Are all left bundle branch blocks the same? Myocardial mechanical implications by cardiovascular magnetic resonance.

AIMS: Left bundle branch block (LBBB) is usually associated with structural myocardial diseases progressively leading to left ventricular (LV) dysfunction. We sought to determine the mechanical implications of LBBB (as defined based on Strauss' criteria) by Cardiovascular Magnetic Resonance (CMR). METHOD AND RESULTS: We included consecutive patients referred to CMR to assess the structural cause of LBBB. CMR scans consisted of cine, stress perfusion, and late gadolinium enhancement (LGE) sequences. Myocardial deformation was assessed by tissue tracking analysis; LGE was quantified using the full width at half maximum method. We included 86 patients [63% male, 70 years (60-72)] with mean QRS duration 150 ± 13 msec. A structural disease was identified on CMR in 53% of patients (ischemic heart disease, IHD, 31%; non-ischemic heart disease, NIHD, 22%), while LBBB-related septal dyssynchrony (SD) was the only abnormality in 47%. LGE was found in 42% of patients. LVEF and myocardial deformation were impaired. Despite similar ECG characteristics, myocardial strain differed significantly between IHD, NIHD and SD patients, and patients with SD showed less impaired myocardial deformation. Indexed LV end-systolic volume and LGE extent were independently associated with impaired strain. CONCLUSIONS: Patients with LBBB show different structural and mechanical properties, and LGE extent has an unfavourable effect on myocardial mechanics.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) mimics: the knot unravelled by cardiovascular MRI.

AIM: To assess the role of cardiovascular magnetic resonance imaging (CMRI) in patients referred for suspected arrhythmogenic right ventricular cardiomyopathy (ARVC), its ability to identify ARVC mimics, and subsequent clinical impact. MATERIALS AND METHODS: The CMRI registry of the year 2014 was analysed to identify all consecutive patients referred for suspected ARVC. A comprehensive CMRI protocol that included anatomy, bi-ventricular function modules, and late gadolinium enhancement (LGE) was performed in all patients. RESULTS: Out of 2,481 CMRI performed, 124 patients (5%) were referred for suspected ARVC. A pathological substrate was identified at CMRI in 36 patients (29%): five patients (4%) had ischaemic heart disease (IHD) and 10 (8%) non-IHD; five patients (4%) met CMRI criteria for ARVC and 16 (13%) were ARVC mimics. right ventricular end-diastolic volume (RVEDV) and right ventricular stroke volume (RVSV) were significantly higher in patients with ARVC mimics (RVEDV p=0.007, RVSV p=0.012) and ARVC (RVEDV p=0.013, RVSV p=0.013), as compared to those with structurally normal hearts. CMRI was superior to echocardiography in the identification of ARVC mimics (13% versus 1%, p=0.01). CONCLUSIONS: CMRI was able to identify 16 (13%) ARVC mimics, from congenital abnormalities to acquired heart disease. CMRI was superior in identifying ARVC mimics compared to echocardiography, and overall provided a change in diagnosis in 22% of patients.

Diagnostic yield of cardiovascular magnetic resonance in young-middle aged patients with high-grade atrio-ventricular block.

BACKGROUND: Atrio-ventricular block (AVB) is a rare finding in young or middle-aged adults, often leading to pacemaker implantation (PM) without further investigation. We sought to assess the diagnostic role of cardiovascular magnetic resonance (CMR) in young and middle-aged adults with high-grade AVB. METHODS: We consecutively enrolled young-middle aged (18-65years) patients with high grade AVB referred to CMR after standard clinical assessment (history, electrocardiogram and cardiac rhythm monitoring) prior to PM implantation. Cine and post-contrast imaging were performed in a 1.5T scanner. RESULTS: 34 patients (59% male, mean age 42±12years) with high grade AVB were referred to CMR for suspected ischemic heart disease (IHD)(n=4) and non-ischemic heart disease (NIHD)(n=20); no clear cause was found in 9 patients prior to CMR and 1 patient had suspected lung disease. A pathologic substrate was found on CMR in 15 patients (44%), while a structurally normal heart was reported in 18 (53%). Non-specific findings were reported in 1 patient (3%). There was a fair agreement between CMR and echocardiographic findings (Cohen's kappa 0.243), and CMR provided an entirely new diagnosis in 34% of patients. As compared to the standard clinical assessment, CMR had an additional role in 65% of patients and guided further testing (genetic testing, extra-cardiac imaging) in 9%. CONCLUSIONS: CMR found a pathologic substrate in 44% of patients, mainly NIHD (32%). Half of the patients (53%) had a structurally normal heart. When added to the standard clinical assessment, CMR had an incremental diagnostic role in two thirds of patients.

Out of hospital cardiac arrest survivors with inconclusive coronary angiogram: Impact of cardiovascular magnetic resonance on clinical management and decision-making.

BACKGROUND: Non-traumatic out of hospital cardiac arrest (OHCA) is the leading cause of death worldwide, mainly due to acute coronary syndromes. Urgent coronary angiography with view to revascularisation is recommended in patients with suspected acute coronary syndrome. Diagnosis and management of patients with inconclusive coronary angiogram (unobstructed coronaries or unidentified culprit lesion) is challenging. We sought to assess the role of Cardiovascular Magnetic Resonance (CMR) in the diagnosis and management of OHCA survivors with an inconclusive coronary angiogram. METHODS AND RESULTS: This is a retrospective multicentre CMR registry analysis of OHCA survivors with an inconclusive angiogram. Clinical, ECG and multi-modality imaging data were analysed. Clinical impact of CMR was defined as a change in diagnosis or management. Out of 174 OHCA survivors referred for CMR, 110 patients (63%, 84 male, median age 58) had an inconclusive angiogram. CMR identified a pathologic substrate in 76/110 patients (69%): ischemic heart disease was found in 45 (41%) and non-ischemic heart disease in 31 (28%). A structurally normal heart was found in 25 patients (23%) and non-specific findings in 9 (8%). As compared to trans-thoracic echocardiogram, CMR proved to be superior in identifying a pathologic substrate (69% vs 54%, p=0.018). The CMR study carried a clinical impact in 70% of patients, determining a change in diagnosis in 25%, in management in 29% and a change in both in 16%. CONCLUSIONS: CMR showed a promising role in the diagnostic work-up of OHCA survivors with inconclusive angiogram and its wider use should be considered.

Enhanced magnetic field probe array for improved excluded flux calculations on the C-2U advanced beam-driven field-reversed configuration plasma experiment.

External flux conserving coils were installed onto the exterior of the C-2U [M. W. Binderbauer et al., Phys. Plasmas 22, 056110 (2015)] confinement vessel to increase the flux confinement time of the system. The 0.5 in. stainless steel vessel wall has a skin time of ∼5 ms. The addition of the external copper coils effectively increases this time to ∼7 ms. This led to better-confined/longer-lived field-reversed configuration (FRC) plasmas. The fringing fields generated by the external coils have the side effect of rendering external field measurements invalid. Such measurements were key to the previous method of excluded flux calculation [M. C. Thompson et al., Rev. Sci. Instrum. 83, 10D709 (2012)]. A new array of B-dot probes and Rogowski coils were installed to better determine the amount of flux leaked out of the system and ultimately provide a more robust measurement of plasma parameters related to pressure balance including the excluded flux radius. The B-dot probes are surface mountable chip inductors with inductance of 33 µH capable of measuring the DC magnetic field and transient field, due to resistive current decay in the wall/coils, when coupled with active integrators. The Rogowski coils measure the total change in current in each external coil (150 A/2 ms). Currents were also actively driven in the external coils. This renders the assumption of total flux conservation invalid which further complicates the analysis process. The ultimate solution to these issues and the record breaking resultant FRC lifetimes will be presented.

Absolute calibration of neutron detectors on the C-2U advanced beam-driven FRC.

In the C-2U fusion energy experiment, high power neutral beam injection creates a large fast ion population that sustains a field-reversed configuration (FRC) plasma. The diagnosis of the fast ion pressure in these high-performance plasmas is therefore critical, and the measurement of the flux of neutrons from the deuterium-deuterium (D-D) fusion reaction is well suited to the task. Here we describe the absolute, in situ calibration of scintillation neutron detectors via two independent methods: firing deuterium beams into a high density gas target and calibration with a 2 × 107 n/s AmBe source. The practical issues of each method are discussed and the resulting calibration factors are shown to be in good agreement. Finally, the calibration factor is applied to C-2U experimental data where the measured neutron rate is found to exceed the classical expectation.

Characterization of compact-toroid injection during formation, translation, and field penetration.

We have developed a compact toroid (CT) injector system for particle refueling of the advanced beam-driven C-2U field-reversed configuration (FRC) plasma. The CT injector is a magnetized coaxial plasma gun (MCPG), and the produced CT must cross the perpendicular magnetic field surrounding the FRC for the refueling of C-2U. To simulate this environment, an experimental test stand has been constructed. A transverse magnetic field of ∼1 kG is established, which is comparable to the C-2U axial magnetic field in the confinement section, and CTs are fired across it. On the test stand we have been characterizing and studying CT formation, ejection/translation from the MCPG, and penetration into transverse magnetic fields.

Development of a magnetized coaxial plasma gun for compact toroid injection into the C-2 field-reversed configuration device.

A compact toroid (CT) injector was developed for the C-2 device, primarily for refueling of field-reversed configurations. The CTs are formed by a magnetized coaxial plasma gun (MCPG), which consists of coaxial cylindrical electrodes and a bias coil for creating a magnetic field. First, a plasma ring is generated by a discharge between the electrodes and is accelerated by Lorenz self-force. Then, the plasma ring is captured by an interlinkage flux (poloidal flux). Finally, the fully formed CT is ejected from the MCPG. The MCPG described herein has two gas injection ports that are arranged tangentially on the outer electrode. A tungsten-coated inner electrode has a head which can be replaced with a longer one to extend the length of the acceleration region for the CT. The developed MCPG has achieved supersonic CT velocities of ∼100 km/s. Plasma parameters for electron density, electron temperature, and the number of particles are ∼5 × 10(21) m(-3), ∼40 eV, and 0.5-1.0 × 10(19), respectively.

Achieving a long-lived high-beta plasma state by energetic beam injection.

Developing a stable plasma state with high-beta (ratio of plasma to magnetic pressures) is of critical importance for an economic magnetic fusion reactor. At the forefront of this endeavour is the field-reversed configuration. Here we demonstrate the kinetic stabilizing effect of fast ions on a disruptive magneto-hydrodynamic instability, known as a tilt mode, which poses a central obstacle to further field-reversed configuration development, by energetic beam injection. This technique, combined with the synergistic effect of active plasma boundary control, enables a fully stable ultra-high-beta (approaching 100%) plasma with a long lifetime.

Fusion proton diagnostic for the C-2 field reversed configuration.

Measurements of the flux of fusion products from high temperature plasmas provide valuable insights into the ion energy distribution, as the fusion reaction rate is a very sensitive function of ion energy. In C-2, where field reversed configuration plasmas are formed by the collision of two compact toroids and partially sustained by high power neutral beam injection [M. Binderbauer et al., Phys. Rev. Lett. 105, 045003 (2010); M. Tuszewski et al., Phys. Rev. Lett. 108, 255008 (2012)], measurements of DD fusion neutron flux are used to diagnose ion temperature and study fast ion confinement and dynamics. In this paper, we will describe the development of a new 3 MeV proton detector that will complement existing neutron detectors. The detector is a large area (50 cm(2)), partially depleted, ion implanted silicon diode operated in a pulse counting regime. While the scintillator-based neutron detectors allow for high time resolution measurements (∼100 kHz), they have no spatial or energy resolution. The proton detector will provide 10 cm spatial resolution, allowing us to determine if the axial distribution of fast ions is consistent with classical fast ion theory or whether anomalous scattering mechanisms are active. We will describe in detail the diagnostic design and present initial data from a neutral beam test chamber.

Tomographic imaging system for measuring impurity line emission in a field-reversed configuration.

A 16 chord optical tomography system has been developed and implemented in the flux coil generated-field reversed configuration (FRC). The chords are arranged in two fans of eight, which cover ~35% of the vessel area at the midplane. Each illuminate separate photomultiplier tubes (PMTs) which are fitted with narrow band-pass filters. In this case, filters are centered at 434.8 nm to measure emission from singly ionized argon. PMT crosstalk is negligible. Background noise due to electron radiation and H(γ) line radiation is <10% of argon emission. The spatial resolution of the reconstruction is 1.5 cm. Argon is introduced using a puff valve and tube designed to impart the gas into the system as the FRC is forming. Reconstruction of experimental data results in time-dependent, 2D emissivity profiles of the impurity ions. Analysis of these data show radial, cross-field diffusion to be in the range of 10-10(3) m(2)∕s during FRC equilibrium.

Field reversed configuration confinement enhancement through edge biasing and neutral beam injection.

Field reversed configurations (FRCs) with high confinement are obtained in the C-2 device by combining plasma gun edge biasing and neutral beam injection. The plasma gun creates an inward radial electric field that counters the usual FRC spin-up. The n = 2 rotational instability is stabilized without applying quadrupole magnetic fields. The FRCs are nearly axisymmetric, which enables fast ion confinement. The plasma gun also produces E × B shear in the FRC edge layer, which may explain the observed improved particle transport. The FRC confinement times are improved by factors 2 to 4, and the plasma lifetimes are extended from 1 to up to 4 ms.

Development of a nine spatial point, multipulse Thomson scattering diagnostic.

A Thomson scattering diagnostic has been developed for the C-2 field-reversed configuration device. Based on a multipulse ruby laser, the system measures the electron temperature at nine spatial points. These points are chosen from 22 selectable positions covering r≈1-41 cm. Twin collection lenses couple the scattered photons to nine optical fiber pairs. Extra fiber lengths delay the signals from different spatial points relative to each other, allowing up to three points to be analyzed by a single polychromator. The polychromator, using compact photomultipliers as detectors, has six spectral channels covering the range of 685-725 nm and is able to estimate electron temperatures of ≈10-200 eV. The photomultiplier output signals are recorded by digital storage oscilloscopes integrated with the main MDSplus database, with temperature and error estimates generated automatically at the conclusion of each plasma discharge.

Two-color CO2/HeNe laser interferometer for C-2 experiment.

A six-channel two-color interferometer has been developed for plasma electron density measurements in the C-2 field reversed configuration experiment. A CO(2) laser is utilized as the main probe beams, while copropagating visible HeNe laser beams are mainly sensitive to vibration. Density measurements in C-2 plasmas have shown that this is a reliable turn-key system. The maximum residual phase noise after vibration compensation is less than ±5°, corresponding to a line integral density of 3×10(18) m(-2). The time resolution for routine operation is 2 µs.

Dynamic formation of a hot field reversed configuration with improved confinement by supersonic merging of two colliding high-ß compact toroids.

A hot stable field-reversed configuration (FRC) has been produced in the C-2 experiment by colliding and merging two high-ß plasmoids preformed by the dynamic version of field-reversed θ-pinch technology. The merging process exhibits the highest poloidal flux amplification obtained in a magnetic confinement system (over tenfold increase). Most of the kinetic energy is converted into thermal energy with total temperature (T{i}+T{e}) exceeding 0.5 keV. The final FRC state exhibits a record FRC lifetime with flux confinement approaching classical values. These findings should have significant implications for fusion research and the physics of magnetic reconnection.

Time-of-flight neutral particle analyzer and calibration.

A time-of-flight diagnostic has been implemented on the Irvine field reversed configuration (IFRC) to obtain an energy distribution function from charge-exchanged neutral hydrogen. The diagnostic includes a 13 cm radius slotted disk rotating at 165 Hz in vacuum which chops the emitted neutrals at a rate of 26 kHz. In situ timing verification was performed with a dc xenon discharge lamp with an uncertainty less than 100 ns for a 38 micros chopping period. Energy calibration was accomplished with a singly ionized lithium source in the range of 300-1500 eV, achieving an average energy uncertainty, DeltaE/E, of 0.11. The diagnostic has measured neutrals in the range of 20-80 eV from the IFRC and the corresponding energy distribution function has been obtained.

[Intensive psychosensorial stimulation of malnourished children. I. Effects on psychomotor development and physical growth]. / Estimulación psicosensorial intensiva en niños desnutridos. I. Efectos en el desarrollo psicomotor y crecimiento físico.

Children under 18 months of age, with primary moderate and severe malnutrition, were treated by a multiprofessional team with an ambulatory system. The prospective effect of intensive psychosensorial stimulation over psychomotor development and physical growth was studied. Control (41 children) and experimental (55 children) groups were compared when the program started and successively followed up after 6 and 12 months. The experimental group were given intensive psychosensorial stimulation at home by their mothers. They were trained and periodically inspected by nurses. Both groups were matched by age, sex and birthweight. They all came from very poor families. Mean age when the program started was 10.4 months. Weight for age, weight for height, height for age (Standard NCHS), serum albumin, serum iron, transferrin saturation, TIBC were evaluated. Psychomotor development was evaluated with Rodríguez S. (EEDP) and Brunet Lezine scales. Both groups had similar increment in weight for age, weight for height, serum iron and transferrin saturation. No change was observed in height for age, serum albumin and TIBC. Psychomotor development improved more in the experimental group (p less than 0.01), coming to normal range in most children in that group. To conclude, intensive psychosensorial stimulation in malnourished children is not shown to improve physical growth but does improve psychomotor development (malnutrition, psychomotor development, physical growth, psychosensorial stimulation).