Transseptal puncture for catheter ablation of atrial fibrillation after device closure of patent foramen ovale

The technique of transseptal puncture for catheter ablation of atrial fibrillation after percutaneous closure of a foramen ovale with the Amplatzer Occluder is demonstrated based on 2 representative cases.

Percutaneous closure of patent foramen ovale for migraine headaches refractory to medical treatment

BACKGROUND: Patent foramen ovale (PFO) has been linked to migraine, and several retrospective studies reported an improvement in migraine prevalence or frequency after PFO closure for other reasons, mostly for secondary prevention of paradoxical embolism or following diving accidents. We investigated the outcome of patients undergoing PFO closure solely for migraine headaches refractory to medical treatment. METHODS: Seventeen patients (age 44 +/- 12 years; 76% female; one atrial septal aneurysm) underwent percutaneous PFO closure using the Amplatzer PFO Occluder (AGA Medical Corporation, Golden Valley, MN). An 18-mm device was used in two patients, a 25-mm device in 13, and a 35-mm device in two. The interventions were solely guided by fluoroscopy, without intraprocedural echocardiography. RESULTS: All implantation procedures were successful. There were no peri-procedural complications. Contrast transesophageal echocardiography after Valsalva maneuver at 6 months showed complete PFO closure in 16 patients (94%), whereas a minimal residual shunt persisted in one (6%). During 2.7 +/- 1.5 years of follow-up, no deaths and no embolic events occurred. After PFO closure, migraine headaches disappeared in four patients (24%), and improved in eight additional patients (47%). Three patients (18%) reported a decrease of their headaches by 75%, three patients (18%) a decrease of 50%, and two patients (12%) a decrease of 25%, while headaches remained unchanged in five patients (29%). No patient experienced worsening headaches. Moreover, the prevalence of migraine with aura decreased from 82 to 24% (P = 0.002). CONCLUSIONS: These results suggest that percutaneous PFO closure durably alters the spontaneous course of shunt associated migraine.

Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients

BACKGROUND: Percutaneous closure of patent foramen ovale (PFO) is generally performed using intra-procedural guidance by transoesophageal (TEE) or intracardiac (ICE) echocardiography. While TEE requires sedation or general anaesthesia, ICE is costly and adds incremental risk, and both imaging modalities lengthen the procedure. METHODS: A total of 825 consecutive patients (age 51 +/- 13 years; 58% male) underwent percutaneous PFO closure solely under fluoroscopic guidance, without intra-procedural echocardiography. The indications for PFO closure were presumed paradoxical embolism in 698 patients (95% cerebral, 5% other locations), an embolic event with concurrent aetiologies in 47, diving in 51, migraine headaches in 13, and other reasons in 16. An atrial septal aneurysm was associated with the PFO in 242 patients (29%). RESULTS: Permanent device implantation failed in two patients (0.2%). There were 18 procedural complications (2.2%), including embolization of the device or parts of it in five patients with successful percutaneous removal in all cases, air embolism with transient symptoms in four patients, pericardial tamponade requiring pericardiocentesis in one patient, a transient ischaemic attack with visual symptoms in one patient, and vascular access site problems in seven patients. There were no long-term sequelae. Contrast TEE at six months showed complete abolition of right-to-left shunt via PFO in 88% of patients, whereas a minimal, moderate or large residual shunt persisted in 7%, 3%, and 2%, respectively. CONCLUSIONS: This study confirms the safety and feasibility of percutaneous PFO closure without intra-procedural echocardiographic guidance in a large cohort of consecutive patients.

Device-less patent foramen ovale closure by radiofrequency thermal energy

The goal of this study was to assess the feasibility, safety and success of a system which uses radiofrequency energy (RFE) rather than a device for percutaneous closure of patent foramen ovale (PFO). METHODS: Sixteen patients (10 men, 6 women, mean age 50 years) were included in the study. All of them had a proven PFO with documented right-to-left shunt (RLS) after Valsalva manoeuvre (VM) during transoesophageal echocardiography (TEE). The patients had an average PFO diameter of 6 +/- 2 mm at TEE and an average of 23 +/- 4 microembolic signals (MES) in power M-mode transcranial Doppler sonography (pm-TCD), measured over the middle cerebral artery. An atrial septal aneurysm (ASA) was present in 7 patients (44%). Balloon measurement, performed in all patients, revealed a stretched PFO diameter of 8 +/- 3 mm. In 2 patients (stretched diameter 11 and 14 mm respectively, both with ASA >10 mm), radiofrequency was not applied (PFO too large) and the PFO was closed with an Amplatzer PFO occluder instead. A 6-month follow-up TEE was performed in all patients. RESULTS: There were no serious adverse events during the procedure or at follow-up (12 months average). TEE 6 months after the first RFE procedure showed complete closure of the PFO in 50% of the patients (7/14). Closure appeared to be influenced by PFO diameter, complete closure being achieved in 89% (7/8) with a balloon-stretched diameter < or =7 mm but in none of the patients >7 mm. Only one of the complete closure patients had an ASA. Of the remainder, 4 (29%) had an ASA. Although the PFO was not completely closed in this group, some reduction in the diameter of the PFO and in MES was documented by TEE and pm-TCD with VM. Five of the 7 residual shunt patients received an Amplatzer PFO occluder. Except for one patient with a minimal residual shunt, all showed complete closure of PFO at 6-month follow-up TEE and pm-TCD with VM. The other two refused a closure device. CONCLUSIONS: The results confirm that radiofrequency closure of the PFO is safe albeit less efficacious and more complex than device closure. The technique in its current state should not be attempted in patients with a balloon-stretched PFO diameter >7 mm and an ASA.

Reynolds-stress turbulence model in the KIVA code for engine simulation

A Reynolds-Stress Turbulence Model has been incorporated with success into the KIVA code, a computational fluid dynamics hydrocode for three-dimensional simulation of fluid flow in engines. The newly implemented Reynolds-stress turbulence model greatly improves the robustness of KIVA, which in its original version has only eddy-viscosity turbulence models. Validation of the Reynolds-stress turbulence model is accomplished by conducting pipe-flow and channel-flow simulations, and comparing the computed results with experimental and direct numerical simulation data. Flows in engines of various geometry and operating conditions are calculated using the model, to study the complex flow fields as well as confirm the model’s validity. Results show that the Reynolds-stress turbulence model is able to resolve flow details such as swirl and recirculation bubbles. The model is proven to be an appropriate choice for engine simulations, with consistency and robustness, while requiring relatively low computational effort.

Characterizing the effects of turbulence on sediment oxygen and sediment nitrate demand using flow-through reactors

Onondaga Lake has received the municipal effluent and industrial waste from the city of Syracuse for more than a century. Historically, 75 metric tons of mercury were discharged to the lake by chlor-alkali facilities. These legacy deposits of mercury now exist primarily in the lake sediments. Under anoxic conditions, methylmercury is produced in the sediments and can be released to the overlying water. Natural sedimentation processes are continuously burying the mercury deeper into the sediments. Eventually, the mercury will be buried to a depth where it no longer has an impact on the overlying water. In the interim, electron acceptor amendment systems can be installed to retard these chemical releases while the lake naturally recovers. Electron acceptor amendment systems are designed to meet the sediment oxygen demand in the sediment and maintain manageable hypolimnion oxygen concentrations. Historically, designs of these systems have been under designed resulting in failure. This stems from a mischaracterization of the sediment oxygen demand. Turbulence at the sediment water interface has been shown to impact sediment oxygen demand. The turbulence introduced by the electron amendment system can thus increase the sediment oxygen demand, resulting in system failure if turbulence is not factored into the design. Sediment cores were gathered and operated to steady state under several well characterized turbulence conditions. The relationship between sediment oxygen/nitrate demand and turbulence was then quantified and plotted. A maximum demand was exhibited at or above a fluid velocity of 2.0 mm•s-1. Below this velocity, demand decreased rapidly with fluid velocity as zero velocity was approached. Similar relationships were displayed by both oxygen and nitrate cores.

Utilizing Gaussian-Schell model beams to mitigate atmospheric turbulence in free space optical communications / by Kyle R. Drexler.

Turbulence affects traditional free space optical communication by causing speckle to appear in the received beam profile. This occurs due to changes in the refractive index of the atmosphere that are caused by fluctuations in temperature and pressure, resulting in an inhomogeneous medium. The Gaussian-Schell model of partial coherence has been suggested as a means of mitigating these atmospheric inhomogeneities on the transmission side. This dissertation analyzed the Gaussian-Schell model of partial coherence by verifying the Gaussian-Schell model in the far-field, investigated the number of independent phase control screens necessary to approach the ideal Gaussian-Schell model, and showed experimentally that the Gaussian-Schell model of partial coherence is achievable in the far-field using a liquid crystal spatial light modulator. A method for optimizing the statistical properties of the Gaussian-Schell model was developed to maximize the coherence of the field while ensuring that it does not exhibit the same statistics as a fully coherent source. Finally a technique to estimate the minimum spatial resolution necessary in a spatial light modulator was developed to effectively propagate the Gaussian-Schell model through a range of atmospheric turbulence strengths. This work showed that regardless of turbulence strength or receiver aperture, transmitting the Gaussian-Schell model of partial coherence instead of a fully coherent source will yield a reduction in the intensity fluctuations of the received field. By measuring the variance of the intensity fluctuations and the received mean, it is shown through the scintillation index that using the Gaussian-Schell model of partial coherence is a simple and straight forward method to mitigate atmospheric turbulence instead of traditional adaptive optics in free space optical communications.

Studies of spatial clustering of inertial particles in turbulence

We present studies of the spatial clustering of inertial particles embedded in turbulent flow. A major part of the thesis is experimental, involving the technique of Phase Doppler Interferometry (PDI). The thesis also includes significant amount of simulation studies and some theoretical considerations. We describe the details of PDI and explain why it is suitable for study of particle clustering in turbulent flow with a strong mean velocity. We introduce the concept of the radial distribution function (RDF) as our chosen way of quantifying inertial particle clustering and present some original works on foundational and practical considerations related to it. These include methods of treating finite sampling size, interpretation of the magnitude of RDF and the possibility of isolating RDF signature of inertial clustering from that of large scale mixing. In experimental work, we used the PDI to observe clustering of water droplets in a turbulent wind tunnel. From that we present, in the form of a published paper, evidence of dynamical similarity (Stokes number similarity) of inertial particle clustering together with other results in qualitative agreement with available theoretical prediction and simulation results. We next show detailed quantitative comparisons of results from our experiments, direct-numerical-simulation (DNS) and theory. Very promising agreement was found for like-sized particles (mono-disperse). Theory is found to be incorrect regarding clustering of different-sized particles and we propose a empirical correction based on the DNS and experimental results. Besides this, we also discovered a few interesting characteristics of inertial clustering. Firstly, through observations, we found an intriguing possibility for modeling the RDF arising from inertial clustering that has only one (sensitive) parameter. We also found that clustering becomes saturated at high Reynolds number.

Dynamics of settling charged particles in turbulence : theory and experiments

It has been proposed that inertial clustering may lead to an increased collision rate of water droplets in clouds. Atmospheric clouds and electrosprays contain electrically charged particles embedded in turbulent flows, often under the influence of an externally imposed, approximately uniform gravitational or electric force. In this thesis, we present the investigation of charged inertial particles embedded in turbulence. We have developed a theoretical description for the dynamics of such systems of charged, sedimenting particles in turbulence, allowing radial distribution functions to be predicted for both monodisperse and bidisperse particle size distributions. The governing parameters are the particle Stokes number (particle inertial time scale relative to turbulence dissipation time scale), the Coulomb-turbulence parameter (ratio of Coulomb ’terminalar speed to turbulence dissipation velocity scale), and the settling parameter (the ratio of the gravitational terminal speed to turbulence dissipation velocity scale). For the monodispersion particles, The peak in the radial distribution function is well predicted by the balance between the particle terminal velocity under Coulomb repulsion and a time-averaged ’drift’ velocity obtained from the nonuniform sampling of fluid strain and rotation due to finite particle inertia. The theory is compared to measured radial distribution functions for water particles in homogeneous, isotropic air turbulence. The radial distribution functions are obtained from particle positions measured in three dimensions using digital holography. The measurements support the general theoretical expression, consisting of a power law increase in particle clustering due to particle response to dissipative turbulent eddies, modulated by an exponential electrostatic interaction term. Both terms are modified as a result of the gravitational diffusion-like term, and the role of ’gravity’ is explored by imposing a macroscopic uniform electric field to create an enhanced, effective gravity. The relation between the radial distribution functions and inward mean radial relative velocity is established for charged particles.

Complications associated with the arterial puncture closure device--Angio-Seal

BACKGROUND: Arterial puncture closure devices (APCD) are frequently used after cardiac catheterization. Here, the diagnosis and therapy of femoral artery complications after the use of the Angio-Seal APCD is reported. PATIENTS AND METHODS: The Angio-Seal APCD was deployed in 1600 patients undergoing transfemoral catheterization. RESULTS: In 7 of 1600 cases (0.4%) vascular complications occurred following Angio-Seal deployment. Diagnosis was made by duplex sonography. Intraoperative findings consisted of a complete occlusion with dissection of the femoral artery in all patients. In 6 cases, the femoral bifurcation had to be reconstructed after endarterectomy. Follow-up is complete with a mean of 6 months. CONCLUSION: The Angio-Seal device should not be used for closure of the superficial femoral artery and in patients with severe arteriosclerosis. The application of arteriography as well as the use of ultrasound-guided puncture is advisable. In all cases, surgical intervention was successful and an adequate therapy for management of complications.

Percutaneous PFO closure with Amplatzer PFO occluder: predictors of residual shunts at 6 months follow-up

OBJECTIVE: The objective of this study was to assess predictors of residual shunts after percutaneous patent foramen ovale (PFO) closure with Amplatzer PFO occluder (AGA Medical Corporation, Golden Valley, MN, USA). METHODS: All percutaneous PFO closures, using Amplatzer PFO occluder performed at a tertiary center between May 2002 and August 2006, were reviewed. Follow-up, including saline contrast transesophageal echocardiography, was performed in all patients 6 months after the intervention. PATIENTS: A total of 135 procedures were performed. Mean age of the patients was 51 years. The indication for PFO closure was an ischemic cerebrovascular event in 92%, paradoxical systemic embolism in 4%, and a diving accident in 4%. Recurrent events prior to PFO closure were noted in 34%. A concomitant atrial septal aneurysm was present in 61%. RESULTS: At 6 months follow-up, a residual shunt was detected in 26 patients (19%). Residual shunts were more common in patients with an atrial septal aneurysm (27 vs. 8%, P= .01) and in patients treated with a 35-mm compared with a 25-mm device (39 vs. 15%, P= .01). A concomitant atrial septal aneurysm remained independently associated with residual shunts when controlled for body mass index, gender, age, atrial dimensions, and presence of a Chiari network (odds ratio 4.1, 95% confidence intervals 1.1-15.0). CONCLUSION: The presence of atrial septal aneurysms in patients undergoing percutaneous PFO closure with an Amplatzer PFO occluder significantly increases the rate of residual shunts at 6 months follow-up, even if 35-mm devices are used.