Neural Networks: Key to improve the Cardiovascular system for telemedicine.

Shivani Joshi
Sr. Lecturer, GNIM

Abstract— Health care system is currently a worldwide trend to bring healthcare services as close as
possible to the patient, either through home healthcare systems, or telemedicine. So it requires general
equipment that can capture patient data electronically for automated review or analysis by a medical
practitioner. This paper illustrated prototype systems that were developed for use in telemedicine settings
in rural areas of India. These devices can be used to electronically capture data on patients from several
sensors in a quick and easy manner. This paper focused on cardiovascular information. One of the main
advantages of the proposed systems is that the data are captured simultaneously from multiple sensors.
The data can be stored and sent electronically for review and analysis, and knowledge-based systems or
neural network type models can be used in the future for semi-autonomous screening of the recordings,
before a patient is referred to a specialist.

Keywords: Electrocardiogram (ECG ), pre-cordial cardiograph (PCG), Impedance

Cardiograph(ICG)
1. INTRODUCTION
Generally the patient moves to nearest healthcare services closer to the patient. The aim
is to decrease the financial burden and morbidity of disease, by improving the access to
healthcare, with a resultant increase of the quality of healthcare. One such historical
example is reflected when general practitioners started performing electrocardiogram
(ECG) tests which were previously performed exclusively by specialists. Now a days one
can purchase an ECG integrated into a wristwatch over the counter. Technology moves
closer and closer to the patient. The skill is to listen the heart sounds and to identify the
abnormalities which is hard to acquire by most medical practitioners and are not
confident to pick up abnormal heart sounds . This places the patient and the medical
doctor at risk. According to the World Health Organization estimates of 2003,
cardiovascular disease accounts for approximately 16.7 million deaths globally, which
amounts to over 29% of all deaths globally. The aim is to present innovative devices that
can assist the doctor with his diagnosing skills for cardiovascular disease.

Normal heart sounds are basic sounds generated when heart valves close. Abnormal heart
sounds are other sounds, like murmurs, generated as the blood flows though an abnormal
small valve, or blood flowing though a valve not closing well. Depending on the position
of an abnormal heart sound on the chest of a patient, the pitch, the changes in amplitude,
and the duration of heart sounds, one can determine which valves have been affected.
Good auscultation and interpretation of heart sounds, accounts the functional and
physical influencing factors on heart sounds, which limit unnecessary specialist doctor
visits and many special investigations. Most abnormal heart sounds are physiologically
normal, and do not need any special investigations or treatment. Currently, electronic
stethoscopes only record in a single position at a time, and cannot record all the heart
sounds at the different positions on the chest wall over the heart simultaneously. These
sounds are also typically not synchronized with an ECG recording. Also, no commercial
device exists that can assist the doctor in identifying abnormal heart sounds quickly and
accurately.
Such a device, if exists, can be used in extensive research studies on diagnosing heart
conditions and monitoring the effect of treatment. If it is easy to use and with the needed
connectivity, such a device can also be used in home healthcare to monitor heart
conditions, as well as in rural clinics where a lesser skilled person has to ‘examine’ a
patient on behalf of the doctor, on the other side of telemedicine connection.

In my paper, I propose two such prototype devices that were developed in a collaborative
effort between academia and industry. The first device is termed an ‘auscultation jacket’
and the second device is called a pre-cordial cardiograph (PCG). The details of both
devices are presented and the uses of the devices are discussed within the context of
telemedicine.

2. AUSCULTATION JACKET
(i) Requirements
A single device that can record all the data from different sensors and devices in a
synchronized fashion must incorporate several technologies. At least four electronic
Stethoscopes that can record heart sounds, at the four most important listening points
over the heart, has to record heart sounds simultaneously. In a synchronized fashion, an
ECG has to record the electrical potential differences of the chest on all 12 ECG leads.
An ICG (Impedance Cardiograph) needs to record the stroke volume and cardiac output.
All the data can theoretically fed to a neural network or knowledge base that will become
output present suggested interpretations to a doctor, as has been done in the literature, but
mainly with single stethoscope systems. Blood pressure, chest circumference, position of
the patient and the hematocrit of the blood will also have to be electronically captured for
such a semi-autonomous diagnosis to be completely feasible.

(ii) Layout and design

The heart sounds of the different heart valves and valve murmurs, if present, can
maximally be heard over specific positions on the precordium of a patient (Fig. 1). The
six precordial leads of a 12 lead ECG overlaps in part the auscultation points for the
Tricuspid and mitral valves (Fig. 2). The four limb of the ECG typically include positions
close to or on the limbs of a patient. The ICG lead positions reach up into the neck and
share the same position as the V6 ECG lead (Fig. 2).

Fig. 1. Auscultation and actual positions of the heart valves

Fig 2: Precordial ECG lead positions and ICG electrode positions

(iii) Prototype
A prototype device was designed in such a manner that all sensors would be positioned at
constant positions on the chest and neck of a patient. A jacket made out of neoprene with
adjustable straps was developed to accommodate and fit adult men with an
anthropometric size in the 40th percentile of the Indian population. This prototype shared
sensor positions like adding ECG lead point to the diaphragms (Fig. 3) of the electronic
stethoscopes and ECG leads sharing ICG leads at the same position. All the hardware
were customized and specifically designed for the jacket and fabricated in-house.

Fig. 3. ECG or ICG electrode lead designed into the diaphragm of an electronic stethoscope.
The jacket has 21 electronic stethoscopes built into the anterior (Fig. 4), lateral (Fig. 4)
and posterior parts (Fig. 5). The posterior stethoscopes were used to also record the lung
sounds and hosted the two limb electrodes of the left and right arm. Normal and abnormal
heart sounds fall between 20 Hz and 1 kHz and hence the stethoscope recordings were
done at 2 kHz. A “neck collar” incorporates ICG electrodes as well as two electronic
stethoscopes to record Carotid bruit sounds. The complete system is shown in Fig. 6.
All the sensors communicate via USB with a host computer. USB hub can be used to
enable many sensors to communicate with the computer. Adobe Audition was used to
record all the sensor data in trial runs, however in the long run customized software will
be used to operate the jacket.

Fig. 4. Anterior and lateral parts of the jacket that demonstrates all the ECG/ICG leads and
multiple stethoscopes.
 Fig. 5. Posterior chest wall part of the jacket to record lung sounds.

Fig. 6. Jacket fitted over a mannequin, demonstrating an anterior view that is positioned over the
precordium and neck, a lateral view demonstrating the lateral stethoscope and electrode positions as
well as a posterior view demonstrating the posterior lung sound recording part.

(iv) Sample recordings

An example recording done with the jacket on a patient with mitral regurgitation is
shown in Fig. 7. Based on a database of recordings on patients and healthy volunteers,
information from the recorded signals was used as inputs to an Artificial Neural
Network-based classification scheme. The network was a feed-forward network with two
hidden layers trained with the back-propagation algorithm. The system is able to classify
between normal and certain abnormal heart sounds with a sensitivity of 86% and
specificity of 94%.
Fig 7: Stethoscope recording of an abnormal heart cycle recorded with auscultation jacket

3. PRECORDIAL CARDIOGRAPH(PCG)
(i) Requirements
The auscultation jacket was developed to investigate the feasibility of an autonomous
diagnosis based on multiple, simultaneous recordings. A more commercially viable
device was then proposed to address the shortcomings of the jacket, and with added extra
functionality. This device is termed the Precordial Cardiograph (PCG) and the intention
was only to examine the heart, and hence the stethoscope. positions intended for lung
sound recordings were removed. The PCG was designed to be easier and faster to use, to
be handheld (pressed against the chest without the need for strapping) and to have built-in
sensors to monitor the patient position and chest circumference. The focus of this new
device was not only to detect abnormal heart sounds and abnormal ECG/ICG parameters,
but also to detect abnormal and changes in the state of Congestive Cardiac Failure
(CCF) in a patient. Furthermore, there was a need for the PCG to be robust, to have
telemedical capacity and to use the minimum number of consumables. The typical user of
the PCG could be a general practitioner that will do a quick spot check on a patient
during a routine consultation, or a nurse in a rural village, positioning the device on the
chest of a patient during a telemedicine visit. Ease of use with perfect positioning was an
essential design consideration.

(ii) Layout and design

A different approach was used in the design of this device. A plastic skeleton
embodiment that largely covered the heart over the precordium was designed to host all
the electronic parts for the 12 lead ECG, four stethoscopes and an ICG. A single USB
cable connects the device to a computer where the user can see the results and play back
the heart sounds. The ease of implementing a screening neural network analysis on a
personal computer is also much easier than implementing a neural network into the
electronics of the device. An accelerometer was also built into the device that can be used
to extract breathing rate information as well as sternal heave information (a sternal
heave is present in heart failure when the heart pushes the sternum forward with each
contraction).

(iii) Prototype
A sternal notch indicator was designed as a ‘golf ball’ like structure at the superior end of
the device that fitted snugly into the hole just above the sternum. Constant positioning is
ensured and the rest of the sensors on the device will always be positioned at the same
positions on the precordium. This correct positioning is possible because
anthropometrically the sternums of all adults are the same length ±10mm (90th
percentile). The lateral part of the PCG was designed to hinge separate to the main
embodiment so as to follow the contour of the chest. This hinge angle correlates to the
size of the chest. Fig. 8 shows a design view of the device and Fig. 9 depicts the
positioning of the device on an adult male. In this design the positions of the stethoscopes
and ECG leads were optimized. The ECG sampled all 12 leads at 500 Hz and the ICG
sample rate was also set at 500 Hz. These inputs were synchronized with the 2 kHz
sample rate of the stethoscopes at the beginning of each recording by tapping once on the
device with a finger. The ECG, ICG and stethoscope deviations due to the tap noise
served as the synchronizing time instant.
 Fig 8 : Posterior view of the PCG demonstrating the positions of the stethoscopes ECG electrodes and ICG electrodes

Fig 9 : Precordial cardiograph positioned on the chest of an adult male

4. DISCUSSION
The proposed systems work well in differentiating between normal and abnormal
recorded heart sounds, whether a doctor listens to the heart sounds from a distance
or whether the doctor is using automated analysis techniques to identify heart sound
abnormalities. The auscultation jacket opened many doors to vast new possibilities to
examine a patient’s heart and lungs. With the extensive shortage of skilled medical
personal affecting billions of people globally, technology is becoming one of the most
important options to help solve this dilemma. A jacket that can record everything that a
doctor will typically look at when he examines a patient creates a situation where
the doctor can remotely ‘examine’ a patient. Artificial intelligence techniques can also
assist the doctor in screening through thousands of recordings in a matter of minutes.
The PCG, on the other hand, addresses the need of a doctor to see his patients faster and
more compliantly. By using a device that can quickly capture 12 lead ECG data
synchronized with heart sound data, the time that the doctor spends with his patient of a
higher quality. Data can also be imported into Electronic Medical Record (EMR)
software system for storage and/or emailing the data to a specialist for specialist opinion.

5 CONCLUSION AND RECOMMENDATIONS

This paper demonstrated the development of two prototype devices for the simultaneous
recordings of heart sounds, ECG and ICG. The devices are termed the auscultation jacket
and the pre-cordial cardiograph, and can be set up on almost any standard personal
computer. Due to the simplicity of use, the devices have a quick set-up time and can be
used by a nurse with only basic training. Preliminary studies with the prototypes
indicated that the quality of the recordings is good enough in order for a medical
practitioner to review the data and make a diagnosis on the other side of a communication
wire. These devices are a major step forward in bringing healthcare closer to the
patient and reducing unnecessary referrals, while also benefiting those who don’t have
ready access to specialist or even basic healthcare. Additionally, the data recorded with
the devices can be used for semi-autonomous diagnosis. These devices are a major step
forward in bringing healthcare closer to the patient and reducing unnecessary referrals,
while also benefiting those who don’t have ready access to specialist or even basic
healthcare.

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