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Semi-invasive electromechanical target interval to guide left ventricular electrode placement
(2011)
Electrical velocimetry to optimize VV delay in biventricular VVIR and DDD pacing for heart failure
(2011)
Introduction: VV delay (VVD) is the only parameter to hemodynamically optimize cardiac resynchronization therapy (CRT) for patients with atrial fibrillation (AF). Electrical velocimetry (EV) has been established to monitor thoracic electrical conductivity and to calculate hemodynamic surrogate parameters. We compared the response of this method to hemodynamic parameter changes between CRT patients with sinus rhythm (SR) and patients with AF.
Methods: VVD was individualized in 17 CRT patients in SR (12m, 5f, 67.0±7.2yrs.) after echo AV delay optimization and in 11 CRT patients in AF (10m, 1f, 69.8±9.6yrs.) using the Aesculon Cardiovascular Monitor (Osypka Medical, Berlin, Germany). Serial 30s EV recordings were accomplished, decreasing the VVD stepwise by 10ms from +60ms to -60ms between right and left ventricular stimulus. Optimal VVD was determined by the maximum of at least two of the three averaged parameters stroke volume (SV), cardiac output (CO) and cardiac index (CI). The response of SV, CO and CI was tested comparing their values in optimal VVD and suboptimal VVD. Suboptimal VVD was defined by optimal VVD±20ms.
Results: In all 28 patients in SR and AF, EV recordings resulted in optimal VVD. Between suboptimal and optimal mean VVD of 18.6±30.8ms between left and right ventricular stimulus, SV increased by 7.2±6.8%, CO by 7.8±7.2% and CI by 10.0±13.3% (all p<0.02). In the SR group with VVD of 18.8± 29.6ms, SV increased by 4.6±2.9%, CO by 5.0±2.9% and CI by 4.9±2.9% (all p<0.02). In the AF group with VVD of 18.2±4.0ms, SV increased by 10.4±8.9%, CO by 11.3±9.5% and CI by 16.4±18.2% (all p<0.02). Significant differences were not found between optimal VVD in SR and AF patients.
Conclusion: EV is a feasible serial method to individualize VVD in DDD and VVIR pacing for heart failure. Its response to hemodynamic changes demonstrates the value of EV for VVD fine-tuning.
Significance of new electrocardiographic parameters to improve cardiac resynchronization therapy
(2011)
Introduction: Oesophageal left heart electrogram (LHE) is a valuable tool providing electrocardiographic parameters for cardiac resynchronization therapy (CRT). It can be utilized to measure left ventricular (LVCD) and intra-leftventricular conduction delays (ILVCD) in heart failure patients to justify implantation of CRT systems. In the follow-up, LHE enables measurement of implant-related interatrial conduction times (IACT) which are the key intervals defining the hemodynamically optimal AV delay (AVD).
Methods: By TOSlim oesophageal electrode and Rostockfilter (Osypka AG, Rheinfelden, Germany), LHE was recorded in 39 heart failure patients (10f, 29m, 65±8yrs., QRS=163±21ms) after implantation of CRT systems according to guidelines. In position of maximal left ventricular deflection, LVCD and ILVCD were measured and compared with QRS width. In position of maximal left atrial deflection (LA), IACT was determined in VDD and DDD operation as interval As-LA and Ap-LA between atrial sense event (As) or stimulus (Ap), resp., and onset of LA. AVD was individualized using SAV =As-LA + 50ms for VDD and PAV=Ap-LA + 50ms for DDD operation.
Results: The CRT patients were characterized by minimal transoesophageal LVCD of 40ms but 73±20ms, at mean, ILVCD of 90±24ms and QRS/LVCD ratio of 2.4±0.6. The measured As-LA of 39±24ms and Ap-LA of 124±26ms resulted into SAV of 89±24ms and PAV of 174±26ms. In case of empirical AVD programming using 120ms for SAV and 180ms for PAV, the LHE revealed inverse sequences of LA and Vp in 4 patients (10%) during VDD and 13 patients (33%) in DDD pacing. In these patients, Vp preceded LA as IACT exceeded the programmed AVD.
Conclusion: Guideline indication of CRT systems is associated with LVCD of 40ms or more. Therefore, individual LVCD offers the minimal target interval that should be reached during left ventricular electrode placement to increase responder rate. Postoperatively, AV delay optimization respecting implant-related IACTs excludes adverse hemodynamic effects.
Surface and interface acoustic waves are two-dimensionally guided waves, as their displacement field is plane-wave like regarding its dependence on the spatial coordinates parallel to the guiding plane, while it decays exponentially along the axis normal to that plane. When propagating at the planar surface or interface of homogeneous media, they are non-dispersive. Another type of non-dispersive acoustic waves which is, however, one-dimensionally guided, has displacement fields localized near the apex of a wedge made of an elastic material. In this short review, their propagation properties are described as well as theoretical and experimental methods which have been used for their analysis. Experimental findings are discussed in comparison with corresponding theoretical work and potential applications of this fascinating type of acoustic waves are presented.
This study presents some results from a monitoring project with night ventilation and earthto-air heat exchanger. Both techniques refer to air-based low-energy cooling. As these technologies are limited to specific boundary conditions (e.g. moderate summer climate, low temperatures during night, or low ground temperatures, respectively), water-based low-energy cooling may be preferred in many projects. A comparison of the night-ventilated building with a ground-cooled building shows major differences in both concepts.
The German Weather Service (DWD) releases a heat warning, when the weather forecast provides a warm, humid, sunny, and windless weather condition during the next days. The heat stress is calculated by the so called Klima-Michel model. If the apparent air temperature exceeds ca. 32°C / 38°C, there is a strong / extreme heat stress. The smallest forecast area is each administrative district. As people (and especially the vulnerable population) stay most of the time indoors, the heat health warning system was extended by the prediction of heat stress in typical rooms. Therewith it is feasible to forecast the heat stress using a combination of the outdoor and indoor heat stress. The prediction for the indoor heat stress is based on the same weather forecast like the Heat Health Warning Systems (HHWS).and calculates the heat stress by the PMV-model (predicted mean vote). Based on a sophisticated data analysis and simulation study, realistic but summer-critical living situations were defined and implemented in the building simulation program ESP-r. As the simulation runs especially for extreme weather conditions, a simplified building model cannot be used. Standardized input/output routines and an adaptive handover of start values provide for short run times for each forecast area. Good building designs and urban planning provide effective measures to reduce heat stress in cities. However, we have to also pay attention to the present building stock under climate change and a higher heat-wave risk. The extended German HHWS provide information for the emergency services to support the social assistants during heat waves.
In-vivo and in-vitro comparison of implant-based CRT optimization - What provide new algorithms?
(2011)
Introduction: In cardiac resynchronization therapy (CRT), individual AV delay (AVD) optimization can effectively increase hemodynamics and reduce non-responder rate. Accurate, automatic and easily comprehensible algorithms for the follow-up are desirable. QuickOpt is the first attempt of a semi-automatic intracardiac electrogram (IEGM) based AVD algorithm. We aimed to compare its accuracy and usefulness by in-vitro and in-vivo studies.
Methods: Using the programmable ARSI-4 four-chamber heart rhythm and IEGM simulator (HKP, Germany), the QuickOpt feature of an Epic HF system (St. Jude, USA) was tested in-vitro by simulated atrial IEGM amplitudes between 0.3 and 3.5mV during both, manual and automatic atrial sensing between 0.2 and 1.0mV. Subsequently, in 21 heart failure patients with implanted biventricular defibrillators, QuickOpt was performed in-vivo. Results of the algorithm for VDD and DDD stimulation were compared with echo AV delay optimization.
Results: In-vitro simulations demonstrated a QuickOpt measuring accuracy of ± 8ms. Depending on atrial IEGM amplitude, the algorithm proposed optimal AVD between 90 and 150ms for VDD and between 140 and 200ms for DDD operation, respectively. In-vivo, QuickOpt difference between individual AVD in DDD and VDD mode was either 50ms (20pts) or 40ms (1pt). QuickOpt and echo AVD differed by 41 ± 25ms (7 – 90ms) in VDD and by 18 ± 24ms (17-50ms) in DDD operation. Individual echo AVD difference between both modes was 73 ± 20ms (30-100ms).
Conclusion: The study demonstrates the value of in-vitro studies. It predicted QuickOpt deficiencies regarding IEGM amplitude dependent AVD proposals constrained to fixed individual differences between DDD and VDD mode. Consequently, in-vivo, the algorithm provided AVD of predominantly longer duration than echo in both modes. Accepting echo individualization as gold standard, QuickOpt should not be used alone to optimize AVD in CRT patients.
The efficient support of Hardwae-In-theLoop (HIL) in the design process of hardwaresoftware-co-designed systems is an ongoing challenge. This paper presents a network-based integration of hardware elements into the softwarebased image processing tool „ADTF“, based on a high-performance Gigabit Ethernet MAC and a highly-efficient TCP/IP-stack. The MAC has been designed in VHDL. It was verified in a SystemCsimulation environment and tested on several Altera FPGAs.
Introduction: Patient selection for cardiac resynchronization therapy (CRT) requires quantification of left ventricular conduction delay (LVCD). After implantation of biventricular pacing systems, individual AV delay (AVD) programming is essential to ensure hemodynamic response. To exclude adverse effects, AVD should exceed individual implant-related interatrial conduction times (IACT). As result of a pilot study, we proposed the development of a programmer-based transoesophageal left heart electrogram (LHE) recording to simplify both, LVCD and IACT measurement. This feature was implemented into the Biotronik ICS3000 programmer simultaneously with 3-channel surface ECG.
Methods: A 5F oesophageal electrode was perorally applied in 44 heart failure CRT-D patients (34m, 10f, 65±8 yrs., QRS=162±21ms). In position of maximum left ventricular deflection, oesophageal LVCD was measured between onsets of QRS in surface ECG and oesophageal left ventricular deflection. Then, in position of maximum left atrial deflection (LA), IACT in VDD operation (As-LA) was calculated by difference between programmed AV delay and the measured interval from onset of left atrial deflection to ventricular stimulus in the oesophageal electrogram. IACT in DDD operation (Ap-LA) was measured between atrial stimulus and LA..
Results: LVCD of the CRT patients was characterized by a minimum of 47ms with mean of 69±23ms. As-LA and Ap-LA were found to be 41±23ms and 125±25ms, resp., at mean. In 7 patients (15,9%), IACT measurement in DDD operation uncovered adverse AVD if left in factory settings. In this cases, Ap-LA exceeded the factory AVD. In 6 patients (13,6%), IACT in VDD operation was less than or equal 10ms indicating the need for short AVD.
Conclusion: Response to CRT requires distinct LVCD and AVD optimization. The ICS3000 oesophageal LHE feature can be utilized to measure LVCD in order to justify selection for CRT. IACT measurement simplifies AV delay optimization in patients with CRT systems irrespective of their make and model.
Introduction: To simplify AV delay (AVD) optimization in cardiac resynchronization therapy (CRT), we reported that the hemodynamically optimal AVD for VDD and DDD mode CRT pacing can be approximated by individually measuring implant-related interatrial conduction intervals (IACT) in oesophageal electrogram (LAE) and adding about 50ms. The programmer-based St Jude QuickOpt algorithm is utilizing this finding. By automatically measuring IACT in VDD operation, it predicts the sensed AVD by adding either 30ms or 60ms. Paced AVD is strictly 50ms longer than sensed AVD. As consequence of those variations, several studies identified distinct inaccuracies of QuickOpt. Therefore, we aimed to seek for better approaches to automate AVD optimization.
Methods: In a study of 35 heart failure patients (27m, 8f, age: 67±8y) with Insync III Marquis CRT-D systems we recorded telemetric electrograms between left ventricular electrode and superior vena cava shock coil (LVtip/SVC = LVCE) simultaneously with LAE. By LVCE we measured intervals As-Pe in VDD and Ap-Pe in DDD operation between right atrial sense-event (As) or atrial stimulus (Ap), resp., and end of the atrial activity (Pe). As-Pe and Ap-Pe were compared with As-LA an Ap-LA in LAE, respectively.
Results: End of the left atrial activity in LVCE could clearly be recognized in 35/35 patients in VDD and 29/35 patients in DDD operation. We found mean intervals As-LA of 40.2±24.5ms and Ap-LA of 124.3±20.6ms. As-Pe was 94.8±24.1ms and Ap-Pe was 181.1±17.8ms. Analyzing the sums of As-LA + 50ms with duration of As-Pe and Ap-LA + 50ms with duration of Ap-Pe, the differences were 4.7±9.2ms and 4.2±8.6ms, resp., only. Thus, hemodynamically optimal timing of the ventricular stimulus can be triggered by automatically detecting Pe in LVCE.
Conclusion: Based on minimal deviations between LAE and LVCE approach, we proposed companies to utilize the LVCE in order to automate individual AVD optimization in CRT pacing.
In large aircrafts the cabling is very complex and often causes reliability problems. This is specially true for modern In-flight Entertainment (IFE) systems, where every passenger can select a preferred movie, play computer games or be able to communicate with other travellers. Due to EMC problems, wireless communication systems (WiFi etc.) didn't succeed in solving these problems. In this paper an innovative communication system is proposed which perfectly supplements an aircraft IFE system. The key innovation of this system is to use structures that are essential parts of the airframe for data transfer, such as seat rails. Those rails consist of rectangular shapes and could easily be modified to fulfill the function of waveguides for microwaves. A waveguide as part of the seat rail would provide enormous benefits for aircrafts, such as a large bandwidth and consequently high data rates, no problems with EMC, unlimited flexibility of seat configuration, mechanical robustness with associated increase of reliability and a few additional advantages related to aircrafts such as reduction of weight and costs.
Home Care Applications and Ambient Assisted Living become increasingly attractive. This is caused as well by market pull, as the number of elderly people grows monotonously, as well as by technology push, as technological advances and attractive products pave the way to economically advantageous offerings. However, in real-life applications, a significant number of challenges remain. Those include seamless communication between products from different supplier, due to the lack of sufficiently standardized solutions, energy budgets, and scalability of solutions. This paper presents the experience from the InCASA project (Integrated Network for Completely Assisted Senior Citizen's Autonomy), where architectures for heterogeneous physical and logical communication flows are examined.
The concept of m-learning which differs from other forms of e-learning covers a wide range of possibilities opened up by the convergence of new mobile technologies, wireless communication structure and distance learning development. This process of converging has launched some new goals to support m-learning where heterogeneity of devices, their operating systems (Linux, Windows, Symbian, Android etc) and supported markup languages (WML, XHTML etc), adaptive content, preferences or characteristics of user have become some of the major problems to be solved. To facilitate the learning process even more and to establish literally anytime anywhere learning, learning material/content should be available to the user always even if the user is in offline. Multiple devices used by the same user should also be synchronized among themselves and with server to provide updated learning content and to give a freedom to the user to choose any device as per his/her convenience. In this paper software architecture has been proposed to solve these problems and has been implemented by using a multidimensional flashcard learning system which synchronizes among all the devices that are being used by the user.
Today's network landscape consists of quite different network technologies, wide range of end-devices with large scale of capabilities and power, and immense quantity of information and data represented in different formats. Research on 3D imaging, virtual reality and holographic techniques will result in new user interfaces (UI) for mobile devices and will increase their diversity and variety. A lot of efforts are being done in order to establish open, scalable and seamless integration of various technologies and content presentation for different devices including mobile considering individual situation of the end user. This is very difficult because various kinds of devices used by different users or in different times/parallel by the same user which are not predictable and have to be recognized by the system in order to identify device capabilities. Not only the devices but also Content and User Interfaces are big issues because they could include different kinds of data format like text, image, audio, video, 3D Virtual Reality data and other upcoming formats. A very suitable and useful example of the use of such a system is mobile learning because of the large amount of varying devices with significantly different features and functionalities. This is true not only to support different learners, e.g. all learners within one learning community, but also to support the same learner using different equipment parallel and/or at different times. Those applications may be significantly enhanced by including virtual reality content presentation. Whatever the purposes are, it is impossible to develop and adapt content for all kind of devices including mobiles individually due to different capabilities of the devices, cost issues and author‘s requirement. A solution should be found to enable the automation of the content adaptation process.
A simple model is introduced that describes the interaction of surface acoustic waves (SAWs) with a 2D periodic array of objects on the surface that give rise to internal resonances. Such objects may be high-aspect ratio structures like micro-pillars fabricated of a material different from that of the substrate. The model allows for an approximate determination of the band structure for the acoustic modes in such systems. Results are presented for the dependence on structural parameters of a total bandgap in the non-radiative regime of a semi-infinite substrate, and it is shown how the frequency and radiation damping of vibrational modes can be determined that are associated with defects in the periodic 2D array.
In this paper we suggest to combine the areas of media streaming services, mobile devices, and manufacturing processes to support monitoring, controlling and supervising production processes in order to achieve high levels of efficiency and environmentally friendly production. It contains a comprehensive and detailed explanation of the proposed E-Learning streaming framework, especially the adaption of streaming services to mobile environments. The key components of our approach are 1) an XML-based streaming service specification language, 2) adaption of multimedia E-Learning services to mobile environments, and 3) a media delivery platform for searching, registration, and creation of streaming services for mobile devices.