Omnipolar Electrogram (OP-EGM) is a recently proposed technique to characterize myocardial propagation in multi-electrode catheters regardless of the angle between propagation direction and catheter bipolar. This work aims to evaluate the accuracy of atrial propagation parameters obtained with OP-EGM in sinus rhythm (SR) and in different patterns of atrial fibrillation (AF).Real and simulated unipolar electrograms (u-EGMs) were used in this study. For both types of data, conduction velocity was obtained for each clique of 4 neighbour electrodes using OP-EGM. As a reference, conduction velocity was also computed from local activation times (LATs) using a linear propagation model.Analysis of simulated data showed that conduction velocity had good concordance with propagation patterns for both estimations, although the LAT-based errors were lower in most of the cases. When conduction velocity magnitude (CV) was 1 mm/ms, its estimation errors (expressed as mean ± std) calculated with OP-EGM and from LATs were 0.053 ± 0.005 mm/ms and 0.003 ±2.1 ×10-5 mm/ms, respectively, when focus was at 30 mm from the bottom of the tissue slice, while propagation direction angular errors were 6.64 ± 4.3°and 4.35 ± 2.8°. In real data, maps obtained with OP-EGM presented smoother and more coherent patterns than those based on LATs

Alcaine, A.

De Groot, N.M.S.

Houben, R.

Laguna, P.

Martínez, J.P.

Riccio, J.

English

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Characterization of Propagation Patterns With Omnipolar EGM in Epicardial Multi-Electrode Arrays

Repositorio Universidad de Zaragoza

Characterization of Propagation Patterns With Omnipolar EGM in EpicardialMulti-Electrode ArraysJennifer Riccio1, Alejandro Alcaine2,1, Natasja MS de Groot3, Richard Houben4, Pablo Laguna1,2,Juan Pablo Martı́nez1,21 BSICoS, Aragon Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza,Zaragoza, Aragon, Spain2 CIBER en Bioingenierı́a, Biomateriales y Nanomedicina (CIBER-BBN), Madrid, Spain3 Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands4 2BMedical BV, Maastricht, The NetherlandsAbstractOmnipolar Electrogram (OP-EGM) is a recently pro-posed technique to characterize myocardial propagationin multi-electrode catheters regardless of the angle be-tween propagation direction and catheter bipolar. Thiswork aims to evaluate the accuracy of atrial propagationparameters obtained with OP-EGM in sinus rhythm (SR)and in different patterns of atrial fibrillation (AF).Real and simulated unipolar electrograms (u-EGMs)were used in this study. For both types of data, conductionvelocity was obtained for each clique of 4 neighbour elec-trodes using OP-EGM. As a reference, conduction velocitywas also computed from local activation times (LATs) us-ing a linear propagation model.Analysis of simulated data showed that conduction ve-locity had good concordance with propagation patternsfor both estimations, although the LAT-based errors werelower in most of the cases. When conduction velocitymagnitude (CV) was 1 mm/ms, its estimation errors (ex-pressed as mean± std) calculated with OP-EGM and fromLATs were 0.053 ± 0.005 mm/ms and 0.003 ± 2.1×10−5mm/ms, respectively, when focus was at 30 mm from thebottom of the tissue slice, while propagation direction an-gular errors were 6.64 ± 4.3oand 4.35 ± 2.81o. In realdata, maps obtained with OP-EGM presented smootherand more coherent patterns than those based on LATs.1. IntroductionAtrial fibrillation (AF) is the most frequent cardiac ar-rhythmia, involving a high number of hospitalizations. Itshows a significant increase with age and its consequencesinclude heart failure, stroke, dementia and doubled mortal-ity [1].AF is a consequence of an incorrect interaction betweenactivation mechanisms and an anomalous atrial substrate.However these mechanisms, as well as those explainingthe maintenance and recurrence of AF, are not completelyunderstood and not mutually exclusive, thus complicatingthe understanding and treatment of this arrhythmia.One of the possible therapies for AF is catheter ablation.It consists on delivering radiofrequency energy using in-vasive catheters to burn the area of cardiac tissue involvedinto the AF, typically around the pulmonary veins (PV) [1].This isolation avoids the ectopic impulses to spread fromthe PV to the atrium and trigger the arrhythmia. Other ab-lation strategies can be used together with PV isolation,in order to prevent the generation and perpetuation of AF.These strategies require analysis of intracardiac electro-grams (EGMs) features in order to better understand themechanisms responsible for AF and, consequently, to findthe appropriate ablation site (EGM-guided ablation).Due to the complexity and instability of AF, high-density simultaneous EGMs are to be preferred over se-quential EGM analysis. This is made possible thanks tothe development of multipolar diagnostic catheters, hav-ing high spatial resolution and allowing spatial multipro-cessing of the signal. Typically, unipolar EGMs (u-EGMs)and bipolar EGMs (b-EGMs) are used to calculate prop-agation parameters. However, the former are very muchaffected by far-field, while the latter are very dependenton the direction of the activation wavefront with respect tothe orientation of the recording electrodes pair. Omnipo-lar EGM (OP-EGM) is a novel technique which overcomesthe above mentioned limitations, using an estimation of thelocal electric field from the EGMs recorded at each cliqueof nearby electrodes to find propagation parameters [3].In this work, we evaluated the accuracy of conductionvelocity magnitude (CV) and propagation direction ob-tained with the OP-EGM method. We also derived thesame propagation parameters from detected local activa-Computing in Cardiology 2019; Vol 46 Page 1 ISSN: 2325-887X DOI: 10.22489/CinC.2019.340tion times (LATs), using a linear model obtained in theleast squares sense. These evaluations have been per-formed both for clinical and simulated u-EGMs.2. Materials and Methods2.1. Simulated dataIn order to assess the accuracy of the conduction ve-locity estimates obtained from EGMs, a uniform double-layer model of a planar slice of atrial tissue was used tosimulate propagating patterns from a single focus. Tis-sue slices of 18×34×2 mm were simulated for isotropicand anisotropic tissues (with an anisotropy ratio of 0.5,i.e. double velocity in y-axis than in x-axis or vice versa).In a rectangular 8 × 16 high-density multi-electrode ar-ray (MEA) centered in the 2-D tissue slice, with inter-electrode distance of 2 mm, u-EGMs were computed. Foreach set of tissue properties, three different foci were con-sidered for the activation: at 30 mm from the bottom, atthe middle and in the right inferior corner of the slice.Each simulated u-EGM contains one activation (corre-sponding to one sinus beat) and was low-pass filtered with150 Hz cut-off frequency. LATs were estimated as thesamples where the u-EGMs present their maximum neg-ative slope.2.2. Clinical dataEpicardial u-EGMs recorded during sinus rhythm (SR)and AF with a 2-D high-density MEA sensor [2] were alsoused in this study. The MEA was positioned on the epicar-dial wall of the right atrium of a patient undergoing open-chest surgery coming from the Erasmus Medical CenterRotterdam (Rotterdam, The Netherlands). The MEA sen-sor was composed by 128 electrodes 2 mm-apart one fromeach other and organized in an 8x16 rectangular grid. Cor-ner electrodes were not available for recording, so just 124u-EGMs were available for this study. The u-EGMs weresampled at 1 kHz and low-pass filtered with 150 Hz cut-offfrequency. The recording length during SR was 5 s and 10s during AF. LATs manually detected by an expert elec-trophysiologist during SR and AF were available for MEAplaced on the right atrium. The propagation pattern in SRas well as several markedly different AF patterns were se-lected for conduction velocity assessment.2.3. Estimation of conduction velocity withOP-EGM methodCV and propagation direction were calculated usingthe OP-EGM method, which assumes a locally plane andhomogeneous wave travelling within each group of fournearby electrodes within the MEA [3], referred as rectan-gular clique. All the features obtained with this method areconsidered to be located at the center of each clique.The OP-EGM method is based on the relationship be-tween the spatial gradient of the unipolar voltage φ(t) andthe electric field E(t) at the extracellular-myocardial inter-face: E(t) = -∇φ(t). A 3-D right-handed omnipolar co-ordinate system, defined by the myocardial surface normal−→n , propagation direction −→a and wavecrest direction −→w ofthe voltage wave, is considered. Therefore, at each point ofthe surface, E(t) has got the following three components,respectively: En(t), Ea(t) and Ew(t). Since we are con-sidering in this study a 2-D arrangement of electrodes, wecan only estimate E(t) in the −→a - −→w plane.For each clique of four electrodes, six different b-EGMscan be computed. From these bipolar signals, the elec-tric field at the center of the clique E(t) can be estimatedusing least squares. Afterwards, under the assumption ofa plane wave propagation in the tissue within the clique,Ew(t) ≈ 0, and the propagation direction −→a can be esti-mated by finding the direction which maximizes the cross-correlation ρφ′,Ea between the first temporal derivative ofthe unipolar voltage (φ′(t) = ∂φ(t)/∂t) and the electricfield in that direction Ea(t) = E(t)−→a , with CV theoret-ically being the proportionality factor between φ′(t) andEa(t). In [3] and [4] CV is estimated by calculating theratio of peak-to-peak values of φ′(t) and Ea(t). In thiswork we proposed a slightly different approach to estimatethe CV more robustly, computing it as the ratio of standarddeviations (SD) of φ′(t) and Ea(t).CV values were discarded if the maximum ρφ′,Ea waslower than 0.6, indicating that the planar wave hypothesiscannot be assumed in the tissue within that clique.2.4. Estimation of conduction velocity withLATIn order to have an alternative estimation of conductionvelocity based on the detected LATs, a linear model wasfitted to the activation times measured from a clique of 4electrodes, similar to [5]:t(x, y) = a1 + a2x+ a3y (1)where t(x,y) is the activation time at each electrode site(x,y) and a1, a2 and a3 are the coefficients estimated byleast squares. Once coefficients are known, the compo-nents of conduction velocity vector vx and vy can be ob-tained by partial differentiation of t(x,y) as follows:vx =∂t∂x( ∂t∂x )2 + ( ∂t∂y )2=a2a22 + a23(2)vy =∂t∂y( ∂t∂x )2 + ( ∂t∂y )2=a3a22 + a23(3)Page 22.5. Conduction velocity maps and valida-tionMaps of estimated CV and propagation directions werecreated for all activations in clinical as well as in simulatedEGM signals, using both the OP-EGM method and theLAT-based estimation. For both methods any CV greaterthan 4 mm/ms was considered an outlier and was not rep-resented.In the case of simulated patterns, as they were createdwith known focus, CV and anisotropy ratio, the true con-duction velocity was obtained at the center of each clique.This allowed to compute the estimation errors for CV(εOPCV , εLATCV ) and for propagation direction (εOPθ , εLATθ ),obtained with both methods and for each propagation pat-tern (expressed as mean ± SD across all the cliques in theMEA). Finally, mean errors were calculated above all thesimulated propagation patterns for both methods.3. Results3.1. Analysis of simulated dataTable 1 shows the errors for CV and propagation direc-tions estimated by the two considered methods with dif-ferent simulation parameters. It can be observed that OP-EGM presents errors slightly greater than the LAT-basedestimation in most of the cases.3.2. Analysis of clinical dataFigure 1 shows (from left to right) the conduction ve-locity maps estimated with OP-EGM and from LATs, to-gether with the manually annotated reference LAT mapsfor some selected activation patterns. In particular, Fig-ure 1(a) shows one representative activation interval dur-ing SR, whereas Figure 1(b), (c) and (d) show differentpatterns observed during AF.Each conduction velocity map consists of CV values andpropagation directions. For each clique, the CV value wascolor-coded from blue (lowest) to red (highest), whereasits respective propagation direction is plotted as an arrowwhose length is proportional to CV value. When an outlierwas obtained (typically due to the non-accomplishment ofthe planar wave hypothesis), no arrow was plotted for thatclique.As a reference, LAT maps were also color-coded fromred (earliest) to blue (latest) in 10 ms isochrones. Whena LAT could not be associated to an electrode within theMEA, a cross appeared in that location [2].(a)(b)(c)(d)Figure 1. Maps of conduction velocities estimated withOP-EGM and with LAT-based method and reference LATmaps observed in SR (a) and during some representa-tive propagation patterns in AF: two different wavefrontscolliding and fusing into one (b), a concentric wavefrontwhose focus is located within the MEA (c) and a chaoticwavefront with several lines of block (d).Page 3Simulated tissue characteristics focus εOPCV (mm/ms) εLATCV (mm/ms) εOPθ (deg) εLATθ (deg)Isotropic,vx = vy = 0.6 mm/mscenter 0.155 ± 0.067 0.015 ± 0.057 4.41 ± 3.9 2.35 ± 2.69bottom 0.121 ± 0.074 0.009 ± 0.062 3.78 ± 3.21 3.15 ± 2.86corner 0.177 ± 0.071 0.006 ± 0.057 7.28 ± 5.04 4.47 ± 3.27Isotropic,vx = vy = 1 mm/mscenter 0.095 ± 0.322 0.045 ± 0.191 11.5 ± 11.8 6.99 ± 6.42bottom 0.053 ± 0.005 0.003 ± 2.11×10−5 6.64 ± 4.3 4.35 ± 2.81corner 0.109 ± 0.257 0.016 ± 0.168 12 ± 8.42 7.56 ± 5.1Anisotropic,vx = 1.2 mm/msvy = 0.6 mm/mscenter 0.104 ± 0.173 0.013 ± 0.133 4.07 ± 3.32 3.95 ± 2.64bottom 0.117 ± 0.095 0.017 ± 0.075 1.43 ± 1.32 1.49 ± 2.35corner 0.118 ± 0.083 0.012 ± 0.071 6.47 ± 4.81 5.16 ± 3.5Anisotropic,vx = 0.6 mm/msvy = 1.2 mm/mscenter 0.143 ± 0.351 0.051 ± 0.222 6.3 ± 6.7 4.53 ± 3.61bottom 0.127 ± 0.067 0.012 ± 0.065 2.41 ± 1.95 3.04 ± 2.12corner 0.154 ± 0.174 0.017 ± 0.124 8.19 ± 6.82 5.16 ± 4.13Anisotropic,vx = 2 mm/msvy = 1 mm/mscenter -0.049 ± 0.149 -0.019 ± 0.069 8.25 ± 6.13 5.67 ± 3.84bottom 0.056 ± 0.003 0.002 ± 7.710−4 1.66 ± 0.974 1.09 ± 0.688corner 0.008 ± 0.187 -0.005 ± 0.11 11.8 ± 10.1 7.68 ± 6.59Anisotropic,vx = 1 mm/msvy = 2 mm/mscenter -0.15 ± 0.253 -0.04 ± 0.141 11.7 ± 9 7.28 ± 52.7bottom 0.051 ± 0.008 8.28×10−4± 0.004 4.24 ± 2.52 2.75 ± 1.66corner 0.035 ± 0.382 0.027 ± 0.265 19.7 ± 21.3 10.3 ± 8.25Mean error 0.08 ± 0.205 0.007 ± 0.13 7.3 ± 8.96 4.86 ± 4.81Table 1. CV and propagation direction angular errors (presented as mean ± SD) calculated with the two consideredmethods for different simulated propagation patterns4. Discussion and conclusionConduction velocity estimated from LATs and with OP-EGM presented low errors both in magnitude and in prop-agation direction when assessed in simulated data, withthe LAT-based estimation having lower errors than OP-EGM. It must be noted, however, that very simple propa-gation patterns were simulated and that LATs were not af-fected by detection errors. When assessed in clinical data,LAT-based maps showed a more incoherent behavior thanOP-EGM maps, especially in AF patterns. This can beexplained with the fact that more complex patterns werepresent in these signals. Also, LAT-based maps in the clin-ical data were based on manually annotated LATs, whichare a source of error affecting conduction velocity.On the other side, OP-EGM maps show smoother andmore coherent patterns both in SR and in the studied AFpatterns, having a good concordance with LAT maps. Thiscan be due to the OP-EGM independence from LATs,whose annotation errors do not affect conduction velocity.AcknowledgementsThis work is part of a project that has received fund-ing from the European Union’s Horizon 2020 research andinnovation program under the Marie Skłodowska-Curiegrant agreement No 766082 (My-ATRIA).This work was also supported by projects DPI2016-75458-R (MINECO) and Aragón Government (ReferenceGroup BSICoS T39-17R) cofunded by FEDER 2014-2020”Building Europe from Aragon”.References[1] Calkins H et al. 2017 HRS/EHRA/ECAS/APHRS/ SO-LAECE expert consensus statement on catheter and surgi-cal ablation of atrial fibrillation. Europace 2018; 20(1):e1-e160.[2] Alcaine A et al. Spatiotemporal model-based estimation ofhigh-density atrial fibrillation activation maps. Digital Sig-nal Processing 2016; 54:64-74.[3] Deno DC et al. Orientation-independent catheter-basedcharacterization of myocardial activation. IEEE TransBiomed Eng. 2017; 64(5):1067-1077.[4] Massé S et al. Resolving myocardial activation with novelomnipolar electrograms. Circ Arrhythm Electrophysiol.2016; 9:e004107.[5] Bayly PV et al. Estimation of conduction velocity vectorfields from epicardial mapping data. IEEE Trans BiomedEng. 1998; 45(5):563-571.Address for correspondence:Jennifer RiccioC/ Mariano Esquillor s/n, Edificio I+D+i, Lab 4.0.0550018 Zaragoza, Spain.jenriccio@unizar.esPage 4

Characterization of Propagation Patterns with Omnipolar EGM in Epicardial Multi-Electrode Arrays

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Characterization of Propagation Patterns with Omnipolar EGM in Epicardial Multi-Electrode Arrays

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