More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\n
Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n
“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\n
Additionally, each book published by IntechOpen contains original content and research findings.
\\n\\n
We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\n
Simba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\n
IntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\n
Since the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\n
Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n
“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\n
Additionally, each book published by IntechOpen contains original content and research findings.
\n\n
We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n
\n\n
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1. Introduction
The transvenous insertion of implantable pacemaker (PM) and implantable cardioverter defibrillator (ICD) leads was a major milestone in antiarrhythmic therapy with the use of cardiac devices. Indeed, based on data published over the last decade the indications for ICD therapy have further expanded [1,2] while cardiac resynchronization therapy (CRT) through bi-ventricular pacing has significantly improved mortality and quality of life in patients with heart failure and ventricular dyssynchrony [3,4,5]. Unfortunately, this exponential increase in the implantation rate of cardiac devices has been accompanied by a parallel increase in the need for explanting some of those [6]. This has been mainly attributed to the so called “increased total lead exposure time” resulting from the expanding indications for device treatments, the implantation of more leads per patient and the longer average life expectancy of device-recipients [7]. Lead removal has been performed only in limited centers from physicians with some expertise in this subject. The volume of procedures in these centers has also been increasing in a continuous manner and the techniques applied have become more and more sophisticated and effective. Indeed, the options for lead extraction were initially very limited and dedicated tools were not available. Life threatening situations such as infection with sepsis were the only reason to attempt a lead removal with these highly morbid and often ineffective techniques [8]. As a necessity to overcome these limitations a significant evolution in lead extraction technology occurred over the past 30 years. More simple, safe and efficacious techniques are nowadays widely used in clinical practice [9].
Dealing with a possible lead extraction, the main technical problems that have to be taken into consideration are: the endovascular reaction surrounding the intravenous lead, the physical characteristics of the lead affecting its removability and the lack of direct visualization along the intravascular route. Fibrotic scar tissue develops at areas of endothelial contact and engulfs the leads. This process begins with thrombus development along the lead at the time of implantation. Fibrosis of the thrombus occurs next resulting in almost complete encapsulation of the lead with a fibrin sheath within 4-5 days post implant [10,11]. Calcification of the fibrous tissue may even occur over time especially in young patients [12]. The most common adhesion sites include the venous entry site, the superior vena cava and the electrode-endocardial interface [13]. (Figure 1). In the majority of patients multiple areas of scar tissue are found. This scar resists against lead explantation and specific manipulations are needed to overcome this particular obstacle. In addition, lead to lead interaction and binding in the case of multiple leads as well as along each of the shocking coils of the ICD leads may happen, which may pose further limitations in the extraction procedure (Figure 2).
Figure 1.
Location of areas of lead adherence.
On the other hand, the material and construction of the lead may promote or resist the development of scar tissue and may also largely affect the lead removability through its specific tensile strength characteristics. To combat the formation of fibrous connections, manufacturers have recently attempted to produce ICD coils coated with expanded polytetrafluoroethylene (ePTFE) or back-filled with medical adhesive (MABF). Both have been shown to be easier to extract due to decreased incidence of fibrosis on and around the filters of the coils [14]. Finally, the indirect control on the procedure from the operator due to the lack of direct visualization urges the outmost care and experience in order to avoid any major or even life-threatening consequences. Because lead extraction is not frequently performed, few high-volume centers can provide the best patient care along with opportunities for adequate physician training in this field. Both European and American Societies of Electrophysiology have set standards for training and accreditation in order to overcome these limitations. Generally, a minimum of 40 lead extractions as the primary operator is required to be considered fully trained, and 20 leads per year is needed to maintain competency [6,15].
Figure 2.
Extensive scarring over an extracted ICD lead.
2. Indications for lead extraction
Indications for device removal can be divided in two categories: infectious and non-infectious. Non-infectious indications include malfunctioning leads or leads which through their presence can cause harm to the patient (for example thrombosis of the superior vena), as well as leads that have to be removed in order to upgrade a device. In all published reports, infection seems to be the most common indication for lead extraction (54-60% of all extraction procedures)[16,17].
Previous reports have indicated an overall rise in the rate of device infection which might have been attributed to the wider implantation of ICDs for primary prevention of sudden cardiac death in a population whose health status is by definition relatively poor (patients post myocardial infarction with low ejection fraction and clinical signs of heart failure). Another reason could have been the subsequent generator changes whose rate has been following the increasing rate of initial implantation. Both ICD implantation and generator replacement have been clearly associated with a higher rate of device infections [18,19]. On the other hand, others have more recently reported that referrals for extraction for infection and upgrade of the device have remained relatively stable in contrast to the incidence of lead failure which seems to have decreased over the last decade (Figure 3) [20].
Figure 3.
Indications for lead extraction in a cohort of 498 patients. There is a clear trend in the decreasing indication for lead removal due to malfunction. Referrals for extraction for infection and upgrade of the device have remained relatively stable over time (From: Jones SO, et al. Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications. Heart Rhythm 2008:5;520-525, with permission)
The indication to remove a lead in all the above circumstances is largely dependent on patient’s age, general condition, the potential of future problems, the risk to extract and the potential harmful circumstances associated with the lead presence such as subclavian or superior vena cava thrombosis. However, infection of the device regardless of its presentation makes the removal of the whole system unavoidable. This has been shown to be the only effective way to totally resolve this potentially life-threatening health problem. Staphylococcal infections dominate the responsible flora. In a recent survey Methicillin-sensitive S. aureus was found in 25% Methicillin-resistant S. aureus was found in 34% and Coagulase-negative S. species were found in 14% of the cases of pacemaker endocarditis [21]. It should be noted that even if the infection is by clinical examination found to be confined to the pocket of the device, complete removal of the system including the leads has to be performed in order to avoid future relapse of the disease in the form of endocarditis. Studies have shown that leads not thought to be infected may in fact be heavily colonized by bacteria entering the systemic circulation at the pocket site [22,23]. Indeed, the majority of extraction procedures are currently performed for infections localized to the device pocket. Nevertheless, a more widespread infection is not uncommon. In a recent review of 189 patient admitted in a single tertiary center with device infection, pocket infection was present in 52% of them while 17% had evidence of pocket infection with blood stream infection and 23% had developed device-related endocarditis [24] Finally, even in patients presenting with an erosion of the pocket, as a consequence of infection or mechanical pressure or both, the system should be considered contaminated and has to be completely removed. Of note, adherence of the generator or leads to the skin often proceeds erosion and is an indication for extraction too (Figure 4) [6,15]. Nevertheless, a few authors may still advocate a conservative approach with debridement and chronic antibiotic administration in elderly, infirmary patients with a limited life expectancy [25].
Controversy continues to exist regarding the other indications for lead removal. The risk posed by abandoned leads is relatively low. Thus many physicians would recommend simply abandoning malfunctioning leads. The opposite is however true as well. In most of the series the attempts to remove abandoned leads has been associated with a relatively low risk of complications. Accordingly, in the hands of more experienced operators non-functioning leads may become a challenge for an extraction attempt [26]. Moreover, the risk of venous obstruction seems to increase proportionally to the number of leads and this has raised some additional concerns regarding the safety of leaving “orphan” leads in place. Accordingly, the decision of explanting a non-infected lead needs to be individualized in most of the cases. The cause of malfunction is insulation defect in the majority of pacemaker lead failures [27]. In the case of ICDs, high-voltage coil failures and disruption of the polyurethane inner insulators represent the most common reason that may lead to a lead replacement. Of note, ICD lead failure rate is not at all negligible. In a recent survey failure rate reached 20% in 10-year-old leads [28].
A comprehensive list of lead removal indications has been recently published in Heart Rhythm Society expert Consensus Statement (Table 1). Nevertheless, it is important to remember that selection of the patients for lead extraction should be done on an individual case-by-case basis taking always into account the patient’s clinical picture and general health status, the lead characteristics and the operator’s experience along with the availability of the specific facilities and tools. Only in the case that the risk of extraction is lower in comparison to the risk of lead abandonment a procedure should be attempted.
Figure 4.
Device adherence to the overlying skin with initiation of erosion
3. The extraction procedure
The goal of extraction techniques of chronic pacemaker and defibrillator leads is to present an approach that is successful in extracting all leads and minimizes or eliminates complications. Separating the lead from the encapsulating inflammatory tissue is the most crucial step in this process. However, regardless of the technique that will be used, clinicians must be prepared to deal with the fact that this procedure may vary from a simple to an extremely complicated one. Thus, careful planning of the procedure along with meticulous patient preparation seems mandatory.
Indication
Class I Procedure should be performed
Class IIa Reasonable to perform procedure
Class IIb Procedure may be considered
Class III Procedure should not be performed
Infection
1. Definite infection of CIED e.g.device endocarditis or sepsis (LOE: B) 2. CIED pocket infection e.g. abscess, erosion or chronic draining sinus (LOE: B) 3. Valvular endocarditis w/o definite lead and/or device involvement (LOE: B) 4. Occult gram-positive bacteraemia (LOE: B)
1. Superficial or incisional infection w/o involvement of device/leads (LOE: C) 2. Chronic bacteraemia due to a source other than CIED when long term suppressive antibiotics are required (LOE: C)
Thrombosis or venous stenosis
1. Clinically significant TE events associated with thrombus on lead or fragment (LOE: C) 2. Bilateral SCV or SVC occlusion precluding implant of needed TV lead (LOE: C) 3. Planned stent deployment in vein with TV lead already to avoid entrapment (LOE: C) 4. Symptomatic SVC stenosis/occlusion (LOE: C) 5. Ipsilateral venous occlusion precluding implant of additional lead when contralateral implant contraindicated (AVF, shunt or vascular access port, mastectomy) (LOE: C)
Ipsilateral venous occlusion precluding ipsilateral implant of additional lead w/o contraindication to contralateral implant (LOE: C)
Functional leads
1. Life threatening arrhythmias due to retained leads (LOE: B) 2. Leads, due to design or failure, may pose immediate threat if left in place (LOE: B) 3. Leads that interfere with CIED function (LOE: B) 4. Leads that interfere with treatment of malignancy (radiation, surgery) (LOE: C)
1. Leads w/potential interference with CIED function (LOE: C) 2. Leads, due to design or failure, with potential threat if left in place (LOE: C) 3. Abandoned leads (LOE: C) 4. Need for MRI imaging w/o alternative (LOE: C) 5. Need for MRI conditional CIED system (LOE: C)
1. Redundant leads with <1 year life expectancy (LOE: C) 2. Known anomalous lead placement (SCA, Ao, pleura, etc) or through a systemic atrium or ventricle* (LOE: C) 3. *Can be considered w/surgical backup
Non-functional leads
1. Leads, due to design or failure, with potential threat if left in place (LOE: C) 2. CIED implant would yield "/>4 leads on one side or "/>5 leads through SVC (LOE: C) 3. Need for MRI imaging w/o alternative (LOE: C)
1. At time of indicated CIED procedure w/o contraindication to TLE (LOE: C) 2. Need for MRI conditional CIED system (LOE: C)
1. Redundant leads with <1 year life expectancy (LOE: C) 2. Known anomalous lead placement (SCA, Ao, pleura, etc) or through a systemic atrium or ventricle* (LOE: C) 3. *Can be considered w/surgical backup
Chronic pain
Severe chronic pain at device or lead insertion site with significant discomfort not manageable by medical or surgical techniques and w/o acceptable alternative (LOE: C)
Table 1.
Indications for transvenous lead extractionAo, aorta; CIED, cardiovascular implantable electronic device; DRE, device related endocarditis; LOE, level of evidence; SCA, subclavian artery; SCV, subclavian vein; SVC, superior vena cava; TE, thromboembolic; TLE, transvenous lead extraction; TV, transvenous; w/, with; w/o, without.
3.1. Pre-procedural and patient preparation
Extractions can be performed either in the electrophysiology / catheterization laboratory on in the operating room. The site varies according to the preference and the availability of each center [29]. In any case, a cardiothoracic surgical back up should be always immediately available to intervene in case of life threatening complications. In the presence of such a team, safety is comparable in both settings [30]. In addition to the stand-by surgeon, the required personnel include the physician performing the procedure, a “scrubbed” and a “non-scrubbed” assistant, a third “outside the door” assistant to provide equipment and assist in an emergency, anesthesia support and an x-ray technician or other personnel to operate the fluoroscopy. Regarding the instrumentation, a full range of extraction tools should be available. Additional emergency equipment that should be present in the room or immediately available includes sets for pericardiocentesis, chest drainage, vascular repair, thoracotomy, sternotomy and cardio-pulmonary bypass. In addition, equipments for transthoracic and transesophageal echocardiography, temporary pacing and general anesthesia as well as vasopressors and other emergency medications should also be available [15].
A detailed patient history should be obtained and a complete physical examination should be performed before the patient arrives to the interventional suite. Co-morbidites (anticoagulation therapy, renal impairment, allergies and antibiotic resistance) should be carefully taken into account when planning the procedure. Details about prior implantations and about the hardware in place are also mandatory. Technical characteristics of the lead should be known in advance. The vascular route has to be also explored in advance. Chest fluoroscopy can define the number, type and location of leads. Extravascular coursing can be detected through chest computed tomography [31]. Venography may be useful in case that a vascular access problem is anticipated. A transesophageal echocardiogram should be performed in all infected patients to check for vegetations. The size, shape and friability of vegetations may preclude transvenous extraction and support the decision to take the patient to the operating room. Although a clear cut-off point for the vegetation size has not been defined, many physicians would advocate surgical removal of leads of infected leads with large vegetations (>1-1,5 cm) [32],[33]. More recent evidence, however, suggests that even larger vegetations can be safely removed percutaneously [21]. Laboratory examinations should include: blood typing and crossmatch, a full blood count, coagulation profile, electrolytes, renal and liver function tests, virology screen (Hep B, C and HIV), C-reactive protein and erythrocyte sedimentation rate. A pregnancy test for young females should not be omitted [15] Finally, the patient preparation concludes with the obtaining of written informed consent.
The day of the procedure 4 packs of red blood cells should be immediately available. The patient is prepared with chlorexidine or povidone iodine and wrapped in a way to allow access ipsilaterally and contralaterally to the site of implantation, as well as to permit emergent pericardiocentesis, thoracentesis, thoracotomy, sternotomy or cardiopulmonary bypass. Large bore iv. cannulae in peripheral veins are placed bilaterally to allow for rapid fluid infusion. A percutaneous arterial line is placed for direct blood pressure monitoring. Non-invasive automated blood pressure measurements, electrocardiographic monitoring and pulse oximetry are also available throughout the procedure. Femoral venous access is obtained for possible rapid fluid administration, for potential upgrade to a transfemoral approach or to facilitate the placement of a temporary pacing electrode. For patients who are pacemaker dependent, a temporary pacemaker lead inserted via the internal jugular or the femoral vein is adequate if the system is not infected and will be immediately replaced. In the case of infected leads several strategies of inserting a longer lasting temporary lead have been described (for example placing an active fixation permanent lead through the internal jugular vein) in order to permit for an adequate lead-free interval of antibiotic administration before the permanent system will be re-implanted. The externalized pulse generator after it has been cleaned and sterilized has been successfully used for temporary pacing in some centers [34]. In patients with ICDs tachycardia therapies should be switched off in order to prevent inappropriate shocks.
3.2. Techniques and tools
Generally speaking, leads can be removed with one of the following techniques:
Manual traction without tools
Traction mediated by some sort of weight or by application of a clamp to the stretched lead
Mechanical sheaths, with or without the use of a locking stylet
Laser-assisted lead extraction, with or without the use of a locking stylet
Open chest extraction, with or without transvenous extraction tools
Thransthoracic extraction using a paraternal, subxyphoid or intercostals approach [7].
If a decision has been made to proceed via the transvenous route after the device has been opened, the pulse generator is removed and the leads to the vascular entrance are freed through careful dissection usually with the aid of electroacautery. The incision is usually performed at the site of the initial one, although some physicians make a second incision over the venous entry site of the leads. Infected pockets should undergo thorough revision and microbial cultures of the tissue should be obtained. Irrigation with hydrogen peroxide or chlorexidine and meticulous removal of all infected tissue must follow. It is not clear if a complete capsulectomy needs to be done, although this is dictated by common sense in the case an ipsilateral implantation is planned. After the leads have been dissected all the way down to the venous entry site, the anchor sleeves are removed along with any suture remnants. It is essential that the leads be completely freed and remain intact. Damaged leads can be hard to extract. When using cautery it should be kept instead that polyurethane insulation is more heat sensitive than silicone [7]. Back bleeding issues may arise when dissecting at the venous entry site. A 2-0 suture placed as a snare in the surrounding tissues may help to solve this problem.
At this stage trasvenous extraction can be successfully performed in one of the following ways applied commonly in a steward fashion:
Simple traction after the insertion of a regular stylet can be sufficient for recently implanted leads. Some experts advocate the gain of ipsilateral venous access through the introduction of a thin (i.e. 5 French) dilator and a guide wire prior to the traction attempt [3]. We do not routinely follow this practice. We simply place moderate traction on the free part of the lead trying to avoid stretching of the insulation or the induction of ectopy in the electrocardiogram. Unfortunately, there is not a priori certainty which lead will be successfully removed through this simple procedure. With traction, fibrous encapsulation often provides sufficient friction to prevent the force applied from being transmitted to the tip of the lead. When more force is needed, the tensile strength of the insulation or the conductor can be exceeded resulting in stretching or rupture. The lead may become irreversibly damaged complicating the extraction process and even leaving part of it indwelling in the venous circulation. Thus, it is of paramount importance for the lead to be removed in on piece. This can happen only if the operator has control of the body lead throughout the procedure binding the elements of the lead together. In that case, the exposed part of the lead can be used as a handle to remove its endovascular segments which will not be the case if the lead becomes distorted or elongated. Although it may be possible to snare fragments of the lead that have remained intravascularly after the main body of the lead has been removed, this may become increasingly hard at times.
Regarding the type of the lead which can be extracted by simple traction, there is always a better chance for recently implanted and active fixation than passive fixation leads, especially if they are isodiametric and can be unscrewed before extraction. Sometimes this is not feasible because the mechanism is damaged or tissue is plugging the helix. In that case manual counterclockwise rotation of the lead body may unscrew the lead. However, to achieve this, the lead body must be free of adhesions in its entire course. In the case of atrial leads, where the helix has often extended through the thin atrial wall, failure to retract the helix makes traction particularly dangerous in removing a plug of atrial tissue with subsequent tamponade. As a rule, traction should not be placed on a lead not fully unscrewed unless a cardiac surgeon is present and the operating room is ready to accept the patient.
In general, invagination of the myocardium may complicate any case of unopposed traction. Arrhythmias and hypotension can be the result of myocardial rupture, avulsion of a tricuspid valve leaflet or rupture of the superior vena cava or the subclavian veins. To avoid these complications, prolonged graded traction has been introduced. Historically speaking Bilgutay et al [35] created a graded weight and pulley system to deliver gentle traction on the externalized portion of the lead. This system required prolonged hospitalization with bed rest, increased the risk of infection and was proven frequently unsuccessful. This technique has been totally replaced nowadays from the use of locking stylets.
Traction via a locking stylet is directly applied at the tip, bypassing the conductor and the insulation. If manual traction is unsuccessful, the inner lumen is reamed with a conventional stylet to remove debris and the lead is cut approximately 5 cm from the vascular entry with a sharp scissor to maintain the shape of the spiral conductors. Care must be taken not to damage the distal lead, which should be firmly held by the assistant with his fingers or with a soft clamp if available. The central lumen of the lead is then identified and a locking stylet is inserted through it. To avoid pulling out the core and leaving the outer insulation in place, a ligature is used to tie down the insulation with the rest of the lead components and with the locking stylet. To choose the locking stylet of the appropriate size, the inner lumen diameter hat to initially be measured with the insertion of a series of gauze pins. A locking stylet of a size corresponding to the largest pin was chosen. This is not longer necessary since most of the contemporary stylets are designed to accommodate a wide range of conductor coil diameters. Locking stylets consist of a straight non-expandable wire that can be locked into the coil close to the tip of the lead. This specific design permits to focus the force of traction as close to the lead tip as possible. As a consequence, the risk of lead disruption is reduced and the likelihood of complete removal of the lead is increased [36],[37]. Several types of stylets with different locking exist. The most commonly used are: the Liberator (Cook Medical, Bloomington, Indiana, USA), the Lead Locking Device (LLD) EZ (Spectranetics, Colorado Springs, Colorado, USA) and the Extor Set (VascoMed, Binzen, Germany) (Figure 5).
The locking mechanisms of the Liberator and the Extor Set are at the distal tip of the stylet providing focal traction at the tip of the lead, whereas the LLD EZ stylet grabs the lead in multiple areas and delivers stable traction along the entire lead length. An additional advantage of both the Extor and the LLD is that they provide the ability to unlock and reposition after initial deployment. This can facilitate the advancement of the locking stylet to the lead tip in cases the later is very tortuous or has sharp bends. In that case, the clinician can advance the stylet to the obstruction, lock the stylet, free the lead at that point, unlock the stylet and advance it to the next obstruction point, repeat the maneuver and manage to reach the lead tip at the end. The Bulldog Lead Extender (Cook Medical) is a tool that can be useful if a lead cannot receive a locking stylet due to extensive damage or a solid core design. It consists of a wire with a threadable handle through which the lead is passed and secured, thereby locking the insulation and conductor to the extender. This way the exposed part of the lead is securely grasped and extended to a workable length allowing a potentially more effective direct traction.
There are still limitations to the use of a locking stylet. If the conductor is broken or distorted, e.g. with subclavian crush syndrome, it is not possible to introduce the stylet. It can also lack grip and dislocate during traction or too much force can damage the delicate locking mechanism. Further, as traction is still exerted via the distal conductor coil, this can unwind or disconnect from the electrode. As with direct traction, there is risk of invagination of the myocardium.
Figure 5.
Various types of locking stylets. (A) The Liberator Locking Stylet (Cook Medical, Bloomington, Indiana, USA). (B) The Lead Locking Device (LLD) EZ (Spectranetics, Colorado Springs, Colorado, USA). In contrast to the Liberator locking stylet, the LLD locking stylet has a braided mesh over the entire length of a solid lead that expands when deployed. (C) The Extor Set (VascoMed, Binzen, Germany) (from Maytine et al. The challenges of transvenous lead extraction. Heart 2011;97:425-434, modified with permission)
Counter-pressure and Counter-traction: to overcome the limitations of a locking stylet, telescoping sheaths can be advanced over the lead with alternating counterclockwise and clockwise motions with moderate pressure. Fibrous bindings can be mechanically disrupted (counter-pressure). The outer sheath also functions as a guiding catheter facilitating the movement of inner sheath and alignment of the inner sheath and the lead. It is of paramount importance to use a locking stylet at the same time, as the leads are often too fragile to withstand the traction necessary to counter the forces applied to advance the sheath. Once the distal electrode is reached, the outer sheath can be positioned against the myocardium to prevent inversion (counter-traction). By pulling on the locking stylet, for several minutes if necessary, the tip of the lead is pulled inside the outer sheath. The force is thus concentrated at a small area of the scar tissue and the myocardium without gross displacement of the myocardium (Figure 6).
Figure 6.
Schematic representation of the forces of counterpressure, traction, and countertraction. (from Maytine et al. The challenges of transvenous lead extraction. Heart 2011;97:425-434, with permission)
Telescopic sheaths are made of different materials (stainless steel, Teflon, and polypropylene) and are available in various sizes (7-16 French) (Figure 7). Sheath selection is determined by the clinical situation and the operator’s preference and experience. Teflon is soft and flexible but is unable to cut through dense scar tissue, while polypropylene is stiffer and better at disrupting encapsulating scar but must be used with caution so as to avoid vascular injury. Stainless steel sheaths are employed only to deal with dense and calcified fibrosis. If despite the use of a stainless steel sheath, tight adhesions prevent further advancement to reach the tip, changing to a power sheath and/or upsizing to a larger sheath may solve the problem.
Figure 7.
Various types of telescopic sheaths (from Maytine et al. The challenges of transvenous lead extraction. Heart 2011;97:425-434, with permission)
Even the removal of large vegetations (up to 4 cm) has been successfully attempted by very experienced operators with the use of 16 French sheaths [7]. Although counter-traction prevents invagination of the myocardium and diminishes the chance of rupture, perforation of the myocardium is still possible, especially in the thin-walled atrium.
Powered sheath assisted extraction: If lead removal still proves unsuccessful, a powered sheath can be used as an alternative. Powered sheaths use a source of energy to make the dissection of encapsulating fibrous tissue easier and more efficient, thus enabling the advancement of the sheath along the lead with reduced countertraction and counterpressure forces. One such powered sheath is the Excimer Laser System (Spectranetics). It consists of optic fibers spirally warped between the inner and outer tubing of the sheath. At the tip of the device the fibers are arranged in a ring. Pulsed laser light is emitted from the fibers to ablate the tissue. The device is connected to a 308 nm XeCl excimer laser (Spectranetics CVX-300), which delivers pulsed light. As the penetration depth of 308 nm light in vascular tissue is ~100 μ, it is completely absorbed in the tissue immediately in front of the tip. This results in an ablation depth, depending on the applied force, between 2 and 15 μ per pulse in the experimental setting. The influence of force is explained by increasing the mechanical effect of the micro-bubbles entrapped beneath the tip of the device in creating microscopic tears [38]. The sheath is advanced under fluoroscopic guidance over the lead body utilising the standard techniques of counterpressure and countertraction, and laser energy is delivered when encapsulating fibrous tissue halts sheath advancement. Tissue in direct contact with the sheath tip is ablated to a depth of 50 mm until the distal electrode is reached. It should be kept in mind that countertraction is still necessary to dislocate the lead tip. Great care must be paid to proper traction/countertraction techniques to prevent complications. Loss of coaxial orientation of the sheath and the lead can result in vascular injury. The leading edge of the bevel of the laser sheath should be oriented away from the vessel wall and the laser energy should be stopped before the lead tip is reached. Care must also be taken to avoid damage of the tricuspid valve. The ablation results in a shearing of the fibrous bindings, often leaving a rim of scar tissue around the lead. Compared with mechanical telescoping sheaths, laser assisted extraction results in more frequent complete lead removal and shortened extraction times without an increase in procedural risk [39]. [40].
The Perfecta Electrosurgical Dissection Sheath (Cook Medical) represents another type of powered sheath. The electrosurgical dissection sheath consists of an inner polytetrafluoroethylene (PTFE) sheath with bipolar tungsten electrodes exposed at the distal tip and an outer sheath for counterpressure and countertraction. Radiofrequency energy is delivered between the bipoles to dissect through fibrous binding sites, much like a surgical cautery tool, although the lead tip must be liberated with countertraction. In contrast to the Excimer Laser Sheath, the Electrosurgical Dissection Sheath permits a localised application of radiofrequency energy with linear rather than circumferential dissection of the encapsulating fibrous tissue. The focused and steerable dissection plane offers the potential advantages of improved precision.
However, the sheath may have to be repositioned repeatedly as a result. The Electrosurgical Dissection Sheath offers a cost effective alternative to the Excimer Laser System without compromising safety or efficacy [41].
Finally, the Evolution and Evolution Shortie Mechanical Dilator Sheaths (Cook Medical) are ‘hand powered’ mechanical sheaths that consist of a flexible, braided stainless steel sheath with a stainless steel spiral cut dissection tip. The sheath is attached to a trigger activation handle that rotates the sheath and allows the threaded metal end to bore through calcified and dense adhesions [42].
An inferior vena cava or transfemoral approach also named as “the inferior approach” has been developed as the alternative mode to be used often only after the approach via the implant vein (“superior approach”) has failed. It is also the procedure of choice for removal of broken or cut lead with free-floating ends. This technique is an old one [43] and over the years the following tools have been developed to assist in the extraction of leads by the femoral vein:
The Byrd Femoral Work Station (Cook Vascular Inc, Leechburg, PA)
The Dotter retriever Snare
The Curry Loop Snare
The Amplatz Snares 25 mm, 25 mm (Microvena Corp)
The Needls Eye Snares (Cook Vascular Corp) [44] (Figure 8)
Virtually all the femoral extraction techniques use some form of snaring. Two fundamental techniques have evolved. The first uses the combination of a wire loop and catheter to snare free ends or free-floating leads. The other creates a loop around the lead to be removed when there is no free end available for simple snaring. In any case, a long sheath is introduced via the femoral vein and positioned close to the lead. Then, a retriever is inserted through the sheath to grab and secure the lead close to the tip. The isodiametric proximal part of the lead (with the connector cut off) is pulled down through the fibrous scar tissue. The outer sheath is then advanced over the doubled up lead to disrupt the scar tissue, while the lead is kept under tension by the retriever. When the sheath reaches the tip, counter-traction is applied. In comparison with the superior approach, only a short distance of scar tissue needs to be disrupted as the proximal isodiametric part of the lead can be simply pulled down. Therefore, even if no locking stylet has been used to reinforce the lead, the shorter distance to cover decreases the chance of elongating the lead. “Reversibility” is one of the most important principles to be followed with snaring techniques since the process of grasping a lead must be totally reversed and the lead freed again if necessary. If this situation cannot be reversed thoracotomy remains the only solution.
Figure 8.
The Needle’s Eye snaring tool
Beyond that, the main challenge of femoral retrieval remains manipulating the tools and snaring the lead in three dimensions under the guidance of two dimensional fluoroscopic imaging. The recent description of a novel technology to facilitate extraction and the maintenance of vascular access proposed a hybrid superior and inferior approach, with femoral snaring of the lead to stabilise the lead while countertraction and counterpressure are used through the right jugular vein to free the lead, reiterating the clinical importance of femoral retrieval [45],[46].
4. Complications
The major risks of transvenous lead extraction include: cardiac perforation (1-4%), emergency cardiac surgery (1-2%) and death (0.4-0.8%).34 (Table 2). However, the risk of an individual varies according to the presence or absence of the following factors:
Age of the patient (risk increase with advanced age)
Gender of the patient (risk higher in female patients)
Comorbidities
Presence of calcifications on the leads
Presence and size of vegetations
Duration of implant
Physical characteristics of the lead (fragility, condition)
Presence of multiple leads
Presence of ICD leads, especially with a superior vena cava coil
Major complications
Minor complications
Death
Pericardial effusion not requiring intervention
Cardiac avulsion requiring intervention (percutaneous or surgical)
Haemothorax not requiring intervention
Vascular injury requiring intervention (percutaneous or surgical)
Upper extremity thrombosis resulting in medical treatment
Respiratory arrest/anesthesia related complication prolonging hospitalization
Vascular repair near implant site or venous entry site
Stroke
Hemodynamically significant air embolism
Cardiovascular implantable electronic device infection at previously non-infected site
Migrated lead fragment without sequelae
Blood transfusion as a result of intraoperative blood loss
Pneumothorax requiring a chest tube
Pulmonary embolism not requiring surgical intervention
Table 2.
Potential complications of transvenous lead extraction.
Complications result primarily from forces applied to separate leads from fibrous connections within the large vessels and the heart. Disruption of the superior vena cava or brachiocephalic vein is the most devastating complication of lead extraction, as it results in swift exsanguination in the thoracic cavity and is very difficult for the surgeon to control or repair. The superior vena cava has a wall thickness of sometimes <1 mm and is vulnerable for damage by the sheaths. Of note, the pathway of least resistance is the vessel wall rather than the scar. Of course, damage to the superior vena cava and its branches veins may be minimized with a femoral approach. Some have suggested the use of a large balloon to tamponade bleed from the superior vena cava until the surgeon arrives. Death can occur or emergency surgery may be needed due the above complication but also due to cardiac tamponade from cardiac rupture or due pulmonary embolism from the dislodgment of large lead vegetations. Infection with re-implantation is another potential problem to consider. Proper care of the infected pocket is essential to prevent recurrent infection. Some operators elect to leave the wound open to heal by secondary intention while others prefer tight suturing of tissues to eliminate any residual cavity. As a rule, a new device should never be placed in a previous infected pocket. However, the most important principle in preventing lead extraction complications is to avoid lead extraction by meticulous operative technique at the time of the initial implantation and by early recognition of potential problems in the immediate post-operative period [47].
5. Lead extraction success rate
The Expert Consensus of the Hearth Rhythm Society has defined the success of the lead extraction procedure in two different ways [6]: Complete Procedural Success has been considered the removal of all targeted leads and all lead material from the vascular space, with the absence of any permanently disabling complication or procedure related death. On the other hand as Clinical Success has been defined the removal of all targeted leads and lead material from the vascular space, or retention of a small portion of the lead that does not negatively impact the outcome goals of the procedure. This may be the tip of the lead or a small part of the lead (conductor coil, insulation, or the latter two combined) when the residual part does not increase the risk of perforation, embolic events, perpetuation of infection or cause any undesired outcome. Finally, the Committee defined as Failure the inability to achieve either complete procedural or clinical success, or the development of any permanently disabling complication or procedure related death.
Results of transvenous extraction have been repeatedly reported as associated with a high success rate of complete (>90%) or partial (>95%) removal with a concomitant low rate of complications in experienced centers [48],[49],[50]. The use of extraction sheaths ranged from 60-80% in these studies. Nevertheless, the success rate of manual only traction alone or with the use of locking stylets is not negligible ranging form 15-30% in recent studies. More recently, de Bie et al [51] reported a substantially higher clinical success rate of ~85% in >250 removal procedures with the use of manual traction without the assistance of extraction sheaths. This finding was particularly true for leads implanted > 2.6 years. Since it is not clearly defined when an attempt should be considered unsuccessful, the efficacy of these simpler techniques seem to be largely dependent of the availability of the more complex ones (i.e. telescopic or laser sheaths). That means that if an operator has a wide range of tools available, he will give up more easily on a resistant to traction lead, moving to more sophisticated techniques and strategies [51].
6. Removal of left ventricular pacing leads
Nowadays CRT is considered a standard therapy used to improve symptoms and prognosis in heart failure. Increasing evidence confirming the benefits of CRT has led to widespread implantation of CRT devices with technically challenging procedures, followed by frequent dislodgement of the coronary sinus (CS) lead or infections and requirement for extraction and re-implantation of the device. During the last decade, evolutionary changes have emerged in CS lead technology and techniques to optimize CRT function during implantation and permit the removal of left ventricular (LV) pacing leads with minor complications.
Coronary sinus lead implantation is a complex procedure with several limitations and hazards. According to several studies, the procedure is usually time consuming with long fluoroscopy times and the implantation success rate is reduced compared to conventional procedures (estimated between 90% to 97%) [52-56]. With the introduction of special delivery sheaths and the so-called ‘over the wire technology’ the breakthrough of LV pacing became reality in the early 2000s, yet lead stability remains problematic mainly due to different coronary sinus anatomies [57-58]. Because no muscular trabeculae is found in the CS for anchoring of the lead, the tip has to be pushed as distal as possible in a wedge position in a lateral or a postero-lateral CS branch and is typically non-actively fixated. Such an ideal position of the LV lead cannot be reached in several cases owing to small and tortuous venous anatomy, phrenic nerve stimulation or sub-optimal hemodynamics due to close proximity to the right ventricular lead. As a result, detectable CS lead dislodgement has been observed in about 4-8.6% of patients during follow-up, accompanied by loss of capture and need for repositioning [52,59,60]. To overcome these limitations, pre-shaped leads (curved in one or more dimensions) have been developed to offer stability even in proximal positions and in larger veins. Coronary sinus side branch stenting has also been performed in several occasions [61-62]. Finally, the development of an active fixation CS lead (Attain StarFix 4195, Medtronic) has also been achieved [63]. This lead body has a 55D polyurethane coating that expands into pleated loops near the electrode tip to increase its diameter and promote fixation (practically reaching stability of 100%), along with a small amount of steroid at the electrode tip to reduce inflammation in the surrounding tissue [64] (Figure 9).
In parallel to the rapid growing experience with the implantation of CS leads, a new and interesting field relating to LV pacing lead extraction and subsequent re-implantation has been developed. It should be noted, however, that in comparison to the extensive data available on conventional pacing and ICD lead extraction, the experience with LV leads is still limited. Similarly to conventional devices, infection seems to be the primary indication for removal in the case of CRT devices too. On the other hand, it might be expected that removing leads from fragile and tortuous CS vein tributaries, especially with the use of larger-bore sheaths (mechanical or laser) which may not fit into the distal branches, would lend itself to a higher risk of complications. Indeed, the high rate of hemopericardium and dense scar tissue in-growth or vein occlusion in animal models [65,66] were early findings suggesting the need for extreme care in the removal of CS leads and for detailed preoperative knowledge of the CS anatomy. Nevertheless, published data so far suggest that CS leads can be safely and successfully removed percutaneously and that CS lead extraction is not more hazardous than conventional PM/ICD lead extraction (Table 3), although post-extraction complete occlusion of the branch vein previously implanted with an LV lead followed by re-implantation complications may become a particular problem occasionally [67]. It appears that CS leads implanted for <2 years are amenable to manual traction [68] and even extraction of active fixation CS leads has been reported due to prolonged manual traction alone or careful use of a laser sheath within the CS. [69],[70],[71].
Figure 9.
Medtronic Attain StarFix 4195 Coronary Sinus Lead at four stages of deployement.
All the previously mentioned techniques have been successfully used for the removal of CS infected or malfunctioning leads. Tyers et al [72] reported a series of 14 left ventricular lead extractions, all successfully removed with the use of locking stylets and powered sheaths. Bongiorni et al [73] have reported one of the earlier and larger single centre experiences on extraction of LV pacing leads: manual traction using a standard stylet only was effective in the majority of cases (73%) and mechanical dilation with polypropylene sheaths was necessary (27%) when tight adherence was found along the catheter course. In particular, adherence in CS lead extraction was located more commonly in the systemic veins (subclavian vein 60%, innominate vein 30%, superior vena cava 20%, right atrium 20%) rather than inside the CS (10%). When areas of adherence were found inside the CS (never in its branches), dissection through a transfemoral approach was chosen and no major complications were seen. Safety and efficacy of transvenous CS lead removal was also confirmed by Di Cori et al [74] in a large, single-center experience involving extraction of 147 CS pacing leads. Nearly one-third of procedures were resistant to manual traction and thus required mechanical dilation or transfemoral approach. Complications were rare, there was no predictable pattern among manual traction or mechanical dilation removal techniques and fibrous adherence sites were also found mainly in non-CS locations (subclavian vein 66%, innominate vein 48%, superior vena cava 32%, right atrium 20% and CS 14%). Most recently, Williams et al [75] confirmed their high procedural success of 10-year experience regarding percutaneous removal of CS leads. Among 71 patients they explanted 60 CS leads and 143 non-CS leads: CS extraction had 0% operative mortality - 2.8% postprocedural mortality (in hospital <30 days) - minor complication rates 5.6% and major complication rates 1.4%. The majority of CS leads were extracted using manual traction and laser sheath dissection was required in 10% (laser was used within the CS only in two cases).
In conclusion, extensive data are available on conventional pacing and ICD lead extraction but only limited experience with LV leads exists. The LV pacing leads may be removed easily by manual traction in a large number of cases, but coronary sinus (CS) adherences may complicate extraction requiring mechanical dilation or ablative extraction techniques. In addition to CS remnant adherences, post-extraction venous occlusion might complicate the eventual re-implantation. Nevertheless, CS lead extraction seems to be not more hazardous than conventional pacemaker and defibrillator lead extraction. The evolving use of CRT in current clinical practice, is expected to improve the techniques and provide us with more data regarding the feasibility and safety of LV lead removal.
Author
CS leads extracted
infection
sepsis
malfunction
time from implant (months)
manual traction
mechanical dilation
major compli-cations
success rate
Bongiorni et al73
37
43.3%
29.7%
27%
19.5 ± 16.5
73%
27%
0%
100%
Williams et al75
60
31%
31%
38%
35.8
90%
10% (laser)
1.4%
98%
Di Cori et al74
147
56%
24%
20%
29±25
70%
30%
0.7%
99%
De Martino et al77
12
58%
42%
13.9±11.7
100%
0%
100%
Hamid et al68
32
56.2
43.8%
26.5±28.7
87.5%
12.5% (laser)
0%
100%
Tyers et al72
14
not available
7%
100%
Kasravi et al76
14
17.4±12.2
0%
100%
Table 3.
Coronary sinus lead extraction: differences and similarities between reports
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Introduction",level:"1"},{id:"sec_2",title:"2. Indications for lead extraction",level:"1"},{id:"sec_3",title:"3. The extraction procedure",level:"1"},{id:"sec_3_2",title:"3.1. Pre-procedural and patient preparation ",level:"2"},{id:"sec_4_2",title:"3.2. Techniques and tools ",level:"2"},{id:"sec_6",title:"4. Complications",level:"1"},{id:"sec_7",title:"5. Lead extraction success rate",level:"1"},{id:"sec_8",title:"6. Removal of left ventricular pacing leads",level:"1"}],chapterReferences:[{id:"B1",body:'Bardy GH, Lee KL, Mark DB, et al.Amiodarone or implantable crdioverter-defirbrillator for congestive heart failure. N Engl J Med 2005352225237\n\t\t\t'},{id:"B2",body:'MossA. J.ZarebaW.HallW. J.et al.Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002346877883\n\t\t\t'},{id:"B3",body:'Abraham WT, Fischer WG, Smith AL, et al.Cardiac reynchronization therapy in chronic heart failure. 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I.Heart Rhythm 20085160162\n\t\t\t'},{id:"B8",body:'Madigan NP, Curtis JJ, Sanfelippo JF, et al.Difficulty of extraction of chronically implanted tined ventricular endocardial leads. J Am Coll Cardiol 19843724731\n\t\t\t'},{id:"B9",body:'FarooqiF. M.TalsaniaS.HamidS.et al.Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads. Int J Clin Pract 20106411401147\n\t\t\t'},{id:"B10",body:'Robboy SJ, Harthorne JW, Leinbach RC, et al.Autopsy findings with permanent pervenous pacemakers. Circulation 196939495501\n\t\t\t'},{id:"B11",body:'HuangT. Y.BabaN.Cardiac pathology of transvenous pacemakers. Am Heart J 197183469474\n\t\t\t'},{id:"B12",body:'Cooper JM, Stephenson EA, Berul CI, et al.Implantable cardioverter defibrillator lead complications and laser extraction in children and youg adults with congenital heart disease: implications for implantation and management. J Cardiovasc Electrophysiol 200314344349\n\t\t\t'},{id:"B13",body:'Smith HJ, Fearnot NE, Byrd CL, et al.Five-years experience with intravascular lead extraction. Pacing Clin Electrophysiol 19941720162020\n\t\t\t'},{id:"B14",body:'HacklerJ. W.SunZ.BDLindsayet.alEffectiveness of implantable cardioverter-defibrillator lead coil treatments in facilitating ease of extraction. Heart Rhythm 20107890897\n\t\t\t'},{id:"B15",body:'DeharoJ. C.BongiorniM. G.RozkovecA.et al.Pathways for training and accreditation for transvenous lead extraction: a European Heart Rhythm Association position paper. Europace 201214124134\n\t\t\t'},{id:"B16",body:'Smith HJ, Fearnot NE, Byrd CL, et al.Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database. Pacing Clin Electrophysiol 1994'},{id:"B17",body:'RouxJ. 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J Am Coll Cardiol 201055886894\n\t\t\t'},{id:"B22",body:'KlugD.WalletF.LacroixD.et al.Local symptoms at the site of pacemaker implantation indicate latent systemic infection. Heart 200490882886\n\t\t\t'},{id:"B23",body:'Baddour LM, Epstein AE, Erickson CC, et al.Update on cardiovascular electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010121458477\n\t\t\t'},{id:"B24",body:'Sohail MR, Uslan DZ, Khan AH, et al.Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 20074918511859\n\t\t\t'},{id:"B25",body:'FieldM.JonesS.EpsteinL.How to select patients for lead extraction. Heart Rhythm 20074978985\n\t\t\t'},{id:"B26",body:'Bracke FA, Meijer A, Van Gelder B. Pacemaker lead complications: when is extraction appropriate and what can we learn from published data? Heart 2001:85:254-259'},{id:"B27",body:'Hauser RG, Hayes DL, Kallinen LM, et al.Clinical experience with pacemaker pulse generators and transvenous leads: an 8-year prospective multicenter study. Hear Rhythm 20074154160\n\t\t\t'},{id:"B28",body:'KleemannT.BeckerT.DoengesK.et al.Annual rate of transvenous defibrillation lead defects in implantable cardioverter- defibrillators over a period of >10 years. Circulation 200711524742490\n\t\t\t'},{id:"B29",body:'CAHenricksonZhang. K.BrinkerJ. A. A.surveyof.thepractice.oflead.extractionin.theUnited.StatesPacing Clin Electrophysiol 201033721726\n\t\t\t'},{id:"B30",body:'FranceschiF.DubucM.DeharoJ. C.et al.Extraction of transvenous leads in the operating room versus electrophysiology laboratory: a comparative study. Heart Rhythm 2011810011005\n\t\t\t'},{id:"B31",body:'HirschlD. A.JainV. R.Spindola-FrancoH.et al.Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT. 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Pacing Clin Electrophysiol 19901318641870\n\t\t\t'},{id:"B37",body:'Goode LB, Byrd CL, Wilkoff BL, et al.Development of a new technique for explantation of chronic transvenous pacemaker leads: five initial case studies. Biomed Instrum Technol 1991255053\n\t\t\t'},{id:"B38",body:'Gijsbers GH, van den Broecke DG, Sprangers RL, et al.Effect of force on ablation depth for a XeCl excimer laser beam delivered by an optical fiber in contact with arterial tissue under saline. Lasers Surg Med 199212576584\n\t\t\t'},{id:"B39",body:'Wilkoff BL, Byrd CL, Love CJ, et al.Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial. J Am Coll Cardiol 19993316711676\n\t\t\t'},{id:"B40",body:'Byrd CL, Wilkoff BL, Love CJ, et al.Clinical study of the laser sheath for lead extraction: the total experience in the United States. Pacing Clin Electrophysiol 200225804808\n\t\t\t'},{id:"B41",body:'NeuzilP.TaborskyM.RezekZ.et al.PacemakerleadI. C. D.extractionwith.electrosurgicaldissection.sheathsstandardtransvenous.extractionsystems.resultsof. a.randomizedtrial.Europace 2007998104\n\t\t\t'},{id:"B42",body:'DelloRusso. A.BiddauR.PelargonioG.et al.Leadextraction. a.neweffective.toolto.overcomefibrous.bindingsites.J Interv Card Electrophysiol 200924147150\n\t\t\t'},{id:"B43",body:'Massumi RA, Ross AN.Atraumatic nonsurgical technique for removal of broken catheters from the cardiac acvities. New Engl J Med 1967'},{id:"B44",body:'Belott PH.Lead extraction using the femoral vein. Heart Rhythm 2007411021107\n\t\t\t'},{id:"B45",body:'FischerA.LoveB.HansaliaR.et al.Transfemoral snaring and stabilization of pacemaker and defibrillator leads to maintain vascular access during lead extraction. Pacing Clin Electrophysiol 200932336339\n\t\t\t'},{id:"B46",body:'BongiorniM. G.SoldatiE.ArenaG.et al.Transvenous removal of diffcult pacing and ICD leads: a new technique through the internal jugular vein. Pacing Clinc Electrophysiol 2000'},{id:"B47",body:'Henrikson CA, Brikner JA. How to prevent, recognize and manage complications of lead extraction.Part I: Avoiding lead extraction- Infectious issues. Heart Rhythm 2008510831087\n\t\t\t'},{id:"B48",body:'KennergrenC.BjurmanC.WiklundR.GabelJ. A.single-centreexperience.ofover.onethousand.leadextractions.Europace 200911612617\n\t\t\t'},{id:"B49",body:'BongiorniM. G.SoldatiE.ZucchelliG.et al.Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur Heart J 20082928862893\n\t\t\t'},{id:"B50",body:'WazniO.EpsteinL. M.CarrilloR. G.et al.Lead extraction in the contemporary setting: the LexICon Study. An observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol 201055579586\n\t\t\t'},{id:"B51",body:'de BieM.FouadD.BorleffsJ. W.et al.Trans-venous lead removal without the use of extraction sheaths, results of >250 removal procedures. Europace 201214112116\n\t\t\t'},{id:"B52",body:'Abraham WT, Fisher WG, Smith AL et al for the MIRACLE Study Group.Cardiac resynchronization in chronic heart failure. N Engl J Med 200234618451853'},{id:"B53",body:'BristowM. R.SaxonL. A.BoehmerJ.et al.Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 200435021402150'},{id:"B54",body:'CazeauS.LeclercqC.LavergneT.et al.Multisite Stimulation In Cardiomyopathies (MUSTIC) Study Investigators. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001344873880'},{id:"B55",body:'ClelangJ. G.DaubertJ. C.ErdmannE.et al.Cardiac-HeartResynchronization.Failure-H. C. A. R. E.StudyF.InvestigatorsThe effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 200535215391549\n\t\t\t'},{id:"B56",body:'AziziM.MACastelBehrens. S.et al.Experience with coronary sinus lead implantations for cardiac resynchronization therapy in 244 patients. Herzschr Elektrophys 2006171318'},{id:"B57",body:'PurerfellnerH.NesserH. J.WinterS.etal. E. A. S. Y. T. R. A. K.ClinicalInvestigation.StudyGroup.EuropeanE. A. S. Y. T. R. A. K.RegistryTransvenous left ventricular lead implantation with the EASYTRAK lead system: the European experience. Am J Cardiol 2000K-164K.'},{id:"B58",body:'SackS.HeinzelF.DagresN.et al.Stimulation of the left ventricle through the coronary sinus with a newly developed ‘over the wire’ lead system- early experiences with lead handling and positioning. Europace 20013317323'},{id:"B59",body:'Leon AR, Abraham WT, Curtis AB et al. MIRACLE Study Program.Safety of transvenous cardiac resynchronization system implantation in patients with chronic heart failure: combined results over 2000 patients from a multicenter study program. J Am Coll Cardiol 20054623482356\n\t\t\t'},{id:"B60",body:'BulavaA.LuklJ.Single-centre experience with coronary sinus lead stability and long-term pacing parameters. Europace 20079523527'},{id:"B61",body:'SzilagyiS.MerkelyB.ZimaE.et al.Minimal invasive coronary sinus lead reposition technique for the treatment of phrenic nerve stimulation. Europace 2008'},{id:"B62",body:'SzilagyiS.MerkelyB.RokaA.et al.Stabilization of the coronary sinus electrode position with coronary stent implantation to prevent and treat dislocation. J Cardiovasc Electrophysiol 200718303307'},{id:"B63",body:'NageleH.AziziM.HashagenS.et al.First experience with a new active fixation coronary sinus lead. Europace 20079437441'},{id:"B64",body:'BaranowskiB.YerkeyM.DresingT.et al.Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. PACE 2011e64e65.'},{id:"B65",body:'Tacker WA, Vanvleet JF, Shoenlein WE, et al.Post mortem changes after lead extraction from the ovine coronary sinus and great cardiac vein. PACE 199821296298'},{id:"B66",body:'WilkoffB. L.BelottP.ScheinerA.et al.Extractibility of coronary sinus defibrillation leads improves with ePTFE and medical adhesive coatings. PACE 2001'},{id:"B67",body:'BurkeM. C.MortonJ.LinA. C.et al.Implications and outcome of permanent coronary sinus lead extraction and reimplantation. J Cardiovasc Electrophysiol 200516830837'},{id:"B68",body:'HamidS.ArujnaA.KhanS.et al.Extraction of chronic pacemaker and defibrillator leads from the coronary sinus: laser infrequently used but required. Europace 200911213215'},{id:"B69",body:'BaranowskiB.YerkeyM.DresingT.et al.Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. Pacing Clin Electrophysiol 2011e64e65.'},{id:"B70",body:'HamidS.ArujunaA.CARinaldiA.shockinglead.inthe.coronarysinus.Europace 200911833834'},{id:"B71",body:'CurnisA.BontempiL.CoppolaG.et al.Active-fixation coronary sinus pacing lead extraction: a hybrid approach. Int J Cardiol 2011Sep 8 {Epub ahead of print}'},{id:"B72",body:'TyersG. F.ClarkJ.WangY.MillsP.BashirJ.Coronary sinus lead extraction. Pacing Clin Electrophysiol 200326524526\n\t\t\t'},{id:"B73",body:'BongiorniM. G.ZucchelliG.SoldatiE.et al.Usefulness of mechanical transvenous dilation and location of areas of adherence in patients undergoing coronary sinus lead extraction. Europace 200796973\n\t\t\t'},{id:"B74",body:'Di CoriA.BongiorniM. G.ZucchelliG.et al.Largesingle-center.experiencein.transvenouscoronary.sinuslead.extractionprocedural.outcomespredictorsfor.mechanicaldilatation.Pacing Clin Electrophysiol 201235215222\n\t\t\t'},{id:"B75",body:'WilliamsS. E.ArujunaA.WhitakerJ.et al.Percutaneous lead and system extraction in patients with cardiac resynchronization therapy (CRT) devices and coronary sinus leads. Pacing Clin Electrophysiol 20113412091216'},{id:"B76",body:'KasraviB.TobiasS.MJBarneset.alCoronary sinus lead extraction in the era of cardiac resynchronization therapy: single center experience. Pacing Clin Electrophysiol 2005285153'},{id:"B77",body:'De MartinoG.OraziS.BisignaniG.et al.Safety and feasibility of coronary sinus left ventricular leads extraction: a preliminary report. J Interv Card Electrophysiol 2005133538\n\t\t\t'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Spyridon Koulouris",address:null,affiliation:'
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Dimitris",authors:[{id:"13667",title:"Dr.",name:"Symeon",middleName:null,surname:"Metallidis",fullName:"Symeon Metallidis",slug:"symeon-metallidis"}]},{id:"13793",title:"Pacemaker and Network Mechanisms of Neural Rhythm Generation",slug:"pacemaker-and-network-mechanisms-of-neural-rhythm-generation",signatures:"Thomas Nowotny and Mikhail I. 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Dénise den Haan, Arie O. Verkerk and Hanno L. Tan",authors:[{id:"15634",title:"PhD.",name:"A. Dénise",middleName:null,surname:"Den Haan",fullName:"A. Dénise Den Haan",slug:"a.-denise-den-haan"},{id:"15637",title:"Dr.",name:"Arie O.",middleName:null,surname:"Verkerk",fullName:"Arie O. Verkerk",slug:"arie-o.-verkerk"}]},{id:"13799",title:"Advances in Research on Pacemaking Function of Interstitial Cell of Cajal in Gastrointestinal Tract",slug:"advances-in-research-on-pacemaking-function-of-interstitial-cell-of-cajal-in-gastrointestinal-tract",signatures:"Wen-Xie Xu",authors:[{id:"14613",title:"Dr.",name:"Wen-Xie",middleName:null,surname:"Xu",fullName:"Wen-Xie Xu",slug:"wen-xie-xu"}]},{id:"13800",title:"Biological Pacemaker – Main Ideas and Optimization",slug:"biological-pacemaker-main-ideas-and-optimization",signatures:"Han-Gang Yu and Yen-Chang Lin",authors:[{id:"14483",title:"Dr.",name:"Han-Gang",middleName:null,surname:"Yu",fullName:"Han-Gang Yu",slug:"han-gang-yu"}]},{id:"13801",title:"The Functional Role of Chloride Channels in Cardiac Pacemaker Activity",slug:"the-functional-role-of-chloride-channels-in-cardiac-pacemaker-activity",signatures:"Zheng Maggie Huang and Dayue Darrel Duan",authors:[{id:"14222",title:"Dr.",name:"Dayue Darrel",middleName:null,surname:"Duan",fullName:"Dayue Darrel Duan",slug:"dayue-darrel-duan"},{id:"14223",title:"Dr.",name:"Zheng Maggie",middleName:null,surname:"Huang",fullName:"Zheng Maggie Huang",slug:"zheng-maggie-huang"}]},{id:"13802",title:"The Funny Current in Cardiac Non-Pacemaker Cells: Functional Role and Pharmacological Modulation",slug:"the-funny-current-in-cardiac-non-pacemaker-cells-functional-role-and-pharmacological-modulation",signatures:"Laura Sartiani, Elisabetta Cerbai and Alessandro Mugelli",authors:[{id:"13800",title:"Dr.",name:"Laura",middleName:null,surname:"Sartiani",fullName:"Laura Sartiani",slug:"laura-sartiani"},{id:"13801",title:"Prof.",name:"Alessandro",middleName:null,surname:"Mugelli",fullName:"Alessandro Mugelli",slug:"alessandro-mugelli"},{id:"15772",title:"Prof.",name:"Elisabetta",middleName:null,surname:"Cerbai",fullName:"Elisabetta Cerbai",slug:"elisabetta-cerbai"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"74651",title:"Can Turn-Taking Highlight the Nature of Non-Verbal Behavior: A Case Study",doi:"10.5772/intechopen.95516",slug:"can-turn-taking-highlight-the-nature-of-non-verbal-behavior-a-case-study",body:'
1. Introduction
Turn-taking is an indispensable part of spontaneous and authentic human communication. Despite its significance, it is not always as obvious and straightforward as one might want it to be. Rather, it is sometimes conveyed by elusive and subtle cues. These cues can be of verbal or non-verbal nature, but, in successful communication, all of them can be picked up by the human observer. To facilitate effective natural communication between machines and humans, significant effort must be put towards understanding and recognizing the inter-dynamics and intent of non-verbal communication, of which turn-taking is also a part.
The theory of dialog acts offers one possible way to gain insight into the functionality of verbal and non-verbal expressions of communication. Dialog act (hereinafter DA) theory has its origins in speech act theory [1, 2]. But despite its name, DA theory is not merely a theoretical concept. As Bunt [3] emphasizes, its goal is to provide a computational model of language in actual use. According to Searle [2], a DA represents the meaning of an utterance at the level of illocutionary force, and hence, it constitutes the basic unit of linguistic communication.
There are numerous DA annotation schemes, some of which are more purpose-specific, such as the Verbmobil scheme, which is based on business appointment-scheduling dialogs [4], the TRAINS scheme, annotating dialogs about train freight management [5], or the Coconut annotation scheme, with dialogs about buying dinning or living room furniture [6], while the ISO 24617-2, the DIT++, the DAMSL and the Switchboard annotation schemes, for example, cover various topics and apply to a wider range of material. The Switchboard scheme was created for a corpus of various authentic, spontaneous telephone calls in the United States and defined 42 types of DAs [7]. The DAMSL scheme, moreover, filled the need for applying multiple tags to a single segment [8] and was the first multidimensional scheme [3]. The concept of dimensions is best described by the ISO 24617-2 annotation scheme, whereby it is defined as a “class of DAs with the same type of semantic content” ([9]: 2). In comparison to multidimensional schemes, one-dimensional schemes use several tags, which are, however, mutually exclusive. Multidimensional schemes are, therefore, more appropriate for the annotation of naturally occurring dialogs. Another example of a multidimensional scheme is the DIT++ annotation scheme, which is partly based on the DAMSL scheme. It distinguishes between general-purpose and dimension-specific functions, which together form a set of ten dimensions – the Task/Activity dimension, the Auto-Feedback, the Allo-Feedback, the Turn Management, the Time Management, the Contact Management, the Own Communication Management, the Partner Communication Management, the Discourse Structuring Management, and the Social Obligations Management dimensions [3]. Furthermore, the DIT++ is not limited to verbal communication only; it also considers non-verbal communication, such as head gestures and prosody. The ISO 24617-2 annotation scheme is partially based on the DIT++ taxonomy. As Bunt [10] elaborates, it was created as a consolidation of selected taxonomies with the aim of avoiding confusion among the several existing annotation schemes and their inconsistent terminology [9]. Moreover, in addition to its multidimensionality, the ISO scheme strives to be a domain-independent scheme. Regarding dimensions, it contains functionally the same dimensions as the DIT++ with the exemption of the Contact Management dimension, which is not included in the ISO 24617-2. Among these nine dimensions, the scheme specifies 57 different functions. Six of these functions pertain to the dimension of Turn Management, namely, the functions of accepting, taking, grabbing, assigning, releasing, and keeping a turn. The functions are relatively self-explanatory as long as we remember that the function is always carried out by the sender, i.e. the “dialogue participant who produces a dialog act” ([9]: 4). The functions of turn management are all dimension-specific, which means that they cannot be assigned to any other dimension. The scheme also acknowledges the need for subtle characteristics of utterances such as conditionality, modality, (un)certainty, stance, and sentiment, which Petukhova and Bunt [11] raised in their analysis of existing annotation schemes. As a solution, the ISO 24617-2 proposes function qualifiers that can be applied to a DA function. Following its predecessor, the DIT++, the ISO 24617-2 also considers non-verbal behavior in terms of DA annotation. Afterall, in its definition of DAs, the ISO 24617-2 does not discriminate between verbal and non-verbal behavior, since it defines DAs as “a semantic unit of communicative behaviour”.
Hence, the ISO 24617-2 is well-suited for the annotation of multimodal material and was implemented in research of non-verbal behavior. Yoshino et at. [12] utilized the scheme to annotate information navigation and attentive listening dialogs to improve natural conversation modeling for caretakers that communicate with the elderly. Navaretta and Paggio [13] explore non-verbal behavior occurring when providing feedback among persons who just met, i. e. in highly spontaneous settings. The one-hour recordings, annotated with the tool Anvil, specifically analyze what kind of head movement or facial expressions accompany a certain subtype of the feedback dimension. Their classification of non-verbal behavior is based on the MUMIN scheme. Petukhova and Bunt [14] utilize almost an hour-long recording from the corpus AMI, which consists of project meetings. They analyze DAs according to the DIT++ and the ISO 24617-2 schemes together with co-occurring non-verbal behavior, which is classified according to the CoGest scheme. In their previous work, Petukhova and Bunt [15] annotate recordings from the AMI corpus according to the DIT scheme. Both the annotation of DAs and the annotation of non-verbal behavior is carried out with the DIT scheme, since, as they emphasize, non-verbal behavior helps us understand the true function of a DA. The pragmatical annotation of the multimodal corpus HuComTech [16], however, is not based on the ISO scheme, yet its main annotation units are very similar. They are referred to as communicative acts, which denote the function or purpose of an utterance (e.g., agreement, turn management, information). The annotation of non-verbal behavior, including facial expressions, eyebrow movement, head movement, touch motions, posture, or emotions, was performed manually and partially automatically with the tool Qannot.
Although there seems to be strong evidence to support the multimodal and multi-signal nature of the human-human interaction, for decades, spoken language understanding has first and foremost focused on speech a priori [17]. The classification of non-verbal behavior by Mlakar et al. [18], draws upon McNeill’s [19] common growth point theory, according to which speech and gestures both stem from a common growth point of a concept and mutually influence one another, Pierce’s [20] semiotics, that provides analysis of non-linguistic signs and symbols as the meaning of non-verbal behavior, Ekman and Friesen’s [21] categories and coding of non-verbal behavior, and Birdwhistell’s [22] insights into the importance of kinesics. Moreover, the classification by [18] utilizes the communication management theory [23, 24] and, therefore, also encompasses discourse functions to some extent. Mlakar et al. [18] refer to ‘gestures’ as behavior generated by moving body parts (i.e., head, hands/arms, face, and posture) performing a communicative purpose, i.e., containing a discourse function, as a non-verbal communication intent (hereinafter NCI). These non-verbal expressions represent the basis of cognitive capabilities and understanding [25]. Namely, although not bound by grammar, non-verbal expressions co-align with language structures and compensate for the less articulated verbal expression models, thus providing a certain degree of clarity of discourse [26]. The non-verbal behavior retains the semantics and at the same time helps in providing suggestive influences and serves for interactive purposes, even such as content expression of one’s mental state, attitude, and social functions. The classification proposed by Mlakar et al. [18] positions the role/intent of non-verbal concepts into five main NCI classes of regulators or adapters, deictics or pointers, illustrators, symbols or emblems, and batons.
Cooperrider’s [27] classification of gestures, on the other hand, concerns itself with the question of whether the gesture “communicates a critical part of a message” ([27]: 179) or not. He divides gestures into foreground and background gestures. Foreground gestures are those gestures of which we are aware when we perform them, such as a thumb up, whereas background gestures occur unconsciously, automatically, such as nodding during a telephone call. Therefore, foreground gestures are also in the foreground of the interaction. Among their characteristics, he lists co-occurrence with demonstratives, absence of speech, and a significant effort in their production, i.e., gestures that are bigger and more precise. Contrary to them are background gestures. They are both smaller in size and precision and occur while the sender is speaking. Despite this clear division, Cooperrider [27] emphasizes that the line between foreground and background gestures is anything but straightforward, as some gestures can break the foreground-background barrier. He demonstrates this with pointing gestures, which are generally in the foreground, but when pointing to oneself, they occur in the background. Furthermore, even symbolic gestures can take the background if performed automatically and if they are void of their communicative message. On the other hand, beats occur only as background gestures. One can, therefore, roughly consider illustrators, symbols, and partially deictics as NCI occurring in the foreground, while regulators, beats, and partially deictics can be considered as NCI occurring in the background, while still bearing in mind that the dividing line can always be crossed.
Hence, Cooperrider [27] differentiates between gestures with a semantic or propositional content, i.e., a message that provides some kind of information, and those that are void of it. The same distinction can be made for DAs. There are DAs that primarily convey information that is indispensable for communication, such as the task dimension, and those DAs that primarily do not contain propositional content (hence, they contain metadiscursive content) yet are vital for successful natural communication, such as the turn and management dimensions. Nevertheless, we must apply the same caveat as the one in the background-foreground distinction for gestures, as some DAs can occur either in the foreground or the background. For example, the dimension of managing social obligations can generally be considered part of the foreground, such as the concept of greeting someone upon the first encounter. Still, if a social convention is performed routinely, unconsciously, and is deprived of its semantic content, such as thanking someone for the floor, such a DA can be considered as occurring in the background. The nine DA dimensions can, therefore, roughly be divided into those occurring in the foreground, such as the task and the social obligation management dimension, and those occurring in the background, such as the feedback dimensions, the time and the turn management dimensions, the discourse structuring dimension, and the own- and the partner communication management dimensions.
For successful communication, the message must be as clear as possible. An utterance with a mismatching underlying nature is potentially confusing. For example, to take a turn, which is a typical background DA, one sometimes begins one’s utterance with “look”. The NCI accompanying “look” is usually a subtle hand gesture (e.g., a referential deictic), completely void of meaning and therefore a background gesture. Whereas when one uses “look” in the propositional sense, one uses a pointing gesture; both the DA and the NCI are, in this case, of foreground nature. To use a pointing (foreground) gesture with the mentioned turn-taking (background) DA in the “look” example would therefore be confusing, steering the collocutor to search for an object in sight, which does not exist. Therefore, to ensure cohesion and for the communication to be more effective, it seems plausible that a non-propositional episodes should require a background DA as well as a background NCI.
In light of this foreground-background link between DAs and the NCI of gestures, we set out to explore whether the theory of DAs can help predict the nature of the NCI of the corresponding unit. Specifically, we hypothesize that turn management DAs correlate with background gestures. Therefore, we propose the following hypothesis:
Turn management DAs, as background expressions, will tend to co-occur with NCI of background nature. In particular, turn management DAs will co-occur primarily with communication regulators.
2. Data and methodology
In order to perform research into authentic non-verbal behavior during turn-taking, we utilized a 57-minute long video recording from the Corpus EVA [18]. Our annotation scheme, adapted from Mlakar et al. [28], outlined in Figure 1, was applied in the dataset to perform conversational analysis. For this research, dialog acts were added as a linguistic branch.
Figure 1.
The topology of annotation in the EVA Corpus: The levels of annotation describing verbal and non-verbal contexts of conversational episodes.
The main objective of the scheme is to identify inferred meanings of co-verbal expressions as a function of linguistic, paralinguistic, and social signals (e.g., where and when to gesture) on a symbolic level, and to identify the physical nature (e.g., articulation of body language) and use of the available “imaginary forms” (e.g., how to gesture, how to vocalize), i.e., the level of the interpretation of non-verbal forms. The first layer, in Figure 1, the symbolic interpretation, is the focus of this research. It is used to analyze the interpretation of the interplay between various conversational signals, that is, verbal and non-verbal (i.e., DAs, gestures, syntax, discourse markers) at a symbolic level. The second layer, the interpretation of form, is concerned with how information is expressed beyond language, through prosody and embodied expressions, as an abstract concept of a non-verbal conversational expression with a specific communicative intent, i. e. how it is physically realized. For example, the ‘form’ of a gesture or ‘accentuation’ of speech. Its primary goal is to provide a detailed description, the closest possible to the physical reality and the entity that will realize it (e.g., an embodied conversational agent). As already mentioned, in this chapter, however, we focus on the first layer. The layer which aims to find patterns and tendencies in how people communicate through joint use of language, prosody, gaze, gesture, facial expressions, and other articulation of the body, specifically focused on turn-taking and analysis of DAs and NCIs overlapping in conversational expressions (episodes).
2.1 The EVA Corpus
The EVA Corpus consists of 228 minutes in total, and includes four video and audio recordings, each 57 minutes long, with corresponding orthographic transcriptions. The discourse in all four recordings is a part of the entertaining evening TV talk show ‘A si ti tut not padu’, broadcast by the Slovene commercial TV in 2010. In this research, we utilize one of the videos.
In total, five different collocutors are engaged in each episode in multiparty discourse. The conversational setting is relaxed and unrestricted. The hosts are skilled interlocutors who engage in witty, humorous, and sarcastic dialog with the guest. Therefore, the discourse is highly spontaneous, authentic, and, in this case, since all the participants know each other privately, also relaxed and full of emotional responses. Overall, the video contains 1,516 utterances, with an average of 303 utterances per speaker. The episode contains 1,999 sentences, with an average of 399.8 per participant. The average sentence duration is 2.8 seconds, whereby the longest is 18.1 seconds, and the shortest is 0.19 seconds. Overall, there are 10,471 words in the episode, and on average, a speaker uttered 2,094 of them, with a mean value of 7.9 words per sentence. While the total length of the recording is just under one hour, the total duration of all utterances without overlapping is 1 hour 33 minutes and 26.3 seconds, which suggests a substantial amount of overlapping speech. Consequently, the dialog is characterized by a vivid and rapid exchange of speaker roles, which makes it ideal for the study of non-verbal behavior that accompanies turn-taking.
2.2 DA annotation
The entertainment show was segmented and transcribed with the transcription tool Transcriber 1.5.1 and annotated in the annotation tool ELAN. The annotation of DAs was performed with the web-based annotation tool Webanno. For the classification of DAs, we applied the ISO 24617-2 scheme, however, it was partially consolidated in accordance with our research’s aim. In the dimension of information-providing functions, we specified the function Correction as it does not clarify whether the sender corrects themselves of the interlocutor. Therefore, we added the function CorrectionPartner, which denotes the action of the sender who is correcting the interlocutor. Among the functions Inform or Agreement, we also filled the need for argumentative acts and added the function Argument. For occasions where the sender quotes someone, the function ReportedSpeech was added. Among the directive functions, the Instruct function did not suffice for acts where the sender provides support to the interlocutor or when the sender warns the interlocutor. Therefore, the functions Encouragement and Warning were added. With regard to feedback-specific functions, we merged the AutoPositive and AutoNegative functions into the OwnComprehensionFeedback function. Similarly, we merged the alloPositive, and the AlloNegative functions into the PartnerComprehensionFeedback function. The dimension of discourse structuring provided the function of opening but lacked the closing action, which we added. As regards the dimension that manages social obligations, we merged the InitGreeing and the ReturnGreeting functions into Greeting. The dimension, however, lacked the function of providing and accepting praise or flattery, which is why the functions Praise and AcceptPraise were included. The annotation of sentiment included the qualifiers Disappointment, Disgust, Emphasis, Hurt, Negative, Positive, Satisfaction, and Surprise.
In line with Cooperrider’s [27] foreground-background distinction, we divided DAs according to whether they are conveying a vital part of the message without which the encounter would be void of propositional content or not. Since task-oriented DAs include the functions of information-seeking and -providing, as well as commissive and directive functions, they are part of the foreground. Similarly, the social obligations management DAs perform functions such as greetings, introductions, apologies, thanking, and valedictions. They contain propositional content and can, therefore, be considered part of the foreground. On the other hand, the feedback DAs, turn management DAs, time management DAs, discourse structuring DAs, and own- and partner communication management DAs perform background functions as their main purpose is not to convey information but to steer the dialog or to provide active listenership. For example, when correcting oneself after misspeaking, the act of correction is not in the foreground; it is the underlying information-related DA. Similarly, when helping the interlocutor to find the correct ending to a word, the act of completion is in the background, while the interlocutor’s primary utterance that is being completed by the partner is in the foreground. As emphasized in the Introduction, some functions can cross this distinction. Let us consider an example with the function of completion. When people try to demonstrate their connection by finishing each other’s sentences, the partner’s act of completing the interlocutor’s primary utterance is in the foreground, since both interlocutor’s purpose of communication was to demonstrate their connection by completing each other’s sentences. Nevertheless, for the majority of cases, the proposed distinction of DAs can be applied as proposed.
In terms of the background-foreground distribution of observed DA episodes, we can conclude that the material is well balanced. It consists of 1,897 instances where the primary role of the DA was recognized as of foreground nature, and 2,020 instances were the primary role of the DA was of background nature.
2.3 NCI annotation
The annotation of non-verbal expressions focusing on gestures, mimics, was carried out in Elan. The annotation of each phenomenon highlighted in Figure 1 (e.g., gesture unit, phrase, NCI) was conducted individually, but by two or three annotators at a time. In terms of annotation disagreement, diverging values were elaborated and argued until consensus was reached. Moreover, before the annotation process began, all annotators were familiarized with the nature of the signal to be annotated and notified with the possible values from which they could choose.
In terms of NCI annotation, we used the following classification:
Illustrators (I) define body movement (embodiment) that illustrates what a speaker is saying. Regarded as foreground behavior, they accompany or reinforce verbal cues and are accompanied by an actual word referent in the speech. Illustrators are further classified into outlines, ideographs, and dimensional illustrators. The outlines (IO) subclass encompasses embodiments that reproduce a concrete aspect of the accompanying verbal content (explicit referents in speech). The ideographic/metaphoric illustrators (Ii) subclass refers to a concretization of the abstract through a specific shape. The spatial/dimensional (Id) subclass refers to the spatial movements outlining or depicting dimensional relations. They are used to ‘paint’ characteristics of entities and actions to further highlight their physical properties.
Regulators/adaptors (R) define embodiments that are primarily used to model the flow of information exchange. Adaptors are regarded as part of background behavior and can be produced even without speech. They exist without a specific speech reference and do not link with a specific speech structure. The regulators are further classified into self-adaptors (RS), the communication regulators (RC) subclass, the affect-regulators (RA) subclass, the manipulators (RM) subclass, and the social function and obligation regulators (RO) subclass. Self-adaptors relate to how a speaker continuously manages the planning and the execution of the speaker’s own communication. The communication-regulators refer to managing interactions with other interlocutors through systems of turn-taking, feedback, and sequencing, e.g., interactive communication management (ICM). The affect-regulators are either self- or person-addressed and are used to further emphasize or express attitude or emotion regarding a topic, object, or person. Manipulators convey relief or release of emotional tension or outline states of the body or mind, such as anxiety, uncertainty, or nervousness. Finally, social function and obligation regulation primarily deals with embodied behavior used in social settings, such as greetings, goodbyes, introductions.
Deictics (D) include entities that can actually be present in the real environment of the gesturer (e.g., indicating objects, persons, or places) or are ideally present in the discourse content or abstract (e.g., pointing upwards or pointing backward to indicate the past). If deictic expressions are actual word referents with a semantic interlink, they are regarded as part of the foreground. If the semantic link does not exist or is weak, deictic expressions will also be recognized as part of the background. We further distinguish between pointers (DP), indexes/referential pointers (DR), and enumerators (DE).
Symbols/emblems (S) tend to establish a strong semantic link with verbal counterparts. They are regarded as foreground and include all symbolic gestures and symbolic grammars. Their specific meaning is often cultural-specific, as the same emblem can have different meanings in different cultures. Nevertheless, there are cross-cultural hand emblems, which are easily recognizable because, despite their arbitrary link with the speech they refer to, they have a direct verbal translation, which usually consists of one or two words or a whole sentence (often a traditional expression shared in a specific culture).
Batons (B) are those staccato strikes that create emphasis and grab attention, such as a short and single baton that marks an important point in a conversation. Whereas repeated batons can “hammer” a critical concept. Batons are equivalent to beats, however, beats may appear as a more random movement (e.g., outlining rhythm). Batons, on the other hand, may also set the rhythm and signal importance but, more importantly, they also outline the structure of verbal counterparts, e.g., tag a set of words that should be processed together (e.g., to produce a summary of the meaning of an utterance).
In terms of the background-foreground distribution of observed NCIs, we can observe that the material contains predominantly non-verbal behavior “functioning” in the background. Overall, we have observed roughly 1,684 non-verbal expressions, out of which 1,274 belonged to regulators (75.65 percent) and 136 (8.08 percent) to illustrators and symbols. The rest, 275 (16.33 percent), belonged to deictic expressions. The majority of NCI is, therefore, of background nature.
A rough classification of NCIs and DAs according to their underlying nature, which can be of background and/or foreground nature is represented in Table 1. It must be emphasized that this classification is purely provisional, as the foreground-background barrier is vague and can, depending on the wider context, be crossed by both NCIs and DAs.
Background nature
Foreground nature
NCIs
Regulators, Batons, Deictics
Illustrators, Symbols, Deictics
DAs
Turn management, Social obligations management, Time management, Discourse structuring, Feedback, Communication management
Task, Social obligations management
Table 1.
A coarse-grained classification of the underlying nature of NCI classes and DA dimensions.
2.4 Annotation agreement
In total, five annotators, two with a linguistic background, and three with a technical background in machine interaction were involved in this phase of annotations. Annotations were performed in separate sessions, each session describing a specific signal. The annotation was performed in pairs, i.e., two or three annotators annotated the same signal. After the annotation, consensus was reached by observing and commenting on the values where the was no or little annotation agreement among multiple annotators (including those not involved in the annotation of the signal). The final corpus was generated after all disagreements were resolved. Procedures for checking inconsistencies were finally applied by an expert annotator.
Before starting with each session, the annotators were given an introductory presentation defining the nature of the signal they were observing and the exact meaning of the finite set of values they could use. An experiment measuring agreement was also performed. It included an introductory annotation session in which the preliminary inconsistencies were resolved. Overall, given the complexity of the task and the fact that the values in Table 2 also cover cases with a possible duality of meaning, the level of agreement is acceptable and comparable to other multimodal corpus annotation tasks [29].
Signal
Kappa score
Word Segmentation (semi-automatic)
0.95
Part-of-Speech (semi-automatic)
0.81
Pitch (automatic)
/
Syntax (semi-automatic)
0.79
Sentence type
0.97
Gesture unit
0.82
Gesture phrase
0.53
Modality
0.88
Prosodic phrases
0.71
Sentiment
0.67
Dialog function
0.64
Dialog dimension
0.71
Intent (semiotic class)
0.48
Emotion label
0.51
Gesture unit
0.75
Movement phase
0.66
Table 2.
Results of the preliminary inter-coder agreement experiment.
For the less complex signals, influenced primarily by a single modality (e.g., pitch, gesture unit, gesture phrase, body-part/modality, sentence type), the annotators’ agreement measured in terms of Cohen’s kappa [30] was high, namely, between 0.75 and 0.9 on the Kappa score. The signals such as, Part-of-Speech, Syntax, Word Segmentation, were annotated (semi)automatically and the two expert annotators (linguists) overviewed the process and corrected the tags manually. The agreement was measured over the agreement on the corrections made. Pitch was annotated completely automatically, no agreement was measured. The only exceptions between less complex, unimodal signals, were Gesture phrase (0.53) and Prosodic phrases (0.71). The disagreements were expected since in some cases it is quite ambiguous to identify where a certain phrase ends and the next stars. Moreover, in a lot of cases, a retraction phase of a gesture can be recognized as stroke phase of the next gesture phrase.
As summarized in Table 3, for the more complex signals that involve multiple modalities for their comprehension (including speech, gestures, and text) the disagreements in interpretation were expectedly higher.
3. Case study
Example 1: DAs as part of background and foreground conversational expressions.
Guest: Ampak se izkaže, da ta zdravnik ne zna nič drugega delat kot vedno iste in samo iste (A) obraze in so vsi poklonirani (B) – no to je (1) to. Fajn, ne (2)?
Co-host: (C) Samo v bistvu, a veš, v bistvu sej če pri nas gledaš sj so tud pol vsi glih.
Guest: But it turns out that this doctor can create only one and the same (A) face and nothing else and that they are all cloned (B) – well this is it (1)1. Great, huh (2)?
Co-host: (C) But actually, you know, actually if you took a look at where we are then they are also all the same.
This segment represents a case of sudden turn release by the main guest. Previously, the participants were discussing the effects of aging, during which several sarcastic comments were uttered. The show’s host afterwards tries to transition to the next topic, which is the play the guest was directing, called The Ugly One. However, the guest is offended by the co-host’s snide remark, where he compares the name of the play and the guest, suggesting that the guest might also be an ugly one. Nevertheless, after being asked to tell the audience about the play, he briefly outlined the plot, which deals with cosmetic surgery in connection with the feeling of self-worth and success. He is still mid-sentence and speaking with a rising intonation (see Figure 2: B, in so vsi poklonirani “and they are all cloned”) when he suddenly takes a deep breath and decides to stop summarizing the play with the words no to je to “well this is it”. Additionally, he emphasizes that he no longer wishes to talk about the topic, as he adds fajn, ne? “great, huh?”. With it, he simultaneously elicits feedback, which is yet another way to assign his turn to someone else.
Figure 2.
Multimodal analysis of the conversational expressions: use of DAs in background and foreground expressions.
The utterance “well this is it” cannot be characterized as any other DA than turn management with the function of turn release as it serves no other communicative purpose. The phrase itself is tautological, deprived of any propositional content. The analysis of the accompanying body behavior also corroborates this fact. While outlining the plot of the play, he uses foreground NCI (A, B), namely illustrators, represented by two very prominent hand gestures. As he decides that he no longer wishes to explain the gist of the play, his NCI also changes. The body behavior is no longer prominent but very quick and even difficult to notice. The guest swiftly turns his head slightly to the right and back again (see Figure 2: 1) as if he was trying to point to the abstract “this” in “this is it” while still keeping eye contact with the host and co-host. The head movement was classified as a deictic NCI, specifically, a referent, since the guest is referring to the abstract “this”. He then adds the utterance fajn, ne? “great, huh?” which primarily acts as feedback elicitation, but secondarily also serves the function of turn management. The accompanying body behavior is, again, subtle, just a slight shrug of the right shoulder (see Figure 2: 2). It was classified as a communication regulator. The co-host perceives his turn release request and takes the turn by commenting on the essence of the play. However, since the release was unexpected, his response is yet to be formulated. This is highlighted through the use of metadiscourse (“But actually, you know, actually”) acting primarily as stalling within the time management dimension. However, of course, stalling functions also as a turn-take maneuver.
Example 2: Ambiguity of DAs in conversational expressions.
Host: eee eee eee(A) no eee (B) dejta ubesedet to midva se mava rada (1)
Host: uh uh uh (A) well uh (B) come on, define this we like one another (1)
The example above is a case of strong turn assigning. As a surprise for the main guest, his stepdaughter was invited to the show. The show’s host is trying to determine the correct nomenclature for the relation non-biological father/adoptive daughter, which are specific and probably less frequently heard words in Slovene. However, he is very clumsy when formulating his question, and neither of the guests understands him, but rather fill their answers with humor. The show’s host is dissatisfied and tries to change the evolution of the conversation. However, he needs time to formulate proper utterances and thus uses fillers (see Figure 3: A and B). After the first filler (A), which acts as stalling, the content is not completely formulated, which is why he uses the second filler (B). At the same time, however, the guests become impatient. The second filler, therefore, functions not only as a stalling element but primarily as turn keep device. Once he formulated his idea, he begins with the imperative formulation dajta (for this purpose best translated as) “come on”. This utterance is accompanied by the host’s extended and raised left arm, both (temporarily) open hands, slightly raised shoulders, and a protruding head movement (see Figure 3: 1). This NCI was classified as a referential deictic (1a), as the host’s hands and head are extending towards the guests. At the same time NCI can also be perceived as visualizing the word dajta, thus being recognized as an illustrator. From the context of DAs, the utterance can be interpreted as having the underlying function of turn-taking or, due to the imperative formulation, the instruct function within the task dimension. As highlighted in the example, the use of DAs determines the perceived NCI.
Figure 3.
Multimodal analysis of the conversational expressions: The duplicity of DAs when interpreted as background or as foreground conversational expressions.
Example 3: DAs in turn management within a multiparty conversation.
Guest: grmičevje je zlo nerodno objemat
Co-host: zakaj?
Guest: ful pič … ful ful te (A)
Host: ful ful pič ful pič
Co-host: ful me
Guest: drevo je fajn men
Host: eee (1)
Co-host: kosmulja (2)
Co-host: nadaljuj (3).
Host: ja (4)
Guest: it’s very tricky to hug shrubs
Co-host: why?
Guest: totally pricks … you get totally totally (A)
Host: totally totally pricks totally pricks
Co-host: I get totally
Guest: trees I like
Host: uh (1)
Co-host: gooseberry (2)
Co-host: continue (3).
Host: yes (4)
This segment illustrates NCI in tree different turn management functions. Prior to the several turn-taking acts, the show’s host is mocking the guest for his alleged morning ritual where he hula-hoops in his garden. The co-host humorously adds that he hugs surrounding trees and shrubs in the garden. First, the guest smiles at this mental image, but then his facial expression changes to serious, and he cautions that it is very hard to hug shrubbery. As the co-host asks why this is so, he turns the answer into a comical depiction of how he gets stung by thorns whereby he uses the colloquial Slovene word ful, which means very or a lot. The co-host is fascinated by this word choice of the guest, a theater actor, who just minutes before teased him for not enunciating correctly. He, therefore, mocks his (almost plosive) pronunciation of the word ful and the guest joins in in the mocking. The show’s host, however, tries to join the conversation (see Figure 4:1), but his co-host still continues the mocking by saying “gooseberry” (see Figure 4: A) in a very comical manner, trigging light laughter from the guest but befuddlement from the host. The host turns to the co-host, hoping for clarification, the co-host stares back at him and finally tells him to continue with the show. After briefly gathering his thoughts, the host nods, says “yes” and changes the topic.
Figure 4.
Multimodal analysis of the conversational expressions: Use of turn-take and turn-grab to mediate the conversation.
This excerpt, therefore, contains turn-taking, turn-assigning, and turn-accepting. Following a series of task dimension DAs, the show’s host tries to take the turn by uttering the filler eee “uh”. He fails, as his co-host drowns him out with “gooseberry”. There is no NCI accompanying the host’s utterance, as he barely moves (see Figure 4: 1). We, therefore, classified the NCI as undetermined. An indicator for his turn-take attempt is his gaze, which remains directed towards the guests (see Figure 4: 1) throughout the co-host’s interruption. As he turns to the co-host, he remains speechless and waits for him to elaborate. The co-host subsequent NCI, on the other hand, is a clear referential deictic (3) accompanying the DA of assigning the turn. His gaze towards the host was not enough to prompt a response, so he adds a firm head nod (see Figure 4: 3) towards him and verbalizes his intent of assigning the turn to him with “continue”. This firm head nod is why the DA was not secondarily classified as a turn release, but as instructing within the task dimension. The host almost simultaneously responds to this NCI with a slight nod himself (see Figure 4: 4) and thereupon the verbal confirmation “yes”. The nod was identified as a communication regulator NCI. The verbal confirmation functions as a turn accept DA. Both the DA and the NCI are of background nature.
4. Discussion
An effective analysis of the non-verbal behavior that accompanies turn-taking requires material that is authentic and rather informal than formal. The episode from the entertainment show As ti tut not padu? offers such a resource. As elaborated in the section The EVA Corpus, the notion that the material is highly spontaneous is corroborated by the video’s statistics. The sheer amount of overlapping speech indicates a high frequency of turn management acts. The notion that the material is spontaneous and performed in a relaxed manner is further supported in Cooperrider’s [27] foreground-background distinction, as the DAs are well-balanced according to their nature. Overall, there are 1,897 foreground DAs and 2,020 background DAs. Therefore, more than half of the DAs are of background nature. This suggests that the material is not task-oriented, but instead serves the purpose of an entertainment show. Moreover, the most frequently observed NCI in the video were NCIs classified as regulators. The group of regulators represents 3/4 of all recognized NCIs in the entertainment episode. Regulators are followed by the group of deictic NCIs representing almost roughly 16 percent of the recognized NCIs. The remaining groups of illustrators, batons, symbols, and undetermined NCI each account for less than a tenth of the recognized NCIs. Again, the dominant NCI groups are of background nature, even if observing only regulators. These findings further support the notion that the material is highly spontaneous, relaxed, and entertaining. Therefore, it was a suitable choice for the analysis of natural turn-taking behavior and its accompanying non-verbal behavior.
Even though it seems relatively elementary to annotate turn management DAs, at times, the process proved to be complex. The acts of turn management are intertwined with stalling and instruction DAs. Examples 1 and 2 show how the stalling function (within the time management dimension) can also act as a turn-taking mechanism. In example 1, on the one hand, the co-host wants to take the floor since the guest suddenly released his turn. On the other hand, he does not know how to start. Hence, it is difficult to determine the primary DA, especially since the remainder of his response can be considered an information-providing DA. Example 2 illustrates how fillers, which generally pertain to the stalling function within the time dimension, act as turn-taking devices. They signal to the interlocutor that one wishes to speak but still requires additional time to properly verbalize one’s thoughts. To further complicate the annotation of turn-taking management, in a conversation, each utterance by another person can secondarily be considered a turn-taking DA. Even the act of posing a question, which would primarily be annotated within the information-seeking dimension, can secondarily be annotated with a turn-assign function (since person A, who is asking person B the question, wishes person B to respond). Nevertheless, we did not annotate such secondary cases of turn management as alternative DAs. Only DAs where turn management is key for an utterance were assigned the turn dimension. Consequently, the share of turn management DAs could be significantly greater, and the ratio between foreground and background expressions notably tilted towards the background spectrum. Again, this only highlights the nature of the material, which is by no means primarily task-oriented.
Since regulators and (partially) deictics are background expressions, we expected them to co-occur with turn management DAs. As noted, deictics are the elusive group of NCIs which can occur both in the foreground and the background. In Example 1, the explicit turn management DA is accompanied by a referential deictic. The semantic link with the word it refers to, however, is weak. The guest speaks of an abstract “this” in his utterance “well this is it”. He does not refer to anything physically present in the room; he just points to a mental image. Therefore, the deictic is part of the background. This, in turn, is in line with the assigned DA, since both concepts are background expressions.
A similar symmetry between the nature of the DA and the NCI is observed in Examples 2 and 3. In Example 2, the NCI can be considered both as a background and a foreground expression (see Figure 3: 1). Within the concept of DAs, it can also be considered as occurring in the background and in the foreground. In the background, it is a turn-assigning DA with which the host hopes to receive a response to his nomenclature dilemma. In this case, the non-verbal behavior is perceived as spontaneous. Rather than to visualize the referential utterance dajta “come on” the speaker tries to emphasize his frustration with the interlocutors, i.e., if you know better then please explain, and thereby assigns the turn someone else. The ‘open hand gesture’ is observed to signal this. In the foreground, it has an instructing function, within the task dimension, since he demands a response. The host is referencing actual people in the room and due to the imperative use of the referential utterance dajta “come on you two”, the observed conversational expression may be interpreted as instructing. Dajta is perceived as an explicit speech referent, and the non-verbal behavior seems to directly visualize it. Similarly, in Example 3, the NCI (see Figure 4: 3) is not a typical background referential deictic as the co-host physically leans towards the host while he nods towards him in order to prompt him to continue. The referent of the NCI is, therefore, an actual person (the host) in the room, and the NCI also occurs in the foreground. This duality is reflected in DAs as well. On the one hand, the co-host assigns the turn to the host (within the turn dimension); on the other, the co-host instructs the host to speak (within the task dimension). Again, this is an example of the difficulty in differentiating between background and foreground expressions.
Finally, as hypothesized, regulators are the group of NCIs that co-occur with unambiguous turn management DAs. In Example 1, the secondary turn management DA co-occurs with the group of regulators, specifically a communication regulator. Whereas the group of deictic NCIs crosses the foreground-background barrier, regulators are background expressions. The fact that the accompanying NCI is a regulator and not a referent from the deictic group, which would be more typical for feedback elicitation, further endorses the assignment of a turn dimension DA and highlights the turn management intent. Example 3 illustrates a similar unambiguity when regulators are used for turn-taking. There is an underlying agreement of the nature of the DAs and the NCI in the last utterance “yes” (see Figure 4: 4). Namely, both take place in the background. And clearly, they were well understood by the interlocutors as no one else tried to take the turn. The opposite phenomenon is observed at the beginning of the same example (see Figure 4: 1) with the host’s filler “uh”. It is an example of a failed turn-take attempt since the co-host interrupts the host. There was no noticeable non-verbal behavior accompanying the host’s filler, which is why no NCI could be assigned. However, one might argue that the fact that there is no NCI accompanying his turn-take attempt, contributes to the reason of why the attempt failed. Consequently, this might be considered a supporting example of Birdwhistell’s [22] findings that successful communication requires both verbal and non-verbal components.
We can therefore confirm our hypothesis that turn management DAs co-occur with regulators. The case analysis further supports the hypothesis that turn management DAs particularly co-occur with communication regulators. Moreover, we can observe that during propositional content, i.e., task-oriented DAs, use of illustrators (foreground NCIs) is more common (see Figure 2: B in Example 1). In accordance with Cooperrider’s [27] characteristics of foreground-background gestures, we observed the spatial prominence of each type of gesture. Example 1 shows how non-verbal behavior changes in parallel with the change of DAs. As the DAs changed from task with the function of informing to turn management with the function of turn release (see Figure 2, B and 1), so did the NCI. It shifted from foreground behavior to background behavior. Moreover, foreground NCIs are far more prominent than the background NCIs. It seems that, as this simultaneous shift in DAs and foreground-background behavior occurs, body behavior is decelerated and minimized. Our findings, therefore, corroborate Cooperrider’s [27] the special hallmarks of foreground-background gestures.
There are, however, border cases. For example, the background DA of providing feedback during active listening, such as uttering the supportive “yes” or “mm-hmm”, can be accompanied by a slight nod of the head. Head nodding is generally considered a foreground gesture, if it signals a “yes” or “no” answer, since it can substitute speech altogether. However, in background use, one does not provide an answer, but merely signals to the interlocutor, that one is listening to them and wishes them to continue their turn. Hence, the act is clearly of background nature. Nevertheless, it is impossible to state that at the same time one does not also agree with what the interlocutor is saying. Agreement, however, is considered a foreground act. This is a typical case where the duality no longer applies. Hence, it is possible even for background DAs, such as feedback providing and eliciting, to co-occur with foreground NCIs. Moreover, even task-oriented DAs are often accompanied with batons, a representative background NCI, since they signal importance or set the rhythm but do not convey any propositional content. It is therefore difficult to extend the shared background-foreground nature hypothesis to other DAs. Despite this observation, the exploration of the shared nature in foreground DAs offers an interesting research question for future research.
A potential concept to further elaborate on the underlying nature is to observe whether the gesture is prominent (in its iteration or spatial dimensions) or subtle [27], as observed in Example 1. In accordance with this distinction, a subtle nod suggests background nature whereas a prominent nod suggest that the gesture is of foreground nature. Moreover, the relative timing may also, provide additional insight in the communicative intent. Although, not directly investigated in this research, is seems that when the stroke phase of the embodiment (especially a hand gesture) co-occurs with a specific speech referent (i.e. the gesture starts at the same time as the spoken articulation) the information provided is propositional, i.e., of foreground nature, whereas when the stroke phase occurs outside boundaries of the targeted referent (or without one) the information provided is of background nature. An example would be phrases “look over there!” and “what do you mean?”. In general, deictics will accompany both phrases. On the one hand, the phrase “look over there” is clearly a task-oriented DA and will be accompanied by a pointer, the stroke of which will occur aligned with the verbal articulation of “there”. On the other hand, the stroke phase of a similar gesture ‘visualizing’ the “you” in “what do you mean?” will co-occur with “mean” and will be recognized as a referential deictic in turn management (i.e., as turn offer). Thus, in our future investigations, we tend to analyze if the alignment of verbal structure with the prosody of non-verbal cues (i.e. the cues preceding verbal acts, cues following verbal acts, cues at the beginning or end of verbal cats) may shed further light on the true purpose of the shared nature.
5. Conclusions
In this chapter, we examined what kind of non-verbal behavior accompanies turn management DAs. For the annotation of turn management DAs, the ISO 24617-2 scheme’s functions sufficed. Nevertheless, turn management DAs frequently overlap with other DAs, especially within the time management dimension. The fact that it is sometimes very difficult to decide which dimension and function is the most fitting shows the importance of multidimensional DA tagging. As a future endeavor, it would be more functional to create annotation schemes that, besides being multidimensional, denote the hierarchical order of the tags assigned, for example, the primary, secondary, tertiary, etc. dimensions and functions.
Cooperrider’s [27] distinction between gestures that occur in the foreground or background proved an effective method within the concept of DAs. We hypothesized that there is an interlink between background NCI and background DAs. Since regulators, specifically, communication regulators, convey typical background NCI, we predicted their co-occurrence with turn management DAs. Indeed, the present case study confirms this hypothesis. Moreover, an interlink with deictic NCI was observed. As they can be of either background or foreground nature, the premise that background DAs co-occur with background NCI is maintained. This duality is not observed only within NCI but also within DAs. An utterance can have alternative expressions, one of background nature and one of foreground nature. However, the duality occurs simultaneously for NCI and for DAs. Hence, the fact that there is the same duality at the NCI level and at the DAs level strengthens the hypothesis of an interlink between the two concepts.
Acknowledgments
This paper is partially funded by the Slovenian Research Agency, project HUMANIPA (research core funding No. J2-1737 (B)). This paper is partially funded by European Union’s Horizon 2020 research an innovation program, project PERSIST (grant agreement No. 875406).
Conflicts of interest
The authors declare no conflict of interest.
\n',keywords:"non-verbal behavior, non-verbal communicative intent, multimodal analysis, background expressions, regulators, deictics, turn-taking, dialog acts, ISO 24617-2",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/74651.pdf",chapterXML:"https://mts.intechopen.com/source/xml/74651.xml",downloadPdfUrl:"/chapter/pdf-download/74651",previewPdfUrl:"/chapter/pdf-preview/74651",totalDownloads:28,totalViews:0,totalCrossrefCites:0,dateSubmitted:"August 24th 2020",dateReviewed:"December 16th 2020",datePrePublished:"January 4th 2021",datePublished:null,dateFinished:"December 30th 2020",readingETA:"0",abstract:"The present research explores non-verbal behavior that accompanies the management of turns in naturally occurring conversations. To analyze turn management, we implemented the ISO 24617-2 multidimensional dialog act annotation scheme. The classification of the communicative intent of non-verbal behavior was performed with the annotation scheme for spontaneous authentic communication called the EVA annotation scheme. Both dialog acts and non-verbal communicative intent were observed according to their underlying nature and information exchange channel. Both concepts were divided into foreground and background expressions. We hypothesize that turn management dialog acts, being a background expression, co-occur with communication regulators, a class of non-verbal communicative intent, which are also of background nature. Our case analysis confirms this hypothesis. Furthermore, it reveals that another group of non-verbal communicative intent, the deictics, also often accompany turn management dialog acts. As deictics can be both foreground and background expressions, the premise that background non-verbal communicative intent is interlinked with background dialog acts is upheld. And when deictics were perceived as part of the foreground they co-occurred with foreground dialog acts. Therefore, dialog acts and non-verbal communicative intent share the same underlying nature, which implies a duality of the two concepts.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/74651",risUrl:"/chapter/ris/74651",signatures:"Izidor Mlakar, Matej Rojc, Darinka Verdonik and Simona Majhenič",book:{id:"9037",title:"Types of Nonverbal Communication",subtitle:null,fullTitle:"Types of Nonverbal Communication",slug:null,publishedDate:null,bookSignature:"Prof. Xiaoming Jiang",coverURL:"https://cdn.intechopen.com/books/images_new/9037.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"189844",title:"Prof.",name:"Xiaoming",middleName:null,surname:"Jiang",slug:"xiaoming-jiang",fullName:"Xiaoming Jiang"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Data and methodology",level:"1"},{id:"sec_2_2",title:"2.1 The EVA Corpus",level:"2"},{id:"sec_3_2",title:"2.2 DA annotation",level:"2"},{id:"sec_4_2",title:"2.3 NCI annotation",level:"2"},{id:"sec_5_2",title:"2.4 Annotation agreement",level:"2"},{id:"sec_7",title:"3. Case study",level:"1"},{id:"sec_8",title:"4. Discussion",level:"1"},{id:"sec_9",title:"5. Conclusions",level:"1"},{id:"sec_10",title:"Acknowledgments",level:"1"},{id:"sec_13",title:"Conflicts of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Austin J L. How to do things with words. Oxford: Clarendon Press; 1962.'},{id:"B2",body:'Searle, J R. Speech acts: An essay in the philosophy of language. Volume 626. Cambridge university press; 1969.'},{id:"B3",body:'Bunt, H. The DIT++ taxonomy for functional dialogue markup. In: Heylen D, Pelachaud C, Catizone R, & Traum D, editors. Towards a Standard Markup Language for Embodied Dialogue Acts. Proceedings. 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Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
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Prof. at Facultad Filología, Universidad Complutense de Madrid since 1994. She holds a PhD Anglo-American Culture and Literary Studies, and Diploma of Advance Studies in Spanish Literature from UNED, and a Master in Educational Management from the Open University London. Her research interests are Comparative and World Literature, Cultural and Education Studies, as well as Cognitive and Intermedial Semiotics.\nIn 2007 she created the research program Studies on Intermediality and Intercultural Mediation SIIM. http://www.ucm.es/siim\nLópez-Varela has been visiting scholar at Brown University (2010) and Harvard University (2013) and visiting professor at Delhi University (2011), Beijng Language and Culture University (every year since 2012), Kazakh National University, Almaty (2013, 2014). Tamkang University, Taipei (2015).\nShe is a member of Hermeneia Research Group at Universitat de Barcelona Mitocriticism Research Group at Complutense Madrid and Semiótica Comunicación y Cultura\nA proactive member of the profession, López-Varela is in the Executive Committee of the Association of Alumni of the Real Colegio Complutense in Harvard University, and in the European Network of Comparative Literary Studies (ex officio)\nShe is also external evaluator for the EU Educational, Audiovisual & Culture Executive Agency EACEA the European Union Research Program Horizon 2020 , the postgraduate programs of Dublin City University and collaborates as advisor with the Department of Romance Studies Harvard University. \nLopez-Varela is keen in giving international visibility to research by colleagues and younger peers, and her editorial activities are a clear sign in this direction. She is Editor International Journal of the Humanities SJR Rank Associate International Editor Journal Comparative Literature and Aesthetics and collaborator in the InTech Open Access series of the European Union Open Aire project.\nProf. López-Varela is Editorial Board Member and Scientific advisor in journals such as: 1616: Anuario de la Sociedad Española de Literatura General y Comparada. Ediciones Universidad de Salamanca deSignis, the journal of the Federación Latinoamericana de Semiótica (FELS) Cultura: International Journal of Philosophy of Culture and Axiology International Journal of Transmedia Literacy Southern Semiotic Review, HyperCultura Journal Hyperion University (Bucharest) \\Studii şi cercetări ştiinţifice. Seria filologie (SCS)\\ (ISSN 1224-841X) of University \\Vasile Alecsandri\\ and the Cypriot Journal of Educational Sciences CJES at World Education Center. She was review editor at Comparative Literature and Culture between 2008 and 2013 and collaborates with other publishing houses such as Routledge Aracne editrice S.r.l. and MacMillan and Peter Lang\\'s Book Series \\Reflections on Signs and Language\\. Some of her publications are at http://www.ucm.es/siim/lopez-varela-publications See also http://orcid.org/0000-0003-1616-5830",institutionString:null,institution:{name:"Complutense University of Madrid",institutionURL:null,country:{name:"Spain"}}},{id:"115114",title:"MA",name:"Jaap",surname:"Den Hollander",slug:"jaap-den-hollander",fullName:"Jaap Den Hollander",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Groningen",institutionURL:null,country:{name:"Netherlands"}}},{id:"116634",title:"Dr.",name:"Carlo",surname:"Sessa",slug:"carlo-sessa",fullName:"Carlo Sessa",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"117596",title:"Prof.",name:"David John",surname:"Farmer",slug:"david-john-farmer",fullName:"David John Farmer",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Virginia Commonwealth University",institutionURL:null,country:{name:"United States of America"}}},{id:"118701",title:"Mr.",name:"Robert",surname:"Garcia",slug:"robert-garcia",fullName:"Robert Garcia",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"118755",title:"Dr.",name:"Sylvain",surname:"Cibangu",slug:"sylvain-cibangu",fullName:"Sylvain Cibangu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Loughborough University",institutionURL:null,country:{name:"United Kingdom"}}},{id:"121172",title:"Prof.",name:"Jeffrey",surname:"Foss",slug:"jeffrey-foss",fullName:"Jeffrey Foss",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"147859",title:"Dr.",name:"Montserrat",surname:"Martínez García",slug:"montserrat-martinez-garcia",fullName:"Montserrat Martínez García",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"order-print-copies",title:"Order Print Copies",intro:'
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She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. 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