Parameters and algorithms to evaluate cardiac mechanics by conductance catheter

This work is structured as follows: In Section 1 we discuss the clinical problem of heart failure. In particular, we present the phenomenon known as ventricular mechanical dyssynchrony: its impact on cardiac function, the therapy for its treatment and the methods for its quantification. Specifically, we describe the conductance catheter and its use for the measurement of dyssynchrony. At the end of the Section 1, we propose a new set of indexes to quantify the dyssynchrony that are studied and validated thereafter. In Section 2 we describe the studies carried out in this work: we report the experimental protocols, we present and discuss the results obtained. Finally, we report the overall conclusions drawn from this work and we try to envisage future works and possible clinical applications of our results. Ancillary studies that were carried out during this work mainly to investigate several aspects of cardiac resynchronization therapy (CRT) are mentioned in Appendix. -------- Ventricular mechanical dyssynchrony plays a regulating role already in normal physiology but is especially important in pathological conditions, such as hypertrophy, ischemia, infarction, or heart failure (Chapter 1,2.). Several prospective randomized controlled trials supported the clinical efficacy and safety of cardiac resynchronization therapy (CRT) in patients with moderate or severe heart failure and ventricular dyssynchrony. CRT resynchronizes ventricular contraction by simultaneous pacing of both left and right ventricle (biventricular pacing) (Chapter 1.). Currently, the conductance catheter method has been used extensively to assess global systolic and diastolic ventricular function and, more recently, the ability of this instrument to pick-up multiple segmental volume signals has been used to quantify mechanical ventricular dyssynchrony. Specifically, novel indexes based on volume signals acquired with the conductance catheter were introduced to quantify dyssynchrony (Chapter 3,4.). Present work was aimed to describe the characteristics of the conductancevolume signals, to investigate the performance of the indexes of ventricular dyssynchrony described in literature and to introduce and validate improved dyssynchrony indexes. Morevoer, using the conductance catheter method and the new indexes, the clinical problem of the ventricular pacing site optimization was addressed and the measurement protocol to adopt for hemodynamic tests on cardiac pacing was investigated. In accordance to the aims of the work, in addition to the classical time-domain parameters, a new set of indexes has been extracted, based on coherent averaging procedure and on spectral and cross-spectral analysis (Chapter 4.). Our analyses were carried out on patients with indications for electrophysiologic study or device implantation (Chapter 5.). For the first time, besides patients with heart failure, indexes of mechanical dyssynchrony based on conductance catheter were extracted and studied in a population of patients with preserved ventricular function, providing information on the normal range of such a kind of values. By performing a frequency domain analysis and by applying an optimized coherent averaging procedure (Chapter 6.a.), we were able to describe some characteristics of the conductance-volume signals (Chapter 6.b.). We unmasked the presence of considerable beat-to-beat variations in dyssynchrony that seemed more frequent in patients with ventricular dysfunction and to play a role in discriminating patients. These non-recurrent mechanical ventricular non-uniformities are probably the expression of the substantial beat-to-beat hemodynamic variations, often associated with heart failure and due to cardiopulmonary interaction and conduction disturbances. We investigated how the coherent averaging procedure may affect or refine the conductance based indexes; in addition, we proposed and tested a new set of indexes which quantify the non-periodic components of the volume signals. Using the new set of indexes we studied the acute effects of the CRT and the right ventricular pacing, in patients with heart failure and patients with preserved ventricular function. In the overall population we observed a correlation between the hemodynamic changes induced by the pacing and the indexes of dyssynchrony, and this may have practical implications for hemodynamic-guided device implantation. The optimal ventricular pacing site for patients with conventional indications for pacing remains controversial. The majority of them do not meet current clinical indications for CRT pacing. Thus, we carried out an analysis to compare the impact of several ventricular pacing sites on global and regional ventricular function and dyssynchrony (Chapter 6.c.). We observed that right ventricular pacing worsens cardiac function in patients with and without ventricular dysfunction unless the pacing site is optimized. CRT preserves left ventricular function in patients with normal ejection fraction and improves function in patients with poor ejection fraction despite no clinical indication for CRT. Moreover, the analysis of the results obtained using new indexes of regional dyssynchrony, suggests that pacing site may influence overall global ventricular function depending on its relative effects on regional function and synchrony. Another clinical problem that has been investigated in this work is the optimal right ventricular lead location for CRT (Chapter 6.d.). Similarly to the previous analysis, using novel parameters describing local synchrony and efficiency, we tested the hypothesis and we demonstrated that biventricular pacing with alternative right ventricular pacing sites produces acute improvement of ventricular systolic function and improves mechanical synchrony when compared to standard right ventricular pacing. Although no specific right ventricular location was shown to be superior during CRT, the right ventricular pacing site that produced the optimal acute hemodynamic response varied between patients. Acute hemodynamic effects of cardiac pacing are conventionally evaluated after stabilization episodes. The applied duration of stabilization periods in most cardiac pacing studies varied considerably. With an ad hoc protocol (Chapter 6.e.) and indexes of mechanical dyssynchrony derived by conductance catheter we demonstrated that the usage of stabilization periods during evaluation of cardiac pacing may mask early changes in systolic and diastolic intra-ventricular dyssynchrony. In fact, at the onset of ventricular pacing, the main dyssynchrony and ventricular performance changes occur within a 10s time span, initiated by the changes in ventricular mechanical dyssynchrony induced by aberrant conduction and followed by a partial or even complete recovery. It was already demonstrated in normal animals that ventricular mechanical dyssynchrony may act as a physiologic modulator of cardiac performance together with heart rate, contractile state, preload and afterload. The present observation, which shows the compensatory mechanism of mechanical dyssynchrony, suggests that ventricular dyssynchrony may be regarded as an intrinsic cardiac property, with baseline dyssynchrony at increased level in heart failure patients. To make available an independent system for cardiac output estimation, in order to confirm the results obtained with conductance volume method, we developed and validated a novel technique to apply the Modelflow method (a method that derives an aortic flow waveform from arterial pressure by simulation of a non-linear three-element aortic input impedance model, Wesseling et al. 1993) to the left ventricular pressure signal, instead of the arterial pressure used in the classical approach (Chapter 7.). The results confirmed that in patients without valve abnormalities, undergoing conductance catheter evaluations, the continuous monitoring of cardiac output using the intra-ventricular pressure signal is reliable. Thus, cardiac output can be monitored quantitatively and continuously with a simple and low-cost method. During this work, additional studies were carried out to investigate several areas of uncertainty of CRT. The results of these studies are briefly presented in Appendix: the long-term survival in patients treated with CRT in clinical practice, the effects of CRT in patients with mild symptoms of heart failure and in very old patients, the limited thoracotomy as a second choice alternative to transvenous implant for CRT delivery, the evolution and prognostic significance of diastolic filling pattern in CRT, the selection of candidates to CRT with echocardiographic criteria and the prediction of response to the therapy.

Background minimization issues for next generation hard X-ray focusing telescopes

The hard X-ray band (10 - 100 keV) has been only observed so far by collimated and coded aperture mask instruments, with a sensitivity and an angular resolution lower than two orders of magnitude as respects the current X-ray focusing telescopes operating below 10 - 15 keV. The technological advance in X-ray mirrors and detection systems is now able to extend the X-ray focusing technique to the hard X-ray domain, filling the gap in terms of observational performances and providing a totally new deep view on some of the most energetic phenomena of the Universe. In order to reach a sensitivity of 1 muCrab in the 10 - 40 keV energy range, a great care in the background minimization is required, a common issue for all the hard X-ray focusing telescopes. In the present PhD thesis, a comprehensive analysis of the space radiation environment, the payload design and the resulting prompt X-ray background level is presented, with the aim of driving the feasibility study of the shielding system and assessing the scientific requirements of the future hard X-ray missions. A Geant4 based multi-mission background simulator, BoGEMMS, is developed to be applied to any high energy mission for which the shielding and instruments performances are required. It allows to interactively create a virtual model of the telescope and expose it to the space radiation environment, tracking the particles along their path and filtering the simulated background counts as a real observation in space. Its flexibility is exploited to evaluate the background spectra of the Simbol-X and NHXM mission, as well as the soft proton scattering by the X-ray optics and the selection of the best shielding configuration. Altough the Simbol-X and NHXM missions are the case studies of the background analysis, the obtained results can be generalized to any future hard X-ray telescope. For this reason, a simplified, ideal payload model is also used to select the major sources of background in LEO. All the results are original contributions to the assessment studies of the cited missions, as part of the background groups activities.

Multi Processor Systems On Chip with Configurable Hardware Acceleration

The evolution of the electronics embedded applications forces electronics systems designers to match their ever increasing requirements. This evolution pushes the computational power of digital signal processing systems, as well as the energy required to accomplish the computations, due to the increasing mobility of such applications. Current approaches used to match these requirements relies on the adoption of application specific signal processors. Such kind of devices exploits powerful accelerators, which are able to match both performance and energy requirements. On the other hand, the too high specificity of such accelerators often results in a lack of flexibility which affects non-recurrent engineering costs, time to market, and market volumes too. The state of the art mainly proposes two solutions to overcome these issues with the ambition of delivering reasonable performance and energy efficiency: reconfigurable computing and multi-processors computing. All of these solutions benefits from the post-fabrication programmability, that definitively results in an increased flexibility. Nevertheless, the gap between these approaches and dedicated hardware is still too high for many application domains, especially when targeting the mobile world. In this scenario, flexible and energy efficient acceleration can be achieved by merging these two computational paradigms, in order to address all the above introduced constraints. This thesis focuses on the exploration of the design and application spectrum of reconfigurable computing, exploited as application specific accelerators for multi-processors systems on chip. More specifically, it introduces a reconfigurable digital signal processor featuring a heterogeneous set of reconfigurable engines, and a homogeneous multi-core system, exploiting three different flavours of reconfigurable and mask-programmable technologies as implementation platform for applications specific accelerators. In this work, the various trade-offs concerning the utilization multi-core platforms and the different configuration technologies are explored, characterizing the design space of the proposed approach in terms of programmability, performance, energy efficiency and manufacturing costs.

Il rapporto madre-figlia nelle letterature femminili maghrebine (1980-2010)

La ricerca Il rapporto madre-figlia nelle letterature femminili maghrebine (1980-2010) comprende due sezioni: la prima analizza le principali caratteristiche del mondo maghrebino femminile e le peculiarità della scrittura dell’intellettuale nord-africana, la seconda è incentrata sull’analisi testuale dei romanzi maghrebini femminili più rappresentativi. Il lavoro di analisi verte sullo studio di varie autrici maghrebine che coprono un vasto ventaglio temporale: dal 1980 al 2010. Di ogni autrice vengono analizzati i romanzi in cui è possibile rinvenire la tematica oggetto della tesi: il rapporto madre-figlia. I romanzi studiati sono raggruppati secondo quattro macro direttrici tematiche: i romanzi in cui il rapporto filiale è caratterizzato dalla violenza; le opere in cui il rapporto madre-figlia è caratterizzato dall’assenza fisica della genitrice; i romanzi in cui il rapporto filiale è caratterizzato dall’incomprensione ed infine le produzioni in cui la relazionalità madre-figlia è caratterizzata da un rapporto di amore e sostegno reciproco.

La performance rituale delle Nava Durgā: musica e danza tra i Banmālā di Bhaktapur, Nepal

Il presente lavoro è il risultato di cinque anni di ricerca sulla performance rituale delle Nava Durgā del popolo newar a Bhaktapur (Nepal). Dal 1512, per circa nove mesi all'anno, gli uomini della casta inferiore Banmālā reincarnano le nove manifestazioni femminili della dea Durgā ed eseguono le danze in maschera. La performance della Nava Durgā è una pratica culturale molto complessa, composta da suoni, danze, processioni, momenti di venerazione (pūjā), rituali tantrici e momenti sacrificali. Gli aspetti musicali e teatrali della performance costituiscono il focus dell’indagine di questo studio. Dopo una descrizione analitica degli strumenti musicali utilizzati nella performance, alcuni elementi sonori vengono trascritti e analizzati mettendo in luce le caratteristiche tipiche della musica newar. I contenuti narrativi delle danze e il ciclo vitale delle Nava Durgā rispecchiano la vita hindu. La loro interpretazione viene realizzata in base alle osservazioni etnografiche; alcuni temi che costituiscono gli obiettivi dei devoti hindu (puruṣārtha) vengono esaminati attraverso l’approccio storico e quello etnografico, anche al fine di sottolineare il ruolo didascalico e formativo della performance. Un altro argomento discusso in questo lavoro consiste nell'identità dei danzatori Banmālā e quella del popolo newar in generale; questo aspetto è emerso in modo rilevante anche durante le fasi di mediatizzazione della performance delle Nava Durgā avvenute nel periodo del COVID-19. Da questo punto di vista, il presente lavoro costituisce un contributo alla diffusione della conoscenza della tradizione delle Nava Durgā; questo converge con l'obiettivo dei Banmālā di aumentare la visibilità della performance al fine di affermare la propria identità sia nel contesto nazionale che in quello internazionale.