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Book your room at Hotel Riche
Basic Double RoomMax Occupancy: 2 guests (up to 1 child, 1 infant)
Deluxe Double RoomMax Occupancy: 2 guests (up to 1 child, 1 infant)
Triple RoomMax Occupancy: 3 guests (up to 2 children, 1 infant)
Family RoomMax Occupancy: 4 guests (up to 3 children, 1 infant)
Single RoomMax Occupancy: 1 guest
4-star hotel in Valkenburg aan de Geul with 2 restaurants
Situated in the city center, this hotel is close to Valkenburg Cable Car, Fluwelengrot, and Valkenburg Castle. Also nearby are Wilhemina Toren and Theodoor Dorrenplein.
Hotel Features
In addition to 2 restaurants, Hotel Riche features a bar/lounge. Other amenities include complimentary wireless Internet access and meeting rooms.
Room Amenities
Flat-screen televisions come with cable channels. Guestrooms also feature complimentary wireless Internet access, desks, and hair dryers.Information missing or incorrect? Tell us!
Hotel Amenities
Hotel Amenities
Dining is available at one of the hotel's 2 restaurants. A bar/lounge is on site where guests can unwind with a drink. This 4-star property offers access to a meeting room and meeting rooms.
Public areas are equipped with complimentary high-speed wireless Internet access. This Valkenburg aan de Geul hotel also offers a terrace, tour/ticket assistance, and multilingual staff. Parking is available onsite for a surcharge.
Hotel Riche has designated areas for smoking.
- 24-hour front desk
- Total number of rooms - 54
- Number of floors - 4
- Bar/lounge
- Elevator/lift
- Fireplace in lobby
- Designated smoking areas
- Tours/ticket assistance
- Free WiFi
- Meeting rooms
- One meeting room
- Multilingual staff
- Garden
- Terrace
- Luggage storage
- Safe-deposit box at front desk
- Free reception
- Number of restaurants - 2
- Self parking (surcharge)
- Long-term parking (surcharge)
- Number of buildings/towers - 2
- Television in lobby
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Long-term parking (surcharge), Self parking (surcharge)
Room Amenities
- Phone
- Daily housekeeping
- Private bathroom
- Free toiletries
- Hair dryer
- Bathtub or shower
- Desk
- Blackout drapes/curtains
- Cable TV service
- Flat-panel TV
- Free WiFi
- Free dial-up Internet access
- Room service (limited hours)
- Connecting/adjoining rooms available
- Free cribs/infant beds
- Down comforter
Where to Eat
Hotel Riche has 2 restaurants serving lunch and dinner.
Brasserie Nextdoor - This brasserie specializes in French cuisine and serves light fare only. Guests can enjoy drinks at the bar. Open select days.
Room service (during limited hours) is available.
Nearby Things to Do
The recreational activities listed below are available either on site or nearby; fees may apply.
- Bicycle rentals nearby
Hotel Policies
Check-in time starts at 3 PM
Check-in time ends at 11 PM
Check-out time is 11:30 AM
Payment types
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation. Special cancellation policies or charges may apply for group reservations (more than 8 rooms for the same hotel / stay dates).
No pets or service animals allowed
Noise-free rooms not guaranteed
- A tax is imposed by the city: EUR 2.00 per person, per night. This tax does not apply to children under 5 years of age.
- Self parking fee: EUR 9.00 per night (in/out privileges)
- Early check-in fee: EUR 15.00
- Late check-out fee: EUR 20.00
- Cribs (infant beds) are available for an additional fee
We should mention
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation. No pets and no service animals are allowed at this property.
National Rating
This hotel has received its official star rating from the Netherlands Tourist Board.


text:
Was £37.00
Now £18.50
Now £11.10
70% Off
Save a total of £25.90
Navy run sports bra
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- Non wired
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subset: commoncrawl


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The Agony of a Dad Whose Son Became a Mass Killer
Elliot Rodger's dad says he never saw a sign of violence in his son.
Santa Barbara Shooter's Father Writes 'We Have to Stop This'
Peter Rodger, Elliot Rodger's father, wrote the open letter exclusively for ABC.
Elliot Rodger's Father Recalls Watching Son's Chilling Retribution Video
Peter Rodger tells Barbara Walters seeing son's YouTube video like being hit with a "dark force of horrible energy."
Lonely Young Elliot Rodger Grows into Introverted Teen
Act 2: Peter Rodger says his son Elliot Rodger was "always obsessive" about finding a girlfriend.
Elliot Rodger Plans for the 'Day of Retribution'
Act 3: Calling his son an "incredible liar," Peter Rodger says he didn't realize his son was sick.
Carnage and Chaos: Elliot Rodger Goes on Killing Spree
Act 4: After three years of planning, Elliot Rodger begins what he called "the day of retribution."
Now Playing: Elliot Rodger's Father Recalls Watching Son's Chilling Retribution Video
Now Playing: Lonely Young Elliot Rodger Grows into Introverted Teen
Now Playing: Elliot Rodger Plans for the 'Day of Retribution'
Now Playing: Carnage and Chaos: Elliot Rodger Goes on Killing Spree
Now Playing: Santa Barbara Rampage Victim's Father Looks to the Future
Now Playing: Woman Claims to Police Husband Was Killed by Intruder
Now Playing: TV Interview Leads to Woman Going on Trial for Murder
Now Playing: How Ex-Customer Service Reps Say They Dealt With Unruly Customers
Now Playing: Former CFO Now Unemployed, on Food Stamps After Viral Video
Now Playing: Ex-Reporter on the Moment She Said 'I Quit' on Live TV
Now Playing: Ex-American Apparel CEO Denies Sexual Harassment Accusations
Now Playing: Former CFO's Chick-Fil-A Video That Got Him Fired: Explained
Now Playing: Woman Recalls Killing Boyfriend with Stiletto
Now Playing: Ex-Fiancee Threatens Man's New Girlfriend, Co-Worker
Now Playing: Man's Ex Goes On Cyberstalking Rampage After Breakup
Now Playing: Wife Blames Years of Abuse in Husband's Murder
Now Playing: Girlfriend Convicted in 'Stiletto Murder' of Boyfriend
Now Playing: How Mary Margaret Farren Saved Herself, Kids From Husband
Now Playing: Mom Races Away From Husband After Brutal Flashlight Attack


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This WETA TV 26 production explores the history, mission and daily operations of Arlington National Cemetery, the final resting place for more than 400,000 Americans. This revered place honors the dead and brings great meaning to the living.
Choral Showcase presents the best in classical choral music from Washington and beyond each Sunday evening.
Author Sue Eisenfeld discusses the creation of Shenandoah National Park, which involved displacing thousands of longtime residents from Virginia's Blue Ridge mountains.
Hundley's hopes to win a spring-cleaning prize are dashed when a burst pipe causes the building to be evacuated. He joins George in the country, but the monkey's efforts to boost his pal's spirits may go for naught when the pooch becomes lost.
Inspired by the film Latino Americans, we decided to seek out a local perspective on the Latino experience in our community with our weta.org Digital Extras. Luis Araya immigrated to Arlington, Virginia from Bolivia in 1966, when very few Latinos lived in the county. He reflects on the changes he has seen over the years and the influence of Latinos in Arlington today.
For more than 30 years, WETA has proudly partnered with Ken Burns to bring landmark documentaries to the nation via public television.


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Goal is to reduce backlog of 497,000 pending claims
The Veterans Affairs Department will test its new paperless claims processing system starting in November at its regional benefits office in Providence, R.I.
The pilot project will operate from November until May 2011. Assuming the project and additional tests are successful, the system eventually will be deployed to all 57 regional benefits offices, according to an announcement dated Aug. 5.
The VA is currently developing a prototype of a paperless rapid claims processing system to deal with the current backlog of approximately 497,000 disability claims. The goal of the paperless system and related initiatives is to "break the back of the backlog," the department said.
IBM to develop automated claims processing for VA Agent Orange claims
VA seeks vendor to automate Agent Orange claims processing
The VA recently contracted with IBM Corp. to help automate part of the disability claims system to deal with an anticipated influx of Agent Orange claims later this year. IBM was awarded a $9.1 million contract to collaborate with VA developers to develop and implement the new claims processing system by November.
Disability claims are expected to surge later this year as a result of a new regulation implementing a presumption of service connection for three disabilities: B-cell leukemia associated with Agent Orange exposure in Vietnam, Parkinson's disease, and ischaemic heart disease.
About the Author
Alice Lipowicz is a staff writer covering government 2.0, homeland security and other IT policies for Federal Computer Week.
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Meet 100 women and men who are doing great things in federal IT.
Click here for the full list
Unisys Federal Systems' Venkatapathi Puvvada, this year's Eagle award winner for industry, stresses the importance of community.
Experts tell committee that business models, not technology, are the main obstacle to better sharing across systems.
Protests have delayed SEWP V, but industry experts say the contract vehicle offers agencies service and value that are hard to find.
The power of the individual informs FCW's coverage each and every day, but with the Federal 100, we take time to really spotlight and celebrate it. Get to know each of this year's winners.
The latest version of the Cybersecurity Information Sharing Act purportedly protects companies from liability and individuals from government intrusion.
Popular CIO is headed for the private sector.
The Census Bureau hasn't established a time frame for its cloud computing plans, including testing for scalability, security, and privacy protection, as well as determining a budget for cloud services.
President Obama's proposal to boost government coordination with the private sector got a warm welcome in the House Homeland Security Committee.
The spy agency wants to better integrate cybersecurity into its traditional human intelligence operations.
I'm glad to see people finally moving toward paperless! As the author of the book series Kiplinger's Taming the Paper Tiger, I have been helping people organize their paper for 30+ years, and have watched as it became more and more difficult for individuals and organizations to do.
But even going Almost Paperless™ isn't easy; the change requires extensive cooperation between management and staff, and time and training to implement the process. However, that doesn't mean that every organization shouldn't get started on the road to paperless!
Dear VA, SSA already has multiple disability processing systems. It is free for 2 government agencies to collaborate with each other, but instead you chose to pay IBM $9.1 M/B to replicate work already done for SSA. This is exactly how the government wastes money. The right hand doesn't know what the left is doing. Agencies, especially DOD, just contract out work without stopping to think that another agency with a similar mission may already have some capabilities that could be leveraged. The government is constantly reinventing the wheel and paying contractors to do so. Meanwhile the contractors are probably just reusing a lot of the same work from project to project and are raking in the bucks because the government doesn't realize it is paying for a project that is already half-completed. If contracts are written correctly with the appropriate records clauses included (big IF, this is another problem), then the contractor's work product becomes government property when the contract ends. The government can then reuse that work (the analysis/code/system) however it sees fit. Wake up Washington! You don't have to pay for the same work to be done over and over!
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Mom creates Beau's Baskets of Hope
Parting Shots: Totes share comfort with cancer patients
LL resident inspired to create 'Chemo Comfort Bags'
LLCT brings talent show parody to life — or to death
'American Idle: Murdering the Music' runs through March 15
Plans underway for community egg hunt
On the March Library page: Friends carry on tea tradition; Library Briefs
History: Socializing at the lake
Neighbors & Neighborhoods: A 2015 series presented by the Liberty Lake Historical Society
In the March Wave: Dedicated to dance
The Wave is a special section just for kids, geared toward children in kindergarten through fifth grade
In the March Fountain: 58 years of lovin' Liberty Lake
The Fountain is a special section about and for Liberty Lake seniors
Austin James Taylor
Community and Education Briefs
History: Lure of the lake hooked fishermen
• Quality time - Time spent relaxing on your boat with your kids, all the while telling them to keep quiet, knock off the clowning around, turn down the music … and quit the worm racing.
• Flying fish - What you see coming at you when you leave a mess of bluegill to be cleaned in your wife's kitchen sink.
• Trophy fish - Any fish weighing more than the gear used to catch it.
Copyright © 2015 Peridot Publishing
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Empire Bank - Mobile
10,000 - 50,000 downloadsAdd this app to your lists
+ By Central Bancompany
What's New in Version 2.6
• We've enhanced our app to better serve newer phones.
Mobile Banking Features
• Full-Featured, Free Money Manager – Access to the same great features available in Online Banking. Track your spending, create budgets, set alerts and goals, monitor your cash flow and more! View all of your financial accounts in on location, even those from other financial institutions.
• Free Mobile Check Deposit† - Save unnecessary trips to the bank and deposit checks into your personal or business, checking or savings accounts. We'll automatically capture the picture of your check. If you've tried depositing your check before and had issues, we've fixed those bugs!
• Free Bill Pay with eStatements† – Add and edit payees, make payments, set up recurring payments and more! Save on stamps and never miss a payment. Plus with eStatements, view up to seven years of account history in one convenient location.
• Add and Edit Travel Notifications – Notify us at least one business day in advance of your expected travel date and we'll monitor transactions out of your normal usage and you'll avoid the possibility of your card being declined while traveling.
• Free Text Banking† – Receive quick balance and account history updates, and make transfers via text message.
• Free Alerts† – Create and manage text alerts for spending limits, balance thresholds, goal progress, check clearance, direct deposit notification, and more!
• Manage your loans, transfer funds, notify us of upcoming travel, find the nearest bank and ATM locations, and more!
† Data and text rates for your mobile carrier may apply.
^ Text Banking is not available on tablet devices.
Member FDIC.
Tags: empire bank, empire mobile banking, empire bank mobile, empire package name, metcalf bank logo, mobile banking images, empire bank mobile banking, text empire, bank mobile, are ozark mountain bank and empire bank connected.
We've enhanced our app to better serve newer phones.
(66 stars)
I love this app. I use it all the time.
(66 stars)
When I first put on phone a few months ago I did the camera deposit. Now not found after hours.
(66 stars)
Have never had issues with the app. I'm pretty simple with my banking & its easy to navigate.
(66 stars)
Can't deposit checks because it claims there is no account available in which to deposit. Prior to this bug, it was a decent app. Until it's fixed, it's good for looking at my balance and that's about it.
(66 stars)
They removed my unique word pass code from the list, so I can't log in at all anymore.
(66 stars)
I love my bank!
(66 stars)
This app is awesome usually, but now it's not letting me sign into my account. It just keeps sending me back to put in my user information. PLEASE FIX ASAP.


text: OverviewBack to top of page Ironman - Energy Boosters Code#:63299 Manufacturer:Ironman Packaged Ship Weight:0.20 Ironman Energy Booster tablets provide sustained, long-acting release of energy-enhancing ingredients to help promote peak physical performance and increase lean muscle.* It's the only energy booster that contains Pro Energy Blend to ensure you maximize your body's energy potential.* It helps fight fatigue because it spares the use of glycogen by increasing the use of fatty acids as energy, thereby enhancing athletic performance. Ironman Energy Booster helps you burn more calories, energizes your workout and helps you train longer and harder.* Promotes physical performance*


text:
Damaged runway lights force temporary airport closure
Canberra airport was forced to close for an hour this afternoon due to a damaged runway.
A chartered 747 damaged the lights on a runway during take-off.
All flights were delayed as safety officials cleaned the runway and replaced the lights.
Topics: air-and-space, canberra-2600


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New Mystery & Detective Books
New arrivals added to our Mystery & Detective Collection in the last 7 days
|Date added
|X is for ... by Grafton, Sue.
|Mar 29, 2015
|Weighed in the balance - a William Monk novel by Perry, Anne.
An exiled German prince falls from his horse in Victorian England and his wife is accused of murder. It's a scandal of international proportions and the man expected to sort out the truth from the lies is series sleuth William Monk. First though he must polish his manners. By the author of Cain His Brother.
|Mar 29, 2015
|Threads of deceit by Fox, Mae, author.
Former antiquities bounty hunter, Julie Ellis, is on the run, trying to stay one stiletto step ahead of her past. She accepts a position as manager of the Quilt Haus Inn in Missouri wine country, thinking it the perfect place to keep a low profile and start a new, less-dangerous career. It is - until Daniel Franklin walks through the door and asks for a room. Daniel claims he's come to Straussberg in search of a famous sunken ship that he believes is buried in a nearby farm field. Julie finds th
|Mar 29, 2015
|The stolen ones by Montanari, Richard, author.
Detectives Kevin Byrne and Jessica Balzano investigate a killing spree that may be the handiwork of a former mental patient living in the catacombs beneath Philadelphia.
|Mar 29, 2015
|The sinister pig by Hillerman, Tony.
The victim, well dressed but stripped of identification, is found at the edge of the vast Jicarilla Apache natural gas field just inside the jurisdiction of the Navajo Tribal Police, facing Sergeant Jim Chee with a complex puzzle. Why did the Washington office of the FBI snatch custody of this case from its local agents, cover it with secrecy, and call it a hunting accident? What was the victim seeking among the maze of pipelines and pumping stations in America's largest gas field? Was he invest
|Mar 29, 2015
|Cold betrayal - an Ali Reynolds novel by Jance, Judith A.
"Revenge isn't the only dish served cold... Ali Reynolds's longtime friend and Taser-carrying nun, Sister Anselm, rushes to the bedside of a young pregnant woman hospitalized for severe injuries after she was hit by a car on a deserted Arizona highway. The girl had been running away from The Family, a polygamous cult with no patience for those who try to leave its ranks. Meanwhile, married life agrees with Ali. But any hopes that she and her husband, B. Simpson, will finally slow down and relax
|Mar 29, 2015
|Dark rooms by Anolik, Lili, author.
"Death sets the plot in motion: the murder of Nica Baker, beautiful, wild, enigmatic, and only sixteen. The crime is solved, and quickly--a lonely classmate, unrequited love, a suicide note confession--but memory and instinct won't allow Nica's older sister, Grace, to accept the case as closed. Dropping out of college and living at home, working at the moneyed and progressive private high school in Hartford, Connecticut, from which she recently graduated, Grace becomes increasingly obsessed with
|Mar 29, 2015
|Lethal beauty by Wiehl, Lis W.
When a key witness goes missing in the case she is prosecuting, Mia Quinn discovers that her case is linked to two murder investigations led by Seattle homicide detective Charlie Carlson and together they must race against time to find the truth before another crime hits too close to home.
|Mar 29, 2015
|An exaggerated murder - a novel by Cook, Josh D., 1980- author.
|Mar 29, 2015
|Endangered by Box, C. J.
"Joe Pickett has lived through plenty of danger, but this time it's his daughter's life at stake and Joe and his family will be tested as never before"--
|Mar 29, 2015
|Grave on Grand Avenue by Hirahara, Naomi
|Mar 29, 2015
|Green and Pleasant Land by Cutler, Judith
|Mar 29, 2015
|A June of ordinary murders by Brady, Conor.
"A thrilling, beautifully written mystery debut that brings 1880s Dublin vividly, passionately to life, from the former editor of The Irish Times This captivating, expertly crafted mystery debut captures the life and essence of Victorian Dublin and draws the reader on a gripping journey of murder and intrigue. In the 1880s the Dublin Metropolitan Police classified crime in two distinct classes. Political crimes were classed as "special," whereas theft, robbery and even murder, no matter how ter
|Mar 29, 2015
|Aftermath by Robinson, Peter, 1950-
"Inspector Allan Banks is swamped with the aftermath of the horrific murder of five teenaged girls, while trying to cope with his divorce, his subordinates and the killer's wife, who might be hiding a lot more than she let on."--
|Mar 29, 2015
|The Devil's Making - A Victorian Detective Mystery by Haldane, Sean
|Mar 29, 2015
|A dangerous place - a novel by Winspear, Jacqueline, 1955- author.
Arriving in turbulent 1937 Gibraltar in the aftermath of a tragedy, Maisie Dobbs raises the British Secret Service's suspicions through her involvement in the murder of a Sephardic Jewish photographer.
|Mar 29, 2015
|The Body in the Birches by Page, Katherine Hall
|Mar 29, 2015
|Tail Gait - a Mrs. Murphy Mystery by Brown, Rita Mae, author.
"In the twenty-third book in the New York Times bestselling mystery series, Rita Mae Brown and her feline co-author Sneaky Pie Brown return with an all-new mystery starring Mary Minor "Harry" Haristeen, intrepid kitty sleuths Mrs. Murphy and Pewter, and Tee Tucker, the ever-faithful crime-solving corgi"--
|Mar 29, 2015
|Some Like It Witchy - A Wishcraft Mystery by Blake, Heather
|Mar 29, 2015
|Skies of Ash by Hall, Rachel Howzell
|Mar 29, 2015
New Arrivals
Movies & Music
Audiobooks and eBooks
Adult Books
- New Adult Fiction Books
- New Adult Nonfiction Books
- New Large Print Books
- New Biographies
- New Cook Books
- New Ellettsville Inspirational Fiction Books
- New Graphic Novels
- New Indiana Room Materials
- New Job Search Materials
- New Mystery & Detective Books
- New Science Books
- New Science Fiction & Fantasy Books
- New Travel Books
- New VITAL Materials
Young Adult Books
- Foreign Language Materials
New Children's Materials
Movies & Music
Children's Books


text:
Zhou Jun shot me an e-mail last week.
He's an electrical engineer and president of Variable Message Signs R&D of Shenzehn, China.
Basically, Dr. Jun was letting me know his firm was having a sale on its products. Its products include those LED speed-monitoring signs like the one the Monroe Police Department puts along certain streets to let motorists know how much they're speeding.
Other VMS products are programmable electronic message signs such as those you might see along the freeway that indicate trouble ahead.
Dr. Jun's e-mail kind of gave me the jitters because it seemed to me that it would make more sense if he was knocking on the doors of Chinese government agencies. But he was knocking on my e-mail door and I'm not even in the market for an electronic highway sign right now.
But maybe Dr. Jun is among the growing numbers of Chinese and others who sense that trouble's ahead for China. If so, that could mean bigger trouble for us, which is spelled U.S.
While there's been a lot of night sweats about the economic instability in Greece and other parts of Europe, China's economy has been like an obscene T-shirt on the fat guy standing in line in front of you at the theme park.
It's big, obvious, and can be annoying. You can't ignore it, you don't want to discuss it, but you can't do anything about it because anything you did about it would have negative consequences. So you just hope it goes away.
But China's economic problems don't seem to be going away. They seem to be getting bigger even as the U.S. economy seems to be teetering on the brink of stability.
Why should we care?
Because this is like having a mortgage with Big Bank Inc., when it suddenly finds itself with money problems. So one day, Big Bank calls you and says, "Hey, you got to pay off that mortgage loan."
And you say: "What!! I've never missed a monthly payment."
And Big Bank says. "Doesn't matter. You got to pay it off today."
This would be unsettling, no?
Well, China is like the Big Bank and the U.S. is like you.
That's because China owns about $3 trillion in U.S. debt — more than any other nation in the universe.
And just last week, China's government bought tons of shares of stock in China's big banks because investors were selling Chinese bank stock, fearing that a lot of Chinese bank loans were going to go belly up.
That's because in order to fuel development of all kinds in anticipation of good times ahead, local governments in China have borrowed heavily and don't yet have the revenue stream to repay those loans. In one province, about 85 percent of local government loans missed payments last year, according to one audit.
In response, some Chinese governments are investing in real estate (yikes!) to generate a future revenue stream.
Meanwhile, small manufacturing firms around China are collapsing, partly because they ramped up to meet global demand for goods and services, but they're timing was a little off, given the global recession that sneaked up on us.
Meaning good times ain't necessarily ahead.
Just last week, the Chinese government said it would provide financial support and preferential tax treatment for small companies and be more tolerant of bad loan ratios for small company loans.
At the same time, China's central government is continuing to encourage growth and local governments are heeding the call, figuring if there is nothing to support such growth, the central government will bail them out anyway. They can do government bailouts in China easier because, despite all of China's capitalist-like problems, they're still a communist central-planning kind of country.
But some observers say this kind of central planning is akin to the lack of central planning that occurred in the U.S. just before the collapse of the subprime mortgage market in 2007. That, you might remember, was back in the day when your house still was worth something.
That also was back in the day when the U.S. trade deficit with China was growing. Last month, uncharacteristically, that deficit shrank, apparently reflecting persistent waves of weakness in the global economy.
Those waves now seem to be breaking on the China shore and that might not be good for the economies of other nations that have been treading water while waiting for good times ahead.


text:
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Hart Foundation
WWE tag team legends The Hart Foundation
Courtesy of MinistryofSlam.com: A Royal Rumble winner in his own right, it's time to once again hop into Rey Mysterio's time machine and go back...
During tonight's WWE WrestleMania 31 main event title match between champion Brock Lesnar and challenger Roman Reigns, Seth Rollins decided to cash in his "Money in the Bank" briefcase!
Japan's Hikaru Shida makes her SHIMMER debut against Mia Yim.
WWE tag team legends The Hart Foundation
Fitness model and WWE "Diva of the Decade" Trish Stratus


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See, that's still a beer I wouldn't mind having a bit of . Love IPAs. I'd keg it. And yeah, you can keg 3gallons only. Just purge the headspace.
I wouldn't keg a beer I wouldn't want that much of. Like a DFH 120 clone, or a really funky sour or something that's too much to have a full pint of, etc.
Only ones that need extended aging due to limited keg space, other than that, so much easier than bottling!
Time to have some fun
I'm thinking along the same lines as DPM. A beer that ages well, and that changes and develops over time, is an ideal candidate for bottling. It doesn't clog up one of your precious taps forever,and you get to see how it develops over time (years, potentially). A big, chewy RIS or a big Belgian are the types of beer that I would think of this for.


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Cheektowaga's consolidation complex
All four Cheektowaga-based school districts are taking baby steps in the direction of consolidation. The various board of education have approved an application for a study which could come up with any number of conclusions. Nothing is guaranteed, but interested parties will definitely be watching to see what the report has to say on the subject of a full-blown merger.
This Business First story explored the issue in some depth. Below are further thoughts by the various Cheektowaga superintendents on the study and the subject of consolidation.
Jon MacSwan, Cleveland Hill:
"Statewide, something needs to be done to stabilize schools. This is not a Cleveland Hill issue, or a Central issue or a Sloan issue, with the erosion of programs due to the lack of funds. Each of us have lost multi-millions of dollars in the last couple of years and that goes for any district across the state…
"(For mergers, the state gives) an influx of cash to equalize contracts, to improve the programs, to improve facilities, to ensure that the transition to a consolidated district is done smoothly. But after that five years the money drops off rather quickly and what you're left with is a much larger program, with increased staff and increased expenditures…
"If you take two poor districts and consolidate them, after five years you have one larger poor district…"
"I'm not saying it's going to happen here. But we need to look at it and set up a plan to make recommendations to us."
Deborah Ziolkowski, Maryvale:
"The whole thing with re-organization, with the state incentive aid, is that when it's over you're in the same boat as you were in before. You have to make sure you build something that works for the community and the students. Hopefully this study will point to the right road and give us some suggestions on what we can do…
Dan Miner is Business First's enterprise reporter. He also covers education and public companies.
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Care Homes / Nursing Homes for Down Syndrome in and around Smalley
Distances given are in a straight line from the centre of Smalley but travel routes may be longer.
from 3 recommendations
Latest Recommendation
Excellent care for money. Good food and drink.… (Tuesday 20 Jan 2015)
160 Heanor Road, Smalley, Ilkeston DE7 6DX 1.1 Miles
Care Group: Ashmere Care Group
Care provided for Down Syndrome
When full, Kidsley Grange Care Home only accommodates 26 residents making the attention to detail here second to none. The family feel to the home makes it homely and creates a warm atmosphere hard to find elsewhere. There is the main lounge and conservatory… more
from 2 recommendations
Latest Recommendation
My mother has been a resident for six years and has received good care during this time. The staff… (Tuesday 16 Dec 2014)
88 Glass House Hill, Codnor, Ripley DE5 9QT 3.5 Miles
Care Group: Ashmere Care Group
Care provided for Down Syndrome
At Codnor Park Residential Home there is a bright, comfortable main lounge, a smaller Garden lounge, both recently redecorated, and a large lounge upstairs with computers. There is a library and large dining room, a resident cat and marine fish tank.… more
from 3 recommendations
Latest Recommendation
Mum moved in to Smalley Hall in August 2013 after living with us for nearly 9 years. Initially for… (Thursday 19 Feb 2015)
Main Road, Smalley, Ilkeston DE7 6DS 0.2 Miles
Care Group: Ashmere Care Group
Care provided for Down Syndrome
Smalley Hall Residential Home has grounds with lovely views. Residents can make good use of the pretty courtyard garden in the summer months. The trees and planting in the garden encourages wildlife and birds to visit. This garden is used for summer… more
from 3 recommendations
Latest Recommendation
My husband has been resident in this home for 3 1/2 years following the onset of Alzheimer's.… (Thursday 18 Dec 2014)
8 Newdigate Street, West Hallam, Ilkeston DE7 6GZ 2.0 Miles
Care Group: Ashmere Care Group
Care provided for Down Syndrome
West Hallam Residential Home is an Extra Care Unit, designed with dementia in mind, offers purpose built en-suite accommodation, constructed around a central courtyard. This area of the home offers round the clock care in this secure and safe environment.… more
from 4 recommendations
Latest Recommendation
I have lived at The Firs for over a year and I feel I have been well looked after.… (Monday 5 Jan 2015)
90 Glass House Hill, Codnor, Ripley DE5 9QT 3.5 Miles
Care Group: Ashmere Care Group
Care provided for Down Syndrome
The Firs is a delightful home located near to the Derbyshire town of Codnor, set in its own grounds. Due to its heritage as a farmhouse, the building itself has a warm and welcoming appearance, adding to the very homely atmosphere that is appreciated… more
Types of Care Homes in and around Smalley: All Care Homes
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The Alexandria House is a condominium community in Old Town Alexandria VA.
Alexandria House is located at the corner of Madison Street and North Pitt Street, Alexandria House overlooks Oronoco Park just four blocks from the Potomac River. Alexandria House condos are at 400 Madison St. Alexandria VA.
Alexandria House is located next door to Port Royal. Port Royal condominiums cater to a smaller budget than the condos found at Alexandria House. Alexandria House also towers over several nearby condo communities that are similarly priced, such as Abingdon Row and Watergate of Alexandria.


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"Leadership lessons applicable to all . . ."
Outstanding listening!!!! It?s like riding a roller coaster. Turns, twists and excitement is felt within the first 10 minutes. However, once the ride is over, you better understand what it means to lead people in trying times. Combat Swimmer is an excellent story. Its also a wonderful lesson on leading people. Great Writing!!!!!
Report Inappropriate Content
If you find this review inappropriate and think it should be removed from our site, let us know. This report will be reviewed by Audible and we will take appropriate action.


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I just received a letter from a delightful lady. She was a member of a church where I was ordained in the ministry. What I remember most about her was the way she offered encouragement to the pastors of that church.
The letter reminded me of so many good laypersons that served sacrificially in churches where I have been. With that in mind, I asked several pastors to recall something very positive said to them by church members. I asked them to try to summarize it in one sentence. Though I shouldnŌĆÖt be surprised, each of the pastors did not hesitate to offer one ŌĆ£joyful sentence.ŌĆØ
Here are the 14 IŌĆÖve accumulated thus far. They are only in the order I received them and wrote them on my iPhone.
- ŌĆ£I would like to babysit your kids so you can go on a date with your wife.ŌĆØ
- ŌĆ£Pastor, let me tell you specifically what I learned from your sermon and how it helped me.ŌĆØ
- ŌĆ£Your wife should have the freedom to be herself in the church.ŌĆØ
- ŌĆ£I confronted your critic about those unfounded claims he made about you.ŌĆØ
- ŌĆ£IŌĆÖm setting aside five minutes every day to pray for you and your family.ŌĆØ
- ŌĆ£I explained to the personnel committee how a package is not the same as your salary.ŌĆØ
- ŌĆ£Your kids should be able to live a normal life.ŌĆØ
- ŌĆ£Thank you.ŌĆØ
- ŌĆ£I want to help you recruit people to do ministry.ŌĆØ
- ŌĆ£I am so thankful for the time you spend in sermon preparation.ŌĆØ
- ŌĆ£We donŌĆÖt expect you to attend every meeting or function.ŌĆØ
- ŌĆ£Let me do that for you.ŌĆØ
- ŌĆ£Tell me how I can most help your wife.ŌĆØ
- ŌĆ£Here is a gift card to get you some books for your library.ŌĆØ
Yes, ministry is tough. Yes, we run into some difficult people more often than we like. But the reality is there are so many good people, so many good church members. These are but a few of the reminders of how pastors have been blessed by those church members.
What would you add to this list?
Thom S. Rainer is president of LifeWay Christian Resources. For the original article, visit thomrainer.com.


text:
Why Obama Needs an (Interim) Deal More Than Iran
It's not his legacy. It's Congress.
It's not his legacy. It's Congress.
Did the Arkansas Republican use Google Translate when assembling a Farsi version of his letter to Iran on the subject of ongoing nuclear negotiations?
The French don't trust Iran's nuclear promises, but they don't trust Washington much, either.
Iran nuclear talks continued Sunday, although it remains unclear if a deal would be made ahead of a March 31 deadline.
The key issues at play as negotiators race toward an agreement.
Iran's Shiite militias aren't a whole lot better than the Islamic State.
Just days before a key deadline in the Iran nuclear talks, British Foreign Secretary Philip Hammond expressed confidence that if a compromise is reached, negotiators would be able to present an agreement that clarifies key two sticking points: how long a final deal would be in effect and how far it pushes back Iran's breakout time to acquiring weapons-grade uranium.
Dear White House Correspondents: I know you have a demanding job with too many stories and too little time. Here is one that I hope ...
The strange love affair between a theocracy and an atheistic dictatorship.
Sectarian war is spreading in the Middle East, and Washington finds itself fighting with Sunnis in one country and with Shiites in another.
You have read of 8 free articles


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How to use Photoshop, Illustrator, InDesign, Acrobat Professional, and Adobe Bridge together effectively and efficiently.
Covers all the basic principles of InDesign CS2, from getting to know the workspace and tools to using advanced new features.
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Page 1
The Use of Live Three-Dimensional
Doppler Echocardiography
in the Measurement of Cardiac Output
An In Vivo Animal Study
James Pemberton, MD,* Xiaokui Li, MD,* Tara Karamlou, MD,† Chloe A. Sandquist, MD,†
Karl Thiele, PHD,‡ Irving Shen, MD,† Ross M. Ungerleider, MD,† Antoinette Kenny, MD,§
David J. Sahn, MD, MACC*
Portland, Oregon; Andover, Massachusetts; and Newcastle upon Tyne, United Kingdom
The purpose of this study was to investigate whether cardiac output (CO) could be accurately
computed from live three-dimensional (3-D) Doppler echocardiographic data in an acute
open-chested animal preparation.
The accurate measurement of CO is important in both patient management and research.
Current methods use invasive pulmonary artery catheters or two-dimensional (2-D) echo-
cardiography or esophageal aortic Doppler measures, with the inherent risks and inaccuracies
of these techniques.
Seventeen juvenile, open-chested pigs were studied before undergoing a separate cardiopul-
monary bypass procedure. Live 3-D Doppler echocardiography images of the left ventricular
outflow tract and aortic valve were obtained by epicardial scanning, using a Philips Medical
Systems (Andover, Massachusetts) Sonos 7500 Live 3-D Echo system with a 2.5-MHz
probe. Simultaneous CO measurements were obtained from an ultrasonic flow probe placed
around the aortic root. Subsequent offline processing using custom software computed the
CO from the digital 3-D Doppler DICOM data, and this was compared to the gold standard
of the aortic flow probe measurements.
One hundred forty-three individual CO measurements were taken from 16 pigs, one being
excluded because of severe aortic regurgitation. There was good correlation between the 3-D
Doppler and flow probe methods of CO measurement (y ? 1.1x ? 9.82, R2? 0.93).
CONCLUSIONS In this acute animal preparation, live 3-D Doppler echocardiographic data allowed for
accurate assessment of CO as compared to the ultrasonic flow probe measurement.
Coll Cardiol 2005;45:433–8) © 2005 by the American College of Cardiology Foundation
(J Am
Cardiac output (CO) is an important parameter both in
clinical medicine and in experimental biology, providing a
guide to the circulatory status and response to therapeutic
interventions. Several methods are available for assessment
of CO; however, these are not without inherent problems.
Two-dimensional echocardiographic (2-DE) Doppler as-
sessment of CO is derived from the velocity time integral of
the pulse wave (PW) Doppler at the level of the aortic valve,
multiplied by the valve diameter and heart rate. This 2-DE
method has inherent inaccuracies, as errors in diameter
measurement are multiplied in the calculations and PW
velocity determination may be inaccurate, especially in
low-output states (1,2). In addition, the aortic valve orifice
diameter is not uniform during the cardiac cycle or with
differing hemodynamic states (3,4). There is also the angle
dependence of Doppler (1,5), the parabolic flow velocity
profile in the aorta (1), and skewing of this profile such that
the higher velocities may be found at the septal or posterior
side of the outflow tract (6,7), which can be more pro-
nounced in larger animals (8).
Esophageal Doppler monitors can be employed for more
long-term CO monitoring in critical care areas. Inaccuracies
may be introduced from probe movement, and several
assumptions are made about aortic diameters (9,10). This
technique is minimally invasive and not suitable for nonse-
dated patients.
Thermodilution techniques of CO monitoring using
invasive pulmonary artery catheters are common in the
critical care setting. These techniques are not without errors,
especially in the presence of intracardiac or pulmonary
shunts, low-output states (11), and tricuspid regurgitation
(12). Catheters are invasive and present risks associated with
both catheter insertion and long-term use, including vessel
perforation, sepsis, and thrombus formation and emboliza-
tion (13).
Previous work by our group developed a reconstructive
three-dimensional echocardiographic (3-DE) technique to
accurately compute intracardiac flow volumes and derive
CO using transvalvular Doppler data (14–17). Three-
dimensional echocardiographic methods of flow volume
computation overcome the angle dependence of 2-D Dopp-
From the *Clinical Care Center for Congenital Heart Disease and the †Depart-
ment of Pediatric Cardiac Surgery, Doernbecher Children's Hospital, Oregon Health
& Science University, Portland, Oregon; ‡Philips Medical Systems, Andover,
Massachusetts; and the §Department of Cardiology, Freeman Hospital, Newcastle
upon Tyne, United Kingdom. Dr. Thiele is an employee of Philips Medical Systems,
and Dr. Sahn is an occasional consultant to the company. Dr. Roberto Lang acted as
Guest Editor.
Manuscript received August 18, 2004; revised manuscript received October 5,
2004, accepted October 12, 2004.
Journal of the American College of Cardiology
© 2005 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 45, No. 3, 2005
Page 2
ler (18) and the limitations of standard 2-DE methods of
volume computation. However, these studies were limited
by the time-consuming acquisitions that required multiple
2-DE slices to be acquired and reconstructed into a 3-D
image. The aim of this study was to assess the accuracy of a
new implementation of live 3-D Doppler echocardiography
in the computation of CO in an open-chested animal. With
this new technology allowing the Doppler data to be
acquired as a complete 3-D volume over only seven alternate
gated cardiac cycles, the need for lengthy acquisition times
or probe position changes is abolished.
Animal preparation. Seventeen juvenile Yorkshire pigs
weighing 2.7 to 11.3 kg (mean 4.29 kg) were studied before
undergoing a separate cardiopulmonary bypass (CPB) pro-
cedure. All animals were intubated and ventilated for the
duration of the procedure, and anesthesia was maintained
with 2% isofluorane and oxygen. The Institutional Animal
Care and Use Committee, Oregon Health and Science
University approved all procedures and operations.
Live 3-D Doppler echocardiography. Live 3-D Doppler
images were acquired using the Philips Medical Systems
(Andover, Massachusetts) Sonos 7500 Live 3-D Echocardi-
ography system with a 3000-element array, 2.5-MHz xMA-
TRIX transthoracic probe. For 3-D color Doppler acquisi-
tions, ensuring adequate frame rate and packet size and capture
of the full cardiac cycle, the system obtains a 30° ? 30° color
Doppler pyramid over 7 alternate gated cardiac cycles (14
cycles in total). The resulting dynamic 3-D tissue and color
Doppler volume can be reviewed and navigated through
immediately to ensure all areas of interest have been captured.
Apical epicardial scanning was performed to obtain 3-D
color Doppler volumes incorporating the left ventricular
outflow tract (LVOT), aortic valve, and ascending aorta
with electrocardiographic gating. Depth settings were ad-
justed as appropriate in each animal (approximately 6 cm)
and the Nyquist limit set to approximately 100 cm/s to
avoid aliasing and to maximize packet size and frame rate
(15 to 20 Hz). An ultrasound gel-filled probe cover (Ad-
vance Medical Designs Inc., Atlanta, Georgia) was used
over the probe, and ultrasound gel was used epicardially for
optimal contact with the heart.
Between 2 and 16 3-D image loops were obtained from
each animal under stable hemodynamic conditions. Loops
were viewed after acquisition to ensure that adequate data
was obtained; specifically, that the whole of the LVOT and
aortic valve were contained in the dataset (Fig. 1A).
Ultrasonic flow probes. A 10-mm ultrasound flow probe
and blood flow meter (Transonic Systems, Inc., Ithaca, New
York) was used to accurately measure CO in each animal.
The probe was placed around the aortic root just distal to
the origin of the coronary arteries in 11 animals and around
the pulmonary root in the remaining animals. A CO value
(ml/min) was recorded for each 3-D acquisition in all
animals. Probes were calibrated to zero and maximal flow
before each study. The flow probes give mean flow rate on
a beat-to-beat basis.
CO computation. After completion of the study, 3-D
Doppler data was transferred to a personal computer for
flow volume computation using specially designed computer
software (4D Echo-View, TomTec Imaging Systems, Un-
terschleissheim, Germany). To achieve this, the software
uploads the full 3-D volume dataset in proprietary 3-D
Cartesian DICOM format. Controls allow for the cut plane
of the 3-D volume to be moved in two perpendicular
longitudinal B-planes to ensure that the LVOT is clearly
seen on both cut surfaces. A sampling curve, the curved
surface of a hemisphere, is then placed on these perpendic-
ular B-plane images at the level of the aortic valve (Fig. 1B).
An arrow is used to indicate the direction of flow to ensure
the software accurately knows this.
The software then projects the velocity data for each
frame of the cardiac cycle to give a color image of the
LVOT at the level of the sampling curve, as if viewed from
the left ventricular cavity perpendicular to the aortic valve. A
sampling area is then traced around the region of inter-
est—in this case, the aortic outflow (Fig. 1C). The software
automatically reads the retained digital velocity assignments
in the dataset, within the region of interest, and then
computes the flow velocity profile and stroke volume for
that given area over the cardiac cycle from the velocity data
(Fig. 1D). In the absence of significant aortic regurgitation,
the aortic forward flow volume should equal the stroke
volume. The CO is calculated by multiplication of the aortic
forward flow with the heart rate. The heart rate is stored as
part of the 3-D Doppler dataset on the echo system.
Statistics. All values are expressed as mean ? SD. Linear
regression analysis was used to obtain correlation coefficients
between the 3-D Doppler and reference flow probe data.
Mean bias agreement between the two methods was tested
according to the Bland-Altman method with a 95% confi-
dence interval (19).
Interobserver variability. Ten randomly selected datasets
were analyzed by a second operator (X. L.) who was blinded
to the results of both the first operator and the reference
flow probe data.
Abbreviations and Acronyms
? aortic valve
? cardiac output
? cardiopulmonary bypass
LVOT ? left ventricular outflow tract
? pulse wave
? two-dimensional
2-DE ? two-dimensional echocardiography
? three-dimensional
3-DE ? three-dimensional echocardiography
434Pemberton et al.
Live 3-D Doppler Echo in Assessing Cardiac Output
JACC Vol. 45, No. 3, 2005
February 1, 2005:433–8
Page 3
One animal was excluded because of severe aortic regurgi-
tation; there were no other significant valvular abnormalities
in any of the other animals. All were in sinus rhythm and
studied under stable baseline hemodynamic conditions. In
addition, four animals were also studied after CPB under a
different but stable hemodynamic state. Heart rates in the
animals ranged from 75.6 to 150 beats/min (mean: 112.8 ?
17.7 beats/min) and were stable for the duration of each
study period.
Cardiac output. One hundred forty-three individual CO
measures with corresponding flow probe reference values
were analyzed from the 20 separate studies (7.15 observa-
tions per study). There was good correlation between CO
derived from 3-D Doppler data and that of the reference
flow probe: y ? 1.1x ? 9.82, R2? 0.93 (Fig. 2).
When the 3-D Doppler and flow probe data for each
study were averaged and compared, as is the case in clinical
practice, where an average of several CO measurements
would be used rather than a single point reading, there was
excellent agreement between the two methods: y ? 1.11x ?
17.5, R2? 0.99 (Fig. 3).
Analysis of the level of agreement between the two methods
in the individual data shows a mean difference of 30.6 ml/min
and a standard deviation of 70 ml/min, with 3-D Doppler data
tending to overestimate CO compared to the reference flow
probe (Fig. 4). Analysis of the combined data for each animal
shows a mean difference of 31.65 ml/min and a standard
deviation of 46 ml/min.
Interobserver variability. The interobserver variability was
tested using 10 randomly selected datasets by a second
observer (X. L.). There was good correlation between the
Figure 1. (A) Three-dimensional echocardiography (3-DE) color Doppler volume showing the Doppler signal filling the left ventricular outflow tract
(LVOT). The septum can also be seen in the image. The three-dimensional volume calculation software uses the Doppler signal in the LVOT. (B) The
two perpendicular cut planes of the three-dimensional Doppler volume at the level of the LVOT and aortic valve (AV). The color Doppler signal fills the
LVOT. The sampling curve (the level at which the volume calculation will be performed) has been placed at the level of the AV. (C) A third plane at the
level of the sampling curve (in this case the AV) as if the LVOT is being viewed from the left ventricular cavity. The color Doppler signal is seen within
the outlined area of interest. (D) The flow velocity profile within the outlined area of interest over the course of the cardiac cycle and the flow rate and stroke
volume calculation for that cycle in the green highlighted area.
JACC Vol. 45, No. 3, 2005
February 1, 2005:433–8
Pemberton et al.
Live 3-D Doppler Echo in Assessing Cardiac Output
Page 4
results of the two observers (y ? 1.28x ? 72.7, R2? 0.96).
Mean difference was 62.6 ml/min with a standard deviation
of 77 ml/min.
Real-time 3-DE technology has previously been utilized to
assess stroke volume and, hence, CO by ventricular volume
measurement. Several studies have investigated this against
reference stroke volume calculation and shown it to be an
accurate method of CO estimation both in vitro (20,21) and
in vivo (22,23). However, time-consuming offline process-
ing is required and border detection can still be a source of
error. One previous study (24) used an earlier real-time 3-D
Doppler system to compute flow at the level of the LVOT.
In that study, the low frame rate of the Doppler acquisition,
approximately 10 Hz, led to underestimation of flow vol-
ume. Accuracy was improved by development of a mathe-
matical correction.
The results of this study show that live 3-D Doppler data
can be used to accurately compute CO from the 3-D
transaortic Doppler profile, as in this animal model. The
resulting increased voxel density from the high line density,
frame rate, and relatively shallow depth lead to improve-
ment in temporal resolution and, therefore, Doppler data
for flow volume estimation. There is improved spatial
resolution with the use of the 3000-element array 4D probe
on the Philips Sonos 7500 system.
Cardiac output values in these animals were in the
physiological ranges for animals of this size, approximately
100 ml/kg (25,26). In this study, the 3-DE results overes-
timated the CO by 7.3%. The flow probe was placed distal
to the coronary artery ostia, whereas the 3-DE estimations
were made at the level of the aortic valve. The flow probe
measures mean aortic flow on a beat-to-beat basis, whereas
the 3-DE method measures systolic forward flow only. The
difference between the two methods could be accounted for
by coronary blood flow, a large proportion of which is
diastolic. We did not attempt to measure coronary artery
flow in this study.
The 3-DE overcomes some of the problems seen with
2-DE, including the assumption of a circular aortic valve
orifice (3–5) and the flat flow velocity profile over the aortic
valve (7,8). This live 3-D Doppler technique overcomes
these limitations by integration of all the flow velocity
vectors in the sampled area over a frame-by-frame time
period to yield a transaortic flow volume.
Previous work by our group used reconstructive 3-DE
data to derive intracardiac flow volumes (14–18). This has
been shown to be accurate, but had some limitations,
including time needed for data acquisition and processing,
and data mismatch due to movement or respiration artifact.
This advancement in 3-D technology, allowing acquisition
of 3-D volumes over seven alternate gated cardiac cycles and
displayed as a full 3-D color Doppler volume, reduces the
problem of variations in measurements due to time taken for
acquisitions and the need for lengthy patient cooperation/
sedation or the need for transesophageal echo. It also
overcomes the cumbersome nature of 3-D gating with the
Flock of Birds or stepper motors systems.
Study limitations. Despite the rapidity of acquisitions, CO
computation still takes place offline. This does not allow for
instantaneous CO monitoring. However, offline processing
of the data is quick and the learning curve for the software,
short. The additional advantage of the use of this echo
technique is the extra information gained regarding cardiac
structure and function.
In this study, the presence of significant aortic regurgi-
Figure 2. Linear regression analysis for the 143 data points in the 16
animals showing good correlation (y ? 1.1x ? 9.82, R2? 0.93) between
the three-dimensional Doppler cardiac output (CO)-derived computations
and the flow meter measurements. Other abbreviations as in Figure 1.
Figure 3. Linear regression analysis for the combined results from each
animal showing excellent correlation (y ? 1.11x ? 17.5, R2? 0.99)
between the two methods of CO calculation. Abbreviations as in Figures
1 and 2.
Figure 4. Level of agreement between the individual results of the two
methods of CO calculation according to the Bland-Altman method.
Abbreviations as in Figures 1 and 2.
436 Pemberton et al.
Live 3-D Doppler Echo in Assessing Cardiac Output
JACC Vol. 45, No. 3, 2005
February 1, 2005:433–8
Page 5
tation was an exclusion criterion, as the flow probe only gave
mean aortic flow on a beat-to-beat basis. Turbulent flow
and flow velocities above the Nyquist limit for the system
may limit accurate flow-volume calculation. In this study,
we did not encounter problems with aliasing in the LVOT
at the Nyquist limit used. The analysis program allows for
"baseline shift." This option allows for some of the aliased
velocities to be incorporated into the flow velocity profile;
we did not use the baseline shift option for our analysis.
As the 3-D acquisition is over seven alternate cardiac
cycles, stable hemodynamic conditions are needed over this
time period. In patients with higher heart rates, the acqui-
sition will be faster than with slower heart rates. In our
study, with an average heart rate of 112 beats/min, acqui-
sition times were approximately 7.5 s, and hemodynamic
conditions in our animals were stable over this short time
period. The maximum frame rate for 3-D Doppler acqui-
sition is 20 Hz, and in our studies with higher heart rates,
this was achieved.
A regular cardiac rhythm is also necessary, as irregularities
such as atrial fibrillation would produce volume mismatch
over the seven-gated sub-volumes. Irregular rhythms are a
problem with most methods of cardiac output determina-
tion as the stroke volume is different with each beat
depending on filling time (27). This could be overcome by
averaging a number of CO estimates, as is often the case
clinically in atrial fibrillation (28).
The animals used in this study were small (average 4.29 kg)
but could serve as a model for neonate echocardiography. In
these animal preparations, epicardial scanning in a controlled
Doppler data quality acquisition. In addition, depth settings
were approximately 6 cm, allowing for excellent imaging of the
LVOT and aortic valve. In clinical applications, depth settings,
especially in adult patients, may be such that the frame rate and
Nyquist limit would not allow for adequate velocity data for
accurate flow volume computation. Further studies will be
required to clarify the maximal depth settings possible for flow
volume computation.
The 3-D probe currently uses a 2-to-4 MHz range for
scanning. In adult patients with poor echo windows, it can
be used with tissue harmonics to improve image quality. In
pediatric patients, this, or a higher frequency, would be
preferable for improved resolution.
Future work. In this study we used an ultrasonic flow
probe as the reference for CO calculation. We felt that this
was the most accurate method of CO calculation in these
animals given the small size of the vessels (?10 mm) and
the potential for inaccurate diameter and PW measures.
The extension of this study to involve both adult and
pediatric human subjects in a clinical setting is the next step
in defining the clinical use of live 3-D Doppler technology
in the computation of flow volumes. In addition, it will be
possible to assess the difference against standard 2-DE
methods. Our initial findings in human studies suggest
good correlation from 3-DE against reference volume
calculation. It may also be possible to extend this technology
to quantify flow over cardiac valves and, therefore, to assess
valvular insufficiency as a product of forward minus reverse
flow volumes.
This study has shown that live 3-D Doppler echocardiog-
raphy can be successfully used to compute intracardiac flow
volumes accurately in this animal model and holds promise
for a noninvasive technique for flow-volume assessment in
human subjects in the future.
Reprint requests and correspondence: Dr. David J. Sahn, The
Clinical Center for Congenital Heart Disease, Oregon Health &
Science University, 3181 SW Sam Jackson Park Road, L608,
Portland, Oregon, 97239-3098. E-mail: firstname.lastname@example.com.
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