The International Society of Electrocardiology —
the North American Contribution

Jerome Liebman

Rainbow Babies & Children's Hospital, Pediatric Cardiology, Cleveland, USA

Dr. Ernst Simonson of Minnesota^(1-6) brought epidemiologic principles to the field, making sure that when discussing standard electrocardiography and orthogonal vectorcardiography, large enough samples were taken to make statistically significant judgments. His group, which included Blackburn and Rautaharju, led the field to an understanding of the need for population studies of the electrocardiogram. In addition to contributing to the early congresses, contributions were made at the very influential meetings in New York in 1965 and 1970 resulting in the books Vectorcardiography 1965 and Vectorcardiography 2. Dr. Otto Schmitt, developer of the Schmitt lead system, was one of Simonson 's major co-investigators, and in addition contributed greatly to innovative electrocardiographic lead theory, presented with great panache at early meetings.

At the International Congress of Electrocardiology in 1993 at Kananaskis, Alberta, organized by Dr. Pentti Rautaharju, a history of contributions from Minnesota was presented by Dr. Henry Blackburn⁽⁷⁾. Diagnostic classifications were developed in collaboration with investigators worldwide, facilitated by meetings of the ISE. In early work in Minnesota, Rautaharju with his Epicore program developed reliable systems and measurement analysis from population studies and clinical trials. Later, in Halifax, Nova Scotia there were many years of productive work, where new predictive and prognostic indices were categorized.^(8,9)

Dr. Hubert Pipberger and his group in Washington D.C. presented landmark work in large numbers of patients mainly using the Frank orthogonal lead system in developing diagnostic classifications.^(10,11) Alan Berson, one of Pipberger's long time collaborators described aspects of the Pipberger lab. ⁽¹²⁾ Through contacts with members of what became the ISE, many seminal papers were published. One of the most influential of the Pipberger papers was published in 1975 for the American Heart Association.⁽¹³⁾

As Berson has stated, "The vision of Hubert Pipberger was to advance our knowledge of electrocardiology through the intelligent use of computer technology. He understood the need to extend the application of biomedical engineering in the areas of signal processing and information theory in order to accomplish this. His efforts and those of his colleagues led to the modern application of automated computer analysis to electrocardiography."

Ronald Selvester provided some of the earlier important work in the inverse and forward problems⁽¹⁴⁾ and was always willing to present and develop issues for discussion, on which these difficult scientific issues could be developed. These issues brought excitement to many of the early meetings as newer and faster computers were being concurrently developed. This was summarized in 1994⁽¹⁵⁾ at the 21^st International Congress on Electrocardiology. Without Selvester 's work, the more definitive forward and inverse work being published today would likely have taken much longer to come to fruition. Selvester edits the Journal of Electrocardiology, which is the official journal of the International Society of Electrocardiology.

In the early years of clinical body surface potential mapping (BSPM), the ISE provided the major forum where the field of clinical BSPM could be presented. An excellent example is provided in the satellite meeting at Smolenice, Czechoslovakia, in 1966 where Dr. Madison Spach was able to demonstrate with BSPM that there was a different type of right ventricular hypertrophy (RVH) in pulmonic stenosis (pressure loading) and atrial septal defect (volume loading).⁽¹⁶⁾ This was a landmark concept at the time. Over the next years, in addition to many other BSPM systems developed and presented from many parts of the world including Eastern Europe, Japan and Western Europe, came the work of Robert Lux.⁽¹⁷⁾ Dr. Lux was the major influence in the development of limited BSPM lead systems. ⁽¹⁸⁾ The Lux system had 32 leads with no electrodes on the back, while Barr and Spach developed a 24 lead system which did include electrodes on the back.⁽¹⁹⁾ In 1985, a special satellite conference of the ISE on BSPM was held, in Nijmegen in the Netherlands where many North Americans attended and presented, including Mirvis, Nadeau, Plonsey and Liebman.⁽²⁰⁾ Other publications of books on BSPM in the United States followed, by Liebman et al⁽²¹⁾ and Mirvis⁽²²⁾. Over the following years, the innovative 32 lead system of Lux was utilized by many groups throughout the world with Dr. Lux helping the groups obtain and utilize the system. Without the forum provided by the International Congress of Electrocardiology, this body of work could not have been presented. Meanwhile, Nadeau 's laboratory in Montreal developed a 64 lead system and used it in many innovative ways including at cardiac catheterization and at surgery.⁽²³⁾

A great leader in the field, helping clinical electrocardiography to have a more accurate scientific base was Dr. Robert Plonsey, whose book "Bioelectric Phenomena" provided a foundation for many investigators, both basic science and clinical, and helped toward providing a better understanding of the myocardial source.^(21,24,35) In Cleveland, Dr. Plonsey worked with Dr. Jerome Liebman in developing the Case Western Reserve University (CWRU) 180 electrode BSPM system where, over a 20 year period, large numbers of papers were published, most of them presented initially at the Congresses of the International Society of Electrocardiology. Among the papers included a key aspect, namely the ability to clinically recognize epicardial right ventricular breakthrough. This allowed, as an example, the separation of RVH with terminal right conduction delay from RBBB.⁽²⁶⁾ Utilizing the above, and other aspects of understanding of conduction abnormalities in the hypoplastic right ventricle syndrome, three distinct types could be distinguished, namely with pulmonary atresia, with tricuspid atresia with and without transposition of the great arteries^.(27) In another study, it was found that with the use of BSPM, the precise location of accessory connections in the WPW Syndrome⁽²⁸⁾ could be delineated more accurately than via electrophysiology at cardiac catheterization. This allowed the surgeons to accurately isolate and cut the connections.

Three new members of the Council of the International Society of Electrocardiology from North America, Rudy, Antzelevich and Zareba continue to be in the vanguard of knowledge in helping to develop the interface between basic and clinical electrocardiography. Rudy continues to work on the myocardial source as well as the solution to the inverse problem.^(29-31) Antzelevitch has been doing landmark work on the various cellular aspects that contribute to the myocardial action potential enhancing our greater understanding of mechanisms of arrhythmias.^(32,33)

Zareba, with Arthur Moss, has developed the International Registry for the long QT Syndrome.^(34,35) and in so doing is continually expanding our knowledge of the basic science, the clinical picture and the natural history.

Selected References

1. Simonson E, Tuna H, Okamoto N, et al. Diagnostic accuracy of the vectorcardiogram and electrocardiogram. Am J Cardiol 1966; 17:829-

2. Richman HG, Yukui M, Gleason D, Nishijima K, Simonson E. Reliability of the vectorcardiographic diagnosis of myocardial infarction in Vectorcardiography 2, publ N Holland ed. Hoffman, Hanby, Glassman, Proceedings of the XI International Symposium on Vectorcardiography 1970 p 343-351.

3. Simonson E, Horiba H, Okamoto N, Schmitt OH. Effects of electrode placement in orthogonal leads. IBID, p 32-46.

4. Blackburn HW, Keyes A, Simonson E, Rautaharju P et al. The electrocardiogram in population studies. Circulation 1960;21:1160-1175.

5. Schmitt OH, Almasi J. Electrode impedence and voltage offset as they affect efficacy and accuracy of VCG and ECG measurements in Vectorcardiography 2, publ. N. Holland, ed Hoffman, Hamby, Glassman. Proceedings of the XI International Symposium on Vectorcardiography 1970. p 343-351.

6. Schmitt OH, Simonson E. The present status of vectorcardiography. AMA Arch Internal Med 1955;96:574-

7. Blackburn H, Minnesota contributions to electrocardiography: A brief history. In Electrocardiology '93 Ed. Mcfarlane and Rautaharju, World Scientific p 24-30.

8. Rautaharju PM, MacInnis PJ, Warren JW, el al. Methodology of ECG interpretation in the Dalhousie program NOVACODE. ECG Classification procedures for clinical trials and population health surveys. Methods Infor Med 1990;29:367-374.

9. Rautaharju PM, Calhoun HP, Chaitman BR. NOVACODE. Serial ECG classification system for clinical trials and epidemiological studies. J Electrocardiol 1992:324: 163-172.

10. Draper HW, Peffer CJ, Stallman FW, Littman D, Pipberger HV. The corrected orthogonal electrocardiogram and vectorcardiogram in 510 normal men (Frank lead system) Circulation 1964; 30:853-864.

11. Gamboa R, Klingman JD, Pipberger HV. Computer diagnosis of biventricular hypertrophy from the orthogonal electrocardiogram. Circulation 1969;39:72-82.

12. Berson A. ECG leads and instrumentation during the Pipberger era in Electrocardiology '93, ed Macfarlane and Rautaharju World Scientific p 31-38.

13. Pipberger HV, Arzbaecher RC, Berson AS, Briller SA, Brody DA, Flowers Nc, Geselowitz DB, Lepeschkin E, Oliver GC, Schmitt OH, Spach M. Recommendations for standardization of leads and of specifications for instruments in electrocardiography and vectorcardiography. Circulation 1975;52:11-31.

14. Selvester RH, Kalalsa R. Bellman R. Kagiwada H, Collier R. Simulated myocardial infarction with a mathematical model of the heart containing distance and boundary effects. In Vectorcardiography 2 1966:p 403-417.

15. Selvester RHS, Solomon JC, Standardization and validation of ECG forward and inverse models. In Proceedings of the 21^st International Congress of Electrocardiology July 4-7, 1994. Yokohama, Japan in Japanese Heart J, Ed. Harumi, Sugimoto, Hiraoka, Toyama Sawanobari, Kato 1994;35:83-90.

16. Spach MS, Boineau JP, Barr RC et al. Isopotential surface maps in children with varying types of right ventricular hypertrophy, Proceedings of the 7th International Symposium in Vectorcardiography, Smolenisce, Czechoslovakia, 1966, published as Blumenschein SD, Spach MS, Boineau JP et al. Genesis of body surface potentials in varying types of right ventricular hypertrophy. Circulation 1968;38:917-932.

17. Lux RL; 1982: Electrocardiographic body surface potential mapping. CRC Crit Rev Biomed Eng 1982;8;253-

18. Lux RL, Smith CR, Wyatt RF, Abildskov JA. Limited lead selection for estimation of body surface potential maps in Electrocardiography. IEEE Trans Biomed Eng. 1978;25:270-

19. Barr RC, Spach MS, Herman-Giddens GS. Selection of the number and positions of measuring locations for electrocardiography. IEEE Trans Biomed Eng. 1971;18:125-

20. Van Dam R, Van Oosterom A (ed) Electrocardiographic Body Surface Potential Mapping. Martinus Nijhoff (publ.) 1986.

21. Liebman J, Plonsey R., Rudy Y, (ed) Pediatric and Fundamental Electrocardiography. Martinus Nijhoff(publ.) 1987.

22. Mirvis DM(ed) Body Surface Electrocardiographic Mapping. Kluwer Academic Publ. 1988.

23. Nadeau R, Shahidi AV, Cardinal R, Paģe P, Savard P. Evaluation of inverse problem solutions using epicardial potential distributions measured during surgery. In Electrocardiology 2001, Atheneu, Sao Paulo, ed. CA Pastore p 545-550.

24. Plonsey R, Bioelectric Phenomena. McGraw-Hill 1969.

25. Plonsey R, Barr RC. Witkowski FX. Cardiac activation and its measurement. Rijlant lecture. in Building Bridges in Electrocardiology. Ed Van Oosterom, Ostendorp Uijen p 152-153.

26. Liebman J, Thomas CW, Rudy Y, Body surface potential mapping in conduction abnormalities (with particular reference to congenital heart disease) in Body Surface Potential Mapping. D. Mirvis (ed) Martinus Nijhoff, Dordrecht 1988:pp 153-166.

27. Liebman J, Thomas CW, Fraenkel R, Rudy Y, Analysis of hypoplastic right ventricle utilizing electrocardiographic body surface potential mapping (BSPM), J. Electrocardiol 1989;22:195-209.

28. Liebman J, Zeno JA, Olshansky B. Electrocardiographic body surface potential mapping in the Wolf-Parkinson-White Syndrome. Non Invasive determination of the ventricular insertion sites of accessory atrioventricular connections. Circulation 1991;83:886-901.

29. Oster HS, Taccardi B, Lux RL, Ershler PR, Rudy Y. Electrocardiographic imaging for reconstructing electrograms and isochrones in addition to potential distribution maps. In Electrocardiology '96. From the Cell to the Body Surface. Ed. J. Liebman, World Scientific p 65-67.

30. Rudy Y, Electrocardiographic Imaging:On the road to its development as a clinical tool. Rijlant Lecture. at 22^nd International Congress of Electrocardiology. Milan, Italy, June 22-July 1 2001 pp 1-10.

31. Burnes JE, Ghanem RN, Waldo A, Rudy Y, Imaging dispersion of myocardial repolarization I: Comparison of body surface and epicardial measures: Circulation, 2001;104:1299-1305.

32. Antzelevich C. Transmural Dispersion of Ventricular Repolarization as the Basis for the Brugada and Long QT Syndrome. In Electrocardiology 2000; publ. Casa Editrice, Scientifica Internationale. Ed. L de Ambroggi pp 19-30.

33. Antzelevich C, Cellular basis for the J, T and U waves of the ECG. Insights into the mechanism underlying life threatening ventricular arrhythmias. Rijlant Lecture. 28^th International Congress of Electrocardiology, Sao Paulo, Brazil Jan 26-30 2001, ED CA Pastore, Electrocardiology 2001. pp 3-4.

34. Zareba W, Moss AJ, Schwartz PF et al. Influence of the genotype on the clinical course of the long QT syndrome. NEJM 1998;339:960-965.

35. Zareba W, Moss AJ, QT Correction Formulae for LQTS presented at 29^th International Congress of Electrocardiology, Montreal, July 2-5 2002 publ. In Special Issue on Electrocardiology and Neurophysiology of the International Journal of Bioelectromagnetism (IJBEM) 2002;4:35-36.