List of the surveys conducted in the Planpincieux and Grandes Jorasses glaciers since 2010.
\r\n\t
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It may occur in isolation, or in association with other congenital heart diseases. The BAV is seen in 1% to 2% of the population and may be complicated by aortic stenosis or aortic insufficiency and infective endocarditis. It may be associated with abnormalities of the aortic wall such as coarctation of the aorta, aortic dissection, and aortic aneurysm. Most patients with a BAV develop some complications during life [1,2].
Congenital coronary anomalies, coronary atherosclerosis, and calcification have been described in association with BAV[3].
BAV has been identified at a prevalence of 4.6 cas-es per 1000 live births. The prevalence of BAV according to sex has been found to be 7.1 cases per 1000 among male neonates, and 1.9 per 1000 among female neonates.
The congenitally BAV may function normally throughout life, may develop progressive calcification and stenosis or may develop regurgitation with or without infection. Aortic root dilatation is common in BAV, even when the valve is haemodynamically normal, and consequently aortic dissection usually occurs in previously asymptomatic patients [4,5].
Aortic stenosis and regurgitation, infective endocarditis and aortic dissection are the most common complications. Left coronary artery dominance is more common in patients with a BAV (29-56.8%) and in 90% of cases, the left main coronary artery is less than 5 mm in length [6-8]. The ignorance of these associations may cause an inadequate myocardial preservation and an increased risk of myocardial infarction[9,10].
Accordingly, associated congenital cardiovascular anomalies have been reported in as many as 25% of patients. Patent ductus arteriosus and ventricular septal defect are the most frequent heart defects associated with BAVdisease [11].
The definitive fetal cardiac structure is evident from the second week of gestation, whereas separation of the heart into four chambers is completed during the sixth and seventh weeks of gestation resulting in separated systemic and pulmonary circulation[12]. The process of aortic valve morphogenesis begins from the cardiac cushions located in the ventricular outflow tract of the primary heart tube. In the outflow tract, the truncal cushion swellings contribute to form three leaflet valves of the aorta and pulmonary artery.The initial endocardial cushions, which will contribute to all four cardiac valves, are formed by the thickening of the extracellular matrix in the region of the atrioventricular and outflow tract.This process is initiated by the secretion of extracellular matrix proteins such as fibronectin and transferrin across the cardiac jelly to the adjacent endocardium. The endocardium then secretes transforming growth factor beta family members, which act synergistically with bone morphogenetic protein-2 secreted by the myocardium, to increase mesenchyme formation and proliferation, which results in the growth of the endothelial cushions. The myocardial cells then invade the margins of the cellular endothelial cushions [13].
The semilunar valves form the division of the truncus arteriosus into two separate channels which form the aortic and pulmonary trunks..The channels are created by the fusion of two truncal ridges across the lumen. In each channel a third swelling occurs opposite the first two which will form the 3rd leaflet. In the normal aortic valve the left and right leaflets of the adult valve are formed from the respective swellings while the posterior leaflet is formed from a swelling in the aortic trunk.
The pathogenesis of BAV is not yet fully understood. There is certainly a genetic component, especially given the association of BAV with other congenital abnormalities. However, fusion of the right and left valve cushions at the beginning ofvalvulogenesis appears to be a key factor in BAV formation [14].
A previous study suggested that BAV is a consequence of the anomalous behavior of cells derived from the neural crest because BAV often is associated with congenital aortic arch malformations and other neural crest-derived systems [15]. Other studies suggest that extracellular matrix proteins may affect the initiation of cell differentiation during valvulogenesis, while a molecular abnormality in this process may lead to the formation of abnormal cusps [16,17]. Some researchers suggest that a molecular abnormality in the extracellular matrix may lead to abnormal valvulogenesis, becouse matrix proteins help direct cell differentiation and cusp formation during valvulogenesis [16-18]. This could also explain why BAVis often linked to other cardiovascular anomalies.
These abnormalities cause the fusion of two cusps and lead to one larger cusp; therefore, the BAV usually includes two unequally sized cusps, the presence of a central raphe, and smooth cusp margin. A previous studies showed that raphal position was between the right and left cusp in 86% of cases [19]. An anomalous origin of coronary arteries depends on the spatial orientation of the two cusps. When the orientation of the cusps is anteroposterior, the coronary arteries originate from the anterior sinus or if cusps laterlateral oriented the right coronary artery originate from the common trunk and right Valsava’s sinus [20].
A recent study has demonstrated that BAVs with fused right and noncoronary leaflets and those with fused right and left leaflets are different etiological entities. BAVs with fused right and noncoronary leaflets result from a morphogenetic defect that occurs before cardiac outflow tract septation on the basis of an exacerbated nitric oxide-dependent epithelialto-mesenchymal transformation. On the other hand, BAVs with fused right and left leaflets result from anomalous septation of the proximal portion of the cardiac outflow tract, caused by dysfunctional neural crest cells [21].
The pulmonary valve can also be bicuspid, although this is much rarer and is most commonly associated with congenital heart disease such as Tetralogy of Fallot. There have been less than 10 cases reported in the literature of an isolated bicuspid pulmonary valve [22].
Deficient fibrillin-1 content in the vasculature of BAV patients may trigger matrix metalloproteinase production, thereby leading to matrix disruption and dilation. It has been noted that the fibrillin-1 content was remarkably reduced in the aorta of BAV patients, compared with that of patients with a tricuspid aortic valve. Aortic elasticity measurements of BAV patients suggest that diminished aortic elasticity is at least part of its causation [23-25].
The bicuspid valve is composed of two leaflets, of which one is usually larger (due to fusion of two cusps leading to one larger cusp), and unequal cusp size the presence of a central raphe (usually in the center of the larger of the two cusps). The raphe or fibrous ridge is the site of congenital fusion of the two components of the conjoined cusps and does not contain valve tissue (Figure 1) Three morphologies are identified: type 1, fusion of right coronary cusp and left coronary cusp; type 2, fusion of right coronary cusp and noncoronary cusp; and type 3, fusion of left coronary cusp and noncoronary cusp. The most common is type 1 (70% to 85%), followed by type 2 (10% to 30%) and most rare type 3 (1% ) [13,19,26] (Figure 2).
Transesophageal short-axis view of a BAV. There is fusion of the right and left cusps. The arrow points to the raphe.
The classification and incidence of BAVs.
The site of cusp fusion can have effects on the prognosis of BAV [27], with the suggestion that type 1 BAVs are more likely to stenose as adults while type 2 valves will have complications at a younger age. The fused valve leaflet in BAV is actually smaller in area. Valvular incompetence is usually caused by the redundancy of one cusp, since the two cusps usually have different dimensions [28]
The coronary anatomy can be abnormal. Most patients with BAV disease have a left dominant coronary circulation [29]. This left coronary can arise from the pulmonary artery. The left main can also be up to 50% shorter than in normal in up to 90% of cases. This is an important consideration for any aortic valve surgery. The commonest abnormality associated with BAV is dilatation of the thoracic aorta, also known as aortopathy. This is thought not only to be due to the altered flow in the aorta, but also due to cellular structural abnormalities including decreased fibrillin, causing smooth muscle cell detachment, and cell death [30].
The other abnormality found in conjunction with BAV disease is coarctation of the aorta. [22,31]. The presence of coarctation and a poor result from repair can lead to more rapid failure of the valve or aortic dissection.
BAV is an inheritable disorder, with a family recurrence rate of approximately 35% [33]. Recent clinical studies have reported a 9% prevalence of BAV in first-degree relatives of patients with BAV which was the estimated population prevalance of 1-2% [33-35].
BAV is likely due to mutations in different genes with dissimilar patterns of inheritance [33].
The first genetic cause of BAV is Anderson syndrome, which is reported to be a result of mutations in the potassium channel gene KCNJ2 (chromosome 17q24.3)], whereas it clinically presents as ventricular arrhythmias, periodic paralysis, and scoliosis [36]. Another mutations in a gene called NOTCH1(gene map locus 9q34.3), a transmembrane receptor that has a role in determining cell outcome in organogenesis, were noted in two families with BAV [37]. Regions 18q, 5q, and 13q are reported to contain genes responsible for BAV and/or associated cardiovascular malformations [38,39]. The region 10q contains the ACTA2 gene, which encodes for smooth muscle alpha-actin (ACTA2), and mutation in this gene can result in thoracic aneurysm and, in some instances, BAV [40]. Also the ubiquitin fusion degradation 1–like gene UFD1L (chromosome 22q11.2) expressed in the outflow tract during embryogenesis is down-regulated in BAV tissue when compared with trileaflet valve tissue [41]. The UFD1L gene encodesa component of a multi-enzyme complex involved in the degradation of ubiquitin fusion proteins, and is highly expressed during embryogenesis in certain tissues. It seems to play a key role in the development of ectoderm-derived structures, including neural crest cells.Downregulation of the UFD1L gene, hypothetically resulting from an anomalous behavior of neural crest cells, may lead to reduced degradation activities, and may finally lead to fusion of valve cushions, a key factor in the development of congenital BAV[42]. Recent American College of Cardiology (ACC)/American Heart Association (AHA) adult congenital heart disease guidelines suggest echocardiographic screening for BAV and aortopathy in first-degree relatives of patients with BAV [43,44].
Although these valves are more common in males than females by a factor of 2:1 in the general population, the prevalance was equal in males and females in families having more than one affected individual [45,46].
Clinical findings are usually limited to auscultation with most patients having an ejection systolic murmur heard loudest at the apex [47]. The S1 usually is normal but sometimes may be associated with ejection click. The S2 is soft, and when aortic stenosis is present, S2 occurs simultaneously with P2. In aortic stenosis, an ejection systolic murmur is heard in the left second intercostal space but may also be transmitted to the carotid arteries. If aortic incompetence is present, a diastolic murmur of aortic regurgitation may be heard.
The electrocardiogram is usually normal; and ECG changes are not specific in patients with BAV: left ventricular hypertrophy, atrial enlargement, and arrhythmias may be present.
The mainstay of diagnosis is echocardiography (transthoracic or transoesophageal) which can provide a definitive diagnosis in the majority of patients [ 92% sensitivity and 96% specificity) [48,49]. Transesophageal echocardiography (TEE) is also very important for evaluating the aortic valve and thoracic aorta, whereas the sensitivity and specifity of multiplane technique for assessing aortic valve morphology is high [13].
The parasternal short axis view allows for direct visualization of the valve cusps. In this view the normal triangular opening shape is lost, becoming more “fish mouth-”like in appearance, more similar to the mitral valve. This is especially pronounced in systole, as in diastole the raphe can appear similar to a commissure of the third cusp. Differentiating severe bicuspid aortic stenosis from severe other aortic stenosis can also be difficult. In order to establish the diagnosis, the valve must be visualized in systole in the short-axis view. In the long-axis view, the valve often has an eccentric closure line and there is doming of the leaflets. If there is uncertainty in diagnosis, a TEE can improve visualization of the leaflets [50].
For BAV associated with stenosis, mean gradient and maximal flow velocity should be measured, but when regurgitation is present, the effective regurgitant area and Doppler jet size should be evaluated. For asymptomatic patients with aortic stenosis, echocardiography is recommended for evaluating disease progression. In asymptomatic patients, TTE recommended: every year for severe aortic stenosis, ever 1-2 years for moderate aortic stenosis and every 3-5 years for mild aortic stenosis [51].
In patients with poor acustic window, cardiac magnetic resonance (MRI) and multidetector computed tomography are useful for measuring the aortic valve area and is an alternative method to echocardiography in selected cases. MRI especially will enable views of the valve to be obtained without interference from calcification. It also allows for excellent assessment of the aorta. A recent study of 123 patients with confirmed BAV found that 10% of the patients were misidentified as having a tricuspid valve using transthoracic echo and 28% had a nondiagnostic study, in comparison to 4% being misidentified as having a tricuspid valve by MRI and 2% having a non-diagnostic study [52].
The current guidelines suggest that cardiac magnetic resonance imaging or cardiac computed tomography is reasonable in patients with BAVs when aortic root dilatation is detected by echocardiography to further quantify severity of dilatation and involvement of theascending aorta (Clas IIa; Level of Evidence: B)[53].
The clinical presentation of patients with BAV can vary from severe valve disease in infancy to asymptomatic valve disease in old age. It may be associated with abnormalities of the aortic wall such as coarctation of the aorta, aortic dissection, and aortic aneurysm. Most patients with a BAV develop some complications during life [1,2].
Congenital coronary anomalies, coronary atherosclerosis, and calcification have been described in association with BAV[3].
The congenitally BAV may function normally throughout life, may develop progressive calcification and stenosis or may develop regurgitation with or without infection. Aortic root dilatation is common in BAV, even when the valve is haemodynamically normal, and consequently aortic dissection usually occurs in previously asymptomatic patients [4,5].
Sudden death may occur as a result of obstruction of the left ventricular outflow tract by a congenital BAV [54]. BAV are in most cases remain undetected until infection or calcification supervenes [55].
Aortic stenosis and regurgitation, infective endocarditis and aortic dissection are the most common complications. Left coronary artery dominance is more common in patients with a BAV (29-56.8%) and in 90% of cases, the left main coronary artery is less than 5 mm in length [7,8]. The ignorance of these associations may cause an inadequate myocardial preservation and an increased risk of myocardial infarction[9,10].
Symptoms associated with aortic stenosis are angina pectoris, syncope, and congestive heart failure. The most common complication of aortic stenosis is congestive heart failure symptomatically presented with dyspnea, which is a result of combined diastolic and systolic dysfunction [56]. Angina pectoris occurs in patients with severe aortic stenosis and in those who do not have coronary artery disease; it may be a result of ventricular hypertrophy.
Syncope is another common symptom in patients with BAV. Syncope reflects the cerebral hypoperfusion caused by the inability to increase stroke volume during physical activity.
The clinical presentation in patients with BAV and presence of other cardiac congenital defects depends from structural complexity of the heart. In patients with interventricular septal defects, the clinical presentation depends on the size of the defect area and the grade of aortic stenosis. If the interventricular defect is small, the patient may be asymptomatic, but when the interventricular defect is large, cardiac output will decrease and Eisenmenger syndrome will develop.
Two large recent series reported that clinical course of unoperated patients with BAV depends on age, stenosis, and aortic incompetence. The severe aortic stenosis, and severe aortic incompetence in older patients increases the risk of primary cardiac events including cardiac death. Both these studies suggest that intervention on the basis of early symptoms or incipient cardiac dysfunction may decreases the mortality of patients with BAV [57,58].
The natural history of BAV has been evaluated several cohort studies. It is known to be variable and of course somewhat dependent on associated abnormalities. It can range from severe aortic stenosis in childhood to asymptomatic disease until old age. There have indeed been incidental findings of a minimally calcified BAV in patients in their 70s.More commonly however [in around 75% of patients] there is progressive fibrocalcific stenosis of the valve eventually requiring surgery. This usually leads to presentation in middle age only around 2% of children have clinically significant BAV disease [59].
The prevalence of fibrosis, cystic medial necrosis, elastic fragmentation, and inflammation has been shown to be significantly higher in patients with fusion of the left coronary and right coronary cusps. fusion of the left coronary and right coronary cusps was associated with a larger aortic root diameter and a smaller aortic arch,than was fusion of the right coronary and non-coronary cusps. Another study demonstraed that fusion of the right coronary and non-coronary cusps correlated with the more rapid growth of ascending aortic diameter in the pediatric population [60-63].
There have been a couple of studies looking at long-term followup of patients with unoperated BAV. A cohort of 212 asymptomatic patients with BAV were found to have the same 20-year survival rate as the normal population but an increased frequency of cardiac events including aortic valve surgery, ascending aorta surgery and any other cardiovascular surgery. Predictive factors for cardiovascular events were found to be age ≥50 years and valve degeneration at diagnosis while baseline ascending aorta ≥40 mm independently predicted surgery for aorta dilatation. Another study [64] 642 patients were followed up for a mean of 9 years, again with a 10-year survival rate similar to the normal population [96%]. One or more primary cardiac events occurred in 25% including cardiac death in 3, intervention on aortic valve or ascending aorta in 22%, aortic dissection or aneurysm in 2%, and congestive heart failure requiring hospital admission in 2%. Independent predictors of primary cardiac events were age older than 30 years, moderate or severe aortic stenosis, and moderate or severe aortic regurgitation [50].
In the another study [61].the incidence of aortic dissection was found to be 1.5% in all patients regardless of the progression of BAV; however this increased markedly in patients aged 50 or older at baseline to 17.4% and even more in those found to have aneurysm formation at baseline to [44.9%]. 25-year rate for aortic surgery was 25% and there was a significant burden of progression of disease to cause aortic dissection with 49 of the 384 patients without baseline aneurysms developing them during followup [22].
Although the clinical presentation of patients with BAV can vary from severe valve disease in infancy to asymptomatic valve or thoracic aortic disease in old age, symptomstypically develop in adulthood. The clinical manifestations relate to the function of the aortic valve,the aortopathy/dissection, and acquired complications such as endocarditis. However in childhood, BAV disease is commonly asymptomatic [61]
Estimates of late cardiac events were approximately 25% at a mean age of 44 years in the study from Toronto and 40% at a mean age of 52 years in the Olmsted County study [62,63]. In the Olmsted County series, 27% of adults with BAV and no significant valve disease at baseline required cardiovascular surgery within 20 years of follow-up. Twenty-two percent of the patients in the Toronto cohort required intervention within 9 years of follow-up. In both studies, age was an important determinant of outcomes supporting the notion held by many that eventually most patients with BAV would require some form of intervention.
A common complication of BAV disease is aortic stenosis. BAV is recognized as a frequent cause of aortic stenosis in adults. Aortic stenosis has been found in 72% of adults with BAV. In 388 patients with severe aortic valve disease alone, BAVs were found in 45% of the patients with aortic stenosis and 24% of the patients with aortic regurgitation. In 110 patients with severe combined aortic and mitral valve disease, BAVs were found in only 12% [64].
Among the 600 patients analyzed, 213 (36%) had pure aortic stenosis, 265 (44%) had pure aortic regurgitation and 122 (20%) had combined stenosis and regurgitation. BAVs represented 18%, as the third most important cause of aortic disorder following degenerative and rheumatic changes, followed by infective endocarditis (5%) [65].
The main symptoms are exertional dyspnea, syncope, and chest pain. These patients should be evaluated and managed similarly to patients with tricuspid aortic valve stenosis.
In the Joint Study of the Natural History of Congenital Heart Defects, one-third of the children in the cohort had increases in catheterization gradients during the 4- to 8-year follow-up period. In the follow-up study, children with baseline peak left ventricular to aortic gradients >50 mm Hg were at risk for serious cardiac events at a rate of 1.2% per year. In theUnited Kingdom cohort.20% of children with mild aortic stenosis at baselinehad mild disease after 30 years of follow-up. Age was the primary determinant of valvular disease progression [50,66].
In adults, with BAV, stenosis occurs by similar methods to the process in patients with tricuspid aortic valves. It is felt to be due to calcification, endothelial dysfunction, inflammation, lipoprotein deposition, and ossification of the aortic side of the valve leaflets. There has been a suggestion that leaflet orientation may be a predictive factor in the rate of valve stenosis. The folding and creasing of the valves and the turbulent flow are felt to contribute to development of fibrosis and calcification [59].more rapid progression in aortic valve gradients occurred in patients with anteroposteriorly located cusps[60]. However, not all studies have found this association, and the 2 large studies in adults have not identified leaflet orientation as a risk factor for late adverse events. Olmsted County study identified a composite index of valve degeneration, which incorporated valve thickening, calcification, and mobility, that was an independent predictor of long-term cardiac events in a population of adults with no baseline valve dysfunction. The predictive role of both morphology and function in adults with BAV parallels that observed in series examining older adults with aortic stenosis mostly of acquired basis [50,62,63].
Primary aortic regurgitation without infective endocarditis was uncommon, and 32% had an apparently normally functioning aortic valve [67].
One cohort of 118 BAV patients found that of 70 patients without aortic stenosis, 28 (40% had moderate to severe aortic regurgitation. The mechanisms of aortic incompetence in children are usually due to prolapsing cusps, myxoid degeneration, postvalve surgery and after balloon valvuloplasty or endocarditis, while as the patients age dilatation of the ascending aorta can lead to a functionally regurgitant valve[68,69]. With age, aortic incompetence may also develop secondary to dilation of the ascending aorta. In the Olmstead study of asymptomatic adults, 47% had some degree of aortic incompetence at baseline; however, interventions for severe aortic incompetence were relatively uncommon, occurring in only 3% of the cohort during follow-up. In the Toronto study 21% of the population had moderate or severe aortic incompetence at baseline; however, only 6% had an intervention for symptomatic aortic incompetence or progressive left ventricular dysfunction [62,63].
BAV patients tend to develop vascular abnormalities of the aorta, such as dilation, coarctation and dissection. Aortic dilation in BAV patients is thought to be caused by intrinsic aortic disease that is characterized by cystic medial necrosis and disruption of the extracellular matrix due to fibrillin deficiency. BAV is often associated with dilatation of the aortic root and the ascending aorta. This is otherwise known as aortopathy. This can lead to aneurysm and dissection. The dilatation has been reported during childhood, and it has also been suggested that increased aortic size at baseline is predictive for earlier dilatation and worse outcomes. Aortic size is larger generally in patients with BAV compared to those with normal valves. The most likely risk factor for progression is felt to be age. Aortic root size itself is related to valve morphology and the presence of significant disease [22,6]; however, a recent study did suggest that while most patients with BAV and ascending aortic aneurysm had severe valve dysfunction, there was a small proportion of patients (5%) who did have aneurysm formation without any aortic valve dysfunction [50].
In the ascending aorta as well as the pulmonary trunk, the severity of cystic medial necrosis, elastic fragmentation and changes in the smooth muscle cell orientation have been found to be significantly more severe in patients with bicuspid valves than in those with tricuspid valves.
Factors leading to aortic dissection four years after the Bentall operation have been considered to be an impact of congenital BAV or proximal anastomosis of venous grafts, or both [70].
Studies have suggested that patients with BAV have an intrinsic defect in the aortic wall that results in aortic disease, regardless of aortic valve function. BAV was associated with significantly less intimal change, and less fragmentation and loss of elastic tissue, compared with patients with a tricuspid aortic valve. Type I and III collagens were significantly decreased in dilated aortas of BAV patients, compared with controls, particularly at the convexity. Expression of messenger RNA [ribonucleic acid] for collagens was lower than normal only in the regurgitant subgroup. Fewer smooth muscle cells and greater severity of elastic fiber fragmentation were observed at the convexity than at the concavity [71-73].
Among 119 cases of fatal dissecting aneurysm of the aorta, 11 cases of congenital BAV (9%) were observed. Among the latter, three had coarctation of the aorta and one had Turner’s syndrome without coarctation. In each case, cystic medial necrosis of the aorta was present. Hypertension was either established or inferred from cardiac weight in 73% of the cases. The high incidence among subjects with dissecting aneurysm suggested a causative relationship between BAV and aortic dissecting aneurysm [74].
Many theories have been postulated for the mechanism of BAV aortopathy. For a long time there has been felt to be a genetic component; however there is increasing evidence for a haemodynamic mechanism. It is felt that it is due to defects in the aortic media, such as elastin fragmentation, loss of smooth muscle cells, and an increase in collagen [6,22]. Systemic features have also been noted in BAV patients which may predispose to aneurysm formation including systemic endothelial dysfunction and higher plasma levels of matrix metalloproteinases [75].
Pathological examination of surgical specimens from the aortic wall of patients with aortic dissection associated with BAV showed cystic medial necrosis or mucoid degeneration [76].
Matrix metalloproteinases (endogenous enzymes that degrade matrix components) have been implicated in atherosclerotic aortic aneurysm formation and appear to be elevated in the aorta of patients with BAVs [77].
The histological findings of BAV are nonspecific, and had been described by several authors in patients with Marfan syndrome [78-80]. The histopathological appearance of thoracic aortic aneurysm in Marfan and BAV is similar, and includes evidence of vascular smooth muscle cell (VSMC) apoptosis and extracellular matrix degeneration in the absence of a significant inflammatory response [81].
Abnormalities in the ascending aorta of the patients with BAV, specifically premature medial layer VSMC apoptosis, have been described, explaining the higherthan-expected prevalance of aortic dissection in these patients [82].
Also recently studies show less elastic tissue in the aortas of BAV patients [83,84].
In patient with BAV there are fibrillin, fibronectin, and tenascin abnormality. Additionally Bonderman et al suggested that a primary role for VMSC apoptosis in the development of aneurysm these patients [85].
The FBN1 gene encodes fibrillin-1, a large glycoprotein that is secreted from cells and deposited in the extracellular matrix in structures called microfibrils. Microfibrils are found at the periphery of elastic fibers, including the elastic fibers in the medial layer of the ascending aorta, and in tissues not associated with elastic fibers.
The histopathological appearance of thoracic aortic aneurysm in Marfan and BAV is similar, and includes evidence of VSMC apoptosis and extracellular matrix degeneration in the absence of a significant inflammatory response. Abnormalities in the ascending aorta of the patients with BAV, specifically premature medial layer smooth muscle cell apoptosis, have been described, explaining the higherthan-expected prevalance of aortic dissection in these patients [82,83].
Aortic root dilation has been documented in childhood, suggesting that this process begins early in life. Furthermore, children with BAV have greater increases in aortic dimensions than do children with trileaflet valves. In both children and adults, progressive dilation of the aorta is more common in patients with larger aortas at baseline. In BAV disease, the aortic annulus, sinus, and proximal ascending aorta are larger than those found in adults with trileaflet valves [50].
In the Olmsted County study, the prevalence of ascending aorta dilation (>40 mm) was 15% and in the subset of patients with repeat measurements, the prevalence increased to 39% at study completion. Dilation of the ascending aorta was an independent risk factor for ascending aorta surgery. Although there are a number of risk factors associated with dilation of the ascending aorta including increased systolic blood pressure, male sex, and significant valve disease, the most important variable is likely age [50,63,64]. Aortic root size is shown to be related to valve morphology and the presence of significant valve disease. In the Toronto series, the prevalence of dissection was 0.1% per patient-year of follow-up, and in the Olmsted County study, there were no cases of dissection. Despite the low rates of dissection, the increasedprevalence of BAV disease relative to Marfan syndrome make dissections due to BAV equal to or more common than dissections due to Marfan syndrome [86]. Dissection in BAV, when it occurs, typically involves the ascending aorta, but involvement of the descending aorta has been reported in older patients. Although dissection is more common in patients with dilated aortas, there are reports of dissection in normal-sized aortic roots and after valve replacement. Risk factors for dissection have included aortic size, aortic stiffness, male sex, family history, and the presence of other lesions such as coarctation of the aorta or Turner syndrome [50].
Endocarditis is more common in BAV. The estimated incidence is 0.16% per year in unoperated children and adolescents [87]. In adults the case series by Michelena give an incidence of 2% per year [56].
Outcomes in BAV patients with infective endocarditis tend to be worse than in those with normal valves. A recent study of 310 patients with infective endocarditis found that the 50 patients with BAV were younger at presentation and had a higher incidence of aortic perivalvular abscess. In-hospital mortality and 5-year survival were also comparable to patients with normal valves [22].
Most patients are unaware of their condition until the onset of infective endocarditis
Patients with BAV endocarditis are young, and there is strong male predominance. Staphylococci and viridans streptococci account for nearly three-quarters of the cases affecting BAVs. Endocarditis can lead to severe acute aortic incompetence, heart failure and it is poorly tolerated [88].
Endocarditis risk was estimated to range between 2% or 0.3%/year. Because the risk of endocarditis is felt to be low, the ACC/AHA practice guidelines no longer suggest bacterial endocarditis prophylaxis in patients with straightforward BAV disease, except in patients with a prior history ofendocarditis [50,89].
Some reports have also suggested that the involvement of coronary arteries, including congenital coronary artery anomalies, coronary artery fistulas, spontaneous coronary artery dissection, immediate bifurcation and a shorter length of the left main coronary artery [6,13]. The incidence of left dominance in BAVs has been found to be unusually high (24.4-56.8%), compared with the incidence in tricuspid valves [9.5%]. Patients with BAVs have higher incidence of immediate bifurcation of the left main coronary artery, and higher incidence of left main coronary length less than 10 mm. The mean length of the left main coronary artery is significantly shorter in BAV patients [90].
Anomalous origins of the right 20,21 and left 22 coronary arteries, association with annuloaortic ectasia, and anomalous origins of the left circumflex coronary artery 23 and single left coronary artery,24 have been noted in patients with BAVs. Spontaneous coronary artery dissection may occur in BAV patients [91]
There have also been some case reports describing patients with BAVdisease associated with coronary heart disease [92] and even with acute myocardial infarction[10].
Also Recently studies[93]Yuan et al. suggested that the prevalence rate of angiographic coronary heart disease was higher among the patients with BAVdisease.
Patent ductus arteriosus and ventricular septal defect are the most frequent congenital heart defects associated with BAV. Patent ductus arteriosus is usually present in pediatric patients with BAV and may be associated with hand anomalies. BAV is reported to be present in up to 30 % of adult patients with small ventricular septal defects. However, BAV may also be associated with large ventricular septal defects and poor clinical outcome. There is significantly higher incidence of aortic arch obstruction (51.1%). The frequency of BAV in specimens with complete transposition of great arteries has been found to be 1% [13,50].
Hypoplastic left heart syndrome, complete atrioventricular canal defect, Ebstein’s anomaly, partial or total anomalous pulmonary venous return, tetralogy of Fallot, double-outlet right ventricle, septal left ventricular diverticulum,Williams syndrome,Down syndrome and annuloaortic ectasia are occasionally associated with BAV. Shone’s complex, which is defined by four cardiovascular defects including supravalvular mitral membrane, valvular mitral stenosis with a parachute mitral valve, subaortic stenosis and aortic coarctation, is a rare entity and forms another association in BAV cases [94].
It has been reported that BAV is presented in > 50 % of patients with coarctation of the aorta [COA]. Patients with COA and BAV are reported to have more severe disease associated with aortic stenosis, aortic regurgitation, and aortic aneurysm. The risk of dissection of the aorta and death is greater when COA and BAV are comorbid.
Turner syndrome characterized by a defect in or the absence of one X chromosome. Except for gonadal dysgenesis, cardiovascular defects are commonly present in this group of patients. Clinical research on patients with Turner Syndrome reports that BAV is present in 30% of cases, that over 95% of BAV s result from fusion of the right and left coronary leaflets, and that aortic ascending diameters are significantly greater in this group of patients [13].
Thrombus formation in a native BAV is a rare complicaton. Pathological studies have indicated that post-inflammatory changes ocur in the resected BAV, which is prone to develop thrombosis on the valve surface or in the calcification area [95].
Microthrombus formation and valve thickening with incompetence could result in embolization, and subsequent cerebrovascular events [96].
Embolization from calcific BAVs may lead to stroke and myocardial infarction. Conservative management with anticoagulation, to treat associated post-stagnation thrombosis, or aortic valve replacement as the treatment, is debatable [97].
Medical therapies are to try and alleviate symptoms and slow progression. It is generally felt that blood pressure should be aggressively controlled to try and slow the progression of aortopathy [51].
High blood pressure should be aggressively treated in patients with BAV disease. In Marfan-associated aortopathy, treatment with beta-blockers to slow the rate of progression is the standard of care at many centers, although debate exists about their effectiveness [50,101]. The ACC/AHA guidelines for the management of adult congenital heart disease and guidelines for the management of patients with valvular heart disease suggest that it is reasonable to use beta-blockers in this population [Class IIa recommendation] [53]. There are emerging data in animal models and in 1 small study in humans supporting the use of angiotensin II receptor blockers to decreased aortic root dilation in Marfan syndrome [50]. Whether these agents will have a role in BAV aortopathy has not yet been demonstrated. Also long-term vasodilator therapy in BAV disease with aortic regurgitation is only recommended if there is concomitant systemic hypertension [47]. The relationship between risk factors for atherosclerosis and the development and progression of degenerative aortic valve disease has been well studied [99]. However, the role of treatment with cholesterol-lowering agents is unresolved. The use of lipid lowering agents specifically in young patients with BAV has not been studied, and the current ACC/AHA guidelines for the management of patients with valvular heart disease do not endorse the use of statins to slow the degenerative process in this population [51]. Concomitant conditions and risk factors should be treated as in the normal population.
Indications for valve surgery in patients with BAV are similar to those with tricuspid aortic valve disease or degenerative aortic valve disease [100].
The 2006 AHA/ACC guidelines also suggest concomitant replacement of the ascending aorta if it is greater than 45 mm in diameter [51]. Estimated 15-year freedom from complications was 86% in patients with an aortic diameter less than 40 mm, dropping down to 81% in those with diameter 40–44 and 43% in patients with a diameter 45 mm or greater.
When rheumatic disease is excluded, a significant portion of adults undergoing surgery for aortic valve disease will have a congenitally malformed valve. During childhood, insertion of a prosthetic valve is suboptimal because of the continuing growth of the child. Fortunately, at this stage, the aortic valve is usually not calcified and valvuloplasty can successfully disrupt the commissural fusion and relieve obstruction. Valvuloplasty is the interventional strategy of choice in children and in some young adults with BAV and aortic stenosis. Symptomatic aortic stenosis is an indication for intervention, similar to standard indications for trileaflet valve disease. However, in the pediatric setting, indications include children with peak-topeak gradients >50 mm Hg who develop symptom at rest or with exercise. An additional indication includes asymptomatic children with peak-to-peak gradients >60 mm Hg. In adulthood, aortic valve replacement is the most common intervention for either aortic valve stenosis or incompetence, and valvuloplasty is rarely performed [50,51,62].
BAV disease involves younger patients and involves both the valves and the ascendan aorta; therefore, surgical decision making is more complicated. Approximately 30% of adults undergoing aortic valve replacement will also need aortic root surgery[63]. The guideline suggest that a cutoff of 5.0 cm be used for intervention or 4.5 cm if the surgery is otherwise being performed for valve indications. In addition, suggest that changes in root size more than 0.5 cm/year are an indication for root replacement [53].
Recently published Guidelines [53] for the diagnosis and management of patients with thoracic aortic disease recommendations for BAV are summarized below:
CLASS I
First-degree relatives of patients with a BAV, premature onset of thoracic aortic disease with minimal risk factors, and/or a familial form of thoracic aortic aneurysm and dissection should be evaluated for the presence of a BAV and asymptomatic thoracic aortic disease. (Level of Evidence: C)
All patients with a BAV should have both the aortic root and ascending thoracic aorta evaluated for evidence of aortic dilatation (Level of Evidence: B)
Should undergo elective operation at smaller diameters (4.0 to 5.0 cm)to avoid acute dissection or rupture. ()Level of Evidence: C)
Patients with a growth rate of more than 0.5 cm/year in an aorta that is less than 5.5 cm in diameter should be considered for operation. (Level of Evidence: C)
Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta. (Level of Evidence: C)
Elective aortic replacement is reasonable for patients with BAV when the ratio of maximal ascending or aortic root area (πr2) in cm2 divided by the patient’s height in meters exceeds 10 (CLASS IIa, Level of Evidence: C).
In regard to valve surgery, there is controversy regarding the use of the Ross procedure and the use of valve repairs in this population. Abnormalities of the media are seen in both the aorta and the pulmonary artery in BAV disease. Intrinsic abnormalities in the wall of the pulmonary artery [neoaorta] may contribute to progressive neoaortic root dilation and/or aortic regurgitation when the pulmonary root is placed in the systemic position [101].
When to surgically treat asymptomatic patients with BAV remains controversial. The risk of sudden death in asymptomatic adult patients with severe aortic stenosis is reported to be less than 1% per year, however, current practice guidelines recommended aortic valve replacement in patients with reduced left ventricular systolic function (EF< 50%) without other explanation even when they are asymptomatic [51].
For high-risk patients to undergo conventional novel methods including aortic balloon valvulotomy or transfemoral valve implantation may be helpful. A patient considered inoperable should be treated orally with angiotensin converting enzyme (ACE) inhibitors, diuretics, and digitalis. In patients with depressed LV associated with pulmonary congestion and atrial fibrillation, diuretics and digitalis may be used with the understanding that in some cases intensive hemodynamic monitoring is needed. Patients with aortic root dilatation > 4.0cm who are not candidate for surgical treatment should be given β-adrenergic blocking agents [51].
During pregnancy there are changes in hemodynamics as well as changes in the aortic media, and therefore, women with BAV and significant aortic stenosis and/or dilated aortic roots are at risk for complications during pregnancy.
In rare instances, women will develop progressive symptoms during pregnancy and require either valvuloplasty or valve surgery. Both interventions can be performed during pregnancy, but are associated with both maternal and fetal risks and should be performed only when necessary.
Although pregnancy can be successfully completed in most instances, aortic surgery may be required early after pregnancy in some women with severe aortic stenosis. Pregnancy itself seems to accelerate the need for surgery postpartum in women with moderate or severe aortic stenosis, perhaps by affecting the ability of the left ventricle to adapt to the fixed outflow obstruction. It is therefore important that women be counseled about both the risk of pregnancy and the potential for late complications [102,103].
Additionally, guidelines suggest that women with BAV and significant aortopathy (ascending aorta diameter >4.5 cm)“should be counseled against the high risk of pregnancy” [43].
There are little data available to support recommendations regarding exercise in subjects with BAV. In children with congenital severe aortic stenosis, for instance, sudden death can occur during exercise [121]. The Task Force on Exercise in Patients with Heart Disease recommends that athletes with severe aortic stenosis or severe aortic incompetence with left ventricular dilation [left ventricular dimensions >65 mm] should not participate in competitive athletics. Athletes with or without aortic valve disease who have dilated aortic roots (>45 mm) are advised to only participate in low-intensity competitive sports. No restrictions exist for those with BAV with no significant valve dysfunction or aortic root/ascending aorta dilation(>40 mm) [50,104,105].
Consequently aortic stenosis and regurgitation, infective endocarditis and aortic dissection are the most common complications of BAV additionaly this process continues after valve replacement. The person with BAV requires continuous surveillance to treat associated lesions and prevent complications. Arterial hypertension should be meticulously controlled. Smoking should be discouraged and control of hypercholesterolaemia considered, in view of the impact of these factors on the development of aortic stenosis. Aortic root dilatation is common in BAV, even when the valve is haemodynamically normal, and consequently aortic dissection usually occurs in previously asymptomatic patients. Beta-blockers and statins are the possibilities for medical treatment, and aortic valve repair/replacement and ascending aorta replacement are indicated for patients with a severely diseased aortic valve and aorta. All patients should therefore be regularly reviewed to identify progressive root dilatation [6,94].
Mountain glaciers represent the main source of fresh water for human activities of the surrounding regions [1, 2]. Furthermore, glaciological processes (e.g. ice break-offs, glacier outbursts, snow/ice avalanches) can threaten population, urban areas and infrastructures [3]. In densely populated areas, such as the European Alps, the interaction between glaciers and anthropic activities is very frequent and it is of crucial importance to study the glaciers to understand their evolution and response to climate change, which is expected to reduce their area coverage and increase their instability [4].
Long-term monitoring of glaciological processes is often complicated and expensive, especially in remote areas and inaccessible terrains, which are common in mountain environment [5]. A practical approach is the adoption of remote sensing apparatuses that allow observing glacial processes with minimal risk for scientists and technicians. In recent years, the free availability of data acquired from satellite platforms has largely improved the possibility to observe wide areas from remote with relatively high spatiotemporal resolution. Nevertheless, satellite surveys suffer complex geometries and the revisit time might be not adequate to measure fast processes. Therefore, the use of close-range remote sensing systems is often the most effective solution for glacier monitoring [6].
Section 2 presents a substantial list of close-range remote sensing techniques that can be adopted to measure glacier surface deformations. Section 3 is devoted to the Planpincieux and Grandes Jorasses glaciers (Mont Blanc massif) case study (Figure 1). In recent years, such a glacial complex has become an open-air laboratory where innovative and experimental monitoring systems have been developed [6, 7, 8, 9, 10, 11, 12]. Several practical examples of close-range remote sensing surveys will be described therein.
Overview of the Planpincieux and Grandes Jorasses glaciers (upper tile) and area of study (lower tile). Yellow and orange rectangles indicate respectively the Montitaz Lobe and the Whymper Serac framed by the time-lapse cameras (
The study of the Planpincieux and Grandes Jorasses glacier surface deformations has been conducted following different approaches: (i) volumetric changes have been evaluated with point clouds and digital elevation models (DEMs). Such measurements have been obtained with laser scanners or structure from motion (SFM) processing. (ii) Surface kinematics maps of specific displacement components, which have been provided by monoscopic time-lapse camera and terrestrial interferometric radars. (iii) 3D displacements measured in specific points with a robotised total station (RTS). Furthermore, helicopter-borne ground-penetrating radar (GPR) campaigns have been conducted to investigate the glacier internal structure and thickness (Table 1).
Glacier | Survey | Dates | References |
---|---|---|---|
Planpincieux | GPR | 2/4/2013, | |
2019 | |||
DIC | August 2013-in | [8] | |
course | |||
TRI | 9/8/2013- | [9, 42] | |
10/8/2013 | |||
7/8/2014- | |||
8/8/2014 | |||
1/9/2015- | |||
14/10/2015 | |||
13/6/2016- | |||
19/6/2019 | |||
26/9/2019-in | |||
course | |||
LiDAR | 9/6/2014 | ||
TLS | 2/10/2015 | ||
Helicopter- | 2017 | ||
borne SFM | 28/10/2018 | ||
20/9/2019 | |||
1/10/2019 | |||
5/11/2019 | |||
Drone SFM | 24/7/2019 | ||
Grandes | RTS | 2010-in course | [11, 12] |
Jorasses | |||
DIC | 2016-in course | ||
GPR | 4/6/2010 | ||
2/4/2013 | |||
Helicopter- | July 2010 | ||
borne SFM | |||
Drone SFM | July 2019 |
List of the surveys conducted in the Planpincieux and Grandes Jorasses glaciers since 2010.
Three-dimensional point clouds are crucial tools in glacier monitoring; the main survey techniques to obtain them are LiDAR [13], terrestrial laser scanner (TLS) [14] and aerial and terrestrial photogrammetry, particularly structure from motion (SfM) approach [15]. LiDAR and TLS are based on a sensor, terrestrial or airborne, capable of emitting laser pulses at high frequency and measure their ‘time of flight’ in order to compute the position of each echo. The absolute position of each point is calculated from the emitter centre, geocoded by a GNSS coupled with an inertial measurement unit [16]. Besides its coordinates, each point can be characterised by the intensity of the echo in order to detect the nature of the target [17]. By the exploitation of laser beam divergence, it is also possible to discriminate and analyse multiple echoes or even the full waveform, thus obtaining multiple measurements of different object hit by the same pulse [18].
Concerning SfM, it is a technique originating from computer vision, which, by processing multiple images from different points of view of the same target object, generates a three-dimensional point cloud. The algorithm matches common features in the images and reconstructs the three-dimensional coordinates of the matching points and of the cameras. Resulting points are then collected in the cloud [19]. Images can be captured by various kinds of sensors including cameras, smartphones and drones [20].
Robotised total station (RTS) is a topographic apparatus that measures the sensor-to-target range and the azimuth and zenith angles, which allow determining the target position in a 3D coordinate system whose centre corresponds to the RTS itself. Typical measurement sensibility of best-quality RTS is of 1.5 mm and 0.5 arcsec, depending on the distance. The RTS is composed of a laser rangefinder and an electronic theodolite that measures respectively distance and angles. The RTS targets retroreflector prisms installed both in and outside the moving area. The latter ones serve as control points for measurement calibration and data corrections.
Since it is required to install prisms within the investigated area, the RTS cannot be considered a remote sensing device in a strict sense. Nevertheless, such installation is needed just once; thereafter, the RTS provides measurements from remote, strongly reducing human and financial costs for accessing the surveyed area. This holds especially when the RTS works in automatic target recognition (ATR) mode, with which it carries out autonomously the measurements. In geosciences, the RTS is widely used for gravitational slope phenomena, such as landslides [21, 22], volcanos [23] and glaciers [11, 12, 24].
Spatially distributed data are a relevant tool in glaciological studies because they allow to analyse the surface kinematic patterns and to identify possible different kinematic sectors. In the Planpincieux-Grandes Jorasses glacial complex, two main remote sensing systems have been applied to measure surface kinematics maps: digital image correlation (DIC) and terrestrial radar interferometry (TRI).
With the advent of digital cameras, time-lapse imagery has become popular since the beginning of the 2000s in glaciology, where it has been applied to survey polar ice flow [25, 26, 27, 28] and mountain glaciers [6, 8, 29, 30, 31, 32, 33].
DIC is an image analysis technique that is applied to a pair of images to obtain spatially distributed maps of the two displacement components orthogonal to the line-of-sight (LOS). In classical DIC processing, a reference template out of the master image is searched for in an investigated larger area of the slave image. The cross-correlation (CC) is calculated for every possible template of the investigated area and the position of the maximum correlation coefficient corresponds to the displacement of the master template. Alternatively, the CC can be calculated in the Fourier domain according to the convolution theorem. Fourier CC is computationally efficient but it is more prone to outliers.
The main DIC advantages concern the low-cost hardware and its high portability even in harsh environments. Nevertheless, it suffers adverse meteorology and it strongly depends on the visibility conditions.
In the last two decades, TRI revealed to be a valuable tool to monitor glaciers [9, 34, 35, 36, 37, 38, 39, 40, 41, 42]. TRI concerns the analysis of the phase difference between two radar acquisitions, which is directly related to the target displacement component parallel to the LOS. Typical radar apparatuses can provide spatially distributed displacement data in an area of several square kilometres with an operative range of a few kilometres. Radars are active sensors, as such, TRI can be applied during the night and severe meteorological conditions. Moreover, TRI measurements have sub-millimetre sensibility in an optimal context. However, the processing is not trivial and it requires high computational costs. Particularly complicated is the phase wrapping solution, which depends on the phase 2 periodicity and which is related to the sensor-to-target range. Moreover, TRI is quite sensitive to possible morphological change of the scattering surface and that causes signal decorrelation and extreme atmospheric conditions can heavily affect the measurements [43, 44]. In glaciological contexts, long distances, morphological surface changes and severe meteorology are common and TRI processing must be handled carefully.
GPR has been widely used as a geophysical method for the study of internal glacier properties. A variation in electrical permittivity creates dielectric interfaces and subsequent reflections that can be analysed. GPR can be used for the definition of firn-ice transition, the detection of subglacial cavities and the ice thickness [45]. GPR systems include a transmitter and a receiver antenna. Typical operating frequencies vary between 10 and 15 MHz, for the investigation of glaciers having depths of hundreds of meters, to 400–600 MHz, for shallow investigations. Different factors can limit the effectiveness of the technique, such as debris cover of the ice surface or highly crevassed areas that can create scattering or absorption phenomena that reduce the possibility of investigation of the glacier sub-surface. Processing of radar data normally implies many steps, which include (i) low-frequency filtering, caused mainly by surface reflection; (ii) selection of a time gain to correct for the amplitude divergence; (iii) temporal and spatial filtering for improving the signal-to-noise ratio; (iV) deconvolution and (v) migration [46].
GPR apparatuses are usually lightweight and compact and they can be easily transported by walking or snowmobile, which allows at acquiring a large number of 2D radar profiles. However, helicopter-borne surveys provide the most versatile platform and they have been used for detecting glacier thickness [47, 48], intraglacial features [49] and snow accumulation [50].
Spatially distributed deformation data provide wide information on the investigated process. Nevertheless, common remote sensing apparatuses only provide specific displacement components or punctual measurements and the integration of different sensors is necessary to obtain spatially distributed 3D data.
Dematteis et al. [6] proposed an innovative solution to obtain 3D displacement using DIC and TRI data integration. DIC and TRI provide different and complementary displacement components that can be coupled to obtain a three-dimensional representation of the surface kinematics. The necessary conditions to couple the different data are that their maps must have the same spatial resolution in the same coordinate system (CS). Therefore, a geometric transformation is required to represent both data in the same CS, which is usually associated with a georeferenced DEM.
A different approach of data integration entails the merging of DIC and RTS data. RTS provides 3D displacement in specific points, while DIC can measure spatially distributed data. Therefore, their integration allows obtaining the displacement direction and versus using RTS data, while the DIC results give the spatial distribution.
The Planpincieux and Grandes Jorasses glaciers form a unique polythermal glacial complex located on the Italian side of the Grandes Jorasses peak (Mont Blanc massif), in the Ferret valley (Figure 1). The glaciers have approximately a South-East aspect and the elevation ranges from 2600 m asl to 4200 m asl. The accumulation area of the Grandes Jorasses Glacier is formed of two 45° steep cirques, which merge in an icefall at 3500 m asl. In the left cirque is located the Whymper Serac, whose front is at an elevation of 3800 m asl (Figure 2b). According to Pralong and Funk [51], this portion is classified as an unbalanced hanging glacier. As such, the serac progressively increases its volume and when its shape reaches unstable geometry, the serac collapses. This cycle follows an irregular periodicity and the time between the break-offs ranges from a few years to more than a decade. Usually, the unstable ice chunk has a volume of the order of 105 m3, which can collapse at once or in several pieces. The instability dynamics is driven only by the geometry and it is not linked to temperature or water percolation. Therefore, the fracture can also occur during the cold season, when the collapse might easily trigger a large snow avalanche that would seriously threaten the underlying buildings and the road at the valley bottom. The last events happened in August 1993, June 1998 [11] and September 2014 [12]. The first one caused the fatality of eight mountaineers, but the ice avalanche did not cause further damages for the absence of snow.
(a) Image of the Montitaz Lobe of the Planpincieux Glacier monitored by a monoscopic time-lapse camera. The terminus width is approximately 100 m. (b) Image of the Whyper Serac acquired by monoscopic time-lapse camera. The serac face is approximately 40-m high. The black circles indicate the prism positions onto the serac surface in 2019.
The Planpincieux Glacier topography presents three distinguished zones: the accumulation area, 3000–3500 m asl, is formed of two steep cirques that merge in a wide plateau at 2900–3000 m asl, and two lobes constitute the ablation area. The right lower lobe (Figure 2a) is 32° steep on average and it is quite crevassed. Its terminus ends in correspondence of a bedrock cliff that causes frequent calving. In the past, several collapses occurred and, in a few cases, they endangered the bridge of the Montitaz stream that originates from the glacier snout. Further information on the Planpincieux Glacier can be found in Giordan et al. [7].
In the last decades, the Planpincieux-Grandes Jorasses Glacier complex has become an open-air laboratory where innovative remote sensing techniques have been developed to monitor the glacier activity [6, 7, 8, 9, 10, 11, 12].
The Planpincieux Glacier is observed by two monoscopic time-lapse cameras placed in the opposite side of the Ferret valley, at a distance of 3800 m from the glacier. The monitoring station is equipped with two solar panels and an electric cell for power supply. It is remotely controlled by a Raspberry Pi 3 connected to the server of the Geohazard Monitoring Group (GMG) of the Research Institute for Geo-Hydrological Protection (IRPI), in Torino, Italy. A robotised webcam has been installed in 2018 to survey the station functioning. The system is active since August 2013 and it acquires images at hourly frequency. In the period August 2013–December 2019, it collected more than 35,000 images and it is probably the longest continuous series of hourly images in the European Alps. The images are processed with the DIC technique to estimate the surface glacier kinematics.
The Grandes Jorasses Glacier is being monitored since 2010 by an RTS installed in the Planpincieux hamlet at a distance of 4800 m. The RTS measures every 2 h the position of the prisms installed onto and in the vicinity of the Whymper Serac (Figure 2b). Due to the extreme meteorological conditions and the exceptional sensor-to-target range, the prisms are not always visible and gaps in the measurement series are frequent, especially during the cold season. Snowfalls and strong wind occasionally cause the loss of some prisms and the intervention of Alpine guides it is necessary for the installation of new targets. Moreover, the Whymper Serac is continuously monitored by a 4800-m-far monoscopic camera. This survey is active since 2010 and the serac surface displacement is estimated with feature tracking of the hourly photographs.
Besides these continuous monitoring systems, in the past, several measurement campaigns have been conducted to increase the glacier understanding and to develop new monitoring techniques of glaciological close-range remote sensing. In Table 1, the complete list of the surveys conducted since 2010 is presented and the related references are reported when available.
DEMs obtained during LiDAR and TLS surveys and from photographic SfM acquired by drones and helicopter-borne cameras allow monitoring the morphology evolution of the glacier surface. In addition, the DEM of difference (DoD) calculation permits to estimate the surface elevation changes and the possible ice mass loss. From the DoD obtained with the DEMs acquired in October 2019 and June 2014 (helicopter-borne SfM and LiDAR respectively), one can observe the glacier thinning of more than 10 m on average (Figure 3). In the considered period, the terminus retreated by several tenths of metres and the bedrock remained exposed. In this part, the DoD shows a thickness loss of 30–40 m approximately, which corresponds to the glacier thickness in 2014.
DEM of difference (DoD) of the Montitaz Lobe. The DoD is calculated as the difference between the DEMs acquired on 1/10/2019 and 9/6/2014. The glacier outlines in both years are represented as dashed lines.
RTS measurements are continuously active since 2010 to monitor the surface velocity of the Whymper Serac. The survey is conducted with a Leica TM30 that operates in ATR mode. The prism network is composed of several stakes installed into the unstable portions, while a few prisms placed in the surrounding bedrock serve as reference points. Complete acquisition of the entire network lasts approximately 45 min and it is conducted every 2h. The sensor-to-target distance is of 4800 m on average, which is beyond the instrument operating limits declared by the manufacture in ATR mode (https://w3.leica-geosystems.com/downloads123/zz/tps/tm30/brochures-datasheet/tm30_technical_data_en.pdf). In addition, extreme atmospheric conditions linked to the high-mountain elevation occur frequently. This situation makes the Whymper Serac a critical scenario for RTS measurements and a robust processing method has been developed ad hoc [11]. However, the RTS data allowed forecasting 10 days in advance the serac break-off of 22/10/2014 [12]. The RTS data acquired before such an event are shown in Figure 4.
RTS measurements of prisms 13, 14, and 2b before the failure of 22/09/2014. Using these data, the break-off was predicted 10 days in advance.
The surface kinematics of the Planpincieux Glacier right lobe has been deeply investigated with image analysis of 6-year-long time-lapse monitoring. The data analysis allowed characterising the terminus dynamics and classifying the instability processes that cause break-offs: (i) disaggregation, (ii) slab fracture and (iii) water tunnelling [7]. Disaggregation is the progressive toppling of small ice pieces caused by the movement of the terminus beyond the frontal bedrock cliff. It is the most frequent process and it involves break-offs of limited size, usually lower than 1000 m3. Slab fracture instability is caused by the aperture of a crevasse orthogonal to the motion direction, located in correspondence to the maximum tensile stress line. When the fracture reaches the bedrock, it triggers a large break-off of an ice lamella that can assume a volume of 104–105 m3. Water tunnelling refers to the formation of R-channels [52] where a large amount of water can accumulate. The water produces a strong pressure on the frontal cliff that can provoke failure of the terminus. Moreover, the empty tunnels increase the instability and they can collapse themselves.
Besides the visual photographic interpretation, DIC in the Fourier domain was applied to the hourly images, obtaining surface displacement maps at daily resolution. During the monitoring period, the surface displacement pattern was composed of four distinct kinematic domains, which were characterised by different velocity regimes. The presence of kinematics domains indicates the action of high strain rates localised at the domain limits, where large fractures appear (Figure 5). The behaviour of the frontal sector is noteworthy, because it reveals the occurrence of a few speed-up periods per year, which culminate with large break-offs (Figure 6). These kinematic fluctuations were characterised by well-defined thresholds of initial velocity (
(a) Image of the Montitaz Lobe acquired by the monoscopic time-lapse camera. The terminus width is approximately 100 m. (b) Surface deformation map. Different velocity regimes clearly identify the four kinematics domains. (c) Longitudinal conceptual scheme of the glacier lobe (not in scale). The black lines indicate bedrock discontinuities that correspond to the kinematic domain limits. Modified from Giordan et al. [
Time series of the daily velocity of sectors A and B (see
DIC in the spatial domain was applied to the images of the Whymper Serac to measure the displacement in July 2019 (Figure 7a, b). The available images presented rototranslation that had to be compensated with robust coregistration. Moreover, the smooth texture and low chromatic contrast of the scene lowered the signal-to-noise ratio (i.e. the correlation, see Figure 7) and hence many artefacts were present in the displacement maps. Therefore, a robust outlier correction method was applied [53]. The results showed a slight acceleration during July, which was confirmed by RTS measurements.
(a) IBIS-L GBSAR surveyed the Planpincieux Glacier area, delimited in black. (b) The cumulative sum of the interferograms acquired in the period September 4, 2015 to October 14, 2015.
The Planpincieux is probably the unique glacier where TRI surveys were conducted using four different terrestrial interferometric radar models, namely: GPRI™ (Gamma Remote Sensing, https://www.gamma-rs.ch/rud/microwave-hardware/gpri.html), IBIS-L™ (IDS Georadar, https://idsgeoradar.com/products/interferometric-radar/ibis-fl), FastGBSAR-S™ (MetaSensing, https://www.geomatics.metasensing.com/fastgbsar-s) and GBInSAR LiSALab™ (LiSALab, http://www.lisalab.com/home/default.asp?sez=6).
The surface kinematics of the glaciers was surveyed in five TRI campaigns, in 2013, 2014, 2015, 2016 and 2019 (Table 1). The first two were conducted using the GPRI™ real-aperture radar (RAR) in Ku band that surveyed the glacier from the valley bottom and the valley ridge opposite to the glaciers. Both campaigns lasted for 2 days and they were able to detect the displacements of the lower portions of the Planpincieux and Grandes Jorasses glaciers, which were approximately 25 cm day−1 and 50 cm day−1 respectively. Instead, the following surveys were conducted using Ku-band ground-based synthetic aperture radars (GB-SAR). The campaign of autumn 2015 (IBIS-L™) lasted much longer and hence it was possible to recognise the different kinematic domains of the Montitaz Lobe (Figure 8). During the campaign, the meteorological conditions were severe and the radar acquisitions were affected by strong APS. To solve the issue, a polynomial APS model that was a function of the topography was developed [9, 42]. In 2016, FastGBSAR-S™ measurements with an acquisition frequency of 10 s were carried out; thereby, the atmospheric disturbance was minimised. Fully polarimetric measurements were experimented, but the very long distance did not allow exploiting the potentiality of such a technology. The last campaign (GBInSAR LiSALab™) began at the end of September 2019 for civil protection and it is still active during the writing of the present chapter.
(a-c) Surface displacement maps of the Whymper Serac of the periods July 1, 2019 to July 7, 2019, July 7, 2019 to July 16, 2019 and July 16, 2019–July 24, 2019. (d) Map of the mean correlation coefficient, which displays low values because of the texture smoothness of the snow surfaces. The serac face is approximately 40 m high.
A helicopter-borne 65-MHz GPR survey was conducted in the Planpincieux-Grandes Jorasses glacial complex in April 2014, when 16 GPR traces homogeneously distributed on the glaciers’ surface were acquired (Figure 9). The noise of the radar data was quite high, because the numerous crevasses caused bounds of the electromagnetic waves and produced echoes and artefacts. Nevertheless, it was possible to estimate the glacier thickness, which was in the range 20–40 m in the Planpincieux Glacier and lower than 20 m in the Whymper Serac.
(a) GPR traces of the Planpincieux (orange line) and Grandes Jorasses (blue line) glaciers. (b-c) GPR profiles of the Whymper Serac and Planpincieux Glacier respectively. The white-red boundary indicates the ice thickness.
In September 2015, time-lapse photography and terrestrial radar campaigns were conducted simultaneously to measure the Planpincieux Glacier surface kinematics. The actual three-dimensional surface kinematics was obtained by coupling DIC and TRI results. Figure 10 reports the mean daily velocity map, where the colour represents the velocity module and the arrows indicate direction and versus. The 3D displacement can be obtained only in the areas visible by both the sensors. In the right lobe, the displacement vectors are not uniformly parallel to the surface, because the seracs move downstream as a single body and the ice is subjected to internal deformation. This result is not trivial, as the most common approach to estimate 3D displacement is to project the single movement components along the local slope obtained from the DEM, but this assumption might be misleading in specific cases.
Velocity field of the surface kinematics of the lower Planpincieux Glacier obtained with the integration of DIC and TRI measurements. Colours and arrows represent velocity module and direction respectively. Modified from Dematteis et al. [
The permanent monitoring system of the Whymper Serac is composed of RTS and time-lapse imagery. In July 2019, the data of the two sensors were integrated and represented in an informative bulletin [54, 55], shown in Figure 11. Such integration allows evaluating the versus and direction of the principal movement (with the RTS data) and the distribution of the strain rates (with the DIC results).
Data integration of DIC and RTS measurements. The image depicts the spatially distributed daily deformation of the Whymper Serac front (coloured dots) and the surface displacement direction measured by the TRS in correspondence with the prism P3-2017. The right plot reports the displacement trend provided by the RTS.
In-depth knowledge of glacier behaviour is fundamental for glaciological risk evaluation and management and it permits to develop mitigation and adaptation strategies against the cryosphere change provoked by global warming. To achieve this aim, data collection about the current glacier state is of primary importance, but the harsh mountain environment makes the survey activities difficult. Measurements from aerospace platforms are affected by complex geometries and might not provide sufficient spatiotemporal resolution, especially when high acquisition rates (i.e. minutes to hours) are necessary. Therefore, ground-based systems are often the most suitable solution. Nevertheless, impervious areas where glaciers are usually located entail the use of high financial and human efforts, as well as potential risks to access the investigated area. Therefore, remote sensing systems represent the best cost-benefit ratio and they are commonly adopted for glacier monitoring. Considering the possible adverse conditions (e.g. extreme meteorology, steep slopes, long sensor-to-target distance, natural hazards) that can occur during the survey activities, ad hoc technologies and methods must be developed. The glacial complex formed of the Planpincieux and Grandes Jorasses glaciers represents an outstanding site where different close-range remote sensing approaches have been experimented, in a heterogeneous Alpine glacier environment. Here, the combined use of multiple sensors proved to be a valuable tool to collect complementary information that allowed improving the understanding of the current state and recent evolution of the glacial area.
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"1",type:"subseries",title:"Oral Health",keywords:"Oral health, Dental care, Diagnosis, Diagnostic imaging, Early diagnosis, Oral cancer, Conservative treatment, Epidemiology, Comprehensive dental care, Complementary therapies, Holistic health",scope:"\r\n This topic aims to provide a comprehensive overview of the latest trends in Oral Health based on recent scientific evidence. Subjects will include an overview of oral diseases and infections, systemic diseases affecting the oral cavity, prevention, diagnosis, treatment, epidemiology, as well as current clinical recommendations for the management of oral, dental, and periodontal diseases.
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Her qualifications are: a specialist in Dental Imaging and Radiology, Master in Dentistry (Periodontics) from the University of São Paulo (FORP-USP, Ribeirão Preto, SP), and Doctor (Ph.D.) in Dentistry (Stomatology Clinic) from Hospital São Lucas of the Pontifical Catholic University of Rio Grande do Sul (HSL-PUCRS, Porto Alegre, RS). She held a postdoctoral internship at the Federal University from Jequitinhonha and Mucuri Valleys (UFVJM, Diamantina, MG). She is currently a member of the Brazilian Society for Dental Research (SBPqO) and the Brazilian Society of Stomatology and Pathology (SOBEP). 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In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. This topic will closely deal with all emerging trends in this discipline.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",keywords:"Phenolic Compounds, Essential Oils, Modification of Biomolecules, Glycobiology, Combinatorial Chemistry, Therapeutic peptides, Enzyme Inhibitors"},{id:"17",title:"Metabolism",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation"},{id:"18",title:"Proteomics",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:{title:"Biochemistry",id:"11"},selectedSubseries:null},seriesLanding:{item:null},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/233577",hash:"",query:{},params:{id:"233577"},fullPath:"/profiles/233577",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()