of an image in communicating a given scenario. Drawing from diverse techniques in biomedical illustration and visualization, we conducted an exploratory study of the criteria that audiences use when evaluating a biomedical process visualization targeted for communication. From this study, we identify opportunities for further convergence of biomedical illustration and visualization techniques for more targeted visual communication design. One opportunity that we discuss in greater depth is the development of semantically-consistent guidelines for the coloring of molecular scenes. The intent of such guidelines is to elevate the scientific literacy of non-expert audiences in the context of molecular visualization, which is particularly relevant to public health communication. All application code and empirical findings are open-sourced and available for reuse by the scientific community and public. The methods and findings presented in this thesis contribute to a foundation of cross-disciplinary biomedical illustration and visualization research, opening several opportunities for continued work in visualization for physiology.Doktorgradsavhandlin

3D Imaging for Planning of Minimally Invasive Surgical Procedures

Novel minimally invasive surgeries are used for treating cardiovascular diseases and are performed under 2D fluoroscopic guidance with a C-arm system. 3D multidetector row computed tomography (MDCT) images are routinely used for preprocedural planning and postprocedural follow-up. For preprocedural planning, the ability to integrate the MDCT with fluoroscopic images for intraprocedural guidance is of clinical interest. Registration may be facilitated by rotating the C-arm to acquire 3D C-arm CT images. This dissertation describes the development of optimal scan and contrast parameters for C-arm CT in 6 swine. A 5-s ungated C-arm CT acquisition during rapid ventricular pacing with aortic root injection using minimal contrast (36 mL), producing high attenuation (1226), few artifacts (2.0), and measurements similar to those from MDCT (p\u3e0.05) was determined optimal. 3D MDCT and C-arm CT images were registered to overlay the aortic structures from MDCT onto fluoroscopic images for guidance in placing the prosthesis. This work also describes the development of a methodology to develop power equation (R2\u3e0.998) for estimating dose with C-arm CT based on applied tube voltage. Application in 10 patients yielded 5.48┬▒177 2.02 mGy indicating minimal radiation burden. For postprocedural follow-up, combinations of non-contrast, arterial, venous single energy CT (SECT) scans are used to monitor patients at multiple time intervals resulting in high cumulative radiation dose. Employing a single dual-energy CT (DECT) scan to replace two SECT scans can reduce dose. This work focuses on evaluating the feasibility of DECT imaging in the arterial phase. The replacement of non-contrast and arterial SECT acquisitions with one arterial DECT acquisition in 30 patients allowed generation of virtual non-contrast (VNC) images with 31 dose savings. Aortic luminal attenuation in VNC (32┬▒177 2 HU) was similar to true non-contrast images (35┬▒177 4 HU) indicating presence of unattenuated blood. To improve discrimination between c