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Day 3 :
- Track 7: Cardiac Nursing Track 8: Heart Failure Track 9: Diabetes and the Heart
Location: Berlin, Germany
Andreas C Petropoulos
Azerbaijan State Medical University, Azerbaijan
Session Introduction
Brojendra Agarwala
University of Chicago Medicine Comer Children's Hospital, USA
Title: Sudden unexpected death in young athlete
Time : 10:00-10:20
Brojendra Agarwala has completed his MBBS from University of Kolkata, India and completed Pediatric cardiology fellowship from New York University Medical Center New York, NY, USA. He is a Pediatric Cardiologist and Professor of Pediatrics at the University of Chicago. He has received best teacher award by the pediatric residents and the medical students. He has published 68 papers in reputed journals. He is named as one of the Top Doctors and Best pediatricians in Chicago magazine for many years.
Competitive athletes are those who participates in an organized team or individual sports that requires regular competition against others. Athletic activities substantially increase the sympathetic drive resulting in surge in catecholamine level that increases blood pressure, heart rate, myocardial contractility and oxygen demand. This can cause myocardial ischemia and arrhythmia that may lead to sudden death in athletes with known and unrecognized heart conditions during athletic activities. It is estimated that 1-2/100,000 SCD/year happens worldwide. According to the International Olympic Committee, SCD rate in athletes is ~ three times higher than in the normal population. There are many structural and acquired heart conditions that are not clinically manifested. Many physicians are involved in medical clearance of children for participations in school sports activities. Physicians have to recognize them to protect athletes from catastrophic events. In order to prevent sudden cardiac death physicians should be aware of cardiac conditions that may cause problem. Also physicians should be familiar with general guidelines for evaluation of an athlete and clearance for participation in athletic activities. Guidelines vary in different parts of the world. In this presentation I will discuss guidelines for European, Italian and in USA outlined by American heart Association. In this presentation the causes of congenital and acquired heart conditions and arrhythmias that can cause sudden cardiac death will be discussed with authors experience and literature review.
Robert Skalik
Wrocław Medical University, Poland
Title: Neglected mechanisms of cardiopulmonary capacity in health and heart failure- Why brain and heat stress really matter?
Time : 10:20-10:40
Robert Skalik, MD, PhD is a consultant in cardiology, exercise physiologist. He completed his PhD in echocardiography from Medical University of Wrocław. He covered internship in the Department of Cardiology at Free University of Amsterdam, the Netherlands. He is a lecturer in Post-graduate School of Cardiology, University of Perugia and an academic teacher and researcher in Department of Physiology, former consultant in cardiology in Department of Cardiac Surgery and Cardiology, Medical University of Wrocław, former Head of Department of Cardiac Rehabilitation, Wrocław, private practice in cardiology, Wrocław, research projects evaluator for EU. He has published 103 papers on cardiology and human physiology.
Physical capacity is a complex process and may be subject to significant modulation due to intensity of aerobic and anaerobic processes, efficacy of thermoregulation, psychomotor performance and psychological factors irrespective of normal functioning of the cardiovascular and musculoskeletal systems. Hence, the dynamics and magnitude of changes in core body temperature in response to acute physical exercise in cardiopulmonary exercise test (CPX) and their relationship to exercise capacity have not been elucidated yet. The role of the cortical centers in modulation of fatigue perception in physically active people is also controversial. The cerebral cortex is a significant determinant of psychomotor performance. The results of the study confirmed a significant relationship between core body temperature at maximal physical effort (Tc) in CPX and psychomotor performance in healthy amateur athletes. The psychomotor performance was also related to carbon dioxide output at maximal physical exercise, ventilatory equivalent for carbon dioxide at the anaerobic threshold. Thermo-metabolic (VO2AT divided by Tc) and neurothermo-metabolic (VO2AT divided by the sum of Tc and psychomotor performance score) index are strongly related to parameters of exercise capacity as measured at maximal physical effort during CPX (VE, VCO2). The Rate of Perceived Exertion (Borg scale) immediately after CPX, is not related to Tc, exercise capacity parameters and psychomotor skills. The magnitude of changes in core body temperature during CPX may affect the parameters of physical fitness through modulation of psychomotor skills. Psycho-motor performance influences ventilator parameters. Subjective perception of physical effort does not correlate with exercise capacity parameters in CPX.
Rohit M Sane
Madhavbaug Cardiac Rehabilitation Centre, India
Title: Functional capacity is an independent predictor of mortality in heart failure patients with low ejection fraction
Time : 10:40-11:00
Rohit M Sane, MBBS, is a pioneer of non-invasive cardiac care management. He is the Founder of Madhavbaug Cardiac Rehabilitation Center which includes 138 OPDs & 2 IPDs in Maharashtra, India.
Abnormal six-minute walk test (6MWT) findings which indicates decreased functional capacity is considered as predictor of increased cardiovascular risk and mortality. However, the importance of this variable as predictor of mortality in heart failure (HF) patients with low ejection fraction (EF) is not well established. Therefore, we aimed to determine the influence of 6MWT findings on prediction of cardiac-related mortality in patients with low EF. Analyses were based on 108 heart failure patients with low EF undergoing treatment at Madhavbaug Cardiac Rehabilitation Centre between January 2012 and January 2014. Estimated functional capacity measured through 6MWT findings (expressed as the distance walked in meters) to determine its prognostic importance during 3 years of follow-up. Of 128 patients, 50(39%) died during follow-up; all reported deaths were found to be as cardiac related. In survived patients group, the distance walked was greater than 409.72(±93) meter while in died patients group; it was less than 300.17(±124) meter. The 2D echo data suggested that in both the groups, the left ventricular mass was 290 g and ejection fraction was 28.7% and 26.62% in survived and died patients, respectively. On uni-variable analysis, estimated functional capacity measured through 6MWT findings was a strong predictor of death, with 50(39%) deaths occurring in patients achieving p<0.05. On multivariable analysis, the strongest independent predictors of cardiac related mortality were poor functional capacity. The distance walked by patients in 6MWT had strong relation to the number of reported deaths; functional capacity was a predictor of death. For reported cardiac mortality; functional capacity remained as independent predictor of mortality.
Klaus-Dieter Schlüter
Justus-Liebig University Giessen, Germany
Title: Swiprosin – How cardiomyocytes can reorganize their sarcomeres and couple remodeling to β -adrenoceptor desensitization
Time : 11:15-11:35
Klaus-Dieter Schlüter, born 09.07.1959, studied biology at the Westfälische-Wilhelms-University, Münster, Germany. He made his PhD at Gesellschaft für Biotechnologische Forschung, Braunschweig, Germany, and spent his Post-Doc education at Heinrich-Heine-University Düsseldorf, Germany. In 2002 he became professor for physiology at Justus-Liebig-University in Giessen, Germany. Research areas are biology of cardiomyocytes, hypertensive heart disease, and ischemia/reperfusion. He published over 100 original articles and several review articles, editorials and book chapters. Current activities include editing of a book entitled "Cardiomyocytes – Active players in cardiac disease". He is member of the German Society of Cardiology and of the German Physiological Society.
Cardiomyocytes are terminally differentiated cells in a term that they lose their ability for cell division shortly after birth. However, cardiac remodeling requires intensive reconstruction of contractile units that is still possible in these cells. Cultivation of adult rat ventricular cardiomyocytes (ARVC), terminally differentiated cells, on culture dishes requires remodeling of cells in order to adapt cell shapes to the two-dimensional surface. It is known that ARVC are able to degrade their contractile units (sarcomeres) and reform new sarcomers alongside stress fibres. However, it is not known which molecules trigger this process and whether this process is comparable to remodeling processes in vivo. We recognized that swiprosin, a calcium-dependent protein that stabilizes actin filaments and thereby stabilizes stress fibres, is required for the reformation of sarcomeres in ARVC. When swiprosin activation is blocked by verapamil or when swiprosin is downregulated by administration of siRNA directed against swiprosin, ARVC were unable to rebuilt sarcomeres. Moreover, in vivo expression of swiprosin was induced in post-infarct hearts during a phase of intensive cardiac remodeling. Swiprosin expression strongly correlated with GRK2 expression that represses β-adrenoceptor coupling. In vitro, silencing of swiprosin reduced GRK2 expression and this improved β-adrenoceptor coupling. A role for increased diastolic calcium levels in cardiac calls has well been described in cardiac remodeling. However, these effects were linked to calcineurin-dependent transcription factor activation and could exlplain only part of the remodeling process. Here we describe another link between diastolic calcium levels and remodeling requiring activation (dimerization) of swiprosin in cardiomyocytes.
Krzysztof Piotrowski
Pomeranian Medical University, Poland
Title: The genetic aspect of human heart development in aspect of prenatal diagnosis
Time : 11:35-11:55
Krzysztof Piotrowski, a specialist in Obstetrics, Gynecology and Clinical genetics, completed his PhD with a dissertation on fetal echocardiography. Putting his knowledge into practice, he performs about 3,000 USG investigations of gravidas annually for prenatal diagnosis. He has published many scientific papers and chapters covering prenatal diagnosis. Having introduced the BACs-on-BEADs TM technology to Polish diagnostics, at present he is focused on applying molecular genetics prenatally. For the last nine years he was the Manager of Cytogenetic Unit for Pomeranian Medical University, Szczecin, Poland. Lately, he has founded a new independent genetic centre, DIAGEN – PREDIAG.
Congenital Heart Diseases are the most common malformations both as an isolated form and a part of genetic syndromes. Extraordinarily fast development of molecular genetics confirms that almost all CHD are genetically dependent in terms of micro aberrations in different regions of a chromosome or single gene mutations. On the other hand, CHD are an important component of diverse genetic diseases, including monogenic, metabolic and mitochondrial disorders, most often as secondary cardiomyopathies. The genes participating therein are located nearly on each chromosome, mainly on pathways, along with ligand genes and co-factors, transcription factors or individually. Many mechanism on heart development are based on the balance between apoptosis, proliferation and migration. Crucial genes controlling fetal development, including the creation of heart tube and the forming of left and right ventricular outflow are primary "homeobox" genes grouped in 4 clusters HOX1- 4 . Other genes condition the forming of different structures. Moreover, in numerous functional disorders, for example the arrhythmia or block, the reason is also genetic, namely the mutation of ion- channel gene placed in 6 chromosomes.Many genes of cardiogenesis were identified thanks to the investigation of other genetic disorders, for example PTPN11 gene in Noonan syndrome. The gene is also responsible for the development of pulmonary valves or TBX5 gene in Holt-Oram Syndrome. Heart development is also affected by the imprinting (about 30 genes) and the inactivation of the X chromosome in day 21 stage of embryo. We propose, e.g. a practical classification could refer to specific CHD characteristic of particular disorders, which might prove helpful in daily practice because in prenatal diagnosis CHD is often the sole syndrome confirmed by USG scan, which may depend on truly isolated nature or non-specific mild ultrasound co-markers.
Youssef Fathy Mohamed Nosir
King Fahad Armed Forces Hospital, Saudi Arabia
Title: TEE monitoring TAVI can predict in procedure complications that allow early management for favorable outcome, KFAFH experience
Time : 11:55-12:15
Youssef Fathy Mohamed Nosir had graduated from Faculty of Medicine, Al-Azhar University, Egypt in 1985. He completed his Cardiology training and obtained MSc in 1991 from Al-Azhar University. He spent a fellowship at Thorax center, Rotterdam, the Netherlands from 1994-99 and obtained his PhD at 1999 from Erasmus University, Rotterdam. He also obtained MD (Doctorate degree in Cardiology) in 2001 from Al-Azhar University. His current position is Consultant Cardiologist at King Fahd Armed Force Hospital, Jeddah, KSA and Professor of Cardiology at Al-Azhar University, Cairo, Egypt.
TAVI is a relatively new procedure for replacing the non operable severely stenotic AV in elderly patients. TEE monitoring the procedure is still questionable. At KFAFH, Jeddah, KSA, TEE was performed during TAVI procedure to re-measure the annulus size and to monitor all procedure steps. 47 patients underwent TAVI procedure at KFAFH between 20112 and 2015. The procedure was successful in all patients. TEE could detect 9 acute complications during the procedure that were managed immediately. 1- One acute fresh mobile thrombus was detected over the catheter in LV after balloon dilatation. The catheter was removed with the thrombus thread over it. 2- Acute severe MR in 4 patients TEE could detect the cause, one was due to acute ischemia and 3 were due to distal displacement of posterior MV leaflet by the LV catheter. MR was disappeared after dealing with the cause. 3- Pericardial effusion was detected immediately post procedure in 3 cases that necessitate tapping. 4- Acute severe hypotension immediately following valve deployment during rapid pacing was detected in one patient. TEE revealed acute severe LV systolic dysfunction with SWMA related to distal LAD segments and development of severe MR. Immediate coronary angiography revealed acute LM stenosis and primary stenting was performed with DES. After LM stenting LV systolic function improved and MR was disappeared. In conclusion TEE is recommended to monitor TAVI procedure for early detection of acute complication during the procedure that allows immediate and proper management of complication for favorable clinical outcomes.
Andreas C Petropoulos
Azerbaijan Medical University, Azerbaijan
Title: Treatment of heart failure in childhood strategies presented in the 2014 guidelines by ISHLT
Time : 12:15-12:35
Andreas Petropoulos graduated from Aristotle University's Medical School, Greece in 1989. Followed 30year career as a medical officer, senior Flight Surgeon in the Hellenic Air-Force. Specialized in Aviation-Hyperbaric Medicine, Pediatrics, Fetal, Pediatrics and Congenital Cardiology in USA, Europe. He holds MSc in Preventive Cardiology and a member of AEPC working groups in "Prevention" & "Heart Failure-Pulmonary Hypertension". He worked and lectured in Athens and Brussels universities. Currently consults in Pediatrics, Fetal. Pediatrics & Congenital Cardiology in MerkeziKlinika and Associate Professor at the State University and Post Graduate, CME Center in Azerbaijan. His research focuses on prevention, CVD imaging techniques, fetal cardiology, heart failure.
Heart failure (HF) in childhood is a clinical and pathophysiological syndrome, resulting from: 1.Ventricular inotropic dysfunction, 2. Volume and/or Pressure overload, 3. Irregular heart rhythm 4.Long standing hyperdynamic circulations leading to a mismatch to the metabolic needs of the body. Presents as failure to thrive, respiratory distress, exercise intolerance and associated with circulatory, neurohormonal, molecular abnormalities. HF has numerous etiologies. It is a common clinical presentation as a consequence of cardiac or non-cardiac disorders, congenital or acquired. The aim of this paper is to present the current advances on treatment of HF in childhood. It focuses on the 2014 International Society of Heart and Lung Transplantation (ISHLT), guidelines. These improve the previous 2004 ISHLT guidelines and amalgamate scientific data from the 2013 ACCF/AHA for management of HF in adults. We will focus on the existing variety in treatment strategies.
Graduate of Al-Azhar University in Cairo, Egypt and specialized in Cardiology since being a resident in the dept. of Cardiology. International training in the University of Pittsburgh medical center, USA ( preventive Cardiology).Later in the university of Britania occidentale in France ( Interventional Cardiology).Full professor of Cardiology and director of the cath lab, Al-Azhar uni. Member of the post graduate teaching and examining board.Supervised and evaluated more than 40 research projects for Master and Doctorate degrees in national universities in Egypt.Consultant of the National health organization in Egypt.Reviewer In the Egyptian Journal of hospital Medicine.
In this work 100 Egyptian patients of age range (53.89+8.11 years) with suspected CAD were included, they underwent full clinical evaluation, coronary calcium score in all calcified lesions along the major epicardial arteries and the whole-heart Agatston score measured using the multi-slice spiral computed tomography. Coronary angio was done to all patients for proper evaluation of degree of coronary stenosis. In the study group, one, two, three and four coronary lesions were found in 40%, 19%, 32% and 8% respectively, while the related median total calcium score was found to be 104, 78, 36 and 249 respectively. LM artery showed Agatston score of 11.73, 128.65 and 241.6 in normal, mild and significant stenosis respectively with P value of P<0.001. LAD artery showed Agatston score of 3.21, 35.3, 68.27 and 87.92 in normal, mild, significant and total occluding lesions respectively with P value of P<0.001. CX artery showed Agatston score of 33.42, 73.09, 11.54 and 12.14 in normal, mild, significant and total occluding lesions respectively with no significant correlation. RCA artery showed Agatston score of 5.58, 0, 4.16 and 101.7 in normal, mild, significant and total occluding lesions respectively with P-value of P<0.001. In this work – First to study an Egyptian population – the Calcium score estimated by non-invasive multi-slice CT in the studied group with low and intermediate calcium scores does not correlate closely with the degree of coronary artery stenosis estimated by coronary angiography and does not correlate with the known international figures and grades for Agatston score. A question about the pathophysiology of the plaque formation in Egyptians and possibly opening the door for specific preventive measures is to be considered.
Nany Hassan Abu Al-Makarim El Gayar
Alexandria University, Egypt
Title: Serum total osteocalcin level as a vascular marker in elderly patients with metabolic syndrome
Time : 13:40-14:00
Nany Hassan Abu Al-Makarim El Gayar is an Assistant Professor of Internal Medicine, Geriatrics Department at Alexandria University, Egypt. He has done MS in Rheumatology and MD in Geriatrics. He has published 10 papers in reputed journals.
Metabolic syndrome (MetS) is a major public-health problem and clinical challenge worldwide. Several epidemiological studies have confirmed the increased risk of CVD in individuals with MetS. Osteocalcin (OCN) is a bone-derived, noncollagenous protein that recently recognized as hormone regulating energy metabolism. Importantly, osteocalcin expression has been described in calcifying vascular smooth muscle cells We aimed in the present study to analyze the correlation between serum levels of OCN and vascular calcification in elderly persons with metabolic syndrome. 74 elderly males, 65 years and older were included in the present study, divided into two groups; group I; 40 patients satisfied at least three criteria of the metabolic syndrome (MetS) according to NCEP-ATP III definition, and group II; 34 age-matched healthy males serving as a control group. BMI was calculated, blood samples were taken for lipid profile, and total OCN levels using ELISA kits. Carotid Doppler B mode ultrasonography was done for all participants. Patients with MetS exhibited significantly higher BMIs, waist circumference, fasting blood sugar, Triglycerides, blood pressure, total cholesterol, and lower HDL-ch, compared to the controls subjects. Patients with MetS had significantly lower levels of total Osteocalcin than control subjects. Also, patients with MetS had significantly higher IMT and higher number of carotid plaques than the control subjects. Total OCN was significantly negatively correlated with parameters of carotid atherosclerosis. It is also negatively correlated with dyslipidemic parameters. Its correlation with components of Mets did not reach a statistical significance. We concluded that serum osteocalcin levels were significantly associated with carotid atherosclerosis in patients with metabolic syndrome. This may reflect the role of osteocalcin as a circulating endocrine factor which regulates glucose metabolism and thereby cardiovascular risk in patients with metabolic syndrome. Prospective studies are needed to assess the time course and relevance of serum osteocalcin in the development of atherosclerosis in patients with metabolic syndrome.
Shailesh Kumar Patil
Fabiani & Budhrani Heart Institute, India
Title: Balloon mitral valvotomy in youngest rheumatic mitral stenosis patient
Time : 14:00-14:20
Shailesh Kumar Patil has done his MBBS and MD internal medicine from reputed institutions in India with academic excellence. Trained in cardiology for 3 years in one of the high volume centre in India, where highest number of pacemaker implantations are done in asia. Also well trained in thansthoracic and trasesophageal echocardiograph and performed around 5000 femoral and radial angiographies, 1000 angioplasties including complex corornary and peripheral angioplasties, pediatric device implantations and balloon mitral valvuloplasty. He has got 7 national and international publications to his name. He is presently consultant cardiologist at 250 bed tertiary hospital in Pune, India.
Rheumatic heart disease occurring at a young age including juvenile mitral stenosis results in morbidity as well as mortality in adolescents and young adults, and also becomes one of the major cause of loss of the most productive years of life in developing countries like India. Rarely rheumatic MS may occur in < 5 years age, wherein rapid hemodynamic progression and cardiac morbidity and mortality occur. Our patient was 4 years old child with severe mitral stenosis (documented since 2 year 6 months of age) presenting with repeated pulmonary edema and the typical echocardiographic findings strongly indicated a rheumatic origin of this condition. Considering the fulminating nature of disease, patient was planned for early intervention and was taken for balloon mitral valvotomy with 20 mm Tyshak balloon. Percutaneous transmitralcommisurotomy (PTMC) may therefore become the only lifesaving intervention in these cases unless contraindicated, although the procedure entails considerable technical issues in this age group like sizing of peripheral venous sheath, choice of balloon, estimation of optimum balloon size by the height criteria. A few case series of balloon mitral valvotomy in patients aged 7 to 12 years have also been reported, and the procedure has been safe and effective even in this young population. To the best of our knowledge,our patient was the youngest documented case of established rheumatic heart disease and also one of the youngest PTMC procedure performed.
Vincenzo Cianci
University of Swansea, UK
Title: MINI-OPCABG an alternative to hybrid coronary revascularization
Time : 14:20-14:40
Vincenzo Cianci I is senior registrar in cardiothoracic surgery at the University of Swansea in UK, previously was staff resident of cardiac surgery at the University of Sacred Heart in Campobasso (Italy). He obtained his medical degree at University of Naples (Italy), and he completed his post graduate training at University of Milan. Dr Cianci began his surgical career as fellow at Humanitas Gavazzeni clinic in Bergamo, after he was staff resident at University of Pavia for five years. In 2011 he was senior registrar in cardiothoracic surgery at Queen Elizabeth Hospital at University of Birmingham (UK). In 2012 He was staff resident in cardiocentro Ticino Lugano (Switzerland). His past clinical practice has encompassed the full spectrum of adult cardiovascular and thoracic surgery including experience in heart and lung transplantation, left ventricular assist device. His current practice focuses on minimally invasive coronary By pass graft, thoracoscopic epicardial atrial fibrillation. He collaborates actively with Prof. Benetti for the development of Hybrid coronary revascularization with a novel surgical technique.
From 1990 to 2016 38 patients received Hybrid coronary treatment during the same Hospitalization in ours Institutions with different surgical off pump approaches, Sternotomy, MIDCAB and MINI OPCABG. 20 patients were stenting after a MINI OPCABG operation. The average age was 69±4.8, 4 patients had Left Main and a Right coronary lesion 10 patients had three vessels disease and 6 two vessel disease; the average SYNTAX score was 35.2 (range33-43). Eight patients received a circumflex and right coronary stenting six patients a right and six a circumflex coronary stenting. We described the technique and methodology for this approach. Technique: The patients are prepared as for standard coronary bypass operation through medium sternotomy. A skin incision is made from the xiphoid up to the level between the third and fourth intercostal space. The sternum is open and the left table is lifted to dissect the left mammary up to the third intercostal space, in general around 7 to 10 cm. isolated without the veins. It is important that the angle of the superior part where the mammary is attached to the sternum has to be below 20% to avoid any potential kinking. After the pericardium is cleaned to identify the area of the pulmonary artery, the pericardium is open to the apex and towards the right around 5 to 6 cm., initially in that moment in most of the cases the area of the LAD is seen and the potential area of the anastomosis is defined, mechanical stabilizer is always in position in this place with the opening part towards the head of the patient to avoid any problem of damaging the graft when you need to take it. The anastomosis is performed in a running way with 7 or 8 polypropylene depending on the size of the artery. We didn't use shunt, normally except if the artery has more than 2,5 mm in size. Results: No thirty day mortality was reported in our series. All patients completed hybrid procedure and there wasn't any conversion to full sternotomy. Mean intubation time was 1.5±3.2 hrs and length of hospital stay was 3.2±1.2 days, two patients reiceved packed RBC (red bloodcells) transfusion, hospital MACCE was 0%. During PCI procedure angiographic evaluation LIMA grafting was routinly performed and LIMA patency rate was 100% at one year follow up. Patients freedom from MACCE was 100%. Conclusion: The introduction of DES with lower rates of restenosis and better clinical outcomes may make hybrid coronary revascularization a more sustainable and feasible option than previously reported. Nevertheless, this hybrid approach has not been widely adopted because practical and logistical concerns have been expressed. These concerns implicate the need for close cooperation between surgeon and interventional cardiologist, logistical issues regarding sequencing and timing of the procedures and the use of aggressive antiplatelet therapy for DES can be minimised. We believe that with MINI-OPCABG can solve these issues because this surgical technique reduces the surgical trauma without opening pleural space with less discomfort for the patient, moreover the partial dissection of LIMA reduces the risk of post operative bleeding The HCR procedure was associated with short hospital stays (including ICU stay and intubation time), low MACCE and 30-day mortality rate, low PRBC transfusion requirements. This study has limitations because it was based on the retrospective design, moreover patients for one stop hybrid coronary revascularization were also carefully selected and our good results should be interpreted with caution. However there is a small sample size and longterm follow-up and randomized multi center trial comparing one stop hybrid revascularization with MINI-OPCABG with conventional CABG will be needed. These favourable preliminary findings warrant further investigation.
Shaimaa Moustafa
Benha University, Egypt
Title: The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris
Time : 14:40-15:00
Shaimaa Moustafa is an Assistant Professor of Cardiology Department of Cardiology, Benha Faculty of Medicine, Benha University, Egypt.
Introduction: Myocardial deformation assessed by two dimensional speckle tracking echocardiography (2D-STE) allows accurate evaluation of regional and global left ventricular (LV) function and is sensitive to detect abnormalities induced by ischemia. Objective: To examine the value of speckle tracking echocardiography to detect the presence, extent and severity of coronary artery affection in patients with suspected stable angina pectoris. Methods: 200 candidates with suspected stable angina pectoris and normal resting conventional echocardiography were subjected to 2D-STE and coronary angiography. Global longitudinal peak systolic (GLPSS) and the most affected segment was calculated and were correlated to the results of coronary angiography for each patient. Results: There was a statistically significant difference in the mean of global longitudinal peak systolic strain between normal coronaries and different degrees of CAD (-20.11± 0.8 for normal, -18.34± 2.52 for single vessel, -16.14± 2.85 for two vessel, -14.81± 2.12 for three vessel, -13.01± 2.92 for left main disease). Global longitudinal peak systolic strain showed high sensitivity for the diagnosis of single vessel CAD (90%, specificity 95.1%, cutoff value: -18.44, AUC: 0.954); two vessels disease (90%, sensitivity 88.9%, cutoff value -17.35, AUC: 0.906) and for three vessels CAD (cutoff value -15.33, sensitivity 63% & specificity 72.2% AUC 0.681) GLPSS also showed statistical significance for localization of the affected vessel for LAD, LCX and RCA(P= 0.001) and significant correlation with syntax score (P= 0.001) . Conclusion: 2D-STE has good sensitivity and specificity to assess the presence, extent and severity of CAD.
- Young Researchers Forum
Location: Berlin, Germany
Andreas C Petropoulos
Azerbaijan State Medical University, Azerbaijan
Session Introduction
Ahmed A
University Hospital of Essen, Germany
Title: Survival analysis and postoperative complications after ventricular assist device implantation, prognostic value of INTERMACS scale
Time : 15:00-15:15
Ahmed is a resident physician and a researcher in the Department of Thoracic Organ Transplantation at the University Hospital of Essen, Germany. He is a graduate of the faculty of Medicine-Alexandria University, 2006, Alexandria, Egypt. He did his Critical Care Medicine residency in Alexandria university hospital. In August 2008 he completed his Master Degree in critical care medicine. He then worked as a specialist in Critical care medicine for 6 years. His most recent study was published in the Transplant International Journal 2015.
Background: Ventricular assist devices (VADs) have been proven to be effective in improving survival and quality of life in patients with refractory heart failure. However, outcomes depend on a variety of preoperative parameters. Aim of the study: This study evaluates retrospectively the patients profiles; clinical outcome, postoperative complications and mortality in patients who underwent VAD implantation in our center taking into account preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels aiming at anticipation of postoperative complications and optimization of the preoperative strategies. Methods: Between August 2010 and March 2015, 104 patients underwent VAD implantation in our university hospital. INTERMACS profiles were as follow: level 1 in 27 patients, level 2 in 20 patients, level 3 in 27 patients, level 4 in 25 patients, level 5 in 4 patients and level 6 in 1 patients respectively. Patients were divided into 3 groups: Group-A included 27 patients at INTERMACS level 1. Group B included 47 patients at INTERMACS level 2/3 and group C included 30 patients at INTERMACS Level 4/5/6. Preoperative clinical, echocardiographic, and hemodynamic and laboratory data were compared between groups as well as the incidence and time of onset of postoperative complications and mortality. Results: Preoperatively, group A had a significantly lower cardiac index, lower mean arterial blood pressure, lower serum hemoglobin, higher serum blood urea nitrogen, higher serum procalcitonin and higher incidence of metabolic acidosis (p<0.05). Postoperatively, group A had a higher incidence of respiratory failure, Hemorrhage, multi-organ failure, right ventricular failure and tracheotomy (p<0.05). Total mortality was higher in group A than in group B (p = 0.017) and in group C (p=0.017) but not between groups B and C (p =0.81). Early mortality (at 30 days after VAD) was higher in group A than in group B (p=0.015) and group C (p=0.010). After 30 days mortality was not statistically different between groups. Sepsis (47.1%), right ventricular failure (37.5%) and respiratory failure (33.7%) were the most common post-operative complications after VAD implantation, whereas renal failure was the most common complication within 1 week after the operation (23.1%). Multi-organ failure was the most common cause of mortality (13.5 % n=10). Predictors of total mortality were preoperative high central venous pressure (HR, 1.077; 95% CI, 1.019–1.138, p=0.008), high systolic pulmonary artery pressure (HR, 1.056; 95% CI, 1.015–1.099 p=0.007), high serum blood urea nitrogen (HR, 1.031; 95% CI, 1.018–1.045; p=0.001), high serum procalcitonin (HR, 1.134; 95% CI, 1.040–1.237; p=0.04), metabolic acidosis (HR, 3.496; 95% CI, 1.708–7.157; p=0.001), low serum Hemoglobin (HR, 0.780; 95% CI, 0.667–0.913; p=0.02). Conclusion: INTERMACS scale correlates with outcomes after VAD implantation in our single center study. Anticipation of postoperative complications allows for preoperative strategies to minimize these complications. Optimization of preoperative volume status, preload, right heart function, correction of preoperative anemia and management of preoperative sepsis are recommended to lower the total mortality in such patients.
Adriana Tamburello
University Hospital "Paolo Giaccone", Italy
Title: The role of NT proBNP in predicting prognosis and cardiovascular events in patients with heart failure
Time : 15:15-15:30
Adriana Tamburello is going to compleate her studies at the age of 25 years from Palermo University School of Medicine with honors, and she is doing research activity in Policlinico Paolo Giaccone Chair of Cardiovascular Diseases, Department for Promoting of Health (PROSAMI), University of Palermo, Italy – Division of Cardiology, Regional Reference Centre for Diagnosis and Care of Heart Failure, Centre for the Early Diagnosis of Preclinical Atherosclerosis and for Secondary Prevention of Cardiovascular Diseases, Department of Emerging Pathologies, University Hospital "Paolo Giaccone", Palermo, Italy.
Background: The Role of Nterminalpro Btype natriuretic peptide (NTproBNP) to stratify risk in patients with heart failure (HF) has been analyzed. NT-proBNP levels are increased in HF, and well correlate with ventricular wall stress and severity of HF. Repeated measurements of this marker through blood sampling, give accuracy of risk stratification. Purpose: To assess the prognostic value of NTproBNP levels and the risk of short-term death in patients with HF. Method: We studied 235 patients with an average age of 74,123 years, with clinical and echocardiographic signs of HF. 161 have HFrEF (EF≤ 45%) while 74 have HFpEF (EF > 45%). NTproBNP was evaluated at the hospitalization and at discharge and in 76 patients it was furthermore checked after 30 days from discharge.The median followup was 8months. We noticed the relationship between percentage NTproBNP increase from baseline to admission, and the percentage NTproBNP reduction from admission to discharge, that it is related with therapy during the hospitalization. Moreover we considered different parameters that may alter basic values NT-proBNP, such as chronic renal failure, physical activities and the use of certain drugs, overcoming these tresholds. Results: NT-proBNP values above 1100 pg/mL are prognostically meaningful in chronic HF, and a rising pattern is predictive of impending adverse outcome. Moreover, drugs used for chronic HF (such as, vasodilators, aldosterone blockers and β-blockers) tend to lower values of NT-proBNP.NTproBNP at discharge give an important prognostic index for mortality (HFrEF 28,9% deceased: CIndex 0,84 P< 0,0001; HFpEF 13,6% deceased: CIndex 0,76 P = 0,0004). In multivariate Cox analysis it is the stronger and independent prognostic factor (HFrEF all P≤ 0,02; HFpEF all P≤ 0,03). The percentage changes stratify the risk only for mortality ( χ2 13,68 P = 0,001) conversely, categorical risk stratification shows a prognostic role for all outcomes (all logrank P< 0,0001) and provides independent prognostic informations when threshold values are specific for HFrEF or HFpEF compared to titrations. Among these patients HF, the median NT-proBNP levels were higher in those patients dying by 45 days median of follow-up (9450 pg/mL) when compared with those surviving (2017 pg/mL, P<0.001 for difference). Conclusions: The determination of levels of NTproBNP in patients with heart failure is important for prediction of cardiovascular events: increased levels of this biomarker indicate the severity of myocardial dysfunction and severity of chronic heart failure. High levels of NT-proBNP are related with decreasing expectation of life and worse quality of daily living.
Maria Nathania
Newcastle University, UK
Title: The role of cardiac high energy phosphate metabolism in cardiac function and performance: The impact of age
Time : 15:30-15:45
Maria Nathania is an intercalating medical student from Universitas Indonesia, currently undertaking her Post-graduate (MRes, Master by Research) degree in Cardiovascular Sciences at Newcastle University (UK). In 2015, she presented her work on the International Student Congress of Medical Sciences held by the University Medical Center Groningen. She has profound interest in Cardiology and participated in a short research fellowship with Prof. Adriaan A. Voors, MD, PhD, looking at the effect of Aliskiren on urine albumin to creatinine ratio in patients with chronic heart failure and renal dysfunction.
Background: Cardiac dysfunction and diminished performance are major characteristics of heart failure. Diminished cardiac energy phosphate metabolism (i.e. PCr/ATP) has been suggested to cause cardiac dysfunction and chronic heart failure. The aim of this study was to define the relationship between cardiac high-energy phosphate metabolism and cardiac performance. Methods: Thirty-six healthy women (younger, ≤50 years, n=20; and older ≥60 years, n=15) underwent cardiac MRI with 31P spectroscopy to assess cardiac high-energy phosphate metabolism (i.e. PCr/ATP ratio), and performed cardiopulmonary exercise testing with non-invasive central hemodynamic assessment. Cardiac power output (CPO), as a measure of cardiac performance, was calculated as the product of cardiac output and mean arterial blood pressure. Results: PCr/ATP ratio was significantly lower in older compared to younger age women (1.92±0.48 vs. 2.29±0.55, p<0.05), as were peak exercise CPO (3.35±0.73 vs. 4.14±0.81 watts, p<0.01), diastolic function (i.e. E/A ratio, (1.33±0.54 vs. 3.07±1.84, p<0.01), and peak exercise oxygen consumption (1382.9±255.0 vs. 1940.3±434.4 ml/min, p<0.01). Further analysis revealed that PCr/ATP ratio shows significant positive relationship with E/A ratio (r=0.42, P<0.05), peak CPO (r=0.40, p<0.05), and peak oxygen consumption (r=0.50, p<0.01). Subgroup analysis based on age however showed that PCr/ATP ratio was significantly related to peak CPO in younger but not in older women (r=0.44, p=0.05 vs. r=0.14, p>0.05). Conclusions: High-energy phosphate metabolism and performance of the heart decline with age. Our findings demonstrate that cardiac high-energy phosphate metabolism plays an important role in overall cardiac function and performance in younger but not older age.
Naresh Sen
Narayana Hrudayalaya Institute of Medical Science, India
Title: Cardiac resynchronisation therapy
Time : 15:45-16:00
Naresh Sen is a Consultant Cardiologist affiliated with Narayana Hrudayalaya Institute of Cardiac Science, India. He got his medical graduation from Rajasthan University, Jaipur and post-graduation in internal medicine from South America and post doctoral training in Cardiology from Cacos & Turks. He has also been elected for Fellowship award of various societies of Cardiology . He worked in Cardiology (Invasive & Non-Invasive) as Registrar or Consultant at renowned cardiac hospital ports of India like NH & Medanta last 5 years. He has special interest in coronary artery disease and heart failure prevention. He has published around 50 publications in Cardiology .For his hard work, he was awarded as best cardiology consultant in Rajasthan, 2013 by Director of AIIMS, New Delhi.
Background: CRT (Cardiac Re-synchronization Therapy) has been approved beneficially in heart failure patients with refractory optimized medical therapy based on many studies. The guidelines have shown CRT is indicated in NYHA class IIIIV, QRS>150 ms, LBBB (Left bundle branch block) to improve heart functions, ventricular re-modeling and clinical symptoms. Purpose: Comparison of stress induced mechanical dys-synchrony between rate dependent LBBB and RBBB (Right bundle branch block) and beneficial role of CRT to improve LV function and reduce mortality. Method: Patients presenting dyspnea on exertion NYHA class I-II to III-IV by stress test, normal QRS to rate dependent LBBB or RBBB by Stress test or Dubutamine Stress Echo were studied. CRT on cardiac function was assessed by Cath-study, Echo and MRI (Magnetic Resonance Imaging). Result: 12-months observational study done on stress induced rate dependent LBBB and RBBB with worsening dys-synchrony and poor LV function were treated with CRT. Results have shown improved LV function in rate dependent LBBB patients (31±6%) vs. RBBB patients (4.5±4%) with P value<0.04. and reduce mortality among rate dependent LBBB with CRT vs. without CRT ( 5% vs. 20%) and another side mortality difference between rate dependent RBBB with CRT and without CRT were not found significantly. Conclusion: Stress induced rate dependent LBBB with mechanical dys-synchrony leads to heart failure is benefited by CRT than Rate dependent RBBB.
Zaid Altheeb
New York Medical College, USA
Title: Value of neutrophil to lymphocyte ratio as a predictor of mortality in patients with heart failure with preserved ejection fraction
Time : 16:00-16:15
Zaid Altheeb is currently a Cardiology fellow at New York Medical College. He graduated from Jordan University of Science and Technology (J.U.S.T) in 2009. He has a Medical degree in medicine and surgery. He is in the American board of internal medicine from New York Medical College at St. Joseph's, Paterson-New Jersey USA. He is a Member in American college of physicians ACP and American College of Cardiology ACC. He has publications in the field of cardiovascular medicine.
Background: Inflammation plays an important role in left ventricular remodeling and myocytes hypertrophy and remodeling. Higher levels of inflammatory markers, like IL-6, TNF-a, and CRP, were found in patients with heart failure with preserved ejection fraction (HFpEF). Neutrophil to lymphocyte ratio (NLR) represents a widely available, non-specific marker of systemic inflammation. It was validated as a significant predictor of adverse outcomes in multiple cardiovascular diseases, such as acute coronary syndrome and valvular heart disease. In this study we aimed to explore the utility of NLR as a predictor of long-term mortality in patients with HFpEF. Methods: 376 patients admitted to our hospital between 2010 and 2012 for acute HFpEF exacerbations were evaluated for study inclusion. 296 patients met the study inclusion criteria. Depending on the initial NLR level, patients were divided into two groups; NLR >= 4.5 and NLR < 4. Three-year vital status was obtained via electronic medical records and Social Security Death Index. Survival analysis was used to evaluate the predictive value of NLR level between these two groups. Results: There was a higher all-cause 3-year mortality (6.8% vs 15.3%, Chi-squared 4.6, p 0.033) in patients with NLR >= 4.5 when compared to those with NLR =4.5 (84.7% vs 93.2%, Chi-squared 5.423, P 0.02, HR 2.3456, CI 1.19-4.64). Using univariate Cox proportional-hazards regression analysis, patients with NLR >=4.5 had 2.35 fold increase in 3-year mortality when compared to those with NLR < 4.5 (HR 2.35, CI 1.12-4.79, P 0.0244). In a multivariate cox regression analysis, with the adjustment for age, sex, race, history of coronary artery disease, stroke, hypertension, diabetes, end-stage renal disease and tobacco use, NLR remained a significant independent predictor of 3-year mortality and patients had a 2.53 fold increased risk of mortality (HR 2.53, CI 1.14-5.62, P 0.0229). Conclusions: NLR, using a cutoff value of 4.5, represents an independent predictor of long-term mortality in patients with HFpEF.
To be updated...
Background: The lack of a correlation of myocardial infarction after coronary artery bypass surgery (type V MI) with electrocardiographic abnormalities is quite complex, creatingnumerous controversies, especially after the emergence of assays with high sensitivity troponin. Objective: To understand the release of myocardial necrosis biomarkers after on-pump coronary artery bypass grafting (CABG) in the absence of new delayed enhancement by gadolinium. Methods: In this prospective study, we evaluated patients with stable coronary artery disease, multivessel, left ventricular function was preserved, normal baseline cardiac biomarkers, and formal indication for elective on-pump CABG. Electrocardiograms and concentrations of high-sensitive cardiac troponin I (cTnI) and creatine kinase (CK)-MB were assessed before and after procedures. Cardiac magnetic resonance (CMR) and late gadolinium enhancement were performed before and after procedures. MI was defined as more than ten times the 99th percentile upper reference limit for cTnI and for (CK)- MB after coronary artery bypass grafting (CABG), and new late gadolinium enhancement for CMR. Result: Of the Sixty-nine patients referred for on-pump CABG, 54 patients showed no evidence of type V MI in the CMR. This group showed a male predominance with 39 (72.2%), mean age of 61.3 (± 8.3) years old and mean score of Syntax 28 (± 10). After surgery, of the 54 (100%) patients who had a cTnI peak above the 99th percentile, 52(96%) were 10 times higher than the 99th percentile. On the other hand, of the 54 (100%) patients that had a peak (CK)-MB above the 99 percentile limit, only 13 (24%) were greater than 10 times the 99th percentile. The mean peak of cTnI release was 3.15(0.12 to 50.0) ng/ml, 78.75x higher than the 99th percentile. Conclusion: In this study sample, different from that observed with (CK)-MB, troponin was excessively increased in the absence of late enhancement. Thus, (CK)-MB was more accurate than cTnI for diagnosing type V MI. These data suggest a higher troponin cutoff for the diagnosis of CABG related MI.


text:
In November, I saw Dethklok.
We got there early-ish and bought shirts because that's just a staple of the concert going experience. The venue was basically a big room with a stage, a bar in the corner and a gently sloping concrete floor. It was standing room only, there literally were no chairs.
So my friend and I stood around for an hour and a half just chatting.
Eventually The Black Dahlia Murder opened the show and they were fine. I'm not much for their music but in an environment like that you can't help but headbang. We were standing at the dividing line between the mosh pit and the mellow people. My friend was in front of me and served as my meat-shield.
The Machinehead came and again we headbanged but Machinehead felt like their set went on forever. Basically everyone was there for either Dethklok or Machinehead. I liked BDM better.
Then my friend went to sit this set out, which were the band All That Remains. In preperation for this concert I had listened to the three other bands in hopes of liking them and finding new music. I actually liked All That Remains. Well, some of their songs. And they sound better recorded.
They played Two Weeks, Hold On, The Last Time, and Some of the People All Of the Time, in which the vocalist held those last growling notes for what seemed like entire minutes. They also played others of course. The screen behind them showed war footage and graves and stuff. Two big metal-head guys next to me were singing along, it was kinda cute. Ah, to be a fan.
Unfortunately their set felt very short, or maybe it's because I'm a fan. Also, there was a fight in the moshpit which was distracting. Not that I could see anything, since I'm short.
So finally it was time for Dethklok!
Some Klokateers came out for sound check and I was positively charmed! I hadn't expected that.
The lights dimmed and I was standing in a place where I could see quite well and the live band comes out, and launch into the Dethklok themesong then I Ejaculate Fire. Then from there it's a blur. I know they played Andromeda, Awaken (Mustakrakish), Hatredcopter, Galaxy, Pull the Plug, Murmaider and a cool video for a song I didn't recognize but later identified as Ghostqueen. Then they started Duncan Hill's Coffee Jingle...
...and the power died.
So impromptu drum solo!
When the power came back "Nathan Explosion" said "Let's pretend that never happened, and then make fun of it later" so they re-started Duncan Hill's.
They played Bloodlines and I've said on twitter before that I love the instrumentation in that song, but it's absolutely amazing live. One of the best things I've ever heard.
They played The Gears because if they didn't we all would have rioted.
There was also an overarching "plot" to the concert which I won't go into in case you get to see it some day.
Then Nathan, Skwisgaar and Pickles talked to the audience about Elmo sucking off Skwisgaar, smearing Twinkies on boobs and how this venue had the best power ever, except when it ran out that one time...
For the encore they played Crush the Industry, Fansong and of course, Thunderhorse complete with the original demo pitch segment for the show playing!(NSFW).
Soooo Dethklok have what I call The Muppet Effect in which I completely forget about the Man Behind The Curtain. I completely immerse myself into the reality of the Klok and forgot that hey, there's Brendon Small playing guitar and singing! Right there! I can see him! Oh look Nathan Explosion is many feet tall on a big screen!!
It was great, one of the best concerts I had ever been to. If you get a chance to see Dethklok, I highly recommend it.
Monday, 17 December 2012
Dethklok Concert 'Review'
In November, I saw Dethklok.

subset: commoncrawl


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White Diamonds Sparkle
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The Heavenly Doves of the Carolinas
The Pride of the Carolinas
Let the White Diamonds add Sparkle to your Day !
Funerals are a time of many emotions. Releasing the Spirit bird can bring peace, comfort, and closure. We will help you with handling the birds. Our birds are handled daily, they are bathed several times a week. They are clean tame and disease free. We have time to help you get videos and pictures to make your day last forever.
You will be able to touch, hold and be involved, not just a spectator. We can handle the speeches or you can
read a poem , prayer, whatever the family wishes. Remember this is ministry. Every Service is handled with love.
If you day is a wedding. We have been supporting Brides for 10 years. We know what can and can't be done.
We will not attempt anything that will bring harm to anyone involved including the (White Diamonds). We are glad to work with your director to get best results including pictures and video.
Please feel free to give us a call or Email. There are no dumb questions. We are Happy to plan with you.
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An artist all my life with a Bachelor's Degree of Fine Art from The Herron School of Art, Indiana University at Indianapolis. I've been living in New York City since 1987 and started in the Fashion Industry by doing hand painted prints for Nicole Miller. Moved onto be co-owner of a Purple Thum Design for about a year then did typography and layout for Housner Printing and Design. I have been a graphic designer for Design Works International since 1997 and am now also an Instructor of Visual Communication Studio, Digital: Flats & Specs and Digital: Illustration at Parsons Fashion.
Bachelor's in Fine Arts, Herron School of Art Indianpolis University, Purdue University at Indianapolis
Visual Communication Studio 1
Digital: Illustration


text:
Thursday, April 15, 2010
Definitions for pelf
- Money; riches; gain; -- generally conveying the idea of something ill-gotten.
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Citations for pelf
. . .a master manipulator who will twist and dodge around the clock to keep the privileges of power and pelf.
She writes about those she might have known first-hand: teenage girls cowering in bunkers . . . friends making promises they can never keep . . . rich folk fattened on wartime pelf, poor folk surviving by wit alone.
Origin of pelf
Pelf comes from Old French pelfre, "booty, stolen goods." It is related to pilfer.


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Heather Hughes is a Certified Management Consultant with over 20 years' experience helping leaders create outstanding results. She has assisted organizations throughout North America, the UK and Europe improve their bottom line, gain a reputation for excellence, build a talented team and reduce labor conflict. Heather provides group facilitation, and is a speaker and educator for businesses, colleges and universities. She is a regular contributor to business publications, writing about current and emerging issues facing business leaders.


text: One also wearies of having to constantly explain every small detail of one's opinions on a blog, which is, by its nature, a short form of communication. Of course the diaconate has its own call and dignity. But the fact remains, Alex Jones was a pastor in his church, and is obviously a powerful leader. One hopes that if the call to priesthood is there, all sides are open.


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Year 9 enjoyed testing their French during the Onatti theatre company's performance of 'Mes Chers Voisins'.
They enjoyed the fun and confusion as five teenagers tried to organise to see a film and try to sort out what to wear. Interactive and lively, it was a great way to get Year 9 actively thinking in French and watch a brave volunteer dress up as Justin Bieber!


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Holiday Inn Lambeth properties are listed below. Search for cheap and discount Holiday Inn hotel prices in Lambeth, United Kingdom for your family, individual or group travels. We list the best Holiday Inn Lambeth properties so you can review the Lambeth Holiday Inn hotel list below to find the perfect place.
This site will also provide Lambeth, United Kingdom venues that get similar quality scores of a Holiday Inn.
How should we direct your call?


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|We are hoping to renovate part of our front garden during the Easter-ANZAC Day break. See the driveway? See the semi-circular curve? All that lies between the curve and the driveway is under consideration. Here is what we are hoping to achieve:
|Here is the area to be dug out in more detail. Along the front, below the Lily-pily "Cascade" hedge, is a brick retaining wall. In the centre front, this brick retaining wall is 9 courses deep. However, over to the left, below the letter box, only 4 courses are visible. Darren suggests that there are 9 courses all along the front.
What I want is a retaining wall to go from the top of the driveway down to the scatter of white rocks, and continue down incorporating the rocks. It goes from 850mm at the top (just to the left of the letterbox) to 100mm at the bottom. It will be pinned into the soil beneath the driveway, and be totally visible from the front porch. It must look "decorative".
Here are some examples that I have sourced from the www.
|Here is a retaining wall built by Alastair. He has done a few more since. Ours will be a feature on display so he will take that into account, too. Next, I will look at the rock sculpture for the girls.


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Earth : North America : United States of America : Texas : Gulf Coast (Texas) : North Barrier Coast : Clute
Clute is a city on the North Barrier Coast of Texas.
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The Brazoria County Airport, located west of State Highway 288 on County Road 220, is a gateway for air commerce into and out of Brazoria County. The full service facility is a Part 139 Certified Reliever Call airfield, operational in all weather twenty-four hours a day.
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Enterprise Rent-A-Car 1223 HIGHWAY 332 CLUTE, TX 77531-5232 Tel.: (979) 265-0088 7:30am-6pm M-F
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Clute Visitors Bureau 1014-B Lazy Lane Clute Texas 77531 Local (979) 265 - 2508 Toll Free (888) GO - CLUTE
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Late Antique Ostia Project 11th-25th September 2011 – Field Staff Required
The University of Kent is carrying out a final season of excavation and survey in the central area of Ostia, Port of Rome, directed by Luke Lavan, as part of the Kent-Berlin Ostia Project. Work focuses on the survey, cleaning and excavation of a public square, an exedra of shops and a nymphaeum: all of late Roman date. We have also studied the transformation of a bath palaestra into a second public square, including the erection of a very late temple. Our site contains early medieval archaeology (house remains and bone dumps), as well as mid-Roman rubbish deposits. The late antique layers are very thin and challenging to excavate.
*Volunteer site assistants*
Experienced diggers of 18 years or over are welcome to apply to join our team, on payment of 100 GBP per week for field participation. This payment would cover accommodation, breakfast and lunch. Graduate students studying late antique archaeology would be especially welcome.
Because of the exceptionally high cost of staying in Rome, accommodation will be in tents in a well-equipped modern campsite. If you are interested in applying for a place please send your CV pasted into an email (not in attachment) to the following email (l.a.lavan at kent.ac.uk). The closing date is Friday 30th June.


text: Hey I was just looking for the speakers and was wondering if 5.1 speakers would work with G5's sound card or i have to get 2.1? I mean if G5's sound card is not designed for 5.1, there isn't much reason to get 5.1, is there? So is G5's sound card work with 5.1 speakers or not? And what's the advantage 5.1 over 2.1? Sometimes i see 5.1 and 2.1 for the same price... What do you suggest?