Adult Congenital Heart Disease with Focus on Pregnancy

The prevalence of Congenital Heart Disease (CHD) has been described to be 8,2 per 1000 live births in European countries.(1) Congenital heart disease is a collective term for a large number of different diagnoses with different anatomical substrate, complexity and prognosis. The most common subtypes that we encounter are: ventricular septal defect (VSD 2.6 per 1000 live births), atrial septal defect (ASD 1.6 per 1000 live births), persistent arterial duct (PDA 0.9 per 1000 live births), pulmonary stenosis (PS 0.5 per 1000 live births), tetralogy of Fallot (TOF 0.3 per 1000 live births), coarctation of the aorta (0.3 per 1000 live births), transposition of the great arteries (TGA 0.3 per 1000 live births) and aortic stenosis (0.2 per 1000 live births)

Associations between N-terminal pro-B-type natriuretic peptide and cardiac function in adults with corrected tetralogy of Fallot

Background Amino-terminal B-type natriuretic peptide (NT-proBNP) may detect early cardiac dysfunction in adults with tetralogy of Fallot (ToF) late after corrective surgery. We aimed to determine the value of NT-proBNP in adults with ToF and establish its relationship with echocardiography and exercise capacity. Methods and results NT-proBNP measurement, electrocardiography and detailed 2D-echocardiography were performed on the same day in 177 consecutive adults with ToF (mean age 34.6 ± 11.8 years, 58% male, 89% NYHA I, 29.

Heart failure in pregnant women with cardiac disease: Data from the ROPAC

Objective Heart failure (HF) is one of the most important complications in pregnant women with heart disease, causing maternal and fetal mortality and morbidity. Methods This is an international observational registry of patients with structural heart disease during pregnancy. Sixty hospitals in 28 countries enrolled 1321 women between 2007 and 2011. Pregnant women with valvular heart disease, congenital heart disease, ischaemic heart disease, or cardiomyopathy could be included. Main outcome measures were onset and predictors of HF and maternal and fetal death. Results In total, 173 (13.1%) of the 1321 patients developed HF, making HF the most common major cardiovascular complication during pregnancy. Baseline parameters associated with HF were New York Heart Association class ≥3, signs of HF, WHO category ≥3, cardiomyopathy or pulmonary hypertension. HF occurred at a median time of 31 weeks gestation (IQR 23-40) with the highest incidence at the end of the second trimester (34%) or peripartum (31%). Maternal mortality was higher in p

Enginyeria de tràfic en xarxes de transport òptiques per a entorns d'àrea metropolitana (RPR) i de gran abast (ASON)

La arquitectura de las redes de transporte actuales está basada en la tecnología de transporte SDH (Synchronous Digital Hierarchy). Las redes SDH se han diseñado y están optimizadas básicamente para el transporte del tráfico de voz. Actualmente, se está experimentando un crecimiento exponencial del volumen de tráfico de datos. Este crecimiento se debe a que el protocolo IP se está consolidando como capa de integración para servicios múltiples, algunos de ellos con requerimientos de Calidad de Servicio (QoS) y también a la introducción de tecnología de acceso de alta velocidad. Las características estadísticas del tráfico de datos son diferentes respecto a las del tráfico telefónico. De hecho, el tráfico IP se caracteriza no solo por su asimetría sino por su naturaleza dinámica, ya que presenta fluctuaciones o picos difíciles de predecir a priori.Como consecuencia, ha surgido la necesidad de emigrar desde las actuales redes hacia una estructura más flexible y dinámica, optimizada para el transporte de tráfico de datos.La evolución de las actuales redes de transporte incluye trasladar todas las funcionalidades de SDH (conmutación, monitorización de la calidad de la señal, protección frente a fallos) a nivel óptico. El resultado consistirá en una red de transporte óptica (Optical Transport Network, OTN) basada en tecnología DWDM, con Optical Cross Connects (OXC) para encaminar canales ópticos de forma permanente o conmutada (Automatic Switched Optical Network, ASON).Uno de los principales problemas a solucionar por las operadoras de red es la eficiente gestión de la capacidad disponible, y así evitar por un lado la necesidad de sobredimensionar la red de transporte y por el otro optimizar la utilización de los recursos mediante la definición de estrategias de ingeniería de tráfico.La introducción de las redes de transporte a conmutación automática (ASON), capaces de proporcionar conexiones ópticas bajo demanda, es considerada como la solución de red que puede proporcionar el rápido y flexible aprovisionamiento de ancho de banda. Tal funcionalidad, posible gracias a la definición de un plano de control basado en el paradigma GMPLS, puede ser usada para gestionar de manera dinámica los recursos disponibles, tanto a nivel SDH como a nivel óptico, respondiendo de forma eficiente a las fluctuaciones del tráfico generado por la red cliente. Sin embargo, el problema que surge es el diseño de un mecanismo para disparar automáticamente las peticiones de establecimiento de circuitos SDH/canales ópticos conmutados.En este sentido, la primera contribución de esta Tesis es el diseño de un mecanismo de disparo de peticiones de circuitos SDH/canales ópticos basado en la monitorización y predicción del tráfico de la red cliente (IP). Además, el mecanismo diseñado incluye la definición de políticas de ingeniería de tráfico para la optimización de la utilización del elevado ancho de banda proporcionado por las conexiones ópticas. Concretamente, el mecanismo diseñado se caracteriza por la interoperabilidad entre la capa cliente y la capa de transporte.La Tesis incluye también una contribución sobre el diseño de una metodología para el dimensionado de la redes ASON, basada en la caracterización del tráfico de llegadas de peticiones de establecimiento de conexiones, mediante su valor medio y el factor de peakedness.Por otro lado, la optimización de los recursos disponibles es muy crítica cuando se produce un fallo en la infraestructura de red debido a la necesidad de encontrar rutas alternativas para el tráfico afectado. Debido al gran volumen de tráfico a transportar, un fallo en la infraestructura de red puede tener graves consecuencias económicas. Por ejemplo, un corte de una única fibra óptica produce el fallo de todas las longitudes de onda que transporta; de esta manera la pérdida de cada longitud de onda operante a 2.5 Gbps o 10 Gbps puede resultar en el corte de un enorme número de conexiones en curso. Por lo tanto, a mayor capacidad, mayor es la importancia de la rapidez y rendimiento de los mecanismos de protección y recuperación.Las estrategias de protección frente a fallos deben ser simples, minimizar las pérdidas de tráfico y deben utilizar eficientemente los recursos disponibles.La recién estandardizada tecnología para redes de entornos metropolitanos, Resilient Packet Ring (RPR) se caracteriza por mecanismos de protección optimizados para minimizar el tiempo de recuperación en caso de fallos. Además, tales mecanismos no requieren la asignación a priori de recursos de red a utilizar solamente en caso de fallos.Por lo que respecta a los mecanismos de recuperación, se puede optar por una estrategia de recuperación en una sola capa (single layer recovery) o alternativamente por una estrategia de recuperación en múltiples capas (multi-layer recovery), donde en la recuperación intervienen diferentes capas de la estructura de red. El esquema de recuperación multi-capas más fácil de implementar es el consistente en ejecutar los mecanismos de protección/recuperación de los distintos niveles de manera paralela e independiente. Esta estrategia no es, sin embargo, la más eficiente. La interoperabilidad entre los mecanismos de protección de las diferentes capas permite reaccionar más rápidamente a los fallos que se pueden producir.La segunda contribución de esta Tesis es el diseño de una política de coordinación entre los mecanismos de protección proporcionados por RPR y los mecanismos de protección definidos por la capa óptica. Concretamente, la estrategia diseñada se basa en la interoperabilidad entre la capa RPR y la capa de transporte (OTN) para redes de entornos metropolitanos. La estrategia diseñada permite, además, la optimización de los recursos de red.The main objective of the traffic engineering (TE) strategies is the efficient mapping of the actual traffic onto the available network resources. Legacy Time Division Multiplexing-based networking architecture was basically designed to transport symmetric voice traffic. However, the volume of data traffic is increasing at explosive rate and already dominates the voice traffic. This is due to a progressive migration of many applications and services over the Internet Protocol (IP) and also to a deeper and deeper introduction of high-speed access technologies. Also there is the convergence towards the IP of real-time applications (i.e. multimedia applications) which have very strict QoS requirements. The statistical characteristics of the data traffic are rather different from those of telephone traffic. Specifically, IP traffic is highly dynamic showing predictable and unpredictable traffic surges/peaks. Such surges are caused by unexpected events such as user' behaviours, weather conditions, accidents, fault, etc. This can cause significant fluctuations of the aggregated data traffic to be carried by the transport networks. The current SONET/SDH transport networks (but also the incoming Optical Transport Networks) tend to be static, which means that connections (SONET/SDH circuits and light paths) are provided manually through the Network Management System. The manual configuration is time consuming, which means that weeks or even months are needed to provide high bandwidth connections.The highly dynamic IP traffic pattern does not match with the static provisioning of capacity of the optical transport networks, leading to non-optimal utilization of the resources (i.e. network congestion or under-utilization of resources).Thus, the problem that arises for Network Operators is how to efficiently manage the network resources in the transport network to efficiently respond to the changes in the traffic demands reaching, in such a way, traffic engineering objectives. The introduction of the Automatic Switched Optical Networks (ASON), which is able to provide dynamically switched connections on demand, is recognized as the enabling solution to meet the requirement of fast and flexible end-to-end bandwidth provisioning. The automatic set up and tear down of optical connections can be used for the dynamic management of the transport network resources to track significant variations in the volume of the network client traffic. In such a context, a mechanism that triggers demands to set up/tear down light paths as a function of the variation of the client traffic to be transported is required. The design of a multi-layer traffic engineering (MTE) strategy for IP/MPLS over ASON/GMPLS networks to face with the dynamic traffic demands is the first contribution of this Ph.D. Thesis. It has to be underlined that the policies for the set up of the light paths are out of the scope of this work. In fact, it is assumed that the set up/tear down of the switched connections is in charge of the ASON control plane, namely the GMPLS-based routing and signalling protocols.As a second contribution, it is presented a practical approach for ASON networks dimensioning purposes based on the approximate characterization of the traffic arrival process, through its mean and the peakedness factor. On the other hand, the optimization of the utilization of network resources is very critical when failures occur in the network as a consequence of the need of rerouting the affected traffic. The increase of the capacity and number of wavelengths that can be multiplexed onto the same fibre, each one carrying 2.5 or 10 Gbps client signals, implies that outages of the network infrastructure can have serious economical and social consequences. Network recovery/resilience, i.e., the capability of the networks to efficiently recover from failures, has become of vital importance. Thus, optical transport networks need to be very robust to face failures. The protection mechanisms should be designed basically with the aim to be simple, to minimize the traffic losses and to optimize the utilization of the network resources.Survivability strategies in current transport networks are based on the pre-allocation of network resources to be used only to switch (route) the affected traffic in case of failures. In legacy multi-layer networks, each layer (e.g. IP, SDH) has its own protection mechanism built in, independent from the other layers. Network recovery basically relies on the SONET/SDH network layer. Indeed, different mechanisms, based on the protection approach, have been proposed that allow fast recovery within the target of 50 ms. Nevertheless, SONET/SDH protection is mainly limited to ring topologies and it is not able to distinguish between different priorities of traffic and it has not vision of higher layer failures.The emerging packet-based Resilient Packet Ring (RPR) technology for metropolitan networks provides powerful protection mechanisms that minimize the time needed to restore the traffic without the pre-allocation of resources.To face to failures, the resilience single-layer strategy (a single layer has the responsibility for the recovery) is very simple from the implementation point of view. However it may not be able to efficiently recover the network from all kind of failures that can occur. Therefore, multi-layer resilience (various network layers can participate to the recovery actions) provides better performance not only in terms of protection but also in terms of resources optimization. Multi-layer resilience strategies require coordinating the recovery mechanisms provided by each layer. In such a context, another contribution of this Ph.D. Thesis is the design and evaluation of a multi-layer resilience mechanism to be used in the IP over RPR over intelligent optical transport network for metropolitan environment to efficiently face with a wide range of network outages, while optimizing the utilization of the network resources. Its novelty relies on the interworking required between the RPR and the optical transport layer. Finally, the fourth contribution of the Thesis deals with the optimization of the bandwidth utlization of the RPR rings taking benefits from the automatic switching of optical connections capabilities of the underlying ASON/GMPLS networks.Postprint (published version