This year has been quite a ride for the American Backflow Prevention Association (ABPA). But as we move into 2017 there is reason to be optimistic for the future. The organization has moved to a different management company which should help with membership & the newsletter/magazine.
The next big national event is the Backflow & Cross Connection Trade Show to be held in San Antonio Texas on April 3rd through the 5th. If you have the chance, this is a must go-to event. The venue is right on the River Walk and just a couple of blocks from the Alamo. But more important: The seminars will be worth the trip, with two Colorado speakers (Your CBPA President and Vice President) speaking on backflow issues on fire systems and regulations. Add the other seminar topics and your chance to talk with vendors from all segments of the industry and this event is well worth your time.
Membership and benefits will be the emphasis for this coming year so expect lots of communication from National to you, the membership.
On a local level, I want to encourage all who receive this to become or retain your CBPA membership or, if you reside in Utah, your Utah Chapter membership. Once a member, actively participate, if only to attend scheduled events. Of course, there is always need for volunteers. Please step up and support ABPA's mission of providing information and education.
The Colorado Backflow Prevention Association (CBPA) will be hosting an event in mid-April (Details in the newsletter) that will discuss fire sprinkler system requirements and an open forum on implementing the new State Regulation 11.39.
We are hoping to have some big news regarding CBPA coming soon. We realize things have been slow here at backflow.org, but we are hoping that will change in the near future. Check back often so you can be the first to know!
We all know how cold winters can be here in Colorado. This winter is turning out to be no exception. Sub-freezing temperatures can be brutal on any equipment that involves water. Obviously that is the case with backflow preventer test kits. Part of my daily duties involves certifying test gauge kits, and I can tell you that I have already come across several kits that have obviously frozen. Not all of them had permanent damage, but at least one certainly did. While I will gladly make repairs to those damaged test kits, we all know it's not cheap and that cost cuts into your company profits.
Drain your test kit after each and every test. Open all the valves on the kit and let as much water drain out as possible. Tilt your kit, shake your kit. Dance with it if you have to. Keep doing it until you are sure that you have drained all the water you can out of it.
Leave the valves open. Once you have drained your kit, don't close the valves! In fact, open them all the way. This ensures that what water is left inside, if it happens to freeze, has room to expand without (hopefully) doing any damage.
Keep your kit where it won't freeze. This is a no-brainer, but I have to say it. If you use a pickup for your testing work, keep the kit in the cab with you when it's below freezing. A test kit can easily freeze in the back of a pickup while you drive between jobs. Also, bring your test kit inside overnight. It wants a warm place to spend the night as much as you do.
By following these three simple steps you can be pretty sure that your kit will be in good working order when it's time for your next test. Test kits are not inexpensive, and they certainly can cost a significant amount to repair, not to mention your down time if you don't have a backup kit available. Test gauge kits are a testers bread and butter, so be nice to them.
A fairly recent case from Louisiana. A lot of folks still don't think that protection on irrigation systems is necessary. This is exactly why it is necessary.


Jane Goodall is a famous researcher and scientist who has devoted her life to studying wild animals, most famously chimpanzees. If your daughter is an animal lover, give her this inspiring coloring page of one of the most famous scientists of the 20th century!
Want to meet more famous women? Browse The whole Women in History coloring series!


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Lucille K. Folz Specht
Lucille K. Folz Specht, 103, of Hot Springs Village, AR, passed away restfully January 15, 2023 at Abundant Life Care Home. She was born August 19, 1919, in Cadott, WI. to Matthew and Agnes (Martin) Folz. She married Harold L. Specht, September 19, 1940. She was a member of Our Lady of Peace Catholic Church in Marshfield, WI until she moved to Arkansas in 2006 and became a member Sacred Heart of Jesus Catholic Church in Hot Springs Village. She was a wonderful mother, homemaker, gardener, seamstress, crafter and floral arranger. She love to play cards, go fishing and became a surrogate grandmother to many young neighborhood kids after her sons had moved away. Lucille is survived by sons Dave (Debbie) Specht of Hot Springs Village, AR, Paul (Disa) Specht of Hot Springs, AR; 3 grandchildren Sam (Denise) Specht of Reedsburg, WI, Meghan (Matt) Standfill of Bauxite, AR, and David Specht of Hot Springs, AR; greatgrandchildren Emma and Everly Specht, Miles and Hayes Standfill, Nation Beard and many nieces and nephews. She was preceded in death by her parents; her husband; brothers Helm Folz, Dale Folz, and Vern Folz; sisters Birdetha Kohlbeck, Irene Ganster and Della Folz. There will be a funeral Mass at Sacred Heart of Jesus Catholic Church in Hot Springs Village, AR later in spring followed by celebration of her life in Marshfield, WI where she will be buried next to her husband. Online condolences at www.caruth-hale.com.

redpajama_set_name: RedPajamaCommonCrawl


The National Register of Historic Places recognizes over 90,000 properties in all fifty states and the territories. Visiting all of these locations would require quite a long road trip, but thanks to the NEH funded project Between the Waters, our nation's history has become more easily accessible to citizens from all across the nation.
This interactive website explores the historic South Carolina coastal estate, Hobcaw Barony, a landmark in the National Register of Historic Places. Once a site of Native American settlement for centuries, Hobcaw was among the original land grants to the Lords Proprietors and was eventually divided into more than a dozen plantations. In the twentieth century, wealthy financier Bernard Baruch purchased the property, creating a haven for the rich and famous, including Franklin D. Roosevelt and Winston Churchill. Belle Baruch, Bernard's oldest daughter, bought the property from her father in the 1930s, and at her death in 1964 she founded the Belle W. Baruch Foundation, which manages the land as an outdoor laboratory for colleges and universities in South Carolina.
Between the Waters highlights Hobcaw's multilayered history, presenting themes of multiculturalism, class, gender, and ethics. The website allows visitors to take a self-directed virtual tour of Hobcaw Barony, moving down the roads and rice canals, entering the buildings, and reading and listening to the stories of those who have witnessed life there. Historians, slave descendants, local Native Americans, and others shed light on universally relevant themes connected to Hobcaw's material culture through multimedia presentations that weave together interviews with photographs, video, and archival film.
The project has promoted humanities education and preserved Hobcaw's history, and was recently recognized for excellence in public history. Between the Waters was awarded the 2017 American Association for State and Local History Leadership in History Award of Merit and was also featured in the "Innovative Formats" session of the March 2017 History Film Forum, a partnership of the NEH and the Smithsonian Institution.
The ETV Endowment of South Carolina received two grants for an interactive website on Hobcaw Barony.


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Megan Thee Stallion Now Officially Owns The 'Hot Girl Summer' Trademark
by D'Shonda BrownPosted on January 13, 2022 January 14, 2022
We talked with a trademark attorney about the process.
Three cheers for the Hot Girls!
Announced by Josh Gerben, trademark attorney and founder of Gerben Intellectual Property, Megan Thee Stallion has officially won her battle to trademark "Hot Girl Summer," which had been used to promote clothing, music, and even food, without Megan's approval.
In an interview with Allure, Megan shared her reasoning behind trademarking the "Hot Girl Summer" phrase dominating marketing campaigns in 2019. "I really didn't even know that it was gonna catch on how it did. It was just me talking shit, telling everybody I was gonna be me for the summer, and they should be them too, like as free as they can be. When I saw Wendy's and Forever 21 saying, 'Hey, are you having a Hot Girl Summer?' I was like, 'Hell no, Forever 21, you're going to have to pay me,'" Megan said. "But I just wanted to get it trademarked because it's me. It's my thing."
"It took Megan Thee Stallion [two plus] years of wrangling with the USPTO," Gerben tweeted referring to the United States Patent and Trademark Office, "but she is now the owner of a federal trademark registration for HOT GIRL SUMMER." According to Gerben's tweet, the registration was issued to Megan at the top of the new year on January 4, 2022.
It took Megan Thee Stallion 2+ years of wrangling with the USPTO, but she is now the owner of a federal trademark registration for HOT GIRL SUMMER.
The registration was just issued to @theestallion on January 4th. 👇#hotgirlsummer#megantheestallion pic.twitter.com/H5cUtNaflS
— Josh Gerben (@JoshGerben) January 8, 2022
In 2019, the Houston Hottie filed to trademark the phrase, which was also the name of her song featuring Nicki Minaj and Ty Dolla $ign. As seen in an official document from Gerben Law, Megan filed multiple trademark applications for her stage name, "Hot Girl Summer," as well as nicknames "Hot Girl Meg" and "Tina Snow" under her very own Hot Girl Trademark Holdings, LLC. "Hot Girl Trademark Holdings also applied for a trademark for "HOT GIRL SUMMER" for use with a variety of goods and services including temporary tattoo transfers, posters, and tour books, as well as for use with clothing items such as t-shirts, night shirts, and jackets," read the statement.
Read ESSENCE's Megan Thee Stallion interview here.
The trademark for "Hot Girl" clothing received pushback due to how popular the slogan became. "Sometimes, if a trademark is too widely used, they won't allow registration," Gerben shared. "The best thing I can think of is, once the cat's out of the bag, it can be really hard to put the cat back in the bag."
We spoke with Gerben to discover more about the trademarking process and why it took two years for Megan to be granted ownership.
"So, normally when you file an application, it takes about six months to get the government to review it," Gerben exclusively said to Girls United. "So, you're filing an application with a government agency called the United States Patent and Trademark Office," he added. Then, they trademark is either approved, or they may circle back to the filer with a problem.
He then explained that a few of technical snags (a misplaced signature and proving how she would be using the trademark) also held up the process. "There are some pretty technical requirements to show the government [how you're] using this," Gerben said. Another issue that needed to be addressed was someone else filing a trademark for Hot Girl Summer a few months prior to Megan." The entertainment company eventually abandoned their application.
With her newly trademarked slogan, it looks like Megan is having a Hot Girl Year.
Additional reporting by Brooklyn White.


Where is value being created, and destroyed?
What better question do bold leaders, passionate about innovation, need to ask, and answer?
how they engage in the market – with their customers, their suppliers, their partners, their stakeholders.
Historically, and across all industries, barriers and constraints – whether internal capabilities or market friction – have been signposts to new opportunities, to explosive sources of growth based on insights into where value is being created, and destroyed and new capabilities to capture the resulting opportunities. It's no different now – hence the opportunity. From this perspective, innovation becomes a pragmatic activity with a clear mission as well as an equally pragmatic way both to talk and to take action with speed and scale.
Its mission: to provide insight into where value is being created, and destroyed, with pragmatic steps to capture the emerging opportunities such insight affords.
Its definition: a set of activities, and competencies – know-how, skill-sets and assets – that overcomes (organizational & market) constraints in service to meeting emerging sources of opportunity and need, as measured by creating both greater societal benefit & economic value.
And, therefore, the bold leader imperative: to catalyze a culture of insight and deepen the foundation of innovation competencies to capture distinctive, and sustainable, sources of value.
What we believe – based on insights and experience, globally – from the Middle East to Africa, North America to Europe, South Korea to China.
1. Many businesses are in transition, whereby "the same old, same old" no longer works.
As a proof point, merely think about who the Industry leaders are today, versus 5 years ago. Who will be the new set of industry leaders in 5 years? Over 30% of once Industry leader leaders "topple" within 5 years and interestingly, only 5% have "superior" economic performance more than 10 years. Think merely of the extraordinary technology innovations and their implications that have always and will continue to outpace 'managerial' or organizational innovations by 5 – 7 years – such as it has always been, and will always be.
How do we grow our revenue, and profitability base?
How do we shape the market to our value proposition – through engaging with our customers differently?
How do sustain it, with speed and scale, by 'nudging' our ecosystem towards greater societal benefit & economic value?
This shift in *what* the strategic questions are has profound implications on decisions made and actions taken. Asking the second set first, makes answering the first set a second priority, and so, so much easier.
What we call the "new 20%" – of capabilities, know-how and technologies that will drive 70% of your value tomorrow, compared to the 20% that drive it today.
How you engage your customers, your partners and equally critically, the "white space" of disruption, and opportunities, that we all face.
How you 'amplify the faint signals' of customer needs and technology shifts – signposts of emergent opportunities.
So, when do you start?
Now, because opportunities for engaging with your market, your customers, your stakeholders in new ways – in a way that creates both greater economic value, and societal value… are all around you. They, to paraphrase the novelist William Gibson, are just unevenly distributed.


Otakuthon Idol is a contest which is looking to bring out the next Gackt or KOTOKO sleeping inside you! If you are one of the lucky selected participants, you could sing on stage and have the chance of winning the title "Otakuthon Idol 2018". To participate, you must learn a Japanese song by heart and pass the auditions. If you are selected, you will be able to perform on stage in front of our judges, who will evaluate your performance.
Don't forget to bring a compact disc containing the karaoke version of your song!
Too shy to go on stage alone? No problem! You can perform in groups! Wait no more and start rehearsing right now!
If you aren't interested in singing, you can simply attend the show; our participants will do their best to entertain you! But more importantly, don't forget to bring your friends!


E-banking is an internet based electronic system that enables our members to conduct their financial transaction on the website operated by us.
Understanding the need in today's modern era of technology we are very pleased to provide the e-banking service to our valued members, which allow you to avail online banking transactions from any part of the world. With our e-banking system you can now have access and full control over your accounts 24 hours 7 days a week.
This facility is secure and comes to all absolutely free of charge. To avail the facility, you just have to subscribe by filling a simple subscription form at the customer service department of our office.
It shows the account summary of the account.
User can view the account statemtent using particular date range with proper account number.
It is the facility from where user can view the forcasted messages and also able to send messages for any enquiries.
It enables user to change the password.
© IME Co-operative 2019, All rights reserved.


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Bury St Edmunds Suffolk
Bury St Edmunds, Suffolk
Click on the map for other historical maps of this place
In 1887, John Bartholomew's Gazetteer of the British Isles described Bury St Edmunds like this:
Bury St Edmunds, parl. and mun. bor., Suffolk, on river Lark, 14 miles E. of Newmarket, 26 miles NW. of Ipswich, and 78 miles NE. of London by rail, 2938 ac., pop. 16,111; 3 Banks, 3 newspapers. Market day, Wednesday; has extensive mfrs. of agricultural implements, and a great trade in agricultural produce. ...
B., with its abbey, was founded by Canute, to commemorate the martyrdom of Edmund, king of East Anglia, in 870. Its Grammar School was founded by Edward VI. Here were born Bishop Gardiner (1483-1555), Bishop Blomfield of London (1786-1857), Sir Nicholas Bacon (1510-1579), lawyer and statesman, and many other eminent men. The bor. returns 1 member to Parliament. It sent 2 members till 1885.
Bury St Edmunds through time
Click here for graphs and data of how St Edmundsbury has changed over two centuries. For statistics for historical units named after Bury St Edmunds go to Units and Statistics.
GB Historical GIS / University of Portsmouth, History of Bury St Edmunds, in St Edmundsbury and Suffolk | Map and description, A Vision of Britain through Time.
URL: http://www.visionofbritain.org.uk/place/832
Not where you were looking for?
Click here for more detailed advice on finding places within A Vision of Britain through Time , and maybe some references to other places called " Bury St Edmunds ".
To buy historical maps of Bury St Edmunds, click here!
Some places near Bury St Edmunds :
Honington | Stradishall | Wickhambrook | Stanton | Ixworth | Thurston | Great Barton | Barrow | Pakenham | Cockfield


The advent of transcatheter aortic valve replacement (TAVR) is one of the most widely anticipated advances in the care of patients with severe aortic stenosis. This procedure is unique in many ways, one of which is the need for a multimodality imaging team-based approach throughout the continuum of the care of TAVR patients. Pre-procedural planning, intra-procedural implantation optimization, and long-term follow-up of patients undergoing TAVR require the expert use of various imaging modalities, each of which has its own strengths and limitations. Divided into 3 sections (pre-procedural, intraprocedural, and long-term follow-up), this review offers a single source for expert opinion and evidence-based guidance on how to incorporate the various modalities at each step in the care of a TAVR patient. Although much has been learned in the short span of time since TAVR was introduced, recommendations are offered for clinically relevant research that will lead to refinement of best practice strategies for incorporating multimodality imaging into TAVR patient care.
Percutaneous placement of aortic valve prostheses is among the most widely anticipated innovations of the past decade (1,2). Such success is critically dependent on careful patient selection, optimal performance of a complex and technically demanding implantation procedure, and careful postoperative care. Multimodality imaging has emerged as an important ingredient of each of these steps such that the care team for patients undergoing percutaneous transcatheter aortic valve replacement (TAVR) must include skilled and knowledgeable cardiologists and radiologists able to perform and interpret a variety of imaging techniques, often in real time during the implantation procedure and who have specific expertise in TAVR imaging. The goal of this review is to comprehensively demonstrate how physicians currently derive multimodality imaging information and integrate it into the decision-making process for patient care for both self-expanding and balloon expandable TAVR. This review offers guidance for future imagers involved in this novel procedure and provides the basis for standardization of the imaging approach to TAVR, which has been lacking. In 3 sections (pre-procedural, intraprocedural, and long-term follow-up assessments), we highlight the importance of multimodality imaging and, when appropriate, compare the utility of various modalities. In some instances, local expertise will dictate which modalities are employed at each stage. It is hoped that this practical review addresses the requirements for and utility of multimodality imaging in the continuum of TAVR patient care.
The overall goals of the pre-procedural assessment are to: 1) ensure patient suitability for the proposed access site; 2) ensure that the proposed device can be safely and successfully implanted on the basis of device characteristics and the anatomic relationships between the aortic valve and root, left ventricle (LV), and coronary ostia; 3) select the device size; and 4) contribute to the development of a procedural plan.
Vascular access complications are common in TAVR implantation, with recently published rates ranging from 6.3% to 30.7% (1,3–5). These rates are influenced by various clinical factors, screening protocols, and the diameter of the arterial sheaths used. Given this high burden of vascular injury, increasing the effectiveness of pre-procedural screening of patients for TAVR is key. This often begins with conventional angiography, because virtually all patients undergo assessment of the descending aorta, abdominal aorta, and iliofemoral system to detect stenosis, occlusion, and aneurysmal disease of the proposed access site. Angiography provides a basic assessment of luminal size but a very limited evaluation of the presence of atherosclerosis and plaque burden as well as the degree of vessel tortuosity.
Because of the limitations of angiography, multidetector computed tomography (MDCT) has become the single most important imaging modality for examination of the abdominal and iliofemoral arteries. A standardized approach reduces morbidity and mortality rates from vascular injury (6) and includes a number of reconstructions, including 3-dimensional (3D) volume rendered imaging, curved multiplanar reformats, and maximum intensity projection images (Fig. 1). Employing a centerline approach to elongate the vessel image, multiple luminal measurements should be made in a plane orthogonal to the vessel rather than in the transverse axial plane. With this approach, MDCT can evaluate vessel size, degree of calcification, minimal luminal diameter, plaque burden, and vessel tortuosity and also identify high-risk features including dissections and complex atheroma. Angulations in the iliofemoral system >90° might preclude insertion of large-bore catheters or cause significant vessel trauma. In the absence of severe calcification, bulky atheromatous burden, or severe tortuosity, short segments of relatively compliant artery can be up to 1- to 2-mm smaller in diameter than the intended sheath, allowing it to be safely cannulated (7). Less than 180° of calcification and eccentric calcification are less likely to create procedural difficulty than almost circumferential and luminal calcification. A sheath/femoral artery ratio of 1.05 or higher has also been shown to predict both vascular complications and 30-day mortality (8). Although minimal vessel diameters have been suggested (7), as smaller sheaths become available the optimal vessel diameter is likely to be a moving target. In general, when imaging characteristics are unfavorable, alternative approaches such as transapical, transaxillary, or direct aortic should be considered (7,9). It should be emphasized that, as devices and technology change, the imaging parameters used to assess patient suitability and access planning might be modified (6). To help reduce the risk of contrast-induced nephropathy, protocols have been published that employ direct power injection of diluted contrast in the infra-renal aorta and provide excellent image quality (6,10).
(A) Three-dimensional volume rendered image of the iliofemoral vessels and boney pelvis. This reconstruction provides landmarks to display the site of minimal luminal diameter. (B) Curved multiplanar reformat of the right iliofemoral system in an 84-year-old male with severe aortic stenosis. The curved multiplanar reformat demonstrates elongation of the arterial system and allows for assessment of luminal diameter and degree of encroachment by calcified plaque in multiple projections.
Surface ultrasound of the access site is not frequently used but can be helpful to assess vessel size, tortuosity, and calcification and identify the optimal site for puncture (11). Intravascular ultrasound is helpful to see the lumen in patients when there is blooming artifact from calcifications. Coronary intravascular ultrasound catheters can be used in the periphery at time of diagnostic coronary angiography for this purpose.
Imaging of the aortic root and heart for pre-procedural device sizing and selection and procedural planning and execution is performed with the goals of: 1) measuring aortic annulus size; 2) measuring leaflet length and calcification; 3) locating the coronary ostia; 4) identifying other features that might interfere with successful implantation; and 5) contributing to pre-procedural planning. In particular, a careful multimodality imaging evaluation with MDCT, echocardiography, and root angiography will identify high-risk predictors of complications in advance and might result in patient exclusion or other anticipatory action.
To fully understand the use and value of imaging it is essential to appreciate the complex anatomy of the aortic valve and root and the specifications of transcatheter heart valves (THVs) currently available. The aortic annulus, the commissures, the sinuses of Valsalva, the coronary ostia, and the sinotubular junction (STJ) are the framework in which the valve leaflets are suspended (12) (Fig. 2). It is well-established that the annulus is an oval-shaped, 3-pronged coronet with 3 anchor points at the nadir of each aortic cusp rather than a cylindrical structure. The attachment of the aortic cusps is semilunar, extending throughout the aortic root from the LV distally to the STJ. Two virtual rings are usually defined: an inferior basal ring formed by joining the basal attachment of the leaflets (aortic annulus), and a superior ring at the top of the crown that is a true ring, corresponding to the STJ (12) (Fig. 2). The aortic annulus measurement by all modalities is assessed at the lowest hinge point of the aortic valve leaflets at the virtual basal plane in systole.
(A) Diagram of aortic root anatomy showing coronet shape and location of various annular planes and coronary ostia relative to leaflet attachments. (B) Imaging planes and leaflet attachments from (A) shown superimposed on postmortem specimen.
A-M = aorto-mitral; VA = ventriculo-arterial.
The THV characteristics are also important and must be integrated with imaging findings (Table 1). The height of the valve prosthesis and the parts of the prosthesis that are covered by fabric (the "skirt") are important to understand with regard to pre-procedural planning and implantation. In the SAPIEN (Edwards Lifesciences, Irvine, California) valve, the skirt covers the proximal 2 links, whereas in the CoreValve (Medtronic, Minneapolis, Minnesota) the proximal 12 mm are covered, and the valve leaflets are mounted supra-annularly. This is an important distinction, because high placement might interfere with coronary flow and future access as well as increase the likelihood of significant paravalvular regurgitation.
Accurate aortic annulus measurement is critical for the success of the TAVR, because the size of the annulus will determine the size of the prosthesis that should be used (12,13) (Table 1). Mismeasurement of the annulus is the most common reason for complications such as aortic regurgitation (AR) (14). Systolic annulus measurement can be obtained by virtually any technique, although results differ across modalities in magnitude and reproducibility, including the ability to accurately capture the true elliptical anatomy of the annulus (Online Figs. 1 and 2).
Echocardiographic measurements of the aortic annulus for selecting THV size (Table 1) have traditionally used the sagittal plane acquired from a 2-dimensional (2D) parasternal long-axis image on transthoracic echocardiography (TTE) or a mid-esophageal long-axis transesophageal echocardiography (TEE) image between 120° and 140° (Fig. 3). The annular dimension most commonly used in decision-making for TAVR bisects the annulus at its maximum diameter during early-systole, from the hinge point of the right coronary cusp to the left-noncoronary commissure. When the cusps are open in systole, the commissure measurement is particularly difficult, and care must be taken not to measure too far into the aortic root. Transesophageal echocardiography measurements underestimate cylindrical sizers during surgery (15), because of the oval shape of the annulus. Biplane imaging or 3D reconstruction can be used to obtain measurements in the sagittal and coronal planes. Finally, TEE imaging of balloon aortic valvuloplasty might help define the annular dimension in difficult cases.
(A and B) Biplane transthoracic imaging shows the sagittal (A) and corresponding transverse (B) plane. The yellow arrows define the imaging plane for the orthogonal view. The red arrow shows the appropriate annular measurement in the on-axis sagittal plane. (C and D) Biplane transesophageal imaging shows the sagittal (C) and corresponding transverse (D) plane. Red arrow in panel C shows the appropriate annular measurement in the on-axis sagittal plane.
Recent improvements in MDCT spatial and temporal resolution and higher detector number systems allow imaging of the aortic root with a minimal slice thickness of 0.5 to 0.75 mm, resulting in almost isotropic datasets allowing oblique reconstruction without degradation of spatial resolution. The aortic annulus plane is obtained by a double oblique multiplanar reconstruction with 2 orthogonal planes representing the short and long axis of the virtual basal ring (Fig. 4). Measurements are taken from systolic phase reconstructions ranging from 20% to 45% of the R-R interval, during retrospective electrocardiographic gating imaging, using the phase with the maximum valve opening as is performed in echocardiography. Computed tomography (CT)-based sizing guidelines under development integrate 3D data afforded by CT into the prosthesis selection process, with recommendations as follows for MDCT mean basal ring measurements: 23-mm valve for annulus ≥19.5 to ≤22.5 mm, 26-mm valve for >22.5 to ≤26.5 mm, and 29-mm valve for >26.5 to ≤29.5 mm (16).
(A) Coronal plane view through the long axis of the left ventricular outflow tract. The longer dimension of the aortic annulus is depicted by the red arrow. (B) Sagittal plane view through the long axis of the left ventricular outflow tract. The shorter dimension of the annulus is depicted by the yellow arrow. Transverse plane reconstructed with the double oblique technique of multiplanar reconstruction (C).
Cardiac magnetic resonance (CMR) allows for an anatomic and functional assessment of the aortic valve and aortic root. However, similar to standard echocardiography, most CMR sequences are 2D with the plane of imaging chosen at the time of the examination (17). Whole heart, echo-gated 3D CMR with contrast and a slice thickness of 1.5 mm, a spatial resolution of 1 mm in-plane and 1 mm through plane (compared with 0.5 × 0.5 × 0.5 mm by MDCT) provides isotropic images for multiplanar reconstruction and shows the oval shape of the annulus with maximal and minimal diameters (Online Fig. 2).
Every technique has its advantages and disadvantages (Tables 2 and 3),⇓ and it often falls to the operator and to local expertise to make the safest and most cost-effective choice. The sagittal plane measurement of the aortic annulus by TTE and TEE usually approximates the minor axis of the elliptically shaped annulus as measured by MDCT. The coronal plane is typically the major (larger) dimension and corresponds to the maximum dimension measured from the anteroposterior view on cine-angiography. In general, the annulus size as measured by TTE is 1-mm smaller than measurements by TEE, and the TEE measurement is 1.0-mm to 1.5-mm smaller than MDCT measurement (18,19). There are no studies to date comparing CMR measurements of the annulus with those by echocardiography or MDCT. Despite these differences, TAVR outcomes with the conventional anteroposterior (sagittal plane) diameter by TEE are excellent (19), and TTE or TEE aortic annulus measurement continues to be the gold standard.
Echocardiography, CMR, or MDCT can be used to measure the distance from the annulus/leaflet hinge point to the left main ostium and the length of the corresponding coronary cusp, important parameters in planning strategies to reduce the risk of coronary obstruction (9). Multiplanar 3D techniques (i.e., TEE, MDCT, or CMR) allow for reconstruction of the plane of the coronary ostia with corresponding better visualization and assessment of these complex structures and their interrelationships (Fig. 5). Bicuspid aortic valves are considered contraindications to TAVR, although it can be difficult to assess whether a valve is bicuspid or not when it is heavily calcified.
(A) Multi-detector computed tomography imaging used to acquire the plane of the left main (LM) coronary artery, with yellow arrow indicating the distance from the hinge point of the left coronary cusp to the LM, and red arrow indicating the length of the left coronary cusp. (B) Multiplanar reconstruction of a 3-dimensional (3D) transesophageal echocardiography (TEE) volume set in the transverse plane. The blue arrow shows the plane of the LM coronary artery. (C) Multiplanar reconstruction of a 3D TEE volume set showing the plane of the LM ostium and coronary artery. This plane is used to measure the length of the left coronary cusp (red arrow) and the distance from the hinge point of that cusp to the LM coronary ostium (yellow arrow) in systole. Ao = aorta; LV = left ventricle.
Both echocardiography and MDCT can evaluate the extent, location, and distribution of aortic annulus and leaflet calcifications, thereby providing important information for successful implantation, although severe calcification might cause acoustic shadowing with echocardiography. For this reason and due to the high spatial resolution of MDCT, this method is currently the test of choice in quantifying severity and identifying the location of aortic cusp calcification. Because of the signal void caused by calcium, CMR is not a suitable choice. Multimodality imaging also provides valuable information about the distribution and extent of calcification in other areas, such as the mitral annulus. For example, dense calcification in the intertrigonal area (the aortomitral curtain) increases the risk of paravalvular AR due to asymmetric expansion of the stented valve (20).
The degree of LV hypertrophy, particularly upper septal hypertrophy and the angle between the aorta and the LV are important in planning the TAVR procedure. A septal bulge protruding into the left ventricular outflow tract (LVOT) provides a challenge to the operator in the accurate placement of the valve and presents a significant risk of THV repositioning with cessation of the pacing run. Left ventricular dysfunction also influences the strategy of the procedure. For instance, in patients with severely depressed LV function, the number of pacing runs should be minimized to avoid hemodynamic compromise. The degree of baseline AR should be evaluated, because balloon dilation might worsen the regurgitant lesion and cause hemodynamic compromise (21). In these cases, the team should be prepared to implant the valve expeditiously. Because catheters and wires are placed in the ventricle, mitral valve compromise might occur at any point in the procedure and therefore the severity of mitral regurgitation should be routinely assessed at baseline and throughout the procedure.
The goals of multimodality imaging in the implantation phase include: 1) ensuring the best prosthesis-patient match; 2) assessing THV position and function after deployment; and 3) identifying immediate complications.
Proper valve placement depends on knowledge of the exact location and orientation of the annular plane, which should be precisely defined either by angiography or CT scan before the procedure (22,23) and overlaid on the screen with fluoroscopy (24) (Fig. 6). Rotational angiography with pacing might also help to define this plane (25) (Online Fig. 3 and Video 1). In addition to fluoroscopic visualization of balloon inflation (Online Fig. 4), injection of contrast at the time of placement is helpful to make final adjustments as necessary with slow balloon inflation and for the final confirmation of the valve position. The CoreValve (Medtronic) can be pulled up while being deployed, if it is thought to be too deep in the ventricle.
(A) Three-dimensional computed tomography reconstruction demonstrating the aortic plane running from right anterior oblique (RAO) caudal to left anterior oblique (LAO) cranial angles. (B and C) Aortic root injection in LAO (B) and RAO (C) views demonstrates the aortic valve plane with location of each leaflet, respectively. LCC = left coronary cusp; NCC = noncoronary cusp; RCC= right coronary cusp. See Online Video 1.
Transesophageal echocardiography provides continuous real time visualization of the annulus, valve, and balloon, thereby aiding device placement and prediction and immediate detection of AR. The desired "50-50" positioning of the SAPIEN (Edwards Lifesciences) valve within the LVOT and aortic root depends on proper identification of the hinge points of the native aortic valve leaflets and its relation to the extent of the prosthesis above or below that point. This landmark is not optimal, because the hinge points are not all at the same level within the oval-shaped annulus and at times can be difficult to visualize. Side-to-side exploration or biplane imaging might minimize some of these limitations. Experience with intracardiac echocardiography is limited.
Differentiating the valve and balloon just proximal to the valve with imaging can be difficult. To overcome this, the operator can compare the length of the stent segment by echocardiography with known stent length to confirm that the stent is identified accurately. Transesophageal echocardiography can also be used to assess whether the delivery system, including the valve, is coaxial to the LVOT. The tips of the leaflets provide another echocardiography landmark necessary to make sure that the distal end of the SAPIEN (Edwards Lifesciences) stent covers the tip of native aortic valve, although the trajectory of the delivery system in relation to the LVOT can also affect this interpretation.
Transesophageal echocardiography is particularly useful in predicting and managing acute AR (1,26,27). When it is suspected that asymmetric calcification might affect final THV shape, imaging during balloon aortic valvuloplasty can be used to localize regions of asymmetric dilation and thus predict the localization of post-TAVR AR (Fig. 7) (Online Video 2).
(A) Biplane imaging during balloon inflation. The green arrows identify the waist of the balloon at the level of the annulus. The blue arrow shows asymmetric balloon dilation at the commissure between the left and noncoronary cusps. The yellow arrows depict acoustic shadowing, which prevents adequate visualization of the peri-balloon region (see Online Video 2 for a moving image of using balloon aortic valvuloplasty for sizing). Biplane imaging immediately after transcatheter aortic valve replacement of the case from (A) shows aortic regurgitation at the sites predicted during balloon aortic valvuloplasty (red arrows) (B). See Online Video 2.
Although minor AR is common after TAVR, moderate or severe AR is not common, occurring in 5% to 22% of cases (28,29). For both types of THVs, the most important determinants of post-TAVR AR are: undersizing of the prosthesis, the extent of calcification of the valve, and the prosthesis position in relation to the annulus (30). Studies of the SAPIEN valve (Edwards Lifesciences) (14) showed that the cover index (calculated as the difference between the prosthesis diameter and TEE annulus diameter, divided by the prosthesis diameter) is also an important predictor of post-TAVR AR. Moderate or greater AR was never observed in patients with a cover index >8% (i.e., valve diameter >8% larger than the measured annulus) (14). Valve anatomy, severity of calcification, symmetry of valve opening, as well as the angle of the LVOT/aorta have also been described by others as potential determinants of post-TAVR AR for the self-expanding valve (31).
To prevent paravalvular leak, the covered part of the prosthesis must be well-apposed to the native leaflets and interleaflet triangles. The ventricular edge of the device must be just below the hinge points of the aortic valve. If the balloon-expandable valve is placed too deep within the LV, it can potentially embolize into the ventricle but more commonly might leave native leaflets uncovered, creating leaflet overhang—which alters the hemodynamic status of THV valve closure and causes significant central AR. If the valve is placed too high within the aorta, it can potentially embolize into the aorta, resulting in coronary artery obstruction or significant paravalvular regurgitation by leaving significant portions of the valve apparatus uncovered by the stent.
Placement of a self-expanding valve too deeply into the ventricle can also cause considerable AR through the uncovered part of the prosthesis (32). Impingement and injury of the anterior leaflet of the mitral valve is also a concern for "deeply" placed valves. There is potential for paravalvular AR if 1 of the commissures is not covered by the stent due to high positioning. Alternatively, central AR can result if the stent is "flared" too much on the aortic side due to high positioning.
Immediately after valve deployment, TAVR stent positioning, shape, leaflet motion, and AR can rapidly be assessed with TEE imaging in biplane mode (Fig. 7) or a single plane short-axis view (33). For paravalvular regurgitation, the short-axis plane of imaging should be just below the TAVR stent and skirt and just within the LVOT; if the imaging plane is above the stent, regurgitation might not be visualized or color flow just above the annulus but contained within the sinuses of Valsalva might be mistaken for regurgitant jets into the LV. Confirmation of the severity of AR should always be performed from multiple echocardiographic views. The deep gastric view allows imaging of the LVOT without acoustic shadowing (Fig. 8). Imaging the entire annulus is mandatory and requires rotating 180° while centered on the valve. The severity of AR typically lessens over the next 30 min after implantation. Thus, small central or paravalvular regurgitant jets are commonly seen and do not require intervention. Patients with more than mild paravalvular regurgitation, however, could be considered for a second balloon dilation (Online Fig. 5 and Online Videos 3 and4). In many instances, post-deployment balloon dilation results in an immediate reduction in paravalvular regurgitation.
Deep gastric transesophageal echocardiography views of post-transcatheter heart valve paravalvular aortic regurgitation (red arrows). Biplane imaging or a full rotation to image 360° of the annulus are required to fully assess the type and severity of aortic regurgitation. See Online Videos 3 and 4 to see how TEE demonstrates reduction of paravalvular aortic regurgitation after a second balloon inflation.
The diagnostic considerations in a severely hypotensive patient with post-deployment cardiovascular collapse are not limited to AR, and real time multimodality imaging can detect and guide the management of many of them. The differential diagnosis includes coronary artery obstruction, pericardial tamponade, severe mitral regurgitation, aortic dissection, LV damage or perforation or rupture, and embolization of the THV (34). As such, TEE or fluoroscopy can yield the diagnosis within seconds by demonstrating a wall motion abnormality, large pericardial effusion, color flow signal of severe regurgitation, dissection of the ascending aorta or rupture of the annulus, and the location of the THV, respectively (Online Videos 5, 6, 7, and 8 for selected examples). Because of the implantation positioning of the ventricular portion of the self-expanding valve, there has been a higher reported incidence of heart block (32).
The goals of post-implantation imaging include: 1) assessment of valve hemodynamic status, including gradients and effective valve area; 2) quantification of valvular and paravalvular regurgitation; 3) determination of the effect of implantation on the disease processes related to outflow obstruction (such as LV hypertrophy, chamber remodeling, diastolic and systolic function); 4) ongoing assessment of concomitant pathology; and 5) detection of long-term complications such as device migration, thrombus formation, ventricular perforation, mitral valve impingement, and endocarditis.
Echocardiography is the imaging modality of choice for long-term surveillance, because it provides substantial benefits over other techniques, including widespread availability, lack of need for ionizing radiation, and ability to image structures as well as accurately measure hemodynamic status. Furthermore, both the SAPIEN (Edwards Lifesciences) and CoreValve (Medtronic) systems have good ultrasound imaging characteristics such that a detailed assessment of position, hemodynamic status, and of the types and degrees of AR with TTE is possible without significant acoustic shadowing (35,36) (Online Videos 9 and 10).
However, MDCT and CMR are playing larger roles in the post-procedural evaluation of TAVR patients, allowing the evaluation of structural integrity, sphericity, position, aortic regurgitant volume, and post-procedural complications (5) (Online Fig. 6). These modalities also afford excellent anatomic detail, allowing for simultaneous assessment of the prosthesis and its relationship to the native valve, root, and ventricle as well as detecting pseudoaneurysms of the root or apex and other rare complications (Fig. 9 and Online Fig. 7).
Coronal multiplanar reconstruction of the aortic root in an 89-year-old female patient 3 days after transcatheter aortic valve replacement. Difficulties with the rapid ventricular pacing were encountered, resulting in a low deployment, root injury, and a resultant pseudoaneurysm (arrow). See Online Videos 5, 6, 7, and 8.
Left ventricular mass regression and improvement in ejection fraction (EF) have been well-documented in patients after surgical aortic valve replacement (SAVR) for aortic stenosis (37). Similarly, in patients undergoing TAVR there are reductions in LV mass, modest improvement in EF (38), and improved diastolic function (39), and mitral regurgitation might improve (40). A recent comparison of SAVR with TAVR in patients with low EF showed a greater increase in EF in the TAVR group (41). The LV mass, size, and diastolic and systolic function should thus be followed routinely after TAVR to quantify the late effects of the hemodynamic improvement. Echocardiography is the imaging modality of choice in evaluating LV mass (42); however, LV mass by CMR also offers a highly accurate estimate (43).
Key metrics of prosthetic valve function include mean and peak transvalvular pressure gradients and the derived indexes of effective orifice area (EOA) and Doppler velocity index (DVI) (36). Determination of valve gradients with continuous wave Doppler is relatively straightforward, noting that suprasternal notch and right parasternal windows and imaging and nonimaging Pedoff probes should be routinely used to ensure that maximal gradients are captured. Both the SAPIEN (Edwards Lifesciences) and CoreValve (Medtronic) have excellent flow characteristics with mean gradients of 10 to 15 mm Hg (Table 4) (44,45). The 3-year results from a balloon-expandable valve (5) suggest that a small increase in mean transvalvular gradient (3.8%/year) and a small reduction in valve area (0.06 cm2 /year) might occur over time.
Although calculations of EOA and DVI provide flow-independent indexes of valve function, they are more challenging to perform in THV than for conventional surgical prostheses because the supporting stent creates acceleration at both the level of the stent and within the stent at the level of the cusps (46) (Fig. 10). This unique flow characteristic and the potential for variability in cross-sectional area calculations make it imperative that the subvalvular velocities used in either the DVI or EOA be routinely sampled proximal to the stent. Sampling within the stent will result in an overestimation of valve area or DVI. Additionally, inconsistent sampling sites (within the stent at 1 time, below the stent at another) will result in variable valve areas that might be misinterpreted as changing valve hemodynamic status.
(A) Schematic presentation of echocardiographic pulse-wave (PW) Doppler patterns when the sample volume is placed pre-stent, in-stent but pre-cusps, and continuous wave (CW) through the aortic valve. Due to flow acceleration, it is imperative that the subvalvular velocities used in either Doppler velocity index or effective orifice area be sampled proximal to the stent. (B) The PW Doppler pattern of a sample volume placed before stent. White arrows show the extent of the transcatheter heart valve in the aortic root. Red arrow shows the level of the prosthetic aortic cusps. (C) The PW Doppler pattern of sample volume placed within the stent but before cusps. (D) The PW Doppler pattern of a sample volume placed at the level of the cusps. See Online Videos 9 and 10.
The projection of the stent into the LVOT can also lead to confusion as to the optimal site for measuring LVOT diameter. Because there is reduced variability and better correlation with transvalvular gradients when EOA is calculated with diameters measured immediately proximal to the stent (47), optimal assessment of EOA and DVI for the SAPIEN valve (Edwards Lifesciences) should employ velocities and diameters obtained proximal to the valve stent. The flow characteristics of the CoreValve (Medtronic) and the optimal site for measuring LVOT diameter for this THV have not been reported.
Prosthesis-patient mismatch (P-PM) occurs when the EOA of the implanted prosthesis is too small in relation to body size, and severe P-PM is defined by an EOA ≤0.65 cm2/m2. The P-PM determines morbidity (48), LV mass regression (49), and mortality (50) after SAVR. A considerable proportion (20% to 70%) of patients have P-PM after open aortic valve replacement (30), but this seems to be less of a problem after TAVR with CoreValve (Medtronic) or SAPIEN (Edwards Lifesciences) THVs (P-PM incidences 16% to 32% and 6%, respectively) (30,51,52). Given that the experience with TAVR is still growing, the long-term imaging assessments after TAVR should include a thorough examination to document the presence or absence of P-PM to understand the potential clinical significance of P-PM in this population.
Both transvalvular and paravalvular AR might be seen after TAVR, with mild or less being the most common severity found for either THV (26,28). Differences between the balloon-expandable (SAPIEN [Edwards Lifesciences]) and self-expanding valves (CoreValve [Medtronic]) have not been fully characterized; however, in 1 registry (53) there was an insignificant but higher odds ratio for significant AR with the self-expanding valve. Follow-up echocardiograms should identify the presence, location, and severity of both types of regurgitation. The optimal views for detection of regurgitant jets include the parasternal long-axis, short-axis, apical long-axis, and 5-chamber views, although—due to eccentric jets—off-axis views should also be used to ensure accurate determination of the location and severity of regurgitation. Color and spectral Doppler techniques are applied in a manner similar to that of other prosthetic aortic valves (36), with determination of flow convergence, measurement of the vena contracta, and extent of regurgitation into the LV and spectral Doppler parameters such as the pressure half-time and holodiastolic flow reversal into the descending aorta. Because both types of regurgitation affect LV hemodynamic status, a summary measurement of regurgitation, or "total AR," should routinely be calculated and measured as outlined in the following text.
Significant transvalvular AR after TAVR is usually due to valvular damage during the implantation procedure, too large a prosthesis for a small annulus resulting in valve deformation, or severe calcification of the native valve leading to deformation of the frame of the THV (54). Short-axis and off-axis views can be especially helpful to characterize the origin of the jet passing through the prosthetic leaflets. With eccentric transvalvular AR jets, care should be taken to measure the vena contracta in the correct plane, because measurements of regurgitant jet width parallel to the LVOT measurement risk overestimating the degree of regurgitation. With the recent prosthetic valve guidelines, transvalvular AR should be reported as: 1) mild; 2) moderate; or 3) severe (55). Trivial or trace regurgitation might also be noted.
Paravalvular AR (or paravalvular leak, perivalvular leak, or paraprosthetic regurgitation), in contrast to transvalvular AR, is usually caused by incomplete prosthesis apposition to the native annulus due to remaining material of the native valve or ridges of calcium, too small a prosthesis for a large annulus, or too-low implantation of the valve leading to paravalvular leakage through uncovered portions of the prosthesis (54,56). Because paravalvular AR jets travel along the natural curvature of the prosthesis-annular interface, imaging in multiple planes is necessary (Fig. 11) and might be difficult to differentiate from transvalvular AR. The transthoracic short-axis view is usually the best to view the true orifice of paravalvular AR and helps to prevent the overestimation of AR severity that can occur when relying solely on apical views. With recently proposed criteria for standard endpoint definitions for TAVR clinical trials, the circumferential extent of paravalvular AR can be graded with <10% being associated with mild paravalvular AR, 10% to 20% being associated with moderate, and >20% being associated with severe AR (55) (Fig. 12). As with all AR parameters, the approximation of circumferential extent should be weighed with all other available criteria for assessing the degree of regurgitation.
(A) Paravalvular aortic regurgitation seems trivial in the short-axis view at the level of the aortic annulus. (B) Paravalvular aortic regurgitation grade is moderate in this off-axis apical 5-chamber view of the same patient.
(A) Schematic and illustrated representation of the short-axis view at the level of the aortic valve by echocardiography. (B) Echocardiographic and schematic illustrations of the short-axis view of the aortic valve. Paravalvular aortic regurgitation (AR) can be graded according to the circumferential extent of the regurgitant jet. Paravalvular AR can be graded as mild, moderate, or severe on the basis of a circumferential extent of <10%, 10% to 20%, or >20%, respectively. See Leon et al. (55). RV, right ventricle. Image credit: CC Patrick J. Lynch and C. Carl Jaffe, Yale University, 2006.
The total amount of regurgitation is the most important factor with regard to the hemodynamic response to the increased volume load, which in turn might affect chamber dilation, LV function, and development of pulmonary hypertension (57). Combining information from color and spectral Doppler for both transvalvular and paravalvular AR with established grading criteria, the total AR should be part of the routine assessment after TAVR as an assessment of the total volume load. In most cases, this will be equal to the most severe degree of AR of either transvalvular or paravalvular AR. However, in some instances, the addition of the 2 flows will push the grading to the next level of severity (e.g., mild transvalvular AR plus mild-moderate paravalvular AR are graded as moderate total AR).
Quantitative assessments of regurgitant fraction and regurgitant volume can also be helpful in determining the severity of total AR (55). CMR might be a useful supplement to echocardiography and might be the modality of choice when the degree is severe or when there is discordance in grading from different echocardiographic windows (58).
There is rich opportunity for research in multimodality imaging related to TAVR, especially because most work to date has been observational and limited to a single THV device. As experience develops, it follows that prospective studies should be performed to compare different imaging strategies and different THV devices. Along with this work, the trial endpoints and methodologies proposed by the Valve Academic Research Consortium (55) and/or used by TAVR core laboratories need to be validated to guide future clinical trials, observational studies, and state-of-the-art clinical practice. Finally—although substantial redundancy in imaging with multiple techniques to assess the same structures or frequently repeated tests is warranted initially—as experience grows, developing a rational algorithm for imaging use both before and after implant will become a priority.
There are also specific research opportunities at each phase of TAVR patient care. Techniques for pre-procedural assessment can be refined and employed in systematic comparisons of the accuracy of different techniques in determining parameters, such as annular dimensions and annulus to left main coronary distance (e.g., a multi-center study that randomizes patients to receive either annular sizing with MDCT or echocardiography). Assessment of the relative value of multimodality imaging findings to select the optimal THV device as well as predictors of subsequent implantation success and complications are other important areas of investigation.
Much of the utility of imaging during implantation comes from offering real time guidance of the procedure, including rapid detection of malpositioning and complications. Because of the novelty of TAVR, case reports and case series with imaging are helpful to document the range of complications and to educate less experienced implanting teams.
The post-implantation THV assessments detailed here reflect expert consensus, and their utility should be validated by comparison with other techniques and long-term outcomes. This is particularly true for quantitative assessments of paravalvular, transvalvular, and total AR—which might differ slightly between devices—and the impact of total AR on long-term cardiac structure, function, and clinical outcomes. With regard to AR, more specific, reproducible, and quantitative criteria need to be developed. Comparison of regurgitant volumes obtained by 2D and 3D TTE and TEE, quantitative Doppler, and CMR as well as consideration of invasive and hemodynamic correlates will be informative and might refine the perceived significance of this complication. The long-term clinical impact of relief of pressure overload on regression of LV hypertrophy, chamber remodeling, diastolic and systolic function, mitral regurgitation, and other compensatory or concomitant cardiac abnormalities needs to be more fully characterized, compared across THVs and with SAVR, and related to functional status and outcome. In a similar way, detection and quantification of P-PM and its frequency and implications is an important and rich area for future investigation.
Dr. Gillam has a Core Lab Contract with Edwards Lifesciences. Dr. Leipsic has served on the Speaker's Bureau and MAB for Edwards Lifesciences and GE Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Revision received November 27, 2011.
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(2010) System to guide transcatheter aortic valve implantations based on interventional C-arm CT imaging. Med Image Comput Comput Assist Interv 13:375–382.
(2010) Association of aortic valve calcification severity with the degree of aortic regurgitation after transcatheter aortic valve implantation. Int J Cardiol 150:142–145.
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(2009) Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 22:975–1014.
(2011) One-year results of transcatheter aortic valve implantation in severe symptomatic aortic valve stenosis. Am J Cardiol 107:1687–1692.
(2011) In-stent flow acceleration in the SAPIEN transcatheter aortic valve: impact on the echocardiographic assessment of valve function. J Am Soc Echocardiogr, In press.
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The oroshigane grater, also known as oroshiki, is widely used in Japanese cooking and is a staple in professional kitchens. It grates more finely than typical western graters and makes short work of garlic, ginger or chillies. It is beautifully packaged with a rather stylish black and white aesthetic. This is the smallest size.
"The oroshiki grater differs from its western counterpart in that it produces a much finer end product. They are generally used for Wasabi and ginger but I find they work equally as well with garlic and horseradish root. They don't have perforations at the back so the ingredients are held at the front, ready to be scraped off."
Check out our tips for homemade horseradish here.
The small grater is 55x75mm. It is made in Japan from stainless steel.


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Australian actor Travis Fimmel, best known for his role in historical TV drama Vikings, will star in a movie about the Battle of Long Tan, and 200 Iraq and Afghanistan war veterans are wanted as extras.
A movie about the Vietnam War Battle of Long Tan will be made in southern Queensland, featuring Australian actor and Vikings star Travis Fimmel.
Queensland Premier Annastacia Palaszczuk made the announcement in Los Angeles at the end of her trade mission to the US.
Ms Palaszczuk said the movie, provisionally titled Danger Close, would be filmed from the end of April in Nerang and Kingaroy.
"So that's great news for regional Queensland, but also sends a really strong message that you don't have to be in the Gold Coast or Brisbane to film a great movie," she said.
"It's probably a medium-range film. This is one of many that will be filmed in Queensland over the next few years.
Ms Palaszczuk said the movie's producer Martin Walsh told her he would like to employ 100-200 Australian veterans of the Iraq and Afghanistan campaigns as extras for the project.
"So we're going to put a call out to those veterans to see if they would be interested in participating," she said.
"I was moved to hear that Martin, himself a former Australian Special Forces commando, is planning a major Anzac Day event during the shoot — bringing Long Tan veterans, cast, crew and locals together for a special memorial service," Ms Palaszczuk said.
The Premier said production would employ an estimated 120 full-time Queensland crew members.
Ms Palaszczuk said there was a growing market for streamed content, and she hoped Queensland would be a destination for future projects.
"What I have learned very clearly over the last two days meeting with the movie studios over here, is that what we are seeing is a huge uptake now in streaming of TV.
However, Ms Palaszczuk said she still wanted to attract more major productions to Queensland, especially after the Commonwealth Games in April.
"We want to sign up for the next blockbuster. What I can say is that there is very keen interest in Dora the Explorer and if we got that movie filmed in Queensland it could be the start of a series," she said.
She said producers of a Barbie movie were also interested in filming on the Gold Coast.
"But once again the biggest barrier we have is the fact that the Federal Government is not increasing the tax offset," she said.


As the title says... My game is a multiplayer game over network and I don't want it to pause whenever the game looses focus (via ALT+TAB or whatever). Therefore I set the runInBackground flag to true. However I noticed that when the window of the game is behing let's say Google Chrome for instance, I still hear the game reacting to the mouseover events (because my buttons trigger a sound when they are hovered). Is it normal? What am I missing here?
You should be able to use OnApplicationFocus to detect when your game is in the background and then ignore input when your app isn't focused.


"A random landing in London and a trip to the Savoy Hotel yield unexpected results for the Doctor. Tea, scones, an American general who knows far too much, and the threat of a Dalek invasion of Earth.
It seems the Doctor's deadliest foes have woven a tangled web indeed. And in order to defeat them, he must cross the forbidden barriers of time and walk into the very centre of their latest, most outlandish scheme of conquest."
What did you think? What happened when he crossed the barriers of time? Does anybody else imagine an epic Lawrence of Arabia landscape with that phrase? Just me?
This one was a little campy for me. It was too long and wasn't totally capturing my attention.
I like that it focuses again on the Dalek invasion of earth in the 22nd century. It's definitely a story that a lot of things refer back to, and here history has been changed and somehow we end up with all these extra companions from....largely American wars. Which made no sense to me honestly. The addition of these characters was sort of fun, but the whole thing I was just thinking that I would just rather have a different story altogether that's a Doctor-companion story.
Still a fun listen, just not my favorite of the bunch.
I kind of enjoyed the fact that it explored American wars, but the characters felt really stereotyped and annoying. Liked how it started it off but it trailed off about halfway through. Very timey-wimey. Not quite sure what the Greylish thing was at the end. Not one of the best audio dramas. Daleks just kind of felt thrown in there and weren't really threatening at all.
This started off with a lot of cool ideas: toy Daleks, mixing in with the American wars, people trying to prevent the Dalek Invasion of Earth. Then it all became very dull. It was too much of characters not knowing what was going on, not knowing what was going on and then long explanations of what's going on before they didn't know what was going on again. One small thing I liked was how they used songs to convey messages, much like the Underground Railroad. Once again, Nyssa was just there for sci-fi mumbo jumbo. Also the character of Alice, the one from Nam, was very very annoying. So this was a bit lame after a bit which is unfortunate.


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She Died Famous by Kyle Rutkin
Kyle Rutkin
A Star is Born meets Gone Girl in this dark and twisted love story with an unforgettable conclusion.
A gripping psychological thriller about iconic superstar, Kelly Trozzo, and her suspected killer, the author she commissioned to pen her shocking Hollywood memoir.
CHECK OUT THE BOOK THAT #BOOKSTAGRAM IS BUZZING ABOUT!
"It was like a psychological thriller version of Daisy Jones and the Six that made friends with Fight Club." - @thebuzzedbookworm
"This was an incredible journey into the dark side of stardom and is written in such a unique way, you won't want it to end!" - @reads.a.latte.thrillers
"The unexpected ending left me stunned and emotional for quite awhile after closing the book."
@hallsofbooksandflowers
"Dark, edgy, and completely captivating." - @brianas_best_reads
"It's a wild ride." - @earlybirdbookworm
"I literally started yesterday and finished yesterday." - @whatsheeseees
"Fully captivated the entire time."-@book.happy
"The ending was jaw-dropping." @the_book_world_of_chessie
"If you are a fan of You by Caroline Kepnes and Dark Places by Gillian Flynn then you would enjoy this!" -@unshelvededition
"I could not get enough of this book!"- @books_beaches_and_tea
"A thrill ride on the dark side." -@waywardreader
"If you enjoyed reading Daisy Jones and the Six, The Silent Patient and My Lovely Wife, you would absolutely love this read." @nursebookie
"Dark, obsessive and oh so readable." -@arianna.reads
Enter the giveaway now!
Flash Crash by Liam Vaughan
Liam Vaughan
*EARLY COPY GIVEAWAY*
The riveting story of a trading prodigy who amassed $70 million from his childhood bedroom--until the US government accused him of helping trigger an unprecedented market collapse
On May 6, 2010, financial markets around the world tumbled simultaneously and without warning. In the span of five minutes, a trillion dollars of valuation was lost. The Flash Crash, as it became known, represented the fastest drop in market history. When share values rebounded less than half an hour later, experts around the globe were left perplexed.
Raised in a working-class neighborhood in West London, Navinder Singh Sarao was a preternaturally gifted trader who played the markets like a computer game. By the age of thirty, he had left behind London's "trading arcades," working instead out of his childhood home. For years the money poured in. But when lightning-fast electronic traders infiltrated markets and started eating into his profits, Nav built a system of his own to fight back. It worked--until 2015, when the FBI arrived at his door. Depending on whom you ask, Sarao was a scourge, a symbol of a financial system run horribly amok, or a folk hero who took on the tyranny of Wall Street and the high-frequency traders.
A real-life financial thriller, Flash Crash uncovers the remarkable, behind-the-scenes narrative of a mystifying market crash, a globe-spanning investigation into international fraud, and the man at the center of them both.
Hidden Valley Road by Robert Kolker
Robert Kolker
The heartrending story of a midcentury American family with twelve children, six of them diagnosed with schizophrenia, that became science's great hope in the quest to understand the disease.
PRAISE FOR HIDDEN VALLEY ROAD:
"Hidden Valley Road raises the bar on what is possible in narrative nonfiction. A marvel of reportage, research, and style, Robert Kolker dives into the exceptional story of one family besieged by humanity's most mysterious malady. Kolker writes about the Galvin family with elegance and insight while weaving together the decades long quest to understand the genetics of schizophrenia, somehow creating a story that is as haunting and intriguing as a great gothic novel. This book is a triumph, an unforgettable story that you should read right now."
—Susannah Cahalan, author of Brain on Fire and The Great Pretender
"An extraordinary case study and tour de force of reporting."
—Sylvia Nasar, author of A Beautiful Mind
"This broad-ranging, highly readable, and deeply unsettling book tells the story of a family beset with schizophrenia, and in doing so provides meaningful insights into the devastation caused by the disease. It is, equally, a study of the multiple ways in which familial denial can exacerbate the inherent pain of mental illness, and of the courage required both of those who are themselves diagnosed with it and of those who choose to help and support them."
—Andrew Solomon, author of Far From the Tree
Losing Jon by David Parrish
David Parrish
ENTER FOR YOUR CHANCE TO WIN A COPY OF LOSING JON BY DAVID PARRISH!
In 1990, Jon and Mickey Bowie, 19 year-old identical twin brothers, met up with friends to drink beers and party at a Red Roof Inn outside of Columbia, Maryland. There were fifteen teenagers and two cases of beer and the music was probably louder than it should have been. Police came to break up the party and while doing so violently beat the twin brothers, leaving their faces bloody and eyes swollen shut. Outraged, the Bowie brothers pressed charges against the police officers for excessive force. These charges led to months of harassment and intimidation by the police. Just before the brothers were to appear in court to face the police, Jon Bowie turns up dead, his body discovered on top of the backstop at the high school baseball field, and his death was immediately declared a suicide. However, as witnesses stepped forward and the events of the weeks and days leading up to Bowie's death are discovered, it became clear that this was no suicide.
Could a charge of excessive force be enough to convince a police officer to murder a teenager?
The Whispers of War by Julia Kelly
The start of World War II looms over three friends who struggle to remain loyal as one of them is threatened with internment by the British government, from the author of the "sweeping, stirring" (Kristin Harmel, internationally bestselling author of THE ROOM ON RUE AMÉLIE) THE LIGHT OVER LONDON.
In August of 1939, as Britain watches the headlines in fear of another devastating war with Germany, three childhood friends must choose between friendship or country. Erstwhile socialite Nora is determined to find her place in the Home Office's Air Raid Precautions Department, matchmaker Hazel tries to mask two closely guarded secrets with irrepressible optimism, and German expat Marie worries that she and her family might face imprisonment in an internment camp if war is declared. When Germany invades Poland and tensions on the home front rise, Marie is labeled an enemy alien, and the three friends find themselves fighting together to keep her free at any cost.
Featuring Julia Kelly's signature "intricate, tender, and convincing" (Publishers Weekly) prose, THE WHISPERS OF WAR is a moving and unforgettable tale of the power of friendship and womanhood in the midst of conflict.
Code Name Hélène by Ariel Lawhon
The newest feat of historical fiction from the New York Times bestselling author of I Was Anastasia, is based on the life of socialite spy Nancy Wake. This astonishing woman led French Resistance forces, saved countless lives, and went on to become one of the most decorated women in World War II. If you're looking for a portrait of a smart, resourceful, powerful woman, look no further.
Bitter Falls by Rachel Caine
Rachel Caine
An Amazon Charts, #1 Wall Street Journal, and USA Today bestselling series.
She's investigating a cold case no one else could—by going places no else would dare.
In spite of a harrowing past still haunting her, Gwen Proctor is trying to move forward. Until a new assignment gives her purpose: the cold-case disappearance of a young man in Tennessee. Three years missing, no clues. Just Ruth Landry, a tortured mother in limbo. Gwen understands what it's like to worry about your children.
Gwen's investigation unearths new suspects…and victims. As she follows each sinister lead, the implications of the mystery grow more disturbing. Because the closer Gwen gets, the closer she is to a threat that looms back home.
In a town that's closed its ranks against Gwen; her partner, Sam; and her kids, there's no bolder enemy than the Belldene family—paramilitary, criminal, powerful, and vengeful. As personal vendettas collide with Gwen's investigation, she's prepared to fight both battles. But is she prepared for the toll it could take on everyone she loves?
Hunting for a Highlander by Lynsay Sands
Enter for a chance to win an early Kindle copy of Hunting for a Highlander, Lynsay Sands' newest Highland romance featuring the Buchanan brothers.
Lady Dwyn Innes feels utterly out of place among the eligible women who've descended on Buchanan Keep, vying for the attention of the last unmarried brothers. She isn't long-legged and slender like her sisters, or flirtatious and wily like other lasses. Since her betrothed died, Dwyn has resigned herself to becoming an old maid. Yet a chance encounter with a stranger in the orchard awakens her to a new world of sensation and possibility...
After weeks away, Geordie Buchanan returns to find his home swarming with potential brides, thanks to his loving but interfering family. But one lass in particular draws his attention from the moment he spies her climbing a tree. Lady Dwyn is not nearly as plain as she thinks. Her lush figure and eager kisses delight him, as does her honesty. But the real test lies ahead: eliminating a hidden enemy, so that he and Dwyn can seal their Highland passion with a vow.


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Belligerence — Belligerents — Proportionality — UN Charter — Ius ad bellum — Neutrality and non-alignment
This chapter focuses on the rights of belligerents against neutrals. Now that the threat or use of force is prohibited in international law, legal principle would suggest that belligerents are limited in their ability to take belligerent measures against neutrals that were previously dependent on a state of war for their operation—such as the right of visit and search, the right to establish a blockade, and the right to set up exclusion zones. Because the relationship between belligerents and neutrals is a peaceful one, interference by belligerents with neutral shipping and aircraft will have to satisfy a double test in order to be lawful: such interference must meet the requirements of necessity and proportionality under the jus ad bellum, and also meet the requirements of the law of neutrality and naval warfare. Therefore, State practice suggests that after the first half of the twentieth century—which saw the expansion of belligerent rights against neutrals to an alarming degree—the situation has, in many respects, been reversed by the influence of the UN Charter and the peacetime freedoms of the sea on the law of naval warfare. Indeed, the scope of permissible belligerent action against neutrals has probably been narrowed considerably, demonstrating the overlap between the law of the UN Charter and the law of neutrality.


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#traveltomorrow Castles And Palaces You Can Explore From Your Couch
#traveltomorrow
You Can Explore From Your Couch
The travel and tourism industry has practically grounded to a halt within a few weeks due to the COVID-19 pandemic. But that doesn't mean we stop dreaming...
While we're all stuck indoors, you can experience some of the world's most breathtaking castles and palaces from your living room.
Neuschwanstein, Bavaria, Germany
Image by Helmut H. Kroiss from Pixabay
Walt Disney based his Cinderella castle on this impossibly ornate fairy tale castle in the 19th century Romanesque Revival style. Perched on the top of a steep hill in the village of Hohenschwangau, Bavaria. They didn't call Ludwig II of Bavaria "Mad Ludwig" for nothing - the sheer mania that must have been behind the construction of a palace in that location must have been formidable.
Neuschwanstein interior courtyard - Image by ian kelsall from Pixabay
Ludwig, aka the Swan King or der Märchenkönig ("the Fairy Tale King"), Count Palatine of the Rhine, Duke of Bavaria, Duke of Franconia, and Duke in Swabia, drained his personal fortune on various palace building projects, and once threatened to commit suicide if his creditors took them over.
Singer's Hall, Neuschwanstein Castle - Image by 272447 from Pixabay
Sadly, in the end Ludwig only spent 11 days in the not-yet-finished castle before his death at age 41 in 1886 in what was deemed to be suicide by drowning. Shortly before his death, the Bavarian parliament had him declared legally insane. The drowning verdict didn't hold up under scrutiny, and anecdotal testimony says he was shot trying to escape the virtual coup.
Ironically, it is tourism revenues from his palaces that funded the House of Wittelstein until after WWI, when the state took control of the heritage site. From the entrance to the highest turret, it's a fantasy come to life.
• Check It Out At The Link
The Taj Mahal, Agra, India
Taj Mahal, exterior - Image by Volker Glätsch from Pixabay
The iconic spires of the Taj Mahal in Agra, India, have captured the public's imagination since it was built in 1632 by the Mughal emperor Shah Jahan as the world's most romantic mausoleum. It was built to house the remains of his favourite wife, Mumtaz Mahal, who died giving birth, and eventually became Shah Jahan's tomb as well.
Taj Mahal colonnade - Image by DEZALB from Pixabay
At the time, it was said to cost 32 million rupees, or about $960 million in today's USD, and is an excellent surviving example of Persian and Mughal architecture of the time. The use of white marble set with semi-precious stones is said to have been the Shah's own idea.
Taj Mahal exterior detail - Image by Balaji Srinivasan from Pixabay
The large marble dome is perhaps its most well known and renowned feature, with a dome about 35 metres high, and the minarets reach more than 40 metres into the sky. Intricate decorations on the exterior as well as interior make it one of the most celebrated works of architecture throughout history.
Versailles, France
Chateau Versailles - Image via www.all-free-photos.com through a CC license
The Palace of Versailles became the principal residence of the French royal family from the days of Louis XIV, the Sun King, until the French Revolution in 1789.
Cour de Marbre du Château de Versailles - Image by Kimberly Vardeman under a CC license
The site had been used by the royal family as a hunting lodge, and a small château occupied the area until The Sun King decided on a super-royal makeover in 1661. It took about 21 years until he deemed the palace large enough to house the entire royal family and their entourage.
Galerie des Glaces du Château de Versailles, à Versailles en France - Image by Myrabella / Wikimedia Commons / CC BY-SA 3.0
Built in the opulent French Baroque style, some of the original furnishings were made of solid silver - but had to be melted down and sold in later years to help cover the costs of war. It was designed and supervised by architect Louis Le Vau, with subsequent work by young architect Jules Hardouin-Mansart.
Bran Castle, Romania
Image by Dobre Cesar (used under a CC 3.0 Romania license)
Interestingly, Bram Stoker never actually visited Bran Castle in Romania before writing his seminal novel, Dracula, but went only by descriptions he found. The castle is surrounded by the five villages that make up the commune of Bran, near the city of Brașov.
Castle Bran - Image by danieldudu from Pixabay
Stoker's Dracula is often thought to be based on Vlad Tepes, aka Vlad the Impaler of Vlad Dracul, a Walachian Prince whose castle ruins are in Transylvania. Castle Bran came to be associated with Stoker's novel and the growing vampire legend because its location corresponds to the book's description: "...on the very edge of a terrific precipice...with occasionally a deep rift where there is a chasm [with] silver threads where the rivers wind in deep gorges through the forests."
Bran Castle, interior courtyard - Image by falco from Pixabay
Old supersitions in the area do speak of strange spirits who live as humans by day and evil demons as night. Thought to have been built around 1377, the castle became a royal residence in 1920, and today houses a collection of period furnishings and art.
Blarney Castle (Caisleán na Blarnan), Blarney, Ireland
Blarney Castle - Image by Len Williams (CC BY-SA 2.0)
This splendid medieval ruin is located near Cork, Ireland, and was originally built around 1210. That structure was destroyed, and rebuilt in 1446 by Cormac Láidir MacCarthy, Lord of Muscry.
Blarney Castle, interior family room - Image by Ben Snooks (CC BY-SA 2.0)
The castle suffered through the ups and downs of the Ireland, taken by Parliamentarian forces in 1646, but given back to Donough KMacCarty, the 1st Earl of Clancarty, after the Restoration. The structure is a partial ruin today, with some accessible areas, and is home - of course - to the legendary Blarney Stone, which is said to bestow the gift of the gab.
View from the top of Blarney Caslte - Imagey by Martie Swart (CC BY 2.0)
The grounds include extensive gardens with natural rock formations called the Rock Close, and a collection of native plants. You can explore the grounds through magical pathways in the forest.
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Can California Doctors Avoid Responsibility for Medical Marijuana Abuses?
Why would the California Medical Association (CMA) support something that every other state and national medical group opposes? In a statement released by the California legalization campaign, the CMA stressed they do not encourage marijuana use and discourage smoking. They gave two reasons. First, under a legal market, cannabis could be monitored, researched, regulated and mitigated to protect the public health. Secondly, improper diversion by healthy patients into the medical marijuana system could be reduced. The second condition gives a hint at how poorly medical marijuana in California really works, contrary to the way for which it was intended.
"Less than half of California doctors belong to the CMA. This endorsement of a just-to-get-high marijuana initiative is more of a union leadership ideology… not a medical, public safety position and not likely supported by the membership generally.
"Ironically, one of the biggest problems contributing to the back-door legalization is the medical malpractice of issuing of marijuana recommendations for any ailment with no examination by doctors who are accomplices in criminal drug dealing.
"I have 3 pot recommendations and have never seen a doctor for any of the recommendations.
The approved medical conditions in California are limitless and anyone age 18 and over can get a card. Today tens of thousands of 18-20-year-olds in California are getting recreational pot this way. Legalization will not stop this problem, and in fact will intensify the problem by making it more available to younger children. The Safe and Drug Free Communities Act would roll back on medical marijuana, limit it to one state grow site and keep it in the hands of county health departments.
Just last week, the American College of Physicians issued a report in the rise in marijuana-related hospital admissions. A hospital in Olympia, Washington, where marijuana is legal for recreational purposes, reported 1-2 cases of emergency treatment for marijuana-induced psychosis each day. A cynical view would see this move by California's physician lobbying arm as the desire to have more people in need of physicians' services, particularly for the psychiatrists.
Rescheduling Marijuana to Get More Research?
When asked about the rescheduling of marijuana for research, Chipman explained: "Scheduling of marijuana as a schedule I drug is not precluding studies. There have been at least 12,000 studies. Some of those studies were suspended after exposing participants to harm." Major court decisions have come down against the rescheduling of marijuana, and President Obama made it clear that loosening restrictions on marijuana is not on his agenda for this year.
While some physicians' groups support the rescheduling of marijuana, basically all national physicians' groups are opposed to marijuana legalization. Many of these groups are very skeptical of "medical" marijuana.
Unfortunately, recent action in the California state legislature suggests that politicians listen to the marijuana industry more than they care about the will of the people and local jurisdictions.


A long straight drive is required staying as close to the right edge of the fairway as possible. The second requires a decision on whether to attack the green or to lay up short; the choice is yours. Playing it as a three-shot hole, place the second shot into the left-hand side of the fairway to set up the easiest line for the third.
From the ladies' tee, the big hitters can aim for the left side of the clubhouse and others at church bell tower. Anything played left of centre can fall into the gathering bunker that is visible from the tee. For the shot to the green, take one more club and aim to the right of the pin.