US20210290094A1 - Pacing induced electrical activation grading - Google Patents

Abstract

In one embodiment, a medical procedure system includes a probe for insertion into a chamber of a heart of a living subject, and including a first electrode to apply a sequence of pacing pulses at a position in the chamber, a second electrode to sense an electrical activation signal responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber, a display, and processing circuitry to evaluate a successful acquisition by the second electrode of the induced electrical activations responsively to the electrical activation signal, the successful acquisition being indicative of a successful capture of the pacing pulses by the myocardium, compute a capture grade responsively to the evaluation of the successful acquisition of the induced electrical activations, the capture grade being indicative of a count of the induced electrical activations evaluated as being successfully acquired, and render the capture grade to the display.

Description

FIELD OF THE INVENTION
• The present invention relates to medical systems, and in particular, but not exclusively, to electrical activation for medical procedures.
BACKGROUND
• A wide range of medical procedures involve placing probes, such as catheters, within a patient's body. Location sensing systems have been developed for tracking such probes. Magnetic location sensing is one of the methods known in the art. In magnetic location sensing, magnetic field generators are typically placed at known locations external to the patient. A magnetic field sensor within the distal end of the probe generates electrical signals in response to these magnetic fields, which are processed to determine the coordinate locations of the distal end of the probe. These methods and systems are described in U.S. Pat. Nos. 5,391,199, 6,690,963, 6,484,118, 6,239,724, 6,618,612 and 6,332,089, in PCT International Publication No. WO 1996/005768, and in U.S. Patent Application Publications Nos. 2002/006455 and 2003/0120150 and 2004/0068178. Locations may also be tracked using impedance or current based systems.
• One medical procedure in which these types of probes or catheters have proved extremely useful is in the treatment of cardiac arrhythmias. Cardiac arrhythmias and atrial fibrillation in particular, persist as common and dangerous medical ailments, especially in the aging population.
• Diagnosis and treatment of cardiac arrhythmias include mapping the electrical properties of heart tissue, especially the endocardium and the heart volume, and selectively ablating cardiac tissue by application of energy. Such ablation can cease or modify the propagation of unwanted electrical signals from one portion of the heart to another. The ablation process destroys the unwanted electrical pathways by formation of non-conducting lesions. Various energy delivery modalities have been disclosed for forming lesions, and include use of microwave, laser and more commonly, radiofrequency energies to create conduction blocks along the cardiac tissue wall. In a two-step procedure, mapping followed by ablation, electrical activity at points within the heart is typically sensed and measured by advancing a catheter containing one or more electrical sensors into the heart, and acquiring data at a multiplicity of points. These data are then utilized to select the endocardial target areas at which the ablation is to be performed.
• Electrode catheters have been in common use in medical practice for many years. They are used to stimulate and map electrical activity in the heart and to ablate sites of aberrant electrical activity. In use, the electrode catheter is inserted into a major vein or artery, e.g., femoral artery, and then guided into the chamber of the heart of concern. A typical ablation procedure involves the insertion of a catheter having a one or more electrodes at its distal end into a heart chamber. A reference electrode may be provided, generally taped to the skin of the patient or by means of a second catheter that is positioned in or near the heart. RF (radio frequency) current is applied to the tip electrode(s) of the ablating catheter, and current flows through the media that surrounds it, i.e., blood and tissue, toward the reference electrode.
• The distribution of current depends on the amount of electrode surface in contact with the tissue as compared to blood, which has a higher conductivity than the tissue. Heating of the tissue occurs due to its electrical resistance. The tissue is heated sufficiently to cause cellular destruction in the cardiac tissue resulting in formation of a lesion within the cardiac tissue which is electrically non-conductive.
• US Patent Publication 2018/0235537 describes a system for assigning zone rankings to a patient. The system includes a processor, at least one database, and a computer readable medium in communication with the at least one database and comprising one or more instructions that, when executed, can cause the processor to receive at least one physiological signal from a medical monitoring device that is worn by a patient; assign a normal zone ranking to the patient based upon historical patient data stored on the at least one database; determine one or more metrics from the at least one physiological signal of the patient; assign a first zone ranking to the patient based upon the one or more metrics, the first zone ranking selected from a plurality of abnormal zone rankings stored on the at least one database; determine one or more actions to initiate based upon the assigned first zone ranking; and initiate the one or more determined actions.
• U.S. Pat. No. 9,560,980 to Charlton, et al., describes an implantable medical device (IMD) that is implanted in a patient. The IMD uses a plurality of electrode vectors to generate intrathoracic impedance measurements. The intrathoracic impedance measurements can be indicative of amounts of intrathoracic fluid in the patient. An accumulation of intrathoracic fluid may indicate that the patient is at an increased risk of experiencing a heart failure event in the near future. The IMD performs a vector selection operation on a recurring basis. When the IMD performs the vector selection operation, the IMD uses impedance measurements to select one of the electrode vectors. The IMD can perform a risk assessment operation on another recurring basis. During performance of the risk assessment operation, the IMD uses impedance measurements of the selected electrode vector and/or other patient characteristics stored within the IMD to determine whether the patient is at an increased risk of experiencing a heart failure event.
• U.S. Pat. No. 10,314,502 to Peterson, et al., describes systems and methods for evaluating multiple candidate sensing vectors for use in sensing electrical activity of a heart. The system can sense physiologic signals using each of a plurality of candidate sensing vectors, and generate respective signal intensity indicators and interference indicators using the physiologic signals sensed by using the respective sensing vectors. The system can also receive electrode information of each of the candidate sensing vectors, including information about sensing electrodes that are also used for delivering cardiac electrostimulation. The system can rank at least some of the plurality of candidate sensing vectors according to the signal intensity indicators, the interference indicators, and the electrode information. The system can also include a user interface for displaying the ranked sensing vectors, and allowing the user to select at least one sensing vector for use in sensing the cardiac electrical activity.
• U.S. Pat. No. 10,092,761 to An, et al., describes systems and methods for evaluating multiple candidate electrostimulation vectors for use in therapeutic cardiac stimulation. The system can include a programmable electrostimulator circuit for delivering electrostimulation to one or more sites of a heart according to multiple candidate electrostimulation vectors. One or more physiologic sensors can detect resulting physiologic responses to the electrostimulation. A processor circuit can generate categories of indicators including therapy efficacy indicators, battery longevity indicators, or complication indicators using the sensed physiologic responses. The candidate electrostimulation vectors can be ranked according to the categories of indicators in specified orders. The system can include a user interface for displaying the ranked candidate electrostimulation vectors, and allowing the user to select one or more electrostimulation vectors and programming the electrostimulator circuit to deliver therapeutic electrostimulation to at least one site of the heart using the selected electrostimulation vectors.
• US Patent Publication 2010/0198292 to Honeck, et al., describes techniques including delivering cardiac pacing therapy from a medical device to a chamber of a heart via a first electrode configuration and determining that the delivery of cardiac pacing therapy via the first electrode configuration inadequately captures the chamber. In response to such a determination, the medical device delivers cardiac pacing therapy to the chamber of the heart via a plurality of additional electrode configurations. The techniques further comprise determining a capture characteristic for each of the additional electrode configurations based on the delivery of cardiac pacing therapy to the chamber of the heart via the plurality of other electrode configurations. A new electrode configuration for cardiac pacing may be selected based on the capture characteristics of the various electrode configurations.
• US Patent Publication 2016/0166166 to Bunch, et al., describes methods for treating cardiac complex rhythm disorder in a patient including receiving a plurality of electrical signals from a sensor system, wherein each electrical signal corresponds with a separate location on a cardiac wall of the heart of the patient, and wherein each electrical signal comprises an electrogram waveform; and ranking the electrical signals relative to each other based on at least a uniformity and a frequency of the electrogram waveform of each electrical signal.
SUMMARY
• There is provided in accordance with an embodiment of the present invention, a medical procedure system, including a probe configured for insertion into a chamber of a heart of a living subject, and including a first electrode configured to apply a sequence of pacing pulses at a position in the chamber, a second electrode configured to sense an electrical activation signal responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber over time, a display, and processing circuitry configured to evaluate a successful acquisition by the second electrode of the induced electrical activations responsively to the electrical activation signal, the successful acquisition being indicative of a successful capture of the pacing pulses by the myocardium, compute a capture grade responsively to the evaluation of the successful acquisition of the induced electrical activations, the capture grade being indicative of a count of the induced electrical activations which were evaluated as being successfully acquired, and render the capture grade to the display.
• Further in accordance with an embodiment of the present invention the processing circuitry is configured to evaluate the successful acquisition by the second electrode of respective ones of the electrical activations induced by respective ones of the pacing pulses responsively to the electrical activation signal exceeding a threshold signal amplitude within a given time window after the respective pacing pulses.
• Still further in accordance with an embodiment of the present invention the processing circuitry is configured to compute the capture grade responsively to a count of the induced electrical activations evaluated as being successfully acquired by the second electrode.
• Additionally, in accordance with an embodiment of the present invention the processing circuitry is configured to compute the capture grade also responsively to a count of unacquired electrical activations.
• Moreover, in accordance with an embodiment of the present invention the processing circuitry is configured to compute the capture grade also responsively to a total count of the pacing pulses.
• Further in accordance with an embodiment of the present invention the processing circuitry is configured to compute the capture grade responsively to a count of unacquired electrical activations and a total count of the pacing pulses.
• Still further in accordance with an embodiment of the present invention, the system includes a pacing unit configured to generate the pacing pulses for application by the first electrode.
• Additionally, in accordance with an embodiment of the present invention the processing circuitry is configured to render to the display the capture grade with a representation of the electrical activation signal.
• Moreover, in accordance with an embodiment of the present invention the processing circuitry is configured to track a location of the second electrode.
• Further in accordance with an embodiment of the present invention the processing circuitry is configured to render to the display a representation of another probe responsively to the tracked location.
• There is also provided in accordance with another embodiment of the present invention, a medical procedure method including inserting a first probe into a chamber of a heart of a living subject, applying with a first electrode of the first probe a sequence of pacing pulses at a position in the chamber, sensing with a second electrode an electrical activation signal responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber over time, evaluating a successful acquisition by the second electrode of the induced electrical activations responsively to the electrical activation signal, the successful acquisition being indicative of a successful capture of the pacing pulses by the myocardium, computing a capture grade responsively to the evaluation of the successful acquisition of the induced electrical activations, the capture grade being indicative of a count of the induced electrical activations which were evaluated as being successfully acquired, and rendering the capture grade to a display.
• Still further in accordance with an embodiment of the present invention the evaluating includes evaluating the successful acquisition by the second electrode of respective ones of the electrical activations induced by respective ones of the pacing pulses responsively to the electrical activation signal exceeding a threshold signal amplitude within a given time window after the respective pacing pulses.
• Additionally, in accordance with an embodiment of the present invention the computing includes computing the capture grade responsively to a count of the induced electrical activations evaluated as being successfully acquired by the second electrode.
• Moreover, in accordance with an embodiment of the present invention the computing also includes computing the capture grade also responsively to a count of unacquired electrical activations.
• Further in accordance with an embodiment of the present invention the computing also includes computing the capture grade also responsively to a total count of the pacing pulses.
• Still further in accordance with an embodiment of the present invention the computing includes computing the capture grade responsively to a count of unacquired electrical activations and a total count of the pacing pulses.
• Additionally, in accordance with an embodiment of the present invention, the method includes generating the pacing pulses for application by the first electrode.
• Moreover, in accordance with an embodiment of the present invention the rendering includes rendering to the display the capture grade with a representation of the electrical activation signal.
• Further in accordance with an embodiment of the present invention, the method includes tracking a location of the second electrode.
• Still further in accordance with an embodiment of the present invention the rendering including rendering to the display a representation of another probe responsively to the tracked location.
BRIEF DESCRIPTION OF THE DRAWINGS
• The present invention will be understood from the following detailed description, taken in conjunction with the drawings in which:
• FIG. 1 is a schematic view of a medical procedure system constructed and operative in accordance with an exemplary embodiment of the present invention;
• FIG. 2 is a schematic view of a catheter for use in the system ofFIG. 1;
• FIG. 3 is a schematic view of an intracardiac electrogram generated by the system ofFIG. 1;
• FIG. 4 is a schematic view of part of the intracardiac electrogram ofFIG. 3;
• FIG. 5 is a schematic view of a user interface generated by the system ofFIG. 1; and
• FIG. 6 is a flowchart including steps in a method of operation of the medical procedure system ofFIG. 1.
DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTSOverview
• Pacing signals may be used in mapping a cardiac chamber or in preparation for mapping a cardiac chamber or in preparation for other medical procedures. For example, pacing signals may be used to map conduction pathways and identify abnormal conduction pathways. Additionally, or alternatively, a physician may observe electrical activation signals (induced by pacing) and captured by a myocardium of the cardiac chamber to determine if the electrode(s) are reliably placed in the cardiac chamber. The reliability of electrode placement may refer to the placement of the electrode applying the pacing signals and/or the electrode sensing the electrical activity induced by the pacing signals. Once an electrode is determined to be reliably placed in the cardiac chamber, the electrode may then be used for mapping or for ablation, or any suitable medical procedure. However, visually analyzing the electrical activation signals is a detailed and lengthy process. This is especially critical during a medical procedure, for example, a cardiac procedure, where time is of the essence. Moreover, if the catheter includes multiple electrodes which could include tens or even hundreds of electrodes, the visual analysis task may become too onerous to perform effectively.
• Exemplary embodiments of the present invention solve the above problems by providing a system that automatically evaluates the successful acquisition by an electrode of electrical activations induced by a sequence of pacing pulses responsively to the electrical activation signal. The successful acquisition is indicative of a successful capture of the pacing pulses by the myocardium. The system also computes a capture grade which is indicative of a count of the electrical activations which were evaluated as being successfully acquired. The capture grade provides a quantitative and/or descriptive measure of how well the electrode acquired the electrical activations and therefore a measure of how reliably the electrode is placed in the cardiac chamber and/or a measure of how well the myocardium captured the pacing pulses. For example, if one out of every five electrical activations is acquired, the score may be “low”, or “poor”, or “1”, or “20%”, and if four out of every five electrical activations is acquired the score may be “high”, or “excellent”, or “4”, or “80%”. The quantitative and/or descriptive measure provides the physician with an immediate evaluation of the reliability of the placement of the sensing electrode and/or the pacing application electrode without having to manually visually analyze the electrical activation signals. The above may be repeated for addition electrodes of a probe.
• The quantitative and/or descriptive measure may be used by the physician to grade to the quality of an electrode for mapping (and/or pacing) so that the physician can map (and/or pace) with confidence or perform some other task such as determine quality of tissue contact for ablation.
• In some exemplary embodiments, a medical procedure system includes a first probe which is inserted into a chamber of a heart of a living subject, and a second probe inserted into the chamber. In some exemplary embodiments the first and second probe may be combined into a single catheter. In some exemplary embodiments, the second probe may be replaced by one or more body surface electrodes to sense the electrical activation signal.
• The system includes a pacing unit which generates a sequence of pacing pulses for application by a “first” electrode of the first probe at a position in the chamber (e.g., at the coronary sinus) to induce a corresponding sequence of electrical activations in the myocardium of the chamber over time. A “second” electrode (of the second probe) senses an electrical activation signal responsively to the sequence of electrical activations.
• The system also includes processing circuitry which tracks a location of the second electrode. In some exemplary embodiments, the processing circuitry may also track the location of the first electrode and/or one or more addition electrodes of the second probe.
• The processing circuitry evaluates a successful acquisition by the second electrode of the electrical activations responsively to the electrical activation signal. The successful acquisition is indicative of a successful capture of the pacing pulses by the myocardium This may be repeated for more electrodes of the second probe. In some exemplary embodiments, the processing circuitry evaluates the successful acquisition by the second electrode of respective ones of the electrical activations induced by respective ones of the pacing pulses responsively to the amplitude of the electrical activation signal exceeding a threshold signal amplitude within a given time window after the respective pacing pulses.
• The processing circuitry computes a capture grade of the second electrode responsively to the evaluation of the successful acquisition of each of the electrical activations. The capture grade is indicative of a count of the electrical activations which were evaluated as being successfully acquired by the second electrode. This may also be repeated for other electrodes of the second probe. In some exemplary embodiments, the processing circuitry computes the capture grade responsively to a count of the induced electrical activations evaluated as being successfully acquired by the second electrode, and a count of unacquired electrical activations, or a total count of the pacing pulses. In other exemplary embodiments, the processing circuitry computes the capture grade responsively to a count of unacquired electrical activations and a total count of the pacing pulses.
• The processing circuitry renders the capture grade to a display, which may also be rendered with a representation of the corresponding electrical activation signal. The processing circuitry may also render to the display a representation of the second probe responsively to the tracked location.
System Description
• Reference is now made toFIG. 1, which is a schematic view of amedical procedure system20 constructed and operative in accordance with an exemplary embodiment of the present invention. Reference is also made toFIG. 2, which is a schematic view of acatheter40 for use in thesystem20 ofFIG. 1.
• Themedical procedure system20 is used to determine the position of thecatheter40, seen in an inset25 ofFIG. 1 and in more detail inFIG. 2. Thecatheter40 is a probe which includes ashaft22 and a plurality of deflectable arms54 (only some labeled for the sake of simplicity) for inserting into a body-part (e.g., chamber of a heart26) of a living subject. Thedeflectable arms54 have respective proximal ends connected to the distal end of theshaft22.
• Thecatheter40 includes aposition sensor53 disposed on theshaft22 in a predefined spatial relation to the proximal ends of thedeflectable arms54. Theposition sensor53 may include amagnetic sensor50 and/or at least one shaft electrode52. Themagnetic sensor50 may include at least one coil, for example, but not limited to, a dual-axis or a triple axis coil arrangement to provide position data for location and orientation including roll. Thecatheter40 includes multiple electrodes55 (only some are labeled inFIG. 2 for the sake of simplicity) disposed at different, respective locations along each of thedeflectable arms54. Typically, thecatheter40 may be used for mapping electrical activity in a heart of the living subject using theelectrodes55, or for performing any other suitable function in a body-part of a living subject, for example, but not limited to, reversible and/or irreversible electroporation and/or RF ablation.
• Themedical procedure system20 may determine a position and orientation of theshaft22 of thecatheter40 based on signals provided by themagnetic sensor50 and/or the shaft electrodes52 (proximal-electrode52aand distal-electrode52b) fitted on theshaft22, on either side of themagnetic sensor50. The proximal-electrode52a,the distal-electrode52b,themagnetic sensor50 and at least some of theelectrodes55 are connected by wires running through theshaft22 via acatheter connector35 to various driver circuitries in aconsole24. In some exemplary embodiments, at least two of theelectrodes55 of each of thedeflectable arms54, the shaft electrodes52, and themagnetic sensor50 are connected to the driver circuitries in theconsole24 via thecatheter connector35. In some exemplary embodiments, the distal-electrode52band/or theproximal electrode52amay be omitted.
• The illustration shown inFIG. 2 is chosen purely for the sake of conceptual clarity. Other configurations of shaft electrodes52 andelectrodes55 are possible. Additional functionalities may be included in theposition sensor53. Elements which are not relevant to the disclosed exemplary embodiments of the invention, such as irrigation ports, are omitted for the sake of clarity.
• Aphysician30 navigates thecatheter40 to a target location in a body part (e.g., the heart26) of a patient28 by manipulating theshaft22 using a manipulator32 near the proximal end of thecatheter40 and/or deflection from asheath23. Thecatheter40 is inserted through thesheath23, with thedeflectable arms54 gathered together, and only after thecatheter40 is retracted from thesheath23, thedeflectable arms54 are able to spread and regain their intended functional shape. By containingdeflectable arms54 together, thesheath23 also serves to minimize vascular trauma on its way to the target location.
• Console24 comprises processing circuitry41, typically a general-purpose computer and a suitable front end andinterface circuits44 for generating signals in, and/or receiving signals from, body surface electrodes49 which are attached by wires running through acable39 to the chest and to the back, or any other suitable skin surface, of the patient28.
• Console24 further comprises a magnetic-sensing sub-system. The patient28 is placed in a magnetic field generated by a pad containing at least one magnetic field radiator42, which is driven by a unit43 disposed in theconsole24. The magnetic field radiator(s)42 is configured to transmit alternating magnetic fields into a region where the body-part (e.g., the heart26) is located. The magnetic fields generated by the magnetic field radiator(s)42 generate direction signals in themagnetic sensor50. Themagnetic sensor50 is configured to detect at least part of the transmitted alternating magnetic fields and provide the direction signals as corresponding electrical inputs to the processing circuitry41.
• In some exemplary embodiments, the processing circuitry41 uses the position-signals received from the shaft electrodes52, themagnetic sensor50 and theelectrodes55 to estimate a position of thecatheter40 inside an organ, such as inside a cardiac chamber. In some exemplary embodiments, the processing circuitry41 correlates the position signals received from theelectrodes52,55 with previously acquired magnetic location-calibrated position signals, to estimate the position of thecatheter40 inside the organ. The position coordinates of the shaft electrodes52 and theelectrodes55 may be determined by the processing circuitry41 based on, among other inputs, measured impedances, or on proportions of currents distribution, between theelectrodes52,55 and the body surface electrodes49. Theconsole24 drives adisplay27, which shows the distal end of thecatheter40 inside theheart26.
• The method of position sensing using current distribution measurements and/or external magnetic fields is implemented in various medical applications, for example, in the Carto® system, produced by Biosense Webster Inc. (Irvine, Calif.), and is described in detail in U.S. Pat. Nos. 5,391,199, 6,690,963, 6,484,118, 6,239,724, 6,618,612, 6,332,089, 7,756,576, 7,869,865, and 7,848,787, in PCT Patent Publication WO 96/05768, and in U.S. Patent Application Publications 2002/0065455 A1, 2003/0120150 A1 and 2004/0068178 A1.
• The Carto®3 system applies an Active Current Location (ACL) impedance-based position-tracking method. In some exemplary embodiments, using the ACL method, the processing circuitry41 is configured to create a mapping (e.g., current-position matrix (CPM)) between indications of electrical impedance and positions in a magnetic coordinate frame of the magnetic field radiator(s)42. The processing circuitry41 estimates the positions of the shaft electrodes52 and theelectrodes55 by performing a lookup in the CPM.
• Other methods of determining the location of the distal end of the catheter may be used, for example, based on ultrasonic transducers and receivers, using imaging techniques such as ultrasound or MRI or CT scans which may include disposing radiopaque tags on thecatheter40.
• Processing circuitry41 is typically programmed in software to carry out the functions described herein. The software may be downloaded to the computer in electronic form, over a network, for example, or it may, alternatively or additionally, be provided and/or stored on non-transitory tangible media, such as magnetic, optical, or electronic memory.
• FIG. 1 shows only elements related to the disclosed techniques, for the sake of simplicity and clarity. Thesystem20 typically comprises additional modules and elements that are not directly related to the disclosed techniques, and thus are intentionally omitted fromFIG. 1 and from the corresponding description.
• Thecatheter40 described above includes eightdeflectable arms54 with sixelectrodes55 perarm54. Any suitable catheter may be used instead of thecatheter40, for example, a catheter with a different number of flexible arms and/or electrodes per arm, or a different probe shape such as a balloon catheter or a lasso catheter, by way of example only.
• Themedical procedure system20 may also perform electroporation or RF ablation (or other ablation technique) of heart tissue using any suitable catheter, for example using thecatheter40 or a different catheter and any suitable ablation method. Theconsole24 may include asignal generator34 configured to generate an electrical signal to be applied by an electrode or electrodes of a catheter connected to theconsole24, (and optionally one or more of the body surface electrodes49), to perform electroporation or RF ablation of a myocardium of theheart26. Theconsole24 may include a pump (not shown), which pumps irrigation fluid into an irrigation channel to a distal end of a catheter performing RF ablation. The catheter performing the RF ablation may also include temperature sensors (not shown) which are used to measure a temperature of the myocardium during RF ablation and regulate an ablation power and/or an irrigation rate of the pumping of the irrigation fluid according to the measured temperature.
• Thesystem20 may also include aprobe36 which is also configured for insertion into the chamber of theheart26, and comprising anelectrode38. Theprobe36 may be implemented as part of thecatheter40 or as part of a different catheter. Thesystem20 also includes apacing unit46 disposed in theconsole24, and configured to generate a sequence of pacing pulses for application by theelectrode38 as described in more detail with reference toFIGS. 3-6.
• Reference is now made toFIG. 3, which is a schematic view of anintracardiac electrogram60 generated by thesystem20 ofFIG. 1. Theintracardiac electrogram60 has been annotated to show the timing of pacing pulses62 which were applied to the myocardium in order to induce electrical activations of the myocardium shown as peaks64 of the signal. Theintracardiac electrogram60 includes two large peaks64-1,64-4 following the pacing pulses62-1,62-4, respectively. The peaks64-1,64-4 exceed athreshold signal amplitude66. The peak64-2 following the pacing pulse62-2 is much smaller than the large peaks64-1,64-4, and is less than thethreshold signal amplitude66. There is no peak following the pacing pulse62-3. Therefore, out of the four pacing pulses62 two electrical activations were acquired by the electrode55 (FIG. 2) that provided theintracardiac electrogram60. Theelectrode55 may be assigned a capture grade of 50%, or (2 out of 4), or “fair”. Another one of the electrodes may acquire 4 electrical activations and could be given a capture grade of 100%, or (4 out of 4), or “excellent”, for example. If one electrode has a capture grade of 100% that implies that all of the pacing pulses were captured by the myocardium of the heart and the other electrode which has a capture grade of 50% failed to acquire some of the electrical activations due to bad placement of that electrode.
• Reference is now made toFIG. 4, which is a schematic view of part of theintracardiac electrogram60 ofFIG. 3 showing the peak64-1 following the pacing pulse62-1. The processing circuitry41 (FIG. 1) is configured to evaluate the successful acquisition by a given electrode55 (FIG. 2) of an electrical activation induced by a corresponding pacing pulse62-1 responsively to the electrical activation signal (e.g., the intracardiac electrogram60) exceeding thethreshold signal amplitude66 within a giventime window68 after the pacing pulse62-1.FIG. 4 shows that theintracardiac electrogram60 exceeds thethreshold signal amplitude66 within thetime window68. Thetime window68 may have any suitable value for example, in the range of 0.04 to 0.3 seconds. Thethreshold signal amplitude66 may have any suitable amplitude, for example, in the range of 0.5 to 1.5 mV.
• Reference is now made toFIG. 5, which is a schematic view of auser interface70 generated by thesystem20 ofFIG. 1.FIG. 5 shows two intracardiac electrograms60-1,60-2, sensed by two respective ones of the electrodes55 (FIG. 2), rendered on thedisplay27. Alongside each intracardiac electrogram60-1,60-2, arespective capture grade72 is displayed. The intracardiac electrogram60-1 shows that two electrical activations above threshold were acquired by therespective electrode55, and is therefore assigned acapture grade72 of 50%. The intracardiac electrogram60-2 shows that four electrical activations above threshold were acquired by theelectrodes55, and is therefore assigned acapture grade72 of 100%.
• FIG. 5 also shows a representation of thecatheter40 inside the chamber of theheart26 with two of the electrodes marked usingannotations74, showing the numbers assigned to each electrode.
• Reference is now made toFIG. 6, which is aflowchart80 including steps in a method of operation of themedical procedure system20 ofFIG. 1. Reference is also made toFIG. 1. Thephysician30 inserts (block82) theprobe36 into a chamber of theheart26 of a living subject (e.g., the patient28). Thephysician30 also inserts (block82) another probe (e.g., part of the catheter40) into the chamber. In the description below the other probe is referred to as thecatheter40 for the sake of clarity. Theprobe36 may be implemented as part of thecatheter40 or as part of a different catheter. In some exemplary embodiments, instead of inserting another probe, thephysician30, applies one or more body surface electrodes to a tissue surface of the patient28.
• The processing circuitry41 is optionally configured to track (block84) a location of one of the electrodes55 (FIG. 2) (referred to as “theelectrode55” hereinbelow). The processing circuitry41 may track the location of theelectrode55 using any suitable position tracking method, for example, one of the methods described above with reference toFIG. 1. The processing circuitry41 may optionally track the location of other ones of theelectrodes55 and/or theelectrode38 of theprobe36.
• Thepacing unit46 is configured to generate (block86) the pacing pulses for application by theelectrode38 of theprobe36. In response, theelectrode38 is configured to apply (block88) a sequence of pacing pulses62 (FIG. 3) at a position in the chamber to induce a corresponding sequence of electrical activations in a myocardium of the chamber over time. Theelectrode55 of the catheter40 (or a body surface electrode) is configured to sense (block90) an electrical activation signal60 (FIG. 3) responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber over time.Other electrodes55 of thecatheter40 may also be configured to sense respective electrical activation signals responsively to electrical activations induced by capture of the pacing pulses in the myocardium of the chamber over time.
• The processing circuitry41 is configured to evaluate (block92) a successful acquisition by the electrode55 (or the body surface electrode) of the induced electrical activations responsively to theelectrical activation signal60. In some exemplary embodiments, the processing circuitry41 is configured to evaluate the successful acquisition by theelectrode55 of respective ones of the electrical activations induced by respective ones of the pacing pulses62 responsively to an amplitude of theelectrical activation signal60 exceeding a threshold signal amplitude66 (FIG. 4) within a given time window68 (FIG. 4) after the respective pacing pulses62. The above step may also be performed for the respective electrical activation signals of other respective ones of theelectrodes55.
• The processing circuitry41 is configured to compute (block94) a capture grade72 (FIG. 5) for the electrode55 (or the body surface electrode) responsively to the evaluation of the successful acquisition of the induced electrical activations by theelectrode55. The capture grade is generally indicative of a count of the induced electrical activations which were evaluated as being successfully acquired by theelectrode55. The step ofblock94 may be repeated forother electrodes55 of thecatheter40. The capture grade may be computed based on the count of: the successful acquisitions of electrical activations and unacquired electrical activations (where they are expected to occur, e.g. within a time window after each pacing pulse); or the successful acquisitions of electrical activations and the total count of the pacing pulses; or the unacquired electrical activations and the total count of pacing pulses. Therefore, the processing circuitry41 may be configured to compute the capture grade responsively to a count of the induced electrical activations evaluated as being: successfully acquired by theelectrode55; and not acquired by theelectrode55 or responsively to a total count of the pacing pulses. In some exemplary embodiments, the processing circuitry41 is configured to compute the capture grade responsively to a count of the unacquired electrical activations and a total count of the pacing pulses. The capture grade may be expressed as a quantitative measure such as a score or a percentage of the successful acquisitions out of the total number of electrical activations or as a descriptive grade, e.g., “very poor” if the capture grade is 20% or less, “poor” if the capture grade is greater than or equal to 20% but less than 40%, “fair” if the capture grade is greater than or equal to 40% but less than 60%, “good” if the capture grade is greater than or equal to 60% but less than 80%, and “excellent” if the capture grade is greater than 80%. The descriptions and the associated ranges are provided by way of example only, and any suitable descriptions and associated ranges may be used.
• The processing circuitry41 is configured to render (block96) thecapture grade72 to thedisplay27 as shown inFIG. 5. In some exemplary embodiments, the processing circuitry41 is configured to render to thedisplay27 thecapture grade72 with a representation of theelectrical activation signal60 as shown inFIG. 5. In some embodiments, the processing circuitry41 is configured to render to the display27 a representation of thecatheter40 responsively to the tracked location(s).Respective capture grades72 and optionally respectiveintracardiac electrograms60 ofrespective electrodes55 may be rendered to thedisplay27. Thecatheter40 may be rendered to thedisplay27 with annotations74 (FIG. 5) which indicate the electrode numbers assigned to theelectrodes55.
• As used herein, the terms “about” or “approximately” for any numerical values or ranges indicate a suitable dimensional tolerance that allows the part or collection of components to function for its intended purpose as described herein. More specifically, “about” or “approximately” may refer to the range of values±20% of the recited value, e.g. “about 90%” may refer to the range of values from 72% to 108%.
• Various features of the present invention which are, for clarity, described in the contexts of separate embodiments may also be provided in combination in a single exemplary embodiment. Conversely, various features of the invention which are, for brevity, described in the context of a single embodiment may also be provided separately or in any suitable sub-combination.
• The embodiments described above are cited by way of example, and the present invention is not limited by what has been particularly shown and described hereinabove. Rather the scope of the invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof which would occur to persons skilled in the art upon reading the foregoing description and which are not disclosed in the prior art.

Claims (20)

What is claimed is:

1. A medical procedure system comprising:

a probe configured for insertion into a chamber of a heart of a living subject, and comprising a first electrode configured to apply a sequence of pacing pulses at a position in the chamber;

a second electrode configured to sense an electrical activation signal responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber over time;

a display; and

processing circuitry configured to:

evaluate a successful acquisition by the second electrode of the induced electrical activations responsively to the electrical activation signal, the successful acquisition being indicative of a successful capture of the pacing pulses by the myocardium;

compute a capture grade responsively to the evaluation of the successful acquisition of the induced electrical activations, the capture grade being indicative of a count of the induced electrical activations which were evaluated as being successfully acquired; and

render the capture grade to the display.

2. The system according toclaim 1, wherein the processing circuitry is configured to evaluate the successful acquisition by the second electrode of respective ones of the electrical activations induced by respective ones of the pacing pulses responsively to the electrical activation signal exceeding a threshold signal amplitude within a given time window after the respective pacing pulses.

3. The system according toclaim 1, wherein the processing circuitry is configured to compute the capture grade responsively to a count of the induced electrical activations evaluated as being successfully acquired by the second electrode.

4. The system according toclaim 3, wherein the processing circuitry is configured to compute the capture grade also responsively to a count of unacquired electrical activations.

5. The system according toclaim 3, wherein the processing circuitry is configured to compute the capture grade also responsively to a total count of the pacing pulses.

6. The system according toclaim 1, wherein the processing circuitry is configured to compute the capture grade responsively to a count of unacquired electrical activations and a total count of the pacing pulses.

7. The system according toclaim 1, further comprising a pacing unit configured to generate the pacing pulses for application by the first electrode.

8. The system according toclaim 1, wherein the processing circuitry is configured to render to the display the capture grade with a representation of the electrical activation signal.

9. The system according toclaim 1, wherein the processing circuitry is configured to track a location of the second electrode.

10. The system according toclaim 9, wherein the processing circuitry is configured to render to the display a representation of another probe responsively to the tracked location.

11. A medical procedure method comprising:

inserting a first probe into a chamber of a heart of a living subject;

applying with a first electrode of the first probe a sequence of pacing pulses at a position in the chamber;

sensing with a second electrode an electrical activation signal responsively to electrical activations induced by capture of the pacing pulses in a myocardium of the chamber over time;

evaluating a successful acquisition by the second electrode of the induced electrical activations responsively to the electrical activation signal, the successful acquisition being indicative of a successful capture of the pacing pulses by the myocardium;

computing a capture grade responsively to the evaluation of the successful acquisition of the induced electrical activations, the capture grade being indicative of a count of the induced electrical activations which were evaluated as being successfully acquired; and

rendering the capture grade to a display.

12. The method according toclaim 11, wherein the evaluating includes evaluating the successful acquisition by the second electrode of respective ones of the electrical activations induced by respective ones of the pacing pulses responsively to the electrical activation signal exceeding a threshold signal amplitude within a given time window after the respective pacing pulses.

13. The method according toclaim 11, wherein the computing includes computing the capture grade responsively to a count of the induced electrical activations evaluated as being successfully acquired by the second electrode.

14. The method according toclaim 13, wherein the computing also includes computing the capture grade also responsively to a count of unacquired electrical activations.

15. The method according toclaim 13, wherein the computing also includes computing the capture grade also responsively to a total count of the pacing pulses.

16. The method according toclaim 11, wherein the computing includes computing the capture grade responsively to a count of unacquired electrical activations and a total count of the pacing pulses.

17. The method according toclaim 11, further comprising generating the pacing pulses for application by the first electrode.

18. The method according toclaim 11, wherein the rendering includes rendering to the display the capture grade with a representation of the electrical activation signal.

19. The method according toclaim 11, further comprising tracking a location of the second electrode.

20. The method according toclaim 19, wherein the rendering including rendering to the display a representation of another probe responsively to the tracked location.

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