Optimal Supervisory Control of Hybrid Vehicles

Hybrid vehicles (HV), comprising a conventional ICE-based powertrain and a secondary energy source, to be converted into mechanical power as well, represent a well-established alternative to substantially reduce both fuel consumption and tailpipe emissions of passenger cars. Several HV architectures are either being studied or already available on market, e.g. Mechanical, Electric, Hydraulic and Pneumatic Hybrid Vehicles. Among the others, Electric (HEV) and Mechanical (HSF-HV) parallel Hybrid configurations are examined throughout this Thesis. To fully exploit the HVs potential, an optimal choice of the hybrid components to be installed must be properly designed, while an effective Supervisory Control must be adopted to coordinate the way the different power sources are managed and how they interact. Real-time controllers can be derived starting from the obtained optimal benchmark results. However, the application of these powerful instruments require a simplified and yet reliable and accurate model of the hybrid vehicle system. This can be a complex task, especially when the complexity of the system grows, i.e. a HSF-HV system assessed in this Thesis. The first task of the following dissertation is to establish the optimal modeling approach for an innovative and promising mechanical hybrid vehicle architecture. It will be shown how the chosen modeling paradigm can affect the goodness and the amount of computational effort of the solution, using an optimization technique based on Dynamic Programming. The second goal concerns the control of pollutant emissions in a parallel Diesel-HEV. The emissions level obtained under real world driving conditions is substantially higher than the usual result obtained in a homologation cycle. For this reason, an on-line control strategy capable of guaranteeing the respect of the desired emissions level, while minimizing fuel consumption and avoiding excessive battery depletion is the target of the corresponding section of the Thesis.

Studio sul ruolo dei fattori genetici coinvolti nella Valvola Aortica Bicuspide e/o nell'Aneurisma dell'Aorta Toracica

La Valvola Aortica Bicuspide (BAV) rappresenta la più comune anomalia cardiaca congenita, con un’incidenza dello 0,5%-2% nella popolazione generale. Si caratterizza per la presenza di due cuspidi valvolari anziché tre e comprende diverse forme. La BAV è frequentemente associata agli aneurismi dell’aorta toracica (TAA). La dilatazione dell’aorta espone al rischio di sviluppare le complicanze aortiche acute. Materiali e metodi Sono stati reclutati 20 probandi consecutivi sottoposti a chirurgia della valvola aortica e dell'aorta ascendente presso l'Unità di Chirurgia Cardiaca di Policlinico S.Orsola-Malpighi di TAA associata a BAV. Sono stati esclusi individui con una condizione sindromica predisponente l’aneurisma aortico. Ciascun familiare maggiorenne di primo grado è stato arruolato nello studio. L’analisi di mutazioni dell’intero gene ACTA2 è stata eseguita con la tecnica del “bidirectional direct sequencing”. Nelle forme familiari, l’intera porzione codificante del genoma è stata eseguita usando l’exome sequencing. Risultati Dopo il sequenziamento di tutti i 20 esoni e giunzioni di splicing di ACTA2 nei 20 probandi, non è stata individuata alcuna mutazione. Settantasette familiari di primo grado sono stati arruolati. Sono state identificate cinque forme familiari. In una famiglia è stata trovata una mutazione del gene MYH11 non ritenuta patogenetica. Conclusioni La mancanza di mutazioni, sia nelle forme sporadiche sia in quelle familiari, ci suggerisce che questo gene non è coinvolto nello sviluppo della BAV e TAA e, l’associazione che è stata riportata deve essere considerata occasionale. L’architettura genetica della BAV verosimilmente dovrebbe consistere in svariate differenti varianti genetiche che interagiscono in maniera additiva nel determinare un aumento del rischio.

Entwicklung eines Pikoliter-Tropfengenerators für die Massenspektrometrische Spuren- und Speziesanalytik

Die Dissertationsschrift beschäftigt sich mit der Entwicklung und Anwendung einer alternativen Probenzuführungstechnik für flüssige Proben in der Massenspektrometrie. Obwohl bereits einige Anstrengungen zur Verbesserung unternommen wurden, weisen konventionelle pneumatische Zerstäuber- und Sprühkammersysteme, die in der Elementspurenanalytik mittels induktiv gekoppeltem Plasma (ICP) standardmäßig verwendet werden, eine geringe Gesamteffizienz auf. Pneumatisch erzeugtes Aerosol ist durch eine breite Tropfengrößenverteilung gekennzeichnet, was den Einsatz einer Sprühkammer bedingt, um die Aerosolcharakteristik an die Betriebsbedingungen des ICPs anzupassen.. Die Erzeugung von Tropfen mit einer sehr engen Tropfengrößenverteilung oder sogar monodispersen Tropfen könnte die Effizienz des Probeneintrags verbessern. Ein Ziel dieser Arbeit ist daher, Tropfen, die mittels des thermischen Tintenstrahldruckverfahrens erzeugt werden, zum Probeneintrag in der Elementmassenspektrometrie einzusetzen. Das thermische Tintenstrahldruckverfahren konnte in der analytischen Chemie im Bereich der Oberflächenanalytik mittels TXRF oder Laserablation bisher zur gezielten, reproduzierbaren Deposition von Tropfen auf Oberflächen eingesetzt werden. Um eine kontinuierliche Tropfenerzeugung zu ermöglichen, wurde ein elektronischer Mikrokontroller entwickelt, der eine Dosiereinheit unabhängig von der Hard- und Software des Druckers steuern kann. Dabei sind alle zur Tropfenerzeugung relevanten Parameter (Frequenz, Heizpulsenergie) unabhängig voneinander einstellbar. Die Dosiereinheit, der "drop-on-demand" Aerosolgenerator (DOD), wurde auf eine Aerosoltransportkammer montiert, welche die erzeugten Tropfen in die Ionisationsquelle befördert. Im Bereich der anorganischen Spurenanalytik konnten durch die Kombination des DOD mit einem automatischen Probengeber 53 Elemente untersucht und die erzielbare Empfindlichkeiten sowie exemplarisch für 15 Elemente die Nachweisgrenzen und die Untergrundäquivalentkonzentrationen ermittelt werden. Damit die Vorteile komfortabel genutzt werden können, wurde eine Kopplung des DOD-Systems mit der miniaturisierten Fließinjektionsanalyse (FIA) sowie miniaturisierten Trenntechniken wie der µHPLC entwickelt. Die Fließinjektionsmethode wurde mit einem zertifizierten Referenzmaterial validiert, wobei für Vanadium und Cadmium die zertifizierten Werte gut reproduziert werden konnten. Transiente Signale konnten bei der Kopplung des Dosiersystems in Verbindung mit der ICP-MS an eine µHPLC abgebildet werden. Die Modifikation der Dosiereinheit zum Ankoppeln an einen kontinuierlichen Probenfluss bedarf noch einer weiteren Reduzierung des verbleibenden Totvolumens. Dazu ist die Unabhängigkeit von den bisher verwendeten, kommerziell erhältlichen Druckerpatronen anzustreben, indem die Dosiereinheit selbst gefertigt wird. Die Vielseitigkeit des Dosiersystems wurde mit der Kopplung an eine kürzlich neu entwickelte Atmosphärendruck-Ionisationsmethode, die "flowing atmospheric-pressure afterglow" Desorptions/Ionisations Ionenquelle (FAPA), aufgezeigt. Ein direkter Eintrag von flüssigen Proben in diese Quelle war bislang nicht möglich, es konnte lediglich eine Desorption von eingetrockneten Rückständen oder direkt von der Flüssigkeitsoberfläche erfolgen. Die Präzision der Analyse ist dabei durch die variable Probenposition eingeschränkt. Mit dem Einsatz des DOD-Systems können flüssige Proben nun direkt in die FAPA eingetragen, was ebenfalls das Kalibrieren bei quantitativen Analysen organischer Verbindungen ermöglicht. Neben illegalen Drogen und deren Metaboliten konnten auch frei verkäufliche Medikamente und ein Sprengstoffanalogon in entsprechend präpariertem reinem Lösungsmittel nachgewiesen werden. Ebenso gelang dies in Urinproben, die mit Drogen und Drogenmetaboliten versetzt wurden. Dabei ist hervorzuheben, dass keinerlei Probenvorbereitung notwendig war und zur Ermittlung der NWG der einzelnen Spezies keine interne oder isotopenmarkierte Standards verwendet wurden. Dennoch sind die ermittelten NWG deutlich niedriger, als die mit der bisherigen Prozedur zur Analyse flüssiger Proben erreichbaren. Um im Vergleich zu der bisher verwendeten "pin-to-plate" Geometrie der FAPA die Lösungsmittelverdampfung zu beschleunigen, wurde eine alternative Elektrodenanordnung entwickelt, bei der die Probe länger in Kontakt mit der "afterglow"-Zone steht. Diese Glimmentladungsquelle ist ringförmig und erlaubt einen Probeneintrag mittels eines zentralen Gasflusses. Wegen der ringförmigen Entladung wird der Name "halo-FAPA" (h-FAPA) für diese Entladungsgeometrie verwendet. Eine grundlegende physikalische und spektroskopische Charakterisierung zeigte, dass es sich tatsächlich um eine FAPA Desorptions/Ionisationsquelle handelt.

Analysis and design of high performance multiphase electric drives for vehicle and aircraft applications

The first part of this thesis has focused on the construction of a twelve-phase asynchronous machine for More Electric Aircraft (MEA) applications. In fact, the aerospace world has found in electrification the way to improve the efficiency, reliability and maintainability of an aircraft. This idea leads to the aircraft a new management and distribution of electrical services. In this way is possible to remove or to reduce the hydraulic, mechanical and pneumatic systems inside the aircraft. The second part of this dissertation is dedicated on the enhancement of the control range of matrix converters (MCs) operating with non-unity input power factor and, at the same time, on the reduction of the switching power losses. The analysis leads to the determination in closed form of a modulation strategy that features a control range, in terms of output voltage and input power factor, that is greater than that of the traditional strategies under the same operating conditions, and a reduction in the switching power losses.

Entwicklung und Charakterisierung eines Drop-on-Demand-Aerosolgenerators für die Probenzuführung kleinster Flüssigkeitsmengen in der analytischen Atomspektroskopie

Die pneumatische Zerstäubung ist die häufigste Methode der Probenzuführung von Flüssigkeiten in der Plasmaspektrometrie. Trotz der bekannten Limitierungen dieser Systeme, wie die hohen Probenverluste, finden diese Zerstäuber aufgrund ihrer guten Robustheit eine breite Anwendung. Die flussratenabhängige Aerosolcharakteristik und pumpenbasierte Signalschwankungen limitieren bisher Weiterentwicklungen. Diese Probleme werden umso gravierender, je weiter die notwendige Miniaturisierung dieser Systeme fortschreitet. Der neuartige Ansatz dieser Arbeit basiert auf dem Einsatz modifizierter Inkjet-Druckerpatronen für die Dosierung von pL-Tropfen. Ein selbst entwickelter Mikrokontroller ermöglicht den Betrieb von matrixkodierten Patronen des Typs HP45 mit vollem Zugriff auf alle essentiellen Betriebsparameter. Durch die neuartige Aerosoltransportkammer gelang die effiziente Kopplung des Tropfenerzeugungssystems an ein ICP-MS. Das so aufgebaute drop-on-demand-System (DOD) zeigt im Vergleich zu herkömmlichen und miniaturisierten Zerstäubern eine deutlich gesteigerte Empfindlichkeit (8 - 18x, elementabhängig) bei leicht erhöhtem, aber im Grunde vergleichbarem Signalrauschen. Darüber hinaus ist die Flexibilität durch die große Zahl an Freiheitsgraden des Systems überragend. So ist die Flussrate über einen großen Bereich variabel (5 nL - 12,5 µL min-1), ohne dabei die primäre Aerosolcharakteristik zu beeinflussen, welche vom Nutzer durch Wahl der elektrischen Parameter bestimmt wird. Das entwickelte Probenzuführungssystem ist verglichen mit dem pneumatischen Referenzsystem weniger anfällig gegenüber Matrixeffekten beim Einsatz von realen Proben mit hohen Anteilen gelöster Substanzen. So gelingt die richtige Quantifizierung von fünf Metallen im Spurenkonzentrationsbereich (Li, Sr, Mo, Sb und Cs) in nur 12 µL Urin-Referenzmaterial mittels externer Kalibrierung ohne Matrixanpassung. Wohingegen beim pneumatischen Referenzsystem die aufwändigere Standardadditionsmethode sowie über 250 µL Probenvolumen für eine akkurate Bestimmung der Analyten nötig sind. Darüber hinaus wird basierend auf der Dosierfrequenz eines dualen DOD-Systems eine neuartige Kalibrierstrategie vorgestellt. Bei diesem Ansatz werden nur eine Standard- und eine Blindlösung anstelle einer Reihe unterschiedlich konzentrierter Standards benötigt, um eine lineare Kalibrierfunktion zu erzeugen. Zusätzlich wurde mittels selbst entwickelter, zeitlich aufgelöster ICP-MS umfangreiche Rauschspektren aufgenommen. Aus diesen gelang die Ermittlung der Ursache des erhöhten Signalrauschens des DOD, welches maßgeblich durch das zeitlich nicht äquidistante Eintreffen der Tropfen am Detektor verursacht wird. Diese Messtechnik erlaubt auch die Detektion einzeln zugeführter Tropfen, wodurch ein Vergleich der Volumenverteilung der mittels ICP-MS detektierten, gegenüber den generierten und auf optischem Wege charakterisierten Tropfen möglich wurde. Dieses Werkzeug ist für diagnostische Untersuchungen äußerst hilfreich. So konnte aus diesen Studien neben der Aufklärung von Aerosoltransportprozessen die Transporteffizienz des DOD ermittelt werden, welche bis zu 94 Vol.-% beträgt.

Wet and dry model granulates under mechanical load : a confocal microscopy study

Granular matter, also known as bulk solids, consists of discrete particles with sizes between micrometers and meters. They are present in many industrial applications as well as daily life, like in food processing, pharmaceutics or in the oil and mining industry. When handling granular matter the bulk solids are stored, mixed, conveyed or filtered. These techniques are based on observations in macroscopic experiments, i.e. rheological examinations of the bulk properties. Despite the amply investigations of bulk mechanics, the relation between single particle motion and macroscopic behavior is still not well understood. For exploring the microscopic properties on a single particle level, 3D imaging techniques are required.rnThe objective of this work was the investigation of single particle motions in a bulk system in 3D under an external mechanical load, i.e. compression and shear. During the mechanical load the structural and dynamical properties of these systems were examined with confocal microscopy. Therefor new granular model systems in the wet and dry state were designed and prepared. As the particles are solid bodies, their motion is described by six degrees of freedom. To explore their entire motion with all degrees of freedom, a technique to visualize the rotation of spherical micrometer sized particles in 3D was developed. rnOne of the foci during this dissertation was a model system for dry cohesive granular matter. In such systems the particle motion during a compression of the granular matter was investigated. In general the rotation of single particles was the more sensitive parameter compared to the translation. In regions with large structural changes the rotation had an earlier onset than the translation. In granular systems under shear, shear dilatation and shear zone formation were observed. Globally the granular sediments showed a shear behavior, which was known already from classical shear experiments, for example with Jenike cells. Locally the shear zone formation was enhanced, when near the applied load a pre-diluted region existed. In regions with constant volume fraction a mixing between the different particle layers occurred. In particular an exchange of particles between the current flowing region and the non-flowing region was observed. rnThe second focus was on model systems for wet granular matter, where an additional binding liquid is added to the particle suspension. To examine the 3D structure of the binding liquid on the micrometer scale independently from the particles, a second illumination and detection beam path was implemented. In shear and compression experiments of wet clusters and bulk systems completely different dynamics compared to dry cohesive models systems occured. In a Pickering emulsion-like system large structural changes predominantly occurred in the local environment of binding liquid droplets. These large local structural changes were due to an energy interplay between the energy stored in the binding droplet during its deformation and the binding energy of particles at the droplet interface. rnConfocal microscopy in combination with nanoindentation gave new insights into the single particle motions and dynamics of granular systems under a mechanical load. These novel experimental results can help to improve the understanding of the relationship between bulk properties of granular matter, such as volume fraction or yield stress and the dynamics on a single particle level.rnrn

Hemizygous deletion of COL3A1, COL5A2, and MSTN causes a complex phenotype with aortic dissection: a lesson for and from true haploinsufficiency

Aortic dilatation/dissection (AD) can occur spontaneously or in association with genetic syndromes, such as Marfan syndrome (MFS; caused by FBN1 mutations), MFS type 2 and Loeys-Dietz syndrome (associated with TGFBR1/TGFBR2 mutations), and Ehlers-Danlos syndrome (EDS) vascular type (caused by COL3A1 mutations). Although mutations in FBN1 and TGFBR1/TGFBR2 account for the majority of AD cases referred to us for molecular genetic testing, we have obtained negative results for these genes in a large cohort of AD patients, suggesting the involvement of additional genes or acquired factors. In this study we assessed the effect of COL3A1 deletions/duplications in this cohort. Multiplex ligation-dependent probe amplification (MLPA) analysis of 100 unrelated patients identified one hemizygous deletion of the entire COL3A1 gene. Subsequent microarray analyses and sequencing of breakpoints revealed the deletion size of 3,408,306 bp at 2q32.1q32.3. This deletion affects not only COL3A1 but also 21 other known genes (GULP1, DIRC1, COL5A2, WDR75, SLC40A1, ASNSD1, ANKAR, OSGEPL1, ORMDL1, LOC100129592, PMS1, MSTN, C2orf88, HIBCH, INPP1, MFSD6, TMEM194B, NAB1, GLS, STAT1, and STAT4), mutations in three of which (COL5A2, SLC40A1, and MSTN) have also been associated with an autosomal dominant disorder (EDS classical type, hemochromatosis type 4, and muscle hypertrophy). Physical and laboratory examinations revealed that true haploinsufficiency of COL3A1, COL5A2, and MSTN, but not that of SLC40A1, leads to a clinical phenotype. Our data not only emphasize the impact/role of COL3A1 in AD patients but also extend the molecular etiology of several disorders by providing hitherto unreported evidence for true haploinsufficiency of the underlying gene.

Regulation of GPCR signaling in hypertension

Hypertension represents a complex, multifactorial disease and contributes to the major causes of morbidity and mortality in industrialized countries: ischemic and hypertensive heart disease, stroke, peripheral atherosclerosis and renal failure. Current pharmacological therapy of essential hypertension focuses on the regulation of vascular resistance by inhibition of hormones such as catecholamines and angiotensin II, blocking them from receptor activation. Interaction of G-protein coupled receptor kinases (GRKs) and regulator of G-protein signaling (RGS) proteins with activated G-protein coupled receptors (GPCRs) effect the phosphorylation state of the receptor leading to desensitization and can profoundly impair signaling. Defects in GPCR regulation via these modulators have severe consequences affecting GPCR-stimulated biological responses in pathological situations such as hypertension, since they fine-tune and balance the major transmitters of vessel constriction versus dilatation, thus representing valuable new targets for anti-hypertensive therapeutic strategies. Elevated levels of GRKs are associated with human hypertensive disease and are relevant modulators of blood pressure in animal models of hypertension. This implies therapeutic perspective in a disease that has a prevalence of 65million in the United States while being directly correlated with occurrence of major adverse cardiac and vascular events. Therefore, therapeutic approaches using the inhibition of GRKs to regulate GPCRs are intriguing novel targets for treatment of hypertension and heart failure.

Mitral regurgitation

Mitral regurgitation (MR) involves systolic retrograde flow from the left ventricle into the left atrium. While trivial MR is frequent in healthy subjects, moderate to severe MR constitutes the second most prevalent valve disease after aortic valve stenosis. Major causes of severe MR in Western countries include degenerative valve disease (myxomatous disease, flail leaflet, annular calcification) and ischaemic heart disease, while rheumatic disease remains a major cause of MR in developing countries. Chronic MR typically progresses insidiously over many years. Once established, however, severe MR portends a poor prognosis. The severity of MR can be assessed by various techniques, Doppler echocardiography being the most widely used. Mitral valve surgery is the only treatment of proven efficacy. It alleviates clinical symptoms and prevents ventricular dilatation and heart failure (or, at least, it attenuates further progression of these abnormalities). Valve repair significantly improves clinical outcomes compared with valve replacement, reducing mortality by approximately 70%. Reverse LV remodelling after valve repair occurs in half of patients with functional MR. Percutaneous, catheter-based to mitral valve repair is a novel approach currently under clinical scrutiny, with encouraging preliminary results. This modality may provide a valuable alternative to mitral valve surgery, especially in critically ill patients.

Aortic flow patterns resulting from right axillary artery cannulation

Right axillary artery (RAA) cannulation is increasingly used in cardiac surgery. Little is known about resulting flow patterns in the aorta. Therefore, flow was visualized and analyzed. A mock circulatory circuit was assembled based on a compliant transparent anatomical silicon aortic model. A RAA cannula was connected to a continuous flow rotary blood pump (RBP), pulsatile heart action was provided by a pneumatic ventricular assist device (PVAD). Peripheral vascular resistance, regional flow and vascular compliance were adjusted to obtain physiological flow and pressure waveforms. Colorants were injected automatically for flow visualization. Five flow distributions with a total flow of 4 l/min were tested (%PVAD:%RBP): 100:0, 75:25, 50:50, 25:75, 0:100. Colorant distribution was assessed using quantitative 2D image processing. Continuous flow from the RAA divided in a retrograde and an antegrade portion. Retro- to antegrade flow ratio increased with increasing RAA-flow. At full RBP support flow was stagnant in the ascending aorta. There were distinct flow patterns between the right- and left-sided supra-aortic branches. At full RBP support retrograde flow was demonstrated in the right carotid and right vertebral arteries. Further studies are needed to confirm and evaluate the described flow patterns.

Thoracic radionecrosis following repeated cardiac catheterization

Radiodermatitis is a known complication in patients having undergone radiotherapy. It usually appears 2 to 5 years after irradiation. We are reporting on a case of radiodermatitis that occurred within months after coronary dilatation and stenting. It started with painful swelling, followed by a typical appearance on the skin surface. Histological finding confirmed the diagnosis. However, magnetic resonance imaging showed changes in the subcutaneous tissue extending into the ribs. A radical debridement was performed including removal of a partially necrotic 4th rib. The defect was closed with a latissimus dorsi transposition flap. Our findings are compared with the literature reports.

Long-term cardiac remodeling and arrhythmias in nonelite marathon runners

Long-term endurance sports are associated with atrial remodeling and atrial arrhythmias. More importantly, high-level endurance training may promote right ventricular (RV) dysfunction and complex ventricular arrhythmias. We investigated the long-term consequences of marathon running on cardiac remodeling as a potential substrate for arrhythmias with a focus on the right heart. We invited runners of the 2010 Grand Prix of Bern, a 10-mile race. Of 873 marathon and nonmarathon runners who applied, 122 (61 women) entered the final analysis. Subjects were stratified according to former marathon participations: control group (nonmarathon runners, n = 34), group 1 (1 marathon to 5 marathons, mean 2.7, n = 46), and group 2 (≥6 marathons, mean 12.8, n = 42). Mean age was 42 ± 7 years. Results were adjusted for gender, age, and lifetime training hours. Right and left atrial sizes increased with marathon participations. In group 2, right and left atrial enlargements were present in 60% and 74% of athletes, respectively. RV and left ventricular (LV) dimensions showed no differences among groups, and RV or LV dilatation was present in only 2.4% or 4.3% of marathon runners, respectively. In multiple linear regression analysis, marathon participation was an independent predictor of right and left atrial sizes but had no effect on RV and LV dimensions and function. Atrial and ventricular ectopic complexes during 24-hour Holter monitoring were low and equally distributed among groups. In conclusion, in nonelite athletes, marathon running was not associated with RV enlargement, dysfunction, or ventricular ectopy. Marathon running promoted biatrial remodeling.

Outcome in adult patients after arterial switch operation for transposition of the great arteries

BACKGROUND: The arterial switch operation (ASO) is currently the treatment of choice in neonates with transposition of the great arteries (TGA). The outcome in childhood is encouraging but only limited data for long-term outcome into adulthood exist. METHODS AND RESULTS: We studied 145 adult patients (age>16, median 25years) with ASO followed at our institution. Three patients died in adulthood (mortality 2.4/1000-patient-years). Most patients were asymptomatic and had normal left ventricular function. Coronary lesions requiring interventions were rare (3 patients) and in most patients related to previous surgery. There were no acute coronary syndromes. Aortic root dilatation was frequent (56% patients) but rarely significant (>45mm in 3 patients, maximal-diameter 49mm) and appeared not to be progressive. There were no acute aortic events and no patient required elective aortic root surgery. Progressive neo-aortic-valve dysfunction was not observed in our cohort and only 1 patient required neo-aortic-valve replacement. Many patients (42.1%), however, had significant residual lesions or required reintervention in adulthood. Right ventricular outflow tract lesions or dysfunction of the neo-pulmonary-valve were frequent and 8 patients (6%) required neo-pulmonary-valve replacement. Cardiac interventions during childhood (OR 3.0, 95% CI 1.7-5.4, P<0.0001) were strong predictors of outcome (cardiac intervention/significant residual lesion/death) in adulthood. CONCLUSIONS: Adult patients with previous ASO remain free of acute coronary or aortic complications and have low mortality. However, a large proportion of patients require re-interventions or present with significant right sided lesions. Life-long cardiac follow-up is, therefore, warranted. Periodic noninvasive surveillance for coronary complications appears to be safe in adult ASO patients.

Control of ventricular unloading using an electrocardiogram-synchronized Thoratec paracorporeal ventricular assist device

OBJECTIVE: Current pulsatile ventricular assist devices operate asynchronous with the left ventricle in fixed-rate or fill-to-empty modes because electrocardiogram-triggered modes have been abandoned. We hypothesize that varying the ejection delay in the synchronized mode yields more precise control of hemodynamics and left ventricular loading. This allows for a refined management that may be clinically beneficial. METHODS: Eight sheep received a Thoratec paracorporeal ventricular assist device (Thoratec Corp, Pleasanton, Calif) via ventriculo-aortic cannulation. Left ventricular pressure and volume, aortic pressure, pulmonary flow, pump chamber pressure, and pump inflow and outflow were recorded. The pump was driven by a clinical pneumatic drive unit (Medos Medizintechnik AG, Stolberg, Germany) synchronously with the native R-wave. The start of pump ejection was delayed between 0% and 100% of the cardiac period in 10% increments. For each of these delays, hemodynamic variables were compared with baseline data using paired t tests. RESULTS: The location of the minimum of stroke work was observed at a delay of 10% (soon after aortic valve opening), resulting in a median of 43% reduction in stroke work compared with baseline. Maximum stroke work occurred at a median delay of 70% with a median stroke work increase of 11% above baseline. Left ventricular volume unloading expressed by end-diastolic volume was most pronounced for copulsation (delay 0%). CONCLUSIONS: The timing of pump ejection in synchronized mode yields control over left ventricular energetics and can be a method to achieve gradual reloading of a recoverable left ventricle. The traditionally suggested counterpulsation is not optimal in ventriculo-aortic cannulation when maximum unloading is desired.

Rationale, scope, and 20-year experience of vascular surgical training with lifelike pulsatile flow models

Vascular surgical training currently has to cope with various challenges, including restrictions on work hours, significant reduction of open surgical training cases in many countries, an increasing diversity of open and endovascular procedures, and distinct expectations by trainees. Even more important, patients and the public no longer accept a "learning by doing" training philosophy that leaves the learning curve on the patient's side. The Vascular International (VI) Foundation and School aims to overcome these obstacles by training conventional vascular and endovascular techniques before they are applied on patients. To achieve largely realistic training conditions, lifelike pulsatile models with exchangeable synthetic arterial inlays were created to practice carotid endarterectomy and patch plasty, open abdominal aortic aneurysm surgery, and peripheral bypass surgery, as well as for endovascular procedures, including endovascular aneurysm repair, thoracic endovascular aortic repair, peripheral balloon dilatation, and stenting. All models are equipped with a small pressure pump inside to create pulsatile flow conditions with variable peak pressures of ~90 mm Hg. The VI course schedule consists of a series of 2-hour modules teaching different open or endovascular procedures step-by-step in a standardized fashion. Trainees practice in pairs with continuous supervision and intensive advice provided by highly experienced vascular surgical trainers (trainer-to-trainee ratio is 1:4). Several evaluations of these courses show that tutor-assisted training on lifelike models in an educational-centered and motivated environment is associated with a significant increase of general and specific vascular surgical technical competence within a short period of time. Future studies should evaluate whether these benefits positively influence the future learning curve of vascular surgical trainees and clarify to what extent sophisticated models are useful to assess the level of technical skills of vascular surgical residents at national or international board examinations. This article gives an overview of our experiences of >20 years of practical training of beginners and advanced vascular surgeons using lifelike pulsatile vascular surgical training models.