Edge-to-edge Research Articles

Effects of water chemistry on microfabric and micromechanical properties evolution of coastal sediment: A centrifugal model study

Water chemistry alteration induced strength weakening of natural sediment, which leads to the differential settlement of infrastructures in coastal areas, has caused numerous disasters and engineering failures. To thoroughly understand the underlying mechanisms of how water chemistry influences the microfabric and mechanical properties evolution of coastal sediments, herein, the authors adopted centrifuge test, X-ray diffraction (XRD), and atomic force microscope (AFM) to quantitatively study the structure anisotropy index (i.e., orientation index (OI)), micromorphological property (i.e., root mean square height (Sq)), and micromechanics (i.e., microscale apparent modulus) of clay sediments in different water chemistry conditions and gravity gradients. The results show that the change rule of OI is: OIsaline > OIalkaline > OIwater > OIacid, along the vertical sedimentary depth. Randomly distributed clay flocs and loose flocculated soil skeleton (mainly consisted by edge-to-face (EF) and edge-to-edge (EE) contact of the kaolinite platelets) are associated with the acidic water chemical conditions. The action of supergravity and face-to-face (FF) repulsive contact mode lead to high degree of anisotropy of kaolinite sediments in alkaline environment. Clay platelets are compacted closely under the synergetic effect of centrifugal pressure and prevailing van der Waals attraction (reduction of electric double layer repulsion) in saline environment. The change of 1/Sq is highly consistent with the change of OI at different depths in different water chemical environments. Along the sedimentary depth (i.e., transition from the normal gravity (1 g) to supergravity (8000 g)), the microscale apparent modulus of kaolinite sediment was found to be the highest in alkaline environment. As the water chemistry changes from alkaline to acidic, however, the microscale apparent modulus of kaolinite aggregate decreased, and it showed the smallest in the saline environment.

Hospitalizations and Mortality in Patients With Secondary Mitral Regurgitation and Heart Failure: The COAPT Trial

BackgroundThe impact of transcatheter edge-to-edge repair (TEER) on the rate and prognostic impact of hospitalizations in patients with heart failure (HF) and severe secondary mitral regurgitation is unknown. ObjectivesThis study sought to evaluate the effect of the MitraClip percutaneous edge-to edge repair system on fatal and nonfatal hospitalizations and their relationship with mortality in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial. MethodsPatients with HF (n = 614) with severe secondary mitral regurgitation were randomized to TEER plus guideline-directed medical therapy (GDMT) versus GDMT alone. Hospitalizations were classified as fatal if death occurred during that hospitalization or nonfatal if the patient was discharged alive. ResultsAt 2 years, TEER treatment, compared with GDMT alone, resulted in lower time-to-first-event rates of any heart failure hospitalization (HFH) (34.8% vs 56.4%; HR: 0.51; 95% CI: 0.39-0.66) and fatal HFH (6.5% vs 12.6%; HR: 0.47; 95% CI: 0.26-0.85). TEER also resulted in lower rates of all-cause nonfatal and fatal hospitalizations. During the 2-year follow-up period, patients who underwent TEER spent an average of 2 more months alive and out of the hospital than did patients treated with GDMT alone (581 ± 27 days vs 519 ± 26 days; P = 0.002). All HFHs (adjusted HR: 6.37; 95% CI: 4.63-8.78) and nonfatal HFHs (adjusted HR: 1.78; 95% CI: 1.27-2.49) were consistently independently associated with increased 2-year mortality in both the TEER and GDMT groups (Pinteraction = 0.34 and 0.39, respectively). ConclusionsIn the COAPT trial, compared with GDMT alone, patients with HF and severe secondary mitral regurgitation undergoing TEER with the percutaneous edge-to edge repair system had lower 2-year rates of fatal and nonfatal all-cause hospitalizations and HFH and spent more time alive and out of the hospital. HFHs were strongly associated with mortality, irrespective of treatment. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] and COAPT CAS [COAPT]; NCT01626079)

Edge-to-Edge Technique Used as a Bailout for Suboptimal Mitral Repair: Long-term Results

BackgroundFor cases of initial suboptimal mitral valve repair, the edge-to-edge (EE) technique has been used as a bailout procedure. However the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long-term clinical and echocardiographic results of the EE technique used to rescue patients with initial suboptimal conventional mitral valve repair. MethodsA retrospective review of our institutional database was done to query for patients who had undergone mitral valve repair with the EE technique used as a bailout procedure. The cumulative incidence function using death as a competing event was used to estimate cardiac death and redo for mitral valve replacement. To describe the time course of mitral regurgitation, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data. ResultsEighty-one patients were selected. The median follow-up was 9.1 years (interquartile range, 6.7-12.1; maximum, 22.6 years). At 15 years the estimated Kaplan-Meier overall survival was 63.2% ± 8.69% (95% confidence interval, 43.76-77.46) and the predicted rate of moderate to severe mitral regurgitation recurrence was 16.67%. At 15 years the cumulative incidence function for redo for mitral valve replacement with death as a competing event was 2.5% (95% confidence interval, 0.48-7.84). No case of more than mild mitral stenosis was detected. ConclusionsThe EE technique can be effectively used as a bailout procedure in patients with suboptimal conventional mitral valve repair with satisfactory long-term results.

The impacts of high salinity and polymer properties on dewatering and structural characteristics of flocculated high-solids tailings

In seeking to better understand the inline flocculation technique for enhanced water recovery from concentrated fine-particle suspensions, polymers of different molecular weight (MW) and chemistry were used to treat a synthetic tailings slurry in a low-shear mixer for continuous flocculation under controlled conditions. The effects of dissolved salts in the slurry and polymer solution make-up water on dewatering performance were evaluated for conventional acrylamide/acrylate copolymers (BASF Magnafloc® products) and an alternative functional chemistry polymer (BASF Rheomax® DR 1050). The properties of the separated liquid and solid phases were examined to understand the impacts of salinity and polymer type on the formation of rapidly dewatering flocculated material. Higher concentrations of NaCl (0.006–0.6 M) and CaCl2 (0.006–0.06 M) salts in the unflocculated slurries formed larger coagulated structures, with focussed beam reflectance measurement (FBRM) showing greater pre-aggregation for the divalent salt. NaCl slurries show edge-to-edge (EE) and edge-to-face (EF) inter-particle associations that are open and easily disrupted while more compact face-to-face (FF) contacts are observed in CaCl2 slurries. For concentrated NaCl slurries, the dosing of medium-to-high MW polymers is generally preferred to maximise net water recovery, with the implication being that bridging mechanisms are still at play in high solids applications. In calcium-enriched slurries, the lower MW conventional copolymer gave comparatively better water returns than the other polymers when applied under low shear conditions, highlighting quite distinct aggregation processes compared to low solids flocculation. These results provide insight on the fundamental complexity of the ionic strength dependence of high solids-high dosage tailings flocculation, towards informing reagent polymer dosing and offering greater flexibility for end-of-pipe dewatering schemes.

Prevalence of cardiac amyloidosis in patients undergoing transcatheter edge-to edge mitral valve repair

Abstract Introduction Cardiac amyloidosis (CA) is associated with severe aortic stenosis, however, its prevalence in patients with severe mitral regurgitation in elderly patients is unknown. Methods Patients scheduled for transcatheter edge-to edge mitral valve repair (TMVR) were prospectively screened for CA using 99m technetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy and subsequent serum as well as urine free light-chain quantification in case of a positive DPD scan, defined as visual cardiac update based on the Perugini grading scale. Results Out of 100 patients undergoing TMVR, 28 patients (28.0%) had a positive DPD-scan (DPD+). 14 patients (14.0%) showed Perugini grade I enhancement, 9 patients (9.0%) grade II enhancement, and in 5 patients (5.0%), grade III enhancement was present. 28 patients suffered from TTR and two from AL- amyloidosis (one patient had a combination of TTR and AL-amyloidosis). When compared to patients with a negative scan (DPD-), DPD+ patients presented with similar baseline characteristics such as age (DPD- vs DPD+ 76y/o vs 77y/o, p=0.44), gender (female; 62.7% vs 50.0%, p=0.25), coronary artery disease (59.7% vs 42.9%, p=0.13), previous valve surgery (25.4% vs 14.3%, p=0.24) and atrial fibrillation (68.7% vs 78.6%, p=0.33). Also, NYHA functional class and EuroScore II were similar (NYHA ≥ III; 85.1% vs 82.1%, p=0.72, and EuroScore II 9.9±9.8% vs 7.0±4.8%, p=0.21, respectively). On echocardiography, DPD+ patients presented with more pronounced left and right ventricular hypertrophy (interventricular septum: 15mm vs 13mm, p<0.01) but similar left ventricular ejection fraction (44.9% vs 42.3%, p=0.34). At 3-months after TMVR, DPD+ patients showed significant improvement in BNP serum levels when compared to DPD- patients (DPD+ vs DPD-: +315±2569pg/ml vs −2404±8696pg/ml, p=0.03), while NYHA functional class remained unchanged (NYHA improvement ≥1 class: 57.6% vs 50.0%, p=0.52) Conclusions In this single centre experience, CA was highly prevalent among elderly patients with severe mitral regurgitation scheduled for TMVR. TMVR in CA patients resulted in significant improvement of NT-pro BNP levels. Future studies need to clarify the prognostic relevance of CA in this specific patient population. Funding Acknowledgement Type of funding sources: None.

Mitral regurgitation severity assessment after percutaneous edge-to-edge mitral valve repair: guidelines-recommended integration versus volumetric assessment

Abstract Background Percutaneous edge-to edge mitral valve repair (PMVr) using the MitraClip device is a common method for treating mitral regurgitation (MR) when mitral valve operation is contra-indicated or deemed too risky. The evaluation of residual MR post PMVr is crucial for understanding the benefit and prognostic effect on patients. The common methods used today, based on color flow Doppler and the appearance of the color Doppler jet, may be misguiding because of the multiple jets created by the PMVr technique. Also, flow acceleration induced by the reduced systolic orifice may exaggerate systolic flow acceleration and thus jet area. Purpose We hypothesized that the guidelines-recommended method to assess MR may underestimate the effect of PMVr in reducing MR. Methods Patients undergoing PMVr in a large-volume PMVr centre were recruited between 2015–2019. Post procedural MR was evaluated using the integrated qualitative approach as recommended by the guidelines. In addition, MR volume for each patient was calculated by subtracting the forward stroke volume (calculated by multiplying LVOT area with the velocity time integral of LVOT systolic flow) from the total stroke volume (using the biplane method of discs), We compared the two methods for concordance. Results Overall, 112 cases were enrolled. In 59% of cases, the calculated volumetric residual MR was lower than the MR assessed by the integrated method. In 25.1% of patients the grade of MR was identical in both methods. In 16.2% the MR was more severe when calculated by the volumetric method (p<0.001, Kappa measure of agreement = 0.053–0.074). The reduction in residual MR degree using the volumetric approach was mostly observed in patients classified as “moderate” by the integrated qualitative approach. When considering basic characteristics and cardiac function of the patients, we did not find any sub-group of patients in whom the tendency for this mistake was higher. Conclusion Because of multiple jet origins and clip-induced flow acceleration, the integrated method to assess MR severity, based mainly on color Doppler, is not ideal in patients after PMVr. In most cases, MR severity after MitraClip is over-estimated by the integrated, guideline-recommended integrative method when compared with a volumetric method. This is especially relevant for patients classified with “moderate” MR. This study suggests that quantitative methods, not based on colour Doppler, should be used to assess MR severity after PMVr Funding Acknowledgement Type of funding sources: None.

Longitudinal stent elongation or shortening after deployment in the coronary arteries: which is dominant?

BackgroundStent manufacturers always record stent shortening data while they do not record stent elongation data. The aim of this study is to identify both stent shortening and elongation occurring after deployment in the coronary arteries and know their percentage.ResultsThe length of coronary stents was measured by intravascular ultrasound (IVUS) by (1) edge-to-edge (E-E) length, measured from the appearance of the first distal strut to the last proximal strut, and (2) area-to-area (A-A) length, measured from the first distal struts seen at more than one IVUS quadrant to the last proximal struts seen at more than one IVUS quadrant. Stent shortening was defined as both E-E and A-A lengths were shorter than the manufacturer box-stated length (shortened group). Stent elongation was defined as both E-E and A-A lengths were longer than the manufacturer box-stated length (elongated group), otherwise unchanged group. Consecutive 102 stents deployed in ischemic patients were included. Stent elongation was detected in 67.6% (69 stents), and shortening was detected in 15.7% (16 stents), while unchanged stents were detected in 16.7% (17 stents). Although the 3 groups had similar box-stated length and predicted foreshortened length, they had significantly different measurements by IVUS, p<0.001 for each comparison. Differences from box-stated length were 1.9±1.4mm, −1.4±0.4mm, and 0.4±0.3mm, respectively, p<0.001. The elongated group had significantly longer differences from the corresponding box-stated and predicted foreshortened lengths, while the shortened group had significantly shorter differences from the corresponding box-stated length and similar foreshortened length. By multinomial regression analysis, the plaque-media area and stent deployment pressure were the independent predictors of the stent length groups, p=0.015 and p=0.026, respectively.ConclusionsChange in stent length is not only shortening—as mentioned in the manufacturer documents—but also stent elongation. Stent elongation is dominant, and the most important predictors of longitudinal stent changes are plaque-media area and stent deployment pressure.

Impact of Leaflet Tethering on Residual Regurgitation in Patients With Degenerative Mitral Disease After Interventional Edge-to-Edge Repair.

Background: Grade 2+ residual mitral regurgitation (MR 2+) is associated with the recurrence of MR and a lower survival rate in interventional mitral valve (MV) edge-to-edge (EE) repair. We sought to determine the MV anatomic factors affecting residual MR 2+ during interventional EE repair with the ValveClamp system in patients with degenerative MR (DMR).Methods: In this multicenter study, 62 patients with significant (grade 3+ to 4+) DMR underwent ValveClamp implantation across eight centers from July 2018 to December 2019. Patient clinical, anatomical, and procedural characteristics were prospectively collected and retrospectively analyzed.Results: A single clamp was implanted in 59 patients, and two clamps were implanted in three patients. Residual MR 2+ was found in 14 patients (22.6%) immediately after the ValveClamp procedure. Patients with residual MR 2+ showed significantly larger preoperative tenting sizes and annular dimensions than the residual MR ≤1+ group. Multivariate analysis identified tenting volume as the major determinant of residual MR 2+ after ValveClamp procedures (odds ratio, 1.410 per 0.1-mL/m2 increase; 95% confidence interval, 1.167–1.705; P < 0.001). Receiver operating characteristic curves identified a tenting volume index ≥0.82 mL/m2 as the optimal cutoff point to predict residual MR 2+ (area under curve, 0.84). Patients with a tenting volume index ≥0.82 mL/m2 were more likely to develop recurrent 3+ MR or undergo MV surgery during short-term follow-up (P < 0.001).Conclusions: Preoperative assessment of the tenting volume index will help to predict intraoperative residual MR 2+ in patients with DMR receiving EE-based interventional repair. Improvements in the interventional strategy are warranted for sustained MR reduction in patients with DMR with unfavorable anatomy.

Microfabric characteristics of kaolinite flocculates and aggregates — Insights from large-scale molecular dynamics simulations

Clay particles are usually associated in flocculates or aggregates with different microfabric manners, which will govern the macroscale mechanical behaviors of clayey soils. In this study, the characteristics of different microfabric manners of defect-free kaolinite were explored applying large-scale full-atomistic molecular dynamics simulations. Due to the special crystal structure, kaolinite particles were more likely to flocculate in Edge-to-Face (EF) and Edge-to-Edge (EE) manners than aggregate in Face-to-Face (FF) manner when analyzed from the system energy point of view. For EF and EE manners, the 1st layer of adsorbed water of every single kaolinite particle was complete while the 2nd and the 3rd layers of adsorbed water arranged in T-, L-/inverted L- or cross-shape according to the wettability performance of surrounding kaolinite particles' surfaces. A series of new schematic diagrams of different microfabric manners with adsorbed water structures were developed according to the corresponding equilibrium topologies and physicochemical characteristics. The conceptual hypothesis of the kaolinite sedimentary process was verified and improved based on the simulation results analysis. The research results enhanced the comprehension of microfabric characteristics of clay colloids. The simulation method applied in this work would foster future investigations into clay colloids in various physicochemical environments.

P923Feasibility of the transcatheter mitral valve repair as the rescue therapy for patients with severe mitral regurgitation and endangered heart failure

Abstract Background For those who carry high or prohibitive surgical risk, the transcatheter edge-to edge mitral valve repair using MitraClip has been a safe and effective treatment for severe mitral regurgitation (MR). In patients with severe MR and cardiogenic shock under hemodynamic supporting devices, emergent surgical mitral valve interventions carry extremely high risk for peri-operative morbidities and mortalities. The feasibility and efficacy of emergent MitraClip to rescue patients in critical conditions remains elucidate. Methods Patients with severe MR were evaluated by the heart team and those with high or prohibitive surgical risks were referred to receive MitraClip procedures. Emergent MitraClip were conducted in patients with unstable hemodynamics and under mechanical or inotropic support. The hemodynamic measures, transthoracic echocardiography, transesophageal echocardiography, and blood tests were performed before MitraClip procedures. Procedural success was defined as having mild mitral regurgitation immediately after MitraClip, and patients were free from in-hospital mortality. Clinical and echocardiographic outcomes were followed by telephones and clinics. Results Among 50 consecutive patients (74.7±11.2 years, 74% male), 8 emergent MitraClip procedures were conducted to rescue patients with cardiogenic shock. Extracorporeal membrane oxygenation were used in 2 patients and intra-aortic balloon pump were applied in 4 patients (50%). The rest of 4 patients received continuous inotropic agent administration. Compare to those who underwent elective procedures, patients underwent emergent MitraClip had higher surgical risk profile (Euroscore II 34.8% vs 5.1% and STS score 19.7% vs 5.1%), poorer renal function and higher right atrial pressure. There was no peri-procedural death, myocardial infarction, stroke or any adverse events requiring emergent cardiac surgery in both groups. Mild mitral regurgitation was achieved in 87.5% patients from the emergent group and 95.2% patients in the elective group (P=0.514). In follow up, there were 5 deaths (three in the emergent group), including 2 non-cardiovascular deaths. The Kaplan-Meier analysis showed patients who underwent emergent procedures have poorer long-term survival rate as compare to those who received elective procedures. (P value = 0.008). Conclusions When open-heart surgery is not feasible and deferred due to excessive risk, trans-catheter mitral valve repair is an alternative way to rescue patients in cardiogenic shock status. The emergent MitraClip procedure may provide comparable safety and efficacy in treating patients with severe MR and unstable hemodynamics.

P917Transcatheter treatment of severe tricuspid regurgitation: first experiences with the edge-to-edge technique using the MitraClip

Abstract Background Due to increased operative mortality in high-risk patients treated for severe tricuspid regurgitation (TR), there is a growing interest in interventional therapy in these patients that are otherwise solely treated with medication. The edge-to edge technique with implantation of one or more MitraClips is an therapeutic interventional option for these patients. So far, data for transcatheter TR treatment are sparse. Purpose The present cohort study investigates safety, feasibility and effectiveness of the edge-to-edge technique treating severe TR after starting a transcatheter TR treatment program at our institution in 2017. Methods A total of 17 high-risk patients (79.18±8.76 years, EUROScore II 9.31±8.23%, table) with symptomatic, severe TR were treated using the MitraClip system from 12/2017 until 12/2018. All patients received pre-interventional clinical, echocardiographic and invasive evaluation and were entered into a database. Safety and feasibility of the procedure, reduction of TR grade and clinical outcomes were collected and analyzed at the day of discharge and at 30-day follow-up. Results MitraClip device was successfully implanted in 16 of 17 patients (94.1%). In one patient grasping of the leaflets was impossible due to bad echo conditions by abdominal air. 76.5% of the patients had severe or massive and 23.5% had a torrential TR (figure). A total of 25 Clips were used (22 in anteroseptal, 3 in posteroseptal commissure). No intraprocedural deaths, emergency surgery or major vascular complications occurred. Postprocedural TR was significantly reduced (TR reduction ≥1 grade) from a mean TR grade of 3.8±0.8 at baseline to 1.74±0.59 postprocedural (p&lt;0.001, table and figure). One patient had device detachment before discharge. There was one death due to progressive cardiogenic shock 4 days after the procedure. However, the procedure was planned as a last therapeutic option in this terminally ill patient. Echocardiography at discharge showed reduction of TR in 82,4% of patients (mean TR grade at discharge 2.21±0.66, p&lt;0.001). At 30 day f/u symptoms were significantly improved from inital mean NYHA class of 3.06±0.56 to a mean NYHA class of 2.55±0.52 (p=0.002) and patients presented with reduced TR (mean TR grade at 30 day f/u 2.58±0.57, p&lt;0.001). Conclusion Interventional treatment of severe TR in high-risk and mostly inoperable patients using the MitraClip technique is safe and effectivly reduces TR grade leading to clinical improvement. However, further investigations are needed to identify clear parameters highly predictive for a favorable acute and midterm procedural success. Also, more data and clinical trials are needed to determine the long-term course in these patients.

Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease: does the surgical approach have an impact on the long-term results?

To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis.

Effects of the Substrate Refractive Index, the Exciting Light Propagation Direction, and the Relative Cube Orientation on the Plasmonic Coupling Behavior of Two Silver Nanocubes at Different Separations

In this paper, we presented a detailed theoretical investigation on the effects of changing the refractive index of the substrate and the interparticle separation distance on the electromagnetic field distribution around the face-to-face (FF) and the edge-to-edge (EE) oriented silver nanocube (Ag NC) dimers. We found that the contribution of the scattering to the absorption components is markedly decreased with increasing the substrate refractive index. This suggests that for surface-enhanced Raman spectroscopic (SERS) applications, the use of a substrate of very low refractive index is highly recommended. However, for photothermal applications, the use of substrate of high refractive index is recommended. Furthermore, we found that the wavelengths corresponding to the dipolar and multipolar modes are nearly unaffected by increasing the interparticle separation distances above 40 nm on the high refractive index substrate. However, on the low refractive index substrate, the dipolar peaks consistently red-s...

Long-term results of mitral repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: does the technique matter?

An isolated undersized annuloplasty was used to treat mitral regurgitation (MR) secondary to dilated cardiomyopathy (DCM) if the baseline coaptation depth (CD) was <1 cm. In the presence of significant tethering of the mitral leaflets (CD ≥1 cm), the edge-to-edge (EE) technique was combined with annuloplasty to improve the durability of the repair. The long-term results of this approach are unknown and represent the objective of this study. To obtain long-term outcome data, we included in the study population the first 105 consecutive patients with severe left ventricular dysfunction (ejection fraction 29 ± 6.6%) and secondary MR submitted to mitral valve repair. Forty patients underwent isolated undersized annuloplasty and 65 patients received the EE technique combined with annuloplasty. Preoperative and postoperative data were prospectively entered into a dedicated database. Clinical and echocardiographic follow-ups were performed in our institutional outpatient clinic. Follow-up was 90% complete. The median follow-up time was 7.2 years (interquartile range 4.3;10.4). The longest follow-up time was 16.5 years. A comparative analysis between the annuloplasty group and the EE group was performed. Baseline LV dimensions and function were slightly worse in the EE group, but only the severity of tethering was significantly more pronounced than in the annuloplasty group. Hospital mortality (3 vs 2.5%, P = 1.0) and 10-year overall survival (42 ± 6.7 vs 55 ± 8.5%, P = 0.2) were not significantly different in the EE and annuloplasty group, respectively. Cumulative incidence functions of cardiac death were similar as well (at 10-years, 34.3 ± 8.1 vs 37.9 ± 6.4%, respectively, P = 0.4). At 10 years, cumulative incidence function of recurrence of MR ≥3+ was lower in the EE patients (10.3 ± 4.1 vs 30.8±8.0%, P = 0.01). Isolated annuloplasty [hazard ratio (HR) 4.84, 95% confidence interval (CI) 1.46-16.1, P = 0.01] and residual MR >1+ at hospital discharge (HR 5.25, 95% CI 2.00-13.8, P < 0.001) were significantly related to the development of MR ≥3. Failure of repair was associated with recurrence of New York Heart Association III or IV symptoms (P < 0.001). In patients with end-stage DCM and secondary MR, the association of the EE technique to the undersized annuloplasty significantly decreases the rate of recurrent MR at long-term. This higher repair durability did not translate into a better long-term prognosis in this series.

Malocclusion in the primary dentition in children with and without deformational plagiocephaly.

Asymmetries of the jaw and orthodontic abnormalities are suspected as long-term consequences of positional cranial deformity. But only few data exist on this issue. As plagiocephaly is a common problem in infancy, potential functional impairments should be investigated to initiate appropriate measures if necessary. The aim of our study was to compare the orthodontic situation in primary dentition of children with positional plagiocephaly and children without cranial deformities. Fifty children treated by helmet therapy for plagiocephaly and 50 non-affected children (age 1.98-5.69years) were examined in a cross-sectional study. Orthodontic parameters of all dimensions were assessed and analyzed. Children of the plagiocephalic group showed more often orthodontic alterations compared to the others. Especially the frequencies of a class II malocclusion (36 vs. 14%), an edge-to edge bite (28 vs. 12%), and deviations of the midline (38 vs. 16%) were conspicuous. However, none of the differences was significant (p>0.003). Of all observed mandibular asymmetries, 69% appeared as a shift to the contralateral side of the former flattened occipital region. Positional head deformity might be associated in some cases with a higher prevalence of occlusal abnormalities in primary dentition. Positional plagiocephaly interfaces medicine and dentistry. As it is a common disorder, this etiology has to be considered in the prevention and therapy of malocclusion.

Modeling marine mud: A four phase system

Fine-grained marine sediment consists of up to four phases: (1) clay Minerals often with some silt and sand, (2) saline water, (3) free gas, and (4) organic matter (OM). Shallow-water, shelf, and slope muds often have all four phases present. The clay minerals are the “building blocks” of mud deposits; these consist of multi-plate face-to-face domains. There are only three possible modes of domain contact (termed signatures): (1) edge-to-face (EF), (2) edge-to-edge (EE), and (3) face-to-face (FF), usually offset. The domain faces are negatively charged and have a large surface area and the edges are both negative and positive charged. OM is usually expressed as total organic carbon (TOC) in percent total dry mass and can range from &amp;lt;0.5% to several percent and the OM can occupy a significant portion of pore volume. OM is usually attached to clay domain signatures and faces with the location partially dictated by electrostatic potential energy fields. When several percent TOC is present, the OM drives up water contents and porosity considerably. When free gas is present, it replaces part of the seawater in the pore space. Several published organo-clay fabric models for mud deposits may improve prediction of acoustic properties.

The formation of a structural framework in gelled Wyoming bentonite: Direct observation in aqueous solutions

HypothesisParticle space arrangement is a very important factor that determines the physico-mechanical properties of soil. Formations of three-dimensional (3D) structured networks within gelled or flocculated suspension may prevent clay particles and aggregates from settling under gravity force and by encapsulate water within such a network, lead to poor sludge dewatering. To better understand this phenomenon, a microstructural investigation of a smectite clay (SWy2) suspension was conducted. ExperimentsSWy-2 was diluted in water and a moderately salty aqueous solution and was studied with the aid of a synchrotron-powered transmission X-ray microscope (TXM) and cryogenic transmission electron microscope (Cryo-TEM). Observations of mutual particle arrangement in 3D spaces were conducted within a natural water environment after vitrification without drying. FindingsA new type of micro-architecture in particle space arrangement was observed. Smectite flakes were mostly in edge-to-edge (EE) contact and formed a 3D network, confirming a “net of flakes” structural model. Clay particles form a complex and multi-hierarchic flocculated structure with characteristic cellular chained networking. Chained aggregates build cellular elements, encapsulating water inside closed voids. Increasing ionic strength results in the development of multi-hierarchic voids categories, with most water retained within nano-pores.

Analysis of Low Frequency Oscillation in Interconnected Power System under Hedge Operation Mode

A phenomenon that the damping ratio will decrease when the power flows from both sides to the primary power grid is summarized and analyzed in the paper. Based on analysis of the damping ratio change of West Inner Mongolia-Shandong oscillation under the sequential operation mode and the hedge operation mode, a three-machine equivalent system is established to study edge to edge (ETE) oscillation mode under hedge operating mode of the power system. The influence of magnitudes and trends of power flow on damping ratio is analyzed, and the reason that why damping ratios decreases when both sides send power to the mid-side power grid is explained.

Procedural Guidance Using Advance Imaging Techniques for Percutaneous Edge-to-Edge Mitral Valve Repair

The complexity of structural heart disease interventions such as edge-to edge mitral valve repair requires integration of multiple highly technical imaging modalities. Real time imaging with 3-dimensional (3D) echocardiography is a relatively new technique that first, allows clear volumetric imaging of target structures such as the mitral valve for both pre-procedural diagnosis and planning in patients with degenerative or functional mitral valve regurgitation. Secondly it provides intra-procedural, real-time panoramic volumetric 3D view of structural heart disease targets that facilitates eye-hand coordination while manipulating devices within the heart. X-ray fluoroscopy and RT 3D TEE images are used in combination to display specific targets and movement of catheter based technologies in 3D space. This integration requires at least two different image display monitors and mentally fusing the individual datasets by the operator. Combined display technology such as this, allow rotation and orientation of both dataset perspectives necessary to define targets and guidance of structural disease device procedures. The inherently easy concept of direct visual feedback and eye-hand coordination allows safe and efficient completion of MitraClip procedures. This technology is now merged into a single structural heart disease guidance mode called EchoNavigator(TM) (Philips Medical Imaging Andover, MA). These advanced imaging techniques have revolutionized the field of structural heart disease interventions and this experience is exemplified by a cooperative imaging approach used for guidance of edge-to-edge mitral valve repair procedures.

Percutaneous mitral repair with-mitraclip system, safety and efficacy; initial Egyptian experience

To evaluate the feasibility, efficacy, and safety of the MitraClip system in patients with severe MR. Mitral valve repair for mitral regurgitation (MR) has been performed by the use of a surgically created double orifice. Percutaneous repair based on this surgical approach has been developed by use of the MitraClip device to secure the mitral leaflets. Five Patients with 3 to 4+ MR were selected in accordance with the American Heart Association/American College of Cardiology guidelines between March 2013 and May 2013 and underwent percutaneous mitral repair with MitraClip system . Patients were followed up for six months after procedure. The primary acute safety endpoint was freedom from major adverse events (MAEs) at 30 days, defined as the composite of death, myocardial infarction, non-elective cardiac surgery for adverse events, renal failure, transfusion of more than 2 units of blood, ventilation for more than 48 h, deep wound infection, septicemia. The primary efficacy endpoint is acute device success defined as clip implant with reduction of MR to equal or less than grade II, based on current guidelines. A total of 5 patients were treated. No patients (0%) had a major adverse event,. Freedom from clip embolization was 100%. Partial clip detachment had not occurred in any patients (0%) patients. Overall, 4 of 5 (80%) patients achieved acute procedural success, and 3 (60%) were discharged with MR of ⩽ 1+. Our initial results with the MitraClip device in a very small number of patients indicate that percutaneous edge-to edge mitral valve repair is feasible and may be accomplished with favorable short-term safety and efficacy results.