US20140100623A1 - Method and apparatus for arrhythmia detection in a medical device - Google Patents

Abstract

A method and device for detecting arrhythmias in a patient that includes electrodes positioned subcutaneously within the patient, a microprocessor, coupled to the electrodes, determining one of a sequence of the sensing of cardiac signals by the electrodes and a duration between the sensing of cardiac signals by the electrodes, and control circuitry delivering a therapy in response to one of the determined sequence and the determined duration.

Description

RELATED APPLICATION
• This application is a continuation of U.S. patent application Ser. No. 11/037,123, filed Jan. 18, 2005 entitled “METHOD AND APPARATUS FOR ARRHYTHMIA DETECTION IN A MEDICAL DEVICE”, herein incorporated by reference in its entirety.
FIELD OF THE INVENTION
• The present invention relates generally to medical devices, and, more particularly, to a method and apparatus for sensing and detecting arrhythmias in a medical device.
BACKGROUND OF THE INVENTION
• Implantable medical devices (IMDs) have many functions including the delivery of therapies to cardiac patients, neuro-stimulators, muscular stimulators, and others. For purposes of this application reference will be made only to implantable cardiac devices, it being understood that the principles herein may have applicability to other implantable medical devices as well.
• An implantable cardiac device (ICD) may be a device commonly referred to as a pacemaker, which is used to stimulate the heart into a contraction if the sinus node of the heart is not properly timing, or pacing, the contractions of the heart. Modern cardiac devices also perform many other functions beyond that of pacing. For example, some cardiac devices may also perform therapies such as defibrillation and cardioversion as well as providing several different pacing therapies, depending upon the needs of the user and the physiologic condition of the user's heart. For convenience, all types of implantable cardiac devices will be referred to herein as ICDs, it being understood that the term, unless otherwise indicated, is inclusive of an implantable device capable of administering any of a number of therapies to the heart of the user.
• In typical use, an ICD is implanted in a convenient location usually under the skin of the user and in the vicinity of the one or more major arteries or veins. One or more electrical leads connected to the pacemaker are inserted into or on the heart of the user, usually through a convenient vein or artery. The ends of the leads are placed in contact with the walls or surface of one or more chambers of the heart, depending upon the particular therapies deemed appropriate for the user.
• One or more of the leads is adapted to carry a current from the pacemaker to the heart tissue to stimulate the heart in one of several ways, again depending upon the particular therapy being delivered. The leads are simultaneously used for sensing the physiologic signals provided by the heart to determine when to deliver a therapeutic pulse to the heart, and the nature of the pulse, e.g., a pacing pulse or a defibrillation shock.
• There has been recent interest in development of implantable defibrillators that may be inserted entirely subcutaneously or sub-muscularly, having no leads or electrodes within the thoracic cavity. The elimination of transvenous or epicardial leads is believed likely to allow for implant of the devices by a wider range of physicians, in some cases at a lower cost than traditional ICDs. Absence of transvene or epicardial leads may reduce acute and long term complications. Such devices, are therefore believed to offer the opportunity for increased levels of use, particularly for prophylactic implant. US Application Publication Nos. 2002/0042634, 200200068958 and 2002/0035377 to Bardy et al., are exemplary of current thinking with regard to such subcutaneous ICDs. Additional subcutaneous ICDs are disclosed in US Application Publication No. 20020082658 by Heinrich et al. and PCT publication WO/04043919A2 by Olson. All of the above cited applications and publications are incorporated herein by reference in their entireties.
• One potential problem associated with the sensing of the physiologic signal from the heart in both the transvenous systems and the subcutaneous systems relates to what is often referred to as “false positive” and “false negative” detections. The most widely accepted detection algorithm is based on the rate of depolarizations of the ventricles, or simply on “heart rate”. Such algorithms rely on detecting events based upon signals obtained between two electrodes positioned within or on the heart. If the number of detected events per a given time is greater than a preset value, then the device charges an energy storage capacitor and then shocks the heart; otherwise no shock is delivered.
BRIEF DESCRIPTION OF THE DRAWINGS
• Aspects of the present invention will be readily appreciated as they become better understood by reference to the following detailed description when considered in connection with the accompanying drawings, wherein:
• FIG. 1 is a schematic diagram of an exemplary medical device according to the present invention;
• FIG. 2 is a schematic diagram of an exemplary medical device according to the present invention;
• FIG. 3 is a schematic diagram of an exemplary medical device according to the present invention;
• FIG. 4 is a schematic diagram of an exemplary medical device according to the present invention;
• FIG. 5 is a top cross sectional view illustrating the positioning of a medical device according to an embodiment of the present invention;
• FIG. 6 is a top cross sectional view illustrating the positioning of a medical device according to an embodiment of the present invention;
• FIG. 7 is a schematic view of a sensor of a medical device according the present invention;
• FIG. 8 is a functional schematic diagram of an implantable pacemaker/cardioverter/defibrillator (ICD) in which the present invention may usefully be practiced;
• FIG. 9 is a schematic diagram of sensing of depolarization events utilizing a medical device of the present invention;
• FIGS. 10 and 11 are schematic diagrams of sensing of depolarization events utilizing a medical device of the present invention;
• FIG. 12 is a flowchart of a method for detecting arrhythmias in a medical device according to an embodiment of the present invention;
• FIG. 13 is an exemplary illustration of determining change in duration for a current rhythm according to an embodiment of the present invention; and
• FIGS. 14A-14C are schematic diagrams of electrode configurations in an exemplary medical device according to the present invention.
DETAILED DESCRIPTION OF THE INVENTION
• FIG. 1 is a schematic diagram of an exemplary medical device according to the present invention. As illustrated inFIG. 1, amedical device100 according to an embodiment of the present invention, which may be an implantable cardioverter/defibrillator (ICD), for example, includes ahousing102 having anelectrode104 positioned along aside wall106 ofhousing102 that is intended to be directed inward towards a heart of a patient when housing is positioned subcutaneously within the patient, as will be described in detail below.Housing102 is coupled to asubcutaneous lead108 carrying conventional conductors (not shown) extending therethrough to electrically couple circuitry located withinhousing102 to anelectrode110 positioned on an insulatedpatch112 positioned subcutaneously within the patient so thatelectrode110 is directed towards the patient's heart.
• According to the present invention,electrodes104 and110 are formed using Laplacian electrodes that are utilized both as sensors to sense cardiac depolarization signals and as high voltage cardioversion/defibrillation electrodes to deliver cardioversion/defibrillation therapy to the patient. Since the sensitivity of Laplacian sensors to events, especially to dipole layers corresponding to the depolarization of the heart, decreases with the inverse distance cube (1/r³),electrodes104 and110 sense signals in a very localized and reduced area, resulting in larger cardiac signal to noise ratios than in conventional sensing methodologies. In addition, because of the reduced sensing area, noise due to body motion will only intermittently affect signal quality when local muscles are activated during the body motion.
• FIG. 2 is a schematic diagram of an exemplary medical device according to the present invention. As illustrated inFIG. 2, amedical device200 according to another embodiment of the present invention includes ahousing202 having anelectrode204 positioned along aside wall206 ofhousing202 that is intended to be directed inward towards the heart of a patient whenhousing202 is positioned subcutaneously within the patient.Housing202 is coupled to twosubcutaneous leads208 and209, each carrying conventional conductors (not shown) extending therethrough to electrically couple circuitry located withinhousing202 torespective electrodes210 and211 positioned on associatedinsulated patches212 and213 that are to be positioned subcutaneously within the patient so thatelectrodes210 and211 are directed towards the patient's heart.
• FIG. 3 is a schematic diagram of an exemplary medical device according to the present invention. As illustrated inFIG. 3, amedical device300 according to the present invention may include ahousing302 having twoelectrodes304 and305 positioned along aside wall306 ofhousing302 that is intended to be directed inward towards the heart of a patient whenhousing302 is positioned subcutaneously within the patient.Housing302 is coupled to asubcutaneous lead208 carrying conventional conductors (not shown) extending therethrough to electrically couple circuitry located withinhousing302 to anelectrode210 positioned on an insulatedpatch212 that is intended to be positioned subcutaneously within the patient so thatelectrode210 is directed towards the patient's heart.
• FIG. 4 is a schematic diagram of an exemplary medical device according to the present invention. As illustrated inFIG. 4, amedical device400 according to the present invention may include ahousing402 having twoelectrodes404 and405 positioned along aside wall406 ofhousing402 that is intended to be directed inward towards the heart of a patient whenhousing402 is positioned subcutaneously within the patient.Housing402 is coupled tosubcutaneous leads408 and409, each carrying conventional conductors (not shown) extending therethrough to electrically couple circuitry located withinhousing402 toelectrodes410 and411 positioned on asecond housing412 that is intended to be positioned subcutaneously within the patient so thatelectrodes410 and411 are directed towards the patient's heart. According to yet another embodiment,electrodes410 and411 are positioned on an insulatedpatch412 so thathousing402 is coupled to insulatedpatch412 vialeads408 and409.
• FIG. 5 is a top cross sectional view illustrating the positioning of a medical device according to an embodiment of the present invention. It is understood that the present invention is not intended to be limited to the exemplary electrode configurations ofFIGS. 1-4. Rather, any desired number of electrodes may be located on the housing and any number of insulated patches containing any number or array of electrodes may be coupled to the housing via corresponding leads. In addition, the electrodes may be utilized only for pacing and/or only for sensing without departing from the invention. Furthermore, placement of the housing and electrodes will depend upon the number of electrodes utilized.
• For example, as illustrated inFIG. 5, in the three electrode embodiment of the present invention illustrated inFIG. 2,housing202 is positioned along side ofcostal muscle220 along the abdomen below the sternum so thatelectrode204 positioned alongside wall206 ofhousing202 is directed inward towards theheart215 of a patient. According to the present invention,housing202 may or may not include one or more electrodes, as described above. In addition, oneinsulated patch212 is positioned in the anterior thorax, overlaying the heart, slightly left of the sternum and within the fourth intercostal space to be positioned at a location associated the V4 lead of the twelve-lead ECG position so thatelectrode210 is directed inward towardsheart215. The otherinsulated patch213 is positioned laterally left of the sternum frominsulated patch212 to be located at the V6 lead location of the twelve-lead ECG position so thatelectrode211 is directed inward towardsheart215. In this way,electrodes210 and211 are positioned so that a vector extending betweenelectrodes210 and211 extends through an appropriate portion ofheart215.
• FIG. 6 is a top cross sectional view illustrating the positioning of a medical device according to an embodiment of the present invention. As illustrated inFIGS. 1 and 6, in the two electrode embodiment of the present invention,housing102 is positioned in the anterior thorax, overlaying the heart, slightly left of the sternum and within the fourth intercostal space to be positioned at a location associated the V4 lead of the twelve-lead ECG position so thatelectrode104 is directed inward towardsheart215.Insulated patch112 is positioned laterally left of the sternum fromhousing102 to be located at the V6 lead location of the twelve-lead ECG position so thatelectrode110 is directed inward towardsheart215. In this way,electrodes104 and110 are positioned so that a vector extending betweenelectrodes104 and110 extends through an appropriate portion ofheart215.
• According to the present invention, aninsulated layer225 may be included along an outer portion of the insulated patches in order to reduce the effects of the current delivered from the electrodes on subcutaneous nerves along electrodes, resulting in a reduction of pain that may be experienced by the patient during delivery of cardioversion/defibrillation therapy by the medical device.
• FIG. 7 is a schematic view of a sensor of a medical device according the present invention. As illustrated inFIG. 7, anelectrode300 of the present invention, such as any of the electrodes described above, includes a disk-shaped, electrically insulatingpatch302 formed of silicone rubber or other compliant, electrically insulating material. Insulatingpatch302 defines a generallyplanar contact surface304 into which an electricallyconductive sub-assembly307 is substantially flushly embedded.Sub-assembly307 includes an electrically conductiveinner pad308 separated by a first insulatinglayer310 from a continuousmiddle loop electrode312.Loop electrode312 is surrounded by a second insulatinglayer314, which, in turn, is surrounded by a continuousexterior loop electrode316. In order to provideelectrode300 with uniform directionality of response in a plane during sensing,inner pad308 is round and circular in shape andloop electrodes312 and316 are formed as circular rings located concentrically with respect to pad308 as well as with respect to one another. In applications where uniform directionality of response is not required or where it is desired to provide enhanced or reduced sensitivity in certain directions,pad308 and/orloop electrodes312 and316 can be formed in other shapes and/or located off center with respect to one another provided that at least some mutual spacing is maintained betweenpad308 andcontinuous loop electrodes312 and316.
• In order to renderelectrode300 sensitive only to the electrical activity of that muscle tissue which substantially immediately underlies the skin surface which sub-assembly307 is placed in contact with,inner pad308 andelectrode316 are electrically coupled to one another, preferably by a short circuit. For example, this is achieved by ajumper wire318 having one end connected to pad308 and its opposing end connected toelectrode316. The portion ofjumper wire318 that crosseselectrode312 is electrically insulated in order to electrically isolateelectrode312 from bothpad308 andelectrode316.Electrode300 is provided with a pair of insulatedlead wires320,322. Aconductor324 extending throughlead wire320 is connected directly toelectrode312 while aconductor326 extending throughlead wire322 is connected electrically in common with bothinner pad308 andelectrode316. This is conveniently accomplished with a singleelectrical connection328 by attaching theconductor326 oflead wire322 directly tojumper wire318. To avoid detachment oflead wires320 and322 fromsub-assembly307, strain relief is preferably provided by anchoringwires320 and322 to patch302. This may readily be achieved by insert molding or use of an adhesive. Concentricity ofpad308 andelectrodes312 and316 may be assured by various means, molding or performingpatch302 with a recess for locatingpad308 and appropriately sized and centered channels for receivingelectrodes312 and316.
• Although a single pad and two concentric rings are shown inFIG. 7, it is understood that other configurations are intended to be included in subcutaneous sensing and detecting according to the present invention. For example,sensor300 may includeinner pad308 and a singleconcentric electrode316, thus eliminating the need forelectrode312, insulatinglayer314 andjumper wire318. The benefit of such a bi-polar configuration is that it provides increased signal amplitudes, although the signal localization may be reduced.
• As the distance between theelectrodes312 and316 increases, or in the bi-polar configuration, as the distance betweenpad308 andelectrode316 increases, the amplitude of the detected signal increases, and thesensor300 becomes more sensitive to sources further away from the immediate vicinity of theelectrode300. Although the desired total radius of the sub-assembly307 associated with the sensor typically will be dependent on the patient's anatomy, the inventors have found that a for a person of median anatomy,sub-assembly307 should be approximately between 10 mm and 70 mm in diameter, for example. According to an embodiment of the present invention,sub-assembly307 is approximately 35 mm in diameter. In one embodiment, a distance330 betweenelectrodes312 and316, in which insulatinglayer314 is located, is approximately equal to 2 mm, although distance330 could have any desired value, depending upon the level of far-field sensitivity desired.
• It is understood that whilepatch302 is shown having a circular shape, the present invention is not intended to be limited to the use of circular patches and electrodes. Rather, the patch may be formed in any shape, including oval, square, rectangular and so forth. In addition, whileelectrodes312 and316 are shown as being concentric and circular, they may have other desired shapes without departing from the present invention.
• FIG. 8 is a functional schematic diagram of an implantable pacemaker/cardioverter/defibrillator (ICD) in which the present invention may usefully be practiced. This diagram should be taken as exemplary of the type of device in which the invention may be embodied, and not as limiting, as it is believed that the invention may usefully be practiced in a wide variety of device implementations, including devices providing therapies for treating atrial arrhythmias instead of or in addition to ventricular arrhythmias, pacemakers which do not provide anti-tachycardia pacing therapies, anti-tachycardia pacers which do not provide cardioversion or defibrillation, and totally subcutaneous devices that deliver defibrillation and/or pacing therapies or subcutaneous monitoring-only devices that do not provide therapy. Most of the components of the ICD as illustrated correspond to those used in prior art Medtronic implantable defibrillators. In particular, reference is made to US Patent Publication No. 20020082658 to Heinrich et al. and PCT Publication No. WO/04043919A2 to Olson, as well as to US Patent Application Publication No. 20010034539 by Olson et al., all incorporated herein by reference in their entireties. While the circuitry described above is based upon implantable device circuitry, similar circuitry would be used in those embodiments in which the invention is practiced as an external pacemaker or defibrillator, coupled to a subcutaneous electrode array according to the present invention.
• The device is provided with electrodes, which may be as described above. Alternate lead systems embodying the invention may also be substituted. The functions of the illustrated electrodes are as follows:Electrode311 is a first defibrillation/cardioversion electrode and corresponds toelectrodes104,204,304,404 and408, located on the device housings, for example.Electrode320 is a second cardioversion/defibrillation electrode and corresponds to the lead mounted cardioversion/defibrillation electrodes110,210,410,411, for example.Electrode318 corresponds to the optional third defibrillation electrode referred to in conjunction withFIGS. 2-4. As such, there may be more or less than the three electrodes illustrated, which are intended to merely be exemplary.
• Electrodes311,318 and320 are coupled to highvoltage output circuit234 andswitch matrix208, which under control ofmicroprocessor224 selectively coupleselectrodes311,318 and320 tosensing circuit204 and/or to pacingoutput circuits216 and214.Sensing circuit204 preferably takes the form of one or more automatic gain controlled amplifiers providing adjustable sensing threshold as a function of the measured depolarization wave amplitudes. A signal is provided to pacer timing andcontrol circuitry212 when a sensed signal or signals indicate occurrence of a cardiac depolarization. The general operation of thesensing circuit204 may correspond to that disclosed in U.S. Pat. No. 5,117,824, to Keimel et al., incorporated herein by reference in its entirety. Amplifier gain would have to be increased as compared to devices employing electrodes directly contacting the heart. Alternatively, amplifiers more closely resembling those discussed in the Heinrich et al. application cited above or in automatic external defibrillators might be substituted.
• Signals fromsensing circuit204 may also be provided tomultiplexer220, and thereafter converted to multi-bit digital signals byND converter222, for storage in RAM/ROM226 under control of directmemory access circuit228.Microprocessor224 may employ digital signal analysis techniques to characterize the digitized signals stored inrandom access memory226 to recognize and classify the patient's heart rhythm employing any of the numerous signal processing methodologies known to the art.
• Control of the ICD by the physician or by a patient is accomplished viatelemetry circuit210. Externally generated programming signals are received byantenna212, demodulated bytelemetry circuitry210 and passed throughmultiplexer220 to the microprocessor viabus218. The telemetry circuitry may be any conventional telemetry circuit employed in prior art implantable pacemakers and defibrillators and may correspond to that described in U.S. Pat. No. 5,752,977 issued to Grevious, et al. or to U.S. Pat. No. 5,999,857 issued to Weijand, et al, both of which are included by reference in their entireties.
• The remainder of the circuitry is dedicated to the provision of cardiac pacing, cardioversion and defibrillation therapies, and, for purposes of the present invention may correspond generally to circuitry known in the prior art. An exemplary apparatus is disclosed of accomplishing pacing, cardioversion and defibrillation functions follows. The pacer timing/control circuitry212 includes programmable digital counters which control the basic rime intervals associated-with single chamber anti-bradycardia pacing, typically ventricular pacing.Circuitry212 also controls escape intervals associated with single chamber antitachyarrhythmia pacing, also typically ventricular pacing, employing any antitachyarrhythmia pacing therapies known to the art. Alternative embodiments in which atrial cardioversion/defibrillation and/or atrial anti-tachycardia pacing are also believed to be within the scope of the invention.
• Intervals defined by pacingcircuitry212 typically include ventricular pacing escape intervals, the refractory periods during which sensed P-waves and R-waves are ineffective to restart timing of the escape intervals and the pulse widths of the pacing pulses. The durations of these intervals are determined bymicroprocessor224, in response to stored data inmemory226 and are communicated to thepacing circuitry212 via address/data bus218.Pacer circuitry212 also determines the amplitude of the cardiac pacing pulses under control ofmicroprocessor224.
• During pacing, the escape interval counters within pacer timing/control circuitry212 are typically reset upon sensing of R-waves as indicated by signals onbus206, and in accordance with the selected mode of pacing on timeout trigger generation of pacing pulses bypacer output circuits214 and/or and216, which are coupled toelectrodes311,318 and320.Output circuits214 and216 may correspond to conventional cardiac pacing output circuits, with the exception that they provide pulses of higher amplitude, e.g. up to 20 volts or higher or up to 35 milliamps or higher. Alternatively,output circuits214 and216 may correspond generally to that disclosed in U.S. Pat. No. 4,349,030 issued to Belgard et al., which employs a long duration pacing pulse to reduce pain associated with transcutaneous pacing or to that disclosed in U.S. Pat. No. 5,018,522 issued to Mehra, which employs a ramped pacing pulse to reduce pain associated with transcutaneous pacing.Output circuits214 and/or216 may also provide pacing pulses of different amplitudes to different pairs or sets of electrodes, under control ofmicroprocessor224 in conjunction with other electrode configurations employing multiple electrode pairs.
• The escape interval counters are also reset on generation of pacing pulses, and thereby control the basic timing of cardiac pacing functions, including antitachyarrhythmia pacing. The durations of the intervals defined by the escape interval timers are determined bymicroprocessor224, via data/address bus218. The value of the count present in the escape interval counters when reset by sensed R-waves and P-waves may be used to measure the durations of R-R, which measurements are stored inmemory226 and used in conjunction with the present invention to diagnose the occurrence of a variety of tachyarrhythmias
• Microprocessor224 operates as an interrupt driven device, and is responsive to interrupts from pacer timing/control circuitry212 corresponding to the occurrences of sensed R-waves and corresponding to the generation of cardiac pacing pulses. These interrupts are provided via data/address bus218. Any necessary mathematical calculations to be performed bymicroprocessor224 and any updating of the values or intervals controlled by pacer timing/control circuitry212 take place following such interrupts. A portion of thememory226 may be configured as a plurality of recirculating buffers, capable of holding series of measured intervals, which may be analyzed in response to the occurrence of a pace or sense interrupt to determine whether the patient's heart is presently exhibiting ventricular tachyarrhythmia.
• In the event that a ventricular tachyarrhythmia is detected, and an antitachyarrhythmia pacing regimen is desired, appropriate timing intervals for controlling generation or anti-tachyarrhythmia pacing therapies are loaded frommicroprocessor224 into the pacer timing andcontrol circuitry212, to control the operation of the escape interval counters therein and to define refractory periods during which detection of R-waves and P-waves is ineffective to restart the escape interval counters.
• In the event that generation of a cardioversion or defibrillation pulse is required,microprocessor224 employs the escape interval counter to control timing of such cardioversion and defibrillation pulses, as well as associated refractory periods. In response to the detection of atrial or ventricular fibrillation or tachyarrhythmia requiring a cardioversion pulse,microprocessor224 activates cardioversion/defibrillation control circuitry230, which initiates charging of thehigh voltage capacitors246,248 via chargingcircuit236, under control of high voltage chargingcontrol line240. The voltage on the high voltage capacitors is monitored viaVCAP line244, which is passed throughmultiplexer220 and in response to reaching a predetermined value set bymicroprocessor224, results in generation of a logic signal on Cap Full (CF) line254, terminating charging. Thereafter, timing of the delivery of the defibrillation or cardioversion pulse is controlled by pacer timing/control circuitry212. Following delivery of the fibrillation or tachycardia therapy the microprocessor then returns the device to cardiac pacing and awaits the next successive interrupt due to pacing or the occurrence of a sensed atrial or ventricular depolarization.
• One embodiment of an appropriate system for delivery and synchronization of ventricular cardioversion and defibrillation pulses and for controlling the timing functions related to them is disclosed in more detail in commonly assigned U.S. Pat. No. 5,188,105 to Keimel, incorporated herein by reference in its entirety. However, any known cardioversion or defibrillation pulse control circuitry is believed usable in conjunction with the present invention. In the illustrated device, delivery of the cardioversion or defibrillation pulses is accomplished byoutput circuit234, under control ofcontrol circuitry230 viacontrol bus238.Output circuit234 determines whether a monophasic or biphasic pulse is delivered, whether the housing serves as cathode or anode and which electrodes are involved in delivery of the pulse. An example of output circuitry for delivery of biphasic pulse regimens may be found in U.S. Pat. No. 4,727,877 to Kallok, incorporated by reference in its entirety.
• An example of circuitry which may be used to control delivery of monophasic pulses is set forth in commonly assigned U.S. Pat. No. 5,163,427, by Keimel, issued Nov. 17, 1992, also incorporated herein by reference in its entirety. However, output control circuitry as disclosed in U.S. Pat. No. 4,953,551, issued to Mehra et al. on Sep. 4, 1990 or U.S. Pat. No. 4,800,883, issued to Winstrom on Jan. 31, 1989 both incorporated herein by reference in their entireties, may also be used in conjunction with a device embodying the present invention for delivery of biphasic pulses.
• In modern implantable cardioverter/defibrillators, the particular therapies are programmed into the device ahead of time by the physician, and a menu of therapies is typically provided. For example, on initial detection of a tachycardia, an anti-tachycardia pacing therapy may be selected and delivered to the pacing electrode array. On redetection of tachycardia, a more aggressive antitachycardia pacing therapy may be scheduled. If repeated attempts at anti-tachycardia pacing therapies fail, a higher level cardioversion pulse may be selected thereafter. Therapies for tachycardia termination may also vary with the race of the detected tachycardia, with the therapies increasing in aggressiveness as the rate of the detected tachycardia increases. For example, fewer attempts at antitachycardia pacing may be undertaken prior to delivery of cardioversion pulses if the rate of the detected tachycardia is above a preset threshold. The references cited above in conjunction with descriptions of prior art tachycardia detection and treatment therapies are applicable here as well.
• In the event that fibrillation is identified, the typical therapy will be delivery of a high amplitude defibrillation pulse, typically in excess of 5 joules. Lower energy levels may be employed for cardioversion. As in the case of currently available implantable pacemaker/cardioverter/defibrillators, and as discussed in the above-cited references, it is envisioned that the amplitude of the defibrillation pulse may be incremented in response to failure of an initial pulse or pulses to terminate fibrillation. Prior art patents illustrating such pre-set therapy menus or antitachyarrhythmia therapies include U.S. Pat. No. 4,830,006, issued to Haluska et al., U.S. Pat. No. 4,727,380, issued to Vollmann et al. and U.S. Pat. No. 4,587,970, issued to Holley et al., all also incorporated herein by reference in their entireties.
• The device illustrated inFIG. 8 provides the full functionality of a modern ICD. If the invention is to be practiced in an embodiment wherein no high voltage cardioversion/defibrillation pulses are to be delivered, such in cases in which the pacing electrode array is coupled to an external or implantable pacemaker, the structures inFIG. 8 associated with delivery of cardioversion/defibrillation pulses can be deleted. Provisions for detection of tachyarrhythmias should be retained if the pacemaker is to provide anti-arrhythmia pacing.
• FIG. 9 is a schematic diagram of sensing of depolarization events utilizing a medical device of the present invention. As illustrated inFIG. 9, during periods of normal depolarization, i.e., periods in which there is proper atrioventricular (AV) conduction resulting in ventricular depolarizations with supraventricular origin, idealized depolarization signals400-406 are generated as a result of corresponding electrical activity generated through the heart for each depolarization. In a three electrode embodiment of the present invention that includeselectrodes204,210 and211 described above, for example, whereelectrode204 is positioned withincostal muscle220 along the abdomen below the sternum,electrode210 is positioned in the anterior thorax, overlaying the heart, slightly left of the sternum and within the fourth intercostal space to be positioned at a location associated the V4 lead of the twelve-lead ECG position, andelectrode211 is positioned laterally left of the sternum frominsulated patch212 to be located at the V6 lead location of the twelve-lead ECG position, a corresponding localized signal408-414 is sensed byelectrodes204,210 and211, respectively, for each depolarization. Each of the sensed localized signals408-414 includes a respective moment of activation (MOA) of the localized ventricular muscle near the electrode, defined as the zero crossing of the signal. Therefore,localized depolarization408 includes MOAs416-420, which occur overdetection duration422,localized depolarization410 includes MOAs424-428, which occur overdetection duration430,localized depolarization412 includes MOAs432-436, which occur overdetection duration438, andlocalized detection depolarization414 includes MOAs440-444, which occur overdetection duration446.
• In this way, as each of the depolarization signals400-406 propagates through the heart, the propagation is sensed locally atelectrodes204,210 and211. Depending upon the electrical activity forming the depolarization event, i.e., whether the depolarization is the result of normal sinus rhythm, a supraventricular event, or a ventricular tachycardia event, and so forth, the sensed localized signals408-414 are detected in a given sequence and duration that is determined to be characteristic of that event for the particular patient. For example, in the exemplary detection result illustrated inFIG. 9, assumingelectrode204 is identified as a first electrode,electrode210 is identified as a second electrode, andelectrode211 is identified as a third electrode, and if depolarizations400-406 are first detected byelectrode204, then byelectrode211, followed byelectrode210, a 1-3-2 detection sequence is generated betweenelectrodes204,210 and211. Thedetection durations422,430,438,446, i.e., the duration between the moment of activation of the first electrode to detect the depolarization and the moment of activation of the last electrode to detect the depolarization, remains approximately the same for each local depolarization408-414. Such a detection sequence and duration may be determined to correspond to normal sinus rhythm, for example. Since this detection sequence and duration represents normal conduction through the patient's heart, it may also represent the patient's normal intrinsic rhythm during atrial fibrillation, or during supraventricular tachycardia such as sinus tachycardia or rapidly conducted atrial fibrillation. Subtle changes indurations422,430,438 and446 may result from accelerated heart rates during supraventricular tachycardia due to physiologic factors such as increased catecholamine levels, etc.
• FIGS. 10 and 11 are schematic diagrams of sensing of depolarization events utilizing a medical device of the present invention. As described previously, the detection sequence and duration during supraventricular tachycardia may be similar to the patient's intrinsic rhythm (i.e. normal sinus rhythm), but at a faster heart rate. As illustrated inFIG. 10, a supraventricular tachycardia event may also have conduction aberrancy which results in a detection duration and sequence corresponding toelectrodes204,210 and211 which differs from the duration and sequence determine to correspond to normal intrinsic rhythm for that patient.Localized depolarization508 includes MOAs516-520, which occur overdetection duration522, localized depolarization510 includes MOAs524-528, which occur overdetection duration530,localized depolarization512 includes MOAs532-536, which occur overdetection duration538, andlocalized detection depolarization514 includes MOAs540-544, which occur over detection duration546. Thedetection durations522,530,538 and546 may or may not differ relative to theduration420 associated with normal sinus rhythm, depending upon the patient, but remain approximately the same for each depolarization500-506.
• In the same way, as illustrated inFIG. 11, during a ventricular tachycardia event, depolarizations600-606 are first detected byelectrode210, then byelectrode204, followed byelectrode211, resulting in a 2-1-3 detection sequence.Localized depolarization608 includes MOAs616-620, which occur overdetection duration622,localized depolarization610 includes MOAs624-628, which occur overdetection duration630,localized depolarization612 includes MOAs632-636, which occur overdetection duration638, andlocalized detection depolarization614 includes MOAs640-644, which occur overdetection duration646. Thedetection durations622,630,638 and646 may or may not differ relative toduration420 associated with normal sinus rhythm ordurations522,530,538 and546 associated with supraventricular tachycardia, depending upon the patient, but remains approximately the same for each depolarization600-606. During a ventricular fibrillation event, the synchronization of the moment of activations is no longer present, and therefore two significant and relatively easily detectable changes occur with the onset of ventricular fibrillation, namely the sequence of moment of activations and the delays with respect to the other sensor sites change from cycle to cycle for any sensor site, and the event-to-event time or interval between consecutive events varies from beat to beat and from sensor to sensor. Thus, the present invention uses these factors to identify a ventricular fibrillation event.
• FIG. 12 is a flowchart of a method for detecting arrhythmias in a medical device according to an embodiment of the present invention. As illustrated inFIG. 12, during an initialization period subsequent to placement ofdevice200 within patient using one of the electrode configurations described above, for example, a determination is made whether normal sensing has been established for each of the electrodes,Step700, such aselectrodes204,210 and211 if the three electrode configuration is utilized. In addition, sensing of cardiac activity may occur between any pair of electrode sub-elements (308,312,316) fromelectrodes204,210,211, or between any electrode sub-elements (308,312,316) and any metallic housing or defibrillation electrodes. Such sensing of cardiac activity from non-concentric electrodes provides a more “global” (non-localized) view of cardiac activity than the more localized concentric sensing fromelectrode204,210, and211. Once normal sensing is established at each electrode, noise levels are determined for each of the electrodes, and, based on the determined noise levels, one of the signals fromelectrodes204,210 and211 or the global sensing vector (described above) is chosen to be utilized for rate detection,Step702. As a result, local noise sensed at electrodes resulting from activation of local muscles during intermittent periods of body motion during patient activity can be reduced. Furthermore, since noise due to body motion only intermittently affects the signal quality at an electrode when local muscles are activated, having more than one electrode provides a “redundant” set of cardiac signals that are each affected by muscle noise only during the time when the local muscle is activated, resulting in increased accuracy in sensing cardiac signals.
• Once the electrode that is to be utilized for rate detection has been established, the sequences and durations of the sensed signal at the electrodes for normal rhythms, such as normal sinus rhythm or supraventricular tachycardia, are determined,step704, such as those described above in reference toFIGS. 8 and 9. Using the sequences illustrated inFIGS. 9 and 10, for example, to determine the detection sequences inStep704, normal sinus rhythm and normal supraventricular tachycardia is identified as being associated with a 1-3-2 detection sequence, and aberrant supraventricular tachycardia is identified as being associated with a 2-3-1 detection sequence between theelectrodes204,210 and211. At least one of these normal detection sequences and durations is stored as a “template” by the device for purposes of rhythm classification during future “unknown” fast rate rhythms. Methods for automatically collecting and updating templates of cardiac activity have been previously described in the patent literature, and could be applied in this device to update the detection sequence and durations associated with the patient's normal rhythm. For example, the template generation methods disclosed in commonly assigned U.S. Pat. No. 6,745,068, issued to Koyrakh et al., U.S. patent application Ser. No. 10/826,618 to Cao et al., U.S. patent application Ser. No. 10/826,512 to Cao et al., and U.S. patent application Ser. No. 11/002,482 to Cao et al., all incorporated by reference in their entireties, may be utilized.
• After the template of normal rhythm is established, the device is ready to apply the template to the rhythm detection and classification process. Determination of the best signal for rate detection is made by continuously monitoring of all cardiac signals. The cardiac signal with best signal to noise ratio is selected for rate determination among the candidate cardiac signals. Noise levels and signal amplitudes are monitored continuously, and increased noise levels and/or reduced signal amplitudes in the current rate detection sensor are both reasons to potentially change the rate detection signal (step708). The device continuously monitors the rate detected at the optimum rate detection electrode and determines whether the detected rate meets a predetermined rate detection criterion. The rate detection criterion may consistent of one or more thresholds, such as when the detected rate exceeds a predetermined rate detection threshold, if the detected rate is slower than a predetermined rate detection threshold (indicative of undersensing of the present rhythm or asystole), or if the detected rate becomes highly irregular (also indicative of undersensing of the current rhythm), for example,Step710. The predetermined detection criterion is programmable, and therefore can be set at any desired set of conditions. According to an embodiment of the present invention, the predetermined rate detection threshold is set to 200 beats per minute, for example, so that an arrhythmia is detected when the detected rate is greater than or equal to 200 beats per minute. Similarly, undersensing may be indicated if the detected rate becomes less than 30 bpm or if the detected rate results in high variability which is indicated by beat-beat variations in detected cardiac intervals of 250 ms or more, or more than some percentage of the patient average heart rate (i.e. beat-to-beat variability of more than 50% of the current heart rate).
• If the rate detection criterion are not satisfied, e.g., the detected rate is not irregular, does not exceed the predetermined rate detection threshold, or is not less than the predetermined asystole rate detection threshold, NO inStep710, a determination is again made as to which electrode is best suited to be chosen to be utilized as the rate detection electrode,Step708, and the determination of whether the rate detection threshold has been satisfied,Step710, is repeated using the current selected rate detection electrode.
• Once the rate detection criteria are satisfied, Yes inStep710, the sequence and/or duration of the corresponding signals sensed by the electrodes is determined,Step712, and, based on the determined sequence and/or duration, the origin of the rhythm is determined,Step714. In particular, for example, if it is determined that the sequence and/or duration of the current rhythm that meets the rate detection criteria (determined in step712) is different than the template of normal or aberrant SVT sequence/duration established instep704, then the appropriate therapy is delivered, such as shock therapy, for example. Beat-to-beat variability of the sequence of activation and/or duration of the current rhythm may indicate a polymorphic rhythm or VF, also indicative of therapy. On the other hand, if it is determined that the sequence and duration established byelectrodes214,210 and211 instep712 is the same as normal or aberrant SVT, then the fast rhythm may be classified as normal and therapy is withheld. Once it is decided to deliver a therapy, the duration and sequences of the events may be used to determine what type of therapy is delivered, such as a pacing therapy or a shock. For example, fibrillatory rhythms may require a shock and will be characterized by disappearance of the synchronization of the MOAs. This may be indicated by the changes in the sequence of MOAs and the delays with respect to the other sensor sites from cycle to cycle for any sensor site and variability of the event-to-event time from beat to beat and from sensor to sensor. On the other hand, rhythms that may be terminated by antitachycardia pacing therapy will demonstrate relative beat-to-beat synchrony of the MOAs.
• An additional confirmatory step,716, may be optionally applied in order to confirm the presence of an arrhythmic event. In particular, rhythms such as fine ventricular fibrillation may be difficult to distinguish from asystole or normal intrinsic rhythm during extended periods (a few cardiac cycles) of noise on one or more of the Laplacian sensors. In order to confirm or refute the presence of a treatable ventricular tachyarrhythmia, one or more pacing pulses could be delivered between two of the sensors, and the cardiac evoked response can be measured by the third electrode/sensor. In asystole, or during electrical noise, there would be a cardiac evoked response but during VF, there wouldn't be a cardiac evoked response. This confirmatory step may or may not be used for rhythms where the activation sequence or duration is consistent from beat-beat, since under these conditions it is more certain that the true rhythm is represented by the electrical events that are being detected, and not corrupted by noise or asystole.
• According to an embodiment of the present invention, the change in duration is determined inStep712 by comparing durations associated with the current rhythm with the durations determined for the determined durations established inStep704. For example, according to an embodiment of the present invention, the detection duration associated with the current rhythm is compared with the detection duration for normal sinus rhythm that was determined inStep704, and if the amount that the current detection duration is greater than the normal sinus rhythm duration is less than or equal to a predetermined threshold, the current rhythm is likely a fast rhythm occurring via the normal conduction pattern, and therefore treatment is withheld. If the amount that the current detection duration is greater than the normal sinus rhythm duration is greater than the predetermined threshold, the current rhythm is likely a fast rhythm occurring somewhere other than the normal conduction pattern, and therefore treatment is delivered.
• FIG. 13 is an exemplary illustration of determining change in duration for a current rhythm according to an embodiment of the present invention. According to an embodiment of the present invention, the detection duration for normal sinus rhythm is classified by identifying the first electrode to detect the rhythm as a reference electrode and setting the reference electrode equal to zero milliseconds. The second and third electrodes are then defined relative to the reference electrode. In particular, as illustrated inFIG. 13, using the exemplary rhythms illustrated inFIGS. 9-11, using the detection sequence associated withelectrodes204,210 and211 for normal sinus rhythm as being determined to be a 1-3-2 sequence (FIG. 8), since the first electrode to detect a signal during normal sinus rhythm iselectrode204, followed byelectrode211 and then electrode210,electrode204 is set as the reference electrode and is therefore set equal to zero. Since the signal is detected byelectrode211 approximately 30 milliseconds after being detected by the reference electrode (electrode204) a detection time value forelectrode211 is therefore set equal to 30 milliseconds. In the same way, since the signal is detected byelectrode210 approximately 80 milliseconds after being detected by the reference electrode, a detection time value forelectrode210 is set equal to 80 milliseconds.
• In the same way, timing values are assigned forelectrodes204,210 and211 during detection of the subsequently sensed rhythm inStep712 so that the first electrode to sense the current rhythm is set as the reference electrode and therefore set equal to zero and the other two electrodes are then defined relative to the reference electrode. In particular, as illustrated inFIG. 13, sinceelectrode210 is the first electrode to detect the current rhythm, followed byelectrode204 and then byelectrode211,electrode210 is set as the reference electrode and is therefore set equal to zero. Since the current rhythm is detected byelectrode204 approximately 80 milliseconds after being detected by the reference electrode (electrode210), a detection time value forelectrode204 is set equal to 80 milliseconds. In the same way, since the current rhythm is detected byelectrode211 approximately 130 milliseconds after being detected by the reference electrode, a detection time value forelectrode211 is set equal to 130 milliseconds.
• It is understood that while a reference point for defining the detection by the electrodes is described in terms of defining the first electrode to detect the rhythm as the reference electrode, other reference points may be utilized. For example, according to an embodiment of the present invention, a peak of a far-field signal detected between two electrodes or between an electrode and the housing of the device, may be utilized as the reference so that the relative times associated with each of the electrodes is defined relative to the detected peak voltage of the far-field signal rather than the first electrode to detect the rhythm locally.
• Once the values have been determined for the current rhythm, the sum of the absolute differences of the relative detection time values associated with one of the rhythms determined inStep704, such as normal sinus rhythm, for example, and the relative detection time values associated with the current rhythm is determined in order to generate a detection duration for the current rhythm. For example, the absolute difference between the relative detection time values associated withelectrode204, i.e., between 0 milliseconds and 80 milliseconds, is determined to be 80 milliseconds, the absolute difference between the relative detection time values associated withelectrode210, i.e., between 80 milliseconds and 0 milliseconds, is determined to be 80 milliseconds, and the absolute difference between the relative detection time values associated withelectrode211, i.e., 30 milliseconds and 130 milliseconds, is determined to be 100 milliseconds, so that the detection duration is determined to be 260 milliseconds (80 ms+80 ms+100 ms), for example.
• According to the present invention, the determined detection duration is used to discriminate between cardiac events and is utilized in determining whether to provide therapy and/or the type of therapy to be provided. For example, if the detection duration is determined to be less than or equal to a predetermined threshold, such as 30 ms for example, it is likely that the conduction pattern of the fast rhythm propagates via the normal His-Purkinje system, and therefore no therapy is delivered. However, once the detection duration is substantial, i.e., greater than the predetermined threshold, it is likely that the rhythm is being propagated along a conduction path different from the normal His-Purkinje pathway, such as a cell-to cell conduction pathway that originates in the ventricles. Therefore, it is likely the rhythm is either ventricular tachycardia or supraventricular tachycardia with bundle branch block aberency, and therapy should be delivered.
• It is understood that while multiple Laplacian electrodes are illustrated as being utilized above, the present invention could include the use of a single Laplacian sensor and a global sensing in order to provide adequate discrimination. Additional Laplacian electrodes would only serve to improve discrimination accuracy and may not be required.
• FIGS. 14A-14C are schematic diagrams of electrode configurations in an exemplary medical device according to the present invention. For example, as illustrated inFIGS. 14A and 14B, a patch electrode according to an embodiment of the present invention may include twoelectrodes902 and904, only one of which is utilized as both a sensing and defibrillation electrode. Defibrillation therapy is delivered using both electrodes. According to another embodiment illustrated inFIG. 14C, apatch906 is formed to integrate one or moreLaplacian sensors908,910 that are utilized both for sensing and for delivering therapy in combination with alarger surface electrode912 utilized during defibrillation. For example, the patch could be Y-shaped with a Laplacian electrode at the top ends of the “Y”, with the “Y” serving as a cathode and energy would be delivered to an active can which would serve as the anode and also contain a Laplacian electrode. The electrode patch could take any desired shape that enables the use of the larger defibrillation electrode with one or more sensing and defibrillation electrodes.
• Some of the techniques described above may be embodied as a computer-readable medium comprising instructions for a programmable processor such as a microprocessor. The programmable processor may include one or more individual processors, which may act independently or in concert. A “computer-readable medium” includes but is not limited to any type of computer memory such as floppy disks, conventional hard disks, CR-ROMS, Flash ROMS, nonvolatile ROMS, RAM and a magnetic or optical storage medium. The medium may include instructions for causing a processor to perform any of the features described above for initiating a session of the escape rate variation according to the present invention.
• The preceding specific embodiments are illustrative of the practice of the invention. It is to be understood, therefore, that other expedients known to those of skill in the art or disclosed herein may be employed without departing from the invention or the scope of the appended claim. It is therefore to be understood that the invention may be practiced otherwise than as specifically described, without departing from the scope of the present invention. As to every element, it may be replaced by any one of infinite equivalent alternatives, only some of which are disclosed in the specification.

Claims (19)

What is claimed is:

1. A medical device for detecting arrhythmias in a patient, comprising:

a plurality of electrodes positioned subcutaneously within the patient;

a microprocessor, coupled to the plurality of electrodes, determining one of a sequence of the sensing of cardiac signals by the plurality of electrodes and a duration between the sensing of cardiac signals by the plurality of electrodes; and

control circuitry delivering a therapy in response to one of the determined sequence and the determined duration.

2. The device ofclaim 1, wherein the microprocessor determines occurrences of variations in a first sequence of moments of activation associated with a first electrode of the plurality of electrodes and a second sequence of moments of activation associated with a second electrode of the plurality of electrodes, and occurrences of differences in durations associated with the first moments of activation and the second moments of activation, and wherein the control circuitry delivers a first therapy in response to the determined occurrences of sequence variations and a second therapy in response to the determined occurrence of both sequence variations and differences in durations.

3. The device ofclaim 1, wherein the control circuitry delivers a pacing pulse between a first electrode of the plurality of electrodes and a second electrode of the plurality of electrodes, and the microprocessor determines an evoked response to the pacing pulse via a third electrode of the plurality of electrodes, and confirms the presence of an event in response to the determined evoked response.

4. The device ofclaim 1, wherein the microprocessor determines whether the sequence and the duration are substantially consistent.

5. The device ofclaim 1, wherein the microprocessor compares a change in the duration between sensed signals to a predetermined threshold, and the control circuitry withholds the delivery of the therapy in response to the comparing.

6. The device ofclaim 1, wherein the microprocessor determines a relative detection time corresponding to the sensing of cardiac signals.

7. The device ofclaim 1, wherein the microprocessor identifies a first electrode of the plurality of electrodes to detect the signals as a reference electrode, determines relative values corresponding to detection of the signals by a second electrode of the plurality of electrodes to detect the signal and a third electrode of the plurality of electrodes to detect the signals relative to the reference electrode, and generates a detection duration corresponding to the signals in response to the determined relative values.

8. The device ofclaim 1, further comprising a patch providing a common substrate integrating the plurality of electrodes thereon.

9. The device ofclaim 1, wherein propagation of the cardiac signals is sensed locally.

10. A method of detecting arrhythmias in a medical device, comprising:

sensing cardiac signals via a plurality of electrodes positioned subcutaneously within a patient;

determining one of a sequence of the sensing of cardiac signals by the plurality of electrodes and a duration between the sensing of cardiac signals by the plurality of electrodes; and

delivering a therapy in response to one of the determined sequence and the determined duration.

11. The method ofclaim 10, further comprising:

generating a template corresponding to one of a sequence and a duration associated with a predetermined rhythm; and

comparing the determined one of a sequence of the sensing of cardiac signals by the first electrode and the second electrode and a duration between the sensing of cardiac signals by the first electrode and the second electrode to the generated template, wherein the therapy is delivered in response to the comparing.

12. The method ofclaim 10, wherein the determining comprises determining occurrences in variation of a first sequence of moments of activation associated with a first electrode of the plurality of electrodes and a second sequence of moments of activation associated with a second electrode of the plurality of electrodes, and occurrences of differences in durations associated with the first moments of activation and the second moments of activation, and wherein delivering a therapy comprises delivering a first therapy in response to the determined occurrences of sequence variations and a second therapy in response to the determined occurrence of both sequence variations and differences in durations.

13. The method ofclaim 10, further comprising:

delivering a pacing pulse between a first electrode of the plurality of electrodes and a second electrode of the plurality of electrodes;

determining an evoked response via a third electrode of the plurality of electrodes; and

confirming the presence of an event in response to the determining of an evoked response.

14. The method ofclaim 13, further comprising determining whether the sequence and the duration are substantially consistent.

15. The method ofclaim 10, further comprising:

comparing a change in the duration between sensed signals to a predetermined threshold; and

withholding the delivery of the therapy in response to the comparing.

16. The method ofclaim 15, further comprising determining a relative detection time corresponding to sensing of the signals.

17. The method ofclaim 16, wherein comparing a change in the duration comprises:

identifying a first electrode of the plurality of electrodes to detect the signals as a reference electrode;

determining relative values corresponding to detection of the signals by a second electrode of the plurality of electrodes to detect the signal and a third electrode of the plurality of electrodes to detect the signals relative to the reference electrode; and

generating a detection duration corresponding to the signals in response to the determined relative values.

18. The method ofclaim 10, wherein propagation of the cardiac signals is sensed locally.

19. A computer readable medium having computer executable instructions for performing a method of detecting arrhythmias in a medical device comprising:

sensing cardiac signals via a plurality of electrodes positioned subcutaneously within a patient;

determining one of a sequence of the sensing of cardiac signals by the plurality of electrodes and a duration between the sensing of cardiac signals by the plurality of electrodes; and

delivering a therapy in response to one of the determined sequence and the determined duration.

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