We present a modular and cost-effective gamma ray computed tomography system for multiphase flow investigations in industrial apparatuses. It mainly comprises a 137Cs isotopic source and an in-house-assembled detector arc, with a total of 16 scintillation detectors, offering a quantum efficiency of approximately 75% and an active area of 10 × 10 mm2 each. The detectors are operated in pulse mode to exclude scattered gamma photons from counting by using a dual-energy discrimination stage. Flexible application of the computed tomography system, i.e., for various object sizes and densities, is provided by an elaborated detector arc design, in combination with a scanning procedure that allows for simultaneous parallel beam projection acquisition. This allows the scan time to be scaled down with the number of individual detectors. Eventually, the developed scanner successfully upgrades the existing tomography setup in the industry. Here, single pencil beam gamma ray computed tomography is already used to study hydraulics in gas–liquid contactors, with inner diameters of up to 440 mm. We demonstrate the functionality of the new system for radiographic and computed tomographic scans of DN110 and DN440 columns that are operated at varying iso-hexane/nitrogen liquid–gas flow rates.

Background Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). Methods 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. Results Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). Conclusion Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

In this paper, a flexibly applicable gamma ray computed tomography scanner for multi-phase flow investigations in industrial apparatuses is presented. It mainly comprises a Cs-137 source and an in-house developed detector arc with overall 16 scintillation detectors offering a quantum efficiency of approximately 75% and an active area of 10×10 mm2 each. The detectors are operated in pulse-counting mode to enable gamma photon energy discrimination. Highest flexible application of the CT scanner, i.e. for various object sizes, is provided by an elaborated detector design in combination with a sophisticated scanning procedure that allows for multi beam projection acquisition.The developed radiation detector arc upgrades, finally, an already existing single pencil beam gamma ray computed tomography setup that is industrially used to discover hydraulics in chemical columns with inner diameters of up to 440 mm filled with structured aluminum packings. As illustrative examples, radiographic as well as computed tomography scans are successfully performed at DN110 and DN440 columns operated with various iso-hexane/nitrogen liquid-gas flow rates.

Background The 12-month follow-up (F/U) efficacy of CBA PVI performed at community hospitals for treatment of symptomatic paroxysmal and persistent atrial fibrillation (AF) is unknown. This study determined the 12-month efficacy of pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) performed at community hospitals with limited annual case numbers. Methods This registry study included 983 consecutive patients (pts) from 19 hospitals, each with an annual procedural volume of < 100 PVI procedures/year. Pts underwent CBA PVI for paroxysmal AF (n = 520), persistent AF (n = 423), or redo PVI (n = 40). The primary endpoint was frequency of documented recurrent AF, the occurrence of atrial flutter or tachycardia following a 90-day period after the index ablation and up to 12 months. The frequency of repeat ablation was determined. Results Isolation of all PVs was documented in 98% of pts at the end of the procedure. Twelve-month F/U data could be obtained in 916 pts. A 24-h ECG registration was performed in 641 pts (70.0%); in 107 pts (16.7%) of them, recurrent AF was documented. The primary endpoint was met in 193 F/U pts (21.1%). It occurred in 80/486 F/U pts with paroxysmal AF (16.4%), and in 107/390 F/U pts with persistent AF (27.4%). Redo PVI was performed in 71 pts (7.8%), and atrial flutter ablation was performed in 12 pts (1.4%). Conclusions CBA PVI for paroxysmal or persistent AF can be performed at community hospitals with adequate rates of 12-month symptom freedom and arrhythmia recurrence. The study was registered at the German register of clinical studies (DRKS00016504).

Introduction: Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) is a guideline recommended treatment for symptomatic paroxysmal and persistent atrial fibrillation. Little is known on performance data of CBA in low to medium volume hospitals. Hypothesis: To determine safety and efficacy of PVI using CBA performed at community hospitals with limited annual case numbers. Methods: This prospective registry included 1004 consecutive patients (pts) who had CBA performed for symptomatic paroxysmal (n=563) or persistent AF (n=441) at 20 hospitals, each with <100 PVI / year. CBA procedures were performed according to local standards. Procedural data, efficacy and complication rates were determined. Results: The mean number of CBA / year / center was 59±25. CBA was performed by a total of 22 operators (1.1/center), 12/20 operators were board certified for invasive electrophysiology. Average procedure time was 90.1±31.6 min, fluoroscopy time was 19.2±11.4 min. Isolation of all pulmonary veins was reached in 97.9% of pts, the most frequent reason for not achieving complete isolation was development of phrenic nerve palsy (PNP). No hospital deaths were observed. 2 pts (0.2%) suffered a clinical stroke. Pericardial effusion occurred in 6 pts (0.6%), 2 (0.2%) required pericardial drainage. Vascular complications occurred in 24 pts (2.4%), 2 pts (0.2%) underwent vascular surgery. PNP occurred in 48 pts (4.8%) and persisted up to discharge in 6 pts (0.6%). The results were independant for board certification status of the operator and independant for the number of enrolled patients per center (if > or < 60 pts). Follow up data at 12 months were available from 14 centers and 75,2 % of their pts so far. Recurrent atrial arrhythmias after a 3 months blanking period were found in 177/536 pts. (33%), 152 (85,9%) were symptomatic. 71 (40%) pts with recurrence were still on antiarrhythmic drugs, 42 (23.7%) underwent Re-PVI. One phrenic nerve palsy persisted, there were no further access site complications and no esophago-atrial fistula. Conclusions: PVI for paroxysmal or persistant AF using CBA can be safely performed at community hospitals with high acute efficacy, low complication rates and good recurrence data after 1 year despite low and moderate annual case numbers.

PURPOSE:The guidelines on the management of patients with heart failure support intensive patient education on self-care. The present study aimed to evaluate the short-term and long-term impacts of a structured education provided by a qualified heart failure nurse on patients' self-care behavior and disease knowledge. METHODS:One hundred fifty patients (66 ± 12 years) hospitalized for heart failure participated in a structured one-hour educational session by a heart failure nurse. Patients completed a questionnaire comprising 15 questions (nine questions from the European Heart Failure Self-Care Behavior Scale [EHFScB-9] and six on the patients' disease knowledge) one day before and one day and six months after the educational session. Possible responses for each question ranged from 1 (complete agreement) to 5 (complete disagreement). RESULTS:After the educational session, the total EHFScB-9 score improved from 24.31 ± 6.98 to 14.94 ± 6.22, and the disease knowledge score improved from 18.03 ± 5.44 to 10.74 ± 4.30 (both P < 0.001). Scores for individual questions ranged from 1.26 ± 0.81 (adherence to the medication protocol) to 3.66 ± 1.58 (everyday weighing habits) before the education. The greatest improvement after education was observed on response to weight gain (-2.00‬±1.57), daily weight control (-1.77 ± 1.64), and knowledge on the cause of patients' heart failure (-1.53 ± 1.43). At 6-month follow-up, EHFScB-9 score was 17.33 ± 7.23 and knowledge score was 12.34 ± 5.30 (both P < 0.001 compared with baseline). No factor was predictive of an insufficient teaching effect. CONCLUSIONS:The educational program led by a qualified nurse improves patients' self-care behavior and disease knowledge with a persistent effect at 6-month follow-up. There are no patient characteristics which preclude the implementation of an educational session.

Background Mitral valve prolapse is the most frequent valvular defect associated with a wide range of electro-hemodynamic abnormalities, leading to heart failure, arrhythmias and sudden cardiac death. Mitral valve prolapse, first described from Barlow in the 1960s, is defined as displacement of mitral leaflet tissue into the left atrium past the mitral annular plane during systole. The correlation between mitral valve prolapse and sudden cardiac death has been investigated and clarified by various studies in recent years. However, identifying patients at risk and applying measures to prevent those from sudden cardiac death is challenging. Case presentation We report on a 61-year-old female patient who had undergone an aborted sudden cardiac death. An arrythmogenic mitral valve prolapse was diagnosed. In addition, electrocardiographically and morphologically risk markers for sudden cardiac death were found in this case. We performed an ICD implantation as secondary prophylaxis and intended to reconstruct the mitral valve. Conclusion This article examines the association of mitral valve prolapse with sudden cardiac death, the underlying pathophysiological mechanisms and the strategies leading to identify the risk group.

AIMS Pulmonary vein isolation (PVI) using cryoballoon ablation (CBA) is an established procedure for treating symptomatic paroxysmal and persistent atrial fibrillation (AF). The safety and efficacy of PVI performed at community hospitals are unknown. We aimed to determine the safety and acute efficacy of PVI using CBA performed at community hospitals with limited annual case numbers. METHODS AND RESULTS This registry study included 1004 consecutive patients who had PVI performed for symptomatic paroxysmal (n = 563) or persistent AF (n = 441) from January 2019 to September 2020 at 20 hospitals. Each hospital performed fewer than 100 CBA-PVI procedures/year according to local standards. Procedural data, efficacy, and complication rates were determined. The mean number of CBA procedures performed/year at each centre was 59 ± 25. The average procedure time was 90.1 ± 31.6 min and the average fluoroscopy time was 19.2 ± 11.4 min. Isolation of all pulmonary veins was documented in 97.9% of patients. The most frequent reason for not achieving complete isolation was development of phrenic nerve palsy. No hospital deaths were observed. Two patients (0.2%) suffered a clinical stroke. Pericardial effusion occurred in six patients (0.6%), two of whom (0.2%) required pericardial drainage. Vascular complications occurred in 24 patients (2.4%), two of whom (0.2%) required vascular surgery. Phrenic nerve palsy occurred in 48 patients (4.8%) and persisted up to hospital discharge in six patients (0.6%). CONCLUSION Pulmonary vein isolation procedures for paroxysmal or persistent AF using CBA can be performed at community hospitals with high acute efficacy and low complication rates.

Modelling flow and mass transfer of thermal separation equipment constitutes one of the most challenging tasks in fluids process engineering. The difficulty of this task comes from the multiscale multiphase flow phenomena in rather complex geometries. Both analysis of flow and mass transfer on different scales as well as validation of models and simulation results require advanced experimental and measurement techniques. As a follow-up to intensive discussions during the 2019 Tutzing Symposium "Separation Units 4.0" a wide set of available modern experimental technologies is presented.

Abstract Objectives This study sought to evaluate the impact of tube angulation on radiation dose using image noise reduction technology in a clinical setting. Image noise reduction technology has been shown to significantly reduce radiation dose in coronary angiography in particular by reduction of radiation in cine mode. Methods In 500 coronary angiograms performed by the same operator the dose-area product (DAP) was determined. The DAP was determined for the cine mode as well as for the fluoroscopy mode. Furthermore, in the cine mode, the DAP on a per image (DAP/frame) basis was determined for the posterior-anterior projection (PA) as well as a left anterior oblique (LAO) cranial (LAO 20°/20°) and caudal (LAO 45°/−20°), right anterior oblique (RAO) cranial (RAO 20°/20°) and caudal (RAO 30°/−20°) angulations. The image intensifier area was kept constant for all angulations. Results Mean body mass index was 28.6±5.5 kg/m2. Mean total DAP was 1227±1417 cGy cm2. The mean ratio of DAP in cine mode/DAP in fluoro mode was 0.54±0.32. Mean DAP/frame in PA angulation was 5.5±3.3 (cGy cm2). Considering the cine mode, for the LAO cranial and LAO caudal angulations, the relative DAP/ frame compared to the PA angulation was 2.8±1.8 and 4.2±1.6, respectively. For the RAO cranial and RAO caudal angulations, the relative DAP/frame compared to the PA angulation was 1.7±2.2 and 1.8±1.4. Conclusions Using image noise reduction technology, radiation during fluoroscopy mode contributes more to total radiation dose than radiation during cine mode. In cine mode, the PA angulation has least radiation/ frame. The LAO caudal angulation is associated with greatest increase in radiation dose compared to the PA angulation, while LAO cranial angulation and RAO cranial and caudal angulations increase radiation dose to a lesser extent. Funding Acknowledgement Type of funding source: None

PURPOSE:The precise assessment of tricuspid regurgitation (TR) using 2D imaging techniques may be associated with significant difficulties due to the nonround regurgitation area. Direct analysis of the regurgitation area by 3D color Doppler echocardiography at the vena contracta (3D VCA) has the potential to adequately quantify even complex TR. This study compared 3D VCA for quantification of the TR with the regurgitant area determined by proximal isovolumetric convergence method (PISA-EROA) considering different clinical settings. METHODS:In 95 patients with TR of different severity, the regurgitant orifice area was determined by 3D color Doppler echocardiography and by PISA-EROA. Using 3D color Doppler echocardiography, the regurgitant orifice area was determined three times in each patient considering 3 datasets. RESULTS:Mean 3D VCA was 0.27 ± 0.14, 0.27 ± 0.13, and 0.29 ± 0.14 cm2 , respectively, as determined by three separate measurements in each of the 95 patients. There was a mean relative deviation between the three measurements in each patient of 12.4 ± 14.9%. The regurgitant orifice area using the PISA method was 0.28 ± 0.14 cm2 . There was a mean difference of 0.07 cm2 (95% CI -0.124 to 0.138 cm2 ) between 3D VCA and PISA-EROA. The correlation between 3D VCA and PISA-EROA was r = .88 (P < .001). Considering a grading of TR severity in grade I (regurgitant area < 0.2 cm2 ), grade II (area 0.2-0.4 cm2 ), and grade III (area > 0.4 cm2 ), there was a good agreement between severity grade determined by 3D VCA and severity grade determined by PISA-EROA (kappa 0.71). CONCLUSION:The analysis of the VCA of a TR using 3D color Doppler echocardiography is an alternative method to determine the regurgitant severity with good agreement to the PISA method.

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = −0.293; p = 0.138) than in patients without LVH (r = −0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Background: Need for a permanent control person and alarm fatigue are limitations of telemetry surveillance systems ending at the central surveillance monitor. This study evaluated an escalation system expanding the alarm sequence by smartphones. Methods: Telemetry system with 26 monitoring units and WLAN based alarm escalation system to three smartphones (Care Event, Philips) was evaluated during 128 days regarding major arrhythmia alarm (MAA) frequency, escalation of alarms within the system and response times. ECG triggering the MAA, patient name and position are shown on the smartphone display. MAA are forwarded initially to smartphone one. Forwarding of MAA to two further smartphones is actively triggered or occurs automatically after 20 sec without response by smartphone one. Results: During the analysis period 11576 MAA were forwarded, ranging from 15 to 238 alarms/day. The number of MAA was minimal at 11 pm and maximal at 8 am (ratio 1:1.8). In 69% only smartphone 1 was involved, in 31% occurred an escalation to smartphone 2 and in 13% to smartphone 3. The median MAA response time at the smartphone was 8 sec at daytime and 9 sec at nighttime. 14 min of running time could be saved on average every day by direct visit of the patient triggering an alarm and omission of the central monitoring system. Conclusions: A smartphone based alarm escalation system redundancies the permanent presence of nursing staff at the central surveillance system. The multilevel surveillance system with smartphone based escalation allows low alarm response times and warrants excellent surveillance quality

This study presents the derivation and validation of a model that permits simulation of interfacial species transfer in rectification and absorption processes in the context of the algebraic Volume-of-Fluid (VoF) approach. The model is based on the Continuous Species Transfer (CST) method introduced by Marschall et al. (2012) and Deising et al. (2016), which is generalised in such a way that not only absorption but also rectification can be simulated, and is therefore termed Generalised Continuous Species Transfer (GCST) model. After briefly setting out the motivation of this generalisation, the derivation of the model is outlined, which is followed by its validation.

Background: Need for a permanent control person and alarm fatigue are limitations of telemetry surveillance systems ending at the central surveillance monitor. This study evaluated an escalation system expanding the alarm sequence by smartphones. Methods: Telemetry system with 26 monitoring units and WLAN based alarm escalation system to three smartphones (Care Event, Philips) was evaluated during 128 days regarding major arrhythmia alarm (MAA) frequency, escalation of alarms within the system and response times. ECG triggering the MAA, patient name and position are shown on the smartphone display. MAA are forwarded initially to smartphone one. Forwarding of MAA to two further smartphones is actively triggered or occurs automatically after 20 sec without response by smartphone one. Results: During the analysis period 11576 MAA were forwarded, ranging from 15 to 238 alarms/day. The number of MAA was minimal at 11 pm and maximal at 8 am (ratio 1:1.8). In 69% only smartphone 1 was involved, in 31% occurred an escalation to smartphone 2 and in 13% to smartphone 3. The median MAA response time at the smartphone was 8 sec at daytime and 9 sec at nighttime. 14 min of running time could be saved on average every day by direct visit of the patient triggering an alarm and omission of the central monitoring system. Conclusions: A smartphone based alarm escalation system redundancies the permanent presence of nursing staff at the central surveillance system. The multilevel surveillance system with smartphone based escalation allows low alarm response times and warrants excellent surveillance quality

BackgroundNovel x-ray systems with real-time image noise reduction technology (INRT) to reduce radiation dose during fluoroscopy and cine acquisition have become available. This study evaluated the reduction of radiation dose in device implantation with INRT. MethodsRadiation dose data from 132 consecutive new device implantation procedures (102 pacemaker [PM] or implantable cardioverter defibrillator [ICD] and 30 cardiac resynchronization therapy [CRT] devices) performed between January 2015 and December 2015 on an angiography system with INRT (Allura ClarityIQ) were collected. For comparison, radiation dose data from 147 consecutive device implantation procedures (121 PM/ICDs and 26 CRT devices) performed between June 2013 and September 2014 on a C-arm system with continuous and pulsed fluoroscopy option (4 frames/second) were evaluated. Total dose area product (DAP), fluoroscopy DAP, and cine DAP were evaluated. ResultsPatient age, gender and body weight, procedure, and fluoroscopy times were similar between systems. In PM/ICD cases, DAP of INRT and C-arm system was similar (423 381 cGycm(2)vs 417 +/- 517 cGycm) due to pulsed fluoroscopy with the C-arm system (78% of time) and sparse use of cine. In CRT procedures requiring higher image quality (82% use of continuous fluoroscopy with C-arm system), DAP of INRT was significantly lower (1,544 +/- 834cGycm vs 7,252 +/- 6,431 cGycm, P<0.001) due to less fluoroscopy DAP (1,414 +/- 757cGycm vs 5,854 +/- 6,767 cGycm) and less cine DAP (130 +/- 106cGycm vs 1,399 +/- 1,342 cGycm). Considering all procedures, total DAP was reduced by 60% using INRT. ConclusionNovel INRT results in a substantial lowering of radiation dose in device implantation, in particular, in complex CRT implantation procedures requiring high image quality.

AIMS:In patients undergoing percutaneous edge-to-edge mitral valve repair for mitral valve regurgitation (MR), our aim was to evaluate acute and follow-up differences with pre-existing sinus rhythm (SR) or atrial fibrillation (AF), as well as comparisons stratified by baseline heart rate.METHODS AND RESULTS:Seven hundred and sixty patients who underwent a MitraClip procedure were prospectively enrolled in the TRAnscatheter Mitral valve Interventions (TRAMI) registry, and stratified according to baseline heart rhythm and heart rate with a cut-off value of 70 beats per minute. Technical success, procedural characteristics and MR reduction were similar throughout the subgroups. Overall, in-hospital adverse event rates were low in this high-risk patient collective. At 12 months, survival was higher in SR (83.5%) than AF patients (74.9%, p<0.05), while the cumulative major adverse cardio-cerebrovascular event rate did not differ, and a sustained improvement of NYHA functional class occurred in all subgroups.CONCLUSIONS:These registry data, comprising the largest number of unselected "real-world" MitraClip patients, suggest that the intervention can be performed safely and effectively, and reduces MR in the majority of patients irrespective of baseline rhythm or heart rate. While 12-month survival was higher for patients with SR, overall MACCE and clinical improvement did not differ between the subgroups.