Automated Interpretation of Cardiac Arrhythmias - Deep Blue

15 Pages·2003·1.57 MB·English

Automated Interpretation of Cardiac
Arrhythmias
Design and Evaluation fo a Computerized ledoM
ozneroL .A ,olraCiD MD, gnipgnoD ,niL ,DhP
dna ecinaJ .M ,snikneJ DhP
Abstract: ,yllacirotsiH eht tnempoleved fo deziretupmoc sledom taht eht
evitcuded sdohtem desu yb snaicinilc for the noitaterpretni of caidrac -htyhrra
saim evah neeb detimil yb the ecnesba of a yltnetsisnoc elbailer snaem of -tceted
gni 1airta .noitavitca nI siht ,yduts a laciteroeht ledom was depoleved htiw a
lacihcrareih noitazinagro of gnivlos-melborp seigetarts gnizilitu detamotua -lana
sisy of 1airta noitavitca morf a yllaicremmoc elbaliava laegahpose llip edortcele
dna ralucirtnev noitavitca morf a ylsuoenatlumis recorded ecafrus -oidracortcele
cihparg .dael ehT laciteroeht ledom was neht tested ni 21 stneitap htiw 1 or
erom of 28 tcnitsid ralucirtnevarpus dna ralucirtnev .saimhtyhrra Of the 641
laudividni caidrac selcyc ,dezylana 636 (99.2%) were yltcerroc .deifitnedi ehT
ycarucca of a ,lautxetnoc that ,si erom ,evisneherpmoc noitaterpretni of -ucesnoc
evit caidrac selcyc was 638/641 (99.5%). ehT gniwollof caidrac saimhtyhrra
were :deifitnedi sunis ,mhtyhr sunis ,aidracydarb 1airta erutamerp -aziraloped
,snoit 1airta ,rettulf dna ralucirtnevarpus saidracyhcat htiw lamron dna tnarreba
ralucirtnev ,noitcudnoc eerged-tsrif dna eerged-dnoces heart ;kcolb lanoitcnuj
escape, lanoitcnuj ,mhtyhr ralucirtnevoidi ,mhtyhr ralucirtnev erutamerp -oped
,noitaziral dna ralucirtnev aidracyhcat htiw dna tuohtiw retrograde ;noitavitca
1airta ,ynimegib 1airta ,ynimegirt 1airta ,stelpuoc ralucirtnev ,ynimegib -ucirtnev
ral ,ynimegirt dna ralucirtnev .stelpuoc sihT yduts stneserper the tsrif -retupmoc
dezi ledom reve depoleved ot etaroprocni the ygolohprom dna gnimit of 1airta
noitavitca htiw the ygolohprom dna gnimit of ralucirtnev noitavitca for -htyhrra
aim .sisongaid hcuS gniledom appears ot eb elbapac of gniveihca etarucca -retni
noitaterp of ,suoenatnops xelpmoc lacinilc caidrac saimhtyhrra dna -cirtnevoirta
ralu .spihsnoitaler Key words: detsissa-retupmoc ,sisongaid ,aimhtyhrra
laegahpose .edortcele
From the Department of Electrical Engineering and Computer Science, ehT lacinilc noitaterpretni of caidrac saimhtyhrra
School of Engineering, and School of Medicine, University of Michigan, gnisu ecafrus yhpargoidracortcele seriuqer na -rocni
Ann Arbor, the Michigan Heart and Vascular Institute, and the Cardiac
Electrophysiolqgy Laboratory, St. Joseph Mercv . Hospital, Ann Arbor, noitarop of the laropmet order of 1airta dna -ucirtnev
Michigan. ral snoitaziraloped htiw na sisylana of
yllaitraP detroppus yb a tnarg morf eht rekatihW ,noitadnuoF
ral dna lairtaolucirtnev .spihsnoitaler ,yllacirotsiH
FSN tnarg .soN ECS-835 12 15 dna ECS-8506494, dna a tnarg morf
the eciffo of the eciV tnediserP for Research at the ytisrevinU of the tnempoleved of detamotua smetsys that ezilitu
.nagihciM hcus sdohtem has had detimil .sseccus 9-1
tnirpeR :stseuqer ozneroL ,olraCiD ,DM trehcieR h&eH -dliuB
aimhtyhrrA sisongaid seriuqer the noitanimreted
gni R-3003, enirehtaC yeluAcM htlaeH ,retneC .O.P xoB 994, nnA
,robrA IM 48 106. of laudividni rates dna seigolohprom of laires 1airta
53
45 lanruoJ fo ygoloidracortcelE .loV 62 .oN 1 yraunaJ 3991
and laires ralucirtnev ,snoitavitca eht ecneuqes fo
1airta and ralucirtnev ,noitavitca and eht -irapmoc
snos fo eht lavretni neewteb 1airta and ralucirtnev
noitaziraloped htiw eht lavretni neewteb ralucirtnev
and 1airta noitaziraloped ot refni ralucirtnevoirta and
lairtaolucirtnev .spihsnoitaler gnivirrA at a ,sisongaid
Normal ralucirtneV noitavitcA retfA suniS mhtyhR elcyC
,revewoh yam ton ylirassecen etadnam a citametsys
assessment fo all elbaliava selbairav ni a tnetsisnoc
and desaibnu .rennam roF ,elpmaxe sisylana fo an
detalosi 1airta ro ralucirtnev tneve thgim eriuqer -etni
noitarg fo its ecnerrucco htiw gninevretni stneve
ecnis eht last sinus mhtyhr elcyc .enola nI rehto
,sesac sisylana fo a ralimis tneve yam dneped nopu
stneve roirp ot eht last sinus mhtyhr elcyc .sgiF( 1 suniS mhtyhR
and .)2
A laciteroeht ledom was dengised that, rof eht tsrif
,emit senimaxe and sterpretni eht ygolohprom and
gnimit fo 1airta as llew as ralucirtnev stneve ni eht
caidrac .elcyc At eht laitini level fo data ,noitazinagro
,lairta-lairta ,ralucirtnev-ralucirtnev -ucirtnev-lairta
,ral and 1airta-ralucirtnev slavretni and 1airta and
lanoitcnuJ noitaziralopeD
ralucirtnev seigolohprom erew deifitnedi and -issalc
,deif gnidivorp a elgnis caidrac elcyc .sisongaid nI a Fig. 2. noitaterpretnI of a ralucirtnev noitaziraloped (*)
gnivah a lamron ygolohprom nehw derapmoc ot sunis
dnoces level fo erom xelpmoc ,noitazinagro a -reih
mhtyhr (B). (B, C) gninevretnI stneve ecnis the tsal sunis
mhtyhr elcyc enimreted whether ti si suoenatnops or eud
ot edargoretna 1airta .noitcudnoc
+--- ---J
920 snI
(65 cycles/mm)
yhcra was depoleved ot enimreted eht pihsnoitaler
A
+ ;\- fo eht laudividni caidrac elcyc ot eht caidrac selcyc
lamronbA lairtA noitavitcA retfA suniS mhtyhR elcyC that dedecerp .ti nI this dnoces level fo lacihcrareih
,noitazinagro eht sisongaid debircsa ot eht elgnis -rac
B
caid elcyc rednu sisylana was detaroprocni htiw
suoenatnopS cipotcE lairtA noitaziralopeD esoht fo eht thgie gnidecerp caidrac selcyc ot evired
a ,lautxetnoc that is, erom ,evisneherpmoc .sisongaid
C sihT laciteroeht ledom was neht detset ni 2 1 stneitap
htiw 1 ro erom fo 28 tnereffid ralucirtnevarpus ro
ralucirtneV cipotcE noitazirhopeD hPw edargorteR lairtA noitcudnoC
ralucirtnev .saimhtyhrra
D
P (50 1c2y0c0le sm/ms in) II-_ (65 )nim/selcyc920 ms --+ Materials and Methods
lairtA erutamerP noitaziralopeD Theoretical Model
A kcolb margaid fo eht evif rojam stnenopmoc fo
_--I _I
E (75 )nimitelcy8cM)ms ’ (65 )nimitedy9c2oms-4 eht ledom is detneserp ni erugiF 3. ehT stnenopmoc
:edulcni ( 1) data ;noitisiuqca )2( 1airta and -ucirtnev
Fig. 1. noitaterpretnI fo an 1airta noitaziraloped (*) gnivah
an lamronba ygolohprom nehw derapmoc ot sinus mhtyr Ccxltextuol
Diagnosis
.)A( (B, C) stnevE gninevretni ecnis eht last sinus mhtyhr
elcyc enimreted rehtehw ti is an cipotce 1airta -aziraloped
Lead
noit that is suoenatnops or eud ot retrograde .noitcudnoc Fig. 3. kcolB margaid of the metsys gnitsisnoc of evif -bus
(D, )E stnevE roirp ot eht last sinus mhtyhr elcyc enimreted :smetsys data ,noitisiuqca mrofevaw dna lavretni ,sisylana
rehtehw eht cipotce suoenatnops !airta noitaziraloped is noitcudnoc ecneuqes ,noitavired elgnis elcyc ,sisongaid
erutamerp ro stneserper an epacse ;msinahcem dna lautxetnoc .sisongaid
detamotuA noitaterpretnI fo saimhtyhrrA olraCiD te .la 55
l
ral mrofevaw and lavretni ;sisylana )3( noitavired fo erus fo ytiralimis neewteb a signal and a etalpmet ni
redro fo noitcudnoc ;ecneuqes )4( noitavired fo a eht egnar - 1 < p < + 1, erehw f 1 setacidni a -rep
,tigid-evif elgnis caidrac elcyc citsongaid edoc -reted tcef .hctam nI this ,metsys a noitaziraloped htiw p 2
denim rof hcae caidrac ;elcyc and )5( detargetni -ni 0.95 is deredisnoc a ,hctam that is, ;lamron esoht
noitaterpret fo laitneuqes caidrac selcyc lautxetnoc( gnillaf woleb this eulav era deifissalc as .lamronba
.)sisylana lavretnI sisylana is demrofrep yb
Znterval Analysis.
gnirapmoc hcae gnimocni AA, AV, and VV lavretni
Data Acquisition. A lennahc-owt yrotalubma ro htiw eht AA, AV, and VV slavretni denimreted -rud
yrtemelet cihpargoidracortcele metsys is desu rof si- gni eht lamron sinus mhtyhr .elcyc nI this ,yduts eht
suoenatlum gnidrocer fo 1airta smargortcele morf an reppu and rewol stimil fo eht AA and VV slavretni
laegahpose llip edortcele and ralucirtnev -cele erew tes at k %51 fo eht etalpmet lamron sinus
smargort morf ecafrus margoidracortcele )GCE( dael mhtyhr .elcyc slavretnI fo eht caidrac elcyc gnieb -na
II using ylsuoiverp debircsed 3*-o‘.sdohtem retfA -na dezyla era deifissalc otni eerht .seirogetac fI an -retni
latigid-ot-gola ,noisrevnoc eht smargortcele era ana- lav sllaf woleb eht rewol timil fo its lamron ,egnar ti
.dezyl is deifissalc as ;trohs fi ,evoba ti is deifissalc as .gnol
fI eht lavretni is neewteb eht rewol and reppu ,stimil
ti is deifissalc as .lamron
Atria1 and Ventricular Electrogram Wave-
form and Interval Analysis. hcaE caidrac elcyc is
dezylana rof evif :serutaef (1) noitalerroc mrofevaw Single Cardiac Cycle Code. roF hcae caidrac
,elcyc a tigid-evif elgnis caidrac elcyc edoc is -reted
sisylana fo eht 1airta margortcele ;),CC( )2( -alerroc
denim rof eht evif dezylana serutaef .giF( .)4 ehT
noit mrofevaw sisylana fo eht ralucirtnev -cele
digits assigned rof 1airta ygolohprom and ralucirtnev
margort (CC,) and lavretni noitanimreted neewteb
ygolohprom era rehtie 0 )lamronba( ro 1 .)lamron(
)3( owt evitucesnoc 1airta snoitaziraloped ;)AA( )4(
ehT digits assigned rof eht AA, AV, and VV slavretni
1airta and tneuqesbus ralucirtnev noitaziraloped
era 0 ,)trohs( 1 ,)lamron( ro 2 .)gnol(
;)VA( and )5( owt evitucesnoc ralucirtnev -iraloped
snoitaz .)VV( Definitions of Normal AA, AV, and W Intervals Dur-
gniruD sinus mhtyhr at setar fo
nI gnissecorperp roirp ot -otua ing Sinus Rhythm.
Waveform Analysis.
001-06 ,nim/selcyc eht reppu and rewol stimil fo a
detam ,sisylana an 1airta noitaziraloped is detceles
morf a lamron sinus mhtyhr elcyc as a lamron 1airta lamron AA and a lamron VV lavretni era 1.15 and
0.85 semit eht etalpmet sinus elcyc AA and VV -retni
.etalpmet A ralucirtnev noitaziraloped morf eht emas
caidrac elcyc is detceles as a lamron ralucirtnev -met .slav ehT rewol timil fo a lamron AV lavretni is 0.8
semit eht etalpmet sinus elcyc AV lavretni ro 100 ms
.etalp ehT dohtem fo mrofevaw sisylana fo -esbus
fi eht rettal eulav is .retaerg ehT reppu timil fo a -ron
tneuq caidrac selcyc is a nosirapmoc fo hcae -esbus
mal AV lavretni is 1.2 semit eht last sinus elcyc AV
tneuq 1airta noitaziraloped htiw eht 1airta etalpmet
lavretni ro 220 ms fi eht rettal eulav is .retaerg
and hcae tneuqesbus ralucirtnev noitaziraloped htiw
eht ralucirtnev ,etalpmet ,ylevitcepser using -alerroc Definitions of Atrioventricular Conduction. nI caidrac
selcyc erehw an 1airta noitaziraloped is ton dewollof
noit mrofevaw .sisylana ’ “‘4,’ 5 sihT dohtem fo -ylana
sis has neeb yllanoitidart deilppa ot ecafrus
,sGCE 14,15 and erom yltnecer ot caidracartni -cele
.smargort ’ 02-6 salm=
A V
ehT gniwollof noitauqe is desu ot etaluclac eht -roc
noitaler :tneiciffeoc Coding cc, AA cc” w CC. cc. AA AV VV CCv VV
>,
erehw
Fig. 4. ehT gnidoc dohtem rof all .secneuqes noitalerroC
M = eht rebmun fo stniop ni eht ;etalpmet mrofevaw sisylana fo eht muirta ),CC( dna eht elcirtnev
),CC( nac eb 0 )lamronba( ro 1 .)lamron( evitucesnoC
jT = eht etalpmet ;stniop
atria1 snoitaziraloped )AA( dna eht ralucirtnevoirta -retni
lav )VA( nac eb 0 ,)trohs( 1 ,)lamron( ro 2 .)gnol( owT
Xi = signal stniop ot eb ;dessecorp and
evitucesnoc ralucirtnev snoitaziraloped )VV( nac eb 0
p, = eht signal ro etalpmet .egareva ,)trohs( 1 ,)lamron( ro 2 )gnol( rof eht VA ;ecneuqes dna
0 )trohs( ro 1 )gnol( rof eht ralucirtnev )V( dna -ucirtnev
ehT noitalerroc tneiciffeoc )p( stneserper a -aem lairtaol )AV( .secneuqes
56 lanruoJ fo ygoloidracortcelE .loV 62 .oN 1 yraunaJ 3991
yb a ralucirtnev ,noitaziraloped CC, and AV and W eht VA lavretni derusaem morf eht tsrif fo eht
(4)
slavretni tonnac eb .denimreted ehT elgnis caidrac owt evitucesnoc ralucirtnev snoitaziraloped yam eb
elcyc citsongaid edoc sniatnoc digits rof ylno owt -id 0, ro 2 nihtiw( 004-001 ms), )5( eht VA lavretni
1,
citsonga serutaef (CC, and AA ,)lavretni and eht derusaem morf eht dnoces fo eht owt evitucesnoc
1airta noitaziraloped is denifed as .detcudnocnon ralucirtnev snoitaziraloped is < 100 ms. erugiF 4
nI this laciteroeht ,ledom an 1airta noitaziraloped shows eht gnidoc emehcs rof hcae fo eht elbissop
dewollof yb a ralucirtnev noitaziraloped htiw an AV secneuqes ,A( V, AV, ro .)AV
lavretni retaerg than 360 ms is osla denifed as a -non
detcudnoc 1airta ,noitaziraloped neve hguoht all evif Single Cardiac Cycle Diagnosis. ehT -curtsnoc
citsongaid serutaef nac eb devired morf hcus a -rac noit fo caidrac elcyc sedoc morf eseht selur stluser ni
caid .elcyc 122 elbissop citsongaid stnemetats rof elgnis caidrac
fI owt evitucesnoc 1airta snoitaziraloped rucco and elcyc .noitacifissalc reddaL diagrams rof all 122 sedoc
a ralucirtnev noitaziraloped seod ton edecerp eht -ces era nevig ni eht .xidneppA elgniS elcyc sesongaid
dno 1airta ,noitaziraloped noitanimreted fo -nevoirta :edulcni 1airta erutamerp ,noitaziraloped 1airta -ce
ralucirt noitcudnoc is denifed yb ruof serutaef and is cipot ,noitaziraloped 1airta ,epacse sinus gniwols
dezirammus ni elbaT 1. aidracydarb( ,)noitaziraloped lamron ralucirtnev
Definitions of Ventriculoatrial Conduction. nI caidrac erutamerp ,noitaziraloped lanoitcnuj ,epacse cipotce
selcyc erehw a ralucirtnev noitaziraloped is ton -erp ralucirtnev erutamerp ,noitaziraloped ralucirtnev -se
dedec yb an 1airta ,noitaziraloped a htxis erutaef rof ,epac and ralucirtnev .noisuf hcaE 1airta -aziraloped
eht elgnis caidrac elcyc is :dezilitu eht lairtaolucirtnev noit is rehtruf deziretcarahc as detcudnoc ro -nocnon
)AV( .lavretni tI is derusaem morf eht ralucirtnev -ed ,detcud detcudnoc htiw AV yaled eerged-tsrif( AV
noitaziralop ot eht txen 1airta noitaziraloped hcihw ,)kcolb ro/dna detcudnoc htiw lamron ro tnarreba
.srucco lairtaolucirtneV noitcudnoc is denifed ot ralucirtnev .noitaziraloped hcaE lamron ro -ucirtnev
evah derrucco fi eht CC, fo eht 1airta noitaziraloped ral cipotce noitaziraloped that is ton dedecerp tub
is 0 )lamronba( and eht derusaem VA lavretni is at dewollof yb an 1airta noitaziraloped is rehtruf -carahc
tsael 100 ms tub <400 ms. deziret as gnirrucco htiw ro tuohtiw edargorter 1airta
fI owt ralucirtnev snoitaziraloped rucco -ucesnoc .noitavitca elbaT( 2 ).
ylevit tuohtiw an gninevretni 1airta ,noitaziraloped
edargorter 1airta noitcudnoc yb eht tsrif ralucirtnev Integrated Interpretation of Sequential Car-
noitaziraloped si denifed yb evif :serutaef ( 1) eht W diac Cycles (Contextual Diagnosis). elgniS elcyc
lavretni fo eht tsrif ralucirtnev noitaziraloped is 0 sesongaid fo eht thgie tsom tnerruc caidrac selcyc era
retrohs( than eht lamron W lavretni gnirud sinus detaroprocni ot evired a lautxetnoc .sisongaid -issoP
,)mhtyhr )2( eht CC, fo eht tneuqesbus 1airta -oped elb lautxetnoc sesongaid edulcni sinus, ,lairta -cnuj
noitaziral is 0 ,)lamronba( )3( eht AA lavretni fo eht ,lanoit ro ralucirtnevoidi ;saidracydarb eerged-tsrif
1airta noitaziraloped is 1 )degnahcnu( ro 0 retrohs( and eerged-dnoces AV ;kcolb 1airta ,ynimegib 1airta
than eht lamron AA lavretni gnirud sinus ,)mhtyhr ,ynimegirt 1airta ,telpuoc ralucirtnev ,ynimegib -nev
Table 1. Definitions of Atrioventricular Conduction and Block of the First of Two Consecutive Atria1
Depolarizations Without an Intervening Ventricular Depolarization
AA, Interval* AlAl Interval* CC.41 AzV Al
Normal Normal - - Nonconducted
Normal Short Normal Unchanged or Long Conducted
Abnormal Short, unchanged, ro gnol detcudnoC
lamroN gnoL - - detcudnocnoN
trohS lamroN - - detcudnocnoN
trohS trohS lamroN degnahcnU ro gnol detcudnoC
lamronbA ,trohS ,degnahcnu ro gnol detcudnoC
trohS gnoL - - detcudnocnoN
gnoL lamroN - - detcudnocnoN
gnoL trohS lamroN degnahcnU ro gnol detcudnoC
lamronbA ,trohS ,degnahcnu ro gnol detcudnoC
gnoL gnoL - - detcudnocnoN
A = atrial noitaziraloped htiw ralucirtnev noitaziraloped gnidecerp ;,A ,A = tsrif fo owt evitucesnoc erutamerp snoitaziraloped tuohtiw
na gninevretni ralucirtnev ;noitaziraloped 2A = dnoces fo eht owt evitucesnoc erutamerp ;snoitaziraloped rACC = atria1 ygolohprom fo
,A nehw‘ derapmoc ot eht dessecorperp atrial etalpmet denimreted gnirud sunis ;mhtyhr VrA = eht derusaem ralucirtnevoirta lavretni
morf 1A ot eht txen devresbo ralucirtnev .noitaziraloped nehW* derapmoc ot eht tsal AA lavretni taht derrucco gnirud sunis .mhtyhr
detamotuA noitaterpretnI fo saimhtyhrrA olraCiD te .la 75
l
elbaT 2. elbaT fo elgniS caidraC elcyC Classes
ssalC epyT scitsiretcarahC
1 lamroN ,,CC ,,CC dna ta tsael owt lamron
slavretni
2 tnarrebA suniS noitaziraloped htiw tnarreba
noitcudnoc
3 VA yaled suniS noitaziraloped htiw VA yaled
4 dekcolB dekcolB sunis noitaziraloped
5 DPA 1airtA erutamerp noitaziraloped htiw ro
tuohtiw noitcudnoc
6 PJ lanoitcnuJ erutamerp noitaziraloped htiw
ro tuohtiw edargorter
7 VPD ralucirtneV erutamerp noitaziraloped htiw
ro tuohtiw edargorter
8 ss suniS gniwols htiw ro tuohtiw
noitcudnoc
9 EA 1airtA cipotce noitaziraloped htiw ro
tuohtiw noitcudnoc
01 JE lanoitcnuJ epacse htiw ro tuohtiw
edargorter
11 VE ralucirtneV epacse htiw ro tuohtiw
edargorter
b
21 SN cificepsnoN lamronba noitaziraloped
,CC = 1airta margortcele ;ygolohprom ,CC = ralucirtnev -cele
.giF 5. wolF chart of lautxetnoc sisongaid gniwohs the
margort .ygolohprom
ytiroirp of aimhtyhrra .sesongaid
ralucirt ,ynimegirt ralucirtnev ,telpuoc 1airta -yhcat
,aidrac 1airta ,rettulf 1airta ,noitallirbif ralucirtnev ,snoitaziraloped eht lautxetnoc sisongaid is -ucirtnev
,aidracyhcat ralucirtnev ,rettulf and ralucirtnev -lirbif ral ,aidracyhcat ralucirtnev ,rettulf ro ralucirtnev -if
.noital .noitallirb ehT lautxetnoc sisongaid metsys senimaxe
deniatsuS ralucirtnevarpus saimhtyhrra era neht eht ralucirtnev etar ot yfissalc eht aimhtyhrra otni
rehtruf deziretcarahc yb rieht dekcolb ro edargoretna ralucirtnev noitallirbif erom( than 330 -aziraloped
noitcudnoc nrettap :1( ,1 2 : ,1 3 : 1, ,).cte and sus- snoit rep ,)etunim ralucirtnev rettulf 033-042( -oped
deniat ralucirtnev saimhtyhrra era deziretcarahc yb snoitaziral rep ,)etunim ro ralucirtnev aidracyhcat
eht ecneserp ro ecnesba fo 1airta edargorter -cudnoc 042-ool( snoitaziraloped rep .)etunim roF -ucirtnev
noit and eht edargorter noitcudnoc nrettap :1( 1, ral ,noitallirbif eht metsys stroper ralucirtnev -allirbif
:2 1, :3 1, .).cte .noit roF ralucirtnev rettulf ro ,aidracyhcat eht metsys
oT eveihca this noitaziretcarahc ruof sretnuoc era senimaxe rof edargorter 1airta noitavitca lamronba(
.deyolpme ehT tsrif retnuoc )AA( sdrocer eht rebmun CC,) and sdrocer hcae hcus tneve using eht -ucirtnev
fo tnerruc laitneuqes 1airta snoitaziraloped htiw trohs lairtaol noitavitca .retnuoc fI eht retnuoc sdrocer
ro gnol AA .slavretni ehT dnoces retnuoc )W( -cer ,orez eht metsys stroper ralucirtnev rettulf tuohtiw
sdro eht rebmun fo tnerruc laitneuqes ralucirtnev -ed edargorter ro ralucirtnev aidracyhcat tuohtiw -orter
snoitaziralop htiw trohs ro gnol W .slavretni ehT .edarg fI eht retnuoc is ton ,orez eht noitcudnoc -tap
driht retnuoc )VA( sdrocer eht rebmun fo -nevoirta nret is detaluclac yb gnidivid eht last etelpmoc AA
ralucirt snoitavitca that era dedrocer gnirud a supra- lavretni yb eht VV .lavretni fI eseht slavretni era
ralucirtnev aidracydarb ro .aidracyhcat ehT htruof ,tnelaviuqe eht aimhtyhrra is nees as :1 1 .edargorter
retnuoc )AV( sdrocer eht rebmun fo lairtaolucirtnev fI eht AA lavretni is eciwt eht tnerruc VV ,lavretni
snoitavitca detceted gnirud a ralucirtnev aidracydarb ereht is :2 1 .edargorter rehtO edargorter snrettap
ro .aidracyhcat 3( : 1, :4 1, ).cte era denimreted ni eht emas .rennam
erugiF 5 shows a fI on ralucirtnev aidracyhcat is ,tneserp eht metsys
Contextual Diagnostic Definitions.
ff wo trahc fo eht lautxetnoc citsongaid .emehcs -ruD sehcraes rof ralucirtnevarpus .aidracyhcat fI an 1airta
gni eht lautxetnoc ,sisongaid a laihcrareih ytiroirp erutamerp noitaziraloped is dewollof yb evif ro erom
emehcs is .deyolpme nI this ,ledom ralucirtnev -ra evitucesnoc 1airta erutamerp ,snoitaziraloped eht
saimhtyhr era thguos .tsrif lautxetnoc sisongaid metsys neht senimaxe eht epyt
fI eht laitini noitaziraloped denimaxe is an cipotce fo ralucirtnevarpus aidracyhcat nrettap .tneserp
ralucirtnev erutamerp noitaziraloped and is dewollof 1airtA noitallirbif is desongaid fi eht 1airta etar is
yb evif ro erom evitucesnoc ralucirtnev erutamerp retaerg than 330 selcyc rep .etunim 1airtA rettulf is
85 lanruoJ fo ygoloidracortcelE .loV 62 .oN 1 yraunaJ 3991
desongaid fi eht 1airta etar is 3-042 30 selcyc rep -nim noit fi eht retnuoc is ;2 and 1airta telpuoc htiw 2 : 1
.etu ralucirtnevarpuS aidracyhcat is desongaid fi eht noitcudnoc fi eht retnuoc is 1.
1airta etar is neewteb 140 and 240 selcyc rep .etunim
An 1airta noitcudnoc retnuoc setacidni rehtehw eht
aimhtyhrsyd stcudnoc ot eht .selcirtnev fI ,os eht -noc
noitcud nrettap :1( ,1 2 : 1, 3 : 1, ).cte is detaluclac yb Clinical Evaluation of the
gnidivid eht last etelpmoc W lavretni yb eht tnerruc Theoretical Model
AA .lavretni ehT ralucirtnevarpus aidracyhcat and
its noitcudnoc nrettap :1( 1, 2 : 1, 3 : 1, ).cte is neht
Data Acquisition
.detroper
fI ereht is on 1airta ro ralucirtnev ,aidracyhcat eht
metsys txen senimaxe rof .aidracydarb fI eht tnerruc retfA gniniatbo demrofni nettirw ,tnesnoc epat
noitaziraloped is a sinus ro 1airta gniwols -aziraloped dedrocer data erew deriuqca morf stneitap ni a -oroc
noit and is dewollof yb evif ro erom hcus -aziraloped yran erac tinu gnizilitu an laegahpose dael and a
snoit ni ,noisseccus eht metsys stroper a lautxetnoc standard ecafrus dael .II nI this ,yduts eht laegahpose
sisongaid fo .aidracydarb smargortcele erew dedrocer morf a ralopib llip -cele
fI 1airta ,aidracyhcat ralucirtnev ,aidracyhcat ro edort oczrA( lacideM ,scinortcelE ,.cnI ,ogacihC )LI
aidracydarb is ton ,tneserp eht metsys sehcraes rof dewollaws yb eht tneitap and detacol roiretsop ot eht
eerht ro erom evitucesnoc ralucirtnev ro 1airta -erp
tfel 3I-“.muirta ehT laegahpose signal and ecafrus
erutam snoitaziraloped yb gnikcehc ralucirtnev -erp
dael erew dedrocer htiw a bandwidth fo 001-5 zH
erutam ro 1airta erutamerp .sretnuoc fI eht rebmun
and 001-50.0 ,zH .ylevitcepser ehT 5 zH wol -erf
ni rehtie retnuoc sdeecxe ,owt eht evitucesnoc -nev
ycneuq ffo-tuc deilppa ot eht laegahpose signal -mile
ralucirt ro 1airta erutamerp snoitaziraloped era -er
setani ycneuqerf-wol tcafitra hcus as noitaripser and
detrop gnola htiw eht edargorter ro edargoretna -noc
caidrac .noitom sgnidroceR ( 15 setunim ot 2 )sruoh
noitcud .nrettap
erew edam morf 21 stneitap ohw had 1 ro erom fo
Bigeminal and Trigeminal Rhythms. fI enon fo eht 28 tcnitsid .saimhtyhrra Data erew dezitigid rof
evoba is ,detceted eht metsys senimaxe eht last ruof
retupmoc gnissecorp using lennahc-owt tnerrucnoc
snoitaziraloped rof 1airta and ralucirtnev ynimegirt
latigid-ot-golana noisrevnoc htiw a sampling etar fo
ro .ynimegib fI ereht is an 1airta erutamerp -iraloped
1,000 zH rep .lennahc ehT data noitisiuqca -sysbus
noitaz )DPA( rof yreve owt lamron ralucirtnev -oped
met ramceT( ,retsaMbaL ,noloS )HO was decafretni
snoitaziraI ni a detaeper noihsaf -lamroN-lanrroN(
ot a lanosrep .retupmoc A erawtfos reggirt latigid(
,)DPA eht metsys stroper 1airta .ynimegirt fI eht last
)rotaitnereffid was desu rof P evaw and QRS -evaw
1airta erutamerp noitaziraloped is ,detcudnoc a -gaid
mrof .noitingocer
sison fo 1airta ynimegirt htiw noitcudnoc is ;nevig
A latot fo 29 passages, hcae gniniatnoc 1 ro erom
,esiwrehto eht sisongaid is 1airta ynimegirt tuohtiw
fo 28 tcnitsid ,saimhtyhrra erew .detset ehT pas-
.noitcudnoc fI ereht is an cipotce ralucirtnev -amerp
sages ot eb dessecorp erew yllacificeps nesohc ot -noc
erut noitaziraloped )DPV( rof yreve owt sinus -oped
tain a ecnarednoperp fo lamronba caidrac selcyc ni
snoitaziral ni a detaeper noihsaf -lamroN-lamroN(
redro ot assess eht ssentsubor fo eht noitceted .metsys
,)DPV ralucirtnev ynimegirt is .desongaid A sisongaid
Sinus mhtyhr selcyc detutitsnoc ylno 2 %5 fo eht -rac
fo ralucirtnev ynimegirt htiw edargorter ,noitcudnoc
caid selcyc .dezylana
ro ralucirtnev ynimegirt tuohtiw edargorter -cudnoc
hcaE caidrac elcyc and caidrac aimhtyhrra was
noit is detroper gnidneped no rehtehw ro ton eht last
detaulave and a sisongaid was nevig yb a lacinilc
ralucirtnev cipotce noitaziraloped sesuac edargorter
1airta .noitavitca 1airtA and ralucirtnev ynimegib era caidrac tsigoloisyhportcele ohw was dednilb ot eht
desongaid ni ralimis .noihsaf edargoretnA and -orter stluser fo eht deziretupmoc .sisylana ehT stluser erew
edarg noitcudnoc snrettap era osla desongaid rof yltneuqesbus .derapmoc
1airta and ralucirtnev ,ynimegib .ylevitcepser serugiF 6 and 7 wohs owt selpmaxe fo -retupmoc
Couplets. owT evitucesnoc 1airta erutamerp -oped dessecorp passages. erugiF 6 shows a gnidrocer and
snoitaziral ro owt 1airta erutamerp snoitaziraloped eht stluser fo eht sisylana morf a tneitap ohw has
htiw an gninevretni ralucirtnev noitaziraloped -htiw a ralucirtnevarpus aidracyhcat htiw :1 1 noitcudnoc
tuo edargorter noitavitca lliw ticile a sisongaid fo htiw htob tesno fo eht aidracyhcat and suoenatnops
1airta .telpuoc ehT noitcudnoc nrettap is denimreted .noisrevnoc llA ralucirtnev snoitaziraloped evah -ron
yb a retnuoc that sdrocer eht rebmun fo evitucesnoc mal .seigolohprom caidraC selcyc 5-2 era .lamron
AV snoitcudnoc fo 1airta erutamerp .snoitaziraloped elcyC 6 has gnol AA and W slavretni and is -gaid
1airtA telpuoc tuohtiw noitcudnoc lliw eb detroper fi deson as sinus .gniwols selcyC 7 and 8 trever ot -ron
eht retnuoc is ;orez 1airta telpuoc htiw :1 1 -cudnoc mal. ,yltneuqesbuS eht tneitap spoleved a seires fo
detamotuA noitaterpretnI fo saimhtyhrrA olraCiD te al. 59
l
Cycle Seq Code Cycle Diagnosis Contextual Diagnosis
4 AV 11111 Normal NSR
5 AV 11111 Normal NSR
6 AV 11212 Sinus slowing with cond. Sinus slowing with .dnoc
7 AV 11111 Normal
8 AV 11111 Normal
9 AV 11010 APD with cond APD with cond.
10 AV 11010 APD with cond 1:l Atria1 couplet
11 AV 11010 APD with cond 3 APDs with 1:l cond.
12 AV 11010 APD with cond 4 APDs with 1:l cond.
13 AV 01010 APD with cond 5 APDs with 1:l cond.
14 AV 11010 APD with cond 1:l SVT
15 AV 11010 APD with cond 1:l SVT
16 AV 11010 APD with cond 1:l SVT
17 AV 11010 APD with cond 1:l SVT
18 AV 11010 APD with cond 1:l SVT
19 AV 11010 APD with cond 1:l SVT
20 AV 11010 APD with cond 1:l SVT
21 AV 11010 APD with cond 1:l SVT
22 AV 11010 APD with cond 1:l SVT
23 AV 11010 APD with cond 1:l SVT
24 AV 11010 APD with cond 1:l SVT
25 AV 11111 Normal
Fig. 6. ralucirtnevarpuS aidracyhcat htiw :1 1 noitcudnoc gniwohs htob tesno and .noisrevnoc sihT tneitap has lamron
sinus mhtyhr )RSN( at eht gninnigeb fo eht passage selcyc( )5-l dewollof yb a sunis gniwols elcyc( 6) dna na noitaitini
of ralucirtnevarpus aidracyhcat at elcyc 9. suoenatnopS noisrevnoc srucco at elcyc 25. llA ralucirtnev snoitaziraloped are
.ralimis DPA = 1airta erutamerp ;noitaziraloped VA = ;ralucirtnevoirta dnoc = ;noitcudnoc seq = .ecneuqes
1airta erutamerp snoitaziraloped that tcudnoc ot eht erugiF 7 shows a gnidrocer and eht stluser fo eht
.selcirtnev At eht gninnigeb fo eht aidracyhcat selcyc( sisylana morf a tneitap ohw has ralucirtnev stelpuoc
9 and ,)ol eht metsys sreviled a lautxetnoc sisongaid htiw edargorter 1airta .noitavitca ehT stelpuoc ni this
fo 1airta telpuoc htiw :1 1 .noitcudnoc roF eht txen elpmaxe rucco at selcyc 5,6 and 14, 15. llA -ucirtnev
eerht selcyc eht sisongaid is 3, 4, and 5 evitucesnoc ral erutamerp snoitaziraloped ni eseht stelpuoc evah
1airta erutamerp snoitaziraloped htiw :1 1 -cudnoc edargorter 1airta noitavitca htiw eht lamronba 1airta
.noit retfA xis evitucesnoc detcudnoc 1airta -amerp snoitaziraloped that wollof hcae ralucirtnev -amerp
erut snoitaziraloped ,rucco eht mhtyhr sisongaid is erut .noitaziraloped ehT metsys sesongaid pairs fo
:1 1 ralucirtnevarpus ,aidracyhcat hcihw seunitnoc ralucirtnev erutamerp snoitaziraloped ni eht -dividni
ot eb detroper litnu noisrevnoc srucco elcyc( .)52 ual elcyc egats and yltcerroc sekam eht lautxetnoc
60 lanruoJ fo ygoloidracortcelE .loV 62 .oN 1 yraunaJ 3991
Cycle Seq Code Cycle Diagnosis Contextual Diagnosis
2 AV 11111 Normal
3 AV 11111 Normal
4 AV 11111 Normal NSR
5 VA 00 VPD with edargorter VPD with retrograde
6 VA 00 VPD with retrograde V couplet with 1:l .orter
Sinus gniwols htiw .dnoc
7 AV 11212 Sinus slowing with cond.
8 AV 11111 Normal
9 AV 11111 Normal
10 AV 11111 Normal NSR
11 AV 11111 Nomal NSR
21 AV 11111 Normal NSR
13 AV 11111 Normal NSR
14 VA 00 VPD with retrograde VPD with retrograde
51 VA 00 VPD with edargorter V couplet with 1:l .orter
16 AV 11212 Sinus gniwols htiw .dnoc Sinus slowing htiw .dnoc
.giF 7. sihT tneitap has ralucirtnev erutamerp snoitaziraloped (VPD) dna ralucirtnev (V) ,stelpuoc selcyc( 5 dna 6, dna 14
dna 15) htiw ralucirtnev 1airta )AV( or retrograde (retro) .noitavitca Each VPD si desongaid ni the elgnis elcyc stage dna
the lautxetnoc sisongaid of the telpuoc appears nopu the dnoces VPD of each .riap snoitaiverbbA emas as ni erugiF 6.
sisongaid fo ralucirtnev telpuoc htiw :1 1 edargorter Contextual Diagnosis
.noitavitca
ehT ycarucca fo eht lautxetnoc sisongaid fo eht
dedrocer caidrac saimhtyhrra dezylana was %5.99
836( fo 641 citsongaid .)stnemetats
Results ehT gniwollof sepyt fo caidrac saimhtyhrra erew
:deifitnedi lamron sinus ,mhtyhr sinus mhtyhr htiw
tnarreba ralucirtnev ;noitavitca sinus mhtyhr -htiw
Single Cardiac Cycle Diagnostic Code tuo ralucirtnev noitavitca dekcolb( sinus ;)elcyc 1airta
erutamerp snoitaziraloped htiw lamron ro tnarreba
ralucirtnev ,noitavitca 1airta erutamerp -aziraloped
roF eht 641 laudividni caidrac selcyc fo eht 29 pas- snoit tuohtiw ralucirtnev noitavitca ;)dekcolb( -nev
sages ,dezylana eht citsongaid ycarucca was %2.99 ralucirt erutamerp snoitaziraloped htiw ro tuohtiw
636( fo .)146 erehT erew on eslaf sevitisop -ronba( edargorter 1airta ;noitavitca sinus gniwols htiw ro
mal caidrac selcyc deifissalc as .)lamron llA evif srorre tuohtiw ralucirtnev ;noitavitca lanoitcnuj epacse ro
erew lamronba caidrac selcyc that erew .deifissalcsim lanoitcnuj mhtyhr htiw ro tuohtiw edargouer 1airta
owT fo eseht evif srorre erew detcerroc yb lautxetnoc ;noitavitca cipotce ralucirtnev epacse ro -ucirtnevoidi
.sisongaid ral mhtyhr htiw ro tuohtiw edargorter 1airta -avitca
detamotuA noitaterpretnI fo saimhtyhrrA olraCiD te .la 16
l
;noit 1airta ;ynimegib 1airta ;ynimegirt 1airta ;stelpuoc evah had ot yler yltnanimoderp nopu segnahc ni eht
ralucirtnev ;ynimegib ralucirtnev ;ynimegirt -cirtnev gnimit and ygolohprom fo ralucirtnev smargortcele
ralu ;stelpuoc ralucirtnev ;aidracyhcat -cirtnevarpus ot refni spihsnoitaler neewteb 1airta and ralucirtnev
ralu ;aidracyhcat 1airta ;rettulf eerged-tsrif -nevoirta .noitavitca As a ,tluser yeht evah had detimil -gaid
ralucirt ;kcolb and eerged-dnoces ralucirtnevoirta citson 9-‘.ycarucca roF ,elpmaxe smetsys desu -ruc
.kcolb yltner rof ,yrotalubma ,edisdeb and evitarepoartni
GCE gnirotinom era elbanu ot yletarucca -nereffid
etait hcus latnemele saimhtyhrra as 1airta -amerp
erut ,snoitaziraloped ro ralucirtnevarpus -rayhcat
Discussion
saimhtyhr htiw tnarreba ralucirtnev noitcudnoc morf
ralucirtnev erutamerp snoitaziraloped ro -moc-ediw
ehT ecnesba fo a yltnetsisnoc elbailer snaem fo -ed xelp saidracyhcat that era ralucirtnev ni .nigiro
gnitcet 1airta noitavitca using standard ecafrus -cele ,yltneceR eht noitaroprocni fo ecafrus GCE htiw
yhpargort has neeb eno fo eht rojam selcatsbo ot eht eht laegahpose llip sedortcele rof eht noitceted fo
noitatnemelpmi fo detamotua sdohtem rof etarucca 1airta ytivitca has neeb detartsnomed ot evorpmi eht
aimhtyhrra .sisongaid sledoM depoleved ot etad ycarucca fo edisdeb caidrac aimhtyhrra -aterpretni
Cycle Seq Code Cycle Diagnosis Contextual Diagnosis
2 AV 02010 APD htiw AV delay APD with AV delay
3 VA VPD htiw edargorter VPD with retrograde
4 VA VPD htiw edargorter V couplet with l:1 .orter
5 VA VPD htiw edargorter 3 VPDs with l:1 .orter
6 VA VPD htiw edargorter 4 VPDs htiw l:1 .orter
7 VA VPD htiw edargorter 5 VPDs with l:1 .orter
8 VA VPD htiw edargorter VT htiw l:1 .orter
9 VA VPD htiw edargorter VT with l:1 .orter
01 VA VPD htiw retograde VT with l:1 .orter
11 VA VPD htiw edargorter VT htiw l:1 .orter
21 V J erutamerp o/w .orter V echo beat
31 VA VPD htiw edargorter VT with l:1 .orter
41 VA VPD htiw edargorter VT with 1:l retro.
51 VA VPD with retrograde VT with l:1 .orter
61 VA VPD htiw edargorter VT with l:1 .orter
71 V J erutamerp o/w .orter V echo beat
81 VA VPD htiw edargorter VT with l:1 .orter
Fig. 8. ralucirtneV aidracyhcat )TV( htiw 1: 1 edargorter and ohce .staeb selcyC 2, 12, dna 17 are ylnekatsim deifitnedi ni
the elgnis elcyc citsongaid emehcs as lanoitcnuj )J( erutamerp noitaziraloped tuohtiw )o/w( edargorter noitcudnoc ot eht
.muirta sihT is eud ot rieht lamron shape dna short VV .lavretni yehT are, ni fact, ralucirtnev echo ,staeb dna the rettal two
era dezingocer as hcus nehw denimaxe yb the lautxetnoc .mhtirogla snoitaiverbbA emas as ni erugiF 6.
62 lanruoJ fo ygoloidracortcelE .loV 62 .oN 1 yraunaJ 3991
noit yb 31-“.snaicinilc ehT stluser fo this yduts sug- reht sledom fo aimhtyhrra sisylana is eht -poleved
tseg that eht noitaroprocni fo ralimis data nac edivorp tnem fo erom denilmaerts sisylana sdohtem ni redro
a lacitcarp snaem fo gnisaercni eht ytixelpmoc and ot esaerced lanoitatupmoc .emit ehT ytilibissop fo -ed
ycarucca fo detamotua GCE .sisylana ehT noitidda gnisaerc lanoitatupmoc sdnamed rof margortcele
fo an laegahpose 1airta signal sedivorp an evitceffe ygolohprom sisylana elihw gniniatniam eht -songaid
erutaef rof eht sisylana fo eht ,ygolohprom as llew as cit ycarucca fo cigolohprom noitaulave has neeb -er
eht gnimit fo 1airta ,noitavitca ybereht gnittimrep eht yltnec .detartsnomed 25,26 rehtruF tnemenifer fo eht
tnempoleved fo an laicifitra ecnegilletni metsys rof lautxetnoc sisongaid metsys lliw eb rehtona -ropmi
eht etarucca and evisneherpmoc noitaterpretni fo -ni tant pets ni eht tnempoleved fo tneiciffe -retupmoc
laudivid caidrac selcyc and ralucirtnevarpus and -nev dezi aimhtyhrsyd .sisylana roF ,elpmaxe erutuf -moc
ralucirt .saimhtyhrra deziretup gniledom that setaroprocni seigetarts hcus
ehT ecnatropmi fo lautxetnoc sisongaid ni etarucca as ytilibaborp dluoc esaercni eht ycneictffe fo eht -xe
aimhtyhrra sisylana is dezisahpme yb eno fo eht -imil isting .metsys yB gnitimil eht latot rebmun fo -yh
snoitat fo this .ledom ehT elgnis caidrac elcyc sisylana sesehtop that must eb deredisnoc nehw laudividni
fo this ledom tonnac etaitnereffid elgnis 1airta -oped caidrac selcyc era detaroprocni otni a lautxetnoc -id
snoitaziral htiw lamron ro degnolorp AV noitcudnoc agnosis, eht latot rebmun selbairavfo gniriuqer anal-
ro tnarreba noitcudnoc morf elgnis 1airta -aziraloped sisy dluoc osla eb .desaerced
snoit dewollof yb a latnedicnioc ralucirtnev cipotce
.noitaziraloped erehT erew owt hcus caidrac selcyc
ni a latot fo 641 dezylana selcyc )%3.0( .giF( .)8 nI
,noitidda eht elgnis caidrac elcyc citsongaid edoc Acknowledgment
dluoc ton tceted ralucirtnev ohce staeb esuaceb ylno
eht eno ro owt tsom tnerruc snoitaziraloped erew
ehT srohtua wish ot sserpxe rieht noitaicerppa ot
deredisnoc gnirud caidrac elcyc .gnidoc As a -esnoc
Ms. eibbeD driaL rof noitaraperp fo eht .tpircsunam
,ecneuq owt ralucirtnev ”ohce“ snoitaziraloped erew
deifissalcsim as lanoitcnuj snoitaziraloped esuaceb fo
rieht ytimixorp ot eht tnedecetna erutamerp -cirtnev
ralu noitaziraloped that was dewollof yb edargorter
References
1airta .noitavitca ehT noitingocer fo VA noitavitca
hcihw( was )etarucca dedulcerp eht noitingocer fo
eht tneuqesnoc AV noitcudnoc that .dewollof -eD 1. regrebpiP ,VH seirF ,DE kcabaT L te al: noitaraperP fo
etips this, eht elgnis caidrac elcyc srorre erew -roc cihpargoidracortcele data rof sisylana yb latigid -cele
detcer yb eht lautxetnoc .sisongaid cinort .retupmoc noitalucriC 2 ,314:1 1960
2. selpatS ,FI nosfatsuG JE, mlaB JG te al: retupmoC
noitaterpretni fo .smargoidracortcele Am Heart J :27
351, 1966
3. rennaB ,ER namtewhcS :DH retupmoC sisongaid fo
Present and Future Applications
eht margoidracortcele .II retupmoC margorp rof -ra
aimhtyhr .sisongaid tupmoC demoiB Res :1 366, 1968
4. rennoB RE, essaverC L, rerreF IM et :la A wen -moc
gnomA eht ,laitnetop lacitcarp snoitacilppa fo eht
retup margorp for sisylana of ralacs -idracortcele
epyt fo ledom depoleved ni this yduts era etarucca
.smargo tupmoC demoiB Res ,926:5 1972
detamotua noitaterpretni fo yrotalubma GCE retloH( 5. royrP ,AT yasdniL ,EA dnalgnE :WR retupmoC -ylana
)rotinoM sgnidrocer and devorpmi detamotua -ylana sis of laires .smargoidracortcele tupmoC demoiB Res
sis gnirud evisnetni erac ro evitarepoartni GCE -inom ,907:5 1972
.gnirot degnolorP gnirotinom htiw laegahpose -cele 6. regrebpiP HV, nahguaCcM D, namttiL D et :la lacinilC
sedort has ydaerla detartsnomed ot eb 12.elbisaef noitacilppa of a dnoces noitareneg -oidracortcele
rehtruF stnemevorpmi and noitatnemelpmi fo -olana cihparg retupmoc .margorp mA J loidraC ,795:53
1975
suog sledom fo aimhtyhrra sisylana otni secived hcus
seddeG JS, renraW :RH A CVP noitceted .margorp
as elbitnalpmi aidracyhcatitna srekamecap and -otua
tupmoC demoiB Res ,394:4 1971
citam srotallirbifed-retrevoidrac thgim edivorp erom
Vetter NJ, nailuJ :GD nosirapmoC of aimhtyhrra -moc
elbailer noitanimircsid fo ralucirtnev aidracyhcat and
retup dna lanoitnevnoc gnirotinom ni erac-yranoroc
ralucirtnev noitallirbif morf ,rehto ralucirtnevarpus
.tinu tecnaL ,1511:1 1975
,saimhtyhrrayhcat and pleh tneverp etairporppani snikneJ :MJ detamotuA yhpargoidracortcele dna -ra
tneitap-ecived 42-22.snoitcaretni aimhtyhr .gnirotinom Prog csavoidraC siD ,763:VXX
gnomA elbissop stnemevorpmi ot eb edam ni -ruf 1983