Cardiac rhythm management systems and methods using acoustic contractility indicator

[0001] This document relates generally to medical systems, devices, and methods, and particularly, but not by way of limitation, to cardiac rhythm management systems and methods using an acoustic contractility indicator.

[0002] When functioning properly, the human heart maintains its own intrinsic rhythm. Its sinoatrial node generates intrinsic electrical cardiac signals that depolarize the atria, causing atrial heart contractions. Its atrioventricular node then passes the intrinsic cardiac signal to depolarize the ventricles, causing ventricular heart contractions. These intrinsic cardiac signals can be sensed on a surface electrocardiogram (ECG) obtained from electrodes placed on the patient's skin, or from electrodes implanted within the patient's body. The surface ECG waveform, for example, includes artifacts associated with atrial depolarizations (“P-waves”) and those associated with ventricular depolarizations (“QRS complexes”).

[0003] A normal heart is capable of pumping adequate blood throughout the body's circulatory system. However, some people have irregular cardiac rhythms, referred to as cardiac arrhythmias. Moreover, some patients have poor spatial coordination of heart contractions. In either case, diminished blood circulation may result. For such patients, a cardiac rhythm management system may be used to improve the rhythm and/or spatial coordination of heart contractions. Such systems are often implanted in the patient and deliver therapy to the heart.

[0004] Cardiac rhythm management systems include, among other things, pacemakers, also referred to as pacers. Pacers deliver timed sequences of low energy electrical stimuli, called pace pulses, to the heart, such as via an intravascular lead wire or catheter (referred to as a “lead”) having one or more electrodes disposed in or about the heart. Heart contractions are initiated in response to such pace pulses (this is referred to as “capturing” the heart). By properly timing the delivery of pace pulses, the heart can be induced to contract in proper rhythm, greatly improving its efficiency as a pump. Pacers are often used to treat patients with bradyarrhythmias, that is, hearts that beat too slowly, or irregularly. Such pacers may also coordinate atrial and ventricular contractions to improve pumping efficiency.

[0005] Cardiac rhythm management systems also include cardiac resynchronization therapy (CRT) devices for coordinating the spatial nature of heart depolarizations for improving pumping efficiency. For example, a CRT device may deliver appropriately timed pace pulses to different locations of the same heart chamber to better coordinate the contraction of that heart chamber, or the CRT device may deliver appropriately timed pace pulses to different heart chambers to improve the manner in which these different heart chambers contract together.

[0006] Cardiac rhythm management systems also include defibrillators that are capable of delivering higher energy electrical stimuli to the heart. Such defibrillators include cardioverters, which synchronize the delivery of such stimuli to sensed intrinsic heart activity signals. Defibrillators are often used to treat patients with tachyarrhythmias, that is, hearts that beat too quickly. Such too-fast heart rhythms also cause diminished blood circulation because the heart isn't allowed sufficient time to fill with blood before contracting to expel the blood. Such pumping by the heart is inefficient. A defibrillator is capable of delivering a high energy electrical stimulus that is sometimes referred to as a defibrillation countershock, also referred to simply as a “shock.” The countershock interrupts the tachyarrhythmia, allowing the heart to reestablish a normal rhythm for the efficient pumping of blood. In addition to pacers, CRT devices, and defibrillators, cardiac rhythm management systems also include devices that combine these functions, as well as monitors, drug delivery devices, and any other implantable or external systems or devices for diagnosing or treating the heart.

[0007] One problem presented by some cardiac patients is determining the extent of any benefit obtained from a particular cardiac resynchronization therapy (e.g., left ventricular pacing, bi-ventricular pacing, and/or multisite pacing within the same heart chamber), or parameter settings controlling such therapy. This may include determining whether a patient is actually benefitting from the CRT or other therapy being received. This may also include determining whether a particular CRT or other therapy benefits a particular patient more or less than another different CRT or other therapy. For these and other reasons, the present inventors have recognized that there exists an unmet need for improved techniques of determining the efficacy of such therapy.

[0008] This document discusses, among other things, systems, devices, and methods that measure a distance between ultrasound or other acoustic transducers to provide a contractility or other therapy efficacy indication. In one example, the indication is communicated to a caregiver for assisting in the caregiver's determination of particular therapy settings. In another example, the indication is used in a feedback controller to automatically adjust one or more therapy parameters based at least in part on the indication.

[0009] In one example, this document describes a system that includes first and second acoustic transducer interfaces. The first acoustic transducer interface is configured to be coupled to a first acoustic transducer located in or about a heart. The second acoustic transducer interface is configured to be coupled to a second acoustic transducer. A controller circuit is coupled to the first and second acoustic transducer interfaces to measure a distance, between the first and second acoustic transducers, that varies during a heart contraction. The controller is configured to provide an indication based on a variation of the distance during at least one heart contraction.

[0010] In another embodiment, this document describes a method. The method includes transmitting, at a first location, an acoustic signal through a portion of a pump. The acoustic signal is received at a second location. A change in distance between the first and second locations is determined during at least one pump contraction. A “contractility” or other indication is provided, based at least in part on a degree of the change in the distance between the first and second locations during the at least one pump contraction.

[0011] Other aspects of the discussed systems, devices, and methods will become apparent upon reading the following detailed description and viewing the drawings that form a part thereof.

[0022] In the following detailed description, reference is made to the accompanying drawings, which form a part hereof, and in which is shown by way of illustration specific embodiments in which the invention may be practiced. These embodiments are described in sufficient detail to enable those skilled in the art to practice the invention, and it is to be understood that the embodiments may be combined, or that other embodiments may be utilized and that structural, logical and electrical changes may be made without departing from the scope of the present invention. The following detailed description is, therefore, not to be taken in a limiting sense, and the scope of the present invention is defined by the appended claims and their equivalents.

[0023] In this document, the terms “a” or “an” are used, as is common in patent documents, to include one or more than one. Furthermore, all publications, patents, and patent documents referred to in this document are incorporated by reference herein in their entirety, as though individually incorporated by reference. In the event of inconsistent usages between this documents and those documents so incorporated by reference, the usage in the incorporated reference(s) should be considered supplementary to that of this document; for irreconcilable inconsistencies, the usage in this document controls.

[0024] This document discusses, among other things, systems, devices, and methods that will be described in applications involving implantable medical devices including, but not limited to, implantable cardiac rhythm management systems such as pacemakers, cardioverter/defibrillators, pacer/defibrillators, biventricular or other multi-site resynchronization or coordination devices, and drug delivery systems. However, these systems, devices, and methods may be employed in unimplanted devices, including, but not limited to, external pacemakers, cardioverter/defibrillators, pacer/defibrillators, biventricular or other multi-site resynchronization or coordination devices, monitors, programmers and recorders, whether such devices are used for providing a diagnostic, a therapy, or both a diagnostic and a therapy.

[0025] FIG. 1 is a schematic diagram illustrating generally, by way of example, but not by way of limitation, portions of a cardiac rhythm management system 100 providing a therapy efficacy indication based on a measured distance between acoustic transducers. System 100 includes a hermetically sealed implantable cardiac rhythm management device 105 and a programmer or other external interface 110. In this example, intracardiac leads 115A–B are catheters connected to device 105, with respective distal portions intravascularly introduced into heart 120. In the illustrative example of FIG. 1, a distal portion of lead 115A is introduced into a right ventricle of heart 120, and a distal portion of lead 115B is introduced through coronary sinus 125 (which, in this document, includes the great cardiac vein) into proximity with a wall of a left ventricle of heart 120. Leads 115A–B include respective ultrasound or other acoustic transducers 130A–B. Transducers 130A–B are respectively disposed in the right ventricle and in proximity to the left ventricle (e.g., within coronary sinus 125), such that at least one of transducers 130A–B undergoes motion during a ventricular heart contraction. In one example, leads 115A–B also include one or more pacing and/or defibrillation electrodes, such as for providing pacing, resynchronization, cardioversion, and/or defibrillation therapy to heart 120.

[0026] In the example of FIG. 1, device 105 carries various electrical components, such as ultrasonic or other acoustic transducer interfaces 135A–B. Transducer interfaces 135A–B are electrically connected to respective transducers 130A–B via wires extending from device 105 through respective leads 115A–B. Transducer interfaces 135A–B collectively include circuits for transmitting an acoustic signal at one of transducers 130A–B and detecting a received acoustic signal at the other one of transducers 130A–B. Device 105 also includes controller circuit 140, which is coupled to transducer interfaces 135A–B. In one example, controller 140 is capable of sequencing through various control states such as, for example, by using a digital microprocessor having executable instructions stored in an associated instruction memory circuit, a microsequencer, or a state machine. However, controller 140 is capable of using many other hardware/firmware/software implementations.

[0027] In the example of FIG. 1, controller 140 includes a transit time calculation module 145 to calculate the transit time of the acoustic signal transceived between transducers 130A–B. Based on the calculated transit time, and the known velocity of the ultrasound or other acoustic signal in the surrounding media (e.g., heart tissue, blood, and/or other bodily fluids), controller 140 calculates a distance between transducers 130A–B. Controller 140 calculates how much the distance between transducers 130A–B varies during a heart contraction (or averaged over several heart contractions), such as by performing several individual distance calculations during a single heart contraction to determine an amplitude of the distance variation. This distance variation is stored in a distance variation memory location 150. In one example, this distance variation may, but need not, be computed with respect to a previously-computed reference distance between transducers 130A–B, which is stored in a reference distance memory location 155.

[0028] The distance variation between transducers 130A–B provides, among other things, a resulting indication of the contractility of heart 120, which is stored in a contractility indication memory location 160. In one example, a wireless telemetry or other communication circuit 165 communicates the contractility indication to a second communication circuit in a programmer or other external interface 110, such as for display on a graphical user interface (GUI) to a physician or other caregiver. Using the displayed contractility indication as an indicator of the efficacy of therapy being provided to heart 120 (e.g., pacing and/or cardiac resynchronization therapy), the caregiver communicates particular values of one or more therapy control parameters (e.g., rate, electrode selection, interelectrode delay, etc.) from external interface 110 to device 105, to be stored in one or more therapy control parameter memory locations 200, as illustrated in the schematic diagram of FIG. 2. In this example, the therapy control parameters control operation of a pacing and/or cardiac resynchronization therapy circuit 205, which is coupled to right ventricular (RV) electrode 210A and left ventricular (LV) electrode 210B. In one example, electrical stimuli are delivered to heart 120 via electrodes 210A–B to coordinate the timing of RV and LV contractions, such as in a patient with congestive heart failure (CHF), to increase cardiac output. In a further example, an interelectrode delay between the RV and LV stimuli associated with the same heart contraction instance is adjusted by the caregiver using efficacy information determined from the contractility indication received at external interface 110 from device 105. The caregiver adjusts the value of the interelectrode delay parameter stored in therapy control parameter memory location(s) 200 such that an increased acute or chronic contractility indication is obtained. In one example, therefore, contractility indication memory location 160 includes several memory locations, such as for logging contractility data over an extended period of time (e.g., between a patient's visits to the caregiver).

[0029] FIG. 3 is a schematic diagram illustrating generally another example, in which device 105 includes a feedback path 300 that uses the contractility indication as at least one basis for automatically occasionally or frequently adjusting one or more values stored in therapy control parameter memory location(s) 200. This, in turn, adjusts how cardiac resynchronization or other therapy is delivered to heart 120. Therapy efficacy is monitored using the distance measurement between acoustic transducers 130A–B for further adjusting one or more therapy parameters using this feedback loop. To reduce power consumption, the distance measurement between acoustic transducers 130A–B is, in one example, performed infrequently, and acoustic transducer interfaces 135A–B are powered off or down during the time periods between such infrequent measurements. In another example, device 105 wirelessly (or otherwise) receives at least some power (e.g., inductively coupled onto communication circuit 165 from external interface 110) from an external power source, either during such acoustic monitoring, or to recharge a battery included in device 105 between and/or during instances of such monitoring. In this manner, the received power energizes (or assists in energizing) acoustic transducers 130A–B and/or associated acoustic transducer interfaces 135A–B, or otherwise compensates for at least a portion of the power consumption of such components. The power may, but need not, be received by communication circuit 165; FIG. 9 is a schematic diagram illustrating generally another example in which device 105 includes a coil or other power interface 900—separate from communication circuit 165—for wirelessly (or otherwise) receiving power from another coil or other external power source 905. The received power at least partially energizes (or compensates for the power consumption of) one or more of acoustic transducers 130A–B and/or associated acoustic transducer interfaces 135A–B.

[0030] FIG. 4 is a schematic diagram illustrating generally, by way of example, but not by way of limitation, further acoustic transducers 130C–F, variously disposed on leads 115A–B or elsewhere (e.g., epicardially or even externally, such as in contact with the skin of the patient). These further acoustic transducers are either multiplexed to acoustic transducer interfaces 135A–B or connected to additional acoustic transducer interfaces. In one example, such multiple transducers 130A–F are used to calculate one or more reference distances between pairs of transducers 130A–F (e.g., using triangulation techniques), which are then stored in reference distance memory locations 155. Heart contraction distance variations between such pairs of transducers 130A–F may, but need not, then be computed with respect to the corresponding stored reference distance. In another example, one or more such additional transducer pairs are used to provide additional distance variation measurements. In one example, such additional distance variation measurements provide localized contractility information between particular different cardiac regions of interest. In another example, such additional distance variation measurements are combined (after any optional weighting) to provide a distributed indication of cardiac contractility.

[0031] FIG. 5 is a schematic diagram illustrating generally further example including one or more additional electrodes, such as electrode 210C disposed within coronary sinus 125 in proximity to the left ventricle. In one example, one therapy control parameter that is adjusted in response to a contractility indication of cardiac resynchronization therapy efficacy is a parameter that controls which electrode(s) are used to deliver such therapy. In this example, the distance between ultrasound transducers 130A–B is monitored, and the resulting contractility-based therapy efficacy indication is used to select which two (or all three) of electrodes 210A–C is used to deliver resynchronizing electrical stimuli to heart 120. In a further example, the efficacy indication is additionally used to determine the value(s) of interelectrode delays between the selected two or three electrodes (or other number of electrodes, such as in an example in which additional electrodes are present).

[0032] Although the above examples have illustrated acoustic transducers 130A–B located in different heart chambers on separate leads, in other examples, acoustic transducers 130A–B will be located in the same heart chamber, on different leads, or even on the same lead, as illustrated in the example of FIG. 6. In the schematic diagram of FIG. 6, a first acoustic transducer 130A is located more apically within coronary sinus of heart 125, and a second acoustic transducer 130B is located more in a more basal position near the left ventricular free wall. In this example, transducer 130A is expected to undergo less movement during a heart contraction than transducer 130B. FIG. 7 illustrates another example in which both transducers 130A–B are located within the right ventricle for obtaining a contractility indication based on the distance therebetween. FIG. 8 illustrates a further example, in which both transducers are located within a particular atrium (e.g., the right atrium, in the illustration of FIG. 8) for obtaining an atrial contractility indication based on the distance therebetween. Many other locations of acoustic transducers within heart 120, on heart 120, or about heart 120, or even external to the patient.

[0033] It is to be understood that the above description is intended to be illustrative, and not restrictive. For example, the above-discussed examples may be used in combination with each other. Many other embodiments will be apparent to those of skill in the art upon reviewing the above description. The scope of the invention should, therefore, be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled. Moreover, the terms “first,” “second,” “third,” etc. are used merely as labels, and are not intended to impose numeric requirements on their objects.