Design and clinical validation of novel imaging strategies for analysis of arrhythmogenic substrate

_CURRENT CHALLENGES IN ELECTROPHYSIOLOGY_ Technical advances in cardiovascular electrophysiology have resulted in an increasing number of catheter ablation procedures reaching 200 000 in Europe for the year 2013. These advanced interventions are often complex and time consuming and may cause significant radiation exposure. Furthermore, a substantial number of ablation procedures remain associated with poor (initial) outcomes and frequently require ≥1 redo procedures. Innovations in modalities for substrate imaging could facilitate our understanding of the arrhythmogenic substrate, improve the design of patient-specific ablation strategies and improve the results of ablation procedures. _NOVEL SUBSTRATE IMAGING MODALITIES_ __Cardiac magnetic resonance__ Cardiac magnetic resonance imaging (CMR) can be considered the most comprehensive and suitable modality for the complete electrophysiology and catheter ablation workup (including patient selection, procedural guidance, and [procedural] follow-up). Utilizing inversion recovery CMR, fibrotic myocardium can be visualized and quantified 10–15 min after intravenous administration of Gadolinium contrast. This imaging technique is known as late Gadolinium enhancement (LGE) imaging. Experimental models have shown excellent agreement between size and shape in LGE CMR and areas of myocardial infarction by histopathology. Recent studies have also demonstrated how scar size, shape and location from pre-procedural LGE can be useful in guiding ventricular tachycardia’s (VT) ablation or atrial fibrillation (AF) ablation. These procedures are often time-consuming due to the preceding electrophysiological mapping study required to identify slow conduction zones involved in re-entry circuits. Post-processed LGE images provide scar maps, which could be integrated with electroanatomic mapping systems to facilitate these procedures. __Inverse potential mapping__ Through the years, various noninvasive electrocardiographic imaging techniques have emerged that estimate epicardial potentials or myocardial activation times from potentials recorded on the thorax. Utilizing an inverse procedure, the potentials on the heart surface or activation times of the myocardium are estimated with the recorded body surface potentials as source data. Although this procedure only estimates the time course of unipolar epicardial electrograms, several studies have demonstrated that the epicardial potentials and electrograms provide substantial information about intramyocardial activity and have great potential to facilitate risk-stratification and generate personalized ablation strategies. __Objectives of this thesis__ 1. To evaluate the utility of cardiac magnetic resonance derived geometrical and tissue characteristic information for patient stratification and guidance of AF ablation. 2. To design and evaluate the performance of a finite element model based inverse potential mapping in predicting the arrhythmogenic focus in idiopathic ventricular tachycardia using invasive electro-anatomical activation mapping as a reference standard

Regulation of type 1 diabetes by a self-MHC class II peptide: role of transforming growth factor beta (TGF-beta).

The present study was undertaken to analyze the regulatory T cells generated in response to class I derived self-I-A beta(g7) (54-76) peptide. It was observed T cells from young unprimed type 1 diabetes (T1D) prone NOD mice did not respond to self-I-A beta(g7) (54-76) peptide although T cells from primed young NOD mice showed a strong response. T cells from young unprimed BALB/c mice responded to self-I-A beta(d) (62-78) peptide. However, a breakdown of tolerance to these peptides was observed with age in both the strains. Culture supernatant from I-A beta(g7) (54-76) peptide-primed cells secreted large amounts of TGF-beta and inhibited T cell responses in allogeneic-MLR. Further, I-A beta(g7) (54-76) peptide specific T cell lines from young (I-A.Y) and diabetic (I-A.D) NOD mice were established. I-A.Y secreted IL-4, TGF-beta and IL-10 while I-A.D T cell line secreted IL-10 and IFN-gamma. We found that I-A.D T cell line induced diabetes when transferred in NOD/SCID mice but I-A.Y T cell line did not induce disease. These results show that immunization of NOD mice with I-A beta(g7) (54-76) peptide at a younger age induces a regulatory T cell response suggesting that correcting the defects in immunoregulatory mechanisms using self-MHC peptides may be one of the approaches to prevent autoimmune diseases like T1D

Hypertonic saline solution for signal transmission and steering in MRI-guided intravascular catheterisation

© Springer International Publishing AG, part of Springer Nature 2018. Use of traditional low-impedance sensor leads is highly undesirable in intravascular catheters to be used with MRI guidance; thermal safety and quality of imaging are particularly impacted by these components. In this paper, we are showing that hypertonic saline solution, a high-impedance body-like fluid, could be a compatible and effective signal transmission medium when used in MRI-compatible catheters. We also propose a simple type of catheter design that can be steered hydraulically using the same saline solution. Integration of hydraulic steering is not required for MRI-compatibility; however efficient design can bring advantages in terms of structural simplicity and miniaturisation. Manufacturing of proof-of-concept prototypes using 3D printing is underway

A priori model independent inverse potential mapping: the impact of electrode positioning

__Introduction:__ In inverse potential mapping, local epicardial potentials are computed from recorded body surface potentials (BSP). When BSP are recorded with only a limited number of electrodes, in general biophysical a priori models are applied to facilitate the inverse computation. This study investigated the possibility of deriving epicardial potential information using only 62 torso electrodes in the absence of an a priori model. __Methods:__ Computer simulations were used to determine the optimal in vivo positioning of 62 torso electrodes. Subsequently, three different electrode configurations, i.e., surrounding the thorax, concentrated precordial (30 mm inter-electrode distance) and super-concentrated precordial (20 mm inter-electrode distance) were used to record BSP from three healthy volunteers. Magnetic resonance imaging (MRI) was performed to register the electrode positions with respect to the anatomy of the patient. Epicardial potentials were inversely computed from the recorded BSP. In order to determine the reconstruction quality, the super-concentrated electrode configuration was applied in four patients with an implanted MRI-conditional pacemaker system. The distance between the position of the ventricular lead tip on MRI and the inversely reconstructed pacing site was determined. __Results:__ The epicardial potential distribution reconstructed using the super-concentrated electrode configuration demonstrated the highest correlation (R = 0.98; p < 0.01) with the original epicardial source model. A mean localization error of 5.3 mm was found in the pacemaker patients. __Conclusion:__ This study demonstrated the feasibility of deriving detailed anterior epicardial potential information using only 62 torso electrodes without the use of an a priori model

Integrated whole-heart computational workflow for inverse potential mapping and personalized simulations

Background: Integration of whole-heart activation simulations and inverse potential mapping (IPM) could benefit the guidance and planning of electrophysiological procedures. Routine clinical application requires a fast and adaptable workflow. These requirements limit clinical translation of existing simulation models. This study proposes a comprehensive finite element model (FEM) based whole-heart computational workflow suitable for IPM and simulations. Methods: Three volunteers and eight patients with premature ventricular contractions underwent body surface potential (BSP) acquisition followed by a cardiac MRI (CMR) scan. The cardiac volumes were segmented from the CMR images using custom written software. The feasibility to integrate tissue-characteristics was assessed by generating meshes with virtual edema and scar. Isochronal activation maps were constructed by identifying the fastest route through the cardiac volume using the Möller-Trumbore and Floyd-Warshall algorithms. IPM's were reconstructed from the BSP's. Results: Whole-heart computational meshes were generated within seconds. The first point of atrial activation on IPM was located near the crista terminalis of the superior vena cave into the right atrium. The IPM demonstrated the ventricular epicardial breakthrough at the attachment of the moderator band with the right ventricular free wall. Simulations of sinus rhythm were successfully performed. The conduction through the virtual edema and scar meshes demonstrated delayed activation or a complete conductional block respectively. Conclusion: The proposed FEM based whole-heart computational workflow offers an integrated platform for cardiac electrical assessment using simulations and IPM. This workflow can incorporate patient-specific electrical parameters, perform whole-heart cardiac activation simulations and accurately reconstruct cardiac activation sequences from BSP's

Non-invasive focus localization, right ventricular epicardial potential mapping in patients with an MRI-conditional pacemaker system ‐ a pilot study

Abstract Background With the advent of magnetic resonance imaging (MRI) conditional pacemaker systems, the possibility of performing MRI in pacemaker patients has been introduced. Besides for the detailed evaluation of atrial and ventricular volumes and function, MRI can be used in combination with body surface potential mapping (BSPM) in a non-invasive inverse potential mapping (IPM) strategy. In non-invasive IPM, epicardial potentials are reconstructed from recorded body surface potentials (BSP). In order to investigate whether an IPM method with a limited number of electrodes could be used for the purpose of non-invasive focus localization, it was applied in patients with implanted pacing devices. Ventricular paced beats were used to simulate ventricular ectopic foci. Methods Ten patients with an MRI-conditional pacemaker system and a structurally normal heart were studied. Patientspecific 3D thorax volume models were reconstructed from the MRI images. BSP were recorded during ventricular pacing. Epicardial potentials were inversely calculated from the BSP. The site of epicardial breakthrough was compared to the position of the ventricular lead tip on MRI and the distance between these points was determined. Results For all patients, the site of earliest epicardial depolarization could be identified. When the tip of the pacing lead was implanted in vicinity to the epicardium, i.e. right ventricular (RV) apex or RV outflow tract, the distance between lead tip position and epicardial breakthrough was 6.0±1.9 mm. Conclusions In conclusion, the combined MRI and IPM method is clinically applicable and can identify sites of earliest depolarization with a clinically useful accuracy

Ground Water Pollution and Emerging Environmental Challenges of Industrial Effluent Irrigation: A Case Study of Mettupalayam Taluk, Tamilnadu

Industrial disposal of effluents on land and the subsequent pollution of groundwater and soil of surrounding farmlands – is a relatively new area of research. The environmental and socioeconomic aspects of industrial effluent irrigation have not been studied as extensively as domestic sewage based irrigation practices, at least for a developing country like India. The disposal of effluents on land has become a regular practice for some industries. Industries located in Mettupalayam Taluk, Tamil Nadu, dispose their effluents on land, and the farmers of the adjacent farmlands have complained that their shallow open wells get polluted and also the salt content of the soil has started building up slowly. This study attempts to capture the environmental and socioeconomic impacts of industrial effluent irrigation in different industrial locations at Mettupalayam Taluk, Tamil Nadu, through primary surveys and secondary information. This study found that the continuous disposal of industrial effluents on land, which has limited capacity to assimilate the pollution load, has led to groundwater pollution. The quality of groundwater in shallow open wells surrounding the industrial locations has deteriorated, and the application of polluted groundwater for irrigation has resulted in increased salt content of soils. In some locations drinking water wells (deep bore wells) also have a high concentration of salts. Since the farmers had already shifted their cropping pattern to salt-tolerant crops (like jasmine, curry leaf, tobacco, etc.) and substituted their irrigation source from shallow open wells to deep bore wells and/or river water, the impact of pollution on livelihoods was minimized. Since the local administration is supplying drinking water to households, the impact in the domestic sector has been minimized. It has also been noticed that in some locations industries are supplying drinking water to the affected households. However, if the pollution continues unabated it could pose serious problems in the future

Mitochondrial physiology

As the knowledge base and importance of mitochondrial physiology to evolution, health and disease expands, the necessity for harmonizing the terminology concerning mitochondrial respiratory states and rates has become increasingly apparent. The chemiosmotic theory establishes the mechanism of energy transformation and coupling in oxidative phosphorylation. The unifying concept of the protonmotive force provides the framework for developing a consistent theoretical foundation of mitochondrial physiology and bioenergetics. We follow the latest SI guidelines and those of the International Union of Pure and Applied Chemistry (IUPAC) on terminology in physical chemistry, extended by considerations of open systems and thermodynamics of irreversible processes. The concept-driven constructive terminology incorporates the meaning of each quantity and aligns concepts and symbols with the nomenclature of classical bioenergetics. We endeavour to provide a balanced view of mitochondrial respiratory control and a critical discussion on reporting data of mitochondrial respiration in terms of metabolic flows and fluxes. Uniform standards for evaluation of respiratory states and rates will ultimately contribute to reproducibility between laboratories and thus support the development of data repositories of mitochondrial respiratory function in species, tissues, and cells. Clarity of concept and consistency of nomenclature facilitate effective transdisciplinary communication, education, and ultimately further discovery