Goal-Driven Workflow for Cardiac Arrhythmia Treatment

Abstract

To perform cardiac electroanatomical mapping.SOLUTION: A system includes a memory and a processor. The memory is configured to store a definition of a cardiac pacing protocol. The processor is configured to: (a) receive the stored definition of the cardiac pacing protocol; (b) in accordance with the pacing protocol, automatically pace from an intracardiac location and acquire respective sensed ECG signals, (c) based on one or more prespecified criteria for validity of the sensed ECG data, automatically accept or reject the sensed ECG signals, (d) based on one or more prespecified criteria for identification of an arrhythmia, identify the intracardiac location as an arrhythmogenic focus or pathway, (e) overlay the identified intracardiac location on an electrophysiological (EP) map, and (f) subsequently identify or reject a new intracardiac location as an arrhythmogenic focus or pathway and overlay the new location on the EP map when pacing again from the new intracardiac location.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] The present invention relates generally to electroanatomical mapping, and more particularly to electroanatomical mapping of the heart. [Background technology]

[0002] Cardiac mapping procedures for identifying potential causes of arrhythmias in cardiac tissue have been previously proposed in the patent literature. For example, U.S. Patent No. 7,907,994 describes a ventricular tachycardia signal that is induced in a living subject. A pace-mapped signal is then obtained from multiple points within the ventricle and automatically compared numerically to the induced signal. Recognition of a high degree of cross-correlation between one or more of the induced and pace-mapped signals identifies arrhythmogenic foci or pathways that can then be ablated so that the arrhythmia becomes non-inducible.

[0003] As another example, US Patent Application Publication No. 2014 / 0200473 describes a method that can determine one or more origins of focal activation. The method can include calculating the phase of electrical signals at a plurality of nodes distributed on a geometric surface based on electrical data over time. The method can determine whether a given candidate node of the plurality of nodes is a focal point based on an analysis of the calculated phase and magnitude of the given candidate node. A graphical map can be generated to visualize the detected focal points on the geometric surface. Summary of the Invention [Means for solving the problem]

[0004] Exemplary embodiments of the invention described below provide an automated workflow for cardiac pacing using one or more catheters, including a goal-driven algorithm capable of making decisions according to the type and pre-settings of the pacing procedure and the cardiac response to such pacing, increasing the efficiency and success rate of the procedure.

[0005] One embodiment of the present invention provides a system including a memory and a processor. The memory is configured to store a definition of a cardiac pacing protocol. The processor is configured to (a) receive the stored definition of the cardiac pacing protocol, (b) automatically control one or more probes in a patient's heart to automatically pace from an intracardiac location according to the pacing protocol and acquire respective sensed electrocardiogram (ECG) signals, (c) automatically accept or reject the sensed ECG signals based on one or more predefined criteria for validity of the sensed ECG data, (d) identify or reject the intracardiac location as an arrhythmogenic focus or pathway based on one or more predefined criteria for arrhythmia identification, (e) overlay the identified intracardiac location on an electrophysiological (EP) map, and (f) thereafter identify a new intracardiac location as an arrhythmogenic focus or pathway and overlay the new location on the EP map when pacing again from the new intracardiac location.

[0006] In some embodiments, the definition includes at least a pacing sequence.

[0007] In some embodiments, the processor is further configured to visually present to a user on the EP map qualitative or quantitative results resulting from the pacing at each paced intracardiac location.

[0008] In one embodiment, the pacing protocol defines one or more criteria for the validity of the sensed ECG and / or intracardiac signal data, including a comparison of the pacing cycle length (PCL) to the tachycardia cycle length (TCL) in the sensed signals.

[0009] In another embodiment, the pacing protocol defines one or more criteria for identification of an arrhythmogenic focus or pathway, including one of a comparison of the tachycardia cycle length (TCL) with the post-pacing interval (PPI) in the same ECG or intracardiac signal, and a comparison of the time difference between the pacing signal and the resulting surface or intracardiac ECG signal with the time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

[0010] In one embodiment, the processor is configured to identify locations as arrhythmogenic foci or pathways by identifying locations in the direction of smaller difference in PPI-TCL values ​​or time difference values.

[0011] In some embodiments, the pacing protocol defines one or more criteria for the validity of the sensed ECG data, which criteria include a comparison of time difference values.

[0012] In some embodiments, the pacing protocol defines one or more criteria for identification of a location as an arrhythmogenic focus or pathway, the criteria including identifying concealed and / or manifested fusion in the sensed ECG signal.

[0013] In one embodiment, the processor is configured to determine the intracardiac pacing location using a position tracking system.

[0014] In another embodiment, the processor is configured to store the cardiac pacing protocol definitions by at least one of saving, importing, and exporting the pacing protocols.

[0015] According to one embodiment of the present invention, a computer-implemented method is provided that includes receiving, at a processor, a definition of a cardiac pacing protocol. Using the processor, one or more probes within the patient's heart are automatically controlled to automatically pace from intracardiac locations according to the pacing protocol and acquire respective sensed ECG signals. Based on one or more predefined criteria for the validity of the sensed ECG data, the sensed ECG signals are automatically accepted or rejected. Based on one or more predefined criteria for arrhythmia identification, the intracardiac locations are identified as arrhythmogenic foci or pathways or rejected as not such foci. The identified intracardiac locations are superimposed on an electrophysiological (EP) map, and then new intracardiac locations are identified as arrhythmogenic foci or pathways, and the new locations are superimposed on the EP map when pacing again from the new intracardiac locations.

[0016] The invention will be more fully understood from consideration of the following detailed description taken in conjunction with the drawings, in which: [Brief description of the drawings]

[0017] [Figure 1] 1 is a schematic, pictorial diagram of a cardiac 3D navigation electrophysiological (EP) diagnostic system with a radio frequency (RF) ablation subsystem, in accordance with an embodiment of the present invention; [Diagram 2] 1 is a flow chart that generally illustrates a goal-driven workflow for catheter-based cardiac arrhythmia therapy, in accordance with an embodiment of the present invention. [Diagram 3] 3 is a schematic pictorial volume rendering of an arrhythmia location guide map of the left atrium automatically generated by a processor using the automated workflow described in FIG. 2, in accordance with an embodiment of the present invention. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0018] overview Cardiac arrhythmias, defined as variations from normal cardiac sinus rhythm, can belong to several categories. One category is characterized by rapid and / or irregular electrophysiological (EP) pulses originating from one or more focal locations within the cardiac tissue. Another category is characterized by repeated loops of electrical activity through one or more portions of the cardiac tissue. An example of the first category is focal arrhythmia, and an example of the second category is reentrant arrhythmia.

[0019] One possible method for finding the location where a focal arrhythmia originates or where a reentrant arrhythmia propagates is to stimulate selected locations of the patient's cardiac tissue with bipolar or unipolar electrical signals. Such stimulation, which can be performed using electrodes on a catheter, may elicit electrocardiogram (ECG) signal patterns that meet one or more criteria for identifying the stimulated location as an arrhythmogenic focus or pathway, or conversely, exclude such a site as generating or contributing to the arrhythmia.

[0020] The underlying assumption is that treating such arrhythmogenic locations (i.e., locations that are arrhythmogenic foci or pathways) by, for example, ablating the locations is likely to reduce or eliminate the arrhythmia in question. The above invasive diagnostic procedures are called "pacing procedures." Pacing procedures are typically a lengthy process, as they must often be manually repeated over multiple locations within the heart to obtain sufficient diagnostic information to allow appropriately targeted ablation.

[0021] The embodiments of the invention described below provide an automated workflow for cardiac pacing operations using one or more catheters. The disclosed technology includes decision-making goal-driven algorithms that integrate separate pacing functions that would otherwise require laborious manual involvement from a physician. Furthermore, the disclosed technology relieves the physician from the mental fatigue of repetitive decision-making that would otherwise be required during a typical set of pacing operations. Such laborious manual decision-making can result in indeterminate or inaccurate results of the pacing procedure, and the physician may not be able to accurately identify target locations requiring treatment.

[0022] In some embodiments, at the start of the disclosed automatic cardiac pacing procedure, a physician selects a pacing protocol according to the type of arrhythmia in question, the protocol including parameters: (i) intracardiac locations for pacing and sensing the resulting ECG signal, (ii) stimulation sequences and waveforms, (iii) monitoring parameters, (iv) acceptance criteria for data validity, and (v) criteria for verifying that the diagnostic goals of the disclosed automated workflow have been achieved.

[0023] Examples of stimulation sequence and waveform parameters include stimulation duration, signal frequency, duty cycle, and amplitude.

[0024] The examples listed below are for specific possible procedures that the disclosed algorithms can perform. In general, multiple procedures can use the disclosed algorithms, with necessary modifications to parameters such as acceptance criteria.

[0025] As an example, for the reentrant type arrhythmia of interest, the acceptance criteria for use in the algorithm to determine whether a set of sensed ECG data is valid may include the pacing cycle length (PCL). In one embodiment, the algorithm checks whether the periodicity of the sensed ECG or intracardiac signal during pacing has reached the PCL, which is the instant the disclosed algorithm uses to stop pacing and start sensing a response signal. If the PCL has not been reached for all target electrodes or sensed signals, the algorithm will return to the next stimulus in the preplanned sequence or instruct the pacing catheter to move to the next predefined pacing location. However, for other types of arrhythmias of interest, other acceptance criteria may be used.

[0026] In another embodiment, the algorithm stops pacing after the processor determines that the ECG or intracardiac signals sensed during pacing have reached the PCL on all relevant channels (also referred to herein as "activation capture"). Validated capture means that pacing is valid as having been successfully achieved. Subsequent analysis required to verify capture on the sensed ECG signal after pacing is described below. Alternatively, the algorithm stops pacing after a certain period of time (i.e., duration of stimulation or number of pacing stimuli delivered) has elapsed.

[0027] In one embodiment, a physician can modify any pre-set parameters and save the resulting new protocol in memory, thus allowing physicians to export and import new automatic pacing protocols and share them among colleagues or on another system.

[0028] In another embodiment, the disclosed automated workflows are configured to utilize one or more guided placements of the catheter. For example, the workflows apply magnetic and / or electrical position tracking of the catheter to guide the placement of the catheter. Additionally, the processor may employ algorithms that the workflows can automatically invoke to register the tracked positions to an anatomical map of at least a portion of the heart.

[0029] In one embodiment, the disclosed workflow is configured to utilize catheter positioning and repositioning that is performed fully automatically, for example, utilizing a processor-controlled robotic catheter subsystem or a magnetic catheter steering system.

[0030] In one embodiment, identifying a location as an arrhythmogenic focus or pathway includes identifying a location in a direction leading toward a minimum or maximum PPI-TCL value, or toward a minimum or maximum difference in time difference values, where the difference is defined by the time difference between the pacing signal and the resulting surface or intracardiac ECG signal and the time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

[0031] In some embodiments, the automated workflow applies pacing signals from a pair of electrodes on the pacing and ablation catheter, consisting of the two most distal electrodes, referred to as "M1-M2" as further described below. Alternatively, the automated workflow applies unipolar pacing from the most distal electrode (M1) to a different electrode in or attached to the patient's body. In such cases, no further stimulus routing is required, except for the initial stimulus routing (to the selected electrode).

[0032] In another embodiment, the disclosed automatic pacing workflow can be directed to perform stimulation from multiple electrode pairs using an automatic stimulus routing feature that switches between different electrode pairs. Alternatively, such pacing may be unipolar from a single electrode at a time to an unrelated electrode within or attached to the patient's body. One example of a procedure that can benefit from automatic stimulus routing is Pulmonary Vein Isolation Validation.

[0033] In some embodiments, the processor may further use the sensed ECG signal to use signal processing to identify in real time the location of the foci or reentrant arrhythmogenic tissue sites or the results of such tests at each location where analysis was attempted. The locations and monitored EP parameters may be indicated and displayed to the user on an anatomical map (which the processor may generate using the disclosed workflows) using visual indicators such as enumerated tags and / or colors. In another embodiment, the processor is further configured to visually indicate to the user on the EP map the qualitative or quantitative results obtained from pacing at each paced intracardiac location.

[0034] Typically, the processor is programmed with software containing specific algorithms that enable the processor to carry out each of the processor-related steps and functions outlined above.

[0035] The disclosed automatic pacing techniques can increase the probability of a cardiac pacing procedure being successful in identifying the source of an arrhythmia, while simultaneously reducing the workload experienced by the physician performing the procedure.

[0036] System Description FIG. 1 is a schematic, pictorial diagram of a cardiac 3D navigation electrophysiological (EP) diagnostic system 20 with a radio frequency (RF) ablation subsystem, according to an embodiment of the present invention. The system 20 may be configured to analyze virtually any EP parameter or combination of such parameters. Herein, by way of example, it is assumed that the analyzed signals are potential-time relationships of intracardiac and / or extracardiac (body surface) ECGs. To fully characterize such relationships, it is necessary to reference the signals to each other in time at various locations (e.g., as may be done while generating a local activation time (LAT) map). The time referencing is achieved by measuring relative to a reference time (e.g., instance), such as the beginning of each QRS complex (i.e., the beginning of every heart beat) of an ECG reference signal. A method for generating LAT maps is described in the aforementioned U.S. Pat. No. 9,050,011.

[0037] In the following description, the system 20 stimulates (i.e., paces) the heart 34 using a pacing and ablation probe 24. The system 20 measures the resultant electrical activity of the heart 34 using the probe 24 itself and / or additional probes 14. A distal end 32 of the probe 24 is assumed to have an electrode 22. The measured signal is used to generate a LAT map of at least a portion of the wall tissue of the heart 34 of the patient 26, which may be shared among other applications.

[0038] Typically, probe 24 comprises a mapping catheter that is inserted into the body of patient 26 during a mapping procedure performed by physician 28 using system 20. As seen inset 25, the procedure embodied in Fig. 1 uses an M1-M2 bipolar electrode pair configuration of probe 24 for pacing (i.e., for EP stimulation). In addition to stimulating and sensing EP signals, electrode M1 is configured to RF ablate, using RF power source 33, tissue sites found to be arrhythmogenic (focal or reentrant).

[0039] During the procedure, the patient 26 is assumed to be attached to a ground electrode 23. In addition, an electrode 29 is assumed to be attached to the skin of the patient 26 in the region of the heart 34.

[0040] The system 20 may be controlled by a system processor 40, which includes a processing unit 42 in communication with a memory 44. In some embodiments, the system processor 40 includes a memory 44 that stores an EP map 62 of at least a portion of the wall tissue of the heart 34 of the patient 26. Additionally or alternatively, the memory 44 may store maps of other patients. Furthermore, any other processor with memory (i.e., not necessarily part of the system 20) may store one or more maps. The processor 40 is typically mounted in a console 46, which includes (a) a patient interface unit 43 to which all catheters connect, and (b) a workstation with an operating control 38, typically including a pointing device 39, such as a mouse or trackball, that the physician 28 uses to interact with the processor.

[0041] Processor 40 (specifically processing unit 42) executes software comprising probe tracking module 30, ECG module 36 including an arrhythmia analysis module, and graphical user interface (GUI) 35 to operate system 20 and / or (using EP map 62 stored in memory 44) to graphically analyze and present results, e.g., to identify the source of an arrhythmia, from the disclosed automatic cardiac pacing workflow described in FIG.

[0042] In one embodiment, ECG module 36 is coupled to receive the electrical signals from electrodes 22 and electrodes 29. The module is configured to analyze the electrical signals and can present the results of the analysis on display 48 in a standard ECG format, typically in a graphical representation of variations over time.

[0043] The probe tracking module 30 typically tracks the position of the distal end 32 of the probe 24 within the heart of the patient 26. The tracking module may use any probe position tracking method known in the art. For example, the module 30 may operate a magnetic field-based position tracking subsystem. (For simplicity, components of such a subsystem are not shown in FIG. 1.)

[0044] Alternatively or additionally, tracking module 30 may track probe 24 by measuring the impedance between electrodes 23 and 22, as well as the impedance to other electrodes that may be located on the probe. (In this case, electrode 22 may provide both an ECG signal and a position tracking signal.) The Carto3® system, manufactured by Biosense Webster (Irvine, Calif.), uses both magnetic field position tracking and impedance measurements for position tracking.

[0045] Using the tracking module 30, the processor 40 can determine the location of the distal end 32. Additionally, by using both the tracking module 30 and the ECG module 36, the processor can determine not only the location of the distal end, but also the LAT of the electrical signals detected at these particular locations.

[0046] The results of the operations performed by processor 40 are presented to physician 28 on display 48, which typically presents a graphic user interface to the physician, a visual representation of the ECG signal sensed by electrodes 22, and / or an image or map of heart 34 while it is being studied. In one embodiment, GUI 35 presents to the physician an EP map updated with one or more locations on the map where an identified arrhythmia occurred or propagated, along with information from each location tested by the method of the present invention. The software may be downloaded to processor 40 in electronic form, for example over a network, or alternatively or additionally may be provided and / or stored on a non-transitory tangible medium, such as magnetic, optical, or electronic memory.

[0047] Goal-Driven Workflow for Cardiac Arrhythmia Treatment Figure 2 is a flow chart that illustrates, in accordance with an embodiment of the present invention, a goal-driven workflow for catheter-based cardiac arrhythmia therapy. While the example illustrated in Figure 2 is valid for the reentrant type of arrhythmia in question, the disclosed workflow may use other parameters for diagnosing other types of arrhythmia. The algorithm according to the presented embodiment implements a process in which the physician 28 initiates uploading a cardiac pacing procedure pre-setting (e.g., an automatic protocol) at upload step 70. A schematic overview of such a protocol provided as an example for use with reentrant atrial flutter is shown in Table I and is further described below.

[0048] [Table 1]

[0049] The PCL, PPI, and TCL are defined as follows:

[0050] [Table 2]

[0051] The physician can modify parameter values ​​in the uploaded protocol and save the modified presets as a new protocol. As noted above, parameters that may be modified include catheter position, stimulation pacing sequence including waveforms, and acceptance criteria for automatic ECG data validation, which the physician must otherwise determine on case. The physician 28 then positions the stimulation and sensing probes 24 and additional (sensing) probes 14 within the heart 34 in a probe (e.g., catheter) positioning step 72.

[0052] Next, physician 38 executes an automatic cardiac pacing protocol in an automatic pacing step 74, with probe 24 stimulating the cardiac location and probe 24 and / or probe 14 sensing the resulting ECG signal. During pacing, processor 40 executing the disclosed automated workflow applies an algorithm to automatically determine whether pacing was achieved successfully in a pacing analysis step 76.

[0053] In one embodiment, processor 40 interprets the sensed ECG signals and analyzes the interpreted signals using, for example, a criterion that such ECG signals sensed from all associated electrodes of probe 24 and / or probe 14 must typically exhibit a cycle length that is within a few milliseconds of the PCL. Such a criterion ensures that the pacing has actually "taken over" the naturally occurring electrical activity of heart 34 at the pacing location, as a necessary condition for the pacing maneuver to be effective.

[0054] If the cycle length (CL) of the analyzed ECG signal is too large, i.e., from Table I, CL>PCL+5 mSec, the processor 40 automatically classifies the detected ECG data set as invalid in a data validation check step 78. It should be noted that without the disclosed automated workflow, the physician would need to manually approve each detected ECG data set as valid. If the ECG data is found to be invalid, e.g., there is no capture, the algorithm can mark the invalid data location on the anatomical map in a marking decision step 79. In either case, the algorithm of FIG. 2 also proceeds directly from step 78 to step 86.

[0055] If the data is found to be valid at step 78, processor 40 generates and presents the results of the automatic pacing, such as a display of the paced locations and the calculated PPI-TCL values, on an anatomical map of the heart, e.g., by locating a temporary validation tag on the map, at a results analysis and presentation step 80. In one embodiment, the algorithm identifies a direction leading toward a lower (i.e., closer to zero) PPI-TCL value, if such a recommendation is necessary, and recommends a location in this direction as the next pacing location by overlaying the recommended direction on the anatomical map.

[0056] A calculated stimulated PPI-TCL value at a given pacing location that is within the range of [0, 30] msec is a strong indication of the location of an abnormal tissue site. For example, the LAT value is directly proportional to the distance from the mapping electrode to the location of the reentrant circuit. In analysis step 76, processor 40 also calculates the PPI and TCL. Assuming that the ECG data is found to be valid, the respective difference between the PPI and TCL is then used as an indication of the physical proximity of probe 24 to the abnormal tissue site. Using the above LAT criteria, processor 40 can diagnose the location as arrhythmogenic in diagnostic target check step 82. If the location is found to be arrhythmogenic, processor 40 updates the anatomical map as part of step 78, for example, by automatically visually indicating (e.g., labeling, coloring) the location on the map as a candidate location for ablation. The physician then positions the ablation catheter at the proposed location for ablation in ablation catheter positioning step 84.

[0057] An additional method for determining a cardiac site as the source of a reentrant arrhythmia is the automatic detection of covert fusion in the ECG signal from that site, which is also applied in diagnostic target checking step 82. Covert fusion is defined, for example, by GD Veenhuyzen et al., "Diagnostic Utility for Supraventricular Tachycardia," Indian Pacing Electrophysiology Journal, 8(1): pages 51-65, (2008).

[0058] The disclosed process then moves to indicate the performance of RF ablation at the visually indicated location using electrode M1 at ablation procedure step 85.

[0059] As noted above, if the sensed ECG data is found to be invalid at step 78, the process proceeds to a check step 86 where the processor 40 checks whether the automatic pacing protocol has been executed in its entirety. If the answer is negative, the process returns to step 74 to continue pacing. If the answer is positive, the algorithm concludes that the given site has been exhausted and directs the movement of the pacing (i.e., stimulation) probe 24 to another tissue location at a reposition stimulation catheter step 88.

[0060] If in step 82 the diagnostic goal has not yet been achieved (e.g. the position is found to be normal), the processor 40 applies a check step 86 as described above and directs a repositioning step 88 if necessary.

[0061] The example flow chart shown in Fig. 2 has been chosen purely for purposes of conceptual clarity. Typically, the physician 28 first anatomically maps the relevant parts of the heart 34 (e.g., using a fast anatomical mapping (FAM) procedure) and may perform additional steps such as obtaining an anatomical map. The criteria may vary depending on the type of pacing procedure and the respective clinical goal. In some embodiments, the disclosed automated workflow is configured to accept additional inputs such as temperature and contact force readings.

[0062] In another embodiment, the presence of a reentrant circuit is automatically identified, for example, using the CARTO® system (Biosent-Webster) by overdrive stimulation (pacing the heart at a rate higher than the tachycardia rate) from various electrodes in the target chamber until a clear and stable fusion signal is achieved and automatically identified. Sensed ECG signals are annotated and analyzed in real time using currently existing algorithms in the CARTO® system.

[0063] 3 is a schematic pictorial volume rendering of an arrhythmia location guide map 100 of the left atrium automatically generated by processor 40 using the automated workflow described in FIG. 2, according to one embodiment of the present invention. FIG. 2 shows analyzed ECG signals 110, 111, and 112 superimposed on an anatomical map 105 of the patient's left atrium. Signal 110 was found to be valid by processor 40 (at step 78 in FIG. 2), and signal 111 was found to be invalid by processor 40 (although shown in FIG. 3 to illustrate the decision-making process applied by processor 40). As can be seen, using the LAT criteria described in analysis step 76 in FIG. 2, processor 40 constructs a path 120 that guides the physician toward potential locations of reentrant circuits 150 that processor 40 analyzes and then validates ECG signal 112.

[0064] The initial pacing location can be selected by the physician based on a previously acquired EP map or previous patient data suggesting the type of patient arrhythmia and its expected location. From there, the physician can move the catheter at a specific location according to the received indication of the PPI-TCL value on the arrhythmia guide map 100. In one embodiment, the physician moves the catheter slightly in several directions to find a trend of values ​​toward zero for the algorithm. Once several such points are collected by the algorithm, the algorithm can identify a location in a direction that can lead toward a lower (i.e., closer to zero) PPI-TCL value and recommend this location as the next pacing location.

[0065] The arrhythmia location guide map 100 generated by the processor 40 provides the physician with an objective outcome of the pacing procedure, eliminating the wasted effort that the physician would experience if attempts to manually create and trace the pathway 120 were unsuccessful, resulting in a diagnostically unsuccessful pacing procedure.

[0066] Although the embodiments described herein primarily address automated diagnostic workflows for cardiac applications, the methods and systems described herein can also be used in other medical applications, such as brain surgery, where pacing can be used to verify that no damage occurs to specific areas in the brain, and the acquired EEG signals can be analyzed, which are indicative of brain activity. Another medical application that can utilize the disclosed technology is orthopedic surgery, such as spinal surgery, to ensure that no neurological damage occurs to the patient during surgery, or to create neurological mapping before the start of surgery.

[0067] It will therefore be understood that the above-described embodiments are cited by way of example, and that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations of the various features described above and subcombinations thereof, as well as variations and modifications thereof that would occur to those skilled in the art upon reading the above description and that are not disclosed in the prior art. Documents incorporated by reference into this patent application are to be considered as part of this application, except that if any term is defined in these incorporated documents in a manner that is inconsistent with the definition expressly or impliedly given herein, then only the definition in this specification shall be considered.

[0068] [Embodiment] (1) a memory configured to store a cardiac pacing protocol definition; a processor, the processor comprising: receiving the stored definition of the cardiac pacing protocol; automatically controlling one or more probes within the patient's heart to automatically pace from the intracardiac locations according to said pacing protocol and acquire respective sensed electrocardiogram (ECG) signals; automatically accepting or rejecting the sensed ECG signal based on one or more predefined criteria for the validity of the sensed ECG data; identifying or rejecting the intracardiac location as an arrhythmogenic focus or pathway based on one or more predefined criteria for identification of the arrhythmia; superimposing the identified intracardiac locations on an electrophysiological (EP) map; The system is then configured to identify a new intracardiac location as an arrhythmogenic focus or pathway and overlay the new intracardiac location on the EP map when re-pacing from the new intracardiac location. (2) A system as described in embodiment 1, wherein the definition includes at least a pacing sequence. (3) The system of embodiment 1, wherein the processor is further configured to visually display to a user on the EP map qualitative or quantitative results obtained from pacing at each paced intracardiac location. (4) The system of embodiment 1, wherein the pacing protocol defines one or more criteria regarding the validity of the detected ECG data, the criteria including a comparison of a pacing cycle length (PCL) to a tachycardia cycle length (TCL) in the detected ECG signal. (5) the pacing protocol defines the one or more criteria for identification of a location as an arrhythmogenic focus or pathway, the criteria comprising: Comparison of tachycardia cycle length (TCL) with post-pacing interval (PPI) in the same ECG signal, and The system of embodiment 1, comprising one of: comparing the time difference between the pacing signal and the resulting surface or intracardiac ECG signal with the time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

[0069] (6) The system described in embodiment 5, wherein the processor is configured to identify a location as an arrhythmogenic lesion or pathway by identifying a location in a direction in which the difference in PPI-TCL values ​​or time difference values ​​is smaller. (7) The system of embodiment 5, wherein the pacing protocol defines one or more criteria regarding the validity of the detected ECG data, the criteria including a comparison of time difference values. (8) The system of embodiment 1, wherein the pacing protocol defines one or more criteria for identifying a location as an arrhythmogenic lesion or pathway, the criteria including identifying one or more of: (i) concealed fusion, and (ii) manifest fusion in the detected ECG signal. (9) The system of embodiment 1, wherein the processor is configured to measure the intracardiac pacing location using a position tracking system. (10) The system of embodiment 1, wherein the processor is configured to store the definition of the cardiac pacing protocol by at least one of saving, importing, and exporting the pacing protocol.

[0070] (11) A computer-implemented method, comprising: receiving, at a processor, a definition of a cardiac pacing protocol; using the processor to automatically control one or more probes within the patient's heart to automatically pace from intracardiac locations according to the pacing protocol and acquire respective sensed electrocardiogram (ECG) signals; automatically accepting or rejecting the sensed ECG signal based on one or more predefined criteria regarding the validity of the sensed ECG data; identifying or rejecting the intracardiac location as an arrhythmogenic focus or pathway based on one or more predefined criteria for identification of arrhythmia; superimposing the identified intracardiac cardiac locations on an electrophysiological (EP) map; thereafter, identifying a new intracardiac location as an arrhythmogenic focus or pathway and overlaying the new intracardiac location on the EP map while re-pacing from the new intracardiac location. (12) The method of embodiment 11, wherein the definition includes at least a pacing sequence. (13) The method of embodiment 11, further comprising visually displaying to a user on the EP map the qualitative or quantitative results obtained from pacing at each paced intracardiac location. (14) The method of embodiment 11, wherein the pacing protocol defines one or more criteria regarding the validity of the detected ECG data, the criteria including a comparison of a pacing cycle length (PCL) to a tachycardia cycle length (TCL) in the detected ECG signal. (15) The pacing protocol defines the one or more criteria for identification of a location as an arrhythmogenic focus or pathway, the criteria comprising: Comparison of tachycardia cycle length (TCL) with post-pacing interval (PPI) in the same ECG signal, and The method of embodiment 11, comprising one of: comparing the time difference between the pacing signal and the resulting surface or intracardiac ECG signal with the time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

[0071] (16) The method described in embodiment 15, wherein identifying a location as an arrhythmogenic lesion or pathway includes identifying a location in a direction in which the difference in PPI-TCL values ​​or time difference values ​​is smaller. (17) The method of embodiment 16, wherein identifying a location as an arrhythmogenic lesion or pathway includes identifying a location in a direction in which the PPI-TCL value or time difference value is minimum or maximum, and recommending the location to a user as the next pacing location. (18) The method of embodiment 11, wherein the pacing protocol defines the one or more criteria regarding the validity of the sensed ECG data, the criteria including a comparison of time difference values. (19) The method of embodiment 11, wherein the pacing protocol defines one or more criteria for identifying a location as an arrhythmogenic focus or pathway, the criteria including identifying one or more of: (i) covert fusion; and (ii) overt fusion in the detected ECG signal. (20) The method of embodiment 11, comprising measuring the intracardiac location using a position tracking system.

Claims

1. a memory configured to store a cardiac pacing protocol definition; a processor, the processor comprising: receiving the stored definition of the cardiac pacing protocol; automatically controlling one or more probes within the patient's heart to automatically pace from intracardiac locations in accordance with said cardiac pacing protocol and acquire respective sensed electrocardiogram (ECG) signals; automatically accepting the sensed ECG signal if a difference between a cycle length of the sensed ECG signal and a pacing cycle length of the cardiac pacing protocol is within a predefined reference range, and classifying the sensed ECG signal as invalid if the difference is outside the reference range; identifying or rejecting the intracardiac location as an arrhythmogenic focus or pathway based on one or more predefined criteria for identification of the arrhythmia; superimposing the identified intracardiac locations on an electrophysiological (EP) map; and then identifying a new intracardiac location as an arrhythmogenic focus or pathway and overlaying the new intracardiac location on the EP map when re-pacing from the new intracardiac location. system.

2. The system of claim 1 , wherein the definition includes at least a pacing sequence.

3. 2. The system of claim 1, wherein the processor is further configured to visually present to a user on the EP map qualitative or quantitative results resulting from pacing at each paced intracardiac location.

4. The cardiac pacing protocol defines the one or more criteria for identification of a location as an arrhythmogenic focus or pathway, the criteria comprising: Comparison of tachycardia cycle length (TCL) with post-pacing interval (PPI) in the same ECG signal; and 2. The system of claim 1, further comprising one of: a comparison of a time difference between the pacing signal and a resulting surface or intracardiac ECG signal with a time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

5. The system of claim 4, wherein the processor is configured to identify a location as an arrhythmogenic focus or pathway by identifying a location in a direction in which the difference in PPI-TCL values ​​or time difference values ​​is smaller.

6. The system of claim 1 , wherein the processor is configured to measure the intracardiac location using a position tracking system.

7. The system of claim 1 , wherein the processor is configured to store the definition of the cardiac pacing protocol by at least one of saving, importing, and exporting the cardiac pacing protocol.

8. 1. A method of operating a system including a processor, comprising: receiving a cardiac pacing protocol definition; acquiring, by the processor, respective electrocardiogram (ECG) signals sensed by pacing from intracardiac locations according to the cardiac pacing protocol; the processor automatically accepts the sensed ECG signal if a difference between a cycle length of the ECG signal and a pacing cycle length in the cardiac pacing protocol is within a preset reference range, and classifies the sensed ECG signal as invalid if the difference is outside the reference range; identifying or rejecting the intracardiac location as an arrhythmogenic focus or pathway based on one or more predefined criteria for arrhythmia identification, the processor overlaying the identified intracardiac cardiac locations on an electrophysiological (EP) map; Thereafter, the processor identifies the new intracardiac location as an arrhythmogenic focus or pathway and overlays the new intracardiac location on the EP map when re-pacing from the new intracardiac location.

9. The method of claim 8 , wherein the definition includes at least a pacing sequence.

10. 10. The method of claim 8, further comprising the processor visually indicating to a user on the EP map qualitative or quantitative results resulting from pacing at each paced intracardiac location.

11. The cardiac pacing protocol defines the one or more criteria for identification of a location as an arrhythmogenic focus or pathway, the criteria comprising: Comparison of tachycardia cycle length (TCL) with post-pacing interval (PPI) in the same ECG signal; and 9. The method of claim 8, comprising one of: comparing a time difference between the pacing signal and a resulting surface or intracardiac ECG signal with a time difference between one or more subsequent pacing signals and their respective resulting surface or intracardiac ECG signals.

12. The method of claim 11, wherein identifying a location as an arrhythmogenic focus or pathway includes the processor identifying a location in a direction in which the difference in PPI-TCL values ​​or time difference values ​​becomes smaller.

13. 13. The method of claim 12, wherein identifying a location as an arrhythmogenic focus or pathway includes the processor identifying a location in a direction in which a PPI-TCL value or a time difference value is minimum or maximum, and recommending the location to a user as a next pacing location.

14. The method of claim 8 , wherein the processor comprises measuring the intracardiac location using a position tracking system.

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