IEEE TRANSACTIONS ON BI0-MEDICAL ENGINEERING, VOL. BME-18. NO.

2, MARCH 1971

125

Selection

of

the Number and Positions of Measuring Locations for Electrocardiography

AND

ROGER C. BARR, MADISON S. SPACH,

G. SCOTT HERMAN-GIDDENS

Abstract-This paper considers how many and which locations on the body surface must be measured (by taking ECGs at these positions) to be able to determine consistently the total-body QRS surface-potential distribution as it varies in time. The answers to these questions have implications about the complexity of models of heart electrical activity in addition to their experimental value. An advantage of using the ability to compute the total-body potential distribution as a criterion of quality is that untestable assumptions about the nature of heart electrical activity are avoided. The accuracy of computed potential distributions with respect to corresponding experimental ones is specified by the mean-square difference between them. Acceptable maps had an average relative mean square error of less than 4 percent in the presence of about 1 percent noise, since inspection of the surface maps showed this to be the maximum error allowable for the same clinical or physiological interpretation of the surface maps analyzed. The approach here involves applying principal component analysis followed by a minimum-rms estimation method. The conclusions are the following. 1) If the surface potential distribution is computed from measuring positions approximating the Frank VCG locations or the standard ECG locations, then for some cases accuracy is unacceptably poor. 2) For consistently acceptable accuracy, a minimum of 24 properly placed measuring locations is required.

I. INTRODUCTION

The data used in this studyr consisted of bodv surfiace isopotential Imlaps recorded from a group of pediatric subjects using mlethods detailed previously [12]. Ini summary, data acquisitioni consisted of recording 150 electrocardiogramiis fromn the locations indicated in Fig. 1 (100 points around the front and sides and 50 poinits over the back). Data recorded frolm these locations in Manuscript received April 16, 1970; revised AugUst 25, 1970. This each patient were processed to review the iniformation paper was supported in part by the Puiblic Health Service under UT. S. Granits 11307, 5372, and 5716, anid bx the North Carolina in the form of QRS isopotential sturface maps for each Heart Association tinider Granit 1968-69-A-77. mlillisecoind throughout venitricular excitation, as well The authors are with the Department of Pediatrics and the Divisions of Biomedical Engineering and Biomathematics, Dulke as to inspect Calcoimip plots of each of tlhe scalar tracings University, DuLrham, N. C., 27706. arranged in a matrix of 150 curves.

HE QUESTIONS considered in this paper are T how many and which locations on the body surface must be measured (by taking ECGs at these positionls) to be able to determiiine consistently the totalbody potential distribution as it varies in time. A slightly narrower problem has leen specifically examlined; namely, how maIny anId whlich pcsitionls should be measured to be able to comiiptute coinsistently and with an acceptable accuracy the potential values at 150 particular positions over the torso duriing QRS. AccLuracv is specified in termls of the imiean-squiare difference between any computed potential distribution and the corresponding experimentally mleasured distribution at these 150 poinlts, and the problem is to decrease this mean-square difference to an acceptable level. The final choice of anI acceptable error level h1as been milade by subjectively finding the minimiiumii accuracy leading to the same clinical or physiological itnterpretation of all the surface mnaps analyzed.

The usefullness of knowing h1ow many and whlichl locations ImlUst be mleasuLred to compute the total-bodv potential distribution lies in 1) the resultin1g insight into the amiiount of informiiation that is available oIn the body sturface for interpreting the statu-s of the heart, and 2) the ability to produce froml measuremiients at a relatively few locations (throughout time) either scalar tracings throughout tinme for manya- locations over the body or surface Imlaps for a series of time inlstanits. A considerable aCmouint of previous work in electrocardiography is related to the questionis of which and how maniy body surface locations should be miieasured. Particularly closely related to this paper have been the principal comiipoineint sttudies of Scher et al. [1 ], Y-oung aind Huggiis [2 ], atnd of Horan et al. [3 ]. Alethods used bv these atuthors were related to previous papers inl psy chology [4], [5]. These previous studies showed that after many leads had been mleasured, these samle measuremiients could be regenerated from somiie sminaller number of time-varying fulnictions. In this study, by u1sinlg results from Foster [6], Straiid and Westwater [7], and a theorem from Shermlain and I\Iorrison [8], [9] a method is established for measuring only a relatively few leads and from these producing the rest. In many respects the methlods proposed lhere serve the same purpose as those of investigators such as Frank [10] or l\Iilnor c! al. [11] wrho used the output of a VCG system to synthesize measuremiients froml precordial leads. The results of thlis study, however, inidicate that the accuracy of stuchi vector miiethods is at tinmes grossly instufficient.
II. METHODS

A4. Experimental Data

126

considered to demionimportant diagncstic features positioined, at one time or another, in imlost all areas of the torso. The final 14 diagnostic categories and the underlying electrocardiographic abnormality represented by each are listed along with the number of patients involved in Table 1. Ten maps fromii each of 45 subjects were selected for inclusion in the final analysis group. In our opinion, the
was

aimple, in the norimial childreIn, miaps were picked close to one another at the time interval of 20-30 ms fromii I onset to view the rapid development of the saddle distribution that heralds right ventricular breakthrough F . F if . F. 'F F [12], while different time instaints were selected for ... .S! Si Si S+ E childreIn Witl right ventricular hypertrophy [13], [14]. . . . St . A second group of patients was utilized to test the mlethods derived using the data from the primary [[ B analysis data group. MAlaps were choseni in a siimiilar W . . . . .. A fashion to that iindicated above from 15 subjects, which, . . . as a group, represented almost all of the diagnlostic r i4 6 7 8 Usi0 eIntities enicoImlpassed in the primary analysis data group. The collection of ten miiaps per patient in this will be designated the "test data group." Sinice Fig. 1. Mleasuring locationis. This figuire shows the poinits over the category chest anid back at which time-varying electrocardiograms were the miiaps were used in the testing of methods derived obtainied. Notice that here well as in the following figuLres shoxw- fromii the anaIysis group, the test group's miiaps were ing the values measuired, the width allocated for the back is half that for the fronit. S marks positionIs uised for approximiiatinig never conisidered in deriving the procedures themiselves. stanldard ECG positioIns, F marks approximate Frank VCG posiVoltage valuLes at the 150 map positions for analysis tionis, anld IT' mllarks approxim iate W'ilsoni Cenitral Termiiinal positionls. For the experimenitally obtained isopotenitial surface inaps, or test grotup data were expressed in reference to a miieasturemenits were obtained from all 150 positions mlarked by weighted average voltage over all 150 map points. It dots. was assumed for the analysis below that the average in time over manyr patients of the voltage thus expressed To obtain the miaps utilized in this study, initial re- was zero for each of the 150 map positions. view was made of the sequence of surface maps available in the Division of Pediatric Cardiology for each of 350 B. M11athematical Procedures patients. From this total, 110 patients' miiaps were selected for further review based oIn prior knowledge of Aiathemiiatical procedures were needed to estimate each patienit by the auithors, the diagncstic category the valtues at all the positioIns a surface imiap when involved, and prior knowledge that each patient's series the values were given at onlyr a subset of these positioins. of QRS maps coIntainied interesting patterns of probable These procedures are outlined in four subsections beelectrophysiological importanice. The nornmal children low, which are coincerned with the following. were judged to have normiial hearts on the basis of 1) UTsing principal comiponent analysis and data fromi auscultation, electrocardiogramiis, and chest X-rays. 45 subjects to find a set of coefficients relating miiatlhAbnormal children had diagnoses conlfirmed at cardiac emiiatical generators to surface points. catheterization. 2) Taking data from a subset of points, represeinitig Criteria for inclusioon in the study coinsisted of agree- it in terms of the above imiathematical generators, and mnent of the authors concerining the following: a) tech- thereby findiing the rest of the surface points. nically acceptable maps with low-noise level, b) absence 3) Decidinig which surface points should be in the of spurious data points, c) isopotential patterns con- subset. sidered to have importanit electrophysiological informa4) Considering extensions to new subjects. tion, d) present patterns that agreed froml past experiTwo sources of error in the overall estimation process ence with the importanit diagnostic features for the are examined. The first type of error (component error) entity represented, aind e) variations comlprised by the is associated with the number of generators used to total group to represent variety anid position in geo- approximate the hieart's activity, and is considered in miietrical arrangemeint of maximiia and miniimia such that subsection 1). The second type of error (available point
I H

+~~JFS

.w.~~~~w *::~i wj :: *F
.s.s+.

~ ~~

1Wt7n^W+FI
~ ~ ~ ~ ~ ~
as

IEEE TRANSACTIONS ON BIO-MEDICAL ENGINEERING, MARCH

1971

FRONT CHEST

BACK
f

,+t

teIn Imlaps chosein for each subject contained the interestinlg and imllportant successive changes in body surface patterins. This resulted in the selection of maps sequento
tially with inicoInsistent time differenices fromii one Imiap the next and fromii one subject to the next. For ex-

I.

on

the total populatioin of imaps

strate

error) is related to the nLumnber and location of measuremiients available for use in estimlating values for the complete set of surface positions, and is considered in subsections 2) and 3). For the reader's convenience, Section VI lists the variables used. 1) Number of Generators Required: This subsection is concerned with finding a geinerator matrix Gf and a coefficient matrix 14 which relates the generators to surface positions. The product of A and Gf is called Wf and

BARR et al.: MEASURING LOCATIONS FOR ELECTROCARDIOGRAPHY

127

TABLE I DIAGNOSES OF PATIENTS IN THE PRIMARY DATA ANALYSIS GROUP

Clinical Diagnosis
1) Aortic stenosis 2) Coarctation of aorta 3) Aortic insufficienicy, congeniital origin 4) Myocardial infarctioni, secondary to anomalouis origini of the left coroniary artery 5) Tricuspid atresia, Type 1B 6) Normal heart 7) Valvular puilimi-onic steniosis 8) Tetralogy of Fallot 9) Ostium secundum atrial septal defect 10) Ostium primnimIatrial septal defect
Number of Patients Electrocardiographic Diagnosis Left 'ventricUlar hypertrophy withouit chamber dilatationi 7 Left ventricular hvpertrophy with normal chamber size 2 Left ventrictLlar hypertrophy with dilatation of left -entricle Inifarctionl patterni, left ventricuilar hypertrophy 2 Left ventricular hypertrophy, absent right venitricle 1 Nornlal 4 Symmetrical right ventricular hypertrophy 3 Asymmetrical hypertrophy of right ventricle 8 Mild hypertrophy with dilatation of riglht ventricle 3 Dilatation of right ventricle with abnormal course of 5 ventricullar excitation Right and left ventricular hypertrephy 4

11) Ventricular septal defect with mild pulmonary 12) Congeniital comiiplete right bundle bratnch block 13) Chronic lutig disease with mild cor puilmonale 14) Wolff-Parkinson-N\Vhite Synidromie, Type B
hypertension

Complete right bunldle branch block (interventricular conduction disturbance) AMlild right venitricular hvpertrophy W\ olff-Parkinson--White Syndrome, Type B (Preexcitation of the right ventricle; interventricular conduction disturbance)

1
1

Total 45

Both the clinical anid electrocardiographic diagnosis are indicated for the 14 different diaginostic categories. For those who may not be familiar with the clinical diagnostic entities, a complete review of each of these can be found in the followinlg. a. A. S. Nadas, Pediatric Cardiology, 2nd ed. Philadelphia, Pa.: Saunders, 1963. b. J. D. Keith, R. D. Rowe, ancd P. Vlad, Heart Diseaise in Infancy and Childhood, 2nd ed. New York: MlacMillani, 1967.

is an approximation of experimentally measured volt- sequently, the differences between subjects were in the ages. The principal concern of the subsection is finding form of changes in either A or Gf. That is, for any parvalues for A and Gf, which lead to a small mean square ticular subject, the values of A were not known a priori. error Qv. In contrast, in this study a requirement was that the The values at each instant of time at the N8 = 150 elements of the A matrix were to remain constant for surface positions can be estimated by assuming that both changes in time within a single subject's surface they can be represented as a linear combination of time- maps and changes from one subject to the next. Correvarying generators spondingly, the input data supplied for analysis took the form of a single series of 450 surface maps, the ten maps from each of the 45 subjects in the analysis data Vf(iV, t) = E A (i, j)Gf(j, t), group combined for one determination of the A values. j=1 The resulting A matrix was constant, therefore, across =i1, * t 1? ... Ni. (1) all the 45 subjects in the N.; analysis data set. As detailed in the references, the basic element of the In general, the estimate WfV(i, t) will not be exact, and principal components method is finding the eigenvalues consequently and corresponding eigenvectors of the matrix V8 V.T. Our procedure for finding the eigenvectors and eigenV8(i, i) = Wf1(i, t) + Ef(i, t), values used the Jacobi iteration method outlined in T ; I . . t = 1, * * ,Nt (2) Ralston [15]. The matrix A consists of eigenvectors of i VS T column normalized (the sum-squared value of any and column of A is equal to one). If all NF eigenvectors are /8Nt \8 used for A, there is no error, Ef =0; however, usually (3) only NK<<NS eigenvalues and vectors are used. The N. Qf= Ef(i, t)2)/ IV eigenvalues used supply the infornmation to compute the generator covariance matrix A procedure that will determine A and Gf in (1) such Nt that Qf is minimized for any given value of N0 is the , 0t. Sg7(j2 k) = t=l Gf (j, t) Gf (k t) N method of principal components [1]-[5]. The version (4) of principal component analysis used here is described in Horan et al. [3 ]. A property of the principal component analysis is that Previous results [I]- [31 have shown that for any S0(j, k) is equal to zero if j-k. Additionally, the N8 single subject, a small value of N0 (less than 10) led to -N, eigenvectors and eigenvalues not used as generaa satisfactory value for the mean-square component tors are assumed to represent the noise and can be used error Qf. For each subject the variation in time of the to compute the covariance matrix of the error: surface voltages was accounted for by variations in generators Gf. When different subjects were analyzed, Sr(i, k) = t=1 Ef(i, t)Ef(k, It) ,/Nt. (5) L however, matrix A was allowed to change, and, con=
7

1,

.2

128

IEEE TRANSACTIONS ON

BIO-MEDICAL ENGINEERING, MARCH 1971

_TsuljIl the N8 - N, eigeinvectors and eigenvalues associated witlh noise are a large number of small eigenvaluIes; consequently, it is assumlied that Sr(2, k) =0 for iXk. Note that the decision to fix N, at a particullar value determiinies the imiean-square component error Qf of (3). 2) lalucs at all Slurace Points from a Sztbsdt: This subsection deals with using experinmental values l'e fro imi a stubset of sturface locationis to estimiiate valties for mathematical geinerators. The estimiiated generator values Ge theii are used along with the .4 matrix fromll the last subsection to estimiiate voltages at all imiap positioIIs. The princil)al point of concern is imakiing accurate estimllates Ge of generator valuLes Gf, thereby decreasinig thle total error E1. With the values from1i only N, surface locations available, we wishl to estitmiate the values at all of the N8 surface I)csitions. Suppose the available positions at which the surface valtues Ve are given are positions p(i), i=l , Ne*If the values of the available points' trantsfer coefticients C are definied by

Defilning the mean-square availal-)le point error Qe to be

A',
i.l

E,(il 1) i=l

ti

(13)

atnd assumning that the available point error Ee is iildepenident of the comiiponenit error Ef aind that Ee aind Ef
have miieans of zero, then

Qt

Qf + Qe.

(14)

Since Qf is fixed by the choice of Ng, we desire to reduce Q, by decreasing Qe. In order to find how to minimize Qe, note that subtracting (1) from (10) results in

Ee(i, t)
Using (13) produces

j-=

E A (i, j)Eg( j, t).

(15)

Vt -Qe =

i=1 t=i =1 /-=1

X, As At A-g

j E A4 (ij j)Eg(j , 1)O(i, k)Eg(k, 1). (16)

C'(i,,j) = A (p(i), j), i ,1,. j = 1, *,g (6) e;

theln

Therefore

L= Q= E

t=1 j=l

E E t)-2 g(j,

X NI.

(17)

llf(p(I), t)
i
=

jE C8(i, j)Gfj(j, I),

J=1

-v

1,

A ;

1- 1,. *Yt

(7)

Since WIVJ is onl1y an approximation to the experimentallNr determiinied valties Vr. aind sinice Ve rathier thian111.f is available, (7) cani only be lsed tc) estimiiate valuLes for G1, i.e., I F 8(p( i), t)--I (P i 1), I "U(ir ) [
I

= ,j C.i, , [.i) G,-jJ f)- I:(,'1)]

where
i=1

(8)

,iV1. (9) If the values for GC, j) t-E j, t) are comiiputed tisinig (8), and the valtues are theni t:sed to estimate p-otentials at all N, surface loc:iti-mns. the restults will b e [from (1) 11'(i, t) =11, 'i) - Ii, t) wlhere
A';
t

1,

Equation (17) follows from (16) since a property of the principal component analysis is that the colutmns of A are orthonormal. Consequently, the prol.lem of imiinimizing Qe for a fixed N, anid arbitrary selection of subset points p becomiies the problem of best estimiiating in a least-scluares senise the values of Gf for (8). The approxinmate valtues Ge that are fotund are then used in (10) to estimate poteintial valties at all N, surface locationis. How- to find Ge lhas been considered previously in detail b) Fcster [6] and Strand and Westwater [7]. These aththors consider the general problem of finding the solLutiois of simiiultaineous linear equatioiis in the presenice of inoise. For the cases theyr consider, solutions are fotinid whichl are optimumi estimates (in the leastsquares sense) to the true solutioins. The solutioni to the probletim of this pa)per is, in miiatrix notation,
Ge
=

GC

E',

Y->CTSr-lVe
-

= F

IV,

(18)
(19)

F =

7Sr

Trhe overall error ini eFtimatitig <gemcratcr and then surface values will be (,1) EI(i, t) = V8(i, ') -' IF 1) 4- UK, t) (11) (f withl corresponding m ean-sq ure i a:re r ( f

S/ -I + (7TS

'(

(20)
(21)

Thlis solution results in a miiean square error of

Q
=

tr X-'.

Q=

L,i

E ,
I

l('i, )'2. I/Al.

(12)

Combining (10) and (18) in a imiore easily used form, we have the finial equationi for performinlg the expansion

BARR et atJ.: MEASURING LOCATIONS FOR

ELECTROCARDIOGRAPHY1

129

froimi a fewx sturface points to all of themn

le(i, f)

shows that for a matrix D and vectors it and v

i-2E A (il j)
j=1
e

.y

E F(j, k)Ve(k, t)
k=1

(D +U vT)-l = D-1_

(VTD-) (D_u)TTD-lu 1 +

(24)

E H(i, k)le(k, t)
= E4 (i, j)F(j Ik),

wlhere the fihlal transformatioin mlatrix H is

(22) Letting D equal X of (20) allows Qe of (21) to be successively evaluated with only order N,2 instead of Ng3
the analysis above has been completed using a data

H(i, k)
t =

essential operatioins required for each evaluation, thus considerably reduLcing the coimiputational load. 4) Extension of the Methods to New Subjects: After

*'.

*7=1

Ys;

k= 1, *

Ne. (23)

3) Selection of the Best Set of Estimating Points: For a fixed value of Ng, the mean-square component error Qf is not affected by the particular choice of surface positions in the subset used to estimate the others. However, the nmeain-square available point error Qe is affected by the particular subset chosen. Section II-B2) inidicated in (21) the value for Qe for an arbitrary selection of surface positions as available points. This section indicates how to redu-ce Qe by selecting an advan tageous set of available points. Anly particular choice of the index of available poiInts , N, fixes the values of C and Sr and, conp(i), i = 1 sequently, allows (21) to be evaluated for Qe. The brute force approach of evaluating (21) for all possible combinations of Ne surface positions fails, however, since the numlber of possibilities is too large. The imiore miiodest approach used here has been to start with the values of p(i), i = 1, *e , N,, set to arbitrary values (arbitrary surface points). Then witlh the values of p(i), i = 2, . , Ne, lheld fixed, p(1) is varied froml 1 thiroughi Ns. At eaclh value of p(1), Qe is conmputed using (21). The final value assigned to p(1) is the numiiber of the locationi producing the minimum value of Qe. After p(1) lhas been set, the analysis is continiued by chlaIngirig p(2) w\Nhile hioldinig p(l) and p(i), i =3, t N6, fixed. The entire process is continued and repeated until a fiinal pass of testing for inew values of p(i), i = 1, * *,~N6, leads to Ino slhifting of the assigned positions. The results preseinted in this paper as "best" positions are the best positions fouind usinlg this metlhod. This approach does not guarantee that the optiimunm positioIns (lowest Qe for any set of locations) will be found, and in practice different starting assignmeints for p somletimnes lead to different final results. However, if several starting points are used, and if the results from analyzing one set of values of N, and Ne are then comiipared with the results from analyses of nearby values of N, and Ne, a consistent pattern emerges. Even Using the more modest approach outlined in the last two paragraphs, however, a considerable computational problem remains, since it is necessary to know the inverse of matrices of order N, to compute Qe in (21). The computation required can be reduced by making use of a theoremii by Sherman and Morrison [8], [9] (quoted in Ralston and Wilf [16]), which
-

base such as the analysis data group of this study, then values for the inumber of expansion points N., the posi-

tions of these points p, and the final transformation

components, the A4 matrix, can continue to be used. It is apparent that the degree to which .4 can be extended to new subjects is related to the number and variety of maps in the original base group from which A4 was derived, using the method of principal components. As a partial check on the appropriateness of usiIng the same A matrix for new subjects, the following procedure was a) The analysis group of subjects was subdivided into subgroups of 1, 10, 20, 30, 40, and 45 subjects. Each larger group contained all the subjects of the preceding smaller group, plus new subjects. b) For each group, an A4 imiatrix was generated and the number of generators N, required to bring Qf down to a fixed level was determined. c) The value of No was plotted against the number of subjects in the group, aind a family of curves was drawn, which corresponded to various values of Qf. These curves are presented in Fig. 2. While no definitive conclusions about future subjects can be reached from Fig. 2, we have interpreted it in the following fashion. For a particular accuracy,, as long as N, was changing rapidly as a function of the number of subjects in the group, the A and H miatrices were considered unsuitable for use in new subjects. As the value of N, became more nearly constant, the A and H matrices were considered possibly suitable for use with new subjects.
III. RESULTS

assumption that the values of Ne, p, and H will still be appropriate for Inew subjects, the miethod may be extended to these subjects if the values of l', are known for the desired time instants. Note that only the sutbset 1'e of the voltages V. is required, and no other data are required. One test of the validity of conitinuing to use the samie Hi matrix for new subjects checks how well one of its

nmatrix H of (22) will have been determined. With the

applied.

A. Deciding the Number of Generators The first results provide information for deciding how many generators are required to provide a good representation of the surface potential data observed. Performing the principal components analysis [Section

130

IEEE TRANSACTIONS ON BIO-MEDICAL ENGINEERING, MARCH

1971

Ng

.r_
c

4-1 LL.

10

40 45 30 20 Cumulative Number of Subjects -

Fig. 2. Numiiber of genierators req lired to produce a given accUracy in variotus niumnbers of subjects collected together. The 45 subjects were stubdivided into grouLps of 1, 10, 20, 30, 40, and 45 sutbjects. Each larger grouip containied all the suLbjects of the preceding ssmaller grouLp, as well as new stubjects. Each grouLp was sLubjected to principal componenit analysis to determinie how many generators N, were necessarx to reconstrLuCt the isopotential sturface maps fromn the subjects in the group with various degrees of accuracy. Each differenit linie on the chart corresponds to a differenit accuracy which is expressed as the percenit of the meani-squLare value of the maps in the grouLp equal to the meatn-squiare error betweeni the experimenital imaps and the recoistruLcted maps. For example, a two-percenit meani-squiare error can be achieved in the one suLbject showiin uising only three genlerators, althouigh 20 genierators are necessary for a two-percent mieani-squLare error in the grouLp of 30 subjects. Note that only the highest accuLracies still conitinuiie to rise significantly from the 40 to the 45 subject grotups. The implicationi of the reSLults showvn is that a mIulch larger grouLp of subjects could be recoiistruicted from abouLt 30 genierators with good accuracy (2 percenit or better), ulnlesS the surface maps had greatly differenit patternis from those present in the 45 sLubject
collectioni.

Ng Fig. 3. Fraction of mean-square map values reproduced by increasing nutmiibers of generators. The meani-square map valtie is the average value across all the maps in the analysis data group of the suim of the squared valuies of all 150 points on the map. If the map valuLes are thouight of as being produced by N07 time-varying generators that are linearly combinied, then principal component analysis can be used to find the mean-square values for the generators (eigenivalues) as well as valuLes for the coefficients relating the generators to the surface points (eigenvectors). These genierators aand coefficients mininmize the mean-square error between the originial experimental values and the valuies compuited from the generators. The principal component analysis produces resuLlts which have the property that the mieain-squiare value oln the experimental maps always equals the meani-square valtue on the compuited maps plus the meani-sqLuare difference, whatever the nlulmber of generators used. This figure show%s the meani-square valUe oni the experimenital maps divided into the meani-squLare value oni the comptuted maps for one generator, two generators together, three, etc. The principal interest is in howr many gellerators are requlired before the meani-squLare differenice between the experimenital aand computed mnaps can be attributed to small experimenital errors, or noise. I nspectinlg this figure shows that the mieani-squiare size of generators (eigenivaluLes) decre-ases rapidly, so that relatively few of the 150 generators will still prodLuce a good
fit.

independeint estimates of the noise in the data acquisition and processing system.
B. Deciding the Nzumber of Available Points Ne It would seem reasonable if increasing values for the choice of N, implied an increasing number of available points Ne for the same mean-square error overall Qt. That no such implication is in fact the case is shown in Fig. 5, which shows the values of Qt versus N, for a number of choices of available points. Inspection of Fig. 5 shows that mean-square error either declines or remains constant with increasing N. Fig. 5 also shows how the value of Qe varies for different selections of Ne. As would be expected, Qe decreases with increasing numbers of available points. For N, =30 and N, = B3, Qe-.2OQf while for Ne=B30, Qe,Qf. Consequently, with N, set at 30, considerable percentage reduction in Qf+Qe is achieved by increasing the number of available points from 3 to 20 or 30. Still further increases achieve diminishiing improvement. Inspection of surface maps produced from various choices for Ne led to the decision that 24 was the minimum number of measuring positions for producing maps that we judged to be identical, with respect to clinical or electrophysiological interpretation, to the

11-B-1) ] oIn the 450 maps of the anialysis data group results in the eigenvalues whose relative sizes are shown in Fig. 3. Each eigenvalue's magnitude is a measure of the mean-square values that would be taken oIn byr some generator. As is apparent from Fig. 3, there is a rapid decrease in the sizes of the eigenvalues. To the end of ascertaining how many eigenvalues are associated with data and how many with noise, consider the surface maps shown in Fig. 4. Beside each of the experimentally mreasured maps are shown maps that have been reproduced using 12 or 30 generators and (1). (The consideration of the fourth column of maps is deferred for the mlomient.) MIany stirface maps are adquately regenerated using only 12 generators; however, those shown here are not. We chose to set N, =30 generators for subsequent analyses since inspectioIn of the maps showed this number would accurately reproduce small features that repeatedly, occur in subjects in the same diagnostic category. The decision to fix N0 at 30 implied a value for Qf of about 1 mV2 per map or an average relative mean-square error of about 1 percent, and these values were consistent with our

BARR et

al.:

EXPERIMENTAL, 150 POINTS

t-7 -2

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NIEASURING LOCATIONS FOR ELECTROCARDIOGRAPHY

131

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experimentally measured maps. This choice resulted in level. Any choice of Ne from B30 to B3 adds at milost 6 mV2 mean--square available poinit error, i.e., the a relative mean-square error of less than 4 percent for imlaps in the analysis data group. The surface mlaps for available poinlt error remainis only a fraction of the several complex distribtitions as produced fromn the comnponent error. Second, it is interesting to notice the B24 mleasuring positions are slhown in the fourthl close approximatioin of the value of Qf+Qe for Ne=B3 to Ne F7, the approximate Frank VCG positions, uIncoltuminl of Fig. 4. is available der the choice of N, =3. Third, following the Ne F7 Other additional interestiing informiiatioin from Fig. 5. First, notice that the choice N, =3 corre- liine from N, 3 to N, = 10, it is interesting to notice the sponds to a general three-function generator-a case decrease in Qf+Qe from abotit 21 ImIV2 to about 13.5 that includes (but is not restricted to) the basic premise mV2, and the further change to 10 mV2 for Ne=B7. of vectorcardiography. This choice produces a value of These changes can be thought of as using the F7 meaQf about equal to 16 mV2 or about 16 times the nioise surements after condensing themii to three-functioni
= =
=

132
lmVelt

IEEE TRANSACTIONS ON BIO-MEDICAL ENGINEERING, MARCH

1971

pected mean-square error Qt was therefore also coiiputed for a number of conveinieince configurations, including the four shown in Fig. 7. c25 0 Fig. 7(a) is the same arrangemiieiit of available poiInts e.,, Ne B3 E 0.30 CEL as the B24 arrangement, except that the tlhree back C, 20 points plus one low front point have been remloved. Fig. 0.25 0'O 7(b), (c), and (d) are regular patterns of 24, 30, and 30 available points. For each case the value of Qf+Qe is ' 15 =e -Ne B5 S substantially higher thain for the B24 configuiration. Ne= F7 .-Ne=S9 0.15 c The 3.36 value fromi Fig. 7(a) is closest to the 2.40 for - X\N .Ne=B7 . . O0 the B24, but inspection of the suLrface imiaps revealed Ne-B9 0.10 o + Imnaps with prominent distributions oIn the back that deteriorated substantially with the remloval of the back -= 2.0 B24 Neoise LevelB_24 pe-B2e4B2 e p _prox 4: poiInts. ConsequeIntly, the elimlinatioin of the four availNe=B3O *-**-**Approx Noise Level I~~~~~~~~~~Ne 5 I able points resulted in a severe degradation of the qual35 30 25 20 15 10 5 ity of relatively few maps. Number of Generators Ng=
w

Fig. 5. Mean-square error for various numbers of generators anid available points. This figure shows the mean-square error, Qt =Qf +Qe versus the number of generators N. Different lines on the plot correspond to different selectionis of surface positions, the measuirements from which are used to estimate values at all other suirface points. The mean-square error value shown on the left vertical axis is the mean-square error per map, i.e., the stITumsquared error over all NS points for a single time instanit. The right vertical axis shows the fraction of the average mean-squiare voltage per map that equtals the iimean-square error. The vertical distance from the bottom of the plot to the dotted line represents Qf, the mean-squiare component error, while the distance from the dotted line tip to any higher line represents the mean-sqliare available point error Qe. Qf and Qe are illuistrated at No= 15. In drawing the line B9 the surface positionis conisidered were the nine positions that led to the lowest Qe, usilng the procedtire in part B3 of the methods (see text aild Fig. 6). Simiilar considerations applN for B3, B5, B7, B20, B24, and B30. The lines marked F7 and S9 were computed uisinig as available poilnts seven or ninie points approximatinig the Frank VCG or standard ECG measurinig positions (see Fig. 1). The approximiiate nioiselevel line represenits the approximate error level duLe to measuLrement artifact, lead misplacemetnt, processing error, or other sources.

C. Extend-ing the MUethod to Additional Sutbjects The results presented in this section are from extendiIng the H matrix derived from the selection of N0 = 30, Ne=B24, and the data of the analysis data group to information from the test data group. No inforimiation froml each subject was used other than the potential values at each time instant froml the available poiInts. The relation between the values of Et and V, for three subjects included in the test group is presented ill detail in Fig. 8. In each graph data are presented for successive timle instants 1.08 Imls apart throughout QRS, not just data for the 10 inlstaints incl-uded in the test data group. The solid line shows the sum-squared values for lV. (measured on the left-hand scale) whlile the dotted line shows the sum-squared values of Et (scale on the right). For m:Iost of QRS in these subjects the error value is about 5 percent of the experimlental value, form, using them without condensation, and then re- although in subject C it rises to about 10 percent at arranging the seven positions into the locations shown in some time instants. All graphs indicate that error levels Fig. 6. Finally, note the similar decrease in Qf+Qe with rise and fall along with the signal levels. For the test NV =30 upon shifting from the S9 to the B9 line corre- group as a whole, the distribution of errors was coimsponding to a rearrangement of standard ECG positions. parable to the distribution for the analysis group. On each of the graphs of Fig. 8 a vertical line mlarks With the choices of Ng = 30 and Ne = B24 an examination of the distribution of the differences between the a tinme instant. The surface maps for the three marked experimentally measured values IV, aind their estimates times are shown in several versions in Fig. 9, correW.1e showed that most of the error values were in the sponding to the three rows. The first columnllI containls magnitude range of 0.0-0.2 mV (about 90 percent were), the experimleintally measured miaps, while the second, a range of values about equal to the noise on the experi- third, and fourth contain maps produced fronm H menital miiaps themselves. Although larger errors occa- mlatrices derived using the anal ysis data group. The sionally occurred, these usually were at positions lo- second columnLII corresponds to Ng = 30 and Ne = B24. cated in regions of high voltages and gradients, where The third column corresponds to N, =30 and Ne = S9, the errors had little effect onI the pattern of the contour and the fourth to N. = 3 and Ne = F7. The maps in the first two columnins are similar, but betveen the first and linies oIn the imiaps. it is possible third columns (standard ECG approximation) there is It is reasonable to inquire whether or not to do alm-iost as well usinlg more regular arrangements a definite deterioration. For many other mllaps not showni of nmeasuring positions than the B24 arrangement. Since all four versions are similar, so the data presented in the B24 configuratioin scatters points widely, a mnore Fig. 9 are representative of the poorer cases. However, regular arrangement perhaps cotild be used more rapidly in the opinion of the authors and for the maps preand reliably for reproducible lead placement. The ex- sented, the deterioration between colu mns one and

BARR et al.: MEASURING LOCATIONS FOR ELECTROCARDIOGRAPHY

133
-

Ng=30 Ne:B3 Qf+Qe=21.9

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Fig. 7. Simplified arranigemiienits for measuring locationis. Sinice a regular array of poinlts is advantageous for simplicity of measuremetnt in practical situation-s, a number of simple "convenience'" arrangements were tested. Four of these are shown above, along with the expected total mean-square error Qf Qe. Each of these arrays leads to a significantly higher error level than the B24 configurationl and is therefore judged Iu nacceptable.

respectively.

values on each surface map throughout QRS (values read on the left scale) while the dotted lines trace the valuies of the suimllsquared errors (on the right scale). The SS Et scale is 20 times the SS V, scale. The results include numilerous instatnts spaced 1.08 ms apart throughout QRS. Each of the three graphs contains a vertical line marking a time; surface maps correspotnding to subjects (a), (b), and (c) here are shown in Fig. 9, rows 1 to 3,

134

IEEE TRANSACTIONS ON BIO-MEDICAL ENGINEERING, MARCH 1971

EXPERIMENTAL 150 POINTS

__ _
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59
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(c)
sx-mbols indicate the magnitude of values in the region (see caption for Fig. 4). The first coltlmn show-s valtles9.mean30.97IV,jwhle3th for each of the 150 points ---as~~~~~~~~~~~~~~S experimentally measured. Columns 2, 3, and 4 show maps comptited tlsing the B24, S9, and F7 positions as available points. These ex-~~~~~~~--------ample areseleted o shw caes were olum 3 an 4 aproxmatins t collmn arepoor In te ma preente.in.he.frst.ow, he U shapedemarcation between..... d th. pstie.n neatv poetilrein (bottom...of.the Uis...... Bi)i.hrceitcftedansso nea ostium primum atrial diagnosis deet[0.I ow2 h atr is chrcersi moderate idrih etiua yprrpvnti case a patient with a septal...... of te map adsecundum atrial septal defect with of painswt to right shunt (note the-positive-potentials of ostium extening upwrd towad FS aswell left tird rowthe.V-saped.di extendin acrossthe botom in-thepositiv potetia reion f te mp (pintof he Vnea H6 isfreqenty sen i paiensasJi 1). n the wih ttraogyof Fllo. Tese-iagostcall sinifcan map faturs arereasnablywellpreseved n theB24 aps, ut tey ae muc les appaent n themap rom te.stndardECG.oint
.
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Fi.9OMspondsto a ifferet subect (se Fig 8). tlmber onaagruRlogwthmpMUsnM4,9 n 7srac auedsTfcempIfoUubetMn h es mps indcate alues n milivolt times100, .g.,

aaAonsSEcDowcre

~ three and especially one and four represents a Considerable loss of information for interpreting the maps from

and particularly themapfrom the Frank points (N0 = 3).

The relationsbetween the experimental (B24) ap- D. H Matrices~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.. proximate standard and approximate Frank grou~~~~~~~~~ps'l of.hevaue.cnsittig.heH.atics .se to con data evident in scalar~~~~~~1- trcnS, asisshwnfr is also ut3te heB4 octon anothe sbeticueintetsgru(Fs..10 and... tinsad 5-pin.mpsfomth .8.maurngloa reaviabezrm h
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.

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authors, computed appropriately for measuring volt.

........

again

l)eated in Fig. 11 for closer comparison. While once ages with respect to the Wilson Central Terminal somle locations exhibit similar tracings in all four reference as it is approximated in Fig. 1.

BARR et

al.:
J,g

MEASURING LOCATIONS FOR ELECTROCARDIOGRAPHY

135

-I

EXPERIMENTALLY MEASURED AT 150 POINTS IV lf v J v _ A 41 I V

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Fig. 10. Scalar tracings for onie test subject. The diagnosis for this patient was valvular pulmonic stenosis. All of the tracings were draws by a Calcomp plotter and photographed: (a) shows the scalar tracings experimentally measured from this subject's chest and back at Ns = i50 locations (see Fig. 1), (b), (c), and (d) show arrays of scalar tracings that were computed tIsing available poinlts the B24, S9, and F7 locations. Tracings at some positions vary little among the four arrays, buLt the four tracings within the dotted lines show considerable variation. rhe tracings within the dotted lines are redrawn in Fig. 11.

IV. DISCUSSION A.4. Limitations of the Study The results of the study are limited by the methodology in several important ways. First, the mathematical approach used is based on a particular linear procedure for finding the potentials at many surface points from the potentials at some subset of them. A more powerful procedure is conceivable, either from the point of view of using, for example, some nonlinear approach, or from the point of view of including information easily obtained fronm the subject pertinent to parameters such as body size. Second, the analysis data group used in this paper was limited to data from only 45 subjects in the pediatric age group. Although the surface potential distributions that occur in this age group are well represented in the analysis data group, it is possible that markedly different surface maps might be obtained from adults or in-

fants. On the other hand, the possibility of a large nuimiber of significantly different maps is decreased by the wide variety of body sizes and diagnostic entities that
are

present in the pediatric group of surface maps used in this study. Third, in the analysis and test data groups tein instants have been selected to represent each subject. These ten maps are the ones that best characterize the subject in our opinion. However, if a different selection of maps had been used, and particularly if a mluch higher percentage of the maps had been from the relatively long-duration and relatively simple low-level distributions near the beginning and end of QRS, the statistics that have been used to clharacterize different error levels would have taken on different values. Furthermore, the other parts of the electrocardiographic cycle outside of QRS are not represented at all. Fourth, to the extent that it is or becomes possible to interpret meaningfully voltage differences in the

136
(mV) 3-

IEEE TRANSACIONS ON

BIO-MEDICAL ENGINEERING, MARCH 1971

2-t
1-I
-AlIi

E,

positions [21]. Okada [22] has given a critical review of many results. A inumber of papers have been concerned with the principal component analysis of electrocardiographic data [1]-[3], [23], although a main
S11
A

Ws~~~~~~~~1

-E

interest of these papers was in how much about the status of the heart could be inferred from body surface data, rather than estimating the complete surface distribution. Several authors have considered directly the problem of estimating one set of measurements from

-I

-2-_
s 1100 ms o -3Fig. 11. Scalar tracings for one stubject at four measuring positions. The data shown in the boxes of Fig. 10 are redrawn here on a single set of axes to facilitate comparison. The computed tracings made with the Franik VCG positioIIs as available poinlts are grossly different from the experimental tracinigs. Note especially the second complex from the left. The computed tracings made with the standard ECG measuring locations as available poinits are more similar, an-d the tracinigs made uISinlg the B24 locations are close to the experinmental data. In the first, second, and fourth groLups of tracings, the experimental tracinig serves as one of the 24 inptut leads to the B24 system, so the E and B lines are virtually idenitical, writh any differenices beinig due to the slight smoothing effect of the B24 system at its 24 available points. Column 3 shows a positioIn at which the experimental tracing does not serve as inlput to the B24, S9, or F7 systems. The error between the E and B tracings in column 3 is roughly typical of locations not serving as iniptsts to the B24 system.

neighborhood of 0.1 or 0.2 mV during QRS, there would be value in having a better method, which would mean inaking measurements at a larger number of surface positions. However, since changes of this magnitude can be induced during QRS at some positions by only a few millimeters shift in electrode position, and since it is difficult to precisely define corresponding electrode positions from subject to subject because of changes in body size and shape, it will be difficult to reduce these

Finally-, even though it may be interesting to know the number and positions of measuring locations from which the entire surface distribution can be calculated, in practice it often may be more convenient to simply measure at all locations of interest.
B. Relation to Previous Work The literature about questions of numbers or positions of leads is extensive, and only a fraction of the valuable papers in this area are referenced below. Many additional references may be found in the papers cited
how

errors very much.

Previous work in vectorcardiography has dealt with well a dipole generator can account for what is observed as surface potentials [10], [11] or how well a dipole generator can cancel out what is observed [17][20]. Other work has been concerned with the value in clinical diagnosis of measuring at different numbers of

here.

another [24]- [26]. The results of this study generally agree with previous results indicating that relatively few generators or measuring locations (fewer than 10) can account for much of the observed electrocardiographic data, particularly when the experimental data is from a restricted number of body surface positions, or when only normal subjects or only a few abnormal subjects are considered. The results of this paper disagree, however, with the possible implication that even with a large number of measuring locations scattered over the torso and considering both normal and many abnormal diagnoses, measurements from only a few nmeasurinig locations allow one to compute the values that would have been measured at all other locations of interest with acceptable accuracy, i.e., such that the computed and experimental tracinigs are consistently and quantitatively equal within a reasonable noise level. The results here indicate that under these circumstances a minimum of 24 properly placed measuring locations are required, along with a model of more than 20 (our selection being 30) time-varying generators. A second group of previous papers [12 ], [27 ]- [311 has examined the complete isopotential surface distribution as measured experimentally. Frequent reports of surface potential patterns that cannot reasonably be explained by means of the equivalent dipole hypothesis, have distinctive features in regions not sampled by Frank VCG or standard ECG measuring positions, and contain transient features consistently associated with a particular pathologic entity are included. AMost of the papers in this group support the point of view that valuable additional information is obtained by measuring more locations than in conventional methods, and usually more than 100 such locations are included in the experimental design. The results of this paper support the contention that measurements at Frank VCG or standard ECG locations do not determine the total surface potential distribution within the noise level, and, therefore, that the possibility of obtaining new clinically or electrophysiologically useful information exists. However, the results here also show that for the subjects in this study it is necessary to measure only about 24 properly placed locations to produce a good quality representation of the entire surface distribution, at least during QRS.
Having more than 24 required positions would imply

BARR et at.: MEASURING LOCATIONS FOR ELECTROCARDIOGRAPHY

137

the ability to attach significance to rather small voltage changes. C. Implicationsfor Simulations and Innverse Solutions The principal implication of these results for inverse solutions is that since about 24 experimental measurerients are sufficient to deternmine the complete potential distribution, no more than about 24 linearly independent parameters can be determined from the QRS electrocardiographic information present on the body surface. Corresponding implications are present for models used in simulations.
V. CONCLUSIONS

V,(i, t) -Wf (i, t), the component error. Eg(j, t) Gf(j, t)- G(j, t), the generator error. Et(i, t) Vs(i, t) - W,(i, t), the total error.
Ef (i, t)

Ge(j, t) Estimated value of Gf(j, t) from data at the

The following conclusions can be justified directly only for the particular methods and subjects analyzed. They depend particularly on the requirement of an average relative mean-square error of less than 4 percent for acceptable reproduction of nmaps in the analysis group. However, some results indicate that the 24 lead method derived and used lhere (or a variation of it) may be generally applicable to all subjects. 1) If voltages at 150 torso positions are computed from the measurements at the seven lead positions of the Frank VCG or the ninie measuring locations of the standard ECG, then in some subjects important features of the surface mnap are missing or incorrectly generated, or for some nmeasuring positions the scalar tracings are significantly different. 2) For consistently acceptable accuracy, a minimum of 24 properly placed leads are required. For the subjects of this study, 24 measuring positions resulted in both scalar tracings and map features being good representations of the experimeintal measuremiients. 3) The best locations found for various numbers of measuring locations were with most of the points in positions geometrically close to the heart, but with a few scattered widely. 4) At the accuracy provided by 24 measuring locatioIns, most of the differences between the potentials as generated and potentials as measured are about the same magnitude as the differences in successive measuremients from the same subject, which are caused by biological or experimental variations. If it should become possible to interpret differences of this magnitude in clinical or physiological terms, then more than 24 measuring positions may be desirable. In the meantime, it is reasonable to measure at more than 24 positions to the extent that it is practical.
VI. NOMENCLATURE

Ne available points. Gf(j, t) Exact value of the jth of Ng generators at the tth time instant as determined from all Ns points. Gf is not taken to have a physiologic meaning. k) Final transformation matrix for producing H(i, values at all surface map points from a subset of them. Number of points whose values are availNe able for estimating values at other points. Number of mathematical generators. Ng Number of points in a full surface map, Ns here 150. Number of time instants in a series of surNt face maps. Index of which points on the full map are p(i) available points. Mean-square value of Ee. Qe Mean-square value of Ef. Qf Mean-square value of Et. Qt S0(j,k) Covariance matrix of Gf(j, t) and Gf(k, t). Sr(i,k) Covariance matrix of Ef(i, t) and Ef(k, t). V8(i, t) Value of Vs(p(i), t), the value at an available point. V8(i, t) Experimentally measured value at the ith surface point for the tth time instant. Wj(i, t) Estimated value of Wf(i, t) from data at the Ne available points, made from approximate generator values Ge. Wf(i, t) Estimate to V8(i, t) made on the basis of exact generator values GC.
REFERENCES

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.A (i, j) Constant coefficient matrix relating the ith

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Roger C. Barr was born in Jacksonville, Fla., on February 21, 1942. He received the B.S. and Ph.D. degrees in 1964 and 1968, respectively, from Duke University, Durham, N. C. He is currently Assistant Professor of Pediatrics and Assistant Professor of Biomedical Engineering at Duke University, where his primary interest is in problems relating to both engineering and pediatric cardiology.

Madison S. Spach was born in Winston-Salem, N. C., on November 10, 1926. He received the A.B. and M.D. degrees in 1950 and 1954, respectively, from Duke University, Durham, N. C. He is currently Professor of Pediatrics and Chief of the Division of Pediatric Cardiology at Duke University. His major interests are the electrophysiology of the heart and electrocardiography.

G. Scott Herman-Giddens was born in Petersburg, Va., on March 21, 1943. He was previously employed by the Beaunit Corporation, Ingalls Iron Works, and the University of Alabama Medical Center, University, Ala. Since 1967 he has been with Duke University, Durham, N. C., working in computer programming and teaching. Mr. Herman-Giddens is a member of ACM, ASA, AMA, and MAA.