Rautaharju, Pentti M.

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Via Medica Journals

HISTORY OF CARDIOLOGYCardiology Journal2007, Vol. 14, No. 4, pp. 420–421Copyright © 2007 Via MedicaISSN 1897–5593420 www.cardiologyjournal.orgThe birth of computerized electrocardiography:Hubert V. Pipberger (1920–1993)Medical electronics started a periodof growth in the late 1950s, some15 years after the end of the SecondWorld War. There was also a slowly in-creasing expectation that digital comput-ers will gradually revolutionize ECG anal-ysis. The Veteran’s Administration (VA)Hospital in Washington, DC, established a SpecialResearch Program for Medical Electronic DataProcessing in 1957, and Dr. Hubert V. Pipberger,a recent immigrant to the U.S., was appointed asthe director of that VA research program. In 1959NIH established its Medical Systems DevelopmentLaboratory and launched an extensive effort direct-ed by Dr. Cesar Caceres to develop a computer pro-gram for ECG analysis.Pipberger was convinced that the use of theFrank three-lead system rather than the conven-tional 12-lead ECG was the method of choice andthat advanced statistical analysis was superior to thetraditional analysis of the 12-lead ECG. Caceres, incontrast, based the approach of his team on the anal-ysis of the 12-lead ECG along the traditional lines,one lead at the time, using conventional clinicalECG criteria. There was a tangible feeling of fiercecompetitive spirit in these pioneering efforts thosedays in Washington. Everything done in computer-ECG was exciting news.By the end of 1959, Pipberger’s collaboratingteam from various VA hospitals had collected nearly1,000 ECG recordings of three-lead vectorcardio-graphic XYZ signals. The missing link was a con-verter that could sample three simultaneous ECGchannels to digital information suitable for digitalcomputer analysis. The National Bureau of Stand-ards was contracted by the VA to build the device.The Bureau also made available a digital computerfor the pilot study of Pipberger’s team.Pipberger’s group first described digital con-version of ECGs at the American Heart Associa-tion’s 1959 Scientific Sessions and in Circulation in1960 [1]. In 1961, they reported the re-sults from a pilot project designed todemonstrate the feasibility of screeningof normal and abnormal ECGs [2]. ThatECG classification program was based onWilson’s ventricular gradient vector con-cept that did not require complex ECGwave detection and measurement. A more compre-hensive automatic ECG wave detection and meas-urement program was described by Stallman andPipberger in 1961 [3]. That same year both com-peting groups described their approach to ECG anal-ysis in the 1961 International Medical ElectronicsConference held in New York City.The initial setup of Caceres at NIH for ECGwave detection and measurement was slow andcumbersome. The analog-to digital conversion wasfirst performed using single-channel ECGs record-ed on magnetic tape and converted to punched cardsfor input to a digital computer [4]. Substantial grad-ual progress was made during the subsequent ten--year effort, which culminated in the release of theECAN-D version of the program. That program wastranslated to several computer languages and adapt-ed to a variety of computers, and a system for cer-tification for compatibility of various versions of theprogram used by new users was established by theHealth Care Technology Division of the institute.Subsequently, various versions of the ECAN pro-gram by commercial enterprises mushroomed.Pipberger collaborated with Jerome Cornfield,a noted statistician, in designing a multi-group clas-sification program based on the so-called Bayesianlogic that used prior probabilities to optimize classi-fication accuracy. After demonstration of the feasi-bility of the approach for differential diagnosis be-tween normal and left ventricular hypertrophy [5],the clinically documented ECG record library stead-ily expanded. Over 2,300 records were selected asthe so-called development set containing seven dia-gnostic categories (in addition of atrial overloads and421Pentti M. Rautaharju, Hubert V. Pipberger (1920–1993)www.cardiologyjournal.orgbundle branch blocks with and without myocardialinfarction). Pipberger labeled the final product as“the second generation ECG program” [6]. A totalof 66 measurements were used by the statisticalanalysis logic, and the prior probabilities were select-ed primarily according the estimated prevalenceof each of the seven clinical conditions among thepatient population in each clinical setup.Inspired by the efforts of these early pioneers,several other groups of investigators in the US andother countries developed ECG programs at thattime based on the use of the 12-lead ECG or vec-torcardiographic leads, or a combination of both thethree-lead and 12-lead ECGs.In final analysis, both the ECAN program aswell as the VA program turned out to be the losersin the overall picture. Pipberger’s approach wasdoomed because cardiologists found it difficult toaccept the Bayesian approach to diagnostic ECGclassification. They also found Frank’s Z lead unfa-miliar because of its inverted polarity in compari-son with V1 and V2. And the ECAN approach to12-lead analysis was doomed to failure becauseECG wave detection logic based on the use of eachsingle ECG lead individually has insurmountableproblems. By 1978 the use of the VA and ECAN pro-grams amounted to a small portion of the overallvolume of computer-processed ECGs.What then, were the importance and the im-pact of the personal contributions of Pipberger inthe evolution of computerized ECG? Perhaps mostsignificantly, Pipberger promoted the objectivity inthe evaluation of the diagnostic performance of ECGclassifiers and in comparing various classificationprograms. He recognized early, that in addition oftesting of the ECG wave measurement accuracy anddetection of arrhythmias, ECG classification accu-racy has to be evaluated primarily using adequate-ly large test libraries, with test cases selected onthe basis of ECG-independent evidence.Secondly, Pipberger had a substantial early andlong-term impact on national and international effortson computer-ECG standardization and on improvingprofessional standards in ECG interpretation.Finally, Pipberger created serious new inter-est in computer-ECG research using tools of ad-vanced biomedical engineering and computing tech-nology for improved ECG signal processing andECG classification.References1. Pipberger HV, Freis ED, Taback L, Mason HL.Preparation of electrocardiographic data for analysisby digital electronic computer. Circulation, 1960; 21:413–418.2. Pipberger HV, Arms RJ, Stallman PW. Automaticscreening of normal and abnormal electrocardio-grams by means of digital electronic computer. ProcSoc Exp Biol Med, 1961; 106: 130–132.3. Stallman FW, Pipberger HV. Automatic recognitionof electrocardiographic waves by digital computer.Circ Res, 1961; 9: 1138–1143.4. Rikli AE, Tolles WE, Steinberg CA et al. Computeranalysis of electrocardiographic measurements.Circulation, 1961; 24: 643–649.5. Klingeman J, Pipberger HV. Computer classification ofelectrocardiograms. Comp Biomed Res, 1967; 1: 17.6. Pipberger HV, McCaugham D, Littman D et al.Clinical application of a second generation electro-cardiographic computer program. Am J Cardiol, 1975;35: 597–608.Pentti M. Rautaharju, MD, PhDWake Forest University School of MedicineWinston-Salem, NCe-mail: penttir@bellsouth.net

The birth of computerized electrocardiography: Hubert V. Pipberger (1920-1993)

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The birth of computerized electrocardiography: Hubert V. Pipberger (1920-1993)

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