Xander A.A.M. Verbeek

Intra-ventricular resynchronization for optimal left ventricular function during pacing in experimental left bundle branch block

OBJECTIVES We sought to investigate to what extent intra-ventricular asynchrony (intraVA) and inter-ventricular asynchrony (interVA) determine left ventricular (LV) function in canine hearts with left bundle branch block (LBBB) during ventricular pacing. BACKGROUND Pacing therapy improves LV pump function in patients with heart failure and abnormal ventricular conduction supposedly due to resynchronization. However, the relationship between LV pump function and measures of asynchrony is not well established. METHODS In 15 experiments, LV (various sites) and biventricular (BiV) pacing was performed at atrioventricular (AV) delays of 20 to 140 ms. Measured were the maximum rate of increase (dP/dt(max)) of LV pressure and LV stroke work (SW) (conductance catheter), interVA (time delay between the upslope of LV and RV pressures), and intraVA (from endocardial electrical activation maps). RESULTS Induction of LBBB increased interVA (-6.4 +/- 8.6 to -28.4 +/- 8.5 ms [RV earlier]) and intraVA (4.9 +/- 2.4 to 18.0 +/- 3.3 ms), whereas LV dP/dt(max) and SW decreased (-13 +/- 18% and -39 +/- 24%, respectively). During LBBB, LV and BiV pacing increased LV dP/dt(max) and SW (mean increases 14% to 21% and 11% to 15%, respectively) without changing diastolic function or preload. Optimal improvement in LV function was obtained consistently when intraVA returned to pre-LBBB values, while interVA remained elevated. Normalization of intraVA required AV delays shorter than the baseline PQ time during LV apex and BiV pacing, thus excluding endogenous LV activation, but AV delays virtually equal to the baseline PQ time (difference 4 +/- 9 ms, p = NS) during pacing at (mid)lateral LV sites to obtain fusion between pacing-induced and endogenous activation. CONCLUSIONS In LBBB hearts, optimal restoration of LV systolic function by pacing requires intra-ventricular resynchronization. The optimal AV delay to achieve this depends on both the site of pacing and baseline PQ time.

The left ventricular apex is the optimal site for pediatric pacing: correlation with animal experience.

Pacing at the commonly used right ventricular (RV) apex results in impaired ventricular performance. Previous animal studies indicated that the left ventricular (LV) apex is a superior pacing site. The purpose of this study was to investigate in dogs whether this good performance is associated with a more synchronous electrical activation pattern of the LV and whether the LV apex is also a good pacing site in children. In 11 healthy dogs and 8 children undergoing cardiac surgery, dual chamber pacing was performed at the RV apex, LV apex and LV lateral free wall (LVFW). In dogs, a basket electrode was inserted into the LV to assess pattern and timing of LV endocardial activation. In the children, hemodynamic measurements were performed immediately after recovery from cardiopulmonary bypass. In dogs, LV apex pacing resulted in synchronous activation around the LV circumference whereas RV apex and LVFW pacing resulted in asynchrony of activation between the septum and LVFW. In both canine and childrens hearts most hemodynamic variables remained at sinus rhythm level during LV apex pacing, but LVdPdtmax, stroke work (dogs), and pulse pressure (children) were reduced as compared with sinus rhythm during RV apex and LVFW pacing. LV apex pacing results in synchronous activation of the LV and is, in adult dogs and in children, associated with superior hemodynamic performance. (PACE 2004; 27 [Pt. II]:837–843)

Experimental investigation of the pulse inversion technique for imaging ultrasound contrast agents

The application of ultrasound contrast agents aims to detect low velocity blood flow in the microcirculation. To enhance discrimination between tissue and blood containing the contrast agent, harmonic imaging is used. Harmonic imaging requires the application of narrow-band signals and is obscured by high levels of native harmonics generated in an intervening medium. To improve discrimination between contrast agent and native harmonics, a pulse inversion technique has been proposed. Pulse inversion allows wide-band signals, thus preserving the axial resolution. The present study examines the interference of native harmonics and discusses the practical difficulties of wide-band pulse inversion measurements of harmonics by a single transducer. Native harmonics are not eliminated by pulse inversion. Furthermore, only even harmonics remain and are amplified by 6 dB, alleviating the requirement for selective filtering. Finally, it is shown that the contaminating third harmonic contained in the square wave activation signal leaks through in the emitted signal. The spectral location of the contaminating third harmonic is governed by the transducer spectral characteristics while the location of the native and contrast agent second harmonics is not. Thus the contaminating third harmonic and the native and contrast agent second harmonics may overlap and interfere. Optimal discrimination requires a balance between maximal sensitivity for the second harmonic at reception and minimal interference from the contaminating third harmonic.

High-resolution functional imaging with ultrasound contrast agents based on RF processing in an in vivo kidney experiment

Knowledge of the relative tissue perfusion distribution is valuable in the diagnosis of numerous diseases. Techniques for the assessment of the relative perfusion distribution, based on ultrasound (US) contrast agents, have several advantages compared to established nuclear techniques. These are, among others, a better spatial and temporal resolution, the lack of exposure of the patient to ionizing radiation and the relatively low cost. In the present study, US radiofrequency (RF) image sequences are acquired, containing the signal intensity changes associated with the transit of a bolus contrast agent through the microvasculature of a dog kidney. The primary objective is to explore the feasibility of calculating functional images with high spatial resolution. The functional images characterize the transit of the contrast agent bolus and represent distributions of peak time, peak value, transit time, peak area, wash-in rate and wash-out decay constant. For the evaluation of the method, dog experiments were performed under optimized conditions where motion artefacts were minimized and an IA injection of the contrast agent Levovist was employed. It was demonstrated that processing of RF signals obtained with a 3.5-MHz echo system can provide functional images with a high spatial resolution of 2 mm in axial resolution, 2 to 5 mm in lateral resolution and a slice thickness of 2 mm. The functional images expose several known aspects of kidney perfusion, like perfusion heterogeneity of the kidney cortex and a different peripheral cortical perfusion compared to the inner cortex. Based on the findings of the present study, and given the results of complimentary studies, it is likely that the functional images reflect the relative perfusion distribution of the kidney.

Measurement of the contrast agent intrinsic and native harmonic response with single transducer pulse waved ultrasound systems

AbstractUltrasound contrast agents, i.e., small gas filled microbubbles, enhance the echogenicity of blood and have the potential to be used for tissue perfusion assessment. The contrast agents scatter ultrasound in a nonlinear manner and thereby introduce harmonics in the ultrasound signal. This property is exploited in new ultrasound techniques like harmonic imaging, which aims to display only the contrast agent presence. Much attention has already been given to the physical properties of the contrast agent. The present study focuses on practical aspects of the measurement of the intrinsic harmonic response of ultrasound contrast agents with single transducer pulse waved ultrasound systems. Furthermore, the consequences of two other sources of harmonics are discussed. These sources are the nonlinear distortion of ultrasound in a medium generating native harmonics, and the emitted signal itself which might contain contaminating harmonics. It is demonstrated conceptually and by experiments that optimization of the contrast agent harmonic response measured with a single transducer is governed by the transducer spectral sensitivity distribution rather than the resonance properties of the contrast agent. Both native and contaminating harmonics may be of considerable strength and can be misinterpreted as intrinsic harmonics of the contrast agent. Practical difficulties to filter out the harmonic component selectively, without deteriorating the image, may cause misinterpretation of the fundamental as a harmonic.

Baseband velocity estimation for second-harmonic signals exploiting the invariance of the Doppler equation

All Doppler systems, whether conventional Doppler domain or radio frequency (RF) processing is employed, relate the temporal frequency characteristics of the signal at a certain point in depth as function of time to the spatial frequency characteristics of the received signal as function of depth. The mean frequency of the latter may change as a result of depth-dependent attenuation, nonlinear scattering mechanisms, as in harmonic imaging of ultrasound contrast agents, or RF signal demodulation. For all these cases, the relationship between spatial and temporal mean frequency and target velocity is still governed by the familiar Doppler expression if the signal modifications have been properly accounted for. A major drawback of RF signal processing to extract the target velocity is the large number of data points to consider. The computational complexity increases further for harmonic imaging. It is shown conceptually, and demonstrated by signal simulations, that prior to velocity estimation RF demodulation followed by decimation (1) does not affect the Doppler equation, (2) enhances the information content of the samples, (3) reduces the computational load by a factor of four and for harmonic signals by a higher factor, and (4) while demodulation does not have to be actually performed, but can be accounted for by a scaling factor in the cross-correlation function. It is concluded that decimation hardly affects the precision of the velocity estimate if possible frequency aliasing is maintained within bounds, suggesting that the decimation factor is not critical.