Closed loop impedance-based cardiac resynchronization therapy systems, devices, and methods

Abstract

This document discusses, among other things, systems, devices, and methods measure an impedance and, in response, adjust an atrioventricular (AV) delay or other cardiac resynchronization therapy (CRT) parameter that synchronizes left and right ventricular contractions. A first example uses parameterizes a first ventricular volume against a second ventricular volume during a cardiac cycle, using a loop area to create a synchronization fraction (SF). The CRT parameter is adjusted in closed-loop fashion to increase the SF. A second example measures a septal-freewall phase difference (PD), and adjusts a CRT parameter to decrease the PD. A third example measures a peak-to-peak volume or maximum rate of change in ventricular volume, and adjusts a CRT parameter to increase the peak-to-peak volume or maximum rate of change in the ventricular volume.

1 . A machine-assisted method comprising: 
 measuring a first impedance signal, the first impedance signal including information indicative of a volume of a first ventricle of a heart as the first ventricle expands and contracts during a cardiac cycle;    using the first impedance signal to measure a peak-to-peak volume difference indicated by a difference between a first impedance value, corresponding to a maximum volume of the first ventricle during a diastole portion of the cardiac cycle, and a second impedance value, corresponding to a minimum volume of the first ventricle during systole portion of the same cardiac cycle; and    automatically adjusting, using the volume difference, at least one cardiac resynchronization therapy parameter that synchronizes left and right ventricular heart contractions, the automatically adjusting tending to increase the volume difference over at least one subsequent cardiac cycle.    
   
   
       2 . The method of  claim 1 , in which the first ventricle is a left ventricle, and in which measuring the first impedance includes: 
 injecting a current through at least a portion of the left ventricle; and    measuring a responsive voltage between a first electrode located at an apex of a right ventricle and a second electrode located in at least one of a coronary sinus and great cardiac vein in association with the left ventricle.    
   
   
       3 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an atrioventricular (AV) delay.  
   
   
       4 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting a left ventricular offset.  
   
   
       5 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an intraventricular delay.  
   
   
       6 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an interventricular delay.  
   
   
       7 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes lengthening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than a previous cardiac cycle's peak-to-peak ventricular volume difference and the current cardiac cycle's atrioventricular delay is less than the previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and the current cardiac cycle's atrioventricular delay is greater than or equal to the previous cardiac cycle's atrioventricular delay.  
   
   
       8 . The method of  claim 7 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes shortening the atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than the previous cardiac cycle's peak-to-peak ventricular volume difference and the current cardiac cycle's atrioventricular delay is greater than or equal to the previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that the current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       9 . The method of  claim 1 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes shortening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is greater than or equal to the previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and a current atrioventricular delay is less than a previous atrioventricular delay.  
   
   
       10 . The method of  claim 1 , including: 
 detecting a cardiac depolarization; and    constraining the measurement of peak-to-peak volume difference to a time window measured from a cardiac depolarization.    
   
   
       11 . The method of  claim 1 , including communicating data indicative of the measurement of the peak-to-peak volume difference from an implantable cardiac function management device.  
   
   
       12 . The method of  claim 11 , including displaying data indicative of the measurement of the peak-to-peak volume difference using an external device.  
   
   
       13 . A system comprising: 
 an implantable cardiac function management device comprising: 
 an impedance measurement circuit, including terminals configured to be coupled to electrodes for association with a first ventricle of a heart to measure an impedance signal to determine a volume of the first ventricle during a cardiac cycle of the heart; and  
 a processor circuit, coupled to the impedance measurement circuit to receive information about the impedance signal, the processor configured to execute or interpret instructions to measure a peak-to-peak volume difference indicated by a difference between a first impedance value corresponding to a maximum volume of the first ventricle during a diastole portion of the cardiac cycle and a second impedance value corresponding to a minimum volume of the first ventricle during a systole portion of the same cardiac cycle, the processor further configured to execute or interpret instructions to automatically adjust in a closed-loop manner, using the measured peak-to-peak volume difference, a cardiac resynchronization therapy parameter that synchronizes left and right ventricular heart contractions in a manner that tends to increase the peak-to-peak volume difference during a subsequent cardiac cycle.  
   
   
   
       14 . The system of  claim 13 , in which the first ventricle is a left ventricle, and in which the system includes: 
 first and second electrodes configured to inject a current through at least a portion of the left ventricle; and    a third electrode positioned on an intracardiac lead to be located at or near an apex of a right ventricle and a fourth electrode sized and shaped on a lead to be introduced into at least one of a coronary sinus and a great cardiac vein in association with the left ventricle, the third and fourth electrodes configured for measuring a voltage responsive to the injected current.    
   
   
       15 . The system of  claim 14 , in which the first and second electrodes are the same electrodes as the third and fourth electrodes, respectively.  
   
   
       16 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an atrioventricular (AV) delay.  
   
   
       17 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting a left ventricular offset.  
   
   
       18 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an intraventricular delay.  
   
   
       19 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an interventricular delay.  
   
   
       20 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by lengthening an atrioventricular delay if either: (1) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay; or (2) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay.  
   
   
       21 . The system of  claim 20 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by shortening an atrioventricular delay if either: (1) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       22 . The system of  claim 13 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by shortening an atrioventricular delay if either: (1) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is less than a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the impedance signal indicates that a current cardiac cycle's peak-to-peak ventricular volume difference is greater than or equal to a previous cardiac cycle's peak-to-peak ventricular volume difference and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       23 . The system of  claim 13 , in which the implantable cardiac function management device includes a depolarization detector to detect a cardiac depolarization, and in which the processor is configured to execute or interpret instructions to constrain the measurement of the peak-to-peak volume difference to occur during a time window measured from a cardiac depolarization.  
   
   
       24 . The system of  claim 13 , in which the implantable cardiac function management device includes a telemetry circuit configured for communicating data indicative of the peak-to-peak volume difference from the implantable cardiac function management device.  
   
   
       25 . The system of  claim 24 , further comprising an external device that includes a display configured to display an indication of information obtained from the peak-to-peak volume difference.  
   
   
       26 . A machine-assisted method comprising: 
 measuring a first impedance signal, the first impedance signal indicative of a volume of a first ventricle of a heart as the first ventricle expands and contracts during a cardiac cycle;    using the first impedance signal to measure a maximum rate of change of volume of the first ventricle during a systole portion of a cardiac cycle; and    automatically adjusting, using the maximum rate of change of volume, at least one cardiac resynchronization therapy parameter that synchronizes left and right ventricular heart contractions, the automatically adjusting tending to increase the maximum rate of change in the volume over at least one subsequent cardiac cycle.    
   
   
       27 . The method of  claim 26 , in which the first ventricle is a left ventricle, and in which measuring the first impedance signal includes: 
 injecting a current through at least a portion of the left ventricle; and    measuring a responsive voltage between a first electrode located at an apex of a right ventricle and a second electrode introduced into at least one of a coronary sinus and great cardiac vein in association with the left ventricle.    
   
   
       28 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an atrioventricular (AV) delay.  
   
   
       29 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting a left ventricular offset.  
   
   
       30 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an intraventricular delay.  
   
   
       31 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes adjusting an interventricular delay.  
   
   
       32 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes lengthening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay.  
   
   
       33 . The method of  claim 32 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes shortening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       34 . The method of  claim 26 , in which the automatically adjusting at least one cardiac resynchronization therapy parameter includes shortening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       35 . The method of  claim 26 , in which the using the first impedance signal to measure a maximum rate of change in the volume includes: 
 detecting a cardiac depolarization; and    constraining the measurement of maximum rate of change in the volume to occur during a time window measured from a cardiac depolarization.    
   
   
       36 . The method of  claim 26 , further comprising communicating data indicative of the maximum rate of change in the volume from an implantable cardiac function management device.  
   
   
       37 . The method of  claim 36 , further comprising displaying an indication representative of information about the maximum rate of change in the volume using an external device.  
   
   
       38 . A system comprising: 
 an implantable cardiac function management device comprising: 
 an impedance measurement circuit, including terminals configured to be coupled to electrodes for association with a first ventricle of a heart to measure an impedance signal to determine a volume of the first ventricle during a cardiac cycle of the heart; and  
 a processor circuit, coupled to the impedance measurement circuit to receive information about the impedance signal, the processor configured to execute or interpret instructions to measure a maximum rate of change in volume of the first ventricle during a systole portion of the cardiac cycle, the processor further configured to execute or interpret instructions to automatically adjust in a closed-loop manner, using the measured maximum rate of change in the volume, a cardiac resynchronization therapy parameter that synchronizes left and right ventricular heart contractions in a manner that tends to increase the maximum rate of change in the volume during a subsequent cardiac cycle.  
   
   
   
       39 . The system of  claim 38 , in which the first ventricle is a left ventricle, and in which the system includes: 
 first and second electrodes configured to inject a current through at least a portion of the left ventricle; and    a third electrode positioned on an intracardiac lead to be located at an apex of a right ventricle and a fourth electrode sized and shaped on a lead to be introduced into at least one of a coronary sinus and a great cardiac vein in association with the left ventricle, the third and fourth electrodes configured for measuring a voltage responsive to the injected current.    
   
   
       40 . The system of  claim 39 , in which the first and second electrodes are the same electrodes as the third and fourth electrodes, respectively.  
   
   
       41 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an atrioventricular (AV) delay.  
   
   
       42 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting a left ventricular offset.  
   
   
       43 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an intraventricular delay.  
   
   
       44 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by adjusting an interventricular delay.  
   
   
       45 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by lengthening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay.  
   
   
       46 . The system of  claim 45 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by shortening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       47 . The system of  claim 39 , in which the processor is configured to execute or interpret instructions to automatically adjust the at least one cardiac resynchronization therapy parameter by shortening an atrioventricular delay if either: (1) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is less than a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is greater than or equal to a previous cardiac cycle's atrioventricular delay; or (2) the first impedance signal indicates that a current cardiac cycle's maximum rate of change in the volume is greater than or equal to a previous cardiac cycle's maximum rate of change in the volume and a current cardiac cycle's atrioventricular delay is less than a previous cardiac cycle's atrioventricular delay.  
   
   
       48 . The system of  claim 39 , in which the implantable cardiac function management device includes a depolarization detector to detect a cardiac depolarization, and in which the processor is configured to execute or interpret instructions to constrain the measurement of the maximum rate of change in the volume to occur during a time window measured from a cardiac depolarization.  
   
   
       49 . The system of  claim 39 , in which the implantable cardiac function management device includes a telemetry circuit configured for communicating data indicative of the maximum rate of change in the volume from the implantable cardiac function management device.  
   
   
       50 . The system of  claim 49 , further comprising an external device including a monitor configured to display an indication of the maximum rate of change in the volume.