Software testing, specifically in the medical device field, has become increasingly complex over the last decade. Technological enhancements to simulate clinical scenarios and advancements in communicating to medical devices have created the need for better testing strategies and methodologies. Typical medical device companies have depended on manual testing processes to fulfill Food and Drug Administration (FDA) submission requirements specifically Class III devices which are life supporting, life sustaining devices. At St. Jude Medical, software testing of Class III devices such as implantable cardioverter-defibrillators (ICDs), pacemakers, and pacing analyzers are given top priority to ensure the highest quality in each product. High emphasis is made on improving software testing for ease of use and for catching more software errors in each device. A significant stride in testing has automated the process and has provided software verification teams with the tools they need to successfully test and deliver high quality products. By creating software libraries which interact with communication to the other interfaces needed to test medical devices, test engineers can focus on fully testing device requirements and will not be concerned with how each test will interact with the device or any other testing tools. The main focus will be a specific St. Jude Medical device known as the Pacing System Analyzer (PSA). The PSA device will be used to demonstrate how verification engineers are able to benefit from software libraries and allow the testing process and test development to be fully automated. New technologies and standards will be created to simulate clinical scenarios and to communicate to new devices. The goal is to use software engineering principles to create standard test libraries which sustain these changes while still allowing testers to focus on finding issues for each device.

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Vorhofflimmern ist die häufigste behandlungsbedürftige Herzrhythmusstörung. Die Erhöhung des Schlaganfallrisikos, die Einschränkung der Herzleistung und nicht zuletzt ein Verlust an Lebensqualität sind bedeutsame Folgen dieser Erkrankung. Bisherige pharmakologische Therapieansätze sind insbesondere beim paroxysmalem Vorhofflimmern nur von unzureichender Wirkung, so dass in letzter Zeit nicht-pharmakologische Therapieoptionen untersucht werden. Elektrophysiologische und klinische Untersuchungen legen nahe, dass bifokale rechtsatriale Schrittmacherstimulation die Rezidivhäufigkeit von paroxysmalem Vorhofflimmern senken kann. In der DUSTI-Studie (DUal-site STImulation for prevention of paroxysmal atrial fibrillation) wurde untersucht, ob bifokale atriale Überstimulation die Rezidivhäufigkeit gegenüber unifokaler Überstimulation und lediglich antibradykarder Stimulation senken kann. Hierzu wurden 19 Patienten (61 ± 12 Jahre, 13 männlich) mit paroxysmalem Vorhofflimmern und einer Indikation zur Schrittmacherimplantation in eine prospektive, einfach-blinde, randomisierte Cross-over-Studie eingeschlossen. Ein herkömmlicher Zwei-Kammer-Schrittmacher, eine ventrikuläre Sonde und zwei über einen Y-Konnektor verbundene rechtsatriale Sonden, eine septal, die andere lateral wurden implantiert. Alle Patienten wurden zunächst 12 Wochen durch Programmierung einer Interventionsfrequenz von 50/min möglichst wenig atrial stimuliert. Danach wurden alle Patienten möglichst immer atrial stimuliert (Überstimulation mit 10/min über der Eigenfrequenz), in zufälliger Reihenfolge 12 Wochen bifokal (septal und lateral) und 12 Wochen unifokal (septal oder lateral). Unter bifokaler Stimulation war die Vorhofflimmerlast ebenso groß wie unter unifokaler Stimulation (6,20% ± 9,91% vs. 6,15% ± 11,09%, Intention-to-treat-Analyse) In den Überstimulationsphasen zeigte sich ein Trend zur Abnahme der Vorhofflimmerlast gegenüber der Phase mit geringen atrialen Stimulationsraten (6,15% ± 10,32% vs. 8,84% ± 11,34%, p=0,09, Intention-to-treat-Analyse). Hinsichtlich der Anzahl der Vorhofflimmerepisoden, der Zeit bis zum Vorhofflimmerrezidiv und der Symptomatik fanden sich signifikante Unterschiede weder zwischen uni- und bifokaler Stimulation, noch zwischen Überstimulation und geringer atrialer Stimulation. Die verwendeten Methoden waren gut durchführbar und sicher. Die schrittmacherbasierte Vorhofflimmerdiagnostik erwies sich, vor allem durch die zusätzliche atriale Elektrode, als technisch kompliziert und teilweise fehlerbehaftet. In einem nicht selektierten Patientenkollektiv ist die bifokale rechtsatriale Schrittmacherstimulation zur Rezidivprophylaxe des paroxysmalen Vorhofflimmerns nicht besser geeignet als unifokale Stimulation. Der höhere Aufwand der Implantation einer zweiten atrialen Sonde scheint nicht gerechtfertigt. Andere Studien müssen zeigen, ob bestimmte Patienten-Subgruppen von der bifokalen rechtsatrialen Stimulation profitieren / Atrial fibrillation is the most common sustained cardiac arrhythmia. It substantially increases the risk of stroke, impairs cardiac output and may lower the quality of life. Because pharmacotherapeutic approaches often yield unsatisfactory results - especially with paroxysmal atrial fibrillation, various non-pharmacological therapies have been studied. Electrophysiological and clinical research suggests, that dual-site atrial stimulation may suppress paroxysms of atrial fibrillation. The DUSTI trial was designed to test the hypothesis that dual-site stimulation prevents atrial fibrillation better than single-site stimulation or support pacing. Nineteen patients (61 ± 12 years, 13 male) with paroxysmal atrial fibrillation and a standard indication for pacemaker implantation were included in a prospective, single-blinded, randomized cross-over-trial. A conventional dual-chamber pacemaker with one ventricular and two atrial leads was implanted. Atrial leads were placed at the atrial septum and at the right atrial wall, and connected via a Y-connector to the atrial port. For the first twelve weeks patients only received support pacing (at 50 bpm). Afterwards patients received continuous atrial pacing (at 10 bpm above the intrinsic heart rate), 12 weeks dual-site pacing (septal and lateral) and 12 weeks single-site pacing (septal or lateral) in random order. Atrial fibrillation burden was the same between dual-site pacing and single-site pacing (6.20% ± 9.91% vs. 6.15% ± 11.09%, intention-to-treat-analysis). A trend towards less atrial fibrillation with continuous pacing compared to support pacing was observed (6.15% ± 10.32% vs. 8.84% ± 11.34%, p=0.09, intention-to-treat-analysis). There was no significant difference in number of atrial fibrillation episodes, time to recurrence and symptoms, neither between dual- and single-site pacing, nor between continuous and support pacing. Dual-site pacing proved to be feasible and safe. The detection of atrial fibrillation by the pacemaker''s diagnostic algorithms was, however, troubled by the additional atrial lead. Dual-site pacing offers no further advantage to single-site pacing for prevention of atrial fibrillation recurrences in unselected patients. The implantation of an additional atrial lead in patients with paroxysmal atrial fibrillation, requiring a pacemaker, seems to be not justified. Future trials will investigate whether certain subgroups of patients will benefit from dual-site atrial pacing.

Le nombre d'adultes porteurs de cardiopathies congénitales, de plus en plus sévères est constante progression. A moyen voire long terme certain d’entre eux posent des problèmes d’insuffisance cardiaque et de troubles du rythme parfois létaux. La physiologie de ces complications est multi factorielle et s’écarte souvent des schémas habituels. L’asynchronisme ventriculaire présentent chez un nombre important d’entre eux est connu pour favoriser un remodelage ventriculaire conduisant à l’insuffisance cardiaque sur cœur sain.Dans ce travail en couplant données expérimentales animales et études cliniques, nous avons étudié : 1) l’impact aigu puis chronique de la resynchronisation biventriculaire sur un modèle animal d’insuffisance cardiaque droite mimant la tétralogie de Fallot et sur une population de patients ; 2) le rôle et la conséquence d’une stimulation conventionnelle sur une physiologie de ventricule droit systémique ; 3) l’effet délétère de la stimulation VD prolongée sur un modèle de cœur animal en cours de développement.Nous avons appris que 1) la resynchronisation biventriculaire permet un bénéfice hémodynamique significatif chez l’animal mais aussi sur une population de Fallot implantées ; 2) que l’asynchronisme généré par la stimulation conventionnelle est délétère pour la fonction du ventricule systémique mais aussi pour le cœur de l’enfant en cours développement. La resynchronisation est un traitement prometteur pour traiter l’insuffisance cardiaque mais pourrait aussi l’être pour en prévenir sa survenue. De nouvelles techniques d’implantation nous permettent aujourd’hui d’implanter des patients qui présentent beaucoup d’obstacles anatomiques et d’éviter nombre de complications grave de la stimulation. / The number of adults with severe congenital heart disease is constantly growing. At medium to long-term follow up, these patients may present with heart failure or conduction disorders, which may lead to death. The pathophysiology and clinical course of these complications is multi-factorial and may be different from that in patients without congenital heart disease. In normal hearts, electromechanical dyssynchrony is known to induce ventricular remodeling and heart failure. Ventricular asynchrony is also present in a substantial number of adults with congenital heart disease. In this study, we combined animal experiments and clinical studies to investigate: 1) the acute and chronic effect of biventricular resynchronization therapy on cardiac function in an animal model mimicking right ventricular heart failure in Tetralogy of Fallot, as well as in patients with Tetralogy of Fallot; 2) the consequences of conventional ventricular pacing in patients with ‘systemic right ventricle physiology’; 3) the effects of chronic right ventricular pacing in an animal model of the developing heart.We found that: 1) biventricular resynchronization induces significant hemodynamic benefit in the animal model of Tetralogy of Fallot as well as in Fallot patients; 2) ventricular asynchrony induced by conventional ventricular pacing is deleterious to the function of the systemic right ventricle; 3) chronic right ventricular pacing is harmful to the developing (pediatric) heart with normal biventricular anatomy. Cardiac resynchronization therapy is promising as a treatment for heart failure, but may also prevent heart failure. Nowadays, new implantation techniques allow us to implant pacing devices in patients with limited anatomical access due to prior surgery and help to avoid numerous severe complications of conventional pacing therapy

Master of Science / Department of Computing and Information Sciences / John Hatcliff / The Heart is a specialized muscle that contracts regularly and continuously, pumping blood to the body and the lungs. Heart’s natural Pacemaker, the SA node is responsible for this pumping action by causing a flow of electricity through the heart. These electrical impulses cause the atria and ventricles to contract and thereby pump the blood to different parts of the body. Malfunction of the SA node leads to a disturbance in the heart’s rhythm in which heart beats lower than 60 times a minute ending up with Bradycardia. It also leads to ventricular arrhythmia which disrupts the ability of the ventricles to pump blood effectively to the body. This can cause a loss of all blood pressure leading to cardiac arrest and eventually death. In order to restore the heart’s natural healthy rhythm, an artificial pacemaker is necessary. A Pacemaker adapts to the present condition of the heart and responds to the heart by either pacing or just sensing it. It paces whenever there is some problem in the heart’s electrical activity and inhibits the pace when there is a proper intrinsic beat. There are various modes in which Pacemaker can operate based on the condition of the heart. Ventricles and atria are individually paced in few modes such as VOO, VVT, VVI, AOO, AAT, and AAI and paced together in some modes such as DVI, DI, DDD, DDDR as per the requirement of the heart. The main goal of this report is to understand the various modes, their nomenclature, working strategy, developing the pseudo code and implementing different modes namely VOO, AOO, VVI, AAI, VVT and AAT modes using an academic, dual chamber pacemaker.

This thesis is devoted to the optimization of pacing strategies in two locomotive endurance sports; cross-country skiing and road cycling. It has been established that constant pace and variable power distributions are optimal if purely mechanical aspects of locomotion are considered in these sports. However, there is a lack of research that theoretically investigates optimal pacing for real world athletes who are constrained in their ability to generate power output through the bioenergetics of the human body. The aims of this thesis are to develop numerical pacing strategy optimization models and bioenergetic models for locomotive endurance sports and use these to assess objectives relevant in optimal pacing. These objectives include: Investigate the impact of hills, sharp course bends, ambient wind, and bioenergetic models on optimal pacing and assess the effect of optimal pacing strategies on performance. This thesis presents mathematical models for optimization of pacing strategies. These models are divided into mechanical locomotion, bioenergetic, and optimization models that are connected and programmed numerically. The locomotion and bioenergetic models in this thesis consist of differential equations and the optimization model is described by an iterative gradient-based routine. The mechanical model describes the relation between the power output generated by an athlete and his/her locomotion along a course profile, giving the finishing time. The bioenergetic model strives to mimic the human ability to generate power output. Therefore, the bioenergetic model is set to constrain the power output that is used in the mechanical locomotion model. The optimization routine strives to minimize the finishing time in the mechanical locomotion model by varying the distribution of power output along the course, still satisfying the constraints in the bioenergetic model. The studies contained within this thesis resulted in several important findings regarding the general application of pacing strategies in cross-country skiing and road cycling. It was shown that the constant pace strategy is not optimal if ambient conditions change over the course distance. However, variable power distributions were shown beneficial if they vary in parallel with course inclination and ambient winds to decrease variations in speed. Despite these power variations, speed variations were not eliminated for most variable ambient conditions. This relates to the athlete’s physiological restrictions and the effect of these are hard to predict without thorough modeling of bioenergetics and muscle fatigue. Furthermore, it vi was shown that substantial differences in optimal power distributions were attained for various bioenergetic models. It was also shown that optimal braking and power output distributions for cycling on courses that involve sharp bends consisted of three or four phases, depending on the length of the course and the position of the bends. The four phases distinguished for reasonably long courses were a steady-state power phase, a rolling phase, a braking phase, and an all-out acceleration phase. It was also shown that positive pacing strategies are optimal on relatively long courses in road cycling where the supply of carbohydrates are limited. Finally, results indicated that optimal pacing may overlook the effect of some ambient conditions in favor of other more influential, mechanical or physiological, aspects of locomotion. In summary, the results showed that athletes benefit from adapting their power output with respect not only to changing course gradients and ambient winds, but also to their own physiological and biomechanical abilities, course length, and obstacles such as course bends. The results of this thesis also showed that the computed optimal pacing strategies were more beneficial for performance than a constant power distribution. In conclusion, this thesis demonstrates the feasibility of using numerical simulation and optimization to optimize pacing strategies in cross-country skiing and road cycling. / Avhandlingen handlar om optimering av farthållningsstrategier inom längdskidåkning och landsvägscykling. Det finns ett utbrett stöd för att konstant fart och varierande effektfördelningar är optimala om endast mekaniska aspekter beaktas i dessa sporter. Ändå saknas teoretiska studier som undersöker optimal farthållning för verkliga idrottsutövare som är begränsade i sin förmåga att generera effekt genom kroppens bioenergetiska system. Målen med den här avhandlingen är att utveckla metoder för bioenergetik och optimering av farthållningsstrategier i uthållighetsidrott. Dessutom är målet att undersöka påverkan av backar, svängar, omgivande vind och bioenergetisk modellering på den optimala farthållningsstrategin samt att utreda potentialen till prestationsförbättring med optimala farthållningsstrategier. Avhandling presenterar matematiska modeller för optimering av farthållningsstrategier. Dessa modeller delas in i en mekanisk modell för förflyttning, en bioenergetisk modell och en optimeringsmodell. De mekaniska och bioenergetiska modellerna som presenteras i avhandlingen består av differentialekvation och optimeringsmodellen utgörs av en gradient-baserad algoritm. Den mekaniska modellen beskriver förhållandet mellan utövarens effekt och den resulterande rörelsen längs banan som ger tiden mellan start och mål. Den bioenergetiska modellen beskriver människokroppens olika energisystem och dess begränsningar att generera effekt. Den bioenergetiska modellen interagerar med optimeringsmodellen genom att utgöra dess begränsningar för vad den mänskliga kroppen klarar av. Sammanfattningsvis försöker optimeringsmodellen minimera tiden mellan start och mål i den mekaniska modellen genom att variera effekten längs banan. Samtidigt ser optimeringsmetoden till att denna effektfördelning inte kränker den bioenergetiska modellen. Studierna som ingår i avhandlingen resulterade i flera viktiga upptäckter om generella tillämpningar av farthållningsstrategier inom längdskidåkning och landsvägscykling. Det visade sig att konstant fart inte är optimalt om omgivande betingelser varierade längs banans sträckning. Däremot var varierande effektfördelning fördelaktig om den varierar parallellt med banlutning och omgivande vindpåverkan för att minska fartens variationer. Trots denna variation, visade resultaten att fartvariationerna inte eliminerades helt. Detta har att göra med utövarens fysiologiska begränsningar, vars påverkan är svår att förutspå utan genomgående modellering av bioenergetik relaterat till muskeltrötthet. Dessutom viii visade resultaten att olika bioenergetiska metoder gav upphov till betydande skillnader i de optimala farthållningsstrategierna. Resultaten i avhandlingen visade också att optimal effektfördelning vid kurvtagning i landsvägscykling innehåller tre eller fyra faser. The fyra faser som var utmärkande på relativt långa banor var en tröskelfas, en rullfas, en bromsfas och en maximal accelerationsfas. Resultaten visar också att positiv farthållning är optimal på relativt långa banor i landsvägscykling där tillgången på kolhydrater är begränsad. Samtidigt visade resultaten på optimala farthållningsstrategier ibland att inverkan av omgivande betingelser förbisågs till fördel för med inflytelserika betingelser som påverkar framdrivningen. Sammantaget visar resultaten i denna avhandling att utövare gagnas av att anpassa effekten med hänsyn till varierande terräng, omgivande vind, atletens egen fysiologiska och biomekaniska förmåga, banans längd och hinder såsom kurvor. Resultaten visar också att de optimala farthållningsstrategier med varierande effektfördelning som beräknats i denna avhandling förbättrar prestationen jämfört med konstanta effektfördelningar. Sammanfattningsvis visar denna avhandling på möjligheterna att använda numerisk simulering och optimering för att optimera farthållningsstrategier i längdskidåkning och landsvägscykling. / <p>Vid tidpunkten för disputationen var följande delarbeten opublicerade: delarbete 5 accepterat, delarbete 6 manuskript.</p><p>At the time of the doctoral defence the following papers were unpublished: paper 5 accepted, paper 6 manuscript.</p>

La variabilité des mouvements humains est caractérisée par la présence de corrélations à long-terme, ou fluctuations fractales. Cette propriété est associée à des états sains et optimaux, tandis que les états non-optimaux sont associés avec une perte des corrélations à long-terme, devenant plus périodique ou plus aléatoire. Les métronomes isochrones sont largement utilisés pour guider le pas dans des protocoles de réhabilitation de la marche, mais leur utilisation modifie la dynamique des séries de pas qui ne présentent plus de corrélations à long-terme (persistantes) mais deviennent anti-persistante (i.e., corrélations négative). Des hypothèses récentes suggèrent que la synchronisation avec un environnement fractal pourrait induire un appariement de la structure temporelle de l'organisme avec la structure temporelle de l'environnement. L'objectif de cette thèse était de tester des stratégies de synchronisation alternatives préservant la nature fractale des séries temporelles. Différentes expérimentations ont été mises en places, impliquant des coordinations interpersonnelles, de la synchronisation avec des métronomes fractals et du « guidage humain ». De manière générale, nos résultats montrent que les séries comportementales des participants étaient corrélée à celle de l'environnement seulement si celui-ci présente des fluctuations fractales. Les résultats de nos modélisations suggèrent également que les métronomes isochrones et non-isochrones impliquent des réactions comportementales fondamentalement différentes. Nos résultats présentent des perspectives cliniques puisque l'élaboration de protocoles de réhabilitation de la marche utilisant des environnements fractals pourrait permettre de préserver les corrélations à long-terme, marqueurs d'adaptabilité du comportement. / Human movements variability is characterized by the presence of long-range (fractal) correlations. This feature is associated with optimal, healthy states while non-optimal states are associated with a loss of long-range correlations, toward more periodicity or more randomness. Isochronous pacing is widely used for gait rehabilitation, but changes the stride time dynamics from persistent long-range correlations to anti-persistent (negative) correlations. It has been recently argued that synchronization with fractal environment could induce a matching between the organism structure and the environmental structure. The aim of this thesis was to test alternatives pacing strategies preserving the fractal nature of stride time series. Different sets of experiments were run, involving interpersonal coordination, synchronization with non-isochronous metronomes and “human pacing”. Overall our results show that the time series produced by participants were correlated to those of the environment only if the environment presented fractal fluctuations. Our models suggest that isochronous and non-isochronous metronomes imply fundamental different behaviours. Our results have clinical perspectives because the use of fractal environment in rehabilitation protocols could help to preserve long-range correlations, a hallmark of behavioural adaptability.

Introdução: A realização do exame de ressonância magnética (RM), classicamente contraindicada aos portadores de dispositivo cardíaco eletrônico implantável (DCEI), passou a ser factível com a introdução dos recentes dispositivos condicionais para RM. Estes demonstraram superior grau de segurança na realização da RM, mas pouco se sabe sobre a qualidade e a capacidade diagnóstica das imagens obtidas no exame. Estas podem ser distorcidas pela presença do DCEI, sobretudo no que se refere ao cardioversor desfibrilador implantável (CDI), cuja quantidade de material ferromagnético é relevante. Objetivo: avaliar a qualidade e a capacidade diagnóstica da imagem de da RM cardíaca de 1,5 Tesla em portadores de CDI condicional. Método: Estudo piloto incluindo portadores de CDI condicional submetidos a RMC prévia (RMC1). Todos os pacientes realizaram exame de RMC pós-implante (RMC2), com protocolo específico de sequências de pulso utilizadas para cineressonância, realce tardio, perfusão miocárdica, mapa T1, mapa de fluxo, avaliação anatômica e de edema miocárdico. Todos foram submetidos à avaliação eletrônica do CDI, pré e pós RMC2, que constou de: medida do limiar de estimulação e sensibilidade, da impedância dos cabos-eletrodo e de choque, assim como da carga da bateria. Três especialistas avaliaram a qualidade das imagens de RMC, pré e pós-implante do CDI, que foram pontuadas por Escala de Likert. Esta gradua de 1 a 5 o impacto do artefato de imagem e a capacidade diagnóstica do exame. Para as imagens obtidas por múltiplos cortes a mesma pontuação foi utilizada para cada segmento do VE (segmentação da American Heart Association - AHA). A capacidade diagnóstica foi expressa, em percentual, pela taxa diagnóstica (sendo considerada diagnóstica pontuação maior ou igual a 3). Resultados: Foram estudados 22 pacientes submetidos a implante CDI condicional no período de agosto/2016 a abril/2018. Todas as imagens da RMC1 tiveram alta pontuação (3 a 5, m= 4,7) na escala de Likert. Por outro lado, em todos os exames da RMC2 ocorreram artefatos de suscetibilidade, sendo que as paredes anterior e lateral do VE foram mais afetadas. A pontuação média segmentar e respectivas taxas de imagens diagnósticas foram: 3,1 pontos e 82,32% para CINE SSFP; 1,74 e 27,80% para RT; 2,08 e 30,4% para perfusão miocárdica. As taxas de imagens diagnósticas obtidas nas aquisições por corte único foram: 0% para o mapa T1; 77,3% para avaliação anatômica (double e triple anatômico); 68,2% mapa de fluxo e 9,0% para avaliação do edema. Conclusão: Em portadores de CDI condicional, a qualidade das imagens e a capacidade diagnóstica do exame de RMC estão comprometidas por artefatos de suscetibilidade, presentes, sobretudo, nas paredes anterior e lateral de VE. Em particular a técnica de realce tardio, uma das mais importantes na RMC para diagnóstico de cardiomiopatias, demonstrou reduzida taxa diagnóstica, apontando a necessidade de novas técnicas para a detecção de fibrose/lesão miocárdica pela RMC. De forma geral, esses achados sugerem que é necessário realizar investigações adicionais, visando otimizar qualidade de imagem e capacidade diagnóstica da RMC nos portadores de CDI condicional / Introduction: Magnetic resonance imaging (MRI), which is classically contraindicated in patients with cardiac implantable electronic device (CIED), became feasible with the introduction of the recent MRI conditional devices. These have been proven to be safer, but little is known about the quality and diagnostic capacity of the acquired images, which can be distorted by the presence of CIED, especially with regard to the implantable cardioverter defibrillator (ICD), whose quantity of ferromagnetic material is relevant. Objective: to evaluate the quality and diagnostic value of the images acquired by cardiac MR in patients with conditional ICD. Method: Pilot study of patients with MR conditional ICD who were submitted to previous CMR (CMR1). All patients underwent an another CMR after ICD implantation (CMR2), under specific protocol of pulse sequences used for cine-resonance, late enhancement, myocardial perfusion, T1 mapping, anatomic and myocardial edema evaluation, and flow map. All patients underwent ICD electronic interrogations, immediate pre and post CMR2 measurements of battery voltage, capture thresholds, sensing, lead and shock impedance. Three specialists evaluated the quality of CMR images, pre and post implantation of ICD, which were scored by the Likert Scale. This graded measure from 1 to 5 the impact of the imaging artifact and the diagnostic ability of the examination. For the images acquired by multiple slices the same score was used for each left ventricule (LV) segment (American Heart Association - AHA criteria). Results: We studied 22 patients submitted to MR conditional ICD implantation. CMR1 had a high score (3 to 5, m = 4.7) on the Likert scale. On the other hand, in all CMR2 exams, there were artifacts of susceptibility, and the anterior and lateral LV walls were more affected. The mean segmental score and respective diagnostic image rates were: 3.1 points and 82.32% for Cine SSFP; 1.74 and 27.80% for LGE; 2.08 and 30,4% for myocardial perfusion. The rates of diagnostic images obtained in the single slice acquisition were 0% for T1 mapping; 77.3% for anatomical evaluation (double and triple anatomic); 68.2% for flow map and 9.0% for myocardial edema evaluation. Conclusion: In patients with MR conditional ICD, the quality of the images and the diagnostic capacity of the CMR examination are compromised by susceptibility artifacts, present mainly in the anterior and lateral LV walls. These findings suggest that further research is needed to optimize image quality and diagnostic capacity of CMR in patients with MR conditional ICD

L’objectif de ce travail de thèse a été d’analyser les stratégies de réduction de la fatigue musculaire en course de trail et potentiellement d’identifier certains paramètres d’influence de cette fatigue. La course de trail est un nouveau sport en essor qui induit une combinaison spécifique de fatigue et dommages musculaires des principaux muscles locomoteurs. Afin de pouvoir conduire des études interventionnelles, une étude descriptive préliminaire a été conduite pour caractériser la fatigue spécifique et les dommages musculaires induits par ce type d’épreuve de trail. Ensuite, la reproductibilité du trail comme modèle de fatigue a été vérifiée afin de pouvoir l’utiliser dans un contexte d’intervention. Enfin, deux études visant à réduire la fatigue induite par le trail ont été conduites. D’une part l’utilisation des vêtements de compression - très à la mode en trail a été analysée comme stratégie d’optimisation de la performance. D’autre part, a aussi été étudié l’effet d’un réchauffement préalable du muscle sur les dommages musculaires : Dans cette optique, une étude contrôlée en laboratoire a été menée, examinant les effets d’un réchauffement passif sur les conséquences fonctionnelles de course en descente chez une population non-entraînée. En résumé, les travaux conduits au sein de cette thèse fournissent une description de la fatigue en trail, et valident l’utilisation du trail comme modèle reproductible de terrain pour investiguer les stratégies de réduction de la fatigue. De plus, ils relativisent l’effet positif des vêtements de compression sur la performance et montrent le lien fonctionnel entre le réchauffement musculaire et la réduction des dommages musculaires induits par un travail excentrique. / The aim of this thesis was to analyse strategies to reduce muscular fatigue in trail running and potentially draw conclusions on the underlying mechanisms. Trail running is a new and upcoming sport that induces a combination of fatigue and muscle damage in the main locomotor muscles. To obtain conclusive evidence on the effect of intervention studies a preliminary descriptive study was undertaken to characterise typical fatigue and damage. Subsequently a model was developed and validated that would allow the investigation of interventions in an applied field setting. A popular current strategy in trail running is the use of compression garments; therefore the effect of these on performance was studied as an intervention. Furthermore, prior heating is anecdotally considered beneficial and recent research has suggested a potential mechanism to link this with reduced muscle damage. Therefore a controlled laboratory study was conducted, examining the effects of passive heating on functional consequences of downhill running in an untrained population. In synopsis, the research conducted for this thesis provides descriptive evidence and a validated terrain model to further investigate fatigue reduction strategies in trail running. Additionally it adds to the current literature in disproving a positive effect of compression garments on performance and demonstrating the functional link between heating and eccentric-induced muscle damage reduction.