Patent Publication Number: US-2022233082-A1

Title: Measuring time to fusion as a means of determining degree of parallel activation of the heart

Description:
TECHNICAL FIELD 
     The present invention is concerned with a method and system for measuring time to fusion as a means of determining degree of parallel activation of the heart. Thus, the invention may be used in relation to patients undergoing pacing, and more specifically can apply to the identification of the degree of parallel activation of a paced heart. A delay in time to fusion indicates that a larger amount of tissue is activated before wave fronts for electrical activation meet, thereby indicating a higher degree of parallel activation, and to what extent the pacing of a heart results in effective resynchronisation. 
     BACKGROUND OF THE INVENTION 
     Cardiac resynchronization therapy (CRT) is consistently provided according to recognized medical standards and guidelines provided by international medical societies in order to treat patients suffering from various conditions such as a widened QRS complex, (left or right) bundle branch block and heart failure. There are some minor differences between the medical guidelines regarding the specific conditions that should occur before CRT is utilized, such as how wide the QRS complex is, what type of bundle branch block is being suffered and the degree of heart failure. 
     CRT is associated with a reduction in mortality and morbidity, however, not all patients benefit from such therapy. In fact, some patients may experience deterioration after treatment, some experience devastating complications, and some experience both. 
     In this regard, it would be beneficial to provide a unifying strategy that reduces the number of non-responders to CRT and optimize the treatment of potential responders, and therefore increases the effectiveness of therapy. 
     SUMMARY OF THE INVENTION 
     Viewed from a first aspect, the present invention provides a method for determining the degree of parallel activation of a heart undergoing pacing, the method comprising: 
     calculating a vectorcardiogram, VCG, or electrocardiogram, ECG, or electrograms, EGM, waveforms from right ventricular pacing, RVp, and left ventricular pacing and/or multisite pacing or multipoint pacing, LVp; 
     generating a synthetic biventricular pacing, BIVP, waveform pacing by summing the VCG of the RVp and the LVp, or by summing the ECG of the RVp and the LVp, or by summing the EGM of the RVp and the LVp; 
     calculating a corresponding EGM, ECG or VCG waveform from real BIVP; 
     comparing the synthetic BIVP waveform and the real BIVP waveform; 
     calculating time to fusion by determining the point in time in which the activation from RVp and LVp meets and the synthetic and the real BIVP curves start to deviate; 
     wherein 
     a delay in time to fusion indicates that a larger amount of tissue is activated before wave fronts for electrical activation meet, thereby indicating a higher degree of parallel activation. 
     As discussed further below, this method allows for an assessment of the degree of parallel activation of a heart undergoing pacing. By determining the degree of parallel activation of the heat, it may be possible to validate the efficacy of pacing in resynchronising activation of the heart. A delay in time to fusion may advantageously be assessed relative to the QRS duration, thereby indicating the relative time to fusion and thereby determining the degree of parallel activation. When pacing the right ventricle, the left ventricle or both, a VCG or ECG can be reconstructed and the time to fusion can be calculated. Thus, different pacing regimes may be directly compared with regards to the amount by which they encourage synchronous activation of the heart. Additionally, the time to fusion may directly be compared when applying pacing through an additional electrode and/or electrodes provided in an alternative position. In this way, a decision may be made whether pacing from additional and/or alternative electrodes should be performed. It should be noted that the method of this aspect is carried out using method steps carried out using data outside of the body. The data that is processed outside of the body can include data already obtained from the body for other purposes. This data may be obtained using at least one sensor of any suitable known type, including sensors commonly used for measurements of the heart, both non-invasively and via implanted sensors, with examples including pressure sensors, ECG electrodes, accelerometers and ultrasound sensors as discussed further below. 
     The method may comprising: comparing the synthetic BIVP and real BIVP waveform when applying pacing from a number of electrodes; calculating time to fusion; adding one electrode; calculating new time to fusion; comparing the first with the second; if adding an electrode does not change time to fusion this indicates that the added electrode activates areas before fusion occurs, thereby indicating a higher degree of parallel activation. 
     Optionally, the method utilises multidimensional VCG, ECG or EGM. 
     Optionally, the method utilises surface ECG or EGM from pacing electrodes instead of VCG. 
     The method may include compensating for a delay in stimulus to QRS onset; suggesting an offset between stimuli; pacing with the new offset generating both synthetic and real BIVP curves with offset; generating a new time to fusion with a RV to LV offset (VV-delay, ventricle to ventricle delay). 
     The calculated time to fusion above may be a first time to fusion, and the method may further comprise providing pacing through an additional electrode and calculating a second VCG or EGM or ECG waveforms from RVp, and LVp, the RVp and LVp being pacing including the additional electrode; generating a second synthetic BIVP waveform pacing by summing the second VCG of the RVp and the LVp, or by summing the second ECG of the RVp and the LVp. A corresponding second EGM or ECG or VCG waveform from real BIVP, the BIVP being pacing including the additional electrode can be calculated, and a the second synthetic BIVP waveform and the second real BIVP waveform can be compared. The method may further comprise calculating a second time to fusion by determining the point in time in which the activation from RVp and LVp meets and the second synthetic and the second real BIVP curves start to deviate. The first time to fusion and the second time to fusion may then be compared. If the second time to fusion is less than the first time to fusion, then the method may comprise determining that there is no benefit of pacing from the additional electrode. 
     In the event of such a finding, it may be determined that pacing should proceed without the additional electrode. 
     The calculated time to fusion again may be considered a first time to fusion, and the method may further comprise providing pacing through at least one electrode at a different position; and calculating a third VCG, or ECG, or EGM, waveforms from RVp, and LVp, the RVp and LVp being pacing including the at least one electrode at a different position. The method may also comprise generating a third synthetic BIVP waveform pacing by summing the third VCG of the RVp and the LVp, or by summing the third ECG of the RVp and the LVp, or by summing the third ECG of the RVp and the LVp; calculating a corresponding third EGM or ECG or VCG waveform from real BIVP, the BIVP being pacing including the at least one electrode at a different position; and comparing the third synthetic BIVP waveform and the third real BIVP waveform. Following these steps, a third time to fusion may be calculated by determining the point in time in which the activation from RVp and LVp meets and the third synthetic and the third real BIVP curves start to deviate. The first time to fusion and the third time to fusion may then be compared. Then, in order to provide the most effective pacing, the method may further comprise selecting the electrode positions corresponding to the longest time to fusion for further pacing. 
     The VCG(s) or ECG(s) or EGM(s) considered above may be calculated from data measured by electrodes implanted in the patient. Additionally or alternatively, the VCG(s) or ECG(s) or EGM(s) may be calculated based on data from surface electrodes on the patient. In such a case, a map of electrical activation may be extrapolated onto the heart; and an inverse solution EGM or ECG or VCG waveform may be calculated. 
     Viewed from a second aspect, the invention provides a system for carrying out the method described above. Thus, the system is for determining the degree of parallel activation of a heart undergoing pacing, the system comprising; 
     one or more sensor(s) to measure biopotentials; 
     one or more electrodes for providing pacing; 
     a data processing module configured to: 
     calculate a vectorcardiogram, VCG, or electrocardiogram, ECG, or electrocardiogram, EGM, waveforms from right ventricular pacing, RVp, and left ventricular pacing, LVp; 
     generate a synthetic biventricular pacing, BIVP, waveform pacing by summing the VCG of the RVp and the LVp, or by summing the ECG of the RVp and the LVp, or by summing the ECG of the RVp and the LVp; 
     calculate a corresponding EGM, ECG or VCG waveform from real BIVP; compare the synthetic BIVP waveform and the real BIVP waveform; 
     calculate time to fusion by determining the point in time in which the activation from RVp and LVp meets and the synthetic and the real BIVP curves start to deviate; wherein 
     a delay in time to fusion indicates that a larger amount of tissue is activated before wave fronts for electrical activation meet, thereby indicating a higher degree of parallel activation. 
     The system may be configured to carry out the method including any or all optional features as above. Thus, the sensor(s) may be as discussed above and the processor may be configured to perform steps as set out above. The system may be provided as a kit including sensors as required along with a processor having the required function. This kit may optionally include the sensors being in place at the patient in order to obtain the required data, or it may be a kit arranged to be used with a patient as required. 
     The system may comprise a screen for visualization of a heart model with any fiducials and representations of the at least one sensor connected. 
     Viewed from a third aspect, the invention provides a computer programme product containing instructions that, when executed, will configure a computer system to perform the method of the first aspect and optionally other features as discussed above. The computer system may be the system of the second aspect, and thus may include the one or more sensor(s) to measure biopotentials; the one or more electrodes for providing pacing; and the data processing module which is configured to perform method steps as set out above. 
     Thus, the instructions of the computer programme product may configure the calculate a vectorcardiogram, VCG, or electrocardiogram, ECG, or electrocardiogram, EGM, waveforms from right ventricular pacing, RVp, and left ventricular pacing, LVp from the measured; 
     generate a synthetic biventricular pacing, BIVP, waveform pacing by summing the VCG of the RVp and the LVp, or by summing the ECG of the RVp and the LVp, or by summing the EGM of the RVp and the LVp; 
     calculate a corresponding EGM or ECG or VCG waveform from real BIVP; compare the synthetic BIVP waveform and the real BIVP waveform; 
     calculate time to fusion by determining the point in time in which the activation from RVp and LVp meets and the synthetic and the real BIVP curves start to deviate; wherein 
     a delay in time to fusion indicates that a larger amount of tissue is activated before wave fronts for electrical activation meet, thereby indicating a higher degree of parallel activation. 
     The above methods, systems and computer programme product may further benefit from combination with the methods, systems, and computer programme product discussed below in connection with determining electrode number and position with reference to the level of parallel activation of the heart. The below aspects are also seen as novel and inventive in their own right. 
     Viewed from a fourth aspect, the present invention provides a method for determining optimal electrode number and positions for cardiac resynchronization therapy on a heart of a patient, the method comprising; 
     generating a 3D mesh of at least part of the heart from a 3D model of at least part of the heart of the patient, or using a generic 3D model of the heart to obtain a 3D mesh of at least a part of the heart, the 3D mesh of at least a part of the heart comprising a plurality of nodes; 
     aligning the 3D mesh of at least part of a heart to images of the heart of the patient; 
     placing additional nodes onto the 3d mesh corresponding to a location of at least two electrodes on the patient; 
     calculating a propagation velocity of the electrical activation between the nodes of the 3D mesh corresponding to the location of the at least two electrodes; 
     extrapolating the propagation velocity to all of the nodes of the 3D mesh; 
     calculating the degree of parallel activation of the myocardium for each node of the 3D mesh; and 
     determining the optimal electrode number and position on the heart of the patient based on the node(s) of the 3D mesh with a calculated degree of parallel activation of the myocardium above a predetermined threshold. 
     In accordance with this method it becomes possible to identify one or more optimal zones for placement of electrodes by using a model of the patient&#39;s heart. This may be done as a part of the method of the first aspect, in order to determine the best placement for electrodes to treat the patient. In effect, this method may find “hotspots” where an electrode is expected to have the most impact, by mapping the regions of the heart with higher degrees of parallel activation. The method may be used to determine an optimal pacemaker configuration. The method may include determining regions with the highest degree of parallel activation, and thus the predetermined threshold may be set based on the highest determined degree of parallel activation. Alternatively, the method may include finding multiple possible regions having a suitably high degree of parallel activation, for example by setting a threshold based on a set minimum number of regions required to be identified, such as four or more proposed nodes. The user can then choose between the regions that are thereby identified. 
     This aspect may be performed with any of the first to third aspects outlined above. In this way, the first to third aspects may be used to validate the degree of parallel activation that is achieved by providing pacing through the optimal electrode number and positions identified in the fourth aspect. 
     Optionally, the step of determining the optimal electrode position on the heart of the patient based on the node of the 3D mesh with the calculated highest degree of parallel activation of the myocardium further comprises determining the node of the 3D mesh with the highest acceleration of propagation. 
     The model of the heart may be a model that is already in existence and/or it may be build using data already in existence, such as a 3D model that has been obtained for other purposes aside from the present method. Alternatively the method may include obtaining the data required to build the 3D model, such as by non-invasive measurements including CT and/or MRI measurements. The method may include providing characteristics to the 3D model of at least a part of the heart of the patient using an MRI scan and/or echocardiography for calculation of geodesic propagation velocity. 
     The method may comprise generating the 3D model of at least part of the heart of the patient from a CT and/or MRI scan of the heart of the patient. 
     The step of generating a 3D mesh of at least part of the heart from the 3D model may comprise fitting a mesh model to the surface of the 3D model of at least part of the heart of the patient. 
     Optionally, the step of calculating a geodesic propagation velocity of the electrical activation further comprises utilising a geodesic distance between the additional nodes of the 3D mesh of at least part of the heart of the patient in combination with electrical measures from the at least two electrodes. 
     The step of extrapolating the geodesic propagation velocity to all of the nodes of the 3D mesh may comprise visualising time propagation of electrical activation throughout the heart at a given time after activation, to calculate the area of the 3D mesh that is activated at said given time utilizing geodesic propagation velocity of the nodes. 
     The method may include updating the 3D model to reflect determined tissue characteristics for use in simulations. 
     After a proposed electrode position has been determined, then in order to determine placement for a further electrode, the method may include calculating the node of the 3D mesh with the largest geodesic distance and/or electrical distance and/or a combination of both from the additional node of the 3D mesh corresponding to an electrode. 
     The step of calculating parallel activation velocity may comprise marking the area of the left ventricle on the 3D mesh of the at least part of the heart that should be part of the calculation, and using tissue characteristic velocity and print out x-axis time and y-axis area when propagating from electrodes. 
     In some examples, the electrodes are surface electrodes configured to acquire surface biopotentials, and the step of calculating a propagation velocity of the electrical activation between the nodes of the 3D mesh corresponding to the location of the at least two electrodes may comprise: using an inverse solution method to calculate the electrical propagation on the 3D mesh of the heart; and calculating propagation velocity in the model using electrical propagation together with geodesic distance. 
     Viewed from a fifth aspect, the invention provides a system for determining optimal electrode numbers and positions for cardiac resynchronization therapy on a heart of a patient, the system comprising; 
     a 3D mesh generating module for generating a 3D mesh of at least a part of the heart comprising a plurality of nodes based on a 3D model of at least part of a heart of the patient, wherein the plurality of nodes include additional nodes corresponding to the locations of at least two electrodes on the patient; 
     an imaging module for providing images of at least part of the heart of the patient; 
     an aligning module configured to align the images of the at least part of the heart of the patient with the at least part of the heart of the patient; 
     an electrode data receiving module for receiving data from the least two electrodes on the patient, with these electrodes being represented on the 3D model by the additional nodes; and 
     a data processing module configured to: 
     calculate a propagation velocity of the electrical activation between the nodes of the 3D mesh; 
     extrapolate the propagation velocity to all of the nodes of the 3D mesh; 
     calculate the degree of parallel activation of the myocardium for each node of the 3D mesh; and 
     determine the optimal electrode numbers and position on the heart of the patient based on the node of the 3D mesh with a calculated degree of parallel activation of the myocardium above a predetermined threshold. 
     The system may be configured to carry out the method of the fourth aspect including any or all optional features as above. In a further system aspect, a system is provided that is configured to carry out the method of the first aspect above. Thus, the electrodes may be as discussed above and the data processing module may be configured to perform steps as set out above. The system may be provided as a kit including electrodes as required along with a data processing module having the required function. This kit may optionally include the electrodes being in place at the patient, or it may be a kit arranged to be used with a patient as required. 
     The at least two electrodes may be surface potential electrodes and/or the at least two electrodes may be situated in the myocardium of the patient. 
     Viewed from a sixth aspect, the invention provides a computer programme product containing instructions that, when executed, will configure a computer system to perform the method of the fourth aspect and optionally other features as discussed above. The computer system may be the system of the sixth aspect, and thus may include the electrodes as well as the data processing module, which would be configured to perform method steps as set out above. 
     Thus, the instructions of the computer programme product may configure the computer system to: 
     provide a 3D model of at least part of the heart of the patient; 
     generate a 3D mesh of at least part of the heart from the 3D model, the 3D mesh of at least a part of the heart comprising a plurality of nodes; 
     align the 3D mesh of at least part of a heart to images of the heart of the patient; 
     place additional nodes onto the 3d mesh corresponding to a location of at least two electrodes on the patient; 
     calculate a propagation velocity of the electrical activation between the nodes of the 3D mesh corresponding to the location of the at least two electrodes; 
     extrapolate the propagation velocity to all of the nodes of the 3D mesh; 
     calculate the degree of parallel activation of the myocardium for each node of the 3D mesh; and 
     determine the optimal electrode number and position on the heart of the patient based on the node of the 3D mesh with the calculated highest degree of parallel activation of the myocardium. 
     In a further computer programme product aspect the invention provides a computer programme product containing instructions that, when executed, will configure a computer system to perform the method of the first aspect and optionally other features as discussed above. The computer system may be the system above, and thus may include the electrodes as well as the data processing module, which would be configured to perform method steps as set out above. 
     Thus, the instructions of the computer programme product may configure the computer system to: 
     calculate a vectorcardiogram, VCG, or electrocardiogram, ECG, waveforms from right ventricular pacing, RVp, and left ventricular pacing, LVp; 
     generate a synthetic biventricular pacing, BIVP, waveform pacing by summing the VCG of the RVp and the LVp, or by summing the ECG of the RVp and the LVp; 
     calculate a corresponding ECG or VCG waveform from real BIVP; 
     compare the synthetic BIVP waveform and the real BIVP waveform; 
     calculate time to fusion by determining the point in time in which the activation from RVp and LVp meets and the synthetic and the real BIVP curves start to deviate; 
     wherein 
     a delay in time to fusion indicates that a larger amount of tissue is activated before wave fronts for electrical activation meet, thereby indicating a higher degree of parallel activation. 
     Viewed from a seventh aspect, the present invention provides a method for identifying reversible cardiac dyssynchrony of a patient by detecting a shortening of a delay to onset of myocardial synergy using measurements of an event resulting from the onset of myocardial synergy, the method comprising: 
     calculating a first time delay between the event resulting from the onset of myocardial synergy and a reference time by:
         using data received from one or more sensor(s) to measure the time of an event resulting from the onset of myocardial synergy;   processing signals from the same sensor(s), or one or more other sensor of the one or more sensor(s), to determine the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time;       

     measuring biopotentials representing electrical activation of the heart; 
     comparing the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of electrical activation of the heart; and 
     if the first time delay is longer than a set fraction of electrical activation of the heart, then identifying the presence of cardiac dyssynchrony in the patient; 
     applying pacing to the heart of the patient; 
     calculating a second time delay between the event resulting from the onset of myocardial synergy following pacing and the reference time following pacing by:
         using the at least one sensor to measure the event resulting from the onset of myocardial synergy following pacing; and   processing signals from the one or more sensor(s) to determine the second time delay between the determined time of the event resulting from the onset of myocardial synergy and the reference time following pacing;       

     comparing the first time delay and the second time delay; and 
     if the second time delay is shorter than the first time delay, then identifying the presence of reversible cardiac dyssynchrony in the patient. 
     Said another way, the seventh aspect, when combined with the above aspects provides a method for identifying reversible cardiac dyssynchrony of a patient, using measurements of an event relating to a rapid increase in the rate of pressure increase within the left ventricle, the method comprising: 
     calculating a first time delay between the event relating to the rapid increase in the rate of pressure increase within the left ventricle and a first reference time by: 
     using data received from one or more sensor(s) to measure the time when an event relating to the rapid increase in the rate of pressure increase within the left ventricle occurs by identifying a characteristic response in the data received from the one or more sensors, the event relating to the rapid increase in the rate of pressure increase within the left ventricle being identifiable in each contraction of the heart; 
     processing signals from the same sensor(s), or one or more other sensor of the one or more sensor(s), to determine the first time delay between the measured time of the identified characteristic response relating to the rapid increase in the rate of pressure increase within the left ventricle and the first reference time; 
     measuring biopotentials representing electrical activation of the heart; 
     comparing the first time delay between the measured time of the identified characteristic response relating to the rapid increase in the rate of pressure increase within the left ventricle and the first reference time with the duration of electrical activation of the heart; and 
     if the first time delay is longer than a set fraction of electrical activation of the heart, then identifying the presence of cardiac dyssynchrony in the patient; 
     applying pacing to the heart of the patient; 
     calculating a second time delay between the identified characteristic response relating to the rapid increase in the rate of pressure increase within the left ventricle following pacing and a second reference time following pacing by: 
     using the at least one sensor to measure the timing of the identified characteristic response relating to the rapid increase in the rate of pressure increase within the left ventricle following pacing; and 
     processing signals from the one or more sensor(s) to determine the second time delay between the determined time of the identified characteristic response relating to rapid increase in the rate of pressure increase within the left ventricle and the second reference time following pacing; 
     comparing the first time delay and the second time delay; wherein 
     if the second time delay is shorter than the first time delay, identifying a shortening of a delay to onset of myocardial synergy, indicating that the time period until the point where all segments of the heart begin to actively or passively stiffen has shortened, thereby identifying the presence of reversible cardiac dyssynchrony in the patient. 
     As discussed further below, this method allows for an assessment of cardiac dyssynchrony that is not available using existing techniques, and which can enable improved assessment of the patient including in relation to cardiac resynchronisation therapy. By characterising cardiac synchronicity using measurements resulting from the onset of myocardial synergy, for example via measurement of electrical activation or by the measuring of events that reflect mechanical action within the heart, it becomes possible to devise strategies to shorten the onset of synergy, such as by optimising the identification of pacing zones. It should be noted that the method of this aspect is carried out using data from the at least one sensor, and hence the method steps carried out using data outside of the body. The data that is processed outside of the body can include data already obtained from the body for other purposes. This data may be obtained using at least one sensor of any suitable known type, including sensors commonly used for measurements of the heart, both non-invasively and via implanted sensors, with examples including pressure sensors, ECG electrodes, accelerometers and ultrasound sensors as discussed further below. 
     Additionally the identification of cardiac dyssynchrony may be achieved using data that has already been measured both before, and after pacing, and therefore method considered herein is equally applicable on pre-existing data sets, to determine whether such data is characteristic of cardiac dyssynchrony. 
     The onset of myocardial synergy relates to the point in time when all segments of the heart either passively or actively stiffen with resulting increase in total force development. This occurs after the earliest electromechanical interval and within the isovolumic phase and before aortic valve opening. This is reflected in several measures, for example by the beginning of an exponential pressure rise within the heart, a rapid increase in the rate of change of pressure in the heart, a beginning of pressure rise above the pressure floor in a filtered pressure signal, the peak of the 2nd order derivative or the onset of pressure rise in the low-pass filtered (below 4 Hz or similar) pressure trace. The peak or onset should be the last peak or onset before aortic valve opening or maximum pressure. Whilst this point in time can be difficult to measure directly, by measuring the time at which an event that occurs as a result of the onset of synergy, it is also possible to obtain an indirect measure of such a time. In reversible cardiac dyssynchrony, a reduction of time to onset of myocardial synergy may be seen with pacing. Therefore, by pacing the heart and measuring the resultant effect on the time of onset of synergy (through an indirect measure), it is possible to identify reversible cardiac dyssynchrony, and therefore identify people who may respond well to CRT treatment. 
     When discussing an exponential pressure rise, the skilled person would understand the meaning in the context of measure pressure data. In this way, whilst there may be an initial small pressure rise resulting from dyssynchronous contraction (wherein segments of the heart are passively stretched), an exponential pressure rise would, for example, be seen to reflect the last point at which there is an identifiable change in the rate of pressure rise increase before ejection. Such a pressure rise could, for example be measured in the frequency range, as the frequencies contained in the pressure trace increase when there is a step change in the pressure change. This occurs beyond the low order harmonics of the frequency spectrum, and the onset of synergy may become evident when low order harmonics are filtered with a low pass filter or band pass filter. Filtering at, for example 4-40 Hz removes the low, slow frequencies that are associated with dyssynergy and the onset of synergy may be seen as the onset of the pressure increase that leads to, or is directly prior to aortic valve opening or maximum pressure. This onset of pressure rise is similar to the peak second order derivative of pressure rise in the left ventricle. Both of these measures will reflect onset of synergy. 
     Similarly a rapid increase in the rate of pressure change would also be well understood in a similar way, as referring to the point at which the rate of pressure change begins to increase at a maximum rate, prior to ejection. This may be reflected in, for example, the final peak in the second order derivative of the pressure of the pressure of the left ventricle prior to aortic valve opening, or maximum pressure. 
     The first and second reference times may relate to different marker points within the measured data. For example, the first reference time may be taken as the beginning of the QRS curve in an un-paced trace. The second reference time may be taken as the time of the onset of pacing. In this case the step of comparing the first time delay and the second time delay further comprises: compensating for a time delay between the first reference time and the second reference time. This allows for the different measurements to be compared whilst accommodating for any intrinsic differences resulting from the different reference points. 
     The step of measuring biopotentials representing electrical activation of the heart may further comprise measuring surface biopotentials of the patient to produce an electrocardiogram, ECG, and determining the reference time from the point of onset, offset or the full duration of a QRS signal measured from the ECG. The duration of the QRS complex may then be determined. The step of comparing the first time delay between the measured time of the event resulting from onset of myocardial synergy and the reference time with the duration of electrical activation of the heart may further comprise comparing the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of the QRS complex; and if the first time delay is longer than a set fraction of the QRS complex duration, then identifying the presence of dyssynchrony in the patient. 
     When identifying potentially reversible dyssynchrony in a patient, the method may further comprise modifying the pacing of the heart, and repeating the measurements of an additional time delay to determine whether the time delay may be reduced with a modified pacing regime. Specifically, the method may further comprise applying modified pacing to the heart of the patient, and calculating a third time delay between the event resulting from onset of myocardial synergy following modified pacing and the reference time following modified pacing by using the at least one sensor to measure the event resulting from the onset of myocardial synergy following modified pacing. Signals from the one or more sensor(s) to may then be processed to determine the third time delay between the determined time of the event resulting from onset of myocardial synergy following modified pacing and the reference time following modified pacing. Then, the second time delay and the third time delay may be compared; and if the third time delay is shorter than the second time delay, then reversible cardiac dyssynchrony in the patient may be identified. Any number of alternate pacings (and associated time delays) may be assessed in this way to determine whether the time delay can be shortened, and therefore whether reversible dyssynchrony is present. 
     The step of measuring biopotentials representing electrical activation of the heart may further comprise measuring surface biopotentials of the patient to produce an electrocardiogram, ECG, and determining the reference time from the point of onset, offset or the full duration of a QRS signal measured from the ECG. The duration of the QRS complex may then be determined. The step of comparing the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of electrical activation of the heart may further comprise comparing the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of the QRS complex; and if the first time delay is longer than a set fraction of the QRS complex duration, then identifying the presence of dyssynchrony in the patient. 
     When identifying potentially reversible dyssynchrony in a patient, the method may further comprise modifying the pacing of the heart, and repeating the measurements of an additional time delay to determine whether the time delay may be reduced with a modified pacing regime. Specifically, the method may further comprise applying modified pacing to the heart of the patient, and calculating a third time delay between the event resulting from the onset of myocardial synergy following modified pacing and the reference time following modified pacing by using the at least one sensor to measure the event resulting from the onset of myocardial synergy following modified pacing. Signals from the one or more sensor(s) to may then be processed to determine the third time delay between the determined time of the event resulting from the onset of myocardial synergy following modified pacing and the reference time following modified pacing. Then, the second time delay and the third time delay may be compared; and if the third time delay is shorter than the second time delay, then reversible cardiac dyssynchrony in the patient may be identified. Any number of alternate pacings (and associated time delays) may be assessed in this way to determine whether the time delay can be shortened, and therefore whether reversible dyssynchrony is present. 
     The method may include selecting the optimal pacing mode and electrode numbers and positions for cardiac resynchronization therapy or pacing therapy. For example, this may be done by comparing one pacing site to the other, and number of electrodes to other number of electrodes. This may furthermore be suggested by measurements of distance between electrodes, either geodesic or linear distance or electrical time separation or electrical delays to certain zones of the heart, or anatomical positions or any combination of these that would provide a location that should be tested and compared. Again measurements of parallelity as mentioned below may be calculated. Anatomical models, either patient specific or other may be used for visualization. 
     The method may comprise measuring surface biopotentials of the patient to produce an electrocardiogram, ECG; and determining the reference time from the point of onset, offset or the full duration of a QRS signal measured from the ECG. 
     Optionally, the one or more sensor(s) includes an accelerometer or piezo-resistive sensor, and the method may hence comprise: receiving data from the accelerometer or piezo-resistive sensor, which may be within, or connected to the surface of the patient; and determining the reference time from the point of onset, offset, full duration and matched template of the acceleration data or piezo-resistive sensor data. 
     In some examples, the one or more sensor to measure the time of event resulting from the onset of myocardial synergy includes an accelerometer, and this may be the accelerometer referenced above. The one or more sensor to measure the time of event resulting from the onset of myocardial synergy may include an ultrasound sensor. 
     The one or more sensor may be configured to detect heart sounds corresponding to the event resulting from the onset of myocardial synergy. 
     The method may involve injecting current through surface skin electrodes; measuring impedance between electrodes within or close to the heart and its vessels; and producing a complex impedance waveform and an amplitude waveform; wherein the event resulting from the onset of myocardial synergy is the time at which the heart muscle shortens and blood is ejected from the heart, and wherein the time of event resulting from the onset of myocardial synergy is determined where the complex impedance and the amplitude waveform meet and deviate. Thus, the one or more sensors may include surface skin electrodes and electrodes within the body. 
     The one or more sensor may be a pressure sensor (piezo-resistive, fibreoptic and similar) mounted on a catheter located in the left ventricle, and in that case the event resulting from the onset of myocardial synergy may include events detectable by the use of such a pressure catheter, such as the peak pressure rise in the time domain (T d ), trajectory advancement, or trajectory delay compared to any trajectory in either the time derivative of a pressure curve trajectory or in the pressure curve trajectory itself. 
     In some examples, when utilizing and external or internal ultrasound probe to measure cardiac tissue motion, the event resulting from the onset of myocardial synergy includes one of the onset of S-wave velocity, onset of S-wave strain rate, onset of global ejection, aortic valve opening, the onset of aortic flow, myocardial wall velocity, strain or any other measure to measure onset of synergy 
     In order to provide effective pacing, any atrioventricular (AV) delay should preferably be calculated so that the atrioventricular delay (AV-delay) of the pacing is calculated so that Atrial Pace-Ventricular Pace time (AP-VP) is shorter than the shortest of Atrial Pace-Right Ventricular sensing (AP-RVs) and Atrial Pace-QRS complex onset (AP-QRSonset). The AV-delay of the pacing may be calculated as 0.7*(AP-RVs), or if AP-QRSonset is known as 0.8*(AP-QRSonset), or in any other way calculated not to allow any intrinsic conduction to occur through the His-Purkinje system resulting from an atrial or ventricular stimulus. 
     The method may include applying modified pacing to the heart of the patient utilizing additional positions of pacing and/or additional electrodes and then further steps to assess the effectiveness of the modified pacing. Such further steps may include calculating an additional time delay between the event resulting from the onset of myocardial synergy following modified pacing and the reference time following pacing by: using the at least one sensor to measure the event resulting from the onset of myocardial synergy following pacing; and processing signals from the at least one sensor to determine the additional time delay between the determined time of the event resulting from the onset of myocardial synergy and the reference time following pacing. The method may then include comparing the additional time delay and the second time delay; and, if the additional time delay is shorter than the second time delay, identifying the presence of less cardiac dyssynchrony with the modified pacing in the patient. 
     Viewed from a eighth aspect, the invention provides a system for carrying out the method described above. Thus, the system is for detecting onset of myocardial synergy as a means of measuring reversible cardiac dyssynchrony of a patient, and the system may comprise; 
     one or more sensor(s) to measure the time of the event resulting from the onset of myocardial synergy; 
     one or more sensor(s) to measure biopotentials representing electrical activation of the heart; 
     at least one electrode configured apply pacing to the patient; and 
     a data processing module configured to:
         use the same sensor(s), or one or more other sensor of the one or more sensor(s), to measure the time of an event resulting from the onset of myocardial synergy by;
           processing signals from the at least one sensor to determine the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time;   comparing the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of electrical activation of the heart;   if the first time delay is longer than a set fraction of electrical activation of the heart, then identify the presence of cardiac dyssynchrony in the patient;   
           apply pacing to the heart of the patient;   calculate a second time delay between the event resulting from the onset of myocardial synergy following pacing and the reference time following pacing by:
           using the at least one sensor to measure the event resulting from the onset of myocardial synergy following pacing; and   processing signals from the at least one sensor to determine the second time delay between the determined time of the event resulting from the onset of myocardial synergy and the reference time following pacing;   
           compare the first time delay and the second time delay; and   if the second time delay is shorter than the first time delay, identifying the presence of reversible cardiac dyssynchrony in the patient.
 
The system may be configured to carry out the method including any or all optional features as above. Thus, the sensor(s) may be as discussed above and the processor may be configured to perform steps as set out above. The system may be provided as a kit including sensors as required along with a processor having the required function. This kit may optionally include the sensors being in place at the patient in order to obtain the required data, or it may be a kit arranged to be used with a patient as required.
       

     The system may comprise a screen for visualization of a heart model with any fiducials and representations of the at least one sensor connected. 
     Viewed from a ninth aspect, the invention provides a computer programme product containing instructions that, when executed, will configure a computer system to perform the method of the first aspect and optionally other features as discussed above. The computer system may be the system of the second aspect, and thus may include the one or more sensor as well as the processor, which is configured to perform method steps as set out above. 
     Thus, the instructions of the computer programme product may configure the computer system to: 
     calculate a first time delay between the event resulting from the onset of myocardial synergy and a reference time by:
         using data received from one or more sensor(s) to measure the time of an event resulting from the onset of myocardial synergy;   processing signals from the same sensor(s), or one or more other sensor of the one or more sensor(s), to determine the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time;       

     measure biopotentials representing electrical activation of the heart; 
     compare the first time delay between the measured time of the event resulting from the onset of myocardial synergy and the reference time with the duration of electrical activation of the heart; and 
     if the first time delay is longer than a set fraction of electrical activation of the heart, then identify the presence of cardiac dyssynchrony in the patient; 
     apply pacing to the heart of the patient; 
     calculate a second time delay between the event resulting from the onset of myocardial synergy following pacing and the reference time following pacing by:
         using the at least one sensor to measure the event resulting from the onset of myocardial synergy following pacing; and   processing signals from the one or more sensor(s) to determine the second time delay between the determined time of the event resulting from the onset of myocardial synergy and the reference time following pacing;       

     compare the first time delay and the second time delay; and 
     if the second time delay is shorter than the first time delay, then identify the presence of reversible cardiac dyssynchrony in the patient. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Certain preferred embodiments will now be described by way of example only and with reference to the accompanying drawings, in which: 
         FIG. 1 a    shows a representation of a normal heart; 
         FIG. 1 b    shows a heart undergoing CRT and hence being implanted with atrial and biventricular electrodes; 
         FIG. 2  illustrates a 3D surface geometry model of the heart with representations of locations of the electrodes of  FIG. 1   b;    
         FIG. 3  is an example system for measuring bioimpedance on the heart; 
         FIG. 4 a    shows measurements of any representation of onset of synergy along with impedance and/or acceleration; 
         FIG. 4 b    shows an echocardiographic representation of time to onset of synergy; 
         FIG. 5 a    illustrates how a pressure catheter located within the left ventricle can be utilized to measure ventricular pressure and the derivative of the pressure waveform; 
         FIG. 5 b    shows the placement of sonomicrometric crystals in the heart for subsequent measurements; 
         FIG. 5 c    shows such a determination of onset of synergy by measuring a peak in the second-order derivative of pressure from the measurement arrangement of  FIG. 5   b;    
         FIG. 5 d    illustrates the change in time to peak dP/dt with a change in position of pacing; 
         FIG. 6  shows an illustration of physiological conditions experienced during heart contraction; 
         FIG. 7 a    shows various signals that can be derived from filtering measured traces; 
         FIG. 7 b    shows various other traces from filtered waveforms; 
         FIGS. 8 a , 8 b  and 8 c    show various examples of how traces may be utilised to determine the onset of synergy, or a signal indicative thereof; 
         FIG. 9  shows a method for generating a 3D model of the heart including a 3D mesh of the ventricle; 
         FIG. 10  illustrates the use of x-ray in relation to alignment of the 3D model with the patient&#39;s heart; 
         FIG. 11  shows x-ray images taken for use in the alignment of the 3D model; 
         FIG. 12  shows reconstruction of the coronary sinus vein in 3D; 
         FIG. 13 a    illustrates a heart model converted to a geometric model; 
         FIG. 13 b    illustrates another geometric heart model in 3D; 
         FIG. 14  is a visualization of time propagation of electrical activation; 
         FIG. 15  shows the use of an object of known size to calibrate the heart model for distance between vertices; 
         FIG. 16  illustrates pacing of the right ventricle in order to extrapolate measurements of recruited area of the heart; 
         FIG. 17  shows a similar process to  FIG. 16  but using separation time based on natural pacing of the heart; 
         FIG. 18 a    shows a calculation of a compound measure, with  FIG. 18 b    showing the addition of geodesic distance and highlighting of areas for potential electrode placement; 
         FIG. 19  shows an example of calculation of geodesic velocity; 
         FIG. 20  is a heart model including a representation of propagation of electrical activation from the nodes; 
         FIG. 21  shows echocardiographic parameters associated with the heart model; 
         FIG. 22  visualizes tissue characteristics with reference to scar tissue; 
         FIGS. 23 and 24  show recruitment curves representing the recruited area in the heart model; 
         FIG. 25 a    shows a vectorcardiogram (VCG) created for an electrode performing right ventricular pacing (RVp); and 
         FIG. 25 b    illustrates a comparison of synthetic VCG LVP+RVp and the real VCG BIVp. 
     
    
    
     DETAILED DESCRIPTION 
     Generally, a first aspect relates to dyssynchronous heart failure, and more specifically to the identification of patients who are likely to respond to therapy such as cardiac resynchronisation therapy (CRT), and determining optimal locations for placement of electrodes in the heart. CRT aims at reducing heart failure associated with dyssynchrony. 
     Dyssynchrony is the deviation of activation and/or contraction patterns from that of the normal activation and/or contraction patterns. Normal activation patterns are typically seen in a normal heart with a normal ECG and QRS complex following normal synergic contraction patterns. However, normal activation and contraction patterns may occur in parts of the heart despite presence of dyssynchrony in other parts. Dyssynchrony can typically be described as electrical and mechanical dyssynchrony. However, more specifically and as proposed by the inventors, dyssynchrony can be characterized by the way electrical dyssynchrony is linked to mechanical dyssynergy. 
     Electrical Dyssynchrony 
     Dyssynchrony may be classified as electrical dyssynchrony. For example, in such a case, the activation pattern may appear normal in the left chamber when right bundle branch block (RBBB) is present, and similarly the activation pattern may appear normal in the right chamber with left bundle branch block (LBBB). However, normal activation is blocked in the presence of bundle branch block, which forces downstream activation of the heart muscle (myocardium) from cell to cell with a slower propagation than when activated from within the conduction system. 
     Such a delayed electrical activation results in a delayed contraction of the myocardium at the site of delayed activation. This contraction pattern may be characterized as dyssynchronous in several ways, such as with imaging as MRI or echocardiography, or utilizing ultrasound crystals implanted within the heart walls. Dyssynchronous contractions are typically characterized by regional different timing of electrical activation and contraction. 
     The extent of dyssynchrony is dependent on the amount of the muscle fibres of the myocardium (sarcomeres) that are activated (contracting) at a time compared to the total amount of sarcomeres. In this regard, preexcitation of a thick heart wall may manifest as a lower degree of dyssynchrony than preexcitation of a thin heart wall, as directional propagation towards the surface of the wall is limited in a thin wall when compared to a thick wall. This results in the excitation of fewer sarcomeres within a certain distance from the origin of activation longer than the distance to the surface of the thin wall (effect of thickness of a wall). 
     The origin of activation within a transverse of the wall may have a profound effect on the degree of dyssynchrony. Activation of a sarcomere at the centre of a thick region of myocardium will allow for activation in all directions in that segment and thereby results in less dyssynchrony (i.e. less sequential activation in series, rather more synchronous activation in parallel) than activation from the outer border of that thick region (which would result in less parallel activation, but more in series). 
     Activation of a myocardial wall at its border will similarly result in more activation in series than activation from the centre of that wall (i.e. more activation in parallel), effect of origin of activation within the length of the wall. 
     QRS Duration 
     The QRS duration is the sum of the electrical vectors of heart activation. The time duration of the QRS complex reflects the duration of cardiac depolarization. With pacing, the pacing site determines the duration of depolarization as depolarization distributes relative to the pacing site until the myocardium is fully depolarized. RV septum activates the heart bidirectionally, activation towards the right and left once the activation of the septum reaches the free walls of the heart. This is even true with an RV apical position, however, one may note that from the apex activation may become tridirectional; into the septum and the right and left free wall. In this way, with septal activation, activation of the left ventricle starts at a location at the left ventricle and once the RV free wall is reached simultaneous with the activation of the RV. The ventricle that is completely activated last determines the QRS duration. With bidirectional activation QRS is narrower than with unidirectional activation from the free wall, either RV or LV. Septal mid-wall activation that spreads out in all directions in the septum and then bidirectional towards right and left should be reflected in the narrower QRS complex or the shortest duration of activation of the heart when paced. This can furthermore be compared to intrinsic activation to determine whether the exit from the His-Purkinje system is more free wall or more septum and if shorter than with RV septal pacing. 
     The QRS duration with RV and LV free wall activation should be similar, however dependent on whether pacing is from the base or mid-wall of either site. 
     When analyzing time to fusion with EGM or VCG, and parallelity, one should make this consideration. The shortest recruitment will occur from the septum and left lateral free wall when unopposed by scar or barriers. Shortest recruitment will occur when pacing from the RV is at the site with the shortest QRS. With pacing the RV from this position QRS has the potential to narrow to the largest extent when the concordant LV position is found. Time to fusion should be as close to 50% of the shortest QRS from RV septum pacing when corrected for Stim to QRS differences between left and right. 
     Issues with Electrical Measures and Additive Value of Tissue Propagation Velocity 
     Electrical measures are in part hampered by being delayed in scar areas, so that measurements between electrodes and at electrodes might not be representative of the global electrical properties of the cardiac muscle, rather that of the region in which it is measured. A long interval may indicate that there is a conduction block between the two electrodes or in the region of one electrode, but it will not reveal where in the tissue the block is located. 
     In a typical left bundle branch block, the region of electrical block may be found proximal in the conduction system, while in the presence of scar and non-specific intraventricular conduction delay (IVCD) the block is within the myocardium or in the distal part of the conduction system. 
     The presence of fibrosis (diffuse disease) may delay conduction in both specific and non-specific conduction tissue. However, without the knowledge of the distance between electrodes, it is not possible to calculate the tissue propagation velocity between electrodes. 
     The propagation velocity between electrodes, if different, may reveal an area of conduction block between different sites. When geodesic distance is measured between electrodes, then geodesic velocity can be calculated as well to reveal cardiac conduction disease, whether distal or proximal block and/or diffuse disease (such as fibrosis, amyloidosis++). 
     Mechanical Dyssynergy 
     Regardless of activation, each sarcomere will contract according to known physiological conditions, which mainly depends on the prestretch of the sarcomere and the load. The action of an isolated sarcomere is termed sarcomeric function, and the action of the heart muscle as whole is termed cardiac function. Whilst measurements of cardiac function have previously been thoroughly studied and described, it has not thus far been useful to determine responders to CRT. 
     Myocardial function (contractility) has been described in many ways. Typically, contractility has been described with the pressure-volume relationship, represented by the elastance curve or the E max . Myocardial functions have also been described with respect to the time intervals of the cardiac phases, either alone or in combination (as a Myocardial Performance Index, or Tei-index). This cardiac function can be quantified by different invasive measures, such as cardiac phase time intervals, dP/dt max  as well as pressure-volume relationships with the load-independent elastance curve E max . Such cardiac function measures can also be quantified non-invasively with echocardiography or MRI. 
     The measurement of dP/dt max  is used for the measurement of cardiac function to determine the effects of resynchronization therapy (particularly in biventricular pacing). 
     Resynchronization is the utility of multiple electrodes for stimulation, or additional electrodes when intrinsic conduction is utilized for simultaneous activation. The measure dP/dt max  is, however, dependent on load and heart rate and does not change with BIVP compared to LVP only. 
     In this way, the measure of dP/dt max  in itself does not reflect resynchronization but instead reflects changes in cardiac function that depends on multiple factors among contractility, like preload and heart rate (heterometric and homeometric regulation of contractility). Similarly, resynchronization does not change the cardiac function (heterometric and homeometric regulation of contractility), but rather provides synchronization of activation of the myocardium that again may result in changes in stroke volume, afterload and preload that change contractility through heterometric and homeometric regulation mechanisms. 
     The maximum value of the time-varying elastance E(t) curves, E max , does not reflect dyssynchrony. However, the offset in time between the E(t) max  with and without dyssynchrony reflects the delayed onset of synergy with dyssynchrony, 
     Therefore, a measure of cardiac function should ideally be a number that is both independent of the loading condition of the heart, and independent of dyssynchrony. Measurements of cardiac function such as the pressure-volume relationship or the force-frequency relationship do not reflect differences in dyssynchrony. 
     On the other side, a measure of dyssynchrony should not reflect changes in contractility, but rather only changes in dyssynchrony. This is again not the case for the known measures of cardiac function as described above. 
     Synergy is a term used for sarcomeres that contract in parallel, whilst dyssynergy may be used to describe the situation where the sarcomeres contract in series. Such dyssynergy does not allow the muscle fibre (which consists of sarcomeres contracting in series) to develop work to its ultimate potential, even though each sarcomere may still have the same degree of contractility. In order to measure the contractility of such a muscle fibre it would necessary to know that all sarcomeres of the muscle fibre are actually working in parallel to reach the full potential of contraction so as to be representative of the contractility of each sarcomere within the fibre. 
     The cardiac conduction system consists of the His-Purkinje network. This network divides in a left and right bundle branch to each cardiac chamber, and both branches split into Purkinje fibres that spread out into a fine endocardial network. One of the main functions of the cardiac conduction system is to activate the cardiac sarcomeres in both chambers close to simultaneously. This leads to activation of sarcomeres in parallel, which in turn allow for synergistic contraction of the cardiac chamber to occur. 
     For a number of potential reasons, regions of sarcomeres in a heart chamber may not be activated (or be passive). These sarcomeres will be passively subjected to the force that develops in adjacent segments, and therefore subsequently stretched or tightened. Such passive segments are not acting in synergy with contracting segments and are therefore dyssynergistic. 
     Segments may be dyssynergistic because they are not electrically activated (depolarized), while other segments are contracting after being activated (depolarized), such a situation is termed dyssynchrony, as outlined above. The degree of dyssynchrony depends on the dispersion of electrical activation. With more activation in series (i.e. when there is a greater degree of dyssynchrony), the larger the electrical dispersion. To the contrary, when activation occurs in parallel, the dispersion is low. 
     However, if the dyssynergy has any other cause than dispersed electrical activation (resulting in activation of the sarcomeres in series), it is not dyssynchrony. Rather, dyssynchrony implies that the electrical timing (chrono) of the activation is out of order (dys), which in turn results in delayed muscle contraction in some regions of the heart, i.e. the sarcomeres are not (dys) cooperating (synergy). 
     Issues with Mechanical Measures 
     While electrical measures are readily available for the implanter of electrodes, the mechanical function is not. Standard measures of cardiac function do not work in a dyssynchronous heart to detect dyssynchrony. 
     In a normal heart with a normal cardiac function, dP/dt max  is reduced with RVP and immediately restored with intrinsic heart rhythm. However, when response to an extrastimulus is tested, potentiation is not hampered, indicating that function is not changed. Cardiac function is not changed during a brief period of pacing or even with a single paced beat; however, the measurement of dP/dt max  is. When paced at a faster rate dP/dt max  increases regardless of pacing the RV or not. 
     Cardiac phase intervals may also reveal changes in cardiac function, however, this may not be appropriate for measuring cardiac function in a dyssynchronous heart. 
     Why the Nomenclature of the Cardiac Phases is Incorrect for Use in the Context of Dyssynchrony and Resynchronization 
     Typically, cardiac muscle contraction is divided into two specific conditions under which responses in contraction is different. In a papillary muscle preparation, isotonic contraction indicates shortening of the heart muscle with a certain velocity at a constant load, with the maximum shortening velocity (V max ) indicating the performance of the muscle. Isometric contraction indicates contraction without shortening at a high load, with force (F) generation being a measure of the performance of the muscle. It is then possible to describe the function as V max  and F max  in such a papillary muscle. 
     The phases of heart contraction as described by Wiggers diagram reflects this and divides the cardiac phases into the isovolumic contraction that is supposed to mimic the isometric papillary muscle contraction, and the rapid ejection and systole that is supposed to mimic the isotonic papillary muscle contraction. It is known to a person skilled in the art that with better function (inotropy), shortening of the IVC interval occurs and with poor function, it lengthens. Time intervals can reflect the inotropic state of the heart, also referred to as cardiac function. It is also known that the isovolumic period is not strictly isovolumic as geometric changes occur which shift volume within the cavity during contraction, and mitral valve insufficiency may allow further volume reduction during this period. 
     With dyssynchrony, onset of contraction occurs at different times within the chamber allowing some regions to contract while other regions will stretch to compensate while still in diastole/relaxation. As this occurs initially at low pressures the potential energy and shortening is wasted and needs to be compensated for by shifting the work load to late contracting segments. The initial phase with dys-coordinated contraction and the resulting remote stretch is a phase dominated by initial dyssynergy, and then synergy once a balance in force is reached between the muscle fibres before opening of the aortic valve. Once more muscle fibres and regions are recruited and activated, stiffening of the walls occur up to an isovolumic state is reached where muscle fibres will start generate force instead of increasing the velocity of shortening. At this moment of onset of synergy, which is delayed because of slow electrical propagation with dyssynchrony and resulting dyssynergy, pressure starts to increase, and with the onset of synergy pressure rise is exponential up to the opening of the aortic valve. 
     Onset of synergy is reflected in all of the events that follow exponential pressure rise, and even though the onset cannot be measured directly, the exponential pressure rise indicate that more forces are recruited than absorbed as synergy increases, while the effects of dyssynergy are lost. Opening of the aortic valve allows shortening of fibres, now at a more or less constant force at the capacity of the fibres, until force generation is no longer possible to maintain the pressure as more and more fibres have completed their contraction cycle. However now, even after aortic valve closure, fibres may still contract delaying pressure decay into diastole. 
     A dyssynchronous heart isovolumic contraction phase (IVC) does not imply isometric contraction of fibres and should be termed differently. This phase is about converting potential energy stored in the muscle fibres effectively into kinetic energy during systole, and this is opposed and delayed by dyssynergy resulting from dyssynchrony. In addition, force and load is regionally different during this phase with dyssynchrony. 
     The electromechanical coupling interval is furthermore not a distinct interval but is dispersed as activation is delayed, allowing fibres to remain in diastole even after onset of electrical activation of the heart. 
     During the isovolumic relaxation phase (IVR), relaxation may only occur to a certain degree while some fibres will continue to shorten, so that systole overlaps with IVR and IVR overlaps with onset of diastole. The intervals of the diagram of Wiggers electromechanical coupling, IVC, systole, IVR and diastole is therefore not valid for a dyssynchronous heart cycle. 
     Resynchronisation 
     Dyssynchrony, as a disease, is further defined in its nature of reversibility, by restoring parallel activation or reducing electrical dispersion. Such restoration may be achieved by providing pacing at multiple sites. However, dyssynchrony may also be promoted with pacing at multiple or single sites. 
     It would therefore be beneficial to avoid a situation where dyssynchrony is actually promoted during CRT by determining how the reversible disease of dyssynchrony may be detected and evaluated, so as to characterize whether the intervention (for example, CRT) causes more or less dyssynchrony (an increase or decrease in parallelity, as described below) and/or more or less dyssynergy (late onset of synergy). 
     Activation of the heart results in depolarization of the cardiomyocytes of the myocardium, so that contraction occurs at the activated site. Parallelity is a term introduced to describe the degree of parallel activation of the myocardium. 
     Whereas synergy describes sarcomeres cooperating and contracting, dyssynergy describes sarcomeres not cooperating. As previously described, the activation of sarcomeres in series leads to a contraction of the sarcomeres in series, as seen with dyssynergy, whilst the simultaneous activation of sarcomeres in parallel leads to cooperation of sarcomeres as seen in synergy. Dyssynergy is characterized by contractions that occurs at different points in time, either sequential (meaning that neighboring tissue start contracting one after the other in a specific pattern, until contraction occurs over the full myocardium), or non-sequential meaning that different parts of the myocardium contracts in parallel following subsequent activation of neighbouring tissue in a certain pattern (thereby again ending up with covering the full myocardium). 
     In this way, it may be said that dyssynergy describes the mechanical action and a lesser degree of parallelity (which considers the parallel activated segments compared to the activation of sarcomeres in series) of the sarcomeres. While electrical activation in terms of recruitment describes electrical action. With resynchronization both of these results are linked so that restoration of electrical action and higher recruitment leads to restoration of mechanical action and more synergy (parallel activation). 
     In a normal, healthy heartbeat, electrical activation occurs during a short period in time, which is represented by a narrow QRS complex. Activation occurs on a microscale in series and non-sequentially at multiple sites within the heart, promoted by the Purkinje system. This results in a rapid onset of contraction at multiple sites in parallel (with synergy) within the chamber within a short time-frame. 
     Once the tension (caused by the contraction of the sarcomeres) is in balance between all the activated segments of the heart (multiple regions), dominantly parallel contraction is rapidly established. This onset of myocardial synergy promotes an exponential pressure rise within the ventricle preceding aortic valve opening and ejection, and any cardiac event that follows. 
     As activation occurs outside the specialized conduction system, the activation process is even more delayed and dyssynchronous compared to a normal heartbeat. In a dyssynchronous heartbeat, the electrical activation occurs at a slower rate in series, and occurs sequentially, which leads to dyssynergic contraction in series. When contraction occurs in series, the contracting segments shorten, and in turn passively stretch the not yet activated segments. As such contraction occurs, the potential energy resulting from contraction of the segments is wasted at a low intraventricular pressure, and only serves to stretch not yet activated segments. This process continues until the tension between the stretched (but not yet activated segments) and contracting (activated) segments are in balance. This balance is promoted by activation of already stretched segments. With such a balance of tension, the shortening contraction of the sarcomeres are hampered and the sarcomere contractions change from an isotonic contraction (i.e. contraction generating shortening velocity at a constant tension) to isometric contraction (i.e. contractions generating force without changing the length of the muscle), which results in more sarcomeres contracting in synergy and hence this defines the onset of myocardial synergy. Such an onset of myocardial synergy in turn allows the sarcomere contraction force to convert into exponential pressure increase. This delayed exponential pressure increase precedes aortic valve opening and ejection, and any cardiac event that follows. 
     As previously mentioned, it is desirable that a measure of dyssynchrony should reflect dyssynchrony only, and not of any other measurements such as cardiac function. 
     Pacing of a ventricle directly in the myocardium can introduce dyssynchrony because activation then no longer follows the conduction system and therefore does not lead to a normal contraction pattern. Potentially any kind of pacing that occurs outside of the conduction system may introduce dyssynchrony which in turn can result in dyssynergy to a large extent. It is important to be able to measure these effects once pacing is initiated in a patient. Pacing can be viewed upon as a model of both dyssynchrony and dyssynergy. 
     Dyssynergy resulting from dyssynchrony delays the pressure rise in the ventricle, thereby resulting in a delayed onset of myocardial synergy, and hence ejection, and the following systolic shortening and any event that follows. However, a delay in onset of synergy may also occur with diminished heart function, mitral valve insufficiency and cardiac fibrosis and scar without dyssynchrony, but to a different extent than when caused by dyssynchrony. Even if a mix of dyssynchrony and other causes of delayed onset of synergy exist, shortening of onset of synergy can only occur as a result of resynchronization (but only to a limited extent depending on the ratio of the mix of causes). 
     Whilst dyssynchrony may be corrected with resynchronization, the other cardiac diseases may not. With resynchronization, the inventors have showed that shortening of the time to onset of maximal pressure rise (or myocardial synergy) results. In this regard, any measurement that reflects the time interval to onset of myocardial synergy will shorten with resynchronization, and the measurement of such a time interval will always be relative to the QRS or any associated feature. 
     In potentially reversible dyssynchrony, the onset of synergy is seen at the end of or after the QRS complex. The delayed onset of synergy resembles the widening of the QRS complex, which therefore indicates the presence of dyssynchrony. However, in a widened QRS complex with a near to normal time to onset of synergy, dyssynchrony is not present, and the delay is rather caused by factors other than potentially reversible dyssynchrony. By detecting the presence of reversible dyssynchrony, it may be determined whether a patient is likely (will) to respond to CRT, while with absence of a delay to onset of synergy the patient will likely not respond to CRT or may experience unwanted effects of CRT. 
     The positioning of electrodes and number of electrodes used for CRT stimulation should aim at shortening the delayed onset of synergy to the largest extent. By defining a relationship between synchronicity, parallelity and the onset of myocardial synergy, and utilizing the lateness of maximum pressure increase (or any other sensor detected delay in this interval) during an intrinsic or paced rhythm, it is possible to predict a site for (left and right) ventricle electrode placements that results in a favourable response to CRT. 
     When a widened QRS is present, the resulting mechanical dyssynergy needs to be defined before resynchronization can occur, then considering optimal parallelity of electrical activation to achieve electrical resynchronization. Validation needs to occur again on the mechanical side to confirm that the time to onset of synergy has been shortened, evidencing resynchronization effects. In this way, mechanical and electrical events of the heart need to be considered in order to both identify for whom treatment may be beneficial, and to optimize treatment in patients with dyssynchrony. 
     When the cause of dyssynergy is dyssynchrony, the wasted work, shifted load and dyssynergy can be reversed with resynchronization. When the cause of dyssynergy is not dyssynchrony, this cannot be reversed with resynchronization. Therefore, it would be beneficial to identify when such dyssynergy is indeed caused by dyssynchrony in order to indicate whether a patient is likely to respond to CRT. 
     By determining how the reversible disease of dyssynchrony may be detected and evaluated, it is possible to characterize whether an intervention (for example, CRT) causes more or less dyssynchrony (an increase or decrease in parallelity, as described below) and/or more or less dyssynergy (lateness in onset of synergy). 
     Therefore, by identifying the presence of the underlying substrate of dyssynchrony as a disease, it is possible to ensure that CRT is only applied to patients that are most likely to respond to such treatment, and avoid providing CRT to patients where the cause of dyssynergy is not electrical dyssynchrony, which may only serve to promote such a defect (dyssynergy). 
     However, as outlined above, resynchronization cannot be measured in the cardiac function domain. Rather, it has been determined by the inventors that dyssynchrony relates to the lack of parallel contraction of myocardial tissue, which is not reflected in traditional measures of cardiac function as such. Equally, resynchronization does not serve to increase cardiac function, but rather to result in synchronization of activation of the myocardium and then to allow the myocardial sarcomeres to work near its optimum in synergy to reflect cardiac function without dyssynchrony. 
     With more dyssynchrony the myocardium changes the pattern of contraction from contraction in parallel to contraction more in series. Dyssynchrony also increases when the intrinsic pattern of electrical activation of the heart changes. This can be seen with pacing or with bundle branch block in specialized conductive tissue (bundle branches). 
     The time duration of the QRS complex, i.e. the QRS width in milliseconds, corresponds to how rapidly the activation of the ventricle occurs. The cause of any delay may be due to conduction properties in the myocardium, either due to conduction block (dyssynchrony) or with lower electrical propagation velocity (myocardial disease), or a combination of both. By determining how dyssynchrony relates to the electrical activation of the heart, and how it subsequently leads to a delay of when the cardiac muscle contraction leads to ejection of blood from the left ventricle, it is possible to determine whether such function can be restored with CRT, and thereby whether a patient is likely to respond to such therapy. 
     In the measurements described herein, bioimpedance measures the point in which muscle contraction (phase) leads to ejection (impedance). Complex impedance is more likely to reflect muscle contraction under given circumstances, and absolute impedance to a larger extent under given circumstances reflect volume changes within the cardiac chambers. While electrodes are submersed in blood, they provide the blood pool with electrode properties, and similarly, when electrodes are positioned within the right ventricle, they give the blood pool of the right ventricle such electrode characteristics. The right ventricular blood volumes can therefore serve as an extended electrode area towards electrodes positioned on the left side of the heart. In this way, when a current is injected between surface electrodes of the body, changes in the impedance field between the right and the left electrodes will reflect volume changes and muscle density between the electrodes. With onset of synergy, the volume of blood starts depleting with ejection of stroke volume and the muscle density increases with thickening of the myocardium. When the curves of impedance are plotted against time and the complex impedance increases with increasing muscle density while the absolute impedance decreases with volume depletion. Therefore, it may be said that the moment in time when the curves deviate from each other reflects onset of synergy, and is delayed with delayed onset of synergy. 
     As discussed above, dyssynchrony can be corrected by modifying the activation of the tissue from being in series to being more in parallel. This can be achieved by stimulating conductive tissue such as the heart muscle or the specialized conduction tissue selectively at certain sites. 
     When one heart chamber contracts, the isovolumic pressure increases up to P max , whilst when contraction occurs with a change in volume, the pressure remains constant whilst the contraction velocity increases depending on the pressure and developed force. With synergy, the sarcomeres contract and energy is rapidly transferred into kinetic energy ejecting blood volume into circulation. This onset of contraction allows for the volume of blood to remain in position within the ventricle in an isovolumic state, and as a result, pressure increases exponentially up to P max  with no wasted work. 
     However, when contraction occurs in series as found in dyssynergy, the volume of blood in the chamber is shifted as the myocardium is stretched whilst other parts are shortening, which generates shortening velocity rather than pressure increase. This occurs until the tension within the chamber wall is balanced, which allows for delayed isovolumic conditions, synergic contraction and energy transfer with an exponential pressure increase up to delayed ejection. 
     Exponential pressure rise within the ventricle is hence linked to the onset of synergy, OoS, and the time may be well defined by the peak pressure rise of the exponential pressure curve, peak dP/dt. It may be said that onset of myocardial synergy occurs close to peak dP/dt, and therefore the peak dP/dt can be used to detect the time of said onset of myocardial synergy. 
     By providing a consistent method of detection of a defined event, the bias from the defined event to the onset of myocardial synergy is constant. In this way, the relative timing differences between the detected event and the true event of onset of myocardial synergy are similar, regardless of the offset between the measured event and the true event. 
     For example, the time to peak dP/dt may be readily measured invasively with a pressure catheter in the left heart chamber, which in turn will occur at a fixed timing delay to the onset of myocardial synergy. Similarly, any event related to the time to peak dP/dt, such as aortic valve opening and closure, onset of ejection, flow in aorta, a negative peak of dP/dt, can be utilized as a surrogate, which when compared to a like measurement, will occur at a same bias towards the true event (of the onset of myocardial synergy). Therefore, such measurement may be used to provide data indicative of the time of onset of myocardial synergy. 
     With dyssynergy and/or dyssynchrony, a delay in pressure increase results. During this delay, potential energy stored in the sarcomeres is wasted in the sarcomeres that contract at low pressures. The load is shifted towards late contracting sarcomeres where potential energy is converted into first pressure, and then kinetic energy once the aortic valve opens. In such a case, dP/dt peaks later relative to the QRS complex duration and thereby every event relative to this is delayed, such as the aortic valve opening and closure. By measuring the time to peak dP/dt relative to the QRS complex duration, in effect calculating a measure of peak dP/dt/QRS, it is possible determine whether dyssynchrony is present or not, and thereby whether the patient is likely to be a responder or a non-responder. A relatively long interval, for example a time to peak dP/dt of greater than 100% of the QRS complex duration indicates that dyssynchrony is present and is the cause of dyssynergy, while with a short Time to peak dP/dt, for example less than 85% of the QRS complex duration, indicates that dyssynergy does not result from delayed electrical activation (long QRS duration). 
     Shortening of this time interval with resynchronization therapy will shorten this interval when parallelity is increased compared to baseline (the parallel/serial ratio increases). A short interval, less than 85% of the QRS, indicates that dyssynchrony is not present and resynchronization therapy may be of limited value unless Time to peak dP/dt is shortened to a larger extent with resynchronization therapy. 
     To the contrary, a short delay to onset of myocardial synergy indicates that no (or less) dyssynchrony is present, and rather that the increase in QRS duration does not translate into dyssynergy. A short QRS duration and a relatively delayed onset of myocardial synergy may be caused by dyssynergy related to myocardial disease and not to electrical dyssynchrony. Resynchronization will not change this, when dyssynergy is not caused by electrical dyssynchrony, and when pacing is needed, pacing the specialized conduction tissue will not change time to peak dP/dt (for example, the use of a known selective His bundle pacing) and should be the treatment of choice to avoid introduction of dyssynchrony and resulting dyssynergy. However, if one would want to apply pacing from multiple points, one should choose pacing sites that result in the shortest time to onset of synergy. 
     When various ways to measure the time to onset of synergy have been identified, and the time reference is known, any time measure that reflects onset of synergy with a constant bias can be used for comparison with the same measurement under different conditions, but with the same time reference, because the bias may be omitted as it will be constant between the compared measurements. Such a measurement, once the underlying theory as outlined herein is understood, can be used for the determination of presence of dyssynchrony, or to determine the effect of resynchronization. Examples of sensors that will provide these measurements are given in the following. 
     Therefore, by determining the point of onset of myocardial synergy using obtainable measurements relating thereto, the synchronicity of activation of the myocardium may be measured. The results of resynchronization therapy on myocardial synergy may then be measured by employing direct electrical and mechanical measures using different electrodes and sensors. 
     For example, various electrical measures can be monitored using electrodes in direct contact with the surface of the body, the heart or anywhere therebetween to inject current or measure biopotentials/characteristics, or complex impedances. Equally, various measures of mechanical events may be accomplished using a variety of sensors, like pressure sensors, accelerometer, phonocardiogram, ultrasound, magnetic sensors or indirect measures of cardiac motion. The connection to sensors and electrodes allow visualization of signals from the patient and measurements time intervals. 
     Signals from these electrodes or sensors can be processed and compared to determine the degree of synergy or dyssynergy. Based on these measures, a patient can be labelled as a non-responder or a responder (i.e. whether the patient would benefit from CRT), and the degree of response or non-response to CRT can be measured. 
     Specifically, a system, device, and a method for detecting onset of myocardial synergy as a means of measuring cardiac dyssynchrony are provided. An optimal pacing mode may then be selected, for example biventricular pacing (BIVP), His Bundle pacing (His) and/or any other pacing. Optimal electrode positions may also be chosen, (whether in the LV coronary vein, His, endocardial or any) for CRT or pacing therapy. 
     Resynchronization Potential 
     When the intrinsic time to onset of synergy is as long as the electrical delay (QRS duration) a resynchronization potential is said to be present. This is confirmed when the intrinsic time to onset of synergy is shortened with pacing from multiple sites; a resynchronization potential is said to manifest. The resynchronization potential defines the presence of dyssynchrony, as time to onset of synergy is at it shortest with intrinsic conduction (i.e. no electrical delay), no further shortening in time to onset of synergy can be achieved with pacing, and said no resynchronization potential is present. 
     Assessment of Cardiac Dyssynchrony 
     A representation of a normal heart may be seen in  FIG. 1 a   . Typically, a heart undergoing CRT may be implanted with atrial and biventricular electrodes  102  as in  FIG. 1 b   , which are connected to a programmable pacemaker  101 . 
     The locations of said electrodes  102  may be represented on a 3D surface geometry model of the heart, thereby showing a heart model display with colour maps representing measurement zones relative to the electrodes as seen in  FIG. 2 . A contour map may then be projected onto the surface of the heart model in order to visualize lines of constant magnitude of a measured value at each area of the heart, and the location of the electrodes within the color zones. Each color represents a measurement, and different degrees of colors represent different degrees of that measure as seen in the scale. For example, measurements pertaining to the intracardiac impedance measured between a pair of electrodes may be visualized on such a model in this way. 
     Firstly, the system may comprise a bioimpedance measurement system is provided to connect to pacing wires that are situated within any chambers and/or vessels of the heart and surface electrodes for current injection. Measurements of complex impedance, phase and amplitude will allow characterization of the time of onset of myocardial synergy. 
     An example system for measuring bioimpedance may be seen in  FIG. 3 . Therein is shown a measurement setup for impedance (dielectric) measurements on the heart, with implanted CRT electrodes as shown in  FIG. 1 b   . Current may be injected through surface skin electrodes  1  and  2 , and impedance may be measured between the electrodes, or between electrodes and patches. Multiple electrodes can be included in measurements of complex impedance. Impedance may then be processed in a processing unit  301 , and converted into digital signals that can further be transferred to any digital signal processing unit  302  for display of complex impedance waveforms. The calculated impedance waveforms may further be utilized for calculation of onset of synergy or be compared to known waveforms for similarity or deviation therefrom. Multiple frequencies of injected current may be adjusted to optimize the amplitude phase relationship and directional change for optimization of the impedance phase trajectory interaction. 
     The electrodes may be placed on the surface of the body, for example perpendicular to the axis of the heart (from center of mitral valve orifice to the LV apex) for current injection. Current injection may also be performed from electrodes located within the heart. 
     The system may further include one or more sensors to provide measures of onset of synergy as described above. For example, an accelerometer or a piezo-resistive sensor or a fibreoptic sensor may also be provided either on the body surface, or embodied within a catheter in the heart (such as an ablation catheter for detection of the His potential) to detect the heart sounds, aortic valve opening or closure. An ultrasound sensor may be used to provide similar measurements. A pressure transducer may be positioned on a catheter within the right or left ventricle, so as to detect peak pressure rise in the time domain, and/or to detect trajectory advancement. The transducer may also measure any delay compared to any trajectory in either the time derivative of the pressure curve trajectory or in the pressure curve trajectory itself. Additionally, and/or alternatively, surface electrodes for producing an ECG may also be provided. 
     The data provided by the sensors may then be processed and used to calculate a degree of offset between the onset of pacing and the onset of myocardial synergy as a measure of cardiac dyssynchrony. 
     For example, a circuit implemented in hardware and/or software is used to receive signals from one or more of the above described sensors and/or measurements, corresponding to the time when the cardiac activation and contraction leads to ejection. 
     The circuit may then additionally receive the ECG signal of the heart, which corresponds to time point when the heart starts depolarizing, as well as when it is fully depolarized. The ECG can be used as a time reference, and the resulting signals can be related to the onset/offset of intrinsic activation of the heart, and/or onset of pacing as seen in the surface ECG. Such information may be utilized as a reference to provide a time interval relative to onset of pacing and/or onset/offset of the ECG. 
     Such a utilization of measurements as a way of measuring the delay to onset of myocardial synergy may be seen in  FIG. 4 a   .  FIG. 4 a    shows measurements of any representation of onset of synergy, measured with impedance and/or acceleration or piezo-resistive sensor signals. 
     The measured impedance is represented with complex impedance (phase), corresponding to the contraction of the heart muscle, and the amplitude, corresponding to the blood volume within the heart. In this way, the amplitude of the impedance signal may be used as a surrogate for volume changes within the left heart chamber, as changes in the amplitude signal is paralleled by changes in ventricular blood volume. The phase of the impedance is used as a surrogate of muscle contraction, as changes are paralleled by changes in muscle volume and intracardiac blood volume. 
     The time from a reference point until the impedance curves meet and deviate ( 1 ) may be measured as a representation of onset of synergy. Such a point occurs at the point where the muscle shortens and blood is ejected from the heart. Acceleration from any acceleration sensor within (or connected to the surface of) the body of the patient can be used to determine onset of acceleration after a given reference point ( 4 ). Any part of the stable acceleration signal that reproduces itself from beat to beat and stimulation site may be used as a representation of onset of synergy. For example, the part of the acceleration signal used to determine the onset of synergy may correspond to any heart sound, aortic valve opening or closure. 
     Further, the ECG signal can be used as the reference point, from any of onset, offset or full duration of the QRS signal ( 3 ), and equally the acceleration signal can be used as a reference ( 2 ) from onset, offset or full duration ( 2 ). As described above, any such measurements can further be visualized on a surface of a heart geometry using color coded zones and a scale, relative to electrodes. 
     As would be appreciated, other measurements may be utilized to relate to the onset of synergy, such as measurements of the myocardial acceleration or when using a phonocardiogram or from seismocardiography. For example, echocardiography, sonography and cardiac ultrasound within or from outside the body to may be utilized to measure myocardial wall velocity, strain or any other measure that repeats in each cycle to measure onset of synergy. Specifically, at least one of onset of S-wave velocity, onset of S-wave strain rate, onset of global ejection, aortic valve opening, onset of aortic flow may be measured. 
       FIG. 4 b    shows tissue Doppler trajectories processed in an echocardiography device to show tissue velocities, thereby showing an echocardiographic representation of time to onset of synergy, in measures such as the time to onset of the S-wave, pSac and shortening. The echocardiograph may be a representation of septal and lateral tissue velocity, acceleration and displacement. The velocity trajectories have letters assigned to them according to which part of the cardiac cycle (Wiggers diagram) they represent isovolumic contraction (IVC), the systolic velocity (S) and isovolumic relaxation (IVR). Through derivation velocity is converted into acceleration and with integration velocity is converted to displacement. Onset of S-wave and peak systolic acceleration reflects onset of synergy and can be used for determining the time from a reference to onset of synergy as described above. Any event that follows can be used for the same purpose. When strain or strain rate is calculated measurements can be performed in a similar fashion. In another example, using the system described above, myocardial dyssynchrony may be measured in the form of the time from pacing spike and/or QRS onset/offset and/or a stable portion of the QRS complex to time to peak dP/dt, or a stable portion of the pressure curve utilizing a pressure catheter or a filtered signal from the pressure trace or pressure sensor, as seen in  FIG. 5   a.    
     As seen in  FIG. 5 a   , a heart may be provided with pacing electrodes  501  connected to pacing leads  502 . A left ventricular pressure sensor catheter  503  may be provided through the aorta  504  to a left ventricular pressure sensor  505 . In this way, a pressure catheter located within the left ventricle can be utilized to measure ventricular pressure and the derivative of the pressure waveform, as seen in  FIG. 5 a   . The time from a reference ( 5 ), such as the onset of the QRS curve, until the LV pressure derivative curve dP/dt peaks ( 1 ) is measured, thereby giving a representation of onset of synergy, and also effectively a measure of time to peak dP/dt/QRS. Various other measurements are also shown in  FIG. 5A , as well as how they may be displayed on a 3d heart model. 
       FIGS. 5 b  and 5 c    show an example of this determination of onset of synergy as measured from one animal study, which shows the onset of synergy when segment tension in the myocardium develops and stretching terminates.  FIG. 5 b    show a model of the heart with schematic representation of sonomicrometry crystals  510  and epicardial sonomicrometric crystals  511  which are used to measure myocardial segment length trajectories in various positions in the heart, for example, as seen in the four different myocardial segment length trajectories  520  plotted in  FIG. 5 c   . These are plotted together with the ECG trace and second order derivative of pressure for comparison purposes in  FIG. 5 c   . It can be seen that the measured time reflecting time to onset of synergy, OoS, (i.e. the point at which segments are no longer stretching) reflects the peak in the second order derivative of pressure in the left ventricle. This is when the rate of change of pressure change in the left ventricle is at the maximum (i.e. a representation of the rapid increase in rate of pressure change), which results from the synchronous contraction of the myocardium. 
     A pressure curve can be compared with any pressure curve with the same time reference ( 5 ) to measure the time offset ( 2 ) between the curves or the different timing of two comparable curves with same reference, i.e. by calculating time delay  4  minus time delay  3 . An example of such a comparison may be seen in  FIG. 5 d   , wherein a reduction in time to peak dP/dt is seen with a different electrode position. Again, any measurement can be visualized on a surface of a heart geometry using color coded zones and a scale, relative to electrodes. Such a measurement may prove to be more robust than the non-invasive measures detailed above. 
       FIG. 5 d    also illustrates why known measures of mechanical activation are not suitable for determining synchrony, and the potential efficacy of any subsequent CRT. As can be seen, with pacing at both position  1  and position  2 , the onset of mechanical activation occurs at a similar time point  51 . However, the onset of synergy, i.e. the point at which the pressure begins to increase exponentially and where there is a rapid increase in the rate of pressure derivative (as seen in  FIG. 5 d   ), is significantly delayed in position  1 , occurring only at time point  52 , whereas this occurs soon after time point  51  in position  2 . This rapid increase in the rate of pressure change reflects the point at which the pressure change begins to increase at a faster rate compared to that seen before, and occurs before the maximum value of pressure derivative. This point may be reflected in the final peak of the second order pressure derivative prior to maximum pressure, or aortic valve opening. 
     Such a delay may, for example, be due to dyssynchrony with isolated areas of the myocardium contracting, causing passive stretch of the myocardium, which is reflected in the comparatively low pressure increase. In this way, typical measures of mechanical activation, such as electromechanical delay (EMD) are measures of time of regional activation to onset shortening, only indicating the performance of the immediate area of myocardium. Further, in dyssynchronous hearts, EMD may vary within the heart, and this may also vary throughout the heart due to other issues, such as dyskinesia. 
     In contrast, onset of synergy is a global marker and reflects the phenomenon when active forces increase as shortening of segments is halted once more and more segments are electrically activated until exponential pressure rise onsets (onset of synergy) and any event that directly follows. 
     Typically in the cardiac cycle one would name the electromechanical delay and the isovolumic contraction as the pre-ejection phase, and keep the EMD and IVC separate. IVC is characterized that there is contraction without shortening (i.e. that the volume is constant). In dyssynchrony there is a great overlap between EMD and isovolumic contraction, and during the isovolumic contraction period there is shortening and hence typically physiological characteristics of this period is lost. The pre-ejection period is therefore very different in a normal compared to a dyssynchronous heart, as is EMD and IVC. 
     An illustration of physiological conditions experienced during heart contraction may be seen in  FIG. 6 . As is illustrated in this Figure, the onset of synergy is illustrated related to a representative ECG, showing the on-set and off-set of electrical depolarization of the heart represented in the QRS complex. 
     As described above, activation of the heart muscle requires electromechanical coupling. Electrical currents passes through the heart muscle within the specialized conduction system at high speed and within conductive muscle tissue at lower speed. With conduction block, in specialized tissue, propagation delays and becomes dyssynchronous with a pattern of conduction no longer determined by the specialized conductive tissue, but by the conductive properties in the heart tissue itself (muscle, connective tissue, fat and fibrous tissue). 
     Electrical activation is defined from the onset of an electrical stimulus that leads to depolarization of cardiac tissue (for example, as measured from the ECG curve or a pacing artefact) to the off-set of the QRS complex. An electromechanical delay is seen between the on-set of pacing and the beginning of local contraction (and also between local electrical and mechanical activation). However, as can be readily seen in  FIG. 6 , such a measure does not reflect the point at which the myocardium starts contracting as a global whole, thereby generating a rapid force. Rather, the early-activated muscle tissue starts contracting, however at no load, and hence shortens with minor force development and stretches relaxed tissue to maintain the volume of the heart chamber. With more electrically activated tissue that shortens more relaxed tissues are stretched, resulting in increased tension in stretched tissue and hence load. Once the electrical activation propagates throughout the heart, and more muscle shortens, there is no more tissue to stretch, shortening and dyssynergy stops and force develops with onset of synergy with exponential pressure increase until the aortic valve opens to allow muscle shortening again. 
     The onset of synergy relates to this point where the shortening of the muscle stops the myocardium contracts simultaneously, beginning to increase the force at a constant volume in the heart. This occurs at some point between the earliest, and latest regional EMD or later, and could be early or late in this phase, but rather reflects the degree of dyssynchrony. In itself, this point is difficult to measure, but this point is reflected in a number of measures, for example (but not limited to), peak derivative of pressure, aortic valve opening, peak negative derivative of pressure. Such measures may have a constant relationship in time to the onset of synergy, such that the measurement of the time of such events will directly reflect the onset of synergy, and therefore may be used as a measure of onset of synergy. Therefore, by using such measurements to measure a representation of onset of synergy in time, it is possible to compare different pacing methods and their efficacy in reducing the time to onset of synergy. If shortening occurs when comparing to a different way of pacing, less dyssynchrony is present, and when the time delay gets longer more dyssynchrony is present. 
     Based on the results of the sensor measurements, it may also be possible to determine the most effective pacing regime to be applied. For example, a second circuit implemented in hardware and/or software may comprise an algorithm to determine how many electrodes should be included and in what position they should be placed in the pacing strategy, and further determines which pacing strategy to follow. For example, it may be determined that the most effective pacing may be achieved by CRT, His bundle, biventricular, multipoint or multisite, or endocardial pacing, or any combination of the mentioned in the form of a suggested algorithm of pacing. For example, if the onset of myocardial synergy with intrinsic activation is short, then His pacing may be desirable. 
     A screen may be additionally provided for visualization of the heart model with any fiducials and representations of any sensor connected. Such a system may allow for an accurate measurement of cardiac dyssynchrony by the indirect measurement of the onset of myocardial synergy described above, such as by way of an accurate measurement of Time to peak dP/dt, time to ejection, time to aortic valve opening, aortic valve closure, dP/dtym, and/or the end of ejection. In this way, any shortening in the time to onset of myocardial synergy may be visualized with a corresponding shortening of any directly measured parameter as previously described, thereby indicating the presence of dyssynchrony. Equally, any pacing measures applied may be reversed when it is determined that dyssynchrony is not present. For example, when measuring the impedance phase and amplitude as an indirect measure of the onset of myocardial synergy in a case where dyssynchrony is not present, the impedance curves will not change with pacing at different locations because no change in contraction occurs with resynchronization. 
     As would be appreciated, certain limitations must be applied to the measurements to allow for meaningful data to be extracted from the measurements, and the measurements must be compared to a known time point. For example, it may be that measurements can only be performed during pacing if at least one of the following conditions apply:
         1) That ventricular stimulation occurs before onset of QRS   2) That timing is corrected relative to onset of QRS   3) That the interval from atrial pacing to ventricular sensing (AP-RVs) is known.       

     In order to provide effective pacing, any atrioventricular (AV) delay should preferably be calculated so that AP-VP is shorter than the shortest of AP-RVs and AP-QRS. Preferably AP-VP should be calculated so as to equal 0.7*(AP*RVs), or if AP-QRS onset is known, the AV-delay interval should preferably be 0.8*(AP-QRS). 
     Measurements may be performed during ventricular pacing with intrinsic conduction, but only when the onset of the QRS complex is not ahead of pacing, unless the QRS onset-VP interval is corrected for in the measurement. 
     Measurements may be performed during atrial fibrillation with ventricular pacing when no fusion with intrinsic conduction is present. However, during atrial fibrillation pacing should preferably occur at a rate shorter than the shortest RR interval seen during a reasonable period in time so that when pacing occurs QRS complexes are not fused with intrinsic conduction, but are fully paced. 
     Measurements performed utilizing one sensor should only be compared with a similar sensor, unless a known correction factor is used to calibrate for differences between sensors. The detection of the reference in time should be similar, and carefully chosen to be the best representation possible of the similar time reference as compared with. A pacing stimulus may be initially negative, then positive in some configurations and equally may be initially positive, then negative in others. While the onset of the signal represents an unbiased reference in time that disregards polarity of the signal, then the maximum peak might be different in time between the two references, and the maximum should be compared to the minimum when this is the best possible detection for the signals with different polarity when compared. When intrinsic activation is detected, as in an intrinsic QRS complex, the onset of the QRS complex may be difficult to exactly define. In such a case, the earliest off-set from the isoelectric line should be chosen. 
     When the activation is paced, there is a delay from the pacing stimulus to the onset of activation such that there is a time delay from the onset of the pacing spike to the QRS onset. When comparing a measurement with a time reference from the QRS onset or the QRS complex with a measurement with a time reference from a pacing spike, such a time delay should be taken in account, for example by adding the same time delay to the non-paced measurement. The delay will typically be calculated based on the type of applied pacing. For example, the delay may be in the range of 10 to 20 ms. 
     In summary, when time reference or sensor is different between measurements, the off-set between the different time references or the sensors should be accounted for in the measurements for comparison. 
     In this way, it may be necessary to make sure, before measuring, that no activation occurs through the conduction system that would need to be compensated for in the measurement. The measurement of onset of synergy only takes meaning when one is not pacing the ventricle only for comparison with the surface ECG offset for determination of resynchronization potential as described. 
     By using the above described methods to measure the onset of synergy, it is possible to identify patients for potential CRT therapy. Traditional measures such as electromechanical activation and delay, onset of force generation, or local electromechanical delay cannot be utilized as suggested herein. As discussed, it is difficult to know exactly when to measure an electromechanical delay, as mechanical activation occurs over a wide range in time across the heart. Such issues can occur with all known methods of measuring electromechanical delay. 
     For example, should an isolated measure of electromechanical delay be measured using aortic valve opening, there would be many associated issues with such. In such a case, if one were to pace LV early, and allow intrinsic activation from RV, and measure from LV pace; then if pacing LV late, aortic valve opening would be determined by RV activation and not by LV, but the time from LV to aortic valve opening would be short. This gives a false measure of the efficacy of pacing in improving the physiological function of the heart. 
     Rather, by knowing the timing of activation through the normal conduction system, it is possible to compensate for measurements performed before pacing occurs. For example, if intrinsic activation occurs before pacing, then one should measure from onset of intrinsic and add the interval from pacing to activation, to allow comparison with other measurements when pacing. 
     Filtered Traces for Determination of Onset of Synergy 
     It has been further found by the inventors that the signature of the cardiac phases lies in the frequency spectrum after the 2 nd  harmonic of the left ventricular pressure trace, where the harmonic is represented by 1/paced cyclerate (s). Early contractions at low pressures (i.e. the contractions that are associated with dyssynergy) do not produce high-frequency pressure components. However, the rapid increase of pressure that occurs with onset of synergy results in high-frequency components of the LVP trace. In this way, the crossing of the x-axis at zero for the 2 nd  and above harmonics captures only the synergy components, and can therefore be used as a reference measure to compare with QRS onset or onset of pacing. Similarly, dyssynergy (being characterised in early contractions) does not produce high-frequency components. 
     With the onset of contraction load against initial load (L0), contraction velocity rapidly increases (Vmax). With contraction, the load increases to Lmax, at the point where V goes to 0. Tension follows a sinus wave, and with synergy tension increases above the sinus envelope. 
     As can be seen in  FIG. 7 a   , filtering of the LVP demonstrates an underlying basal sinus wave in the first harmonic that reflects the heart rate. The following 2 nd  and above harmonics contain the information that shapes the sinus wave into a characteristic pressure waveform. High frequency (40-250 Hz) components initiates with onset of contraction and mid range frequencies (4-40 Hz) increase from onset of synergy until aortic valve opening. The inventors have discovered that, when the above mentioned filtered pressure range crosses 0 it is timely connected to peak dP/dt, and therefore may be representative of the onset of synergy. Synergy with increasing force and exponential pressure increase above the sinus waveform starts with onset of synergy and stops with aortic valve opening. 
     High-frequency components can be assessed as vibrations and translate from the left ventricle to the aorta and surrounding tissue through the solid fluids and tissue. Filtering high pressure components from aortic pressure (AoP) waveforms or atrial pressure waveforms, or detecting vibrations using accelerometers or any other sensor will therefore reflect synergy, and as long as the measurement occurs at a similar position on the measured trace/curve, for example, when the trace crosses zero, from the onset of vibrations or a certain characteristic of a waveform, or a template waveform. 
       FIG. 7 b    shows various other traces from various filtered waveforms, and how they may be used to give various measures of Td, each of which relates to the onset of myocardial synergy, OoS. By taking one of these measures, and measuring how it varies with pacing, then it is possible to identify the presence of dyssynchrony in a patient due to the constant delay between the specific measure of Td and the actual event of onset of myocardial synergy. 
     Further information regarding the onset of synergy may be deduced from filtering various measured signals, as seen in  FIGS. 8 a , 8 b    and  8   c.    
     Starting from  FIG. 8 a   , each phase discussed above is annotated on the traces. Initially, there is a delay between the onset of pacing seen on the ECG trace, and the beginning of increase in LV pressure. 
     Then, there is dyssynergy when the mechanical force begins to slowly increase, due to the passive stretch of the myocardium. Low-frequency components in left ventricular pressure (less than 2 nd  to 4 th  harmonics of the heart rate) are typical for dyssynergy. With dyssynergy there is onset of active force with sarcomeric cross-bridge formation at high rate in specific regions of the heart that result in shortening of the sarcomers (and myofibrills) that leads to stretch of not yet contracting segments and regions of the heart, with only a small increase in pressure resulting (with low-frequency components), as discussed extensively above. 
     The onset of synergy is reflected in a rapid increase of force at a relatively constant volume, which is reflected in the increased rate of increase of pressure. With activation of all segments and synergy, pressure increases rapidly (with high-frequency components) when approaching isometric (and isovolumic) conditions as load increases. This can, for example, be seen in the identifiable change in the rate of increase of the left ventricular pressure between the initial (relatively) slower increase in pressure due to dyssynergistic contraction and the exponential increase of the synergistic contraction. This may be seen in a step change in the rate of increase of the left ventricular pressure, and/or may be identified by further post-processing of the data. For example, this change can be measured in the frequency range, as the frequencies contained in the pressure trace increase when there is a step change in the pressure change. This occurs beyond the low order harmonics of the frequency spectrum, and the OoS may become evident when low order harmonics are filtered with a low pass filter or band pass filter. Filtering at, for example, a band-pass 4-40 Hz removes the low, slow frequencies that are associated with dyssynergy and the onset of synergy may be seen as the onset of the pressure increase that leads to, or is directly prior to aortic valve opening or maximum pressure. Alternatively or additionally, this may be seen in the peak second order derivative of pressure rise in the left ventricle. 
     This change in rate of pressure increase is because of increasing and exponential cross-bridge formation while passive stretched segments tension increase, either because depolarization or because elasticity model reaches its near maximum. Rapid cross bridge formation with isometric or eccentric contraction leads to high-frequency components in the pressure curve frequency spectrum, reflecting onset of synergy. This phase of the cardiac cycle may be seen when filtering LVP with high pass filter above the 1 st  or 2 nd  harmonics. The filtered and characteristic waveform has a near linear increase, from onset of synergy to crossing 0, and continues with a linear increase up to aortic valve opening. The line of linear increase reflects the period with synergy, crossing zero at halfway in the phase, which corresponds to peak dP/dt as described above, and onset of synergy is reflected in where this line starts to rise above the floor of the filtered pressure curve or at its nadir. 
     Ejection then occurs with the opening of the aortic valve, thereby reducing the LV volume at a relatively constant pressure. Another example trace is seen in  FIG. 8 b   , which has been annotated to show each of the above phases in  FIG. 8 c   .  FIG. 8 c    also shows a high-frequency filter of the aortic pressure, which also shows peaks in the high-frequency domain at points that could be used as a measure of OoS (onset of synergy). 
     Electrode Positioning Using Cardiac Parallelity 
     By measuring the degree of cardiac parallelity (i.e. the degree of parallel activation of the myocardium), it is possible to characterize cardiac synchronicity as well as identify anatomical pacing zones that result in more parallel activation of the myocardium to reduce cardiac dyssynchrony (resynchronization). Such a measure may be utilized to guide and optimize CRT. 
     Firstly, in order to measure the degree of cardiac parallelity, a recruitment curve is generated, showing the area of the heart that is recruited following pacing from an electrode against time. From such a graph, the degree of parallelity may be determined. 
     With reference to the method  10  of  FIG. 9 , a 3D model of the heart may be generated using medical images such as an MRI scan or a CT scan to generate a 3D mesh of the left ventricle, right ventricle and of late enhanced areas in step  11 . Alternatively, the method may use a generic heart model, or a heart model mesh imported from a segmented CT/MRI scan, as in step  12 . The 3D model of either steps  11  or  12  is then aligned to x-ray images of the patient, with the patient&#39;s heart at the isocenter  1001 . One such method of aligning the 3D model with the heart of the patient may be seen in  FIG. 10 . At least two x-ray images  1001 ,  1002 , as seen in  FIG. 11 , are taken at a known angle relative to each other, and are aligned relative to the fluoroscopy panels and to the isocenter  1001  in order to produce a 3D heart geometry  1004 . Using the at least two x-ray images, the coronary sinus vein in 3D may be reconstructed as seen in  FIG. 12 . Using fluoroscopy panels and their known angles relative to each other with the patient&#39;s heart at the isocenter  1001 , the coronary sinus vein may be reconstructed and overlaid over the 3D heart model of either steps  11  or  12 . 
     As can be seen in  FIGS. 13 a  and 13 b   , the heart model  1004  (either a generic heart model or a specific heart model based on an MRI scan) may be converted into a geometric model consisting of multiple nodes (vertex)  1005  connected in a triangular network (vertices), representing a surface ( FIG. 13 a   ) or a volume ( FIG. 13 b   ). Electrodes  1006  may then be implanted into the heart, and during or after implantation additional nodes are marked on the geometry of the heart reflecting the positions of the implanted electrode. Between the nodes, intervals are input that reflect electrical intervals as measured by the electrodes in the patient when one of the electrodes are stimulated (paced). As will be understood by the skilled person, it is envisaged that the electrodes have already been implanted into the patient, and a heart model may then be updated to include nodes located at the points that the electrodes are located. A mathematical interpolation (e.g. inverse distance weighting) can be performed to assign values to the nodes between nodes with already measured values. In this way all nodes in the model will have values based on the measured values and the calculated ones to reflect electrical activation in the model. Calculation of electrical activation can be updated when new measurements are performed between electrodes, or modified with identification of areas of scar and/or fibrosis and/or other barriers to electrical propagation. The calculated values of all nodes is performed in such a way that electrical activation between all nodes in the model are at least partly explained. 
     The resulting geometry then contains multiple nodes with electrical time intervals measured between them and assigned to them. As the geodesic distance between all nodes may be calculated and calibrated, the geodesic propagation velocity of the electrical activation may then be calculated. The propagation velocity is then input to all existing nodes in the heart geometry (step  14 ). 
     In step  15 , the propagation from multiple nodes or electrodes  1006  may then be calculated, resulting in a visualization of time propagation of electrical activation throughout the heart as coloured isochrones  1007 , taking velocity at each vertex of the heart model mesh into account as can be seen in  FIG. 14 . 
     The geodesic distance between each node of the patient may be calculated. With reference to  FIG. 15 , an object  121  of a known size may be used on the fluoroscopy screen so as to calibrate the heart model for distance between vertices, which may then be represented and projected on the surface of the heart geometry as color zones and in a scale. In such a way, the heart geometry that is generated based on a generic heart model may be specifically tailored to each patient, with a known scale. 
     As may be seen in  FIG. 16 , by pacing at one node  1006  and sensing in the other nodes, it is possible to extrapolate measurements of recruited area of the heart and represent such measurements as color zones/isochrones. For example, as seen in FIG.  16 , the right ventricle may be paced. The time delay from the pacing and then the sensing (RVpLVs) at another electrode can be used to assign time measurements to the known vertices. By utilizing the known geodesic distances between the vertices, it is possible to extrapolate said measurements to the other vertices of the heart geometry and thereby produce isochrones of the additional recruited area at a given time point. Therefore, these isochrones are based on measurements acquired from the specific heart of a patient from the implanted electrodes and are projected onto the model or patient specific reconstruction of coronary sinus vein. This allows for a patient specific heart geometry for visualization of numbers and allows further calculations to be taken into account using already known values of vertices and any number of vertices in between. 
     A similar process may be performed using separation time, as seen in  FIG. 17 . In this case, the heart is not actively paced, rather isochrones are generated on the heart geometry based on the separation time (SepT), i.e. when the electrodes  1006  are activated due to the natural pacing of the heart. 
     Using a combination of one or more of the measurements described above, it is possible to build additional compound measures and present them on a geometric model of the heart of the patient. 
     For example, as seen in  FIG. 18 a   , a calculation based on SepT+RVpLVs may be calculated. Herein, such a measurement is termed “electrical position” and the calculation of this value provides different color representations of the heart model associated with certain regions of the heart (such as apical, anterior, lateral) for measurements obtained with the right ventricular electrode in the apex of the right ventricle. 
     By further adding geodesic distance, as in  FIG. 18 b   , the optimal electrical and anatomical position may be considered. By such a measure, the result with the highest number on the scale representing a potential optimal (OptiPoint) position of an electrode. 
     Such a position will represent the area most remote from present electrodes with the greatest effect. Such a placement of an electrode will achieve high parallelity when activated together with the right ventricular apical positioned electrode. Positions corresponding to the highest OptiPoint value are highlighted on a heart model, such as that of  FIG. 18 b   , as being an area for potential electrode placement. 
     As seen in  FIG. 19 , measurements of time intervals from pacing one electrode to sensing at another electrode, in combination with the geodesic distance between the electrodes allows for calculation of geodesic velocity. Such a geodesic velocity may provide input to an inverse weighted interpolation algorithm/calculation to provide velocity values to all vertices in the model. In this way, velocity values can be extrapolated to all remaining vertices with no nodes attached, which can then be indicative of characteristics of the heart tissue. For example, each vertex may be assigned a value for its specific velocity that has been calculated using an inverse distance weighted interpolation taking into account the geodesic distance between the target and source nodes, as well as the number of neighbouring vertices. These values can then be used to extrapolate velocity values to vertices with no nodes attached. 
     When the velocity at each vertex has been interpolated as outlined above, the propagation of electrical activation from the nodes may be represented on a heart model, as seen in  FIG. 20 . This allows for the propagation of electrical activation to be visualized based on the tissue characteristics as isochrones on a color scale on the model of the heart. Such a time propagation may show a change in area over a change in time, and can be visualized from single, or multiple nodes  1006 . 
     Further, echocardiographic data using segmentation may be transferred onto the heart model, and be used to modify and enhance the tissue characteristics of the heart model. For example, as shown in  FIG. 21 , using American Heart Association (AHA) left ventricular segmentation model or similar, echocardiographic parameters may be assigned to segments in the heart model and transferred to the vertices of the heart geometry. Such an assignment can be applied on to the existing vertices of the existing heart model and be used therefore to further classify all of the nodes of the geometry, as seen in the flow chart  2100 . 
     Similarly, scar tissue  2201  of the heart muscle, such as that which may be identified by a 3D MRI scan may be used to assign tissue characteristics of the heart geometry. This is further visualized in  FIG. 22 , wherein the area of scar is projected onto the heart geometry, and each vertex is assigned a value for velocity, enhancing the tissue characteristics. Such classifications may be utilized to modify a velocity model and assign new velocity values to the vertices that have been identified with additional tissue characteristics. 
     In step  16 , the additional recruited area (of activated sarcomeres) at each point in time from the calculated velocity models can be calculated from multiple electrodes and the recruitment curve for said electrode(s) can be drawn based on the time propagation in the heart model when considering the added area at each time step until the full area, or a limited area, of the model is covered in isochrones, and their propagation from time=0 to time=x+1, as can be seen in  FIGS. 23 and 24 . In other words, the recruitment curve represents the recruited area or volume in the heart model with a measure of the change of area or volume of recruitment on the y-axis, and a scale of time on the x-axis. The recruitment curves can be characterised by multiple features, for example, the duration, slope, peak, mathematical expression, template matching. 
     Given the recruitment curve for a given node, a parabola may be fitted to the recruitment curve as can be seen in  FIG. 23  and as described in step  17 . The acceleration, peak and time to peak values of the propagation velocity can thereby be extracted from each recruitment curve, as well as the time to full recruitment (i.e. the time until the full heart model is recruited). More parallelity can be seen with a shorter time to peak propagation velocity, and thereby more propagation acceleration, as well as a larger peak value and a shorter time to full recruitment. Optimal curve characteristics can be provided, such that the peak recruitments should occur preferentially at 50% of the total recruitment time. The electrodes that create more parallelity (i.e. the greatest amount of total area of activation when the activation fronts meet) are chosen. 
     As can be seen in  FIG. 24 , the propagation curves may change with a change in electrode location and with the presence of scar. A number of recruitment curves are shown, and how each one varies is displayed for comparison. Based on such a comparison, the electrodes that result in the most ideal response may be chosen for pacing. 
     If the sensed activation pattern indicates too slow propagation through the tissue, the geodesic velocity is below a threshold, or the inability to provide sufficient parallel activation in the presence of scar tissue, the implantation of a CRT device should not take place, as such symptoms are not representative of dyssynchrony that may benefit from resynchronization therapy. 
     With pacing from each of the electrodes, a vectorcardiogram (VCG) recording the magnitude and the direction of the electrical forces that are generated during pacing of the heart is created. For each position that is tested, pacing is performed at each electrode, as well as for the two electrodes in combination, and a VCG is created for each situation. As seen in the example of  FIG. 25 b   , a VCG RVp may be created for an electrode performing right ventricular pacing (RVp), and a VCG LVp may be created for an electrode performing left ventricular pacing (LVp). A synthetic VCG LVP+RVp may then be calculated from the sum of two of the created VCGs, and the real VCG is obtained when biventricular pacing is performed from the electrodes in combination, and collecting the resulting VCG BIVp. 
     The synthetic VCG LVP+RVp and the real VCG BIVp are then compared, as seen in  FIG. 25 a   , and the point in time of deviation of the curve trajectories from each other is noted and the interval from onset of pacing to the point in time is calculated as a time to fusion time interval. Whilst the examples shown in in  FIG. 25 b    are displayed in 2D, it will be appreciated by the skilled person that the comparison may occur in 3D in order to improve accuracy. 
     The time interval between the pacing stimulus and the point of deviation of the curve trajectories represents the time to fusion (i.e. the time until the electrical propagation in cardiac tissue from multiple sites meet). The longer period of time until the point of deviation indicates more parallel activation of the myocardium. Therefore, the time to the point of deviation between the synthetic and the real VCG should be as long as possible. The time to fusion may be calculated in isolation, or relative to QRS width to determine the degree of synchronicity (parallel activation). 
     A similar method may be performed with electrograms (EGMs) and electrocardiograms (ECGs) in one or multiple dimensions. If adding an electrode stimulus site does not shorten the time interval to deviation of the curve trajectories, or if the time to deviation increases; an additional benefit of adding the electrode is seen, such that the electrode can be added to the stimulation site and number of electrodes. 
     The method allows analyzing the additional effect of adding one electrode and compare this new state of pacing an additional electrode to the state of not pacing this electrode. If the new electrode does not decrease time to fusion, this indicates that the addition of this electrode allows capture and activation of tissue without promoting fusion at an earlier stage than without. Thus, more parallel activation occurs when time to fusion does not decrease with adding an electrode. 
     Whilst the recruitment curves described above suggest positions for the electrodes, the generated VCGs may be further used to validate them. In this regard, VCGs and recruitment curves are measures of electrical activation that should reflect each other. When these measures are concordant, it gives validity to the suggested electrode positions and validity to the model. To this point, once good positions are found for the location of the electrode based on the generated recruitment curves, this position is then validated based on VCG. As would be appreciated by the skilled person, these measures are not necessarily only used in combination, rather each of the recruitment curves or determining the point of deviation may both be used individually to determine suitable electrode positions. Both of these measures reflect parallelity, the degree of parallel activation of the myocardium, and therefore may be utilized alone to identify anatomical pacing zones that result in more parallel activation of the myocardium to reduce cardiac dyssynchrony (resynchronization). Such a measure may be utilized to guide and optimize CRT. 
     An inverse solution ECG may also be utilized in addition, or as an alternative to using implanted electrodes to measure the degree of electrical activation. By utilizing data obtained from surface electrodes applied to patients, it is possible to extrapolate a map of electrical activation onto the heart model using an inverse solution approach, given that the heart model has been positioned in an anatomically correct position as described above and the relative electrode position to the heart model is correct and known. 
     In such a case, activation of each node in the heart geometry is seen relative to the distance from the first activated area, and therefore calculation of velocity can be performed for the model. This velocity can then be used to calculate recruitment curves. When pacing from a single electrode, the activation can be calculated, similar to the calculation of activation from a different electrode. These measurements can form the basis of propagation velocity calculations and recruitment curves. 
     In such a case, body surface electrodes are used to determine parallelity (i.e. the degree of parallel activation of the myocardium) by collecting surface potentials. Such surface potentials may then be extrapolated onto the heart model that has been aligned so as to be collocated with the actual location of the patient&#39;s heart, as previously described. Thereby, an inverse solution ECG activation map of the heart may be produced, and the activation map may be manipulated as described above in order to determine propagation velocity, and thereby the presence of dyssynchrony. 
     In order to obtain such an inverse solution ECG, a system may be provided with surface electrodes to acquire multiple surface biopotentials (ECG). The system may be configured such as to provide an inverse solution, in order to calculate electrical propagation on a segmented model of the heart, which can include scar tissue including scar. By utilizing the geodesic distance (from the heart model which is aligned with the patient&#39;s heart) in combination with the electrical propagation together, the system may be configured to calculate propagation velocity in the heart model based on the inverse solution electrical wavefront activation of the heart in combination with the geodesic distance. Once geodesic velocity is assigned to each vertex in the heart model, time propagation and parallelity can be measured from any and multiple sites in the model. 
     Further, the surface potentials may be incorporated in the cardiac model as a characteristic utilized to calculate propagation velocity from single or multiple points on the heart model. This, as described above with respect to measurements directly from electrodes implanted into the heart, allows for the generation of multiple propagation velocity curves in order to calculate the differences multiple different points. Using such a comparison between the multiple propagation velocity curves, it is possible to choose the ones having better acceleration, peak velocity or propagation time as an indication of the preferred location for placement of electrodes. 
     Example Method 
     The systems and methods described herein may be used both before and during treatment of patients with presumably dyssynchronous heart failure, with a resynchronization pacemaker (CRT) in order 1) identify the presence of an underlying substrate that identifies patients that are likely to respond positively (manifest resynchronization potential present) to and 2) identify optimal locations for placement of pacing leads/electrodes. 
     Patients are currently referred for implantation of a CRT pacemaker based on international guidelines that describe indication criteria. These criteria are based on inclusion criteria in larger clinical trials and, amongst other things, consists of symptoms of heart failure, reduced ejection fraction (heart function) and a widened QRS complex (preferably left bundle branch block) beyond 120-150 ms. However, currently only 50-70% of patients with one or more indications for treatment with a CRT actually respond to treatment. Reasons for these non-responders are multiple, but lead position, the underlying substrate (dyssynchrony), scar and fibrosis and electrode positions are the most prominent reasons. By improving the detection of the underlying substrate that indicates dyssynchronous heart failure, it is possible improve the selection of responders (in a diagnostic capacity) for optimization of treatment (allowing therapy to be personalized to the patient). 
     Firstly, it is desirable to detect and define the underlying substrate (resynchronization potential) that defines whether a patient will respond to CRT, and whether the substrate is present or not in patients with standard inclusion criteria. When the substrate is present, one should proceed implantation of a CRT pacemaker, but when the substrate is not present one should follow other guidelines that apply. 
     When underlying substrate is present, or even if the underlying substrate has not yet been identified, an optimal position for the leads may be found, based on measures of parallelity, which takes scar and fibrosis into account. The measurement of parallelity is performed with guidewires or leads with electrodes inside the heart (for example, in veins or chambers of the heart). Optimal positions are for the placement of the electrodes is then suggested. 
     When the leads are in optimal position, according to the determined optimal position taking into account the measured parallelity from each node, it is then possible to confirm the response (by either direct or indirect measurements of onset of myocardial synergy), or alternatively reject the position. 
     If the desired response is confirmed, then a CRT pacemaker should be implanted. If the response is not confirmed, the mapping and measurements of parallelity should be refined before final confirmation. If response is not able to be confirmed, the implantation should be abandoned and known guidelines should be followed for alternative implantations. 
     It is envisaged that all of the methods and systems described herein may be used together, or equally may be used separately. In this regard, it is possible to detect the presence dyssynchrony and resynchronization potential, and confirm resynchronization without selecting the optimal lead position, and equally, it is possible to select optimal lead position without confirming underlying substrate and resynchronization. 
     Therefore, a system may be provided that includes connection to electrodes that allow visualization of signals from the patient and measurements time intervals. Alternatively or additionally, a system may also be provided that includes sensors and electrodes and allows visualization of a heart model and calculations based on the heart model&#39;s geometry. Both of the above systems can be combined in the operating room. 
     An implementation of the above systems and methods will be further described herein by way of an example implementation during surgery. 
     A patient is firstly taken in to the operating room and sensors and electrodes are fixed on the patient&#39;s body surface. 
     In order to determine the delay to onset of myocardial synergy (OoS), one or more additional sensors may be utilized. For example, one or more of a pressure sensor, piezo-resistive sensor, fibreoptic sensors, an accelerometer, an ultrasound and a microphone may be utilized. Measurements from the additional sensors may be taken in real-time and be processed on location. If the delay to onset of myocardial synergy is short relative to the QRS complex or short in absolute values (for example either shorter than 120 ms or less than 80% of the QRS duration), then the implantation of a CRT device should not occur. 
     When the delay to onset of myocardial synergy is measured to be long compared to the QRS complex or long in absolute values (for example either longer than 120 ms or longer than 80% of the QRS duration), then implantation of the CRT device should occur. 
     Body surface electrodes are used to determine parallelity (the degree of parallel activation of the myocardium) by collecting surface potentials for an inverse solution ECG activation map of the heart as described above to determine propagation velocity, and thereby the presence of dyssynchrony. Additionally or alternatively, electrodes implanted within the patient&#39;s heart may also be used to produce electrical activation maps, and thereby determine the presence of dyssynchrony. If the sensed activation pattern indicates too slow propagation through the tissue, or the inability to provide sufficient parallel activation in the presence of scar tissue, the implantation of a CRT device should not take place. 
     The patient is then prepared for surgery and sterile draped. Surgery is started as usual and leads are placed in the patient&#39;s heart through a skin incision below the left clavicle and puncture of the subclavian vein. The leads are then moved into position in the right atrium and right ventricle. 
     Dyssynchrony may then be introduced by pacing the right ventricle, and can be confirmed when measuring the delay of myocardial synergy as discussed above. A sensor may be placed in the left heart chamber, or in the right heart chamber, in order to determine the delay of onset of myocardial synergy. In this way, the same calculation may be performed as previously utilized in order to calculate the delay to onset of myocardial synergy. 
     Once the leads are in position, the coronary sinus is cannulated and an angiography in two planes are performed to visualize the coronary veins. 
     Once the coronary vein is visualized, cannulation can be performed with either a thin guide wire with an electrode at the tip, or any catheter with one or multiple electrodes for mapping purposes. Measurements of time intervals are then used to characterize one or more of the intrinsic activation, tissue properties and vein properties. The coronary anatomy is then reconstructed in software, and measurements are assigned to positions in the heart model relative to the reconstructed coronary sinus vein. 
     This data may then be used, in a method performed outside of the body, to calculate parallelity in order to highlight the electrode positions with the highest value of parallelity. Based on these measurements, the surgeon is advised to position the left ventricular (LV) lead with electrodes in a desired position/vein. Similar advice can be given also to reposition the right ventricular (RV) lead. Based on the acquired measurements and the processing thereof, advice can also be provided to include other and/or further electrodes to achieve a higher degree of parallelity. Other electrodes refer to other electrode positions than those available (endocardial, surgical access), and further electrodes refers to the use of multiple electrodes (more than two). 
     As a result of the above, the coronary vein branches are now seen in two planes and a suitable vein is selected for placement of a left ventricular lead. 
     When the LV electrodes are in position, the sensors may be used to determine the delay to onset of myocardial synergy, when pacing both the RV and the LV. Different electrodes may be analyzed by repositioning the LV lead at different positions. 
     Measurements of the delay to myocardial synergy may occur using one or more of a pressure sensor, piezo-resistive sensor, fibreoptic sensor, an accelerometer, an ultrasound or by measured bioimpedance (when connected to the RV and LV leads). If the delay to myocardial synergy is not shortened, at least to less than for example 100% of the intrinsic measured value or when the bioimpedance measurements indicate by paradoxical movements that resynchronization is not taking place, the proposed lead positions should be abandoned. The intrinsic value measured from the QRS onset does not include the time from the onset of pacing to ventricular capture, and hence is by definition shorter than that measured from the stimulus. 110% would therefore approximate the time interval measured with intrinsic activation. In this way, the intrinsic delay to onset of synergy measured from the QRS complex can be calibrated by adding, for example, 15 ms to the value reflecting the time from pacing spike onset to electrical tissue capture that occur when artificially pacing. 
     When pacing the RV, the LV or both, a VCG can be reconstructed and the time to fusion can be calculated. The time to fusion may further be used in order to confirm the already measured parallelity. Surface electrodes can be used for inverse modelling to measure time to fusion. If the measured time to fusion, and the measured parallelity does not concur, the causes of such a discrepancy should be further reviewed. 
     It is possible that LV leads with multiple electrodes can be used on the discretion of the physician. The use of multiple electrodes can be used in measuring parallelity, and when found to increase parallelity, such an increase in parallelity can be confirmed using time to fusion, and by measuring the delay to onset of myocardial synergy. 
     Once the lead is in desired position, wherein the delay to onset of myocardial synergy is less than (for example) 110% of initial intrinsic value and less than (for example) 100% of the biventricularly paced QRS complex and, the CRT may be implanted and the device generator connected and implanted in a subcutaneous pocket. If the lead is found not to capture the myocardium or if the location is determined suboptimal based on scientific empiric data or measured intervals (QLV), the lead is repositioned and retested before the device generator is connected. The skin incision is then sutured and closed. 
     The systems described above may be embodied in an overall system that contains a signal amplifier or analogue digital converter (ECG, electrograms and sensor signals), a digital converter (sensor signals), processor (computer), software, connector to x-ray (either by direct communication with a dicom server or PACS server, or indirect with a framegrabber and an anglesensor). It is possible to use the system with different sensors at user discretion. Further, the system may also be used to solve other problems as well. For example, the systems may be utilized for identification of His region and placement of a pacing lead in the His bundle, with additional measurement of the delay to onset of myocardial synergy.