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Fig. 1. Methods for choosing the primary puncture site. Theupper end of the tricuspid valve at systole (T) is determined ona stop-frame frontal right atrial angiographic image (left panel)and translated to a stop-frame left atrial image (right panel). Onthe latter image, an imaginary horizontal line is drawn fromPoint 1 ntil it intersects the right lateral edge of the left atrium(L,).A vertical line is drawn at the midpoint between T and L,(the "midline"), and its intersection w ith the caudal edge of theleft atrium is regarded as Point C. The puncture site (P) is de-termined on the "midline" at about a vertebral body heightabove Point C. When the left atrial silhouette is clearly visibleunder fluoroscopy, right atrial angiography may be omitted: the

use of right atrial angiography to ensure a safe and op-timized transeptal puncture for the PTMC procedure[lo]. Right atrial angiography is performed during nor-mal respiration until the aorta is visualized. The positionof the upper end of the tricuspid valve at systole on astop-frame frontal right atrial image is regarded as PointT (Fig. I , left panel). The point is translated to the stop-frame left atrial image (Fig. 1 , right panel). On the latterimage, an imaginary horizontal line is drawn from PointT until it intersects the right lateral edge of the leftatrium, denoted as Point L ,. A vertical line is drawn atthe midpoint between T and L , (the "midline"), and itsintersection with the caudal edge of the left atrium isregarded as Point C. The puncture site is determined onthis vertical line at a point (designated as point P) aboutone vertebral body height above Point C. This position is

landmark for the upper end of the tricuspid valve (T) is substi-tuted with the position of the aortic valve (A) marked by the tipof an arterial pigtail catheter touching the valve. An imaginaryhorizontal line is drawn from Point A to point L,, the site wherethe line intersects the right lateral edge of the lefl atrium (rightpanel). A vertical line (the "midline") is drawn at the midpointbetween A and L,, and its intersection with the caudal edge ofthe left atrium is regarded as Point C. The puncture site is de-termined on the "midline" at a point about a vertebral bodyheight above Point C. This primary target puncture site is mem-orized in relation to the vertebral bodies.

then translated to an equivalent point to the fluoroscopicimage of th e vertebral bodies for performing the septalpuncture.

This Inoue's modified angiographic method is espe-cially suited for operators inexperienced with the tech-nique. Furthermore, in extremely difficult cases of trans-septal puncture, e.g., in the presence of a giant leftatrium, it may be necessary to perform biplane (frontaland lateral) right atrial angiography to properly visualizethe atrial septal orientation and relative anatomic rela-tionships of the right atrium, th e left atrium, the tricuspidvalve, and the aorta, thereby facilitating safe and accu-rate puncture of the septum (Fig. 2) .Without right atrial angiography. Because in mostcases of mitral stenosis, the left atrial silhouette is visibleon chest X-ray film and under fluoroscopy, this author


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Fig. 2. Frontal (left panel) and lateral (right panel) biplane right angiograms performed tofacilitate transseptal puncture in a patient with a giant left atrium. The markedly distorted atrialseptal orientation is well demonstrated. The black arrow (right upper panel) indicates the trans-septal puncture site, and white arrows (left lower panel) the lateral border of the left atrium. LA= left atrium; PA = pulmonary artery; R A = right atrium; R V = right ventricle.

has modified Inoues method of targeting the transseptalpuncture site without right atrial angiography. In thisalternative method, the aortic valve is substituted as thelandmark for the upper end of the tricuspid valve becausethe two valves are in close proximity to each other (Fig.1) . The position of the aortic valve (point A ) is markedby the tip of an arterial pigtail catheter touching thevalve. Under fluoroscopic frontal view an imaginaryhorizontal line is drawn from Point A to point L,, the sitewhere the line intersects the right lateral edge of the leftatrium. A vertical line (the midline) is drawn at themid point between A and L,, and its intersection with thecaudal edge of the left atrium is regarded as Point C. Thepuncture site is determined on the midline at a pointabout a vertebral body height above Point C. This pri-mary target site is memorized in relation to th e image ofthe vertebral bodies. The midline derived from theauthors alternative method is usually identical to thatfrom Inoues angiographic method.

Lateral ViewIn the lateral projection, locating an appropriate punc-ture site is less precise as the landmarks in this viewdepend very much on the left and right atrial sizes. How-ever, the lateral view serves to confirm the appropriateposterior direction of the needlekatheter assembly andenables the atrial septal outline and orientation to be

determined either by right atrial angiography (Fig. 2) orby the septal flushlstain method (Figs. 3, 4) describedbelow.Septal flush method. This method involves continu-ous flushing of the posteromedially directed needle withcontrast medium as it is withdrawn caudally. This ma-neuver will outline the right atrial margin of the septumand its orientation (Figs. 3 , 4 ) and a high septal puncturecan thus be avoided. Puncture at a high site results inatrial septal dissection and at a low site in right atrialpuncture.


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Fig. 3. Lateral fluoroscopic view showing the septal flushistain method in a patient with a giant left atrium (LA). A. As thecathetermeedle assembly is withdrawn caudally, it is flushedwith contrast medium, which well delineates the right atrial mar-gin of the septum (white arrowheads). The atrial septumprojects markedly towards the right atrium (RA) . 8 . A punctureis made at a high septal area where the septal plane is parallelto the direction of the cathetermeedle. A vertical septal stainwith contrast m edium indicates a small septal dissection (whitearrow). C. The catheter/needle is withdrawn and a puncture ISmade at a more caudal site (black arrowhead). Entry of theneedle into the left atrium IS confirmed by contrast opacification(white arrowheads).

Septa1 staining method. Staining of the atrial septumwith contrast medium , originally described by M ullins asthe "tag" [181 is used when there is no blood aspiratedafter an attempt is made at needle puncture. In this casethe needle has either dissected the high septum or iscaught in the thickened septum. W hen the high septum is

dissected, it appears stained in more vertical fashion(Figs. 3 B, 4 A) . In this situation the catheterheedleshould be withdrawn and septal puncture made a t a lowersite (Figs. 3C, 4B).Usually the transseptal puncture site is in the inferiorand posterior fossa ovalis. In cases w herein the punctureis made more caudally, it is made in the muscular septum(Fig. 4B). When the needle is caught in the thickenedmuscular septum, the stain takes on a more horizontaldirection (Fig. 4C). When the catheterheedle is ad-vanced, a "tenting" of the septum is observed before theseptum is entirely pierced by the catheterheedle (Fig.4D). Staining of the septum with a small amount ofcontrast medium is of no consequen ce since contrast me-dium is absorbed rapidly.Right Anterior Oblique View

A 30" right anterior oblique (RAO) projection, whichis identical to the projection used when m anipulating thecatheter balloon across the mitral valve [lo], is veryuseful in both choosing an optimal atrial septal puncturesite as well as avoiding puncture of other structures.Frontal and lateral biplane views are sufficient for expe-rienced operators, but the RAO view is especially vitalfor inexperienced operators a nd in facilities where lateralX-ray projection is not available.Stop-frame left ventriculogram. In choosing thepuncture site in the RAO projection, a stop-frame of thediagnostic left ventriculograms in the RAO projection isused as a reference. In addition to assessing the degree ofmitral regurgitation and left ventricular function, theventriculogram outlines the anatomic relationship of themitral orifice with the vertebrae, ribs, diaphragm, anddiagnostic catheters and provides information on the mi-tral valve-left ventricular apex orientation (M-A axis)(Fig. 5 , left panel).Adjustment of primary target site. The primarypuncture site as dictated by the landmarks in the frontalplane described ab ove is usually ad equate for the smoothadvancement of the catheter balloon across the mitralvalve. In our patient population the distance of this punc-ture point from the m idpoint of the mitral annulus (pointM ) is usually about 1.2 times the vertebral width (or- 3 .8 cm) when viewed in the RAO projection [unpub-lished observations] (Fig. 5 , right panel). Neverthelessminor adjustments of the site may at times be necessary,especially in patients with relatively small left atria, verylarge left atria, or with more horizontally oriented M-Aaxes. The M -A axis usually aligns with the horizontalline in angles ranging from 30"-60".After the spring w ire J-tipped stylet is inserted into theballoon catheter, the catheter assumes an inverted Ushape in the left atrium . In order t o facilitate the passageof the balloon across the mitral valve, the catheter loop


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Atrial Septa1 Puncture in Mitral Valvuloplasty 279

Fig. 4. Lateral fluoroscopic view showing the septal flush!stain metho d in a patient with a usual-size left atrium. A. As thecathetermeedle assembly is withdrawn caudally, it is flushedwith contrast medium, which outlines the right atrial margin ofthe septum. The tip of the cathetermeedle (black arrow) is at thehigh anterior septum. B. The catheter ne edle is withdrawn to set

its tip at the lower septum a nd the need le is advanced. C . Sincethe puncture is made in the thickened muscular septum, theneedle is caught in the septum as demonstrated by the morehorizontal septal stain. When the ca theterme edle is advanced, atenting of the septum is observed. D. he needle is carefullyforced through the septum.

should be adjusted to align the direction of the balloonsegment along the M -A axis, hence maintaining a co-axial relationship. Based on imaginary catheter loop, thepuncture site is slightly adjusted in each individual pa-tient, depending on the left atrial size and the M-A axis.In patients with a relatively small left atrium, the pri-mary target puncture site determined on the frontal viewmay be too close to the mitral orifice, thus creating twopotential problems in crossing of the mitral orifice withthe catheter balloon. First, if a puncture is made too closeto the mitral valve (or relatively anterior in the septum),the catheter tip has a tendency to get caught in the pos-teriorly located pulmonary ve ins. Sec ond, during manip-ulation of the catheter, the balloon segme nt takes a morevertical orientation relative to the M-A axis, thus dis-rupting the co-axial alignment. In such a situation, thestylet can be reshaped into a tighter loop o r an alternativeloop method [6,10] can be deployed to cross the mitral

valve. To circumvent these problems, however, one mayuse the RAO view to select a puncture site slightly moredistant from the mitral valve by maintaining a moreclockwise rotation on the ca theter heed le. When viewedin the frontal plane before puncture, the site is slightlylateral to the midline.In patients with a large left atrium, the center of theatrial septum projects markedly toward the right atriummaking tran sep tal access close to the center of the sep-tum or the midline difficult. Furthermore, it is diffi-cult to make a puncture at the primary target site chosenin the frontal plane because a t this point the septal planeis more or less parallel to the direction of the catheter/needle and the puncture will result in septal dissection.Even when the puncture is successful at this point, sub-sequent insertion of a balloon catheter into the mitralorifice is difficult because the balloon catheter tip tendsto be directed toward the posterior wall of the left atrium.


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Fig. 5. Left panel, a stop-frame diastolic left ventriculogram in30" right anterior oblique view. It is used as a reference inchoosing the puncture site (P ) in avoiding puncture of the aorta(AO), the tricuspid valve (TV), and the coronary sinus (CS) andin determining the mitral valve-left ventricular apex orientation(M-A axis), about 60" in this case. The ventriculogram also out-lines the position of the mitral orifice i n relation to the vertebrae.ribs diaphragm, and diagnostic catheters to be memorized for

manipulation of the balloon catheter across the mitral valve.Right panel, 30" ight anterior oblique fluoroscopic view show-ing an appropriate distance and height of the puncture site (P )from the center of the mitral valve annulus (M). Usually thedistance (PM) is about 1.2 times the vertebral width (w) and thepuncture site (P) is slightly higher than the M point. See ext fordetailed discuss ions.

Therefore, in cases of large left atrium, the puncture siteshould be adjusted more caudally. The puncture site inthis case is more distant from the mitral valve and usuallyon the same horizontal plane with the M point or evenlower (more caudal). Because the balloon segment takesa more horizontal direction relative to the M-A axis, itmay be necessary to reshape the J tip of the stylet into awider curve to better facilitate the catheter balloon cross-ing the mitral valve.

In another potentially problematic scenario commonlyencountered when the M-A axis is more horizontal (e .g .,30"), the puncture site should be placed more caudally. Itmust be stressed that when the puncture site is adjusted

Therefore, when the transeptal needle is pushed forwardonly either the septum or the right atrial wall is punc-tured. The latter situation can be avoided by making surethe needle tip is remote from th e right lateral border ofthe left atrium and above the center of the mitral annulus(M point) in the frontal projection before making a punc-ture. When a puncture is to be made at a site lower thanthe M point and closer to the lower edge of the left atrialsilhouette in the frontal view, a definite septal outline inthe lateral view should be visualized either by the septalflush method or by right atrial angiography as statedabove.

INAPPROPRIATE PUNCTURE SITESore caudally for any reason (large left atrium o r morehorizontally oriented M-A axis), a definite septal outlinebe visualizkd either by the septal flush method or by theright atrial angiography in the lateral view before pro-ceeding with septal puncture. Otherwise, one runs therisk of cardiac perforation resulting from right atrialpuncture.Avoiding inadvertent puncture of the aorta, tricus-pid valve, and coronary sinus. In the RAO projection,the intended puncture site is clearly separated from theaorta, the tricuspid valve and the coronary sinus (Fig. 5 ) .

The following sites should not be punctured, lest car-diac tamponade ensues or lest there arises difficulty inmanipulating the catheter balloon across the mitral ori-fice.High Atrial Septum

If the puncture is made too high (cephalid) at the thickmuscular wall of the upper edge of the fossa ovalis, astrong resistance is met during needle puncture and no


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Atrial Septa1 Puncture in Yitral Valvuloplasty 281eventful if the needle is withdrawn immediately [181.However, should the operator unknowingly advance thecatheter into the aorta, it should not be withdrawn. Thepatient should be sent for emergency surgery with thecatheter left in the aorta.

blood is retrieved upon aspiration. Upon injecting asmall amount of contrast medium, the septum shows amore vertical stain indicating a small septal dissection(Fig. 3B). When this occurs the catheterheedle shouldbe withdrawn and septal puncture attempted at a lower(caudal) site (Fig. 3C). Otherwise, if the catheterheedleis forged forward, extensive septal dissection may resultbecause the catheterheedle is more or less aligned par-allel with the septal plane. The dissection may lead tocardiac tamponade. Even if the transseptal puncture issuccessful, subsequent manipulation of the catheter willbe limited by the thickened septum.Anterior Atrial Septum

If the puncture is made left (medial) to the midline,it will be in the anterior atrial septum. This site is tooclose to the mitral orifice and the catheter tends to pointmore posteriorly. This will make it difficult to manipu-late the catheter balloon across the mitral orifice unlessthe alternative loop method [6,10] is used. Furthermore,when the puncture is also made lower in the region me-dial to the midline, there is a risk of injury to thetricuspid valve or the coronary sinus. Therefore, septalpuncture should not be made at a site medial to themidline.Coronary Sinus

The ostium of the coronary sinus is just above thetricuspid valve. Viewed in the RAO projection, it is lo-cated near th e Swan Ganz catheter placed in the pulmo-nary artery (Fig. 5, left panel). When the catheter entersthis site, the operator may erroneously assume that its tiphas entered the fossa ovalis. Puncturing the coronarysinus will lead to intractable hemorrhage, which requiressurgical intervention.Vicinity of Right Lateral and Inferior LeftAtrial Edge

There is no atrial septum in the region beyond or nearthe right lateral and inferior borders of the left atrialshadow viewed in the frontal projection. This is espe-cially true in patients with a large left atrium. If thisregion is punctured, the catheterheedle may perforatethrough the right atrial wall and then enter the left atrium(the so-called stitching phenomenon). After the guidewire is placed in the left atrium and the catheter is with-drawn, cardiac tamponade ensues. This was preciselywhat happened in the only instance of cardiac tamponadeencountered by the author in a patient with a giant leftatrium.Aorta

Inadvertent puncture of the aorta, as confirmed bycontrast injection or pressure recording, is usually un-

PROCEDURE OF ATRIAL SEPTAL PUNCTURECathetedNeedle Fitting Exercise

The atrial septal puncture is performed using a 7F or8F Mullins transseptal catheter (with or without itssheath) and a Brockenbrough needle. The sheath is rec-ommended for inexperienced operators to prevent inad-vertent perforation of the catheter by the needle during itsinsertion. A catheterheedle fitting should be performedbefore its insertion into the patient. First, fully insert thetransseptal needle until it extends beyond the catheter.Then withdraw th e needle until its tip is concealedslightly (2-3 mm) within the tip of the catheter. Theoperator should place his or her right index finger as astopper on the needle between the direction indicator andthe catheter hub to prevent the needle from moving for-ward and protruding from the catheter tip (Fig. 6).Placement of Transseptal Catheter and Needle

Under local anesthesia, a J-tipped 0.032-inch guidewire is inserted via the right femoral vein into the supe-rior vena cava. The transseptal catheter is inserted overthe guide wire into the vena cava and the guide wire isremoved. The catheter is aspirated and flushed. Then,the Brockenbrough transseptal needle is inserted into thecatheter and carefully advanced under fluoroscopic viewuntil its tip is about 2-3 mm proximal to the catheter tip.The needle is allowed to rotate freely during its passage.A 5 cc plastic syringe containing contrast medium isattached to the needle. With the right hand, the needle isaspirated and flushed with contrast medium while the lefthand keeps the needle from moving forward. The right-hand stopper-finger, with its predetermined position andangulation, is now firmly kept between the catheter huband the direction indicator of the needle to prevent theneedle from moving forward. Extreme care should betaken not to let the needle slip further during subsequentmanipulation of the catheterheedle.Catheter/Needle Manipulation

Under frontal fluoroscopic view, the needle-fittedtransseptal catheter with its direction indicator pointingabout 4 oclock is slowly withdrawn downward (cau-dally) from the superior vena cava. In the process a sud-den sharp movement towards the left may be observedwhen the tip of th e transseptal assembly falls over thelimbic ledge and enters the fossa ovalis [15,21]. How-ever, in cases of mitral stenosis, the motion is often


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Fig. 6 . Catheterheedle fitting exercise. After the needle iswithdrawn, until its tip is concealed slightly (2-3 mm) from thecatheter tip, the index finger is used as a stopper on the needlebetween the direction indicator and the catheter hub. This is toprevent the needle from moving forward and protruding fromthe catheter tip. The depth (A and B) and the angle of the stop-per-finger (C ) is adjusted according to the distance between thedirection indicator and the catheter hub in each cathetermeedleset.

difficult to detect because the atrial septal bulging to-wards the right atrium m akes the fossa ovalis more shal-low. In either case, a clockwise rotation is applied to thedirection indicator to place the catheterheedle perpen-dicular to the atrial septum. As it is withdrawn caudallyto the primary target site , the catheter tip is aligned withthe midline.At this point the ca theter heed le direction varies ac-cording to left atrial sizes. In gen eral, it is at 4 clock inrelatively small left atrium (< 4 m) , between 4 nd 5oclock in a usual-size left atrium, and at 6 oclock in alarge left atrium (> 5 cm) . Howeve r, it should be notedthat the groupings for small, usual and large left atrium

by M-mode echocardiograms are arbitrary, and the nee-dle direction may vary considera bly among patients witha similar size left atrium. Usually it is not difficult toengage the catheter tip at the primary target site in pa-tients with relatively small or usual-size left atrium. Inour patient population, 10% had a relatively small leftatrium, 50% a usual-size left atrium (4-5 cm) and theremaining 40% a large left atrium (> 5 cm ), including5% with a giant left atrium ( 2 cm ). The left atrial sizeranged from 3 O-9.2 cm (unpublished observations).If the atrial septum bulges markedly toward the rightatrium, especially in cases of a giant left atrium, it isdifficult to align the catheter tip with the mid line andperpendicular to the septum. The catheter tip faces astrong resistance at 4 clock when it touches the bulgedseptal surface. As the needle is being rotated clockwise,the cathe terhe edle will give way suddently. In effect,the needle tip flips over the crest of the bulge and to-wards the right side of the patient pointing to 9 oclock.To prevent this, the catheter should be pressed slightlyagainst the septum as the needle is being rotated clock-wise to 6 to 7 oclock. At the same time, a slight coun-terclockwise twist is applied to the catheter with the lefthand to counter any excessive clockwise rotation of theneedle. If the crest of the bulge happens to be at themid line, it is not possible to make a puncture on theline. In this ca se the pu ncture site is settled in the regionslightly lateral to the midline.When the septal bulge begins in the upper septum,the cathe terhe edle being withdrawn from the superiorvena cava takes a lateral course to the midline. In thiscase, turning the needle to the 3 oclock direction maylead the ca thete rhee dle to a m edial position. If not, theneedle alone can be withdrawn slightly, and the floppytip of the catheter should tend to flip medially. Then theneedle is advanced slowly and carefully to bring its tipback to the original position while keeping the cathetertip in the medial position. If the above m eans also fail toplace the cathe ter he edl e medially, the latter is with-drawn further downward and close to the lower edge ofthe left atrium (passing the caudal end of the bulge).With the needle pointing toward the left (about 3ocloc k), the catheter tip is allowed to shift medial to themid line and then carefully advanced cephalid. Aclockwise twist is mad e to the needle and the catheter tipis steered to or near the target point.If the initial pass of the transeptal catheterheedle isnot successful in engaging it at an appropriate puncturesite, the needle is removed from the catheter and thesecond attempt is begun by repositioning the catheter inthe superior vena cava ov er a guide w ire. Th e alternativeis to reposition the ca the ter he edl e high in the rightatrium. This is done by setting the needle in the 12oclock direction (ventrally) and carefully moving the


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Atrial Septal Puncture in Mitral Valvuloplasty 283process the operator must be prepared to withdraw theneedle as soon as the catheter enters the left atrium, lestthe excessive forward momentum carries the needle for-ward and perforate the left atrial wall causing cardiactamponade. Upon removing the needle after the catheteris placed in the left atrium, heparin, 100 units/kg bodyweight, should be given immediately through the cathe-ter. After baseline hemodynamic studies, including si-multaneous measurement of cardiac output, PTMC isperformed.

catheterheedle upward (cephalid) while slightly rotatingthe direction indicator of the needle clockwise and coun-terclockwise to make certain the catheter tip is free andnot caught against the right atrial appendage or its freewall.Septal Puncture

When the operator is satisfied with the intended punc-ture site, the catheterheedle is pressed firmly against theseptum. Usually cardiac pulsations (so-called septalbounce) are felt by the right hand holding the catheter/needle. While keeping the catheter firmly against theseptum to prevent it from slipping away from the punc-ture site, the operator releases the stopper-finger andforcefully advances the needle forward. The needle isaspirated and contrast medium is injected to confirm itsentry into the left atrium. If no blood is aspirated, theneedle either has dissected the high septum or is caughtin the thickened septum. Staining of th e septum withinjection of a small amount of contrast medium easilydistinguishes he two (Figs. 3 ,4 ). When the high septumis dissected, it is stained in more vertical fashion (Fig.3B). In this situation the needle is withdrawn and septalpuncture is made at a lower (caudal) site. When theneedle is caught in th e thick septum, th e stain takes morehorizontal orientation (Fig. 4C). In this case the catheter/needle is carefully forced across the septum as describedbelow or the puncture is attempted at another site. It isnot possible to differentiate dissection of the high septumfrom entrapment of the needle in the thick septum withpressure monitoring. This is another reason why the au-thor performs the transseptal puncture without constantpressure monitoring.Confirmation of Left Atrial Entry

After entry of the needle in the left atrium is con-firmed, first by contrast medium injection followed bypressure recording and blood oximetry , the needle direc-tion is set toward 3 oclock (left side of the patient). Ifthere is no or little resistance, the catheterheedle is ad-vanced forward about 2 cm into the left atrium. Then, thecatheter alone is advanced another 2 cm (or until th e tipof the transseptal sheath meets a resistance at the septumif sheath is used), while the needle is being withdrawn.When a marked resistance is encountered, a sustainedforce is applied to the catheterheedle. After several car-diac beats, not infrequently a give is felt or seen onfluoroscopy when the catheterheedle finds its way intothe left atrium. If this means fails to place the catheter/needle across the septum, a Bing stylet, which has ablunt tip, is inserted and extended beyond the needle.The catheterheedle is carefully forced through the toughseptum by forward push with the right hand while ap-plying counter resistance with the left hand. During the

ACKNOWLEDGMENTSThe author expresses his gratitude to Kanji Inoue,

M.D., Kean Wah Lau, M.D., and Sadie Peters for re-viewing the manuscript, and Ting-Ching Tsai for assis-tance with manuscript preparation.

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