Published on Jul 03, 2020
ECG T-shirt was devoloped with a portable recorder for unobtrusive and long-term multichannel ECG monitoring with active electrodes. A major drawback of conventional 12-lead ECGs is the use of adhesive gel electrodes, which are uncomfortable during long-term application and may even cause skin irritations and allergic reactions. Therefore, we integrated comfortable patches of conductive textile into the ECG T-shirt in order to replace the adhesive gel electrodes.
In order to prevent signal deterioration, as reported for other textile ECG systems, we attached active circuits on the outside of the T-shirt to further improve the signal quality of the dry electrodes.
Finally, we validated the ECG T-shirt against a commercial Holter ECG with healthy volunteers during phases of lying down, sitting, and walking. The 12-lead ECG was successfully recorded with a resulting mean relative error of the RR intervals of 0.96% and mean coverage of 96.6%. Furthermore, the ECG waves of the 12 leads were analyzed separately and showed high accordance. The P-wave had a correlation of 0.703 for walking subjects, while the T-wave demonstrated lower correlations for all three scenarios (lying: 0.817, sitting: 0.710, walking: 0.403). The other correlations for the P, Q, R, and S-waves were all higher than 0.9. This work demonstrates that our ECG T-shirt is suitable for 12-lead ECG recordings while providing a higher level of comfort compared with a commercial Holter ECG.
Unobtrusive sensing of vital signs, such as cardiac activity and respiration, has been increasingly applied in the past decade. The aging of our society has resulted in an increasing demand on medical staff, which cannot always be met. As a result, an increasing number of technical solutions, the so-called personal healthcare systems, are being developed. They aim at enabling sick and elderly patients to stay at home for a longer period , rather than facing prolonged hospital stays. When staying at home, patients generally benefit from increased comfort, which may accelerate their recovery. In turn, costs for the healthcare system will be reduced by shortening the stay in hospital. This is the main rationale for developing long-term monitoring solutions for the home environment. One of the established long-term cardiac monitoring devices is the Holter.
This is a portable electrocardiography (ECG) device with up to 12 leads for long-time application. These ECG recorders are often used to diagnose cardiac conditions over the duration of several days. For this, patients wear the device while continuing their daily routine. Commercial Holter devices consist of a portable ECG recorder with adhesive electrodes. However, these electrodes have one major problem: the gel that ensures good conductivity can lead to skin allergies. Moreover, the longer the gel is applied, the greater the possibility that more problems arise.
Signal quality is deteriorated if the gel dries up, which is highly probable during long-term monitoring. In addition, in some cases (e.g., if patients are sweating), the electrodes detach themselves, requiring reapplication. If this occurs, the patient may not reattach them in the correct place. In order to address these problems and to improve patient comfort, we developed a 12-lead ECG T-shirt with active electrodes and a portable ECG recorder. Various textile ECG T-shirts have been investigated in the last decade. Whereas some systems were developed mainly for research purposes only [1–4], some shirts are commercially available: CardioLeaf (Clearbridge VitalSigns, Singapore) and hWear (HealthWatch Technologies, Kfar Saba, Israel) [5,6]. The latter type is a shirt that is compatible with a 12-lead ECG recorder.
Materials and Methods
The portable 12-lead ECG measurement system consists of a T-shirt, active electrodes and an ECG recorder. The active electrodes of the capacitive measurement system record the potentials on the body’s surface. The analogue signals from the active electrodes are digitalized in the ECG recorder, which also calculates the 12 ECG leads. The signals of the leads are then processed by a microcontroller and stored on an SD card in the ECG recorder. In terms of practicability, it would have been an option to send the data wirelessly. The two main reasons why no wireless module was used are medical data protection and power consumption. A wireless module would drastically reduce battery life, especially when sending data of 12 channels at a high sample rate.
A 12-lead ECG requires 10 electrodes on the patient’s limbs and chest: 10 physical channels are recorded (3 limb leads, 6 thoracic leads, 1 RL lead), as shown in Figure 1. In Holter ECGs, the electrodes are placed only on the chest. Figure 1 shows that, additional to the 3-lead setup for Einthoven and Goldberger, 6Wilson leads are included. Einthoven and Goldberger leads are calculated from three electrodes forming a triangle, namely the left leg (LL), left arm (LA) and right arm (RA), also called limb electrodes. The fourth electrode applied is the neutral or right leg electrode. The bipolar Einthoven leads are calculated as follows:
I = LA - RA, (1)
I I = LL - RA, (2)
I I I = LL - LA, (3)
so that I I I = I I - I.
The regular shape of the Einthoven II lead is shown in Figure 2. The ECG can be divided into different waves that are referred to as P to T. They reflect the stages of the electrical excitation propagation of the heart. The P-wave is the depolarization of the atria. The QRS complex (QRS waves) reflects the depolarization of the ventricles and the T-wave is their repolarization.
The unipolar Goldberger leads are also recorded for the 12-lead ECG. The Goldberger leads, denoted aVR, aVL and aVF, are augmented leads. These leads are formed using an augmented reference electrode, which is a combination of the two other limb electrodes. This is calculated as follows:
TheWilson leads are placed around the left side of the rib cage. Wilson leads are used to detect local irregularities of electric cardiac function, such as infarctions. The leads are labeled V1 to V6. Their reference is called the Wilson central terminal (WCT). It is a reference potential that is formed by connecting all three limb electrodes to 5 kohm resistors resulting in their average
The T-shirt is a commercially available breathable sports T-shirt (Nike Legend Pro DRI-FIT, Beaverton, OR, USA) . Ten textile patches made of electrically conductive fabric (Shieldex Med-tex P180, Statex, Bremen, Germany) serve as electrodes. The patches (4cm 4 cm) are sewn into the interior of the T-shirt. This fabric is silver plated with 99% silver and has been used as electrodes by two other group. While other conductive textile materials exist, silver coating was selected. It was found that silver electrodes are advantageous even at recording low frequencies
The locations are chosen according to the common 12-lead ECG setup (see Figure 1). The driven right leg (DRL) electrode has a larger area to ensure good contact (30 cm 5 cm). Each electrode has a snap fastener connection, where the amplifier boards (or in the case of the DRL electrode, the cable) that lead to the ECG recorder are fastened. The T-shirt needs to fit relatively tightly, since signal quality improves with contact pressure of the electrodes. Therefore, we added a few Velcro straps to “tighten” the T-shirts and keep the electronics in place.
The textile electrodes are followed by active circuits. The aim was to improve the signal quality of a dry or an optionally capacitive setup. The main principle of the active electrodes is shown in Figure 4. As mentioned, the textile patches serve as electrodes and they are connected to the outside of the T-shirt by snap fasteners. An active circuit PCB is placed on the snap fasteners from the exterior. More precisely, an impedance converter with OPA129U (Texas Instruments, Dallas, TX, USA) on the PCB decouples the ECG signal at the snap fastener from the following electronics. A highly resistive bias resistor (10 G ohm) prevents the build-up of static charge at the input on the impedance converter. Then, the analogue output of the impedance converter is led to the ECG recorder with a shielded six-wire cable. This cable also carries extra wires for the power supplies
This paper introduces a novel ECG T-shirt for 12-lead measurements with fully active and dry electrodes. A portable 12-lead ECG recorder was developed, which is compatible with the T-shirt. The system is portable and has a battery life of two days. To our knowledge, a 12-lead ECG T-shirt specifically with active electrodes has not been developed before. In a study with three volunteers, the functionality of the device was successfully compared with a commercial device in everyday scenarios. The relative error of the RR intervals was 0.96% with a mean coverage of 96.6%. The P-wave had a correlation of 0.703 for walking subjects, while the T-wave demonstrated lower correlations for all three scenarios (lying: 0.817, sitting: 0.710, walking: 0.403). The other correlations for the P, Q, R, and S-waves were all higher than 0.9. This work shows that a comfortable ECG T-shirt with active electrodes is suitable for 12-lead ECG recordings.
1. Kim, S.; Leonhardt, S.; Zimmermann, N.; Kranen, P.; Kensche, D.; Müller, E.; Quix, C. Influence of contact pressure and moisture on the signal quality of a newly developed textile ECG sensor shirt. In Proceedings of the IEEE 5th International Summer School and Symposium on Medical Devices and Biosensors (ISSS-MDBS 2008), Hong Kong, China, 1–3 June 2008; pp. 256–259.
2. Linz, T.; Kallmayer, C.; Aschenbrenner, R.; Reichl, H. Fully integrated EKG shirt based on embroidered electrical interconnections with conductive yarn and miniaturized flexible electronics. In Proceedings of the BSN 2006: InternationalWorkshop on Wearable and Implantable Body Sensor Networks, Cambridge, MA, USA, 3–5 April 2006; pp. 23–26.
3. Ottenbacher, J.; Romer, S.; Kunze, C.; Grosmann, U.; Stork, W. Integration of a Bluetooth Based ECG System into Clothing. In Proceedings of the Eighth International Symposium onWearable Computers, Arlington, VA, USA, 31 October–3 November 2004; pp. 186–187.
4. Karlsson, J.;Wiklund, U. Wireless Monitoring of Heart Rate and Electromyographic Signals using a Smart T-shirt. In Proceedings of the International Workshop on Wearable Micro and Nanosystems for Personalised Health, Valencia, Spain, 21–23 May 2008.
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