Journal of Medical Engineering & Technology

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Modified electrode placements for measurement

of hemodynamic parameters using impedance
cardiography

Vu Duy Hai , Phan Dang Hung & Chu Quang Dan

To cite this article: Vu Duy Hai , Phan Dang Hung & Chu Quang Dan (2020): Modified electrode
placements for measurement of hemodynamic parameters using impedance cardiography, Journal
of Medical Engineering & Technology, DOI: 10.1080/03091902.2020.1799089

To link to this article: https://doi.org/10.1080/03091902.2020.1799089

Published online: 25 Aug 2020.

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JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY
https://doi.org/10.1080/03091902.2020.1799089

INNOVATION

Modified electrode placements for measurement of hemodynamic

parameters using impedance cardiography
Vu Duy Hai, Phan Dang Hung and Chu Quang Dan
Biomedical Electronics Center, Hanoi University of Science and Technology, Hanoi, Viet Nam

ABSTRACT ARTICLE HISTORY

Measuring and monitoring hemodynamic parameters has brought many benefits in supporting Received 10 October 2019
diagnosis and treatment for cardiovascular patients. There are many advantages to measuring Revised 3 July 2020
hemodynamic parameters by non-invasive technique based on impedance cardiography (ICG) Accepted 6 July 2020
such as simplicity, real-time and low cost. However, the electrode positions of this method are
KEYWORDS
very difficult to implement in cases where the patient has to use multiple medical devices at Impedance cardiography;
the same time, especially for patients on active treatment and resuscitation. This paper presents hemodynamic parameters;
the results of the study proposing new three locations of ICG electrodes to overcome the above cardiac output; stroke
limitation. Accordingly, we measured and evaluated 10 volunteers on the Niccomo device. The volume; elec-
results show that all three positions of proposed electrode can be used to replace standard elec- trode placement
trode position. In particular, the 1st proposed position, can be used to measure all five hemo-
dynamic parameters HR, SV, LVET, Zo, CO and ICG waveforms, expressed by the average
correlation and the relative average difference of five parameters, R2 ¼ 0.9641 and Mean ¼
3.31%. The 2nd proposed position can be used to measure four parameters HR, SV, LVET, CO
and ICG waveforms shown by R2 ¼ 0.9091 and Mean ¼ 8.67%. The 3rd proposed position can
be used to measure three parameters HR, Zo and LVET, expressed by R2 ¼ 0.8485 and Mean
¼ 9.26%.

1. Introduction mortality to patients because of requirement to insert

catheter into the patient’s body. To overcome some
Cardiac output (CO) is the volume of blood pumped
of the limitation of these invasive techniques, non-
into the aorta each minute by the heart and is per-
haps the most significant factor to be considered in invasive techniques have been developed for many
relation to the circulation. Some of the possible rea- years. The non-invasive techniques widely used in
sons for increase in the cardiac output to above nor- diagnosis and treatment consists of Oesophageal
mal are beriberi, anaemia, hyperthyroidism, Doppler [6], partial CO2 breath analysis [7], Impedance
arteriovenous fistula [1]. Besides, there are some fac- cardiography (ICG) [8,9] and Bioreactance technique
tors decreasing the cardiac output under the normal [10]. The first two invasive techniques require highly
value like decreased blood volume, acute venous dila- skilled technician and is not suitable for monitoring
tion, obstruction of the large veins, or decreased tissue cardiac output continuously for long-term [2]. Among
mass, especially decreased skeletal muscle mass. the non-invasive techniques, ICG has been investi-
Therefore, determining cardiac output is an important gated and developed since the 1940s and has advan-
parameter for detecting abnormalities related to circu- tages such as non-invasive, simplicity, low-cost, ability
lation, interventional cardiology and is used during to monitor cardiac output continuously without need
cardiothoracic surgery [1]. for highly skilled examiner [8,11].
To determine cardiac output, invasive or non- The configuration of electrode placement generally
invasive techniques can be used. Some standard inva- accepted in ICG technique is the 8-spot electrode con-
sive techniques are thermodilution [2,3], Fick’s method figuration proposed by Bernstein [12]. The standard
[3,4], or dye-dilution [3,5]. These invasive techniques position of electrodes is placed as Figure 1. Each dual
give accurate results, however there is possibility of electrode includes a pair of pads to inject current and
side effect due to risk of infection, morbidity, or even measure voltage signal simultaneously. The distance

CONTACT Vu Duy Hai [email protected] Biomedical Electronics Center, Hanoi University of Science and Technology, R307 C9 Building,
Hanoi, Viet Nam
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 V. D. HAI ET AL.

in final result of hemodynamic parameters compared

to the standard one.

2. Proposed method
The basic principle of ICG is based on the changes of
thoracic impedance corresponding to blood volume
changes in thorax region during each cardiac cycle. By
injecting a low intensity high frequency current source
to the body through electrodes, these changes can be
measured in order to estimate stroke volume (SV). In
the 1960s, based on mathematically modelling the
thorax region as a cylindrical conductor, Kubicek et al.
(1966) suggested an equation to calculate SV param-
Figure 1. The standard of ICG electrode positions. eter [8]. In combination with heart rate of the patient,
cardiac output can be apparently calculated. As a
between these pads in one pair is fixed. For the upper result, the position to inject current and sense the
part, two electrodes are positioned to each side of the impedance changes should adhere to following crite-
patient’s neck. The lower pads of the electrodes are ria: (a) be close to large blood vessels as much as pos-
placed at the root of the neck. For the lower part, the sible where almost amount of blood flow out and
two remaining electrodes are applied on each side of flow in causing a considerable change in impedance
the thorax along the mid-axillary line. The upper pad [19], (b) ensure that the unit under test is most similar
of the sensor is positioned closest to the heart at the as the mathematical model used to construct SV equa-
level of the Xiphoid point [13]. However, intravenous tions [8,12] and (c) obtain the most homogeneous
catheterisation is usually indicated for most patients electric field of the current flow through the chest to
admitted to an intensive care unit, and central venous restrict the distortion [20]. Based on these criteria, we
catheterisation is used in case of impracticality to use propose two positions to place the upper electrodes
peripheral venous cannulation [14]. In the United State around the region between the root of the neck and
more than 5 million central venous catheterizations clavicle bone for replacement of the neck position as
are conducted each year [15]. The central venous cath- the standard suggestion. We hypothesise that the
eterisation is usually indicated to access for giving modified positions following the mentioned criteria in
drugs, access for extracorporeal blood circuits, and this paper would give the result of hemodynamic
hemodynamic monitoring and interventions [16]. The parameters with an acceptable error compared to the
most common positions to insert catheters at proximal standard one. We also additionally suggest a position
central veins are the internal jugular, subclavian, or at arm arteries to verify the mentioned hypothesis.
femoral vein [16]. The two positions frequently The lower electrode positions are moved to equal the
selected are subclavian and internal jugular sites due distance between upper and lower electrodes as
to their lower risk of infection and fewer mechanical shown in Figure 2.
complication [17]. The experiments were conducted using the com-
Unfortunately, the position to insert catheter mercial device, NiccomoTM monitor of Medis, Germany
through the internal jugular overlaps the standard (https://medis.company/cms/uploads/PDF/niccomo.pdf)
position of ICG electrodes placed on the patient’s to acquire data at these new positions and to
neck area. In this circumstance, it is impossible to compare with the data using standard positions as
apply ICG technique to measure cardiac output [18]. Figure 3. The data acquisition included, ICG signal,
According to the survey in some hospitals in Vietnam, heart rate (HR), Zo, left ventricular ejection time (LVET),
the number of patients having overlapping area with SV and CO values.
the standard position for ICG accounts for 80 percent We measured and collected data on ten volunteers
of total number of heart diseased patients that are including five men and five women. Volunteers are all
being treated. This is the number of cases making ICG healthy people, without any medical treatment, aged
technique impossible to monitor cardiac output. To between 19 and 22 years and all the experiments were
solve this problem, this paper proposes modified posi- approved by the Ethics committee at our University
tions for electrode placement with an acceptable error Clinic and done by the doctors at our campus.
 JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 3

Figure 2. Proposed three positions to place the upper electrodes (1,2,3) follow and the lower electrode positions are moved to
equal the distance between upper and lower electrodes.

Figure 3. The data of the new positions and the standard positions on the same volunteer. Data will be taken alternately from
the two electrode positions via a switching.

Volunteers were mounted with electrodes on all meas- the proposed position is evaluated directly against the
uring positions, including one standard position and measured value at the standard position through two
three new proposed positions as shown in Figures 2 criteria: (1) scatter plot with R-squared and (2) agree-
and 3. We used a NiccomoTM device to measure data ment Bland-Altman. The calculation formulas used in
for each of these electrodes positions in turns. For the data processing process include:
each electrode position, data was collected from vol- PN
x
i¼1 i
unteer three times, once a day. The average value ðMeanÞ : x ¼ (1)
Each of the hemodynamic parameter was received N
through three values: (1) average value with error of Margin of error at confidence level of 95%
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
PN ffi
three measurements for the standard position (SP); (2) 1
ðx i xÞ 2
N1 i¼1
the average value with the error of three measure- : 1:96  pffiffiffiffi (2)
ments for the proposed position (PP) and (3) mean dif- N
1X N
ference between two positions (D), calculated by Mean difference : D ¼ xSP  xPP (3)
N i¼1
Equations (1–3). For ICG signals, two corresponding PM
x  x iPP
i¼1 iSP
waveforms will be obtained for the standard position Mean absolute difference : Mean ¼
and the proposed position. The reliability of the hemo- M
dynamic parameters when performing the reception at (4)
 4

Figure 6.
Figure 5.
Figure 4.
3. Results
¼ t
u

shown in Table 1.
V. D. HAI ET AL.

electrode positions
M

M  1 i¼1
u 1 X

two positions are very similar.

¼

value at the proposed position.

i¼1

3.1. Results of the 1st new upper

M

Lower limit of agreement : 1:96 SD

Upper limit of agreement : 1:96 SD
Mean relative difference : Meanð%Þ

x iSP
PM jx iSP x iPP j

ðx iSP x iPP MeanÞ2

vffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Standard deviation of difference : sCL

hemodynamic parameters will be evaluated as:

¼ Mean  1:96  sCL
¼ Mean þ 1:96  sCL
 100%

As can be seen, the ICG waveform received between

electrode positions is obtained as shown in Figure 7.
between the CO parameter measured at the standard
C. The correlation and the agreement Bland-Altman
between the LVET parameter measured at the stand-
B. The correlation and the agreement Bland-Altman
between the SV parameter measured at the standard
A. The correlation and the agreement Bland-Altman
parameters of ten volunteers at the standard position
N ¼ 3 is the number of measurements, M ¼ 10 is the
Where, x i is the hemodynamic parameter value,

and the 1st proposed position is summarised as

(8)
(7)
(6)
(5)

D. Measurement result of ICG waveform for two

value at the standard position, x iPP is the average
number of measurement objects, x iSP is the average

position and the proposed position are shown in

ard position and the proposed position are shown in
position and the proposed position are shown in
From the results summarised in Table 1, measured
The measurement result of the five hemodynamic
Table 1. Summary of measurement result at the standard and the 1st proposed position.
HR (bpm) SV (mL) Zo (X) LVET (ms) CO (lpm)
No SP PP D SP PP D SP PP D SP PP D SP PP D
1 70.3 ± 1.3 70.3 ± 0.7 0.0 ± 1.1 67.7 ± 3.6 67.7 ± 6.6 0.0 ± 3.0 34.8 ± 0.6 32.4 ± 0.2 2.4 ± 0.5 292.0 ± 3.0 284.3 ± 3.6 7.7 ± 3.5 4.8 ± 0.4 4.8 ± 0.5 0.0 ± 0.1
2 53.3 ± 2.4 52.7 ± 3.6 0.7 ± 1.7 82.7 ± 2.4 85.3 ± 1.7 2.7 ± 1.3 31.8 ± 0.1 30.5 ± 0.3 1.4 ± 0.3 310.7 ± 2.4 311.7 ± 4.6 1.0 ± 4.5 4.4 ± 0.3 4.5 ± 0.4 0.1 ± 0.2
3 69.7 ± 0.7 70.0 ± 2.0 0.3 ± 1.7 49.7 ± 1.3 52.3 ± 1.7 2.7 ± 0.7 44.2 ± 0.4 39.5 ± 0.3 4.7 ± 0.5 295.3 ± 2.8 310.7 ± 1.3 15.3 ± 1.7 3.4 ± 0.1 3.7 ± 0.1 0.2 ± 0.1
4 70.3 ± 1.7 70.7 ± 0.7 0.3 ± 1.7 75.7 ± 1.7 73.7 ± 0.7 2.0 ± 2.0 54.0 ± 0.2 49.4 ± 0.3 4.6 ± 0.2 280.7 ± 1.3 274.7 ± 2.8 6.0 ± 2.0 5.3 ± 0.2 5.2 ± 0.1 0.1 ± 0.1
5 87.3 ± 0.7 86.7 ± 1.7 0.7 ± 2.4 70.7 ± 2.4 71.3 ± 1.7 0.7 ± 2.8 42.4 ± 0.2 34.8 ± 0.2 7.7 ± 0.3 228.7 ± 4.6 233.7 ± 4.3 5.0 ± 2.3 6.2 ± 0.2 6.2 ± 0.1 0.0 ± 0.2
6 61.0 ± 1.1 61.3 ± 2.8 0.3 ± 3.5 85.0 ± 4.1 84.7 ± 1.7 0.3 ± 2.6 32.6 ± 0.1 30.2 ± 0.2 2.4 ± 0.4 308.7 ± 5.6 295.7 ± 3.6 13.0 ± 2.0 5.2 ± 0.2 5.2 ± 0.3 0.0 ± 0.2
7 88.3 ± 1.7 87.3 ± 0.7 1.0 ± 1.1 74.7 ± 2.6 76.7 ± 1.7 2.0 ± 1.1 36.8 ± 0.2 32.6 ± 0.1 4.2 ± 0.1 262.3 ± 2.8 261.3 ± 2.6 1.0 ± 5.2 6.6 ± 0.3 6.7 ± 0.2 0.1 ± 0.1
8 76.0 ± 2.0 76.0 ± 1.1 0.0 ± 1.1 58.7 ± 1.3 62.0 ± 2.3 3.3 ± 1.3 41.8 ± 0.1 40.1 ± 0.1 1.7 ± 0.1 256.3 ± 1.7 255.3 ± 1.3 1.0 ± 1.1 4.4 ± 0.1 4.7 ± 0.1 0.3 ± 0.1
9 72.0 ± 2.0 72.0 ± 1.1 0.0 ± 1.1 63.0 ± 1.1 64.3 ± 1.3 1.3 ± 2.4 43.5 ± 0.3 41.3 ± 0.3 2.2 ± 0.1 259.3 ± 1.3 261.3 ± 1.7 2.0 ± 1.1 4.5 ± 0.2 4.6 ± 0.1 0.1 ± 0.2
10 54.7 ± 1.7 55.7 ± 1.3 1.0 ± 2.0 82.7 ± 0.7 84.3 ± 0.7 1.7 ± 0.7 40.3 ± 0.1 35.1 ± 0.1 5.2 ± 0.1 334.7 ± 1.7 339.3 ± 1.3 4.7 ± 0.7 4.5 ± 0.2 4.7 ± 0.1 0.2 ± 0.1
 JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 5

90.0 3.00
+1.96 SD

SV at standard posion
2.00

SV difference (mL)
80.0 +2.00
1.00
70.0 0.00

(mL)
−1.00 Mean
60.0 −2.00 −1.20
(2.51%)
y = 1.0383x - 3.9682 −3.00
50.0
R² = 0.9811 & p < 0.05 −4.00 −1.96 SD
40.0 −5.00 −4.40
40.0 50.0 60.0 70.0 80.0 90.0 40.0 60.0 80.0 100.0
SV at modified posion (mL) Average SV of 2 posions (mL)
Figure 4. The scatter plot with R-squared and agreement Bland-Altman between SV values measured at standard position and
the 1st proposed position.

20.00
360.0 +1.96 SD
LVET at standard posion

15.00
+15.4

LVET difference (ms)

10.00
320.0
5.00
Mean
(ms)

280.0 0.00
0.1
−5.00 (1.96%)
240.0 y = 0.9617x + 10.911 −10.00
−1.96 SD
R² = 0.9400 & p < 0.05 −15.00
−15.3
200.0 −20.00
175.0 225.0 275.0 325.0 375.0 175.0 225.0 275.0 325.0 375.0
LVET at modified posion (ms) Average LVET of 2 posions (ms)
Figure 5. The scatter plot with R-squared and agreement Bland-Altman between LVET values measured at standard position and
the 1st proposed position.

7.0 0.20
+1.96 SD
CO at standard posion

CO difference (L/min)

0.10 +0.1
6.0
0.00
(L/min)

Mean
5.0 −0.10 −0.1
−0.20 (2.49%)
4.0 y = 1.0621x - 0.4024
−0.30 −1.96 SD
R² = 0.9883 & p < 0.05 −0.3
3.0 −0.40
3.0 4.0 5.0 6.0 7.0 2.0 4.0 6.0 8.0
CO at modified posion (L/min) Average CO of 2 posions (L/min)
Figure 6. The scatter plot with R-squared and agreement Bland-Altman between CO values measured at standard position and
the 1st proposed position.

ICG waveform at first proposed posion compared to standard posion

Proposed Posion Standard Posion
15000
Amplitude (quanzaon unit)

10000

5000

−5000

−10000

−15000
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Time (ms)
Figure 7. ICG waveforms at standard position and 1st proposed position.
6 V. D. HAI ET AL.

3.2. Results of the 2nd new upper

0.4 ± 0.2
0.8 ± 0.1
0.3 ± 0.2
0.4 ± 0.1
0.5 ± 0.1
0.9 ± 0.1
0.5 ± 0.0
0.7 ± 0.1
0.7 ± 0.2
0.5 ± 0.2
D
electrode positions
The measurement result of the five hemodynamic

CO (lpm)

4.6 ± 0.1
4.0 ± 0.1
3.1 ± 0.1
4.9 ± 0.1
4.9 ± 0.1
4.7 ± 0.1
5.7 ± 0.1
3.7 ± 0.1
4.1 ± 0.2
3.7 ± 0.1
parameters of ten volunteers at the standard position

PP
and the 2nd proposed position is summarised as
shown in Table 2.

5.0 ± 0.1
4.7 ± 0.1
3.5 ± 0.2
5.3 ± 0.1
5.4 ± 0.1
5.6 ± 0.1
6.2 ± 0.1
4.5 ± 0.2
4.9 ± 0.2
4.2 ± 0.1
From the results summarised in Table 2, measured

SP
hemodynamic parameters will be evaluated as follows:
A. The correlation and the agreement Bland-Altman

0.0 ± 4.9
9.3 ± 2.6
12.0 ± 3.0
9.0 ± 4.5
0.0 ± 3.0
6.0 ± 2.3
18.3 ± 2.4
10.7 ± 2.4
13.7 ± 0.7
35.7 ± 3.6
between the SV parameter measured at the standard
position and the proposed position are shown in

D
Figure 8.
B. The correlation and the agreement Bland-Altman

294.0 ± 0.0
315.0 ± 4.9
354.3 ± 1.3
273.3 ± 1.7
233.0 ± 2.0
337.3 ± 2.4
289.3 ± 0.7
251.3 ± 1.7
269.3 ± 0.7
303.0 ± 4.1
LVET (ms)
between the LVET parameter measured at the stand-

PP
ard position and the proposed position are shown in
Figure 9.
C. The correlation and the agreement Bland-Altman

294.0 ± 4.9
305.7 ± 4.6
342.3 ± 2.8
282.3 ± 2.8
233.0 ± 4.1
331.3 ± 1.7
271.0 ± 2.0
262.0 ± 2.0
255.7 ± 1.3
338.7 ± 0.7
between the CO parameter measured at the standard

SP
position and the proposed position are shown in
Figure 10.
D. Measurement result of ICG waveform for 2 elec-

5.4 ± 0.1
4.3 ± 0.1
5.1 ± 0.1
9.0 ± 0.1
10.2 ± 0.3
4.4 ± 0.1
5.5 ± 0.1
5.5 ± 0.1
3.4 ± 0.2
5.1 ± 0.2
trode positions are obtained as shown in Figure 11.

D
Qualitatively the ICG waveform received between two
positions are similar, however, the amplitude of the

29.4 ± 0.1
26.1 ± 0.1
36.3 ± 0.3
40.2 ± 0.1
30.8 ± 0.2
25.7 ± 0.2
30.7 ± 0.1
35.1 ± 0.1
40.8 ± 0.2
35.2 ± 0.2
Z0 (X)
signal is smaller than at the standard position.
PP
Table 2. Summary of measurement result at the standard and the 2nd proposed position.

3.3. Results of the 3rd new upper

34.9 ± 0.1
30.5 ± 0.1
41.4 ± 0.2
49.2 ± 0.1
41.0 ± 0.1
30.1 ± 0.1
36.2 ± 0.1
40.6 ± 0.1
44.2 ± 0.1
40.3 ± 0.1
electrode positions
SP

The measurement result of the five hemodynamic

parameters of ten volunteers at the standard position
5.3 ± 0.7
10.3 ± 0.7
5.0 ± 1.1
5.0 ± 1.1
5.0 ± 1.1
16.0 ± 2.3
5.0 ± 1.1
9.7 ± 2.4
9.0 ± 2.0
11.7 ± 2.6
and the 3rd proposed position is summarised as
D

shown in Table 3.
From the results summarised in Table 3, measured
64.7 ± 0.7
68.3 ± 1.3
60.3 ± 0.7
71.7 ± 0.7
56.0 ± 1.1
81.7 ± 1.7
67.3 ± 0.1
51.7 ± 1.7
53.3 ± 1.7
68.3 ± 1.3
SV (mL)

hemodynamic parameters will be evaluated as follows:

PP

A. The correlation and the agreement Bland-Altman

between the SV parameter measured at the standard
position and the proposed position are shown in
70.0 ± 1.1
78.7 ± 1.7
65.3 ± 1.7
76.7 ± 0.7
61.0 ± 2.0
97.7 ± 3.6
72.3 ± 0.7
61.3 ± 1.3
62.3 ± 1.3
80.0 ± 2.3

Figure 12.
SP

B. The correlation and the agreement Bland-Altman

between the LVET parameter measured at the stand-
0.3 ± 2.4
2.3 ± 0.7
2.0 ± 2.0
1.0 ± 0.0
1.3 ± 0.7
0.0 ± 1.1
1.0 ± 1.1
0.3 ± 1.7
1.0 ± 1.1
1.7 ± 1.3

ard position and the proposed position are shown in

D

Figure 13.
C. The correlation and the agreement Bland-Altman
between the CO parameter measured at the standard
HR (bpm)

71.0 ± 1.1
58.0 ± 1.1
51.3 ± 1.7
68.0 ± 1.1
87.3 ± 2.8
58.0 ± 1.1
85.0 ± 1.1
72.3 ± 0.7
77.0 ± 1.1
54.3 ± 0.7
PP

position and the proposed position are shown in

Figure 14.
D. Measurement result of ICG waveform for 2 elec-
71.3 ± 1.7
60.3 ± 0.7
53.3 ± 1.3
69.0 ± 1.1
88.7 ± 3.5
58.0 ± 1.1
86.0 ± 1.1
72.7 ± 1.3
78.0 ± 1.1
52.7 ± 0.7

trode positions are obtained as shown in Figure 15. As

SP

can be seen, the ICG waveforms received between

two positions are not similar and the amplitude of the
No

signal is smaller than at the standard position.

10
1
2
3
4
5
6
7
8
9
 JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 7

110.0 20.00

SV at standard posion
100.0 +1.96 SD

SV difference (mL)
90.0 15.00 +15.63
80.0

(mL)
10.00
70.0 Mean
+8.20
60.0 5.00 (11.12%)
y = 1.178x - 3.2506
50.0
R² = 0.9095 & p < 0.05 −1.96 SD
40.0 0.00 +0.77
40.0 50.0 60.0 70.0 80.0 90.0 40.0 60.0 80.0 100.0
SV at modified posion (mL) Average SV of 2 posions (mL)
Figure 8. The scatter plot with R-squared and agreement Bland-Altman between SV values measured at standard position and
the 2nd proposed position.

375.0 40
+1.96 SD
LVET at standard posion

30
+30.6

LVET difference (ms)

325.0 20
10
(ms)

0 Mean
275.0 −0.4
−10 (3.83%)
−20
225.0
y = 0.9138x + 24.757 −30 −1.96 SD
R² = 0.8296 & p < 0.05 −31.4
−40
175.0 175.0 225.0 275.0 325.0 375.0
200.0 250.0 300.0 350.0 400.0
LVET at modified posion (ms) Average LVET of 2 posions (ms)

Figure 9. The scatter plot with R-squared and agreement Bland-Altman between LVET values measured at standard position and
the 2nd proposed position.

7.0 1.20
CO at standard posion

+1.96 SD
CO diference (L/min)

6.0 1.00
+1.0
0.80
(L/min)

5.0
0.60 Mean
+0.6
4.0
0.40 (11.8%)

3.0 y = 0.9984x + 0.5837 −1.96 SD

0.20
R² = 0.9396 & p < 0.05 +0.2
2.0 0.00
2.0 3.0 4.0 5.0 6.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
CO at modified posion (L/min) Average CO of 2 posions (L/min)

Figure 10. The scatter plot with R-squared and agreement Bland-Altman between CO values measured at standard position and
the 2nd proposed position.

ICG waveform at second proposed posion compared to standard posion

Proposed Posion Standard Posion
Amplitude (quanzaon unit)

8000
6000
4000
2000
0
−2000
−4000
−6000
−8000
−10000
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Time (ms)
Figure 11. ICG waveforms at standard position and 2nd proposed position.
8 V. D. HAI ET AL.

4. Discussion

1.2 ± 0.1
0.8 ± 0.1
0.2 ± 0.3
0.2 ± 0.1
1.1 ± 0.4
0.8 ± 0.2
1.2 ± 0.1
0.8 ± 0.2
1.0 ± 0.1
0.3 ± 0.1
D
With the data set of measured hemodynamic parame-
ters, the authors conducted some calculations to

CO (lpm)

4.2 ± 0.1
3.9 ± 0.1
3.2 ± 0.1
4.9 ± 0.1
4.0 ± 0.3
4.7 ± 0.2
4.9 ± 0.1
3.8 ± 0.0
3.9 ± 0.1
3.7 ± 0.1
assess the relation of obtained results between pro-

PP
posed position of electrodes and the standard one.
We perform a hypothesis test of the significance of

5.4 ± 0.1
4.7 ± 0.1
3.5 ± 0.1
5.1 ± 0.1
5.0 ± 0.1
5.4 ± 0.1
6.1 ± 0.1
4.6 ± 0.2
5.0 ± 0.1
4.0 ± 0.1
SP the correlation coefficient to decide whether the linear
relationship in the sample data is strong enough to
use to model the relationship in the population. The
3.7 ± 0.7
10.7 ± 0.7
12.0 ± 3.0
17.7 ± 1.7
2.7 ± 0.7
14.3 ± 0.7
11.7 ± 3.3
11.0 ± 1.1
2.0 ± 2.3
27.7 ± 1.3
conclusion is decided through two estimated statistical
D

parameters that are coefficient of determination,

denoted R2 and p-value (with p-value is calculated
from t-test distribution in Excel data analysis function).
290.0 ± 1.1
299.7 ± 2.4
354.3 ± 1.3
298.3 ± 0.7
227.7 ± 0.7
315.3 ± 0.7
252.7 ± 2.8
260.3 ± 1.7
251.3 ± 2.6
311.7 ± 1.7
LVET (ms)

Additionally, the authors also estimated some auxiliary

PP

parameters such as mean absolute difference and

mean relative difference for further evaluation.
293.7 ± 1.3
310.3 ± 1.7
342.3 ± 2.8
280.7 ± 1.3
230.3 ± 0.7
329.7 ± 0.7
264.3 ± 1.3
271.3 ± 1.3
253.3 ± 1.3
339.3 ± 0.7
SP

4.1. Evaluation for the 1st proposed position

The hemodynamic parameters measured at the 1st
2.9 ± 0.1
2.4 ± 0.1
3.3 ± 0.1

2.2 ± 0.8
3.1 ± 0.2
3.4 ± 0.1
1.5 ± 0.1
3.3 ± 0.1
8.3 ± 0.3

proposed electrode position suggest very high correl-

10.90.0

ation with the standard electrode position, expressed

D

by the average correlation and the relative average

difference of five parameters, R2 ¼ 0.9641 and Mean ¼
30.5 ± 0.1
29.1 ± 0.1
38.1 ± 0.2
38.2 ± 0.1
38.7 ± 0.2
27.7 ± 0.1
32.8 ± 0.1
38.8 ± 0.1
41.8 ± 0.1
31.1 ± 0.2
Zo (X)

3.31%. Qualitatively, the ICG waveforms obtained from

PP

this position have high similarities in terms of shape

Table 3. Summary of measurement result at the standard and the 3rd proposed position.

and amplitude compared to the standard position.

The results show a strong correlation and a good fit
33.4 ± 0.1
31.5 ± 0.1
41.4 ± 0.2
49.1 ± 0.1
40.9 ± 0.7
30.8 ± 0.1
36.1 ± 0.1
40.3 ± 0.1
45.2 ± 0.1
39.4 ± 0.2
SP

between the measured values. Shown on the parame-

ters R2 ¼ 0.9982 (p < 0.05) and Mean ¼ þ0.33bpm
(0.65%) for HR, R2 ¼ 0.9811 (p < 0.05) and Mean ¼
15.0 ± 1.1
12.7 ± 1.7
5.3 ± 2.6
2.3 ± 0.7
15.0 ± 2.0
11.3 ± 1.3
13.0 ± 1.1
11.0 ± 1.1
13.3 ± 0.7
7.7 ± 0.7

1.20 ml (2.51%) for SV, R2 ¼ 0.9127 (p < 0.05) and

D

Mean ¼ þ3.60X (8.92%) for Zo, R2 ¼ 0.9400 (p < 0.05)

and Mean ¼ þ0.10 ms (1.96%) for LVET and R2 ¼
55.7 ± 0.7
62.7 ± 1.3
58.0 ± 1.1
69.3 ± 0.7
45.3 ± 0.7
82.7 ± 2.4
54.3 ± 0.7
49.3 ± 0.7
48.0 ± 1.1
70.7 ± 0.7

0.9883 (p < 0.05) and Mean ¼ 0.10 L/min (2.49%)

SV (mL)
PP

for CO.
70.7 ± 0.7
75.3 ± 0.7
63.3 ± 1.7
71.7 ± 0.7
60.3 ± 1.3
94.0 ± 1.1
67.3 ± 0.7
60.3 ± 0.7
61.3 ± 0.7
78.3 ± 0.7

4.2. Evaluation for the 2nd proposed position

SP

The hemodynamic parameters measured at the 2nd

proposed electrode position suggest quite high correl-
0.0 ± 1.1
0.0 ± 1.1
1.0 ± 2.0
0.7 ± 1.7
4.7 ± 5.3
1.0 ± 1.1
1.0 ± 1.1
0.7 ± 0.7
0.3 ± 1.7
1.0 ± 0.0

ation with the standard electrode position, expressed

D

by the average correlation and the relative average

difference of five parameters, R2 ¼ 0.9091 and Mean ¼
8.67%. Qualitatively, the ICG waveforms obtained from
HR (bpm)

75.7 ± 1.7
62.7 ± 0.7
56.0 ± 1.1

87.7 ± 6.2
56.7 ± 1.7
90.0 ± 2.0
77.3 ± 1.3
81.3 ± 0.7
52.3 ± 0.7
71.0 ±
PP

this position also are quite similar in terms of shape

compared to the standard position, however, the amp-
litude of the signal at the proposed position is smaller.
75.7 ± 1.3
62.7 ± 1.3
55.0 ± 1.1
71.7 ± 1.7
83.0 ± 1.1
57.7 ± 1.3
91.0 ± 1.1
76.7 ± 1.7
81.7 ± 1.3
51.3 ± 0.7

The results show that there is a quite strong correl-

SP

ation and a good fit between the measured values.

Shown on the parameters R2 ¼ 0.9925 (p < 0.05) and
Mean ¼ þ0.77bpm (1.71%) for HR, R2 ¼ 0.9095
No

10
1
2
3
4
5
6
7
8
9
 JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 9

100.0 23.00
+1.96 SD

SV at standard posion
90.0 18.00 +18.97

SV difference (mL)
80.0
13.00
(mL)
Mean
70.0 +10.67
8.00
60.0 (15.57%)

3.00 −1.96 SD
50.0 y = 0.8319x + 20.685
+2.36
R² = 0.8724 & p < 0.05
40.0 −2.00
40.0 60.0 80.0 40.00 60.00 80.00 100.00

SV at modified posion(mL) Average SV of 2 posions (mL)

Figure 12. The scatter plot with R-squared and agreement Bland-Altman between SV values measured at standard position and
the 3rd proposed position.

40.00
400.0
+1.96 SD
LVET at standard posion

30.00
+30.96
360.0
LVET difference (ms)
20.00

320.0 10.00 Mean

(ms)

0.00 +5.40
280.0 (3.74%)
−10.00
240.0 −1.96 SD
y = 0.9497x + 19.802 −20.00
−20.16
R² = 0.8861 & p < 0.05
200.0 −30.00
175.0 225.0 275.0 325.0 375.0 175.00 225.00 275.00 325.00 375.00
LVET at modified posion (ms) Average LVET of 2 posions (ms)
Figure 13. The scatter plot with R-squared and agreement Bland-Altman between LVET values measured at standard position
and the 3rd proposed position.

7.0
CO difference (L/min)
CO at standard posion

1.70 +1.96SD
6.0
+1.52
1.20
5.0
(L/min)

Mean
0.70 +0.77
4.0
(15.24%)
3.0 0.20 -1.96 SD
y = 1.1908x - 0.0169
R² = 0.7595 & p< 0.05 +0.02
2.0 −0.30
2.0 3.0 4.0 5.0 6.0 2.00 4.00 6.00 8.00
CO at modified posion (L/min) Average CO of 2 posions (L/min)
Figure 14. The scatter plot with R-squared and agreement Bland-Altman between CO values measured at standard position and
the 3rd proposed position.

(p < 0.05) and Mean ¼ þ8.20 ml (11.12%) for SV, R2 ¼ 4.3. Evaluation for the 3rd proposed position
0.8741 (p < 0.05) and Mean ¼ þ5.80X (14.88%) for Zo,
The hemodynamic parameters measured at the 3rd
R2 ¼ 0.8296 (p < 0.05) and Mean ¼ þ0.20 ms (3.83%)
proposed electrode position suggest quite correlation
for LVET and R2 ¼ 0.9396 (p < 0.05) and Mean ¼
with the standard electrode position, expressed by the
þ0.60 L/min (11.80%) for CO.
10 V. D. HAI ET AL.

ICG waveform at third proposed posion compared to standard posion

Proposed Posion Standard posion
10000
Amplitude (quanzaon unit)
8000
6000
4000
2000
0
−2000
−4000
−6000
−8000
−10000
−12000
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Time (ms)

Figure 15. ICG waveforms at standard position and 3rd proposed position.

average correlation and the relative average difference standard position in the case of accurate monitoring
of five parameters, R2 ¼ 0.8485 and Mean ¼ 9.26%. of three hemodynamic parameters are HR (R2 ¼
Qualitatively, the ICG waveforms obtained from this 0.9850, Mean ¼ 0.43bpm/1.44%), Zo (R2 ¼ 0.7396,
position are not quite similar in terms of shape com- Mean ¼ þ4.1X/10.33%) and LVET (R2 ¼ 0.8861, Mean
pared to the standard position, the amplitude of the ¼ þ5.4 ms/3.74%).
signal at proposed position is smaller. The results These ten normal subjects aged 19 to 22 participat-
show that there is a correlation and a fit between the ing in this study are obviously not representative of
measured values. Shown on the parameters R2 ¼ coronary care patient. However, at this time, we have
0.9850 (p < 0.05) and Mean ¼ 0.43bpm (1.44%) for not concentrated on the investigation of a specific dis-
HR, R2 ¼ 0.8724 (p < 0.05) and Mean ¼ þ10.67 ml ease. This study is the first phase to investigate the
(15.57%) for SV, R2 ¼ 0.7396 (p < 0.05) and Mean ¼ replacement of standard electrode positions in case of
þ4.10X (10.33%) for Zo, R2 ¼ 0.8861 (p < 0.05) and impossibility to use these positions. We aim to verify
Mean ¼ þ5.40 ms (3.74%) for LVET, and R2 ¼ 0.7595 the correlation of measured cardiac parameters
(p < 0.05) and Mean ¼ þ0.80 L/min (15.24%) for CO. between the standard electrode positions and the
modified one as well as the feasibility of replacement
5. Conclusion in case of necessity. The results presented in this
paper were initial results and they will not be trans-
With the achieved results based on the data of heathy lated to the clinical situation. In the next phase, we
subjects, all three proposed electrode positions could plan to conduct the experiments and collect the data
potentially be used to replace the standard position in on the diseased patients in the hospital environment
necessary cases. Accordingly, the 1st proposed pos- to investigate the effect of specific diseases on the
ition can be used as a good replacement for the measured results and make appropriate
standard position, all five hemodynamic parameters recommendations.
and ICG waveforms measured were almost unaffected,
having very high similarities, whereby HR (R2 ¼
0.9982, Mean ¼ þ0.33bpm/0.65%), SV (R2 ¼ 0.9811, Disclosure statement
Mean ¼ 1.20 ml/2.51%), Zo (R2 ¼ 0.9127, Mean ¼ No potential conflict of interest was reported by
þ3.60X/8.92%), LVET (R2 ¼ 0.9400, Mean ¼ þ0.10 ms/ the author(s).
1.96%) and CO (R2 ¼ 0.9883, Mean ¼ 0.10 L/min/
2.49%). With the 2nd proposed location, we can use it References
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