Sports engineering can be considered as the bridge between the knowledge of sports science and the principles of engineering and has an important role not only in improving the athletic performance, but also in increasing the safety of the athletes. Testing and optimization of sports equipment and athletic performance are essential for supporting athletes in their quest to reach the podium. However, most of the equipment used by world-class athletes is chosen based only on subjective tests and the athletes’ feelings. Consequently, one of the aims of this thesis was to combine mechanics and mathematics to develop new objective test methods for sports equipment. Another objective was to investigate the possibility to accurately track and analyse cross-country skiing performance by using a real-time locating system. A long term aim is the contribution to increased knowledge about objective test and analysis methods in sports. The main methodological advancements are the modification of established test methods for sports equipment and the implementation of spline-interpolated measured positioning data to evaluate cross-country skiing performance. The first two papers show that it is possible to design objective yet sport specific test methods for different sports equipment. New test devices and methodologies are proposed for alpine ski helmets and cross-country ski poles. The third paper gives suggestions for improved test setups and theoretical simulations are introduced for glide tests of skis. It is shown, it the fourth paper, that data from a real-time locating system in combination with a spline model offers considerable potential for performance analysis in cross-country sprint skiing. In the last paper, for the first time, propulsive power during a cross-country sprint skiing race is estimated by applying a power balance model to spline-interpolated measured positioning data, enabling in-depth analyses of power output and pacing strategies in cross-country skiing. Even though it has not been a first priority aim in this work, the results from the first two papers have been used by manufacturers to design new helmets with increased safety properties and cross-country ski poles with increased force transfer properties. In summary, the results of this thesis demonstrate the feasibility of using mechanics and mathematics to increase the objectiveness and relevance when analysing sports equipment and athletic performance. / <p>QC 20160927</p>

O objetivo do estudo foi examinar a influência de variáveis fisiológicas, perceptuais e mecânicas nas diferentes estratégias de corrida e no desempenho de atletas. Doze corredores especialistas em 5.000m realizaram: 1) um teste escalonado máximo para identificação do consumo máximo de oxigênio (VO2máx), velocidade de corrida associada ao VO2máx (vVO2máx), pico de velocidade em esteira (PVE) e velocidade de corrida associada ao limiar anaeróbio (vLAn); 2) uma prova de corrida de 5.000m avaliada a cada trecho (n = 5) de 1.000m em pista de atletismo para registro da frequência cardíaca (FC), percepção subjetiva de esforço (PSE) e velocidade de corrida. Os sujeitos foram divididos em dois grupos: saída lenta (SL) e saída rápida (SR) de acordo com a estratégia adotada, que por sua vez foi baseada na relação da velocidade de corrida no trecho inicial (Vel20%) com a velocidade média do teste de 5.000m. Os dados foram comparados entre os grupos de estratégia e posteriormente entre os trechos da prova esportiva para cada variável analisada. A velocidade de corrida no trecho inicial (SL = 16,9km.h-1 e SR = 19,1km.h-1) e no trecho final (SL = 19,1km.h-1 e SR = 16,7km.h-1) foi significantemente diferente (p < 0,05), o mesmo não ocorreu com a PSE. Já a FC nos três últimos trechos (SL = 185; 188 e 195 bpm e SR = 191; 193 e 200 bpm) apresentou diferença significante (p < 0,05) entre os grupos avaliados. Adicionalmente, foram encontradas associações entre PVE e Vel20% (rs = 0,57; p < 0,05), vVO2máx e Vel20% (rs = 0,55; p < 0,05), e entre vLAn e Vel20% (rs = 0,54; p < 0,05). Quando os parâmetros de desempenho (FC, PSE e velocidade de corrida) foram comparados dentro de cada grupo, apresentaram diferença significante (p < 0,05) entre todos os trechos analisados do teste. Dessa forma, concluímos haver influência da estratégia adotada no início da prova sobre a regulação da velocidade e sobre o desempenho na corrida de 5.000m, sobretudo, quando relacionada a parâmetros fisiológicos, perceptuais e mecânicos / The objective of this study was to examine the influence of physiological, perceptual and mechanical parameters in different pacing strategies and performance of athletes. Twelve runners performed: 1) a test scaled maximal to identify the maximum oxygen uptake (VO2max), running velocity associated with VO2max (vVO2max), peak treadmill velocity (PTV) and running velocity associated with the anaerobic threshold (vAnT); 2) a time trial evaluated in each 1,000m in the track to record heart rate (HR), rating of perceived exertion (RPE) and running speed. The subjects were divided into two groups: slow start (SS) and fast start (FS) in accordance with the strategy used, which in turn was based on the ratio of the velocity of the initial split (Vel20%) with the speed average of the time trial. Data were compared between groups of the pacing strategy for each variable analyzed. The velocity at the initial split (SS = 16.9 km.h-1 and FS = 19.1 km.h-1) and in the final split (SS = 19.1 km.h-1 and FS = 16.7 km.h-1) was different significantly (p < 0.05), but the same did not occur with the RPE. The HR in the last three splits (SS = 185, 188 and 195 beats.min-1 and FS = 191, 193 and 200 beats.min-1) showed significant difference (p < 0.05) between groups. In addition, associations were found between PTV and Vel20% (rs = 0.57, p < 0.05), vVO2max and Vel20% (rs = 0.55, p < 0.05) and between vAnT and Vel20% (rs = 0.54, p < 0.05). When the performance parameters (HR, RPE and running speed) were compared within each group, there were significant differences (p < 0.05) among all splits analyzed. Thus, we conclude there is influence of the strategy adopted at the start of the time trial and the speed regulation on the performance in the 5,000m running, especially when related to physiological, perceptual and mechanical parameters

Les travaux conduits dans le cadre de cette thèse avaient pour objectif d’étudier les mécanismes psychophysiologiques impliqués dans la mobilisation et la gestion des ressources nécessaires à la réalisation d’une performance de haut niveau en cyclisme sur route. Les mécanismes centraux et les paramètres psychologiques susceptibles d’influencer la commande motrice ont ainsi été analysés dans le contexte de compétitions cyclistes de haut-niveau.L’ensemble des résultats obtenus mettent en évidence que les mécanismes de régulation de l’intensité d’exercice, évalués à l’aide de la nouvelle méthode « Exposure Variation Analysis » (EVA) développée dans le cadre de cette thèse, seraient des paramètres déterminants pour la performance cycliste en contre-la-montre (CLM). En compétition officielle, la capacité du cycliste à exploiter au mieux ses qualités physiques et donc à développer la plus haute puissance moyenne possible était directement reliée à sa capacité à maintenir un niveau d’intensité d’exercice constant sur l’ensemble du CLM. De plus, cette justesse de régulation de l’intensité de l’effort serait également liée aux paramètres psychologiques de plaisir ressenti et de focus attentionnel : plus l’athlète ressentait un plaisir important et était capable de focaliser ses pensées sur des éléments extérieurs pertinents pour la performance et plus il était capable de maintenir un niveau de puissance constant sur l’ensemble de l’effort. Ainsi, la performance cycliste serait dépendante de l’interaction complexe entre les paramètres psychologiques, les mécanismes de régulation de l’effort et les qualités physiques des athlètes.Cependant, les résultats des études menées dans le cadre de cette thèse mettent également en évidence que les mécanismes de régulation de l’intensité d’exercice et les paramètres psychologiques associés varient selon le contexte environnemental et les caractéristiques de l’effort réalisé. Par exemple, la présence d’un équipier en montée permettrait au cycliste de ressentir un plaisir plus élevé pendant l’effort et de puiser davantage dans ses réserves afin de réaliser un sprint final plus important dans les derniers mètres avant l’arrivée. A l’inverse, les cyclistes de niveau élite possèderaient des qualités de gestion de l’effort remarquables leur permettant de réguler l’effort de manière identique lors de plusieurs montées répétées que lors d’un effort unique. L’étude de la performance cycliste doit donc prendre en compte le contexte environnemental ainsi que les caractéristiques des athlètes et de l’effort réalisé afin de réellement permettre une compréhension complète de la performance cycliste de haut-niveau.De plus, ces résultats mettent également en évidence que les mécanismes de régulation de l’effort peuvent évoluer entre les différentes compétitions, et pourraient ainsi expliquer les variations journalières de performance pour un même niveau de qualité physique. Les travaux menés dans le cadre de cette thèse ont ainsi tenté d’optimiser la méthode EVA afin de permettre le suivi de la justesse des mécanismes de régulation de l’effort du cycliste lors de plusieurs CLM. Cette méthode pourrait se révéler très intéressante pour les entraîneurs et les athlètes sur le terrain afin de tenter d’optimiser leurs mécanismes de régulation de l’effort avec l’entraînement dans le but d’exploiter au mieux leurs qualités physiques. Des techniques psychologiques pourraient notamment être utilisées afin d’augmenter le plaisir ressenti des athlètes ou d’optimiser leur gestion des pensées pendant l’effort, leur permettant ainsi de mieux réguler l’intensité d’exercice et d’améliorer leurs performances en CLM. / The studies conducted during this PhD thesis aimed to analyse the psychophysiological mechanisms of effort regulation during elite road cycling performance. Central mechanisms and psychological parameters influencing motor units recruitment were studied in different contexts of elite road cycling competitions.All the results show that exercise intensity regulation, quantified using the “Exposure Variation Analysis” method developed during this PhD, is a key parameter of cycling individual time-trial (ITT) performance. During official competitive ITT, the cyclists’ abilities to have a maximal use of their physical capacities in order to develop the highest mean power output possible was strongly related to their abilities to maintain a constant level of exercise intensity during the entire ITT. These exercise intensity regulation mechanisms were also strongly related to pleasure and attentional focus psychological parameters: the more the athletes felt a high level of pleasure and were able to focus mainly on external thoughts salient to the performance, the more they were able to maintain a constant power output over the entire ITT. Cycling performance seems related to the complex interaction between psychological parameters, exercise intensity regulation mechanisms and physical capacities.However, the studies conducted also revealed that exercise intensity regulation mechanisms and psychological parameters varied depending on the environmental context and the characteristics of the effort. For example, a leading teammate in uphill cycling allowed the athlete to increase their pleasure and to dig deeper into their physiological reserves in order to perform a greater end-spurt. Conversely, elite cyclists exhibited outstanding exercise intensity regulation capacities which allowed them to regulate their effort during repeated uphill ITT in the same way that during single ITT. Consequently, the study of elite cycling performance must consider both environmental context and characteristics of the athletes concerned to allow a complete understanding of the mechanisms underlying performance.Furthermore, these results also underline that exercise intensity regulation mechanisms can vary between races, and consequently can explain the day-to-day variability in cycling performance despite similar physical capacities. Thus, the EVA method was optimised in order to monitor exercise intensity regulation mechanisms during several ITT performed by the same athletes. This method can be interesting for coaches and athletes on the field to try to improve their exercise intensity regulation with training. Specific psychological interventions can be added to the training programs in order to help the athlete to increase their pleasure or to improve their attentional focus, allowing them to improve their exercise intensity regulation and to have a greater use of their physical capacities during ITT.

INTRODUÇÃO: O intervalo PR longo, em conjunto com a duração e a morfologia do QRS gerado pela estimulação cardíaca artificial, associam-se com dessincronia e disfunção cardíaca em diferentes níveis. Na doença do nó sinusal, durante a programação do marca-passo, podemos optar por duas estratégias: PR longo com QRS estreito (quando se busca evitar a ativação ventricular em detrimento do sincronismo atrioventricular) ou PR otimizado e QRS largo estimulado pelo marca-passo (quando se busca corrigir o intervalo atrioventricular em detrimento da sincronia ventricular). Neste estudo, buscamos comparar a evolução clínica e estrutural cardíaca destas estratégias. MÉTODOS: Acompanhou-se por 1 ano uma coorte com doença do nó sinusal, bloqueio atrioventricular de 1º grau (doença binodal) e marca-passo DDD. Através da ecocardiografia Doppler de fluxo transmitral avaliou-se a duração do enchimento diastólico ventricular e sincronia atrioventricular (? ondas E+A>=40% do ciclo cardíaco). Os pacientes dessincrônicos (DAV) tiveram o intervalo atrioventricular otimizado (intervenção) ao melhor rendimento hemodinâmico, porém com QRS estimulado. Estes retornavam ao PR basal após 6 meses (cross-over). Os sincrônicos (SAV) foram mantidos sob PR longo e QRS intrínseco durante todo o seguimento (controles). RESULTADOS: Quarenta e três pacientes foram incluídos e 41 completaram o estudo (idade média= 71,5 anos). Confirmou-se a existência dos 2 grupos (p= <0.001): os SAV (n=19), distintos daqueles com dessincronia atrioventricular (DAV, n=24). PR>=263ms mostrou especificidade de 78,9% para diagnóstico de dessincronia AV, e a maior duração do PR mostrou relação direta com pior função sistólica ventricular basal. Os DAV eram predominantemente homens, tinham PR mais longos (média= 283,5ms) e menor duração da diástole (p= 0.032). Um subgrupo dos DAV com PR >300ms mostrou pior qualidade de vida, maior duração do QRS quando estimulado, e dessincronia não corrigível por otimização. De modo notável, em 6 meses, o grupo DAV mostrou tendência a melhora da FEVE apesar do QRS alargado, e decréscimo ao retornar ao basal. O grupo SAV apresentava PR longo antifisiológico e evolutivamente piora da regurgitação mitral (p= 0.008) e também registros de fibrilação atrial de aparição mais precoce. Foram preditores independentes de dessincronia atrioventricular o PR >263ms (RR= 1,84; p= 0.024) e a duração da diástole inferior a 40% do ciclo cardíaco (RR= 0,99; p<0.001). CONCLUSÕES: Em pacientes com doença binodal e marca-passo DDD, a mera intenção de evitar o QRS largo da estimulação ventricular artificial não resolve todos os problemas. Intervalos PR longos (>263ms) associados ao decréscimo do enchimento diastólico ventricular caracterizariam outro prejuízo eletromecânico cardíaco: a dessincronia atrioventricular, disfunção que tem repercussão hemodinâmica, clínica e estrutural. / BACKGROUND: Long PR interval and wide QRS duration duo to ectopic morphology generated by artificial cardiac pacing are associated with cardiac dysfunction and dyssynchrony at different levels. When programming a permanent pacemaker in sinus node disease, two strategies can be considered: long PR with narrow QRS (avoiding ventricular pacing despite the risk of losing atrioventricular syncrony) or optimized PR interval with pacemaker-induced wide QRS (aiming to correct the atrioventricular delay despite loss of the ventricular synchrony). In this study, we aimed to compare the clinical and cardiac structural outcomes of these two strategies. METHODS: Sudy a cohort of patients with sinus node disease, first-degree AV block (binodal disease) and DDD pacemaker was followed for 1 year follow-up. atrioventrucular synchrony (AVS) was assessed echocardiographically by the ventricular diastolic filling time on Doppler transmitral flow: sum of the duration of E and A waves >=40% of the cardiac cycle. Patients with AV dyssynchrony (AVD) had the AV delay optimized (intervention group) for the best hemodynamic performance, but under wide artificially paced QRS. These returned to baseline PR interval after 6 months (cross-over). Those with AVS were kept under intrinsic QRS throughout the follow-up period despiste long PR interval (control group). RESULTS: Forty-three patients were included (mean age = 71.5 years), and 41 completed the 1-year follow-up. The existence of the 2 groups was confirmed (p<=0.001): patients with AVS (n=19), differed from those with AVD (n=24). Within a homogeneous sample (mean age= 71.5 years), PR >=263 ms had a specificity of 78.9% for the diagnosis of AVD, and longer PR intervals were associated with worse baseline ventricular systolic function. Most patients with AVD were men, had longer PR intervals (mean= 283.5 ms), and had significantly lower diastole duration (p= 0.032). A subgroup of AVD patients with PR >300 ms had poorer quality of life, significantly greater use of ?-blockers (p= 0.011), longer paced QRS width, and AV dyssynchrony that is non-correctable by optimization. Notably, at 6 months, the AVD group lean towards to have better LVEF values despite the wide QRS and a decrease when returning to baseline. Patients with AVS also had PR intervals different from the physiological condition (157.9 to 330 ms) and, over time, had worsening of mitral regurgitation (p=0.008) and earlier atrial fibrillation. PR>263 ms (RR= 1.84; p= 0.024) and diastole duration <40% of the cardiac cycle (RR= 0.99; p<0.001) were independent predictors of AVD. CONCLUSIONS: For patients with binodal disease and DDD pacemaker, the strategy of avoiding the wide QRS, usually applied by modern algorithms for minimizing ventricular pacing, is not enough to solve all problems. Long PR intervals (>=263 ms) may be associated with decreased ventricular diastolic filling time and characterize another cardiac electromechanical impairment: AV dyssynchrony, with hemodynamic, clinical and structural repercussions by itself.

O objetivo do estudo foi examinar a influência de variáveis fisiológicas, perceptuais e mecânicas nas diferentes estratégias de corrida e no desempenho de atletas. Doze corredores especialistas em 5.000m realizaram: 1) um teste escalonado máximo para identificação do consumo máximo de oxigênio (VO2máx), velocidade de corrida associada ao VO2máx (vVO2máx), pico de velocidade em esteira (PVE) e velocidade de corrida associada ao limiar anaeróbio (vLAn); 2) uma prova de corrida de 5.000m avaliada a cada trecho (n = 5) de 1.000m em pista de atletismo para registro da frequência cardíaca (FC), percepção subjetiva de esforço (PSE) e velocidade de corrida. Os sujeitos foram divididos em dois grupos: saída lenta (SL) e saída rápida (SR) de acordo com a estratégia adotada, que por sua vez foi baseada na relação da velocidade de corrida no trecho inicial (Vel20%) com a velocidade média do teste de 5.000m. Os dados foram comparados entre os grupos de estratégia e posteriormente entre os trechos da prova esportiva para cada variável analisada. A velocidade de corrida no trecho inicial (SL = 16,9km.h-1 e SR = 19,1km.h-1) e no trecho final (SL = 19,1km.h-1 e SR = 16,7km.h-1) foi significantemente diferente (p < 0,05), o mesmo não ocorreu com a PSE. Já a FC nos três últimos trechos (SL = 185; 188 e 195 bpm e SR = 191; 193 e 200 bpm) apresentou diferença significante (p < 0,05) entre os grupos avaliados. Adicionalmente, foram encontradas associações entre PVE e Vel20% (rs = 0,57; p < 0,05), vVO2máx e Vel20% (rs = 0,55; p < 0,05), e entre vLAn e Vel20% (rs = 0,54; p < 0,05). Quando os parâmetros de desempenho (FC, PSE e velocidade de corrida) foram comparados dentro de cada grupo, apresentaram diferença significante (p < 0,05) entre todos os trechos analisados do teste. Dessa forma, concluímos haver influência da estratégia adotada no início da prova sobre a regulação da velocidade e sobre o desempenho na corrida de 5.000m, sobretudo, quando relacionada a parâmetros fisiológicos, perceptuais e mecânicos / The objective of this study was to examine the influence of physiological, perceptual and mechanical parameters in different pacing strategies and performance of athletes. Twelve runners performed: 1) a test scaled maximal to identify the maximum oxygen uptake (VO2max), running velocity associated with VO2max (vVO2max), peak treadmill velocity (PTV) and running velocity associated with the anaerobic threshold (vAnT); 2) a time trial evaluated in each 1,000m in the track to record heart rate (HR), rating of perceived exertion (RPE) and running speed. The subjects were divided into two groups: slow start (SS) and fast start (FS) in accordance with the strategy used, which in turn was based on the ratio of the velocity of the initial split (Vel20%) with the speed average of the time trial. Data were compared between groups of the pacing strategy for each variable analyzed. The velocity at the initial split (SS = 16.9 km.h-1 and FS = 19.1 km.h-1) and in the final split (SS = 19.1 km.h-1 and FS = 16.7 km.h-1) was different significantly (p < 0.05), but the same did not occur with the RPE. The HR in the last three splits (SS = 185, 188 and 195 beats.min-1 and FS = 191, 193 and 200 beats.min-1) showed significant difference (p < 0.05) between groups. In addition, associations were found between PTV and Vel20% (rs = 0.57, p < 0.05), vVO2max and Vel20% (rs = 0.55, p < 0.05) and between vAnT and Vel20% (rs = 0.54, p < 0.05). When the performance parameters (HR, RPE and running speed) were compared within each group, there were significant differences (p < 0.05) among all splits analyzed. Thus, we conclude there is influence of the strategy adopted at the start of the time trial and the speed regulation on the performance in the 5,000m running, especially when related to physiological, perceptual and mechanical parameters

Les vidéos sont de plus en plus utilisées dans l’enseignement. C’est également le cas dans la formation médicale et paramédicale et, entre autres, dans l’apprentissage de procédures qui seront à réaliser de manière différée. Malgré l’intérêt pédagogique qu’elles offrent aux apprenants, leur utilisation peut entrainer des difficultés spécifiques dans le processus d’apprentissage des utilisateurs en raison de la nature transitoire des informations fournies. Pour limiter la surcharge cognitive que cela peut engendrer, il est possible de laisser le contrôle du rythme de la vidéo à l’apprenant, avec un bouton pause sur l’interface du lecteur par exemple. Cependant, les modèles mentaux des apprenants novices peuvent ne pas être suffisamment pertinents pour savoir à quel moment de la procédure arrêter la vidéo. Ainsi, l’introduction d’une segmentation, avec des pauses imposées par le système à chaque étape de la procédure, peut s’avérer plus efficace lors d’un apprentissage d’une compétence clinique. Ces modalités de présentation de l’information ont été étudiées sous l’angle de la théorie de la charge cognitive et de la théorie cognitive de l’apprentissage multimédia. Une série d’études est menée afin de déterminer la manière dont il est préférable de présenter l’information délivrée par les vidéos pour faciliter son apprentissage. Nous avons tout d’abord vérifié que l’association de la segmentation au contrôle du rythme par l’apprenant améliore la qualité de l’apprentissage (expé. 1) et que cet effet positif était bien lié à la segmentation et non au temps d’exposition au matériel pédagogique (expé. 2) ou à la durée des pauses imposées (expé. 3). Enfin, deux autres modalités, permettant d’optimiser encore l’apprentissage, ont été testées. Alors que l’indiçage verbal n’a pas amélioré l’apprentissage (expé. 4), nous avons pu montrer qu’une incitation à faire des pauses lors de la consigne avait un effet positif sur les comportements des apprenants et sur la qualité de l’apprentissage (expé. 5). Les résultats de ces études sont discutés et des perspectives proposées. / Videos are increasingly being used in education. This is also the case in medical and paramedical training and, among other things, in the learning of procedures that will have to be carried out later. Their use can lead to specific difficulties in term of users’ learning processes, owing to the transient nature of the information that is delivered. To cope with potential cognitive overload, learner controls can be provided (e.g., pause button), but novice users’mental models may not be sufficiently relevant for them to know when to halt the video. Thus, the introduction of segmentation, with breaks imposed by the system at each step of the procedure, may be more effective when learning a clinical skill. These information presentation modalities were studied from the perspective of the cognitive load theory and the cognitive theory of multimedia learning. A series of studies is being conducted to determine how it is best to present the information provided by the videos to facilitate learning. We first verified that the combination of segmentation and pacing improves the quality of learning (exp 1) and that this positive effect was related to segmentation and not to the time of exposure to the teaching material (exp 2) or the duration of the imposed breaks (exp 3). Finally, two other modalities, to further optimize learning, were tested. While signaling did not improve learning (exp 4), we were able to show that an incentive to pause during the instruction had a positive effect on learners' behaviors and on the quality of their learning (exp 5). The results of these studies are discussed and perspectives proposed.

<p>Atrial fibrillation is a common disease. With pharmacological therapy most patients with atrial fibrillation have moderate or little symptoms, but a number of patients have severely symptomatic disease. This study evaluates two new non-pharmacological therapies for atrial fibrillation, the Maze procedure and atrial overdrive pacing.</p><p>In the patients planned for Maze surgery the quality of life, assessed with the SF-36 questionnaire, was very low before the operation. The quality of life was markedly improved 6 and 12 months after the Maze operation, and was comparable to values of the general Swedish population.</p><p>In the patients with sinus rhythm before surgery, the atrial size and transport function was assessed with echocardiography, and the autonomic balance was assessed with heart rate variability (HRV). The sizes of both atria were reduced and the transmitral early filling / atrial filling (E/A) ratio was increased at 6 months after the operation compared to before. A progressive increase of the E/A ratio was seen during the 24 months follow-up period, indicating a progressive decline of the left atrial transport function.</p><p>All components of HRV, including the parameters expressing sympathetic and parasympathetic modulation, were markedly decreased early after the Maze procedure compared to before. Late after the operation all components of HRV were still markedly depressed. This is interpreted as a partial autonomic denervation of the heart</p><p>Single-site right atrial overdrive pacing with two different levels of overdriving was compared with no pacing in patients with paroxysmal atrial fibrillation in a cross-over study. Overdrive pacing reduced the median number of episodes of atrial fibrillation with 50% compared to no pacing. There was no difference between medium rate overdrive pacing and high rate overdrive pacing.</p>

Atrial fibrillation is a common disease. With pharmacological therapy most patients with atrial fibrillation have moderate or little symptoms, but a number of patients have severely symptomatic disease. This study evaluates two new non-pharmacological therapies for atrial fibrillation, the Maze procedure and atrial overdrive pacing. In the patients planned for Maze surgery the quality of life, assessed with the SF-36 questionnaire, was very low before the operation. The quality of life was markedly improved 6 and 12 months after the Maze operation, and was comparable to values of the general Swedish population. In the patients with sinus rhythm before surgery, the atrial size and transport function was assessed with echocardiography, and the autonomic balance was assessed with heart rate variability (HRV). The sizes of both atria were reduced and the transmitral early filling / atrial filling (E/A) ratio was increased at 6 months after the operation compared to before. A progressive increase of the E/A ratio was seen during the 24 months follow-up period, indicating a progressive decline of the left atrial transport function. All components of HRV, including the parameters expressing sympathetic and parasympathetic modulation, were markedly decreased early after the Maze procedure compared to before. Late after the operation all components of HRV were still markedly depressed. This is interpreted as a partial autonomic denervation of the heart Single-site right atrial overdrive pacing with two different levels of overdriving was compared with no pacing in patients with paroxysmal atrial fibrillation in a cross-over study. Overdrive pacing reduced the median number of episodes of atrial fibrillation with 50% compared to no pacing. There was no difference between medium rate overdrive pacing and high rate overdrive pacing.

Introduction. Multiple clinical methods for detecting myocardial ischemia are utilised in the hospital setting each day, but there is uncertainty about their diagnostic accuracy. In the operating room, multiple methods may be employed, while in the CCU advanced electrophysiological (ECG) techniques for myocardial ischemia detection, and in particular, ST segment analysis, are common. Vectorcardiography (VCG) is one form of ECG. Several conditions other than ischemia may cause marked ST changes, which can impair the process of diagnosis of clinical ischemia. Elevated HR is one of these factors, which is studied here. The hypotheses were about concordance of different methods to detect ischemia, and relation of ECG ST levels to HR with and without myocardial ischemia. Methods. Study I. Anesthetised vascular surgical patients with coronary artery disease were studied during the start of anesthesia and surgery: ECG, hemodynamic, mechanical, and metabolic parameters were measured and categorised as positive or negative with reference to a specific definition of myocardial ischemia. Study II. Awake patients with no ischemic heart disease were paced in graded steps, and VCG ST analyses were performed. Study III. Anesthetised pigs were studied for local metabolic and VCG ST changes related to controlled HR levels and transient coronary occlusion. Study IV. Thirty five anesthetised coronary artery disease (CAD) patients and ten non-CAD patients were paced at controlled levels, and great coronary artery vein (GCV) lactate measurement was used to determine presence or absence of myocardial ischemia. The CAD patients were paced up to HR levels where myocardial ischemia could be confirmed. The relation of HR-related VCG ST levels to presence or absence of ischemia was analysed. In Studies II,, III, and IV the ST vector magnitude (ST-VM), the change from baseline in ST-VM (STC-VM), and the vector angle change from baseline (STC-VA) were analysed for each step. Results. Study I. Poor concordance was demonstrated for positive events (presumed myocardial ischemia) between the hemodynamic, ECG, mechanical, and metabolic detection methods. Study II. STC-VM but not ST-VM levels demonstrated HR-related increases in the presumed absence of myocardial ischemia in 18 awake subjects. J point time to ST measurement did not affect the response of VCG ST to HR. Study III. STC-VM levels showed HR-related increases in the absence of ischemia (tested by local metabolic observations). VCG ST parameters responded positively to transient regional ischemia. Study IV. CAD patients, which demonstrated a clear pattern of onset and progress of ischemia during pacing, were further analysed for the relation of VCG ST level to ischemia. Sensitivity and specificity of STC-VM levels were described by ROC analysis for a range of STC-VM levels. Conclusions. Concordance of different measures for detection of onset of myocardial ischemia is difficult to assess in the absence of a very reliable reference method. The contribution of HR and ischemia to VCG ST levels were estimated in study subjects. HR-related increases in STC-VM occur in the absence of ischemia. HR levels need to be considered when interpreting STC-VM as a diagnostic test for ischemia. Further study is needed to establish criteria that take into account multiple clinical factors in order to improve the predictive value of our tests for myocardial ischemia.

Orientadores: Jose Wilson Magalhaes Bassani, Rosana Almada Bassani / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia Eletrica e de Computação / Made available in DSpace on 2018-08-15T01:38:31Z (GMT). No. of bitstreams: 1 Fonseca_AlexandraValenzuelaSantelicesda_M.pdf: 1311974 bytes, checksum: ab061a6f8d63a1175d6a3c9281e0704e (MD5) Previous issue date: 2009 / Resumo: O procedimento mais efetivo para reverter arritmias cardíacas consiste na aplicação de choques elétricos de alta intensidade, como e o caso da desfibrilação. Estimulação com campos elétricos (E) elevados, entretanto, exerce efeitos deletérios sobre o músculo cardíaco, podendo causar disfunções elétrica e contrátil e até a morte celular. Privilegiar a estimulação na direção longitudinal, para qual o limiar de excitação das células cardíacas e menor, seria uma forma de se reduzir a amplitude do estimulo sem perder a efetividade da estimulação. Para isto, foi desenvolvido e testado, em miócitos ventriculares orientados de maneira aleatória, um sistema de estimulação multidirecional automática que permite o chaveamento controlado de estímulos sequênciais para três diferentes pares de eletrodos (cada um correspondendo a uma direção) em um intervalo de tempo inferior a duração do potencial de ação (período em que a célula se encontra eletricamente refrataria). A estimulação multidirecional com uma intensidade de E 20% acima do limiar estimulatório (1,2× ETM) dobrou o recrutamento (excitação) de células (80 vs. 40% com estimulação unidirecional, p<0,001). Adicionalmente, o recrutamento com a estimulação multidirecional automática foi maior (p< 0,001) do que a soma dos recrutamentos obtidos com a estimulação em cada direção individualmente (sem intersecção), o que sugere que a estimulação sublimiar durante o procedimento automático pode aumentar a excitabilidade celular. Foi observado também que, para uma dada amplitude do estimulo, o uso da forma de onda bipolar (para a qual o valor de ETM foi menor que para pulsos monopolares: 3,2 ± 0,1 vs. 3,9 ± 0,1 V/cm; p< 0,001) promoveu um recrutamento maior do que com o pulso monopolar (recrutamento de 50% das células foi obtido com 2,97 ± 0,04 e 4,18 ± 0,05 V/cm para pulsos bipolares e monopolares, respectivamente; p< 0,05). A combinação da estimulação multidirecional automática com o uso da forma de onda bipolar permitiu, portanto, uma redução de cerca de 50% no valor do E absoluto (3,8 vs. 7,8 V/cm com estimulação unidirecional e pulso monopolar) para um recrutamento de ~80% das células. A aplicação destes procedimentos na estimulação cardíaca (marcapasso e desfibrilação) pode otimizar o processo, levando a uma melhor eficiência e uma menor incidência de lesão. / Abstract: The most effective procedure to revert cardiac arrhythmias consists in the application of high intensity electric discharge, such as in cardiac defibrillation. Nevertheless, stimulation using high electric fields (E) may cause injury to the cardiac muscle, generating electric and contractile dysfunctions and even cell death. A possible way to reduce the stimulus intensity while maintaining the stimulation effectiveness would be stimulate cardiac cells with E applied parallel to the cell major axis, in which case the stimulation threshold is lower. To test this possibility, a multidirectional stimulation system was developed and tested on randomly-oriented rat ventricular myocytes. The system allows the controlled switching of sequential stimuli delivered to three different pairs of electrodes (each one corresponding to one direction), in a period shorter than the action potential duration (when cell is electrically refractory). The multidirectional stimulation with E intensity 20% above the stimulation threshold (1.2× ETM) doubled the percentage of recruited (excited) cells (~80 vs. ~40 % with unidirectional stimulation, p<0.001). Additionally, recruitment with automatic multidirectional stimulation was greater (p< 0.001) than the sum of recruitments obtained from stimulation of each direction individually (without intersection), which is suggestive that subthreshold stimulation during the automatic procedure might enhance cell excitability. Moreover, it was observed that for a given absolute stimulus amplitude, the use of biphasic waveforms (for which ETM was lower than for monophasic pulses: 3.2 ± 0.1 vs. 3.9 ± 0.1 V/cm; p< 0.001) promoted higher recruitment than monophasic stimuli (50% recruitment was attained with 2.97 ± 0.04 and 4.18 ± 0.05 V/cm with biphasic and monophasic pulses, respectively; p< 0.05). Thus, the association of automatic multidirectional stimulation and biphasic waveform enabled a 50% reduction of the absolute E value (3.8 vs. 7.8 V/cm with unidirectional stimulation and monopolar pulse) to evoke excitation in ~80% of the cells. The application of these procedures to cardiac stimulation (pacemaker and defibrillation) might optimize the process, leading to greater efficiency and lower injury incidence. / Mestrado / Engenharia Biomedica / Mestre em Engenharia Elétrica