# Patent

## Title
Method and apparatus for intrachamber resynchronization

## Abstract

Methods, apparatus, and systems are provided to control contraction of the heart. At least one sensing element receives signals indicating electrical activity of sinus rhythm of the heart. Based on the received signals, the progress of contraction of the heart is determined. Based on the progress of contraction, the chamber of the heart may then be stimulated at a plurality of locations. In another embodiment, a plurality of electrodes are implanted in the left ventricle to stimulate at multiple locations in the left ventricle for the purpose of improving hemodynamic performance and increasing cardiac output in a patient who is suffering from congestive heart failure.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a continuation of U.S. application Ser. No. 10/656,222 filed Sep. 8, 2003, the entire content of which is incorporated herein by reference.


FIELD OF THE INVENTION
The present invention relates to medical devices, and in particular, to methods and apparatus for controlling contraction of a heart.
BACKGROUND
During a normal heartbeat, the heart contracts in a coordinated fashion to pump blood. In particular, the heart contracts based on rhythmic electrical impulses, which are spread over the heart using specialized fibers. These rhythmic electrical pulses are initiated by the heart's natural pacemaker called the sino-atrial node (“SA node”). The SA node initiates electrical impulses to cause the right and left atria to contract. As the atria contract, the electrical impulses from the SA node propagate to the atrial-ventricular node (“AV node”). The time these impulses take to propagate from the SA node through the AV node is known as the A-V delay. The A-V delay allows the atria to fully contract and fill the ventricles with blood.
The AV node then transmits the impulse, which causes contraction in the right and left ventricles. Blood from the ventricles then flows out of the heart and to the rest of the body. Therefore, the heart relies upon a rhythmic cycle of electrical impulses to pump blood efficiently.
A heart may suffer from one or more cardiac defects that interfere with the rhythmic cycle or conduction of electrical impulses. For example, one known heart condition is an AV block. An AV block inhibits transfer of impulses from the SA node to the AV node, and thus, inhibits or prevents contraction of the right and left ventricles. Other conditions, such as myocardial scarring and bundle branch block, may slow conduction of impulses, and thus, cause the heart to beat in an uncoordinated fashion.
Typically, an artificial pacemaker is installed to treat these cardiac deficiencies. The artificial pacemaker senses impulses from the SA node and then supplies stimulating electrical pulses to cause contraction in chambers of the heart, such as the ventricles. Therefore, an artificial pacemaker may compensate for blocked or slowed conduction of electrical impulses in the heart.
The specialized cardiac fibers in the heart are completely surrounded by a cell membrane. In a given chamber of the heart, at the points where the ends of the individual fibers meet, two individual cell membranes fuse into a single structure. These structures are known as intercalated discs and they provide a strong connection among all of the individual fibers of the heart. Intercalated discs provide bridges of low electrical resistance, and thus, allow for the rapid propagation of electrical signals throughout the heart during contraction. This phenomenon is known as a functional synctium.
Since adjacent cardiac fibers in a chamber of the heart normally form a functional synctium, known artificial pacemakers include only a single electrode in each chamber. Known artificial pacemakers thus rely on the functional synctium to propagate a stimulating electrical pulse throughout a chamber, even though the stimulus originates from a single electrode.
However, there are cardiac deficiencies that may interfere with the proper contraction within a particular chamber. For example, a chamber may suffer from a defect or injury that blocks the propagation of electrical impulses within the chamber or prevents a portion of the chamber from contracting in a coordinated fashion with other chambers of the heart. As another example, patients with congestive heart failure (CHF) may experience sufficient asynchrony within a single chamber of the heart that the chamber is unable to properly pump blood within a normal rhythmic cycle.
Previously, treatment by stimulating right and left ventricles at the same or similar times has assisted in treating asynchrony. Unfortunately, known artificial pacemakers cannot completely compensate for asynchrony within a single chamber. As noted above, known artificial pacemakers only apply stimulating pulses to a single location within a given chamber using only one electrode. Accordingly, it would be desirable to provide methods, apparatus, and systems, which can overcome these and other deficiencies in the prior art, for example, to assist any given chamber of the heart to contract in a much more coordinated fashion, and thus, assist the heart in contracting more efficiently as a whole in a coordinated fashion. In addition, it would be desirable to provide methods, apparatus, and systems, which can stimulate multiple sites in a chamber of the heart, such as the left ventricle.
SUMMARY OF THE INVENTION
In accordance with an aspect of the present invention, methods and apparatus are provided for controlling contraction of a heart. Signals indicating the electrical activity of sinus rhythm are received from at least a portion of the heart. The progress of contraction in a single chamber of the heart is determined based on the received signals. Alternatively, the progress of contraction of the entire heart or a portion of the heart is determined based on the received signals. The heart is then stimulated at a plurality of locations in a single chamber based on the progress of contraction in the chamber, the entire heart, or other portion of the heart.
In accordance with another aspect of the present invention, a system comprises at least one sensing element, a processor, and a signal generator. The sensing element is configured to receive signals that indicate electrical activity of sinus rhythm of the heart. The processor is coupled to the sensing element and is configured to determine the progress of contraction in the heart based on the received signals. In addition, the processor provides one or more control signals to initiate stimulation of the heart. The signal generator is coupled to the processor, receives the one or more control signals, and is configured to provide at least one signal to stimulate a plurality of locations in the chamber of the heart.
In another embodiment, a plurality of electrodes are implanted in the left ventricle to stimulate at multiple locations in the left ventricle for the purpose of improving hemodynamic performance and increasing cardiac output in a patient who is suffering from congestive heart failure. Electrodes may be implanted in the interventricular septum, in the coronary sinus, in a coronary vein in the left ventricle, in the epicardial wall of the left ventricle, or in any location suitable for stimulating the left ventricle without causing harm to the patient.
Two other techniques for improving cardiac output may also be used with the system and method of the present invention. First, an anodal or cathodal pre-excitation voltage may be applied to pre-condition a portion of the heart. Second, a field stimulation pulse of increased current (on the order of approximately 10 milliamps) may also be applied to improve cardiac output.
Additional features and advantages of the invention will be set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice of the invention. The features and advantages of the invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims.
It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention as claimed.



BRIEF DESCRIPTION OF THE DRAWINGS
The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments of the invention and together with the description, serve to explain the principles of the invention. In the figures:
FIG. 1 illustrates an environment in which methods, apparatus, and systems may be applied consistent with the principles of the present invention;
FIG. 2 illustrates a functional block diagram of a controller for controlling contraction of a heart consistent with the principles of the present invention; and
FIG. 3 illustrates a method of controlling contraction of a heart consistent with the principles of the present invention.
FIG. 4 illustrates an embodiment of the present invention wherein a plurality of electrodes are implanted in the left ventricle.



DESCRIPTION OF THE EMBODIMENTS
Methods, apparatus, and systems are provided to control contraction of the heart. At least one sensing element receives signals indicating electrical activity of sinus rhythm of the heart. Based on the received signals, the progress of contraction in a chamber of the heart is determined. Alternatively, the progress of contraction in a portion of the heart or across the entire heart is determined. As explained further below, the progress of contraction may be determined by sensing at multiple electrodes or even by sensing at a single electrode. Based on the progress of contraction, the chamber of the heart may then be stimulated at a plurality of locations to correct an asychrony.
Reference will now be made in detail to exemplary embodiments of the invention, examples of which are illustrated in the accompanying drawings. Wherever possible, the same reference numbers will be used throughout the drawings to refer to the same or like parts.
FIG. 1 illustrates an environment in which methods, apparatus, and systems may be applied consistent with the principles of the present invention. As shown, a controller 104 may accompany a heart 102. In addition, heart 102 is shown with a superior vena cava 106, a right atrium 108, a left atrium 110, a right ventricle 112, a left ventricle 114, a sinoatrial node (“SA node”) 116, an atrial-ventricular node (“AV node”) 118, a Bundle of His 120, a right bundle branch 122, a left bundle branch 124, and Purkinje fibers 126.
Heart 102 normally contracts in two stages based on sinus rhythm. Sinus rhythm is where heart 102 contracts in response to electrical impulses generated from SA node 116. In order to cause contraction in the cardiac muscle of heart 102, the electrical impulses from SA node 116 must depolarize the muscle fibers above a threshold voltage of approximately −80 mV.
Accordingly, as the electrical impulses propagate from SA node 116 to AV node 118, right atrium 108 and left atrium 110 contract. Typically, the electrical impulses take approximately 120 to 200 milliseconds to travel from SA node 116 to AV node 118 and allow right ventricle 112 and left ventricle 114 to fill with blood.
Once the electrical impulses propagate to AV node 118, it then emits another electrical impulse. This electrical impulse propagates relatively quickly over heart 102 down Bundle of His 120, and over right bundle branch 122, left bundle branch 124, and Purkinje fibers 126. In response, cardiac muscles in right ventricle 112 and left ventricle 114 depolarize and contract to pump blood to the rest of the body (not shown).
Controller 104 assists heart 102 to contract in a coordinated fashion based, for example, on sinus rhythm. For example, controller 104 may monitor the progress of contraction in a chamber of the heart 102, such as right ventricle 112 or left ventricle 114, based on analyzing the propagation of electrical impulses throughout heart 102. If controller 104 detects an improper progress of contraction in a chamber, then controller 104 may selectively or automatically stimulate a plurality of locations in that chamber by using a plurality of implanted electrodes.
In particular, controller 104 may be coupled to heart 102 through leads 128 and 130. Leads 128 and 130 may be installed endocardially into heart 102 via superior vena cava 106 using known surgical procedures. Other known surgical procedures include shallow and deep insertions into the coronary sinus, which contains heart 102, septal puncture, sub-xyphold intra-pericardial insertion, or a thoracotomy. Leads 128 and 130 may be implemented within one or more hollow catheters made of an insulating material, such as silicone rubber, and provide a plurality of connection paths for carrying signals representing electrical activity of heart 102 and carrying electrical signals, such as electrical pulses, from controller 104. For example, lead 128 may further include an atrial lead branch 132, an atrial electrode 132, a right ventricle lead branch 136, a first right ventricle electrode 138, a left ventricle lead branch 142, and a left ventricle electrode 144. Lead 130 may include a second right ventricle electrode (not shown). Alternatively, leads 128 and 130 may be implemented as an integrated lead within a single catheter having multiple, internal connection paths.
In addition, although controller 104 as shown is coupled to two electrodes implanted in right ventricle 112, controller 104 may be implemented with any number electrodes in any chamber of heart 102. For example, methods and systems consistent with the present invention may include two or more electrodes implanted in right ventricle 112 and two or more electrodes implanted in left ventricle 114. One skilled in the art will recognize that the number of electrodes and their placement may depend on the therapy desired. For example, the therapy desired may be evaluated based on electrical criteria, such as p-wave duration, wall-motion of chambers of heart 102, or parameters indicating hemodynamic efficiency of heart 102, such as filling pressure of right atrium 108.
In one embodiment, electrodes may be implanted in heart 102 to form an axis across a chamber of heart 102, such as right ventricle 112 or left ventricle 114. For example, right ventricle electrodes 138 and 140, may be implanted in right ventricle 112 to form a short (or horizontal) axis across right ventricle 112. Alternatively, electrodes 138 and 140 may be implanted in right ventricle 112 to form a long (or vertical) axis across right ventricle 112.
In another embodiment, electrodes may be implanted in heart 102 to surround a chamber of heart 102, such as left ventricle 114. In order to surround the chamber with a relatively few number of electrodes, the electrodes may be placed at relatively equidistant points from each other. For example, right ventricle electrode 138 may be implanted high in the coronary os and right ventricle electrode 140 may be implanted low (or deep) near the apex of right ventricle 112 and the septum between right ventricle 112 and left ventricle 114. In addition, left ventricle electrode 144 may be implanted in the coronary sinus of heart of 102. Although three electrodes are described above, one skilled in the art would also recognize that any number of electrodes may be used in accordance with the principles of the invention. In addition, one skilled in the art would also recognize that the electrodes may be placed at a variety of locations in heart 102.
Atrial lead branch 132 provides a connection path between controller 104 and right atrium 108 for carrying signals associated with right atrium 108 and SA node 116 and electrical signals from controller 104. Although atrial lead branch 132 is shown integrated within lead 128, atrial lead branch 132 may also be implemented using a separate lead from controller 104.
Atrial electrode 132 senses electrical activity in heart 102 associated with right atrium 108 and SA node 116 and delivers electrical signals from controller 104. Atrial electrode 132 may be implemented, for example, as a helical coil of wire made of a metal, such as stainless steel. Although a single electrode is shown, a plurality of electrodes may be implemented with atrial electrode 132.
Right ventricle lead branch 136 provides a connection path for carrying signals associated with right ventricle 112 and providing electrical signals from controller 104 to right ventricle 112. Although right ventricle lead branch 136 is shown integrated within lead 128, right ventricle lead branch 136 may also be implemented using a separate lead from controller 104.
First right ventricle electrode 138 senses electrical activity in heart 102 associated with a location in right ventricle 112, such as electrical impulses from AV node 118 and propagating over right bundle branch 122. Right ventricle electrode 138 may also be implemented, for example, as a helical coil of wire made of a metal, such as stainless steel. In addition, a plurality of electrodes may be implemented with right ventricle electrode 138.
Second right ventricle electrode 140 also senses electrical activity in heart 102 associated with another location in right ventricle 112, such as electrical impulses from AV node 118 and propagating over right bundle branch 122. Second right ventricle electrode 140 may also be implemented, for example, as a helical coil of wire made of a metal, such as stainless steel.
Left ventricle lead branch 142 provides a connection path for carrying signals associated with left ventricle 114 and providing electrical signals from controller 104 to left ventricle 114. Although left ventricle lead branch 142 is shown integrated within lead 128, left ventricle lead branch 142 may also be implemented using a separate lead from controller 104.
Left ventricle electrode 144 senses electrical activity in heart 102 associated with left ventricle 114, such as electrical impulses from AV node 118 and propagating over left bundle branch 124. Left ventricle electrode 144 may also be implemented, for example, as a helical coil of wire made of a metal, such as stainless steel. In addition, a plurality of electrodes may be implemented with left ventricle electrode 144. Moreover, a second electrode may be provided for sensing electrical activity in another portion of left ventricle 114.
FIG. 2 illustrates a functional block diagram of controller 104 for controlling contraction of heart 102 consistent with the principles of the present invention. As shown, controller 104 includes sense amplifiers 200, 202, 204, and 206, a processor 208, a memory 210, a telemetry module 212, and a signal generator 214.
Sense amplifiers 200, 202, 204, and 206 are coupled to atrial electrode 132, first right ventricle electrode 138, left ventricle electrode 144, and second right ventricle electrode 140, respectively via leads 128 and 130. Sense amplifiers 200, 202, 204, and 206 receive signals indicating electrical activity of heart 102 from their respective electrodes, amplify these signals, and provide them to processor 208. Sense amplifiers 200, 202, 204, and 206 may be implemented using, for example, well known circuitry.
Processor 208 receives and monitors signals from sense amplifiers 200, 202, 204, and 206 and generates one or more control signals. For example, in order to monitor the progress of contraction in right ventricle 112, processor 208 may monitor the signals from sense amplifiers 202 and 206 to detect when the electrical activity of heart 102 indicates asynchrony in right ventricle 112.
Processor 208 may detect asynchrony based on a variety of parameters. For example, processor 208 may monitor the electrical activity of heart 102 during sinus rhythm and detect when the electrical activity sensed from second right ventricle electrode 140 fails to reach a threshold level within a predetermined period of time of sensing electrical activity from first right ventricle electrode 138. Processor 208 may be configured to then provide one or more control signals to initiate a stimulating pulse at second right ventricle electrode 140. Processor 208 may use other parameters and values consistent with the principles of the present invention, for example, to treat other conditions. Processor 208 then provides one or more control signals to signal generator 214 based on the electrical activity of heart 102.
Alternatively, processor 208 may be configured to provide one or more control signals to signal generator 214 automatically. For example, upon detecting electrical activity from first right ventricle electrode 138, processor 208 may be configured to provide one or more control signals to initiate a stimulating pulse at second right ventricle electrode 140 after a predetermined delay.
Processor 208 may be implemented using known devices. For example, processor 208 may be implemented using a series of digital circuits or logic gates. Alternatively, processor 208 may be implemented using a microprocessor, such as those manufactured by Intel Corporation.
Memory 210 provides storage for information used by processor 208. For example, memory 210 may include instructions for configuring processor 208 and instructions for monitoring the electrical activity of heart 102. Memory 210 may be implemented using known types of memory, such as a random access memory and read-only memory.
Telemetry module 212 provides diagnostic information indicating the performance of controller 104. For example, telemetry module 212 may transmit the signals received from sense amplifiers 200, 202, 204, and 206 and signals generated by signal generator 214 via a radio link to another device, such as an external programmer (not shown). Telemetry module 212 may also collect and transmit other types of information. Telemetry module 212 may be implemented as a radio receiver/transmitter using a known radio frequency, such as 100 kHz.
Signal generator 214 generates electrical pulses for treating heart 102 via leads 128 and 130. Signal generator 214 may direct electrical pulses to one or more sites in heart 102, such as in right ventricle 112 or left ventricle 114. For example, signal generator 214 may direct one or more electrical pulses to right ventricle 112 through first right ventricle electrode 138 and second right ventricle electrode 140.
Signal generator 214 may generate one or more electrical pulses to assist contraction in heart 102 and compensate for an improper progress of contraction, such as from asynchrony in right ventricle 112. In particular, signal generator 214 may generate one or more electrical pulses using conventional circuitry, such as “one-shot” circuitry. In addition, based on the one or more control signals from processor 208, signal generator 214 may selectively or automatically deliver electrical pulses to electrodes 134, 138, 140, and 144. For example, signal generator 214 may send an electrical pulse to first right ventricle electrode 138, but withhold sending of an electrical pulse to second ventricle electrode 140, and vice versa. Alternatively, signal generator 214 may be configured to deliver electrical pulses automatically to each of electrodes 134, 138, 140, and 144 simultaneously or based on a timing sequence.
In order to stimulate contraction, signal generator 214 may provide a cathodal pulse of 5 V for a duration of approximately 2 milliseconds to electrodes 134, 138, 140, and 144 to stimulate contraction in heart 102. Signal generator 214 may use other types of pulses, such as biphasic pulses or anodal pulses, to stimulate contraction in heart 102. Signal generator 214 may also vary the electrical pulses delivered to each of electrodes 134, 138, 140, and 144. Signal generator 214 may vary the number of pulses, the pulse amplitude, and pulse width. For example, signal generator 214 may vary the electrical pulses delivered based on the desired therapy or effect on heart 102.
Connector 216 provides a connection point for leads 128 and 130. Connector 216 may be implemented using known configurations and components.
FIG. 3 illustrates a method of controlling contraction of a heart consistent with the principles of the present invention. In stage 300, controller 104 receives signals indicating electrical activity of heart 102. For example, atrial electrode 132, first right ventricle electrode 138, second right ventricle electrode 140, and left ventricle electrode 144 may provide signals to sense amplifiers 200, 202, 204, and 206, respectively. Sense amplifiers 200, 202, 204, and 206 may then amplify these signals and provide them to processor 208.
Processor 208 may interpret these signals to determine the electrical activity of sinus rhythm for heart 102. For example, based on signals received from first right ventricle electrode 138 and second right ventricle electrode 140, processor 208 may monitor the progress of contraction in right ventricle 112. In addition, processor 208 may store data from these signals in memory 210, for example, for later transmission by telemetry module 212 to another device.
The system of the present invention can monitor the progress of the contraction across a single chamber and can also monitor the progress of the contraction across the entire heart or a portion of the heart. To rapidly determine the progress of contraction, it is desirable to receive sensing signals from multiple electrodes implanted in various locations across the heart. However, it is also possible to monitor the progress of contraction with only a single electrode. For example, a single electrode in the right atrium can sense when a depolarization occurs in the right atrium. As the depolarization impulse moves into the other chambers of the heart, the single electrode in the right atrium may still be able to sense the subsequent contractions of each successive chamber. For example, the atrial electrode may be able to sense a signal indicating that the left ventricle has contracted—although it the signal will be diminished in magnitude and delayed in time by the time the signal reaches the electrode implanted in the atrium. Thus, the processor will need to account for these factors. The single electrode implanted in the atrium may thus provide sensing signals as each separate chamber contracts, and the progression of the contraction can thereby be monitored with only a single electrode. Similarly, a single electrode could also monitor the progression of a contraction across a single chamber. For example, the electrode may sense a declining ramp in voltage as the depolarization impulse moves away from the electrode. The speed of the decline of the ramp may indicate the speed of the progression of the contraction. The use of multiple electrodes, however, will most rapidly enable the system to effectively determine the progress of the contraction.
In stages 302 and 304, processor 208 determines the progress of contraction in a chamber of heart 102 and detects whether there is asynchrony in the chamber of heart 102. For example, processor 208 may compare the timing of electrical activity indicated in signals from first right ventricle electrode 138 and second right ventricle electrode 140. If the signals from second right ventricle electrode 140 do not reach a threshold level within a period of time of the signals from first right ventricle electrode 138, then processor 208 may interpret this condition as indicating an asynchrony in right ventricle 112 and proceed to stage 306. Accordingly, processor 208 may then generate one or more control signals to assist or resynchronize the contraction of right ventricle 112. In addition, processor 208 may store information related to this event, such as time and amplitude of the event, in memory 210. Alternatively, if processor 208 does not detect any asynchrony in the chamber of the heart 102, then processing repeats again at stage 300.
In stage 306, controller 104 stimulates one or more locations in heart 102, such as one or more locations in right ventricle 112 and/or left ventricle 114. In particular, based on the one or more control signals from processor 208, signal generator 214 may generate and deliver electrical pulses to electrodes 134, 138, 140, and 144. For example, if processor 208 detects asynchrony in right ventricle 112, then processor 208 may generate one or more control signals to command signal generator 214 to deliver electrical pulses to first right ventricle electrode 138 and second right ventricle electrode 140. The pulses delivered to first right ventricle electrode 138 and second right ventricle electrode 140 may be delivered simultaneously or based on a timing sequence. For example, the electrical pulses delivered to second right ventricle electrode 140 may be delayed in comparison to the electrical pulses delivered to first right ventricle electrode 138. Signal generator 214 may control the amount of delay using known techniques and circuitry, such as one-shot circuitry. Processing then repeats again at stage 300.
FIG. 4 illustrates a significant embodiment of the invention that involves stimulating the left ventricle at multiple locations. This embodiment is particularly useful for patients with congestive heart failure (CHF). It has been recognized that patients with CHF can be made to exhibit improved hemodynamic performance by using electrical stimulation to optimize systolic and diastolic function. U.S. Pat. No. 4,928,688 describes an arrangement for achieving bi-ventricular pacing in which electrical stimulating pulses are applied, via electrodes on separate pacing leads, to both the right and left ventricular chambers so as to obtain a coordinated contraction and pumping action of the heart.
More recently, it has been found that pacing only in the left ventricle can produce beneficial hemodynamic results in some circumstances. However, in some of these cases, a single pacing lead in the left ventricle may not be sufficient to produce optimal hemodynamic performance, especially when the left ventricle suffers from conduction defects. In those cases, a system having multiple pacing leads in the left ventricle according to the description below can produce optimal results.
While it is relatively safe to insert a pacing lead and associated electrode(s) into the right ventricle, installing a similar lead into the left ventricle may create a danger to the patient due to the possibility of a thrombus being generated which might result in an ischemic episode. It is therefore important to implant the leads in the left ventricle using a safe method. FIG. 4 illustrates two pacing electrodes 402 and 404 that are designed to be implanted in the left ventricle in a safe manner. Left ventricular pacing electrode 402 may be a helical screw-type electrode. Screw electrode 402 can be approximately 0.375 inches long and may be screwed into the lower portion of the interventricular septum towards the left ventricular wall. This type of pacing electrode, and a method of installing such an electrode, is disclosed in U.S. Pat. No. 5,728,140 to Salo. Left ventricular pacing electrode 402 is screwed in sufficiently so that it stimulates the left ventricular wall.
Left ventricular pacing electrode 404 is advanced through the superior vena cava, the right atrium, the ostium of the coronary sinus (CS), the CS, and into a coronary vein descending from the CS, and is implanted at a desired pacing site in the coronary vein. Alternatively, left ventricular electrode 404 is implanted relatively high in the coronary sinus just within the ostium of the CS.
The ventricular electrodes can alternatively be placed in other locations in the left ventricle. For example, one electrode may be implanted in the interventricular septum, such as pacing electrode 402, and another electrode may be implanted outside of the heart in the epicardial wall of the left ventricle using a screw-in epicardial lead. In another embodiment, one electrode may be implanted in the interventricular septum, and two electrodes may be implanted in the left ventricular epicardial wall—one high up on the epicardial wall nearer the base of the heart, and one lower down on the epicardial wall, nearer the apex. Furthermore, electrode 402 can be implanted to lie even higher or lower in the upper portion of the interventricular septum. For example, as disclosed in U.S. Pat. No. 5,487,758 to Hoegnelid et al., a left ventricular electrode can be passed through the wall of the right atrium and implanted into the upper septum of the superior part of the outer ventricular wall.
Another alternative embodiment is to use two or more screw-in electrodes in the interventricular septum. For example, one electrode could be implanted relatively high on the septum and one lower down on the septum.
Another optional feature that may effectively be used with the system of the present invention is the application of a pre-excitation voltage. A pre-excitation voltage may be applied to either increase or decrease the speed of conduction of a subsequent heart depolarization and the accompanying heart contraction, as will now be further explained.
Before a particular portion of the heart depolarizes and contracts, a pre-excitation voltage may be applied to either increase or decrease the depolarization speed of conduction and contractility of the heart tissue cells in that area of the heart. The pre-excitation voltage is a “sub-threshold” voltage. A sub-threshold voltage is a voltage which is below the threshold stimulus, the minimum strength needed to cause depolarization and contraction of the heart tissue cells.
As mentioned above, a pre-excitation voltage may be applied to heart tissue cells to either speed up or slow down a subsequent depolarization of those cells. To speed up the conduction and enhance contractility of the heart tissue, an anodal (positive polarity) pulse is applied to hyperpolarize the heart tissue cells. On the other hand, to slow down conduction and decrease contractility of the heart tissue, a cathodal pulse (negative polarity) is applied to partially depolarize the tissue cells.
U.S. Pat. No. 6,343,232 to Mower, the inventor of the present invention, discloses augmentation of the electrical conduction and contractility of the heart by biphasic stimulation of muscle tissue. This patent is hereby incorporated by reference. A subthreshold anodal stimulation is applied followed by a cathodal stimulation. The subthreshold anodal stimulation acts as a conditioning mechanism to improve conduction through the heart muscle. A similar concept may be used in conjunction with the system of the present invention.
The mechanism by which pre-excitation affects the speed of conduction and contractility will now be described. Typically, normal heart tissue cells have roughly −90 degrees phase. After the cells are stimulated, an impulse starts traveling down the fiber and the cells shift to an action potential with zero phase. Sick or damaged cells, however, typically do not have −90 degrees phase; they may, for example, have a phase of somewhere in the range of −70 degrees or −80 degrees phase. That is why sick cells conduct slowly. One way to make sick cells conduct faster and more like normal cells that have −90 degrees phase is to artificially enhance the intracellular negativity of the sick cells to −90 degrees phase. If that is done, then when an above-threshold stimulation pulse is applied to depolarize the tissue cells, the cells may have a conduction speed and contractility that is more like a normal cell rather than a sick cell. Even if one were to pre-excite a normal cell and thereby artificially enhance the intracellular negativity to −120 degrees, for example, rather than −90 degrees, the speed of conduction of the cell would become supernormal and result in even more contractility. Thus, the nature of the driven beat depends on the initial electronegativity of the cell, which may be varied by means of pre-excitation.
The decision of whether to use a cathodal or anodal pre-excitation pulse depends on the particular heart condition that is being treated. An anodal pre-excitation pulse is well suited for treating a heart with a asynchrony where one part of the heart is conducting the impulse too slowly (i.e., contracting too slowly). In such a case, an anodal pre-excitation pulse may be applied to hyperpolarize the slowly conducting heart tissue cells, thereby increasing the intracellular negativity of those cells and augmenting conduction in that part of the heart before the depolarization impulse arrives. If an anodal pre-excitation impulse is used to hyperpolarize the tissue, when the tissue later is subsequently stimulated so that it depolarizes, the tissue will depolarize from a more electronegative amount and therefore the phase zero of the action potential and the speed of conduction are increased. Thus, in such a case, the hemodynamic performance of the heart may be improved by the application of an anodal pre-excitation pulse.
A cathodal pre-excitation pulse, on the other hand, may be used to treat a heart condition where it is desired to slow down the conduction of the depolarization impulse. For example, in some hearts, instead of contracting too late, a particular part of the heart may contract too early. This type of event may occur, for example, in patients who have Wolff-Parkinson White syndrome. In some cases, the patient's body automatically pre-excites the heart itself. This may lead to a re-entrant arrhythmia and is undesirable. To treat this kind of condition, a cathodal pulse may be applied to partially depolarize the heart tissue cells in that part of the heart where it is desired to slow down the conduction. By partially depolarizing the tissue, the contractility of the affected area is reduced and the speed of conduction may be delayed or even extinguished by the use of an appropriate cathodal pre-excitation pulse. Thus, the conduction is inhibited in that part of the heart, allowing the rest of the heart to catch up. When the rest of the heart catches up, the inhibition may be released. In other words, the cathodal pre-excitation partially depolarizes the affected tissue cells thereby making the depolarization impulse travel slower and provide a weaker contraction. Thus, the cathodal excitation allows the heart to be resynchronized by inhibiting the conduction speed of the depolarization impulse.
The application of a pre-excitation voltage using the system of the present invention will now be described. First, an electrode senses that the heart has begun to depolarize and contract. Since, the heart begins to contract in the left atrium, an electrode placed in the left atrium will be well-suited to detect the beginning of the heart's contraction. However, an electrode implanted in the right atrium, the right ventricle, or elsewhere in the heart could also be used to detect the beginning of the heart's contraction.
Before the contraction reaches the interventricular septum, a pre-excitation voltage may be applied to the interventricular septum. For example, the pre-excitation voltage may be applied shortly before the right ventricle is predicted to contract or shortly before the left ventricle is predicted to contract. The basic idea is to enhance or inhibit the contractility of the heart tissue cells before the depolarization impulse arrives and before the pre-excited portion of the heart contracts. An anodal voltage may be applied to enhance the speed of conduction, or a cathodal voltage may be applied to inhibit the speed of conduction, depending on the particular heart condition being treated. Alternatively, a pre-excitation voltage could be applied to other areas of the heart besides the interventricular septum, such as at an electrode implanted in the right ventricle or at an electrode implanted in a coronary vein of the left ventricle. Alternatively, a pre-excitation voltage could be applied to multiple electrodes simultaneously. For example, a pre-excitation voltage could be applied simultaneously to electrodes 402 and 404 in the left ventricle, as shown in FIG. 4. For example, if the patient had damaged tissue throughout the left ventricle, an anodal pre-excitation at multiple points in the left ventricle may be effective in speeding conduction through the left ventricle. As another example, as soon as the beginning of the heart contraction is sensed, a pre-excitation voltage could be applied simultaneously to an electrode implanted in the right ventricle, an electrode implanted in the interventricular septum, and an electrode in the coronary ostium above the left ventricle.
The pre-excitation voltage could take the form of a single pulse or multiple pulses. It may have a square pulse shape or it may ramp up and/or ramp down. Potentially, an anodal pre-excitation may be so successful in enhancing conduction that there may be no need to stimulate the heart with an above-threshold stimulation pulse. Thus, as an alternative embodiment, the system may sense whether the contraction progresses sufficiently rapidly with the application of just an anodal pre-excitation voltage, and no above-threshold stimulation. If so, the patient's hemodynamic performance may be optimized by only applying an anodal pre-excitation voltage—there is no need to apply an above-threshold stimulation pulse. If the pre-excitation voltage, by itself, is not sufficient to restore adequate conduction, then the pre-excitation voltage may be followed by an above-threshold stimulation pulse to depolarize the affected area of the heart. More specifically, after the anodal pre-excitation voltage is applied, if a signal indicating that depolarization has occurred is not received from a particular site within a predetermined time, then that site is then stimulated by an above-threshold stimulation pulse.
Thus, as described above, pre-excitation may be used with the system of the present invention to improve resynchronization in a patient with heart failure, thereby improving the cardiac output of the heart.
Another optional feature of that may be used with the present invention to improve resynchronization in a patient with heart failure is the use of “field” stimulation pulses that deliver an increased current. Typically, a conventional pacemaker delivers a current roughly in the range of 3 to 4 milliamps when stimulating the heart. One feature of the present invention is to increase the voltage so that a higher current is delivered, for example, around 10 milliamps.
It has recently been found that if the voltage of the stimulation pulses is increased thereby increasing the current, the resynchronization of the heart tends to improve. The higher amplitude stimulation pulse tends to affect not only the immediate area being stimulated, but also affects the surrounding tissue areas. By delivering a higher current than typically used, the surrounding and distant tissue areas become affected in a manner similar to the application of a pre-excitation voltage. In other words, the higher amplitude stimulation pulse affects the intracellular negativity of surrounding tissue areas. The conductivity of these surrounding areas increases even though the tissue is not completely depolarized immediately upon application of the stimulation pulse. The higher amplitude stimulation pulse pre-conditions the surrounding and distant tissue areas by hyperpolarizing those areas, so that when the depolarization impulse arrives, the conduction speed in those hyperpolarized areas will be increased.
These pulses of increased current are referred to as “field” stimulation pulses because the pulses affect not only the immediate point of stimulation, but they also have an affect on the surrounding field.
Other embodiments of the invention will be apparent to those skilled in the art from consideration of the specification and practice of the invention disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims.

## Claims

1. Circuitry to improve hemodynamic efficiency of a human heart, comprising:
a first electrode configured to be implanted in a left ventricle of said human heart to sense an intrinsic signal that stimulates said left ventricle, and to stimulate said left ventricle;
a second electrode configured to be implanted in said left ventricle and spaced apart from said first electrode to stimulate said left ventricle;
a processing circuit to monitor contraction progress in said left ventricle based on said intrinsic signal; and
a generator circuit to generate a signal to stimulate said left ventricle through said first and second electrodes based on the monitored contraction progress,
wherein the first electrode is configured to be implanted in a first location in an interventricular septum of said human heart and the second electrode is configured to be implanted in a second location in the interventricular septum of said human heart, the first location being different from the second location, and
the generator circuit is further configured to generate a pre-excitation signal delivered to said left ventricle via at least one of the first and second electrodes to regulate a contraction of said left ventricle, the pre-excitation signal having a voltage level lower than a voltage level required to cause depolarization and contraction of said left ventricle, the pre-excitation signal having a negative polarity to slow contraction of the left ventricle.

2. Circuitry to improve hemodynamic efficiency of a human heart, as set forth in claim 1, wherein the first and second electrodes are integrated in a single catheter.

3. Circuitry to improve hemodynamic efficiency of a human heart as set forth in claim 1, wherein the pre-excitation signal has a positive polarity to accelerate contraction of said left ventricle.

4. Circuitry to improve hemodynamic efficiency of a human heart as set forth in claim 1, wherein the pre-excitation signal has a negative polarity to slow contraction of said left ventricle.

5. Circuitry to improve hemodynamic efficiency of a human heart comprising:
a first electrode configured to be implanted in a chamber of said human heart to sense an intrinsic signal that stimulates said chamber, and to stimulate said chamber;
a second electrode configured to be implanted in said chamber and spaced apart from said first electrode to stimulate said chamber;
a processing circuit to monitor contraction progress in said chamber based on the intrinsic signal; and
a generator circuit to generate a signal to stimulate said chamber through said first and second electrodes based on the monitored contraction progress,
wherein the first electrode is configured to be implanted in a first location in a wall of said chamber that separates said chamber from an adjacent chamber, and the second electrode is configured to be implanted in a second location in the wall of said chamber that separates said chamber from an adjacent chamber, the first location being different from the second location, and
the generator circuit is further configured to generate a pre-excitation signal delivered to said chamber via at least one of the first and second electrodes to regulate a contraction of said chamber, the pre-excitation signal having a voltage level lower than a voltage level required to cause depolarization and contraction of said chamber, the pre-excitation signal having a negative polarity to slow contraction of the left ventricle.

6. Circuitry to improve hemodynamic efficiency of a human heart as set forth in claim 5, wherein the first and second electrodes are integrated in a single catheter.