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BACKGROUND This study compared aortic pressures estimated using a SphygmoCor XCEL PWA device (ATCOR, Naperville, IL) noninvasively with aortic pressures obtained using pressure catheters during catheterization procedures and analyzed the impact of a linear-fit function on the estimated pressure values. METHODS One hundred and thirty-six patients scheduled for cardiac catheterization procedure were enrolled in IRB approved studies. Catheterization procedures were performed according to standard-of-care to acquire aortic pressure measurements. Immediately after the catheterization procedure with the pressure catheters removed, while the patients were still in the catheterization laboratory, central aortic pressures were estimated with the SphygmoCor device (using its inbuilt transfer function). The error between measured and estimated aortic pressures was evaluated using Bland–Altman analysis (n = 93). A linear-fit was performed between the measured and estimated pressures, and using the linear equation the error measurements were repeated. A bootstrap analysis was performed to test the generalizability of the linear-fit function. In a subset of cases (n = 13), central aortic pressure values were also obtained using solid-state high-fidelity catheters (Millar, Houston, TX), and the error measurements were repeated. RESULTS The magnitude of errors between the measured and estimated aortic pressures (mean errors >6.4 mm Hg; mean errors >8.0 mm Hg in the subset) were reduced to less than 1 mm Hg after using the linear-fit function derived in this study. CONCLUSIONS For the population examined in this study, the SphygmoCor data must be used with the linear-fit function to obtain aortic pressures that are comparable to the measurements obtained using pressure catheters. CLINICAL TRIALS REGISTRATION Trial Numbers NCT03243942 and NCT03245255.

Introduction: The SphygmoCor (ATCOR, Naperville, IL) device utilizes a generalized transfer function based on patient’s age and gender to derive the aortic pressure pulse from the brachial-cuff based pressure measurements. This study compared aortic pressures obtained using SphygmoCor with aortic pressures obtained during cardiac catheterization. Hypothesis: Mean differences in aortic pressures obtained using SphygmoCor and pressure catheters will be less than 5 mmHg. Methods: After IRB approval, 136 patients were enrolled. During standard-of-care catheterization procedure, aortic pressure measurements were obtained using fluid-filled catheters. In a subset of patients (n = 13) the aortic pressure values were also obtained using solid-state high-fidelity Millar catheters. Immediately after the catheterization procedure, while the patients were still in the catheterization laboratory (on the procedure table), central aortic pressures were estimated with the SphygmoCor device. The measured and estimated aortic pressures were compared using linear regression and Bland-Altman analysis. A linear fit was performed to derive an additional transfer function to convert SphygmoCor pressure values to catheter-based aortic pressures, and the resulting differences in pressure values were compared. A bootstrap analysis was performed to test the generalizability of this transfer function. Results: Mean differences in systolic, diastolic and pulse aortic pressures obtained using the two techniques ranged from 6.5 to 18.0 mmHg (p < 0.001). In the subset with high-fidelity catheters, the differences ranged from 8.0 to 18.9 mmHg. With the linear-fit transfer function, the differences in systolic, diastolic and pulse aortic pressures were low (< 1 mmHg) corresponding to a reduction in bias noted with Bland-Altman analysis. The bootstrap analysis of the transfer function (100 iterations) achieved a coefficient of variation for the root mean square error < 8.4% for systolic, diastolic and pulse aortic pressures. Conclusions: The magnitude of the differences between the SphygmoCor-estimated and catheter-based systolic, diastolic and pulse aortic pressures reduced considerably after using the linear-fit transfer function derived in this study.

Context: As lingual bonded retainers are required for long-term retention in the oral cavity, the wire-composite combination of choice may be the determining factor for the success of lingual bonded retainers. Aim: We compared the shear bond strength of different wire-composite combinations used for lingual bonded retainers and identified the combination of choice for lingual retention in terms of the shear bond strength. Materials and Methods: A total of 108 extracted human maxillary premolars in pairs were divided into 6 groups of 9 samples each. Three different types of retainer wires (namely, Respond [Ormco Corp., Orange, CA, USA], Leone Ligature Wire [Leone S.p.a., Firenze, Italy], and SRW™ Stranded Retention Wire [Ortho Classic Inc., USA]) were bonded to the teeth with the composites (G-aenial™ Universal Flo and Tetric N-Flow). The shear bond strength was measured on debonding using universal testing machine INSTRON. Results: The maximum shear bond strength (58.28 N) was observed in group IV (Respond wire with Tetric N-Flow), whereas the minimum (25.28 N) was observed in group VI (SRW™ Stranded Retention Wire with Tetric N-Flow). A highly significant difference was observed when the shear bond strength of group IV was compared with all the other groups. Conclusions: The maximum shear bond strength was observed in the wire-composite combination of Respond dead-soft wire with Tetric N-Flow composite. Therefore, it could be the wire-composite combination of choice for bonded lingual retainer.

Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE).Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOAThe average EOA for all BE THV valves (77% SAPIEN 3) was 2.3 ± 0.5 cmEOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Introduction: Subharmonic aided pressure estimation (SHAPE) utilizes ambient pressure sensitivity of subharmonic signals from ultrasound contrast agents. The objective was to evaluate SHAPE with Definity (Lantheus Medical Imaging, Inc.) and Sonazoid (GE Healthcare) microbubbles for intra-cardiac pressure estimation. Hypothesis: Errors between SHAPE and pressures obtained during cardiac catheterization ≤ 5 mmHg. Methods: IRB approved this study. Consenting patients received an infusion of Definity (56 patients; 2 vials in 50 mL of saline; infusion rate: 4-10 mL/min) or Sonazoid (77 patients; rate (mL/hour) = 0.18 x weight in kg co-infused with saline at 120 mL/hour) during cardiac catheterization. Subharmonic data was acquired using a SonixTablet (PA 4/2 array; BK Ultrasound) synchronously with pressures from the left and right ventricles and the aorta (for left heart catheterizations only). Subharmonic data (in dB) was converted to pressure values (in mmHg) using calibration factors (mmHg/dB) based on data obtained from the aorta - utilizing pressures from the aorta either during the catheterization procedure or pressures obtained using a SphygmoCor (AtCor Medical Pty. Ltd.) device after the catheterization procedure. Clinically relevant pressures between the SHAPE technique and the pressure catheter were compared. Results: Correlation coefficient between the subharmonic and pressure data was -0.8 ± 0.1. With Definity, mean absolute errors ranged from 2.9 ± 1.5 to 5.0 ± 4.2 mmHg and from 4.4 ± 5.7 to 23.7 ± 28.3 mmHg for calibration factors utilizing aortic pressures from pressure catheter and SphygmoCor, respectively. For Sonazoid microbubbles, these errors ranged from 7.9 ± 12.0 to 10.1 ± 12.4 mmHg and from 7.2 ± 11.5 to 15.0 ± 23.2 mmHg, respectively. Two adverse events occurred during Definity infusion; these were resolved with return to baseline conditions. Conclusion: SHAPE may be useful for estimating intra-cardiac pressures noninvasively.

The objective of this work was to investigate if central cardiac pressures are obtainable noninvasively using the subharmonic aided pressure estimation (SHAPE) technique with Definity (Lantheus Medical Imaging Inc, N Billerica, MA, USA) or Sonazoid (GE Healthcare, Oslo, Norway) microbubbles. Patients scheduled for a left and/or right heart catheterization procedure and providing written informed consent were included in IRB approved clinical trials (NCT03243942 for Definity; NCT03245255 for Sonazoid). A standard-of-care catheterization procedure was performed advancing clinically used pressure catheter into the left and/or right ventricles and/or the aorta. After pressure catheter placement, patients received an infusion of either Definity (56 patients; 2 vials in 50 mL of saline; infusion rate: 4–10 mL/min) or Sonazoid (60 patients; rate (mL/hour) = 0.18 mL/hour/kg x weight in kg co-infused with saline at 120 mL/hour). A customized interface on a SonixTablet scanner (BK Ultrasound, Peabody, MA, USA) was used to acquire SHAPE data synchronously with the pressure catheter data. Linear correlation between the SHAPE and pressure catheter data were computed using MATLAB (Mathworks, Natick, MA, USA). Central aortic pressures were estimated using cuff-based brachial pressure measurements with a SphygmoCor device (AtCor Medical Pty Ltd, West Ryde, NSW, Australia). Central aortic pressures and SHAPE data from the aorta were used to calculate a conversion factor (in mmHg/dB) for each patient to estimate pressures and determine errors associated with the SHAPE technique. Two adverse events were observed during Definity infusion; both were resolved. Errors between the pressure catheter and SHAPE derived mean diastolic pressures were less than 5 mmHg when using Definity microbubbles and greater than 5 mmHg when using Sonazoid microbubbles. These results indicate that SHAPE is a useful technique to noninvasively obtain central cardiac pressures.

About 92.1 million Americans suffer from at least one type of cardiovascular disease. Worldwide, cardiovascular diseases are the number one cause of death (about 31% of all global deaths). Recent technological advancements in cardiac ultrasound imaging are expected to aid in the clinical diagnosis of many cardiovascular diseases. This article provides an overview of such recent technological advancements, specifically focusing on tissue Doppler imaging, strain imaging, contrast echocardiography, 3D echocardiography, point-of-care echocardiography, 3D volumetric flow assessments, and elastography. With these advancements ultrasound imaging is rapidly changing the domain of cardiac imaging. The advantages offered by ultrasound imaging include real-time imaging, imaging at patient bed-side, cost-effectiveness and ionizing-radiation-free imaging. Along with these advantages, the steps taken towards standardization of ultrasound based quantitative markers, reviewed here, will play a major role in addressing the healthcare burden associated with cardiovascular diseases.

This study evaluated the feasibility of noninvasive intracardiac pressure estimation using subharmonic signals from ultrasound contrast agents in humans. This IRB approved proof-of-concept study included 15 consenting patients scheduled for left and right heart catheterization. During the catheterization procedure, Definity (Lantheus Medical Imaging, N Billerica, MA) was infused intravenously at 4–10 ml/min. Ultrasound scanning was performed with a Sonix RP (BK Ultrasound, Richmond, Canada) using pulse inversion, three incident acoustic output levels, and 2.5 MHz transmit frequency. Radiofrequency data were processed and subharmonic amplitudes were compared with the pressure catheter data. Correlation coefficient between subharmonic signals and pressure catheter data ranged from −0.3 to −0.9. For acquisitions with optimum acoustic output, pressure errors between the subharmonic technique and catheter were as low as 2.6 mmHg. However, automatically determining optimum acoustic output during scanning for each patient remains to be addressed before clinical applicability can be decided.

ObjectiveCurrent guidelines define severe aortic stenosis (AS) as an aortic valve area (AVA)≤1.0 cm2, but some authors have suggested that the AVA cut-off be decreased to 0.8 cm2. The aim of this study was, therefore, to better describe the clinical features and prognosis of patients with an AVA of 0.8–0.99 cm2.MethodsPatients with isolated, severe AS and ejection fraction ≥55% with an AVA of 0.8–0.99 cm2 (n=105) were compared with those with an AVA2 (n=155) and 1.0–1.3 cm2 (n=81). The endpoint of this study was a combination of death from any cause or aortic valve replacement at or before 3 years.ResultsPatients with an AVA of 0.8–0.99 cm2 group comprised predominantly normal-flow, low-gradient (NFLG) AS, while high gradients and low flow were more often observed with an AVA2. The frequency of symptoms was not significantly different between an AVA of 0.8–0.99 cm2 and 1.0–1.3 cm2. The combined endpoint was achieved in 71%, 52% and 21% of patients with an AVA of 0.8 cm2, 0.8–0.99 cm2and 1.0–1.3 cm2, respectively (p2, NFLG AS was associated with a lower hazard (HR=0.40, 95% CI 0.23 to 0.68, p=0.001) of achieving the combined endpoint with outcomes similar to moderate AS in the first 1.5 years of follow-up. Patients with high-gradient or low-flow AS with an AVA of 0.8–0.99 cm2 had outcomes similar to those with an AVA2. The sensitivity for the combined endpoint was 61% for an AVA cut-off of 0.8 cm2 and 91% for a cut-off of 1.0 cm2.ConclusionsThe outcomes of patients with AS with an AVA of 0.8–0.99 cm2 are variable and are more precisely defined by flow-gradient status. Our findings support the current AVA cut-off of 1.0 cm2.

Rationale and Objectives Multimodality evaluation of the aortic annulus is generally advocated to plan for transcatheter aortic valve replacement (TAVR). We compared aortic annular measurements by cardiac computed tomography angiography (cCTA) to three-dimensional transesophageal echocardiography (3D-TEE), and also evaluated the use of semi-automated software for cCTA annular measurements. Materials and Methods A retrospective cohort of 74 patients underwent 3D-TEE and electrocardiogram-gated cCTA of the heart within 30 days for TAVR planning. 3D-TEE measurements were obtained during mid-systole; cCTA measurements were obtained during late-systole (40% of R-R interval) and mid-diastole (80% of R-R interval). Annular area was measured independently by manual planimetry and with semi-automated software. Results cCTA measurements in systole and diastole were highly correlated for short-axis diameter (r = 0.91), long-axis diameter (r = 0.92), and annular area (r = 0.96), although systolic measurements were significantly larger (P Conclusions Although all cCTA measurements are highly correlated with measurements by 3D-TEE, diastolic phase cCTA measurements tend to be closer to standard mid-systolic 3D-TEE measurements. Semi-automated measurement of the aortic annulus with cCTA is highly correlated with manual planimetry. Nonetheless, annular contours derived by semi-automated software should be visually inspected, as the variability in area estimates for individual cases between manual and automated measurements may alter the sizing of an aortic prosthesis.

Subharmonic aided pressure estimation (SHAPE) measures ambient pressure dependent subharmonic signals from contrast microbubbles. This study evaluated if Definity® (Lantheus Medical Imaging, N Billerica, MA, USA) or Sonazoid (GE Healthcare, Oslo, Norway) microbubbles are useful for real-time noninvasive intra-cardiac pressure estimation using SHAPE. Patients scheduled for a right and/or left heart catheterization procedure were approached to participate in this IRB approved study and provided written consent. During the standard-of-care catheterization procedure, a pressure catheter was advanced into the cardiac chambers or the aorta to obtain clinically relevant systolic and diastolic pressures. After catheter placement, the patients received either an infusion of Definity (40 patients; 2 vials in 50 mL of saline; infusion rate: 4-10 mL/min) or Sonazoid (41 patients; rate (mL/hour) = 0.18 x weight in kg co-infused with saline at 120 mL/hour). A customized interface on a SonixTablet scanner (Analogic Corporation, Peabody, MA, USA) was used to acquire SHAPE data synchronously with the pressure catheter data. Previously determined optimal transmit parameters were used for data acquisition with Definity (f transmit : 3.0 MHz; chirp down pulse) and Sonazoid (f transmit : 2.5 MHz; square wave pulse) microbubbles. An algorithm to determine optimum incident acoustic output was initiated for each patient (to account for attenuation differences). Then, SHAPE data were acquired at the optimum incident acoustic output. Linear correlation between the SHAPE and pressure catheter data were computed using MATLAB (Mathworks, Natick, MA, USA). The correlation coefficient between SHAPE and pressure catheter data obtained using Definity was −0.86 ± 0.06 (n=15) and −0.87 ± 0.06 (n=18) for data obtained from the left and right ventricles, respectively. In two cases, adverse events were observed post Definity infusion. Both events were resolved with return to baseline conditions. Using Sonazoid, the correlation coefficient between the SHAPE and pressure catheter data was −0.83± 0.05 (n=10) and −0.82 ± 0.06 (n=7) for data obtained from left and right ventricles, respectively. These results indicate that SHAPE is a useful technique to noninvasively obtain intra-cardiac pressures in real-time.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

Introduction Pulmonary hypertension (pHTN) complicating structural heart disease leads to distinct diagnostic and management dilemmas. We present a case of severe pulmonary hypertension in the setting of perimembranous VSD and severe AS. Case Report 76 yo female with restrictive VSD and severe AS presented with heart failure. Cardiac findings included RV heave and AS murmur. TTE revealed normal EF with severe pHTN, severe RV dysfunction, and severe AS. Her perimembranous septum was aneurysmal, with systolic jet velocity of 4.5 m/s. There was no CAD. RHC demonstrated PAP of 96/38/57 mmHg, PVR of 7.2 WU, PCWP 23 mmHg, CI of 3.04, and Qp/Qs of 1.1. The PCWP and PVR indicated pre- and post-capillary pHTN due to longstanding AS. She was deemed inoperable and was high risk for TAVR given aortic annular continuity with the VSD and ∼25% annular deficiency. There was concern that her elevated LVEDP was masking Eisenmenger physiology, and that relieving the AS may precipitate hypoxia. Balloon aortic valvuloplasty (BAV) was performed as bridge to decision. This enabled assessment of the integrity of the aortic annulus, the pulmonary pressure response to LV unloading, and development of right to left shunting after a decrease in LVEDP. Successful BAV was performed, and the patient was discharged. Following improvement in both PA pressures and her symptoms, a TAVR was offered. A self-expanding valve was selected to minimize risk of annular rupture. After successful deployment, her PAP were 78/42/54 and PCWP 23. She was diuresed and discharged. Summary Our case highlights important points in management of such complex patients with pHTN. Careful evaluation of hemodynamics is paramount in guiding decision making. The preserved PAPi with minimal shunting suggested the VSD was not significantly contributing to the severe pHTN. Additionally, BAV plays an important role as a bridge to determine potential response to TAVR. Although patients with WHO II pHTN can develop an irreversible pre-capillary component, such assessment can only be made following durable reduction in LVEDP. Lastly, interdisciplinary patient care is essential. Successful management of our patient required input from a multidisciplinary team consisting of pulmonology, structural cardiology, critical care cardiology and heart failure.

Introduction: The aim of the study was to evaluate the horizontal and vertical forces for effective torque control of maxillary incisors during retraction in the lingual technique using a three-dimensional (3D) finite-element method. These horizontal and vertical forces were analyzed and compared. Subjects and Methods: A 3D finite-element model of the maxilla and maxillary incisors and molars was made. The maxillary incisors were subjected to horizontal retractive force and the vertical intrusive force was calculated such that the resultant of the horizontal and vertical forces passed through the center of resistance of the maxillary incisors to maintain torque and simulate bodily retraction in labial and lingual mechanics. Results: For equal magnitude of horizontal retractive force (100 g) the calculated vertical force vector (Fv) was 129 g and the resultant force was 163 g in labial mechanics, while in lingual mechanics, the vertical force vector was 222.66 g and the resultant force was 244 g. Conclusion: In lingual orthodontics, it is more appropriate to reduce the magnitude of horizontal retractive forc and keep the vertical intrusive force within biological limits, thus maintaining torque and achieve bodily retraction of incisors.

Case presentation A 54-year-old woman underwent diagnostic electrophysiological study because of recurrent symptomatic narrow complex tachycardia (NCT) and intolerance to metoprolol therapy. Baseline atrio-His and His-ventricular intervals measured 116 and 37 ms, respectively. Dual antegrade atrioventricular (AV) nodal physiology was observed during programmed atrial extrastimulation. Ventriculoatrial conduction was decremental and concentric (earliest at the anteroseptum). Her clinical tachycardia (Figure 1A) was repeatedly induced by rapid atrial pacing. Attempt to entrain tachycardia from the ventricle is shown in Figure 1B. Figures 2A and 2B show the response of tachycardia to atrial premature depolarization (APD) and overdrive pacing from the coronary sinus (CS), respectively. Figure 3 shows tachycardia before ablation. Based on these observations, what is the mechanism of tachycardia?

Aims The aim of the study was to evaluate the horizontal and vertical forces for effective torque control of maxillary incisors during retraction in lingual technique using a 3-dimensional (3D) finite element method. These horizontal and vertical forces were analysed and compared. Methods and materials A 3D finite element model of the maxilla and maxillary incisors and molars was made. The maxillary incisors were subjected to horizontal retractive force and the vertical intrusive force was calculated such that the resultant of the horizontal and vertical forces passed through the centre of resistance of the maxillary incisors to maintain torque and simulate bodily retraction in labial and lingual mechanics. Results For equal magnitude of horizontal retractive force (100 g) the calculated vertical force vector (Fv) was 129 g and the resultant force was 163 g in labial mechanics, while in lingual mechanics, the vertical force vector was 222.66 g and the resultant force was 244 g. Conclusion In lingual orthodontics, it is more appropriate to reduce the magnitude of horizontal retractive force and keep the vertical intrusive force within biological limits, thus maintaining torque and achieve bodily retraction of incisors.

A 73-year-old male with a remote history of renal cell carcinoma presented with an asymptomatic left ventricular mass. Biopsy of the mass revealed a late recurrence of his renal cell carcinoma. Given the size and location of the mass, resection was not possible. Treatment with pazopanib was initiated with good clinical response.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Introduction: Cephalometric analysis forms the backbone of orthodontic diagnosis and treatment planning. However most of the angles used to assess antero-posterior jaw base discrepancy are based on landmarks that change with age, jaw rotation and orthodontic treatment. Walkers point is one landmark that has been suggested to be stable and easy to locate on radiograph. Objective: To derive SAR angle based on Walkers point, points M and G to assess true sagittal discrepancy. Materials & method: Sixty pretreatment lateral cephalograms of North Indian subjects were grouped in three classes of skeletal pattern based on fulfillment of any two of the three criteria: ANB angle, Witt’s appraisal and Beta angle. The mean and SD for the SAR angle in three groups were calculated. ANOVA one-way of variance and Newman-Keuls tests were done to compare the groups. Result: The mean value for SAR angle of Class I skeletal pattern group was 55.98 o (SD 2.24), whereas mean value for Class II and Class III skeletal groups were 50.18 o and 63.65 o with standard deviations 2.70 and 2.25 respectively. The receiver operating characteristic curves show that the cutoff point between Class I and Class II groups could be considered a SAR angle of approximately 53 o , and the cutoff point between Class I and Class III groups could be considered a SAR angle of approximately 59 o . Conclusion: The SAR angle can be a reliable diagnostic aid to assess the sagittal jaw discrepancy more consistently.

Objectives This study sought to examine the frequency of indications for and the immediate and long-term clinical outcomes of transcatheter closure of patent foramen ovale (PFO). Background Transcatheter PFO closure is commonly performed for several indications, including cryptogenic stroke, despite conflicting data regarding the efficacy of this intervention. Methods We report the outcomes of 800 consecutive patients (52% male, 50 ± 14 years of age) who underwent PFO closure at our institution after multidisciplinary evaluation over a 16-year period. Results Indications for closure included cryptogenic cerebrovascular event (94%), hypoxemia (2%), peripheral embolism (3%), and migraine headaches (2%). Procedural success was 99% with effective closure obtained in 93% of patients. At a mean follow-up of 42.7 ± 33.4 months, 21 patients suffered a recurrent ischemic neurologic event (12 strokes, and 9 transient ischemic attacks) for an incidence rate of 0.79 events per 100 person-years and freedom from recurrent events of 91.6% at 10 years. There was no device-based difference in the rate of recurrent ischemic neurologic events (p = 0.82). Only Eustachian valve prominence (hazard ratio: 9.04; 95% confidence interval: 2.07 to 39.44; p = 0.0034) was associated with recurrent neurologic events. Conclusions Transcatheter PFO closure is safe and feasible in patients with several clinical indications. The long-term efficacy of this intervention in patients with paradoxical embolism appears superb in this observational study. Carefully selected patients with features suggestive of paradoxical embolism are the most likely to benefit from PFO closure and should be the focus of future investigation.

Fixed or removable orthodontic appliances impede the maintenance of oral hygiene and result in plaque accumulation. Many studies have evaluated the effects of fixed orthodontic appliances on microbial flora and periodontal status, but only a few have evaluated the method of ligation as an additional factor. AIMS AND OBJECTIVES: To determine the amount of microbial colonization with different elastomeric ligation techniques. MATERIALS AND METHODS: Subjects for this study was selected on the basis of good oral hygiene. Amount of microbial colonization was evaluated from both right and the left sides of the maxillary dental arch at day 1 that is (after receiving through oral prophylaxis) and then the arch wire ligated with split mouth technique using Super Slick ties (TP Orthodontics) and Dumbell ligatures (Leone) on right side & Aelastixs- Quick stick ties- Angulated ties (3M Unitek) and Aelastixs- Easy to fit Ties (3M Unitek) on left side. Elastomeric ligatures were removed from the patients' mouth after a period of 7 days and sent for culture of the aerobic and anaerobic bacterial colonies. The amount of microbial colonies was then compared using stereomicroscope. RESULTS: The current study revealed that the teeth ligated with elastomeric rings exhibited greater number of aerobic as well as anaerobic microorganisms and the difference was found to statistically significant.

Objectives We aimed to explore the relationship between brain natriuretic peptide (BNP) levels and right ventricular (RV) function in patients with mitral stenosis (MS), and to investigate the hemodynamic parameters that predict reduction of BNP levels after percutaneous mitral valvuloplasty (PMV). Background Few studies have evaluated BNP in the context of MS, specifically the impact of the RV stroke work (RVSW) on serum BNP levels has not been defined. Methods Thirty patients with symptomatic rheumatic MS in sinus rhythm who were referred for a PMV were enrolled. Right and left heart pressures were obtained before and after valvuloplasty. RVSW index (RVSWI) was calculated by cardiac catheterization. Results Basal BNP levels were elevated in MS patients and correlated with several hemodynamic parameters including pulmonary pressure, pulmonary vascular resistance index, cardiac index (CI), and RVSWI. In multivariate analysis, CI and RVSWI were independent predictors of raised basal BNP levels. PMV resulted in a significant decrease in the RVSWI with a concurrent increase in CI (2.4 ± 0.43 to 2.9 ± 0.8 L/min/m2, P = 0.010). Overall, plasma BNP levels significantly decreased from 124 (63/234) to 73 (48/148) pg/ml postvalvuloplasty. Multivariate analysis revealed that the reduction of left atrial (LA) pressure post-PMV was an independent predictor of change in BNP levels. Conclusions Elevated baseline BNP level in MS patients was independently associated with CI and RVSWI. Plasma BNP levels were reduced after successful PMV, which was associated with the reduction of the LA pressure. (J Interven Cardiol 2013;26:501-508)

Bonding has transformed the tedium of appliance construction into an efficient and pleasant operation for both patient and clinician. The bonding procedure requires debonding at the termination of treatment. The objectives of debonding are to remove the attachments and all adhesive resin from tooth and to restore the surface as closely as possible to its pretreatment condition. To achieve these objectives correct bonding and debonding are of fundamental importance. The introduction of the acid etch bonding technique has led to dramatic changes in the practice of orthodontics. The increased adhesion produced by acid pretreatment, using 85% phosphoric acid, was demonstrated in 1955 by Buonocore. 1 In 1965, with the advent of epoxy resin bonding, Newman 2 began to apply these findings to direct bonding orthodontic attachments. The future of bonding is promising, product development in terms of adhesives, brackets, devices and technical details is continually occurring at a rapid rate. The purpose of this review article is to update the current available information on direct bonding to natural and artificial teeth.

Multimodality evaluation of the aortic annulus is generally advocated to plan for transcatheter aortic valve replacement (TAVR). We compared aortic annular measurements by cardiac computed tomography angiography (cCTA) to three-dimensional transesophageal echocardiography (3D-TEE), and also evaluated the use of semi-automated software for cCTA annular measurements.A retrospective cohort of 74 patients underwent 3D-TEE and electrocardiogram-gated cCTA of the heart within 30 days for TAVR planning. 3D-TEE measurements were obtained during mid-systole; cCTA measurements were obtained during late-systole (40% of R-R interval) and mid-diastole (80% of R-R interval). Annular area was measured independently by manual planimetry and with semi-automated software.cCTA measurements in systole and diastole were highly correlated for short-axis diameter (r = 0.91), long-axis diameter (r = 0.92), and annular area (r = 0.96), although systolic measurements were significantly larger (P 0.001), most notably for the short-axis diameter. Good correlation was observed between 3D-TEE and cCTA for short-axis diameter (r = 0.84-0.90), long-axis diameter (r = 0.77-0.79), and annular area (r = 0.89-0.90). As compared to 3D-TEE, annular area is overmeasured by 28 mmAlthough all cCTA measurements are highly correlated with measurements by 3D-TEE, diastolic phase cCTA measurements tend to be closer to standard mid-systolic 3D-TEE measurements. Semi-automated measurement of the aortic annulus with cCTA is highly correlated with manual planimetry. Nonetheless, annular contours derived by semi-automated software should be visually inspected, as the variability in area estimates for individual cases between manual and automated measurements may alter the sizing of an aortic prosthesis.

Dobutamine and exercise echocardiography are well-validated modalities used for the evaluation of patients with suspected myocardial ischemia. Patients undergoing dobutamine stress echocardiography (DSE), however, experience less angina, ST-segment depressions, and wall motion abnormalities. Other than the effect on heart rate, the physiologic and volumetric differences between pharmacologic and exercise-induced stress that affect myocardial oxygen demand are not well defined. The aim of this study was to test the hypothesis that in the absence of ischemia, dobutamine reduces left ventricular (LV) volume, wall tension (WTN), and peak systolic stress (PSS) compared with exercise.Seventy patients without ischemia were prospectively enrolled (35 underwent exercise echocardiography and 35 DSE), and various hemodynamic parameters were measured and LV volumes calculated (using the Simpson and Teichholz formulas). Systolic WTN and PSS were determined at rest and stress.LV end-diastolic volume index fell significantly more with dobutamine than with exercise (-34% vs -9%, P.0001), as did mean end-systolic volume index (-55% vs -37%, P = .07). Systolic blood pressure increased more with exercise (41 ± 22 vs 1 ± 33 mm Hg, P.0001), as did cardiac index (2.5 ± 0.7 vs 1.0 ± 0.8 L/min/m(2), P.0001). Systolic WTN increased with exercise by 24% (P.0001) but decreased with dobutamine by 18% (P.0001). PSS increased with exercise by 21% (P.0001) but decreased with dobutamine by 23% (P.0001).The degree of stress achieved with DSE appears to be considerably different than with exercise. DSE produces greater reductions in LV end-diastolic and end-systolic volumes than exercise and decreases rather than increases in WTN and PSS. The lower WTN and PSS were related to both a decrease in LV volume and lower systolic blood pressure with dobutamine. These observations support recommendations favoring exercise stress testing in patients able to exercise and reinforce the notion that high-risk echocardiographic features of ischemia such as stress-induced LV dilatation may be less striking or absent with DSE.

Maxillary canines are known as the cornerstones of mouth. They are considered to be important for esthetics and for functional occlusion. Any disturbance in the eruption process leading to an aberrant position will hamper esthetics as well as function. Orthodontic tooth movement of total buccally blocked-out canine is usually difficult as it is related with the problems of severe crowding, midline deviation, involvement of long root movement and risk of gingival recession. Such conditions can be treated orthodontically in various ways, but this clinical innovation helps to correct the buccally placed canines into the arch with a precise control of the canine in all the Three-dimensions (3D) of space as well as providing maximum comfort to the patient by placing the canine loop on the palatal surface of the tooth, reducing soreness on the labial mucosa. It can be easily fabricated and activated at chairside for either simultaneous or sequential control in 3D.

High radiation exposure among male radiologists has been reported to result in a significantly higher proportion of female offspring. This study examined whether work-related radiation exposure was associated with a higher propensity for female offspring among male interventional cardiologists. On behalf of the interventional committee of the Society for Cardiovascular Angiography and Interventions, an Internet-based questionnaire was sent to the society's 2063 members. The 402 male respondents had a total of 518 biological offspring; 48.6% of them were female. Among the 172 high-volume male diagnostic operators (those who performed >300 cases annually), there were 218 biological offspring, of whom 46.8% were female. Among the 59 high-volume male interventional operators, there were 70 biological offspring, of whom 45.7% were female. P values were nonsignificant for all three groups. In conclusion, work-related radiation exposure of male invasive and interventional cardiologists was not associated with a statistically significant preponderance of female offspring.

Background Risk prediction is a critical step in patient selection for aortic valve replacement ( AVR ), yet existing risk scores incorporate very few echocardiographic parameters. We sought to evaluate the incremental predictive value of a complete echocardiogram to identify high‐risk surgical candidates before AVR . Methods and Results A cohort of patients with severe aortic stenosis undergoing surgical AVR with or without coronary bypass was assembled at 2 tertiary centers. Preoperative echocardiograms were reviewed by independent observers to quantify chamber size/function and valve function. Patient databases were queried to extract clinical data. The cohort consisted of 432 patients with a mean age of 73.5 years and 38.7% females. Multivariable logistic regression revealed 3 echocardiographic predictors of in‐hospital mortality or major morbidity: E/e’ ratio reflective of elevated left ventricular (LV) filling pressure; myocardial performance index reflective of right ventricular (RV) dysfunction; and small LV end‐diastolic cavity size. Addition of these echocardiographic parameters to the STS risk score led to an integrated discrimination improvement of 4.1% ( P LV end‐diastolic cavity size; LV mass index; mitral regurgitation grade; right atrial area index; and mean aortic gradient Conclusions Echocardiographic measures of LV diastolic dysfunction and RV performance add incremental value to the STS risk score and should be integrated in prediction when evaluating the risk of AVR . In addition, findings of small hypertrophied LV cavities and/or low mean aortic gradients confer a higher risk of 2‐year mortality.

Evaluation of the right heart is critical in patients with pulmonary arterial hypertension (PAH). However, in many echocardiography laboratories this evaluation remains qualitative in nature. We sought to determine which quantitative right heart parameters by echocardiography were predictive of

Left ventricular outflow tract (LVOT) geometry is variable and often elliptical, which can affect aortic valve area calculation in patients with aortic stenosis (AS). Specific differences in LVOT geometry and dynamics between patients with AS and normal control subjects have not been described. The aim of this study was to test the hypothesis that differences in LVOT geometry in patients with AS might relate to variable LVOT remodeling and stiffness relative to normal control subjects.In 54 patients with severe AS and 33 control subjects without AS, LVOT geometry, dynamics, remodeling, and stiffness were assessed by three-dimensional transesophageal echocardiography. LVOT stiffness was measured by calculating the distensibility coefficient, defined as the percentage change in LVOT area relative to change in left ventricular pressure. LVOT remodeling was assessed by measuring the posterior LVOT wall thickness. Multivariate linear regression analysis was used to determine independent associations with peak systolic LVOT ellipticity. LVOT area by three-dimensional transesophageal echocardiographic planimetry was compared with areas obtained assuming circular or elliptical geometry.At end-diastole, LVOT geometry was similar between patients with AS and normal control subjects. In patients with AS, however, the percentage change in cross-sectional area (7.5% vs 14.7%, P .001) from end-diastole to peak systole was lower compared with normal control subjects, while peak systolic ellipticity index was higher in patients with AS (1.18 vs 1.08, P .001). Compared with control subjects, patients with AS had lower distensibility coefficients (4.7 ± 1.9 × 10(4) vs 12.5 ± 5.3 × 10(4) mm Hg(-1), P .001) and higher posterior LVOT wall thickness (3.5 ± 0.8 vs 2.3 ± 0.5 mm, P .001). In multivariate analysis, posterior LVOT wall thickness and distensibility coefficient were independently associated with peak systolic LVOT ellipticity index. LVOT area underestimation by transthoracic echocardiography was higher in patients with AS when assuming circular geometry (20% vs 12%, P = .001).The LVOT is less distensible and undergoes remodeling in severe AS. These changes lead to greater peak systolic ellipticity and greater LVOT cross-sectional area underestimation relative to normal control subjects. These findings have important implications for the assessment of AS severity.

Implants have long been known as temporary anchorage devices serving the purpose of absolute anchorage to bring about effective tooth movement of dentoalveolar tissues. Many methods have been advocated for its precise placement including various designs for stent fabrication against which a proper site could be chosen for implant placement. This article provides an insight to a simplified way for chair-side fabrication of a stent that can help in reducing the risk of damage to adjacent dental roots, reducing the operator-patient time and improving the patient comfort and compliance.

Preserved ejection fraction, low-flow, low-gradient (PLFLG), severe aortic stenosis (AS) is characterized by small left ventricular (LV) cavity size, excessive concentric remodeling, and subclinical LV dysfunction. The extent of these characteristics, however, varies in any given individual with