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The Reliability of the Fetal Magnetocardiogram The Reliability of the Fetal Magnetocardiogram Jeroen Gustaaf Stinstra 2001 Ph.D. thesis University of Twente Twente University Press Also available in print: http://www.tup.utwente.nl/uk/catalogue/technical/fetal-mcg/ RELIABILITY OF THE FETAL MAGNETOCARDIOGRAM Jeroen Gustaaf Stinstra Electronic full color version Acknowledgement This research was financially supported by: • The Netherlands Heart Foundation • The Institute for Biomedical Engineering (BMTI), University of Twente J.G. Stinstra, Reliability of the fetal Magnetocardiogram Proefschrift Universiteit Twente, Enschede. ISBN 90-365-1658-7 Copyright c J.G. Stinstra, [email protected], 2001 RELIABILITY OF THE FETAL MAGNETOCARDIOGRAM PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Twente, op gezag van de rector magnificus, prof. dr. F.A. van Vught, volgens besluit van het College voor Promoties in het openbaar te verdedigen op vrijdag 2 november 2001 te 16.45 uur. door Jeroen Gustaaf Stinstra geboren op 7 oktober 1974 te Leeuwarden Dit proefschrift is goedgekeurd door: prof. dr. M. J. Peters (promotor) en prof. dr. H. Rogalla (promotor) voor mijn ouders Contents 1 Introduction 11 1.1 Reliability of the fetal magnetocardiogram ............... 11 1.2 Layout of this thesis ........................... 12 1.3 Monitoring the fetal heart ........................ 14 1.4 Fetal magnetocardiography ........................ 18 2 Signal-processing 29 2.1 Objectives signal-processing ....................... 29 2.2 The signal-processing procedure ..................... 30 2.3 Description of the recorded signals ................... 31 2.4 Filtering .................................. 40 2.5 Detection and averaging of fetal complexes ............... 48 3 Modeling fetal MCG 53 3.1 Physical model .............................. 53 3.2 Boundary element method ........................ 56 3.3 Fetoabdominal compartments ...................... 61 3.4 Conductivity of fetoabdominal compartments ............. 66 3.5 Modeling the fetal heart ......................... 75 4 The vernix caseosa and its effects on fetal MCG and ECG 85 4.1 The vernix caseosa ............................ 85 4.2 Modeling thin highly resistive layers ................... 89 4.3 Modeling thin highly resistive layers and holes ............. 98 4.4 The influence of the vernix caseosa ................... 103 4.5 Capacitive effects due to the vernix caseosa ............... 113 5 The forward problem in fetal magnetocardiography 121 5.1 Fetoabdominal volume conduction .................... 121 5.2 The layer of subcutaneous fat and amniotic fluid ............ 123 5.3 Inter-individual differences during gestation .............. 126 5.4 The P-wave to QRS-complex ratio .................... 134 5.5 An effective model for volume conductor plus source ......... 137 5.6 Comparison between measurement and simulations .......... 146 CONTENTS 7 6 Database of normal values 151 6.1 The intracardiac time intervals ...................... 151 6.2 Statistics .................................. 154 6.3 Comparison with previously measured data ............... 156 6.4 Factors influencing intracardiac time intervals ............. 160 6.5 Application of intracardiac time intervals ................ 163 7 The classification of arrhythmia by fetal magnetocardiography 169 7.1 Fetal arrhythmia ............................. 169 7.2 Complete atrioventricular block ..................... 170 7.3 Atrial flutter ................................ 175 7.4 Premature atrial contractions ...................... 178 7.5 Bundle branch block ........................... 180 7.6 Discussion ................................. 184 8 Conclusions and discussion 185 8.1 Influence of the signal-processing .................... 185 8.2 Models ................................... 185 8.3 Amplitude of the fetal MCG ....................... 186 8.4 Ratios of the amplitudes in the fetal MCG ............... 187 8.5 Field distribution of the fetal MCG ................... 187 8.6 Field distribution of the fetal ECG ................... 188 8.7 The intracardiac time intervals ...................... 188 8.8 Classification of arrhythmia ....................... 189 References 191 Abbreviations 199 Samenvatting (summary in dutch) 201 Summary 205 Dankwoord 209 Curriculum Vitae 211 8 Chapter 1 Introduction According to Barker’s theorem disease originates in the womb. Barker (1999) and his team uncovered a relation between abnormal fetal growth and the development of diseases like coronary artery disease, hypertension, and diabetes in later life. According to his theorem, those children who are already suffering from health problems in their prenatal life are the same persons that suffer most health problems in adult life. Therefore Barker stresses the need for preventing abnormal fetal development. This implies the need for an accurate means of monitoring fetal well-being. Congenital anomalies of the heart are more common than anomalies in any other organ with about one percent of the children affected. Thence, this calls for monitoring the fetal heart. One way of monitoring the fetal heart activity is fetal magnetocardiography. Fetal magnetocardiography (MCG) is the recording of the magnetic fields generated by the fetal heart’s electric activity. The scope of this thesis is to evaluate this technique and its ability to reflect the electrical phenomena taking place within the fetal heart. An important aspect for fetal magnetocardiography in order to become a clinical accepted tool, is that it is not only able to measure fetal heart activity, but it has also to be a method, whose readings are reliable for diagnosis. This reliability aspect will be the central theme throughout this thesis. Although this thesis will focus on the reliability of fetal magnetocardiography, other methods like fetal electrocardiography and Doppler- ultrasound will be discussed as well as they provide important clues on the origin of the magnetic field measured. 1.1 Reliability of the fetal magnetocardiogram For a proper operation, a fetal magnetocardiogram (MCG) has to reflect the elec- trophysiological processes taking place in the fetal heart. If not, the fetal MCG has to be used cautiously in the diagnosis of fetal heart diseases. Moreover, it needs to be investigated, which aspects of the recorded signals can be trusted and which not. This reliability aspect is not restricted to the fetal MCG magnetometer system as there are other factors involved. The question is whether the changes in the magnetic field over the maternal abdomen can be predominately ascribed to the fetal heart and Introduction 11 which other factors play a role in the formation of the magnetic field over the mater- nal abdomen. As the magnetic data recorded over the maternal abdomen contains much more than fetal heart data alone, the fetal heart signals need to be extracted from the recorded signals. Hence, the algorithms in this signal-processing stage need to be robust and their flaws need to be known. In order to evaluate the reliability of fetal magnetocardiography, three aspects are considered, the duration, the amplitude and the ratio of the different depolarisation/repolarisation waves in the fetal magne- tocardiogram. As the field of fetal magnetocardiography is developing, the question is raised how to spot irregularities in the fetal heart functioning. For this purpose the signals need to be compared with other methods such as postnatal ECGs. Although the techniques are alike the differences need to be known. Throughout this thesis the different aspects of fetal magnetocardiography mentioned will be addressed in order to answer the question whether the fetal magnetocardiogram is reliable for diagnosis. In the next section the layout of this thesis will be described, followed by a short historic overview of the methods used to monitor the fetal heart and a description of fetal magnetocardiography. 1.2 Layout of this thesis In chapter 2, the signal-processing techniques will be discussed as currently used in the Biomagnetic Center Twente. The averaging and filtering techniques will be discussed as well as the influence of the magnetometer system itself. It will be investigated to what extent the signals will be dependent on the signal processing algorithms. In chapter 3 the volume conduction problem will be introduced. The volume conduc- tor consists of all tissues surrounding the fetal heart. As the currents generated in the fetal heart flow through these tissues, the differences in conductivity of these tissues influences the magnetic field over the maternal abdomen. Direct measurements of the volume conductor influence are not feasible, as it is not possible to separate the contributions to the magnetic field generated by the fetal heart from those due to the currents in the other tissues in the maternal abdomen. Hence, the volume conduction may compromise the reliability. The direct measurement of the current density in the fetus and maternal abdomen is not possible due to practical reasons. Hence, simula- tions are used to estimate the effects of the volume conductor. These simulations are used to answer the question whether the amplitudes or the amplitude ratios in the fetal magnetocardiogram can be trusted. In chapter 3, the volume conductor mod- els will be introduced which are used in these simulations, as well as the numerical techniques needed to perform the simulations. The bounds of the conductivity of the tissues present in fetoabdominal volume conductor will be estimated. The vernix caseosa is a fatty layer, which covers the
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