The ever-changing field of mechanical circulatory support: new challenges at the advent of the 'single device era'

Cardiolog

A rare case of Takotsubo syndrome in a patient 5 months after heart transplantation

Takotsubo syndrome is an acute heart failure syndrome with a pathogenesis that is attributed to sympathetic stimulation. This case report describes a unique case of a 5 month heart‐transplanted female patient who developed apical ballooning on an echocardiography exam performed following an emotional stress event. Detailed clinical investigations and imaging techniques confirmed the diagnosis of Takatsubo syndrome. Our case indicates that Takatsubo's cardiomyopathy should be included in the differential diagnosis of heart‐transplanted patients presenting with sudden graft dysfunction mimicking acute graft rejection or acute coronary syndrome

Factors associated with lack of improvement in submaximal exercise capacity of patients with heart failure

Aims Improvement in exercise capacity is the primary goal of physical activity programmes for patients with heart failure (HF). Although activity programmes are effective for some patients, others do not benefit. Identifying factors related to a lack of improvement in submaximal exercise capacity may help us interpret findings and design new interventions. The aim of this study is to identify factors contributing to a lack of improvement in submaximal exercise capacity 3 months after physical activity advice or an exergame intervention in patients with HF. Additionally, we aimed to assess differences in lack of improvement in submaximal exercise capacity of patients whose baseline exercise capacity predicted a worse compared with better prognosis of HF.Methods and results This secondary analysis of the HF-Wii study analysed baseline and 3 month data of the 6 min walk test (6MWT) from 480 patients (mean age 67 years, 72% male). Data were analysed separately in patients with a pre-defined 6 min walking distance at baseline of <300 m (n = 79) and >= 300 m (n = 401). Among patients with a baseline 6MWT of >= 300 m, 18% had deteriorated submaximal exercise capacity. In the multiple logistic regression analysis, lower baseline levels of self-reported physical activity [odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.97], lower baseline levels of cognitive function (OR = 0.87, 95%CI = 0.79-0.96) were significantly associated with lack of improvement in exercise capacity at 3 months. Not randomized to exergaming (OR = 0.63, 95%CI = 0.37-1.09) was likely (P = 0.097) to be associated with lack of improvement in exercise capacity at 3 months. Among the 79 patients with baseline 6MWT of <300 m, 41% (n = 32) did not improve 6MWT distance at 3 months. Independent predictors for the lack of improvement for 6MWT were New York Heart Association class III/IV (OR = 4.68, 95%CI = 1.08-20.35), higher levels of serum creatinine (OR = 1.02, 95%CI = 1.003-1.03), lower cognitive function (OR = 0.86, 95%CI = 0.75-0.99), and fewer anxiety symptoms (OR = 0.84, 95%CI = 0.72-0.98).Conclusions Lower self-reported physical activity and cognitive impairment predict lack of improvement in submaximal exercise capacity in HF patients. Patients who have a worse prognosis (score <300 m at the 6MWT) are often frail and gain less in exercise capacity. These patients may need a more comprehensive approach to have an effect on exercise capacity, including an individually tailored exercise programme with aerobic exercise (if tolerated) and strength exercises

ULTRAVIOLET SPECTROSCOPY OF TYPE IIB SUPERNOVAE: DIVERSITY AND THE IMPACT OF CIRCUMSTELLAR MATERIAL

We present new Hubble Space Telescope (HST) multi-epoch ultraviolet (UV) spectra of the bright Type IIb SN 2013df, and undertake a comprehensive analysis of the set of four SNe IIb for which HST UV spectra are available (SN 1993J, SN 2001ig, SN 2011dh, and SN 2013df). We find strong diversity in both continuum levels and line features among these objects. We use radiative-transfer models that fit the optical part of the spectrum well, and find that in three of these four events we see a UV continuum flux excess, apparently unaffected by line absorption. We hypothesize that this emission originates above the photosphere, and is related to interaction with circumstellar material (CSM) located in close proximity to the SN progenitor. In contrast, the spectra of SN 2001ig are well fit by single-temperature models, display weak continuum and strong reverse-fluorescence features, and are similar to spectra of radioactive 56Ni-dominated SNe Ia. A comparison of the early shock-cooling components in the observed light curves with the UV continuum levels which we assume trace the strength of CSM interaction suggests that events with slower cooling have stronger CSM emission. The radio emission from events having a prominent UV excess is perhaps consistent with slower blast-wave velocities, as expected if the explosion shock was slowed down by the CSM that is also responsible for the strong UV, but this connection is currently speculative as it is based on only a few events

Effects of exergaming on exercise capacity in patients with heart failure: results of an international multicentre randomized controlled trial

Aims Exergaming is a new tool to increase physical activity. This study aimed to determine the effects of access to a home-based exergame (Nintendo Wii) in patients with heart failure (HF) on exercise capacity, self-reported physical activity and patient-reported outcome measures.Methods and results We enrolled 605 HF patients in New York Heart Association functional class I-IV, independent of ejection fraction, in an international multicentre randomized controlled trial. Patients were randomized to exergame (intervention) or motivational support (control). The primary endpoint was change in submaximal aerobic exercise capacity as measured by the distance walked in 6 min (6MWT) between baseline and 3 months. Secondary endpoints included long-term submaximal aerobic exercise capacity, muscle function, self-reported physical activity, exercise motivation, exercise self-efficacy at 3, 6 and 12months. At baseline, patients on average walked 403142m on the 6MWT. Patients in the exergame group walked further compared to controls at 3 months (454123 vs. 420 +/- 127m, P = 0.005), at 6 months (452 +/- 123 vs. 426 +/- 133m, P = 0.015) and 12months (456 +/- 122 vs. 420 +/- 135m, P = 0.004). However, correcting for baseline 6MWT values by means of a linear mixed-effects model revealed no main effect for the intervention on 6MWT. Small significant effects on muscle function were found. Statistically significant treatment effects were found for muscle function but after correction for baseline and confounders, only the treatment effect for the heel-rise left at 6 months was significant (P<0.05). No treatment effect was found for exercise motivation, exercise self-efficacy, or self-reported physical activity.ConclusionExergaming was safe and feasible in patients with HF with different profiles in different health care systems, cultures and climates. However, it was not effective in improving outcomes on submaximal aerobic exercise capacity. Subgroup analysis did not identify specific subgroups benefiting from the intervention.Clinical Trial Registration: Identifier: NCT01785121

Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion

In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan

iPTF16fnl: a faint and fast tidal disruption event in an E+A galaxy

We present ground-based and \textit{Swift} observations of iPTF16fnl, a likely tidal disruption event (TDE) discovered by the intermediate Palomar Transient Factory (iPTF) survey at 66.6 Mpc. The lightcurve of the object peaked at absolute $M_g=-17.2$ mag. The maximum bolometric luminosity (from optical and UV) was $L_p~\simeq~(1.0\,\pm\,0.15) \times 10^{43}$ erg/s, an order of magnitude fainter than any other optical TDE discovered so far. The luminosity in the first 60 days is consistent with an exponential decay, with $L \propto e^{-(t-t_0)/\tau}$, where $t_0$=~57631.0 (MJD) and $\tau\simeq 15$ days. The X-ray shows a marginal detection at $L_X=2.4^{1.9}_{-1.1}\times 10^{39}$ erg/s (\textit{Swift} X-ray Telescope). No radio counterpart was detected down to 3$\sigma$, providing upper limits for monochromatic radio luminosity of $\nu L_{\nu} < 2.3\times10^{36}$ erg/s and $\nu L_{\nu}<1.7\times 10^{37}$ erg/s (VLA, 6.1 and 22 GHz). The blackbody temperature, obtained from combined \textit{Swift} UV and optical photometry, shows a constant value of 19,000 K. The transient spectrum at peak is characterized by broad He II and H$\alpha$ emission lines, with an FWHM of about 14,000 km/s and 10,000 km/s respectively. He I lines are also detected at $\lambda\lambda$ 5875 and 6678. The spectrum of the host is dominated by strong Balmer absorption lines, which are consistent with a post-starburst (E+A) galaxy with an age of $\sim$650 Myr and solar metallicity. The characteristics of iPTF16fnl make it an outlier on both luminosity and decay timescales, as compared to other optically selected TDEs. The discovery of such a faint optical event suggests a higher rate of tidal disruptions, as low luminosity events may have gone unnoticed in previous searches.Comment: 14 pages, 11 figures, accepted for publication in Ap

Fatigue evaluation in maintenance and assembly operations by digital human simulation

Virtual human techniques have been used a lot in industrial design in order to consider human factors and ergonomics as early as possible. The physical status (the physical capacity of virtual human) has been mostly treated as invariable in the current available human simulation tools, while indeed the physical capacity varies along time in an operation and the change of the physical capacity depends on the history of the work as well. Virtual Human Status is proposed in this paper in order to assess the difficulty of manual handling operations, especially from the physical perspective. The decrease of the physical capacity before and after an operation is used as an index to indicate the work difficulty. The reduction of physical strength is simulated in a theoretical approach on the basis of a fatigue model in which fatigue resistances of different muscle groups were regressed from 24 existing maximum endurance time (MET) models. A framework based on digital human modeling technique is established to realize the comparison of physical status. An assembly case in airplane assembly is simulated and analyzed under the framework. The endurance time and the decrease of the joint moment strengths are simulated. The experimental result in simulated operations under laboratory conditions confirms the feasibility of the theoretical approach

Observational and Physical Classification of Supernovae

This chapter describes the current classification scheme of supernovae (SNe). This scheme has evolved over many decades and now includes numerous SN Types and sub-types. Many of these are universally recognized, while there are controversies regarding the definitions, membership and even the names of some sub-classes; we will try to review here the commonly-used nomenclature, noting the main variants when possible. SN Types are defined according to observational properties; mostly visible-light spectra near maximum light, as well as according to their photometric properties. However, a long-term goal of SN classification is to associate observationally-defined classes with specific physical explosive phenomena. We show here that this aspiration is now finally coming to fruition, and we establish the SN classification scheme upon direct observational evidence connecting SN groups with specific progenitor stars. Observationally, the broad class of Type II SNe contains objects showing strong spectroscopic signatures of hydrogen, while objects lacking such signatures are of Type I, which is further divided to numerous subclasses. Recently a class of super-luminous SNe (SLSNe, typically 10 times more luminous than standard events) has been identified, and it is discussed. We end this chapter by briefly describing a proposed alternative classification scheme that is inspired by the stellar classification system. This system presents our emerging physical understanding of SN explosions, while clearly separating robust observational properties from physical inferences that can be debated. This new system is quantitative, and naturally deals with events distributed along a continuum, rather than being strictly divided into discrete classes. Thus, it may be more suitable to the coming era where SN numbers will quickly expand from a few thousands to millions of events.Comment: Extended final draft of a chapter in the "SN Handbook". Comments most welcom

PTF11kx: A Type-Ia Supernova with a Symbiotic Nova Progenitor

There is a consensus that Type-Ia supernovae (SNe Ia) arise from the thermonuclear explosion of white dwarf stars that accrete matter from a binary companion. However, direct observation of SN Ia progenitors is lacking, and the precise nature of the binary companion remains uncertain. A temporal series of high-resolution optical spectra of the SN Ia PTF 11kx reveals a complex circumstellar environment that provides an unprecedentedly detailed view of the progenitor system. Multiple shells of circumsteller are detected and the SN ejecta are seen to interact with circumstellar material (CSM) starting 59 days after the explosion. These features are best described by a symbiotic nova progenitor, similar to RS Ophiuchi.Comment: 27 pages, 5 figures. In pres