They provide pretty complete descriptions of each option, and are themselves the source for most of the information presented here. The most authoritative source on configuration details will always be the configuration files themselves. Most settings will come over without changes, then you can review any tricky changes that remain. To migrate your settings to a new Configuration you can use tools like Notepad++ or Winmerge to compare old configurations with the newer (default) configurations and copy settings over on a change-by-change basis. As part of the build process, Marlin will check for outdated options and show error messages that explain exactly what needs to be changed. To use configurations from an earlier version of Marlin, first try dropping them into the newer Marlin, updating CONFIGURATION_H_VERSION and CONFIGURATION_ADV_H_VERSION, and building the firmware. #define THIS_IS_DISABLED // this switch is disabled #define OPTION_VALUE 22 // this setting is "22" #define THIS_IS_ENABLED // this switch is enabled Settings can be enabled, disabled, and assigned values using C preprocessor syntax like so: A build of Marlin can range from 50K to over 230K in size. This results in the smallest possible binary. This allows Marlin to leverage the C++ preprocessor and include only the code and data needed for the enabled options. Marlin is configured using C++ compiler directives. Hundreds of user-donated configurations are posted at the Configurations repository to get you started. Simply edit or replace these files, then build and upload Marlin to the board. h files contain all of Marlin’s build-time configuration options. See the Configuration with INI page for more information. config.ini may be included to modify the configuration at the start of a PlatformIO build.Configuration_adv.h contains more detailed customization options, add-ons, experimental features, and other esoteric settings.Configuration.h contains the core settings for the hardware, language and controller selection, and settings for the most common features and components.Marlin is a huge C++ program composed of many files, but among the most important are the files that contain all of Marlin’s compile-time configuration options: With much lower power consumption than the original Hard drive, longer runtimes and quicker user interface. M306: Model predictive temperature control For those seeking solid state storage capabilities for their iPod, the iFlash-CF allows you to install and use CF Compact Flash Cards.
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Friedenthal completed her undergraduate education at Yale University. Jenna Friedenthal is a Fellow in Reproductive Endocrinology and Infertility at Reproductive Medicine Associates of New York. If you are trying to conceive and your period is more than one week late with a negative pregnancy test, you should consider consultation with a fertility doctor so that you can be properly evaluated and treated, if necessary.ĭr. If you suspect you are pregnant, even though the test is negative, the test should be repeated in one week. Remember, hCG rises differently in each woman. Most brands instruct you to wait until the first day of your missed period to test. Your body needs time for the hormone to rise to a high enough level to be detected. It is possible that although an egg may be fertilized, your body has not started secreting enough hCG to register as positive on a test. Pregnancy tests vary in how soon they can detect hCG in your urine. Taking a Home Pregnancy Test Too SoonĪnother reason for a false negative pregnancy test may simply be that you took the test too early. Certain brands state that they can detect lower thresholds of hCG depending on how soon you are taking the pregnancy test after the missed period, it may be worth trying again with a more sensitive brand, ensuring you are using the first morning urine for your test (hCG concentrations are highest in the first morning urine). Some reasons for this may include: Home Pregnancy Test with a Low SensitivityĪ home pregnancy test will only detect pregnancy when the level of “pregnancy hormone,” also known as human chorionic gonadotropin (hCG), reaches a certain threshold, and it simply may not be sensitive enough to produce a positive result. Second, there are a few reasons why your pregnancy test may read negative when you are, in fact, pregnant. Charting Basal Body Temperature or using Ovulation Prediction Kits (OPKs) can help you get a firm grasp on your menstrual cycle to predict when you are most likely to conceive. Additionally, cycles can sometimes vary in length from month to month. The average menstrual cycle is 28 days, but far too often we forget to note day 1 of our cycle. As the ovarian follicle count is depleted prematurity, falling estrogen levels lead to hot flashes, vaginal dryness, and an absence of menses as the woman prematurely enters menopause. In POI, the symptoms experienced are similar to those of menopause. Some women may have a condition known as primary ovarian insufficiency (POI). There are many causes for ovulatory dysfunction or anovulation. When you are trying to conceive, it is important to determine whether you are successfully ovulating each month, as ovulatory dysfunction or anovulation may play a role in your missed period and can affect your ability to conceive. There are a several possible explanations for a negative pregnancy test with a missed period that may occur in the absence of pregnancy. But what should you think, then, when the pregnancy test is negative? Causes of a Negative Pregnancy Test For couples trying to conceive, the missed period is often the first exciting sign of a positive pregnancy. Players move their tiles according to the die, and land on properties they can buy to an imaginary bank. Boards, tiles, and cards are all included for free in each game. Top 10: Soccer Managers Snail Park I Want to Be a Billionaire 2 How to play Monopoly Enjoy a classic In this game you'll have to develop your monopoly by owning all the real state properties available. Grab some friends to play this online version of the popular board game Monopoly. Set personal records in Mahjong tile games, or challenge yourself to a colorful version of Mastermind. Sit around the dinner table, and play a competitive game of Uno. No need to introduce Monopoly, probably the most famous board game in the world, whose goal is to ruin your opponents through real estate purchases. A free to play Monopoly themed game that offers exciting multiplayer action and supports up. Play one-on-one Battleship with the computer, or sink other players' boats around the world! Take at-home gaming to the next level, with 3D pieces, realistic sounds, and addictive, multiplayer gameplay. Download Business Tour - Online Multiplayer Board Game 2.16.0. No need to register, no software to download and no Java or Flash interfaces. Go head-to-head with smart AI, or crush your friends online.Īll kinds of nostalgic and entertaining challenges are included in our collection of board games. Webopoly is an free online property trading game you can play in your browser. Play your favorite, retro games, or delve into uncharted gaming territory. Enjoy and share with your friends This classic version of the online game Monopoly can play up to 4 players with friends. Offline playing with others via one or more screens. Key features: Online multiplayer mode, 2-4 players. Monopoly, the popular board game about buying and trading properties, is now available to play online and for free on. Difficulty and unpredictability make the classic table-top game more interesting, and the gameplay more diverse. Try to outsmart your friends or the computer at any difficulty level. Youll have to use all your bravery and business acumen to defeat real opponents. The best starting point for discovering board games. Want to play Board Games Play Master Chess, Battleships Armada, Monopoly and many more for free on Poki. Turn classic cardboard pieces into animated, virtual characters! Enter a card tournament, and prove your skills at the high-limit tables. What are the most popular Board Games for the mobile phone or tablet Master Chess. Every great board game from your past is available for free in our collection! You can play all types of chess and checkers variations, including 3D and themed games. It likely is for your browser, but maybe not your Java installation. This needs to be in your trust store as a trusted certificate ( cacerts). Your company should be providing the certificate that they use to re-encrypt proxy traffic. This should fail in all other cases except this one where you are willing to trust the MitM (basically because you have to in order to access these from the company network). The proxy is terminating the SSL connection with, then re-encrypting it with a self-signed certificate. The request is encrypted, but the company wants to decrypt it and make sure that there’s nothing bad in it before allowing you to have it. How can I solved this error, considering that the server where I am installing Elasticsearch is behind a corporate proxy?Ĭorporate proxies are essentially an allowed MitM attack. Picked up JAVA_TOOL_OPTIONS: -Dfile.encoding=UTF8Įxception in thread “main” : PKIX path building failed: .SunCertPathBuilderException: unable to find valid certification path to requested targetĪt java.base/.createSSLException(Alert.java:131)Īt java.base/.fatal(TransportContext.java:325)Īt java.base/.fatal(TransportContext.java:268)Īt java.base/.fatal(TransportContext.java:263)Īt java.base/$T12CertificateConsumer.checkServerCerts(CertificateMessage.java:645)Īt java.base/$T12CertificateConsumer.onCertificate(CertificateMessage.java:464)Īt java.base/$nsume(CertificateMessage.java:360)Īt java.base/.consume(SSLHandshake.java:396)Īt java.base/.dispatch(HandshakeContext.java:445)Īt java.base/.dispatch(HandshakeContext.java:423)Īt java.base/.dispatch(TransportContext.java:182)Īt java.base/.decode(SSLTransport.java:171)Īt java.base/.decode(SSLSocketImpl.java:1475)Īt java.base/.readHandshakeRecord(SSLSocketImpl.java:1381)Īt java.base/.startHandshake(SSLSocketImpl.java:441)Īt java.base/.startHandshake(SSLSocketImpl.java:412)Īt java.base/ java.base/ java.base/ java.base/ java.base/ .downloadInternal(Download.java:83)Īt .download(Download.java:66)Īt $1.call(Install.java:68)Īt $1.call(Install.java:48)Īt .access(ExclusiveFileAccessManager.java:69)Īt .createDist(Install.java:48)Īt .execute(WrapperExecutor.java:107)Īt .main(GradleWrapperMain.java:63)Ĭaused by: : PKIX path building failed: .SunCertPathBuilderException: unable to find valid certification path to requested targetĪt java.base/.doBuild(PKIXValidator.java:439)Īt java.base/.engineValidate(PKIXValidator.java:306)Īt java.base/.validate(Validator.java:264)Īt java.base/509TrustManagerImpl.checkTrusted(X509TrustManagerImpl.java:231)Īt java.base/509TrustManagerImpl.checkServerTrusted(X509TrustManagerImpl.java:132)Īt java.base/$T12CertificateConsumer.checkServerCerts(CertificateMessage.java:629)Ĭaused by: .SunCertPathBuilderException: unable to find valid certification path to requested targetĪt java.base/.SunCertPathBuilder.build(SunCertPathBuilder.java:141)Īt java.base/.SunCertPathBuilder.engineBuild(SunCertPathBuilder.java:126)Īt java.base/.build(CertPathBuilder.java:297)Īt java.base/.doBuild(PKIXValidator.java:434) gradlew -Dhttps.proxyHost= -Dhttps.proxyPort=8080 :distribution:archives:oss-linux-s390x-tar:assemble -parallel gradlew -Dhttps.proxyHost= -Dhttps.proxyPort=8080 :distribution:archives:oss-linux-s390x-tar:assemble -parallelĪnd I got the elasticsearch]$. Then I changed to specifying our sorporate proxy: gradlew :distribution:archives:oss-linux-s390x-tar:assemble -parallelĮxception in thread “main” java.io.IOException: Downloading from failed: timeout I am building Elasticsearch on Red Hat 8 on z System (s390x) following the procedure Building Elasticsearch ( ), on step 6) Build, considering we have a corporate proxy, It's important to keep this in mind, and you may want to keep a list of irregular verbs and their proper conjugations. They break the rules you're about to learn. However, some verbs are irregular, meaning they get conjugated differently. In other words, Spanish verbs ending in AR are conjugated differently than verbs ending in ER and IR.įor the most part, what you'll learn in this article applies to any verb in the Spanish language. There are different rules for conjugation depending on the last two letters of these verbs. * Indicates verb has irregular conjugations
In the fifth and sixth Q&A livestreams, it was revealed that Joy Kill is male.When test running Chapter 4, Vince confirmed Joy Kill to be the enemy who caused him the most deaths in the chapter.This isn't the case for any other bosses so far. Their name is shared with the OST's title for their boss encounter. For the rest of the scene, it stands there and watch Doug getting beat up, marked by Malak, and thrown back into the portal. Joy Kill's relationship with the Joy Joy Gang's clones is mostly unknown, but it does allow them to deal with Doug and take Joy Kill's composing members' place as the new Joy Joy Gang.īehavior Chapter 4 Mascot Mayhem Boss Battle I īefore Doug was able to reach the portal, Joy Kill escapes the facility and jumps in front of him and tells him that he was so close while walking towards him to get beaten up by Lucky, Hangry, and Penny. It shows a complete refusal to stop chasing Doug until it has him cornered and dealt with by the Joy Joy Clones. Joy Kill, due to being an amalgamation of the original Joy Joy Gang, it's connected to the Joy Joy Clones, allowing them to transfer memories to the clones if needed.Īs with all of Malak's minions, Joy Kill is eternally loyal to him, especially due to the fact that it retains the original memories of the Joy Joy Gang used.ĭue to retaining the Joy Joy Gang's original memories, Joy Kill shows a complete desire to kill Doug for what he did to them, carrying with them some of the Joy Joy Gang's personality. Even when Doug uses another one to push him into molten metal Joy Kill simply comes back later without a scratch of damage on it. When Doug tried to use the crusher pistons on them again, it barely did anything outside of reminding Joy Kill to kill him. Joy Kill seems to be incapable of taking any visible damage from anything. These lasers do require various amounts of time to charge up, though, so they do become vulnerable while doing so.Īn ability retained from Lucky, Joy Kill is capable of jumping to any desired location regardless of its distance without any effort.Īn ability retained from Penny, Joy Kill is capable of summoning eggs from its Penny hand and throwing them at Doug to stun him.Īn ability retained from Hangry, Joy Kill possesses enough physical strength to swat Doug around like a bug, as well as using it to break through walls and other obstacles to get to Doug. Joy Kill uses two types of lasers: one small but quick laser shot by Lucky's head and three slower but longer ranged lasers shot by all three heads. Joy Kill is capable of shooting laser beams out of any one of their three heads, disintegrating anything they remotely touch. Although it has been shown that Hangry and Penny can control their respective arms on the fusion. While it is shown that each member can speak and think independently, it is unknown whether the body is controlled entirely by Lucky or by all three members in coordination. After all, that's not even their final form.īecause Joy Kill is an amalgamation of the three Joy Joy Gang Members, it does not possess its own personality. Joy Kill's arms are made from the arms of Penny and Hangry, including one unknown robotic arm that is implied to be Lucky's, but isn't confirmed because it seems to have five fingers.ĭon't celebrate just yet. At the back of the heads are large wire cables attached to the back of the main robot body. Lucky's head is located in the middle, with Penny's head located at his right, and Hangry's head located at his left. After the reconstruction of the animatronics, their body takes a more bulky metallic and robotic appearance, with the heads of the three located on top. Joy Kill is made from the destroyed parts of Hangry, Penny, and Lucky, most notably their heads. How much is the Train fare to Hilton-Home2 Suites?.The Bus fare to Hilton-Home2 Suites costs about $2.00. How much is the Bus fare to Hilton-Home2 Suites?.The Subway fare to Hilton-Home2 Suites costs about $1.40 - $3.00. How much is the Subway fare to Hilton-Home2 Suites?.The 551 is the last Bus that goes to Hilton-Home2 Suites in Philadelphia. What time is the last Bus to Hilton-Home2 Suites in Philadelphia?.The 17 is the first Bus that goes to Hilton-Home2 Suites in Philadelphia. What time is the first Bus to Hilton-Home2 Suites in Philadelphia?.The TRENTON is the last Train that goes to Hilton-Home2 Suites in Philadelphia. What time is the last Train to Hilton-Home2 Suites in Philadelphia?.The TRENTON is the first Train that goes to Hilton-Home2 Suites in Philadelphia. What time is the first Train to Hilton-Home2 Suites in Philadelphia?.The MFL is the last Subway that goes to Hilton-Home2 Suites in Philadelphia. What time is the last Subway to Hilton-Home2 Suites in Philadelphia?.The BSL is the first Subway that goes to Hilton-Home2 Suites in Philadelphia. What time is the first Subway to Hilton-Home2 Suites in Philadelphia?.The 11 is the last Light Rail that goes to Hilton-Home2 Suites in Philadelphia. What time is the last Light Rail to Hilton-Home2 Suites in Philadelphia?.The 13 is the first Light Rail that goes to Hilton-Home2 Suites in Philadelphia. What time is the first Light Rail to Hilton-Home2 Suites in Philadelphia?.The nearest bus stops to Hilton-Home2 Suites in Philadelphia are 12th St & Arch St and Arch St & 12th St. What’s the nearest bus stops to Hilton-Home2 Suites in Philadelphia?.The nearest train station to Hilton-Home2 Suites in Philadelphia is Jefferson Station. What’s the nearest train station to Hilton-Home2 Suites in Philadelphia?.The nearest subway station to Hilton-Home2 Suites in Philadelphia is 13th St Station. What’s the nearest subway station to Hilton-Home2 Suites in Philadelphia?.The nearest light rail station to Hilton-Home2 Suites in Philadelphia is 13th St. What’s the nearest light rail station to Hilton-Home2 Suites in Philadelphia?.These Subway lines stop near Hilton-Home2 Suites: BSL, MFL Which Subway lines stop near Hilton-Home2 Suites?.These Train lines stop near Hilton-Home2 Suites: AIRPORT, MANAYUNK/NORRISTOWN, MEDIA/WAWA, PAOLI/THORNDALE, WARMINSTER Which Train lines stop near Hilton-Home2 Suites?.Which Bus lines stop near Hilton-Home2 Suites?.Jefferson Station is 891 yards away, 11 min walk.City Hall is 376 yards away, 5 min walk.Greyhound Terminal, 1001 Filbert St is 359 yards away, 5 min walk.Market St & 11th St - Mbns is 329 yards away, 5 min walk.13th St & Market St - Mbfs is 309 yards away, 4 min walk.Market St & 12th St is 282 yards away, 4 min walk.Market St at 12th St is 257 yards away, 4 min walk.13th St Station is 243 yards away, 3 min walk.Arch St & 11th St is 197 yards away, 3 min walk.Arch St & 12th St is 40 yards away, 1 min walk.12th St & Arch St is 33 yards away, 1 min walk.The closest stations to Hilton-Home2 Suites are: What are the closest stations to Hilton-Home2 Suites?. Lastly, this book covers advanced topics related to persistence architecture and design patterns, and is ideal for beginning developers looking to learn more in these areas. In this revised edition, authors Christian Bauer, Gavin King, and Gary Gregory cover Hibernate 5 in detail with the Java Persistence 2.1 standard (JSR 338). Because the book covers several persistence frameworks, it is suitable for anyone interested in learning more about Spring or any of the frameworks covered. Books Java Persistence with Hibernate, Second Edition Java Persistence with Hibernate, Second Edition explores Hibernate by developing an application that ties together hundreds of individual examples. Why am i getting hibernate.invalidmappingexception when i try to save an object in database with hibernate. The authors created Hibernate and they field questions from the Hibernate community. It builds on a single example to show you how to use Hibernate in practice, how to deal with concurrency and transactions, how to efficiently retrieve objects and use caching. What You'll Learn Use Spring Persistence, including using persistence tools in Spring as well as choosing the best Java persistence frameworks outside of Spring Take advantage of Spring Framework features such as Inversion of Control (IoC), aspect-oriented programming (AOP), and more Work with Spring JDBC, use declarative transactions with Spring, and reap the benefits of a lightweight persistence strategy Harness Hibernate and integrate it into your Spring-based enterprise Java applications for transactions, data processing, and more Integrate JPA for creating a well-layered persistence tier in your enterprise Java application Who This Book Is For This book is ideal for developers interested in learning more about persistence framework options on the Java platform, as well as fundamental Spring concepts. Hibernate in Action carefully explains the concepts you need, then gets you going. Today, the agile and open source Spring Framework is the leading out-of-the-box, open source solution for enterprise Java developers in it, you can find a number of Java persistence solutions. In Java development, persistence is a key factor in enterprise, e-commerce, and other transaction-oriented applications. Persistence is an important set of techniques and technologies for accessing and using data, and ensuring that data is mobile regardless of specific applications and contexts. After reading and using this book, you'll have the fundamentals to apply these persistence solutions into your own mission-critical enterprise Java applications that you build using Spring. Spring Persistence with Hibernate, Second Edition has been updated to cover Spring Framework version 4 and Hibernate version 5. by Christian Bauer (Author), Gavin King (Author) 3.8 106 ratings. Experienced authors Joseph Ottinger with Dave Minter and Jeff Linwood provide more in-depth examples than any other book for Hibernate beginners. Other persistence solutions available in Spring are also shown including the Java Persistence API (JPA). This book illustrates how these two frameworks can be best utilized. Learn how to use the core Hibernate APIs and tools as part of the Spring Framework. “Humans, not places, make memories.” – Ama Ata AidooĤ3. The tears dry, the smiles fade, but the memories last forever.” – AnonymousĤ2. “Life brings tears, smiles, and memories. “Live your life so when you’re dying, you are smiling, even if everyone else is crying.” – AnonymousĤ1. Because in the end, that’s all you have-happy memories.” – Sarah Strohmeyer Great Memories QuotesĤ0. “I think the only answer is to live life to the fullest while you can and collect memories like fools collect money. “Some memories are realities and are better than anything that can ever happen to one again.” – Willa Catherģ9. “When it comes to memories, the good and the bad never balance.” – Jodi Picoultģ8. “Isn’t it funny how the memories you cherish before a breakup can become your worst enemies afterwards?” – Allyson Braithwaite Condieģ7. “The happiest memories are of moments that ended when they should have.” – Robert Braultģ6. “When you are joyful, when you say yes to life,and have fun, and project positivity all around you, you become a sun in the center of every constellation, and people want to be near you.” – Shannon L. “Sometimes, I think the things I remember are more real than the things I see.” – Arthur Goldenģ4. It’s forgetting that’s hard.” – Brodi Ashtonģ3. “Make sure that your life is full of happy memories in the end.” – Anonymousģ2. They make us laugh when we remember the times we cried, but make us cry when we remember the times we laughed!” – Anonymousģ1. They remain with us forever, like a touchstone.” – Haruki Murakami Good Memories Quotesģ0. But still, no matter how much time passes, no matter what takes place in the interim, there are some things we can never assign to oblivion, memories we can never rub away. “There are just too many things we have to think about everyday, too many new things we have to learn. “Nothing is ever really lost to us as long as we remember it.” – L.M. “Sometimes, things become possible if we want them bad enough.” – T.S. “A moment lasts all of a second, but the memory lives on forever.” – Anonymousġ7. “Things end but memories last forever.” – Kumar Milanġ6. “The real moment has disappeared, but you will always have the memories to remind you.” – Anonymousġ5. “The best thing about memories is making them.” – Anonymousġ4. “It takes one thought, one second, one moment, or positive memory to act as a catalyst for the light to gradually seep in again.” – Fearne Cottonġ3. “You don’t just take a picture with a camera, you take it with your heart.” – Anonymousġ2. “A picture is worth a thousand words, but a memory is priceless.” – Anonymousġ1. So make sure you be a good one.” – Anonymous Unforgettable Memories Quotesġ0. “At some part of life or the other, we all become memories for others. “A moment lasts for seconds, but the memories last forever.” – Anonymousĩ. “I knew that looking back on the tears would make me laugh, but I never knew that looking back on the laughs would bring tears.” – Cat StevensĨ. “We never realize the value of something in our life until it becomes a memory.” – Dr. They make me smile no matter what is going on in my present life.” – AnonymousĦ. “Those sweet memories of my life spent with you are the best. “What I like about photographs is that they capture a moment that’s gone forever, impossible to reproduce.” – Karl Lagerfeldĥ. Memories are sweet, cherish them.” – AnonymousĤ. But you can capture them in your memories forever.” – Anonymousģ. “You may have lost things, persons in your life. Memories need to be shared.” – Lois LowryĢ. “The worst part of holding the memories is not the pain. During the test, you will sit with your chin resting on a support. The OCT scan uses light waves to create an image, similar to an ultrasound that uses sound waves to create an image. SEE RELATED: What Is a Digital Retinal Image? Schedule an appointment with an eye doctor near you, if you suspect you may have glaucoma or any other eye condition that an OCT exam can help detect. The OCT scan can also be performed in a dark room, which facilitates faster and more accurate results- especially when the position of the anterior angle in a darkened room is of utmost importance in the diagnosis of angle-closure glaucoma. The OCT provides cross-sectional images of the anterior angle, and facilitates detection of open-angle or angle closure glaucoma, as well as narrowing of the anterior angle, which can lead to angle-closure glaucoma. If the drainage channel is not working properly, it can lead to an increase in eye pressure, and cause damage to the optic nerve and vision loss. The anterior angle is the drainage channel for fluid inside the eye. The OCT scan is a useful tool in evaluating the anterior angle in patients at risk of developing glaucoma. OCT scans are used for diagnosis, management or treatment of a variety of ocular conditions: The images produced by the OCT scan are also a practical tool in helping patients understand the problem they may be experiencing, as the complication can be seen clearly and in 3D on the screen. The color-coded images provide a wealth of information to help your eye doctor measure the thickness of your retina and identify any optic nerve abnormalities. The OCT scan uses a laser (without radiation) to obtain higher resolution images of the layers of the retina and optic nerve. The use of intra-vessel imaging.An optical coherence tomography scan (OCT scan) is a critical device for the early diagnosis of many serious eye conditions.Īn OCT eye exam is a non-invasive test that provides 3-D color-coded, cross sectional images of the retina to enable early detection and treatment of ocular disease that may develop without any noticeable symptoms. The BPA is an emerging method of treatment of patients with inoperable CTEPH. m2) and 6-minute walking test (6-MWT) increased to 430 m.Three more BPA sessions at intervals of a few weeks were performed and mPAP was reduced to 29 mm Hg (mRAP – 7 mm Hg, PCWP – 13 mm Hg, PVR – 167 dyn Four inflations of a 2.0 mm × 20 mm semi-compliant balloon with the pressure of 4–10 atm were performed along the entire artery with good angiographic and hemodynamic effects (Figure 1 C). The diameter of the vessel was 2.23 mm × 2.42 mm. Surprisingly, OCT revealed extensive changes in the proximal and mid part of the target artery (“colander lesions” or meshwork) (Figure 1 B). Subsequently the vessel was accurately measured in several locations and the proper size of the balloon was selected to reduce the risk of post-reperfusion oedema. Iodinated contrast was infused at a flow rate of 5 ml/s over 4 s at 400 psi of pressure and OCT images were acquired. Then optical coherence tomography (OCT) of the target vessel was performed with the DragonFly (St. Subsequently a Whisper MS coronary guidewire (Abbott Vascular, Santa Clara, Ca, USA) was advanced through the lesion to the distal part of the vessel. Selective pulmonary angiography revealed the subtotally occluded A1 segmental branch of the left pulmonary artery (Figure 1 A). The 90-cm long 6Fr sheath (Flexor Shuttle Guiding Sheath, Cook Medical, Bloomington, IN, USA) and right Judkins 6-Fr guide catheter were used to achieve a good approach to the ostium of the A1 + A2 segmental branch. The BPA was performed from a right femoral vein approach. Functional testing demonstrated a reduced 6-minute walk distance of 220 m. m2) and pulmonary scintigraphy showed multiple segmental perfusion defects (segments 1, 2, 8, 9 in the left lung and 2, 3, 4, 5, 6 in the right lung).Right heart catheterisation confirmed pulmonary hypertension (mean pulmonary artery pressure (mPAP) 37 mm Hg, mean right atrial pressure (mRAP) 6 mm Hg, pulmonary capillary wedge pressure (PCWP) 13 mm Hg, pulmonary vascular resistance (PVR) 214 dyn A 71-year-old woman with non-operable, peripheral type chronic thrombo-embolic pulmonary hypertension (CTEPH) and with World Health Organisation (WHO) class III dyspnoea was admitted to our department for balloon pulmonary angioplasty (BPA). |
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