Abstract:
A method of controlling an external counterpulsation apparatus includes selecting a patient treatment pressure; outputting a signal corresponding to the selected treatment pressure; detecting a pressure of a compressed fluid reservoir; comparing the selected treatment pressure to the compressed fluid reservoir pressure; and controlling a pressure regulator valve based on a difference between the patient treatment pressure and the compressed fluid reservoir pressure. The compressed fluid reservoir pressure may be decreased when the compressed fluid reservoir pressure is greater than a preset difference from the patient treatment pressure, particularly by venting the compressed fluid reservoir to atmosphere. The compressed fluid reservoir pressure may be necessary when the compressed fluid reservoir pressure is less than a preset difference from the patient treatment pressure, particularly by operating a compressor.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application is a divisional of U.S. patent application Ser. No. 10/037,974 filed on Nov. 9, 2001, which is a continuation-in-part of U.S. patent application Ser. No. 09/710,692 filed on Nov. 10, 2000. The disclosures of the above applications are incorporated herein by reference. 
     
    
     DISCUSSION OF THE INVENTION  
       [0002]     The present invention relates to an external counterpulsation apparatus and method for controlling the same and, more particularly, to such an external counterpulsation apparatus and method for controlling the same having improved efficiency and utility.  
         [0003]     External counterpulsation is a noninvasive, atraumatic means for assisting and increasing circulation in patients. External counterpulsation uses the patient&#39;s physiological signals related to their heart cycle (e.g., electrocardiograph (ECG), blood pressure, blood flow) to modulate the inflation and deflation timing of sets of compressive cuffs wrapped around a patient&#39;s calves, lower thighs and/or upper thighs, including the lower buttocks. The cuffs inflate to create a retrograde arterial pressure wave and, at the same time, push venous blood return from the extremities to reach the heart at the onset of diastole. The result is augmented diastolic central aortic pressure and increased venous return. Rapid, simultaneous deflation of the cuffs produces systolic unloading and decreased cardiac workload. The end results are increased perfusion pressure to the coronary artery during diastole, when the heart is in a relaxed state with minimal resistant to blood flow; reduced systolic pressure due to the “sucking effect” during cuff deflation; and increased cardiac output due to increased venous return and reduced systolic pressure.  
         [0004]     Under normal operating conditions, when the heart contracts and ejects blood during systole, the aortic and coronary perfusion pressure increases. It should also be noted that the workload of the heart is proportional to the systolic pressure. However, during systole the impedance to coronary flow also increases significantly due to the contracting force of the myocardium, thereby restricting coronary blood flow. Also, during diastole, the myocardium is in a relaxed state, and impedance to coronary flow is significantly reduced. Consequently, although the diastolic perfusion pressure is much lower than systolic pressure, the coronary blood flow during diastole accounts for approximately eighty (80) percent of the total flow.  
         [0005]     The historical objectives of external counterpulsation are to minimize systolic and maximize diastolic pressures. These objectives coalesce to improve the energy demand and supply ratio. For example, in the case of patients with coronary artery disease, energy supply to the heart is limited. External counterpulsation can be effective in improving cardiac functions for these patients by increasing coronary blood flow and therefore energy supply to the heart.  
         [0006]     During a treatment session, the patient lies on a table. Electronically controlled inflation and deflation valves are connected to multiple pairs of inflatable devices, typically adjustable cuffs, that are wrapped firmly, but comfortably, around the patient&#39;s calves, lower thighs, and/or upper thighs, including the buttocks. The design of the cuffs permits significant compression of the arterial and venous vasculature at relative low pneumatic pressures (200-350 millimeters Hg).  
         [0007]     The earlobe pulse wave, finger pulse finger or temporal pulse wave is used as a timing signal to give the appropriate time for application of the external pressure so that the resulting pulse produced by external pressure in the artery can arrive at the root of the aorta just at the closure of the aortic valve. Thus, the arterial pulse wave is divided into a systolic period and a diastolic period. The earlobe pulse wave, finger pulse wave or temporal pulse wave signals, however, may not reflect the true pulse wave from the great arteries such as the aorta.  
         [0008]     According to the present invention, there are two factors that should be taken into account to determine the appropriate deflation time of all the inflatable devices: (1) release of all external pressure before the next systole to produce maximal systolic unloading, i.e., the maximum reduction of systolic pressure; (2) maintenance of the inflation as long as possible to fully utilize the whole period of diastole so as to produce the longest possible diastolic augmentation, i.e., the increase of diastolic pressure due to externally applied pressure. One measurement of effective counterpulsation is the ability to minimize systolic pressure, and at the same time maximize the ratio of the area under the diastolic wave form to that of the area under the systolic wave form. This consideration can be used to provide a guiding rule for determination of optimal deflation time.  
         [0009]     Furthermore, the various existing external counterpulsation apparatuses only measure the electrocardiographic signals of the patient to guard against arrhythmia. Because counterpulsation applies pressure on the limbs during diastole, which increases the arterial pressure in diastole and makes it higher than the systolic pressure, the blood flow dynamics and physiological parameters of the human body may vary. Some of these variations are beneficial.  
         [0010]     An external counterpulsation apparatus according to the invention generally includes a plurality of inflatable devices adapted to be received about the lower extremities of the patient, a source of compressed fluid in communication with the plurality of inflatable devices, and a fluid distribution assembly interconnecting the source of compressed fluid and the inflatable devices. The fluid distribution assembly includes a selectively operable inflation/deflation valve interconnected between each of the inflatable devices and the source of compressed fluid. The fluid distribution assembly distributes compressed fluid from the source of compressed fluid to the inflation/deflation valve and operates each inflation/deflation valve to sequentially inflate and deflate each of the inflatable devices. Each inflation/deflation valve has an input in fluid communication with the source of compressed fluid, an inflation/deflation port in fluid communication with one of the inflatable devices, and a deflation exhaust port in fluid communication with the atmosphere. The deflation exhaust port is normally open so as to exhaust compressed fluid upon loss of power to the external counterpulsation apparatus.  
         [0011]     The source of compressed may include a compressor and a power ramp-up device. The power ramp-up device, upon startup of the apparatus, converts electrical power to the compressor from 110/120 VAC 50/60 Hz to three-phase 220 VAC at a variable frequency. The power ramp-up device also increases the electrical power to a preselected full power level over a period of approximately three to five seconds.  
         [0012]     In an external counterpulsation apparatus according to the invention, a treatment table is provided upon which the patient Is situated during the treatment. The treatment table includes a main portion and an articulating portion selectively adjustable to a plurality of angulated positions relative to the main portion. The treatment table further includes a motor-driven elevation assembly actuable to selectively raise and lower the treatment table to a plurality of different elevated positions. The treatment table further includes a plurality of wheels allowing the treatment table to be selectively moved between a plurality of locations.  
         [0013]     The treatment table may further include an inflation/deflation valve mounted to the treatment table and movable therewith. The inflation/deflation valve selectively inflates and deflates an inflatable device attachable to the patient. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0014]      FIG. 1  is a block diagram of an external counterpulsation apparatus according to the present invention.  
         [0015]      FIG. 2  is a block diagram of an external counterpulsation apparatus according to the present invention.  
         [0016]      FIG. 3  is a block diagram of an external counterpulsation apparatus according to the present invention.  
         [0017]      FIGS. 4A and 4B  are partial schematic diagrams of a portion of the fluid distribution assembly according to the present invention, illustrating fluid pipes connected to a semiconductor cooling device and air-conditioner cooling evaporator, respectively.  
         [0018]      FIG. 5  is a diagrammatic view of an external counterpulsation apparatus according to the present invention.  
         [0019]      FIG. 6  is a diagrammatic representation of fluid flow of the external counterpulsation apparatus of  FIG. 5 .  
         [0020]      FIG. 7  is another flow diagram of fluid flow of the external counterpulsation apparatus according to the present invention.  
         [0021]      FIG. 8  is a control diagram for the external counterpulsation apparatus of  FIGS. 5 through 7 .  
         [0022]      FIGS. 9A and 9B  are diagrammatic representations of inflation and deflation of inflatable cuff devices of the present invention, coordinated with the associated portions of the patient&#39;s ECG.  
         [0023]      FIG. 10  is a graphic representation of the relationship between the patient&#39;s ECG, the valve opening signals and the inflatable cuff device inflation pressure waveforms during operation of the external counterpulsation apparatus of  FIGS. 5 through 9 .  
         [0024]      FIGS. 11A and 11B  are graphic representations of possible inflation time advances and delays and possible deflation time advances and delays.  
         [0025]      FIGS. 12 through 18  illustrate an exemplary inflation/deflation valve for use in an external counterpulsation apparatus according to the present invention.  
         [0026]      FIGS. 19 through 22  illustrate a pressure regulator assembly for use in an external counterpulsation apparatus according to the present invention.  
         [0027]      FIG. 23  is a block diagram depicting a computer system for monitoring and recording the treatment of a patient using an external counterpulsation device in accordance with the present invention.  
         [0028]      FIG. 24  illustrates an exemplary treatment control screen for the enhanced computer system of the present invention.  
         [0029]      FIG. 25  illustrates an exemplary main menu control screen for the enhanced computer system of the present invention.  
         [0030]      FIG. 26  illustrates an exemplary patient information screen for the enhanced computer system of the present invention.  
         [0031]      FIG. 27  illustrates an exemplary site information screen for the enhanced computer system of the present invention.  
         [0032]      FIG. 28  diagrammatically illustrates initiation timing logics for the inflation/deflation valves of an external counterpulsation apparatus according to the present invention.  
         [0033]      FIG. 29  is a diagrammatic representation of exemplary timing for the inflation/deflation valves and the air pressure waveforms in the inflatable devices of the external counterpulsation apparatus according to the present invention. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0034]     A detailed description of varied and merely exemplary embodiments of the present invention follows with reference to the accompanying drawings. One skilled in the art will readily recognize that the principles of the invention are equally applicable to other embodiments and applications.  
         [0035]      FIG. 1  is a block diagram of a first exemplary embodiment of an external counterpulsation apparatus according to the present invention, wherein a controller  10  controls the gas compressor  20  and set of solenoid valves  24 . The compressor can be of rotary vane, piston, diaphragm or blower type. One suitable compressor is a scroll-type compressor as described in U.S. Pat. No, 5,554,103, commonly assigned and incorporated herein by reference, which essentially consists of two scroll basin with very narrow gaps between them; with one scroll basin adapted to rotate at very high speed (3,000 rpm) while the other scroll basin remains stationary. The clenching of the scroll basins compresses the air radially inwardly toward the center and the compressed air comes out of the center shaft. During operation, the compressor  20  operates to produce pressurized gas, such as pressurized air, which is sent into the positive pressure reservoir  22  via a cooling means  21 . A pressure-limiting valve  23  is provided on the reservoir  22 , which keeps the internal pressure of the reservoir  22  constant. For this variation of the invention, the opening and closing of the set of solenoid valves  24  is, controlled by the inflation and deflation driving signals generated by the controller  10 . The set of solenoid valves  24  may include a number of two-position, three-way solenoid valves corresponding to the number of inflatable devices  25 . When a valve is in the first of the two positions, it inflates the inflatable device; when it is in the second of the two positions, it deflates the inflatable device, under control of the control system. Other valve assemblies, including those disclosed below, may be used in accordance with the invention. Each inflatable device.  25  may include a balloon or air bladder surrounded by a cuff, or may be unitary in structure. The inflatable devices  25  may include cuffs wrapped tightly around the lower limbs with inflatable devices  25  put in between the cuffs and the body. When compressed gas is injected into the inflatable devices  25 , the cuff will also expand and extend outward, due to the elasticity and extensibility of its material. Suitable cuff and balloon apparatuses shown and described in U.S. Pat. No. 5,554,103, are incorporated herein by reference. More or fewer inflatable devices  25  may be used, but three are shown here for explanation purposes. For example, more devices may be used to improve the fit, and thus the effectiveness of counterpulsation.  
         [0036]      FIG. 2  illustrates another external counterpulsation apparatus according to the present invention. In this variation, a control signal generated by the controller  10  signals the compressor  20  to compress gas into the positive pressure reservoir  22  after being cooled by the cooling means  21 . A pressure-limiting valve  23  is provided on the positive pressure reservoir to keep its internal pressure constant. A negative pressure reservoir  26  connected to the inlet of the compressor  20  is a source of negative pressure. The control system  10  controls the opening and closing of the set of solenoid valves  24  by issuing inflation and deflation control signals in accordance with the results of detection. When the set of solenoid valves  24  are in the first position, they inflate the inflatable devices  25 , when they are in the second position, they deflate the inflatable devices  25 . The gas discharged from the inflatable devices is discharged into the negative pressure reservoir  26  via the set of solenoid valves  24 , and then returns to the compressor  20 . As there may be leakage during the circulation of gas, which may affect the amount of gas output from the compressor  20 , a pressure-limiting valve  27  is provided to adjust the negative pressure in the negative pressure reservoir  26 . When the negative pressure exceeds a certain value, the pressure-limiting valve  27  is opened to inject a certain amount of gas into the negative pressure reservoir  26 .  
         [0037]      FIG. 3  illustrates another external counterpulsation apparatus according to the present invention, wherein the controller  10  generates control signals and the compressor  20  operates to produce two portions of pressurized gas, one portion of pressurized gas is sent to the positive pressure reservoir  29 , while another is sent into the positive pressure reservoir  22  via the cooling means  21  and a throttle valve  28 . The pressure limiting valve  23  is operative to adjust the pressure inside the reservoir  22 . The reference numeral  30  indicates a two-position-five-way solenoid valve or two two-position-three-way solenoid valves,  31  indicates a mono-directional throttle valve,  35  indicates a cylindrical gas distribution means or cylinder,  37  is a partition, and  36  indicates a piston. When an inflation driving signal is issued by the controller  10 , the solenoid valve  30  opens to the first of the two positions, and the gas flow is introduced into the portion I of the cylinder from the reservoir  29  via the solenoid valve  30  and the throttle governor  31  to push the piston from a first towards a second end of the cylinder  35 . A space portion III is formed by the piston  36  and the cylinder  35  and is always in communication with the reservoir  22 . Vents for the inflatable devices  25  are situated in sequence in the cylinder  35 , the inflatable devices  25  being sequentially inflated as the piston  36  moves towards the second end of the cylinder  35 . When a deflation signal is issued by the controller  10 , the solenoid valve  30  is moved to its second position, and the gas in the reservoir  29  enters portion  11  of the cylinder  35  via the solenoid valve  30  to push the piston  36  back to the first end of the cylinder  35 . At that time, the gas in portion I is discharged via the solenoid valve  30 , and the gas in the inflatable devices  25  is discharged to the negative pressure reservoir  26 . In order to speed of deflation, a solenoid valve  34  is also opened at the same time and the gas discharged from the inflatable device  25  is discharged to both negative pressure reservoirs  26 ,  33 . Negative pressure reservoir  33  is kept at a negative pressure by the input portion of compressor  32 . Discharged gas is also sent to the reservoir  22  by the output portion of the compressor  32 .  
         [0038]     During the deflation phase, in such an embodiment, if the pressurized inflatable devices  25  is simply exhausted into the atmosphere, exhaustion of the inflatable devices may not be completed, with the residual gas pressing on the tissue mass surrounded by the inflatable devices, reducing the much needed vascular space in the body to receive the volume of blood ejected by the heart. This can reduce the ability of external counterpulsation to unload systolic blood pressure and reduce cardiac workload. The addition of negative pressure reservoirs  26 ,  33  serve to more rapidly evacuate the pressurized gas in the inflatable devices  25 , thereby ensuring complete absence of pressure on the lower extremities, enabling the vasculature that has been previously compressed and emptied during the diastolic period to act as a source of suction to help the heart eject blood and unload systolic blood pressure. In addition, the negative pressure reservoirs  26 ,  33  ensure the smooth operation of the solenoid valves  30 , 34  and prevent the leakage of large volumes of pressurized gas exhausting into the atmosphere. This closed gas system also reduces noises generated by the opening and closing of solenoid valves and movement of air from escaping the system. It should be noted, however, that a negative pressure reservoir might not necessarily be required in each variation, embodiment or application of the present invention.  
         [0039]     Furthermore, during normal operation of external counterpulsation, there is always some leakage of compressed air from the inflatable device  25  during the inflation period. To compensate for this leakage and to ensure there is adequate air supplied to the compressor  20  for producing air pressure in the range of five (5) to fifteen (15) psi, leakage compensation might be required, such as the use of a vacuum limiting valve, a vacuum pump, or compressor, or some combination thereof. An example of the leakage compensation means is a vacuum limiting valve  27  connected to the negative pressure reservoir  26 , set at approximately negative 100 mm Hg. When the negative pressure reservoir is less than approximately 100 mm Hg, the vacuum-limiting valve  27  is open and air is sucked into the reservoir  26  to provide more air to the intake of the compressor  20 .  
         [0040]     One variation of the present invention includes a gas cylindrical distribution system  35 , as shown in  FIG. 3 , including a syringe-type system to push a piston in one direction to provide sequential inflation of the inflatable devices  25 , with the inflatable devices  25  furthest from the heart being inflated first. The inflatable device openings are placed on both sides of the cylinder, connecting to the left and right limbs as well as buttock. The number of inflatable devices can be two (2) to eight (8) or more on each side, but more or fewer may be used. This is achieved by connecting the inflatable devices  25  furthest from the heart to the portion of the cylinder closest to the piston  36 , as the piston  36  moves from left to right as shown in  FIG. 3 . This gas distribution system uses compressed air to move the piston  36  back and forth along cylinder  35 , producing a quiet operation without requiring much power. The solenoid valve  30  is a normally open valve to portion  11  of the cylinder  35 , thereby connecting portion  11  to the positive pressure reservoir  29  in case of power failure, moving the piston  36  to the left in  FIG. 3 , exposing all the inflatable devices  25  to the negative pressure reservoir  26 , thereby deflating all inflatable devices  25  and reducing the possibility of inducing trauma to the patient.  
         [0041]     When air is compressed, heat will be generated. In external counterpulsation, approximately twenty-five (25) cubic feet of air is compressed to five (5) to fifteen (15) psi pressure, generating a gas with temperature reaching as high as seventy (70) to ninety (90) degrees Celsius, depending on the environment and efficiency of the compressor. When compressed gas with such high temperature is sent to the inflatable devices  25 , which are in close contact with the patient&#39;s skin, it may produce abrasion or burn to the skin, or at least, an uncomfortable feeling to the patient. Therefore, in some embodiments of the invention, cooling the compressed air is preferred. In general, any means of cooling can be utilized in this invention, including exposing to the atmosphere a long piece of coil or metal pipe connecting the compression means to the positive pressure reservoir, blowing air through a coil of metal pipe carrying the heated gas, water cooling such as that used in the radiator of automobile, running cooling water, or air conditioner, for examples.  
         [0042]     Further cooling examples are shown in  FIGS. 4A and 4B  which are partial schematic diagrams of the fluid distribution assembly of the external counterpulsation apparatus according to the present invention, illustrating a gas pipe  39  connected to a cooling means. The pipe  39  may be associated with fans  38  and/or heat isolation materials  40 , as shown in  FIG. 4A , wherein cooling means  21  includes semiconductor-type heat isolation materials  40 . In  FIG. 4B , the cooling means is an evaporator, i.e., fluid-cooled tubing. Alternatively, the cooling means  21  can be a fan, as shown in  FIG. 2 . Any other suitable cooling mechanism can be used.  
         [0043]     Beginning with  FIG. 5 , another embodiment of the external counterpulsation apparatus according to the invention is illustrated and described. External counterpulsation apparatus  201  includes three component assemblies, namely, a control console assembly  202 , a treatment table assembly  204 , and an inflation/deflation assembly  206 . The control console assembly  202  is mounted for mobility from one location to another upon wheels  214 , and similarly the treatment table assembly  204  is mounted for mobility from one location to another upon wheels  216 . As used herein the term “wheels” includes casters, rollers, track-type belts, or other lockable and unlockable wheel-type devices configured for allowing the components to be “wheeled” from one location to another and then locked in order to maintain the desired position or location. The control console assembly  202  generally includes a user interface device, such as a computer monitor or touch screen  220 , and a cabinet or housing  222 , in which various components described below are located and housed.  
         [0044]     The treatment table assembly  204  generally includes an upper surface  205  on an articulating portion  226  and a horizontal portion  228 , with the articulating portion  226  being hingedly or otherwise pivotally interconnected with the horizontal portion  228  for adjustment (either manually or by way of a power drive) to a plurality of angulated positions relative to the horizontal portion  228 . In this regard, it should be noted that the angulated position of the articulating portion  226  relative to the horizontal portion  228  is preferably limited to an angle  230  that is thirty (30) degrees above the horizontal. Thus, by way of the motor-driven elevation assembly  224  and the articulating portion  226  of the treatment table assembly  204 , a patient receiving treatment can be easily positioned or situated on the upper surface  205 , elevated to a desired treatment height, and made comfortable by adjusting the articulating portion  226  relative to the horizontal main portion  228 . In this regard, it should be noted that the motor-driven elevation assembly  224  preferably includes a limiting switch or other limiting device (not shown) that limits the elevation of the top or upper surface of the horizontal main portion  228  of the treatment table between heights of twenty-four (24) inches and thirty-six (36) inches from the floor or other surface upon which the treatment table assembly  204  is situated.  
         [0045]      FIGS. 6 and 7  are schematic or diagrammatic representations of the compressed gas flow arrangement for the external counterpulsation apparatus  201  generally including the control console  202 , treatment table  204 , and inflation/deflation assembly  206 . The control console  202  preferably includes an air intake/filter assembly  232 , a muffler  233 , which can be located before or after a compressor  234  (as shown in contrast in  FIGS. 6 and 7 ), a tank  236 , a pressure sensor  238 , a pressure relief valve  240 , and a pressure regulator  242 . The pressure sensor  238  is preferably a pressure transducer, but can be any pressure or temperature sensoring device. A temperature sensor  239  may also be included, as shown in  FIG. 7 .  
         [0046]     A hose connection assembly  244  is used for quick connecting and disconnecting the above-described components with those mounted on, or otherwise associated with, the treatment table assembly  204 . Such treatment table assembly components include a valve manifold  246 , as shown in  FIG. 7 , a number of inflation/deflation valves  248 ,  250  and  252 , each with an associated pressure transducer/sensor  254 ,  256 , and  258 , respectively. A connect/disconnect assembly  260  is provided for quick and easy connection and disconnection of the inflation/deflation valves  248 ,  250  and  252  with their associated inflatable devices  208 ,  210 , and  212 , respectively, of the inflation/deflation assembly  206 .  
         [0047]      FIG. 8  diagrammatically illustrates the electrical/logic/control interconnections of the various components of the external counterpulsation apparatus  201 . The control console assembly  202  includes a power supply  264  that feeds power to a computer assembly  219 , which includes a CPU and the user interface monitor  220 , as well as other input provisions such as a keyboard and touch screen; as well as to the compressor  234 , by way of a power switch panel  213 , transformer  215 , and power module  266 , which includes a power converter and ramp-up assembly. The power module  266  converts electrical power to the compressor from 110/120 VAC 50/60 Hz to three-phase 220 VAC at a variable frequency and increases the electrical power to a preselected full power level over a period preferably of approximately three (3) to approximately five (5) seconds. At the onset of external counterpulsation treatment for the patient, electrical power is required to power the three sets of inflation/deflation valves  248 ,  250 ,  252 , as well as to provide the base line requirement of electrical energy to the computer  219 , the user interface monitor  220 , and other electronics associated with the external counterpulsation apparatus  201 . This can result in a power surge of up to or even exceeding  30  amperes. This power requirement is too high for most normal house power supply systems. Therefore, the power module  266  includes a variable frequency drive transistorized inverter (e.g., Mitsubishi Model FR-E520-1.5K) to slowly ramp up the power supply to the compressor  234  over the above-mentioned preferred period of approximately three (3) to five (5) seconds. The power module  266  converts 110/220 VAC 50/60 Hz line input and converts it to three-phase 220 VAC and with variable frequencies, starting at zero (0) Hz and up to a preset frequency (e.g., 72 Hz). Thus, the operation of the compressor  234  is independent of the input line&#39;s frequency, and there is no sudden power surge required to start the compressor  234 .  
         [0048]     In terms of user friendliness, various related functions of the system  201  are grouped for easy and logical operation. All patient-related inputs (patient ECG, finger plethysmography, patient call button, etc.) are located in one location, namely on a patient input panel  209  associated with the treatment table assembly  204 . Outputs, such as printer outputs, patient signals, outputs, service signals, outputs, etc., are also grouped in one location, preferably as part of an output module  211  on the control console assembly  202 . Operator inputs for purposes of adjusting performance of the apparatus  201 , are all on the touch screen display of the user interface monitor  220 , and include inflation/deflation timings, magnitude of pressure applied, and other important data discussed below, including the display of the patient&#39;s ECG, graphic representations of the inflation/deflation timings, plethysmogram (ear lobe, finger, temporal, etc.) for monitoring appropriate timing adjustment and other operational factors. A keyboard  217  also may be provided. All inputs and outputs are preferably communicated through signal module  219 .  
         [0049]     All of the above-described controls and features are configured and calculated to provide for sequential pressurization of the patient&#39;s lower limbs, beginning at the most distal area at which the inflatable device  208  is applied, followed by an intermediate area at which the inflatable device  210  is positioned, and ending with the pressurization by the inflatable device  212  at the upper end of the patient&#39;s leg or the buttock area. This sequence is indicated graphically in  FIGS. 9A and 9B , with the exhausting of all pressure to the inflatable devices  208 ,  210  and  212  occurring near the end of the ECG cycle, as illustrated in  FIG. 9B . This relationship is also graphically illustrated in  FIG. 10 , which juxtaposes the ECG signal  277 , the valve opening signals  283  and the inflatable cuff device pressure waveforms  285 . As illustrated in  FIGS. 11A and 11B , the inflation time can be advanced or delayed by the operator between certain minimums and maximums.  
         [0050]      FIGS. 12 through 18  illustrate an exemplary inflation/deflation valve  248 , which should be regarded as typical for the inflation/deflation valve  250  and  252  as well. The inflation/deflation valve  248  (and  250  and  252 ) is preferably a rotary actuable butterfly-type valve, which can be actuated pneumatically or in the preferred embodiment electrically by the respective operators  289  on opposite ends of a body portion  288  for controlling the rotatable rotors  290 . Attached to the rotors  290  are butterfly valve elements  292 ,  294  which open and close the compressed gas or compressed air inlet  295  and the inflation/deflation port  296 , which is connected to the respective or associated inflatable cuff devices  208 ,  210 , or  212 , with the butterfly valve element  294  being rotatable actuable to open and close fluid communication between the inflation/deflation port  296  and a deflation exhaust port  297 . The quick-acting operators  290  are respectively actuated and controlled by way of the control system described herein, in order to provide for proper inflation and deflation timing and sequential operation of the inflatable devices  208 ,  210 ,  212 . The butterfly valve elements  292 ,  294  and their associated rotors  290  are preferably rotatable through a maximum rotation angle of approximately 60 degrees between open and closed positions. A larger or smaller rotation angle is within the scope of the invention.  
         [0051]     The inflation passageway through each of the butterfly valve openings between the input port  295  and the inflation/deflation port  296  is more restricted than the deflation passageway between the inflation/deflation port  296  and the deflation exhaust port  297 , with the restriction being approximately twenty (20) to thirty (30) percent larger on the deflation side than on the inflation side in order to allow deflation of the inflatable devices  208 ,  210 ,  212  at the same rate as the inflation rate, owing to the fact that the inflation has a higher pressure gradient between the compressed gas at the input  295  and the inflation/deflation port  296  when compared with the pressure gradient between the inflation port  296  and the deflation exhaust port  297 .  
         [0052]     The butterfly valve elements  292 ,  294 , along with their associated rotors  290  are driven by a rotary solenoid using fifteen (15) volt DC continuous power or twenty-seven (27) volt DC, fifty milliseconds pulse, dropping back to a fifteen (15) volt holding voltage. This lower power consumption is important not only, to reduce the overall electrical power requirement, but to reduce the heat output.  
         [0053]     For safety and other quick-acting purposes, the deflation butterfly valve element  294  is normally open (such as in a power-off condition) and the inflation butterfly valve element  292  is normally closed. Thus, in the case of a power loss, the inflation valve element  292  will be closed and the deflation valve element  294  will open to allow air from the inflatable cuff devices to deflate and exhaust to atmospheric pressure.  
         [0054]     Each of the butterfly valve elements  292  and  294  can be opened from approximately fifty (50) to three hundred (300) milliseconds, and are preferably open from one hundred (100) milliseconds to two hundred (200) milliseconds, to allow compressed air from the above-mentioned reservoir to be admitted to the inflatable devices during the onset of a diastole. As mentioned above, the timing and opening times of the inflation valves are variable in order to correctly correspond with the patient&#39;s heart rate, but preferably not less than approximately one hundred (100) milliseconds duration. At the end of a diastole, the deflation butterfly valve element  294  opens (even without electrical power) for a period of approximately fifty (50) to three hundred (300) milliseconds and preferably one hundred twenty (120) to two hundred twenty (220) milliseconds. It is desirable to make the period of opening of the deflation butterfly valve element  294  variable according to the heart rate, but with an opening time of not less than approximately one hundred twenty (120) milliseconds during normal operation. It should be noted that it would be possible to use three-way valves, as discussed above. It is important, however, to prevent cross-overleakage if such three-way valves are used when switching from the inflation port to the deflation port and vice versa.  
         [0055]     As illustrated in  FIGS. 19 and 20 , the exemplary pressure regulator assembly  242  is a proportional-control pressure-relief valve, preferably providing for an adjustment range of approximately one (1) to approximately ten (10) psi for the tank  236  discussed above. Upon startup of the external counterpulsation apparatus  201 , a pressure regulation chamber  502  is vented to atmosphere. Once the compressor comes on and begins to pressurize the tank  236 , a control or load valve  504  of the pressure regulator assembly  242  remains open to an exhaust port  506 , providing for minimum tank pressure built-up. The flow of fluid to the pressure control chamber is controlled by the load valve  504 . When the load valve  504  is energized, compressed fluid will flow through a pathway  508  connecting the pressure regulation chamber  502  to a pressure control chamber  510 . As shown in  FIG. 23 , the pressure control chamber  510  and pressure regulation chamber  502  are separated by a pair of diaphragms  518 . As long as the pressure in the pressure regulation chamber  502  is lower than the pressure in the pressure control chamber  510 , there is no fluid leak through the pressure exhaust port  506 . When the operator-selected pressure is reached, the load valve  504  is closed, pressure continues to build up in the reservoir and the pressure regulation chamber  502  will push a reservoir control piston  512  against the bias of spring  514 , opening the exhaust port  506  and leak the build-up pressure to atmosphere. When the pressure drops to the operator-selected pressure, i.e., the pressure in the pressure control chamber  510 , the reservoir control piston  512  will move back into cylinder  516 , closing the pressure exhaust port  506 . When the operator wants to lower the selected pressure, a bleed valve  518  is opened, leaking fluid from the pressure control chamber  510 , lowering its pressure, and the reservoir control piston  512  will again move against the bias of spring  514 , exposing the pressure regulation chamber  502  to the atmosphere through the exhaust port  506 , and thereby lowering the pressure in the pressure regulation chamber  502 . The bleed valve  518  is open to atmosphere via port  522 .  FIG. 24  illustrates a similar embodiment, differing chiefly in that a single diaphragm  520  separates the control chamber  510  and the pressure regulation chamber  502 .  
         [0056]     When the rotary solenoid inflation/deflation valves open, a sudden drop in tank  236  pressure occurs. This sudden drop Is sensed by the dome diaphragm which instantly moves down closing the servo vent valve. Immediately, the pressure regulation chamber  502  pressure builds, causing the load valve  504  to close so that the compressor  234  can make up for the sudden tank pressure drop below the desired preset level. If operation of the subsequent inflatable cuff devices causes a drop in the tank pressure, the load valve  504  stays closed so that the tank pressure can recover to the desired preset pressure level in the shortest possible time. When the inflatable cuff devices  208 ,  210  and  212  are exhausted, the tank pressure recovers quickly due to the fact that the compressor is constantly providing pressurized gas into the tank. When the desired tank pressure set point is reached, the dome diaphragm, sensing the increased tank pressure, moves up, thus opening the pressure exhaust port and reducing the pressure regulation chamber pressure to a value that holds the load valve open at a position that maintains the tank pressure at the desired preset level and exhausts the compressor flow into a muffler and exhaust system.  
         [0057]     Preferably the dome control solenoids operate at 24 volt DC 0.6 watts each. The orifice is preferably 0.031 inch in diameter, and the load and bleed valves are two-way two position solenoids, with the bleed valve preferably being a three-way two position solenoid. The load valve is preferably a two-way normally closed solenoid, using 24 volt DC to increase dome pressure. The bleed valve is a two-way normally closed solenoid, using 24 volt DC to decrease dome pressure. A power failure causes the vent port to open and vents the dome pressure, which correspondingly vents the tank pressure.  
         [0058]     In use, the operator can adjust magnitude of external counterpulsation treatment pressure to be applied to the patient using digital or analog means, as best shown in  FIG. 22 . The output is either a digital voltage signal or a voltage proportional to the selected pressure. When the operator begins treatment of a patient, the source of compressed fluid, i.e., compressor  234 , is activated, sending compressed fluid through a valve, such as a solenoid valve or servo or proportional valve, which is controlled by computer  219 . The computer  219  compares the output from the pressure transducer in the reservoir (in analog form and translates to digital form using a analog-to-digital converter) and the operator-selected treatment pressure, and then controls the valve to direct compressed fluid to the reservoir to increase the pressure in the reservoir to the operator-selected level or vent the compressed fluid to atmosphere. When the inflation valve opens, pressure in the reservoir drops and the computer  219  closes the valve to atmosphere and directs compressed fluid to the reservoir to maintain its pressure at or near the operator-selected level. The computer  219  also provides damping means so that the pressure in the reservoir does not run-away in a wild swing to a high or low pressure, but maintains the pressure in the reservoir to within 10-20 mm Hg of the operator-selected level or set point.  
         [0059]      FIG. 23  depicts a computer system  318  for monitoring and recording the treatment of a patient who is receiving treatment from the external counterpulsation device of the present invention. As previously described, the computer system  318  is used to control the operations of the external counterpulsation device. The computer system  219  is further operable to monitor and record information associated with the treatment of the patient.  
         [0060]     More specifically, the computer system  318  includes a patient database  320  for storing demographic information for one or more patients; a patient treatment database  324  for storing treatment information for one or more patients; a site database  324  for storing information regarding the site of the patient treatment; and the computer  219 . For illustration purposes, the computer  219  is a personal computer (PC) having an associated user interface  220 , such as a touch screen monitor and keyboard. In this case, the data structures are defined in a storage device associated with the personal computer (e.g., an internal hard drive). More specifically, the data structure for the patient database may include patient identification, such as a number; patient name; patient address; patient medical history, including physician name, disease history, and emergency contact information; image data, such as magnetic resonance images, x-ray images, CAT scan images, etc.; hemodynamic data, such as blood pressure and blood flow information in waveform and data formats; and laboratory test results. The data structure for the patient treatment database may include patient identification; treatment time, such as inflation time, deflation time, and cumulative treatment time; ECG data (in waveform and data formats); plethysmograph data; applied pressure data (for a specific treatment session and cumulative); ECG electrode position; and ECG electrode type. The data structure for the site database may include site identification, such as a number; site name; site address; physician name; device operator name or ID; external counterpulsation device type; and external counterpulsation system configuration.  
         [0061]     As is mentioned or described in detail below, the user interface  220  is preferably a touch screen for easy monitoring of patient treatment status, treatment parameters, and other relevant data, and provides the capability for adjustment to control operation. As shown in  FIG. 24 , the user Interface  220  or touch screen display includes patient data in the upper left hand portion of the display, which is in communication with the patient&#39;s data base allowing an operator to create a patient file for each new patient and allowing the system or apparatus  201  to track the accumulated treatment time for proper dosage for the patient.  
         [0062]     Ease of initiation and termination of operation is accomplished with three buttons on the top line of the display, namely a start button  336  for initiation and continuation of treatment; a standby button  338  that can be used to place the external counterpulsation apparatus  201  on “hold”, whenever the patient needs to rest, use a restroom, or otherwise temporarily pause the treatment, and to then resume when the patient returns to complete the treatment session; and an exit button  340  to stop treatment. The treatment timing function does not run when the standby button is selected, thus allowing it to keep track of total treatment time. The exit button  340  is provided to stop the treatment session for a particular patient and to record the elapsed treatment time in the patient database for use in future treatment sessions.  
         [0063]     An ECG display is included with timing markers  352  and bars  350  superimposed on or adjacent the ECG signal  342  for easy identification of inflation and deflation timing, which is illustrated by the graphic inflation/deflation timing markers and bars. The timing markers  352  are amplitude signals superimposed on the ECG signal  342 , and should not be misinterpreted as noise. Further, the markers  352  can be turned “on” or “off” for easier identification of the ECG signal  342 . The timing bars identify a trigger signal  353 , which can be checked against the ECG&#39;s R-wave, as well as the inflation and deflation times, which demonstrate the period of the cardiac cycle when external pressure is applied. This enables operators to easily identify and verify that they are not inflating the inflatable devices  208 ,  210 ,  212  during the cardiac systole, when the heart is pumping or ejecting blood. The user interface  220  also includes digital display of inflation and deflation time  358 , digital display of the magnitude of external pressure applied  370 , digital display of the intended treatment period  360 . The default treatment period is preferably 60 minutes. Inflation time, deflation time, magnitude of pressure applied, and treatment period can be manually adjusted by the operator. Digital display of the elapsed treatment time is also provided at  362  and the three pairs of inflatable devices can individually be turned “on” or “off” at  372 , which condition is easily identified and displayed in the lower right hand of the display screen. Further, the inflatable devices can be triggered on every heartbeat, or every other, at  374 . Moreover, control of printer functions is provided at  376 , including a five (5) second chart or continuous chart. A freeze-display option is provided at  378 , whereby a user can freeze the screen for extended examination.  
         [0064]      FIGS. 24 through 27  illustrate some exemplary control screens that help to better understand the functionality of the enhanced computer system  320 . As shown in  FIG. 25 , a main menu screen  326  allows the operator to select from one of four options: (a) patient information, (b) site information, (c) ECP Treatment, or (d) system diagnostics. The patient information and site information options allow the operator to enter patient information and clinical site information, respectively, into the system. The ECP treatment option allows the operator to monitor and control the treatment of a patient; whereas the system diagnostic option allows the operator to simulate treatment of a patient for purposes of training the operator and/or testing the equipment of the external counterpulsation device.  
         [0065]     Referring to  FIG. 26 , the patient information screen  328  permits the operator to input and/or edit demographic information for one or more patients. The patient demographic information may include (but is not limited to) the patient&#39;s name, address, phone number, sex, date of birth and other documentation relating to the medical treatment of the patient (e.g., medication, disease history, etc.). Once this information is entered for a new patient, it may be stored into the patient data structure  320 . Each new patient may also be assigned a randomly generated patient identification number that is stored in the patient data structure  320 .  
         [0066]     Similarly, the site information screen  330  permits the operator to input and/or edit information relating to the clinical site as shown in  FIG. 28 . The site information may include (but is not limited to) the clinical site&#39;s name, address, phone number, facsimile number, and the name of the physician associated with the clinical site. The site information is stored in the site information data structure  324 .  
         [0067]      FIG. 24 , as discussed above, illustrates the primary treatment control screen  332  for monitoring and controlling the patient&#39;s treatment as provided by the external counterpulsation device of the present invention. Patient treatment information is prominently displayed in the center of the user interface. The upper waveform  342  is an electrocardiogram (ECG) signal taken from the patient. As will be apparent to one skilled in the art, the R wave portion of the ECG signal is typically used to monitor the cardiac cycle of the patient. The lower waveform  344  is a pressure signal indicative of the blood pressure of the patient. The pressure signal is also used to monitor the cardiac cycle of the patient as well as to monitor the counterpulsation waves being applied to the patient by the external counterpulsation device in a preferred embodiment, the pressure signal is further defined as a plethysmograph waveform signal as received from a finger plethysmograph probe. Two amplitude adjustment switches  346  and  348  are positioned just to the right of each of these waveforms which allow the operator to adjust the resolution at which the signals are viewed.  
         [0068]     Timing bars  350  are simultaneously displayed between the upper and lower waveforms. The timing bars  350  indicate when the inflation/deflation cycle is being applied to the patient by the external counterpulsation system. More specifically, the timing signal includes a timing bar for each inflation/deflation cycle, where the leading edge of the timing bar corresponds to the initiation of inflation and the trailing edge of the timing bar corresponds to the initiation of deflation. Further, the timing bars  350  include the trigger signal  353 , which indicates the time at which the inflation/deflation cycle is triggered.  
         [0069]     The safety and effectiveness of the external counterpulsation therapy depends on the precise timing of the inflation/deflation cycle in relation to the cardiac cycle of the patient. For instance, an arterial wall with significant calcium deposits (hardened artery) will transmit the external pressure pulse up the aorta faster than an elastic vasculature. Therefore, the inflation valves should be opened later for a calcified artery than for a normally elastic artery. Because it is difficult to measure the elasticity of the arterial wall, the operator may have to manually adjust the proper timing of the inflation valves by imposing the requirement that the arrival of the external pulse at the root of the aorta be after the closure of the aortic valves. The enhanced display of the three patient treatment signal enables the operator to more accurately adjust the timing of the inflation valves. This is one exemplary way in which the computer system of the present invention improves the patient treatment provided by the external counterpulsation device.  
         [0070]     To further improve the monitoring of the timing of the inflation/deflation cycle in relation to the cardiac cycle of the patient, timing markers  352  may be superimposed over the ECG signal. The timing markers  352  appear for each interval of an QRS wave on the ECG signal. The markers appear as high-frequency noise superimposed on the ECG wave to indicate inflation and deflation in relation to the ORS wave. As will be apparent to one skilled in the art, the amplitude of the signals are adequately sized so that the markers will not be misinterpreted as noise associated with the ECG signal. The timing markers switch  354  allows the operator to turn on/off the display of the timing markers  352  on the screen.  
         [0071]     The treatment control screen  332  also provides the switches for adjusting the timing of the inflation/deflation cycle. The inflation adjustment switch  356  allows the operator to adjust the setting of the time for the start of sequential inflation as it is measured relative to the R peak of the ECG signal. Each press of the left arrow causes the inflation to occur some predefined time increment earlier (e.g., ten (10) milliseconds); whereas the right arrow causes the inflation to occur some predefined time increment later. The current setting of the inflation start time is displayed on the middle window of the switch  356 . Likewise, the deflation adjustment switch  358  allows the operator to adjust the setting of the time for the start of deflation as it is measured relative to the R peak of the ECG signal. Deflation may be simultaneous or sequential.  
         [0072]     In addition, the treatment time for the patient is monitored and controlled by two additional interfaces. The treatment setting switch  360  allows the operator to set the time for the patient treatment. Again, each press of the left arrow causes an increase in the treatment time by some predefined time increment (e.g., one (1) minute) and each press of the down arrow decreases the treatment time by the same predefined time increment. The current setting of the treatment time is displayed on the middle window of the switch  360 . An elapsed treatment time display  362  shows the elapsed time of the current treatment session.  
         [0073]     Other patient treatment information may also be displayed and/or adjusted through the use of the treatment control screen  332 . For instance, a heart rate display  364  may show the heart rate of the patient and a diastolic/systolic ratio display  368  may show the peak ratio and the area ratio of the plethysmograph signal. These displays may be updated periodically, such as upon freezing the display or polling every predefined time period, or may be updated in real time. Additionally, a pressure adjustment switch  370  may be provided to allow the operator to adjust the inflation pressure of the compressed air. It is envisioned that other patient treatment information may be displayed and/or adjusted through various user interfaces as provided on the treatment control screen  332 .  
         [0074]      FIG. 28  is a block diagram or flow chart summarizing the procedures of the initiation operation and the automatic set up of the inflation/deflation logic for the external counterpulsation apparatus  201 . The opening of the inflation/deflation valves are performed by a power switch circuit which reads the values of T 1  and T 2  from memory. Even though the inflation time T 1  appears to be relatively short, i.e., less than one-half of the R-R interval, it represents the time at which the inflation signal is being sent to the power switching circuit to initiate opening of the inflation valves. It takes approximately twenty (20) milliseconds for the valves to fully open, approximately another thirty (30) milliseconds for the air pressure to arrive at the inflatable devices  208 ,  210 ,  212 , approximately another seventy (70) milliseconds to reach full inflation pressure, and approximately an additional two hundred (200) to three hundred (300) milliseconds for the applied pressure wave to travel from the peripheral vasculature of the legs and thighs to the root of the aorta. By that time, the systolic period would have already passed. For example, take a heart rate of sixty (60) beats per minute, the systolic time is approximately four hundred (40) to five hundred (500) milliseconds per beat. Therefore, for the applied pulse wave to arrive at the root of the aorta at the time the aortic valve closes, the inflation signal should start at about one hundred fifty (150) to two hundred (200) milliseconds after the R wave. In addition, it can be shown that the deflation time happens approximately one hundred sixty (160) milliseconds before the next R wave. Deflation valves for the lower leg and thigh cuffs open to the atmosphere for a duration of one hundred twenty (120) milliseconds. Because the decay time T 4  is eighty (80) milliseconds at the most for the inflatable device pressure to drop to zero (0), there is no residual pressure existing in the cuffs at the beginning of the next systolic phase, giving the peripheral vascular bed ample time to refill during cardiac systole.  
         [0075]     During the operation stage following the initiation stage, the values of T 1  and T 2  will be stored in memory and used to control the inflation/deflation timing. However, the memory will be updated with every new heartbeat using the updated TR to calculate the new T 1  and T 2  and stored in memory replacing the old T 1  and T 2 . In addition, the CPU will interrogate every ten (10) milliseconds a flag in one of the registers to determine if any of the manual adjustment buttons have been pushed. The inflation/deflation adjustment buttons  356 ,  358  are located on the front panel (screen) for advancing or retarding the inflation or deflation times.  
         [0076]     Each depression of the inflation advance button will trigger the CPU to compare the vale (TR−T 1 ) to 200 ms. If (TR−T 1 ) is larger than two hundred (200) milliseconds, then T 1  will be lengthened by ten (10) milliseconds. This is done by adding ten (10) milliseconds to C 1  which has been initially set at approximately two hundred ten (210) milliseconds as used in T 1 =(12.65*TR+C.−300) milliseconds. The same logic is applied to limit the ability of advancing T 1  to approximately two hundred (200) milliseconds or less before the next R wave, in order to prevent the inflation valve of the lower leg cuffs from opening so late that not enough time remains for the deflation valves to open before the next R wave; keeping in mind the facts that the inflation valve for the thigh cuffs opens approximately fifty (50) milliseconds after T 1  and remains open for approximately another one hundred (100) milliseconds, leaving only approximately fifty (50) milliseconds for the pair of deflation valves to open before the next R wave. Since the logic used in controlling the manual adjustment of the deflation valves sets a limit for the deflation to open no later than approximately thirty (30) milliseconds before the next R wave, it is clear that the deflation valves will have to open to the atmosphere within approximately thirty (30) milliseconds after the inflation valve of the thigh cuffs is closed.  
         [0077]     The other manual inflation/deflation adjustment buttons  356 ,  358  work on the same principle; that is, with each depression of one of the buttons, the CPU will check the conditions limiting the timing of the valves, and if the limits are not reached, then the timing for the inflation/deflation valves can be advanced or retreated by subtracting or adding ten (10) milliseconds to C 1  or C 2  of the above equation and the equation T 2 =(TR−C 2 ) milliseconds.  
         [0078]     The formula used in calculating T 1  is given by: 
 
 T   1 =(12.65 *{square root}{square root over (T     R     )}   +C   1 −300) ms 
        where the constant 12.65 is used instead of 0.4 when converting the unit of TR from seconds to milliseconds, and C 1  is a constant that is initially assigned with a value equal to two hundred ten (210) milliseconds. However, this value can be changed later by manual adjustment. The factor three hundred (300) milliseconds has been experimentally determined to be equal to the approximate maximum time it takes for the applied external pressure wave to travel from the lower leg to the aortic valves.        
 
         [0080]     After T 1  has been determined, it is comprised with a value of one hundred fifty (150) milliseconds. If T 1  is less than one hundred fifty (150) milliseconds, it is then set to one hundred fifty (150) milliseconds. If T 1  is larger than one hundred fifty (150) milliseconds, then the calculated value will be used. These procedures guarantee that the inflation valves will not open in less than one hundred fifty (150) milliseconds after the R wave. Even when T 1  is set at one hundred fifty (150) milliseconds, the leading edge of the pressure wave will not arrive at the aortic root until approximately three hundred fifty (350) milliseconds after the R wave, taking into account the time required for the pulse to travel up from the peripheral vasculature to the root of the aorta.  
         [0081]     Once the value of T 1  has finally been determined, it is used to calculate T 2  using the following formula: 
 
 T   2 =( TR−C   2 ) ms 
 
         [0082]     where the constant C 2  is initially set at one hundred sixty (160) milliseconds and can be increased or decreased later by manual adjustment. From this equation, it is clear that the deflation valves open one hundred sixty (160) milliseconds before the next R wave. C 2 , however, can be increased or decreased manually to achieve an optimal hemodynamic effect.  
         [0083]     The logic used in the timing of the inflation/deflation valves fulfill two basic criteria: (1) the inflation valves must not be opened so that the pressure pulse wave reaches the root of the aorta during systole, forcing the aortic valve to close prematurely, thereby creating systolic loading; and (2) the deflation valves must be opened to the atmosphere before the next R wave to allow enough time for the air pressure in the cuffs to decay to zero so that there is no residual pressure causing a tourniquet effect. Finally, the inflation/deflation valves will not be operational when the heart rate is higher than one hundred twenty (120) beats per minute or lower than thirty (30) beats per minute.  
         [0084]     The inflation/deflation valve timing logic controls the timing of external pressure applied to the lower legs and thighs of the patient. A diagram of how the inflation/deflation valves are connected to the compressor and air tank is shown in  FIG. 9 .  
         [0085]     The inflation/deflation timing logic is divided into two main parts: (1) the initiation stage upon power up during which the inflation/deflation times are set up automatically; and (2) the operation stage during which the inflation and deflation time can be adjusted manually. The operations of these timing logic systems are controlled by a microprocessor, and no signal will be sent out to the inflation/deflation valve power supply when the heart rate is higher than one hundred twenty (120) beats per minute or lower than thirty (30) beats per minute.  
         [0086]     As shown, there are three (3) inflation valves and three (3) deflation valves. One pair of inflation/deflation valves are for the calves, one pair for the lower thighs, and one pair for the upper thighs. The valves are normally open, and selectively closed when energized. Upon receipt of a signal from the inflation/deflation timing control, electrical power to the inflation valves will be switched on for a period of one hundred (100) milliseconds and will open them to the air tank. Similarly, upon receipt of the deflation valve signal, power to the deflation valves will be switched on for a period of one hundred twenty (120) milliseconds and will open the lower leg and thigh cuffs to the atmosphere. In addition, two safety valves can be provided, each of them located between the inflation valve and the cuffs. The safety valves are normally open to air. These two optional valves (not shown) are independent of the logic controlling the inflation/deflation valves. They are installed in case of power failure so that pressure remaining in the leg and thigh cuffs can be vented to the atmosphere automatically.  
         [0087]     During initiation stage when power is turned on, the computer  214  of the control console  202  will start a series of initiation procedures. The first step is to maintain the deflation valves open to atmosphere. Each deflation valve will remain open for one hundred twenty (120) milliseconds, or long enough to relieve all the air pressure from the leg and thigh cuffs. The computer  219  will then look for the input of the electrocardiogram (ECG) and determine the presence of the QRS complex. If the QRS complex is not detected, the inflation/deflation valves  208 ,  210 ,  212  will not be activated and the external counterpulsation will not start. The inflation valves will remain open to atmosphere; no compressed gas will enter the inflatable devices  208 ,  210 ,  212  from the tank  236 .  
         [0088]     After the detection of four (4) complete R-R intervals, the CPU will determine their average (TR), and will update TR by taking the mean of the last TR and. the new R-R interval. Meanwhile, the two constants used for the calculation of inflation time T 1  and deflation time T 2  will be initiated with the values C 1 =210 milliseconds and C 2 =160 milliseconds. Definitions of T 1  and T 2  and other variables are shown diagrammatically in the example of  FIG. 29 . They are: 
        TR(R-R interval): average R-R interval in ms.     T 1  (inflation time): interval from R wave to the opening of lower leg inflation valve in ms. Note that the inflation valve for the thigh cuffs open twenty to seventy milliseconds, and preferably fifty milliseconds after T 1 . In addition, inflation valves are normally closed. However, they will be opened for a duration of one hundred milliseconds or more when energized.     TD(duration time): interval between the opening of the lower leg inflation valve and the opening of the deflation valves for both the lower legs and thighs in milliseconds.     T 2 (deflation time): interval from R wave to the opening of, the deflation valves in milliseconds. Note that the deflation valves for both lower leg and thigh cuffs are normally open to the atmosphere, but are selectively closed when energized. This opening time has been experimentally determined to be approximately at least forty (40) milliseconds longer than the pressure decay time T 4 .     T 3 (pressure rise time): interval between the time when the air pressure in the lower leg or thigh cuffs is zero (0) and the time when it reaches equilibrium with the pressure in the reservoir. This value has been measured experimentally under many different situations with various cuff sizes and is equal to approximately fifty (50) milliseconds.     T 4 (pressure decay time): interval for the air pressure in the cuffs to drop to zero when the deflation valves are opened to the atmosphere. The value of T 4  has been determined in a variety of situations with various cuff sizes and has an average value of eighty (80) milliseconds.        
 
         [0095]     A diagrammatic representation of the time for inflation/deflation valves and air pressure waveforms for the three pair of cuffs shown in  FIG. 29 . The patient electrocardiogram (ECG) using a 3-lead system is digitized and the R-R interval TR determined. The R-wave is then used as a triggering signal. The inflation time T 1  for the lower leg cuffs is calculated according to the square root formula of Bazett (see FDA 510(K) submission K882401, incorporated herein by reference): 
 
 T   1 =(12.65 *{square root}{square root over (T     R     )}   +C   1 −300) ms 
        where C 1  is a constant with an initial value of two hundred ten (210) milliseconds. The inflation time can be adjusted manually, and the adjustment changes the C 1  value. Therefore application of external pressure to the body begins with the lower leg T 1  milliseconds after the ORS complex. Inflations of the lower thigh cuffs begin approximately twenty (20) to seventy (70) milliseconds, and preferably fifty (50) milliseconds after the inflation of the lower leg cuffs, and the upper thigh cuffs will be inflated approximately twenty (20) to seventy (70) milliseconds, and preferably fifty (50) milliseconds after the lower thigh cuffs.        
 
         [0097]     The initial value assigned to T 1  (as discussed above) is based on the square root formula of Bazett (Heart 7:353,1920) which approximates the normal Q-T interval of the ECG as the product of a constant (0.4) times the square root of the R-R interval measured in seconds. The Q-T interval is measured from the beginning of the QRS complex to the end of the T wave. It represents the duration of ventricular electrical systole and varies with the heart rate; it can be used to approximate the hemodynamic systolic interval.  
         [0098]     The foregoing discussion discloses and describes merely exemplary embodiments of the present invention for purposes of illustration. One skilled in the art will readily recognize from such discussion, and from the accompanying drawings and claims, that various changes, modifications, and variations can be made therein without departing from the principles, spirit or scope of the invention as defined in the following claims.