Real-Time Cardiac Mapping with a Noninvasive Imageless Electrocardiographic Imaging System
April 11th, 2025
This study introduces a novel approach for real-time cardiac mapping using a noninvasive, imageless electrocardiographic imaging system. This system enables the acquisition of electrophysiological cardiac maps without requiring pre-procedural computed tomography or magnetic resonance imaging scans, enabling efficient guidance for cardiac procedures such as ablation and cardiac resynchronization therapy implants.
The scope of this research is to describe the features and clinical applications of a novel non-invasive ECGI system, also known as imageless ECGI, which enables the real time cardiac mapping without the need of pre-procedural CT or MRI scans.
Electrochemical mapping systems are used today to guide catheter ablation procedures, however they struggle to capture spatiotemporal dispersion patterns of atrial fibrillation and non-sustained arrhythmias. Moreover, its invasive nature makes them impractical to guide implantations of cardio/respiratory synchronization therapies and the rest of cardiac devices.
Real time ECGI imaging is opening an era of new possibilities of non-invasive mapping of the cardiac activity. As compared to classical ECGI systems, the imageless ECGI allows for a real time mapping without the need of a previous image like CT, for example.
Imageless ECGI overcomes key limitations of classical ECGI systems by eliminating the need of CT or MRI, reducing patient preparation time and using advanced single processing algorithms to improve arrhythmia localization accuracy and procedural outcomes.
[Narrator] To begin, position the patient either standing or sitting on a chair or the electrophysiology table, ensuring the entire torso area is free of clothing. After inspecting the patient's skin, correctly position the four parts of the sensor vest on the patient's torso. Adjust the vest to the patient's size by folding the connections between the electrodes if necessary. Place the right leg driven, or RLD, electrode of the sensor vest on the right leg and the reference electrode on the left leg, ensuring they are positioned as far away from the other vest electrodes as possible. Position the patient with their arms over their head to prevent interference with the 3D torso reconstruction. For the 3D torso reconstruction, grab the 3D scanner platform and open the 3D scanning application. Scan the QR code on the lateral side of the front right vest component to validate the sensor vest. Ensure the vest is single use and not expired. Position the 3D scanner platform at the torso level in front of the patient. Hold the scanner firmly with both hands and complete a full 360 degree rotation around the patient to acquire the 3D torso reconstruction. Conduct a visual inspection of the 3D torso reconstruction to ensure the entire torso is covered by a gray shadow and that no holes are present in the reconstructed mesh. Save the 3D torso reconstruction in the application once the scan is finished. Have the patient lie down on the electrophysiology room table. Connect the four parts of the sensor vest to the corresponding right and left connector cables. Attach the front right and back right vest connectors to the right cable socket and the front left and back left vest connectors to the left cable socket. Power on the bio potential amplifier to enable the imageless electrocardiographic imaging software to receive real-time electrophysiological signals. Next, to estimate the patient's cardiac geometry, click the load torso scan button and upload the 3D torso reconstruction. In the torso geometry window, check the torso reconstruction and click on refine model. Now, select the Compute Geometry button. Choose the Estimate Heart Geometry option, followed by Compute Geometry Data and Confirm to estimate the patient's cardiac geometry. For noninvasive imageless ECGI mapping, go to the Amplifier window and click on the Connect Amplifier button to start acquiring realtime electrophysiological signals. Click on different leads to visualize the signals on the amplifier screen. Navigate to the Realtime window to obtain realtime noninvasive cardiac mapping. Then, to exclude noisy signals, go to view electrodes. Click on the 128 Lead View button and select User Only as the Noisy Lead Selection mode. Double click on noisy signals to exclude them before generating the ECGI map. Click the 12 Lead View button to visualize an estimated 12 lead ECG in real time. Ensure the RT On button is active to automatically update signals in the signal analysis section. This option automatically triggers and defines the onset and offset of the QRS complex to be analyzed. Configure the electrocardiographic imaging activation mapping analysis by clicking the Options button to generate an optimal basal rhythm map for the cardiac resynchronization therapy, or CSPCRT procedure. Select the Analyze Ventricle option to only map the ventricles. Select Wavelet Based Analysis option for the activation times algorithm. Choose the Average Beat option under Mapping Type to calculate the average wave of the last 10 QRS complexes. Leave the default settings for Offset Correction, Beat Number, Sync Option, and Delineator Option features. Now, select the View Two Maps option in the Maps Visualization section. Write the name of the left map. Ensure that it is set to Update mode so it continuously updates with each newly averaged QRS complex analyzed and save the map. Then navigate to the Maps list. Select the last map that was saved and visualize the biventricular basal activation map on the right side. Set the right map to Freeze mode once it is reproducible. Next, configure the ECGI activation mapping analysis by clicking the Options button to obtain optimal maps during the screwing and pacing process in the septal region. Select the Analyze Ventricle option to only map the ventricles. Select the Wavelet Based Analysis option for the activation times algorithm. Choose the Single Beat option under Mapping Type to analyze the wave of a single beat and capture changes in electrocardiographic signals during the simultaneous screwing and pacing process at different septal positions. Leave the default settings for Offset Correction, Beat Number, Sync Option, and Delineator Option features. Set the left panel map to Update mode to ensure it continuously updates with each newly analyzed single beat QRS complex during the screwing process. Synchronize the color map range of the left panel map with the basal map in the right panel using the Linked Values menu and link their camera positions via the linked camera menu. Finally, whenever a change in the activation pattern is observed during the screwing process in the septal region, write the name and save each map by clicking the Save Map button. Continue this process until the left bundle branch area is reached. The optimization of the biventricular pacing using imageless ECGI is shown here. Ventricular activation mapping at baseline showed delayed activation in the basal lateral wall of the left ventricle with a total activation time of 116 milliseconds, confirming ventricular dyssynchrony. Following biventricular pacing with optimized lead positioning, no late activated regions were observed and total activation time improved to 70 milliseconds. X-ray imaging confirmed the positioning of pacing electrodes with both distal and proximal poles of the left ventricular leads, successfully delivering pacing therapy. Imageless electrocardiographic mapping during ventricular tachycardia ablation identified conduction slowing in the infra basal segment of the left ventricle during sinus rhythm. Right ventricular pacing confirmed slow conduction in the basal and medial segments, pinpointing the arrhythmogenic substrate. Ventricular tachycardia activation mapping accurately identified the isthmus in the same region, facilitating targeted ablation. The non-invasive findings were in agreement with invasive EAM during substrate and VT activation mapping.
Overview
This study introduces a novel non-invasive electrocardiographic imaging system that enables real-time cardiac mapping without the need for pre-procedural imaging scans. This advancement aims to enhance the guidance of cardiac procedures such as ablation and cardiac resynchronization therapy.
Key Study Components
Area of Science
- Cardiology
- Electrophysiology
- Medical Imaging
Background
- Traditional electrochemical mapping systems are invasive and struggle with spatiotemporal dispersion patterns.
- Current methods require pre-procedural CT or MRI scans, increasing patient preparation time.
- Real-time ECGI imaging offers a non-invasive alternative for cardiac activity mapping.
- Imageless ECGI improves arrhythmia localization accuracy and procedural outcomes.
Purpose of Study
- To describe the features of the imageless ECGI system.
- To demonstrate its clinical applications in real-time cardiac mapping.
- To highlight the advantages over traditional ECGI systems.
Methods Used
- Patient positioning and sensor vest application.
- 3D torso reconstruction using a scanning platform.
- Real-time electrophysiological signal acquisition.
- Mapping and analysis of cardiac geometry and rhythms.
Main Results
- The imageless ECGI system successfully maps cardiac activity in real-time.
- It eliminates the need for pre-procedural imaging, reducing preparation time.
- Improved accuracy in localizing arrhythmias was observed.
- Facilitates better guidance for cardiac procedures.
Conclusions
- The imageless ECGI system represents a significant advancement in non-invasive cardiac mapping.
- It has the potential to improve patient outcomes in various cardiac procedures.
- Further studies are warranted to explore its full clinical applications.
Frequently Asked Questions
Executive Industry Relevance
Noninvasive, imageless electrocardiographic imaging (ECGI) enables real-time, high-resolution cardiac mapping without pre-procedural imaging, addressing critical workflow and risk challenges in electrophysiology R&D. This technology enhances predictive confidence for arrhythmia localization and device placement, supporting more efficient and reproducible decision-making at key discovery and translational inflection points. Its integration can streamline early validation and reduce biological ambiguity in cardiac device and therapy development pipelines.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables precise interrogation of cardiac electrical pathways for mechanistic de-risking.
- Supports functional validation of arrhythmogenic substrates and pacing targets.
- Improves predictive confidence in identifying actionable cardiac regions for intervention.
Screening & Assay Development
- Facilitates standardized, reproducible mapping of cardiac activation patterns for device and therapy screening.
- Provides quantitative, real-time outputs for comparative evaluation of pacing and ablation strategies.
- Enables rapid assessment of lead positioning and therapy optimization in preclinical models.
Translational & Preclinical Research
- Aligns noninvasive mapping outputs with disease-relevant arrhythmia models for translational continuity.
- Supports risk-adjusted advancement of cardiac devices and therapies by confirming mechanistic endpoints.
- Bridges discovery and preclinical validation with real-time, patient-specific mapping data.
Pipeline & Workflow Integration
The imageless ECGI system fits from early discovery through translational and preclinical cardiac device development, enabling hypothesis testing, mechanistic de-risking, and quantitative assessment of intervention strategies.
- Discovery Biology: Provides real-time mapping to clarify arrhythmia mechanisms and validate intervention targets.
- Screening: Delivers reproducible, quantitative activation maps for evaluating device and therapy performance.
- Analytics: Offers high-resolution, beat-to-beat measurements to compare procedural conditions and outcomes.
- Translational Research: Ensures continuity between noninvasive mapping and invasive validation in preclinical models.
- Enterprise Reuse: Establishes a scalable, noninvasive mapping platform for repeated use across cardiac R&D programs.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence and reduces mechanistic ambiguity in cardiac target validation.
- Operational Value: Streamlines workflows by eliminating pre-procedural imaging and reducing patient preparation time.
- Strategic Value: Enables faster, more informed go/no-go decisions for device and therapy development.
- Portfolio Impact: Supports risk-adjusted prioritization and advancement of cardiac R&D assets.
Implementation Considerations
- Requires expertise in electrophysiology and computational cardiac mapping.
- Needs access to advanced sensor vests, 3D scanning, and signal processing infrastructure.
- Demands cross-team standardization for data acquisition and analysis protocols.
- Adaptation may be needed for different cardiac models and arrhythmia types.
- Dependent on robust signal quality and artifact exclusion for reliable outputs.
