**9.3 Commissural alignment**

ALIGN TAVR was a study done in 2020 which was the first complete evaluation of the importance of commissural alignment in TAVR. The study compared the effect of the initial deployment orientation of the 483 SAPIEN 3, 100 ACURATE-neo, and 245 Evolut transcatheter heart valves on the final orientation of commissural alignment. 828 patients from 5 centers were studied who had undergone the TAVR procedure from March 2016 to September 2019. The patient's pre-TAVR computed tomography (CT) imaging and procedure fluoroscopy were studied. The pre-TAVR CT had coplanar fluoroscopic views added to it to help determine the commissural alignment. The severe overlap in between the coronary arteries and neocommisural posts were defined as 0° to 20° apart. The different types of valves were classified differently. The Evolut and ACURATE-neo deployment commissural post were defined as center back (CB), center front (CF), inner curve (IC), and outer curve (OC). The Sapien 2 valve had commissural post at clock position 3, 6, 9, and 12. This study showed that valve alignment can be optimized. The SAPIEN 3's orientation did not have an impact on alignment. While ACURATE-neo commissural post showed less coronary artery overlap at the CB or IC in deployment versus in CF or OC. The Evoult "Hat"

had less overlap at OC or CF at initial deployment versus IC or CB. This study showed the significance of optimizing valve alignments in order to avoid coronary artery overlap [49].


**2. Ultrasound biomicroscopy (UBM) (Fig. 1)**

UBM, which originally was used in ophthalmology to image the posterior segment (B-scan ultrasonography), is an objective alternative for anterior chamber angle assessment. Although ultrasound and UBM are based on the same principle, the frequencies are different. Objective and reproducible measurements of the anterior chamber structures can be obtained with crosssectional imaging by UBM. Electric signals are converted by a radiofrequency signal generator coupled to a piezoelectric transducer into 50 MHz frequency ultrasonic sound waves, which are transmitted to the eye via saline solution that is held in a cup reservoir [11]. The examination may be performed through a viscous material such as sodium hyaloronate. UBM generates high-resolution images of the angle, which can be used in quantitative analysis, and it adds useful information regarding mechanisms of angle closure [11]. Although angle dimensions measured by UBM correlated significantly with gonioscopy in general [12], gonioscopic assessment sometimes resulted in an overestimation of the angle width in eyes with occludable angles [13]. Gonioscopy is the gold standard examination, because it allows direct viewing of the angle. Nevertheless, it may induce changes in the apposition of the iris depending on the technique and the lens.

gonioscopy. However, it is limited by its dependency on subjective interpretation and difficulties in manipulation techniques. Ultrasound biomicroscopy (UBM) generates highresolution images of the angle, which can be used in quantitative analysis, and it adds useful information regarding causal mechanisms of angle closure. However, this method also requires trained and experienced technicians and is time consuming. Both gonioscopy and UBM require contact with the globe, and as a result, they can be unpleasant for the patient and

New devices for evaluating the anterior ocular segment in a more objective and quantita‐ tive manner have been introduced. Anterior-segment optical coherence tomography (AS-OCT) is a noninvasive technique allowing the measurement of the anterior ocular structures. A new generation of OCT, swept-source OCT (SS-OCT), has been recently in‐ troduced for the measurement of the anterior ocular segment. The SS-OCT is over ten‐ fold faster than the time-domain OCT and gives a three-dimensional (3D) observation of the anterior ocular segment. The SS-OCT employs 1,310 nmin the nearinfrared light

The scanning peripheral anterior chamber depth analyzer (SPAC) is a non-invasive device that objectively and quantitatively assesses the anterior ocular segment by employing the Scheimp‐ flug camera principle. The SPAC measures the peripheral ACD and converts the measure‐ ments into numerical and categorical grades by comparison with a normative database. The

In the study reported here, we review the advantages and limitations of newer anterior chamber imaging technologies, namely ultrasound biomicroscopy (UBM), anterior segment optical coherence tomography (AS-OCT), and scanning peripheral anterior chamber depth analyzer (SPAC). Additionally, the present study assessed the effectiveness and possibility of

UBM, which originally was used in ophthalmology to image the posterior segment (B-scan ultrasonography), is an objective alternative for anterior chamber angle assessment. Although ultrasound and UBM are based on the same principle, the frequencies are different. Objective and reproducible measurements of the anterior chamber structures can be obtained with crosssectional imaging by UBM. Electric signals are converted by a radiofrequency signal generator coupled to a piezoelectric transducer into 50 MHz frequency ultrasonic sound waves, which are transmitted to the eye via saline solution that is held in a cup reservoir [11]. The examination may be performed through a viscous material such as sodium hyaloronate. UBM generates high-resolution images of the angle, which can be used in quantitative analysis, and it adds useful information regarding mechanisms of angle closure [11]. Although angle dimensions measured by UBM correlated significantly with gonioscopy in general [12], gonioscopic assessment sometimes resulted in an overestimation of the angle width in eyes with occludable angles [13]. Gonioscopy is the gold standard examination, because it allows direct viewing of

SPAC has been proposed as a clinician-independent screening tool for angle closure.

can induce artifacts.

252 Glaucoma - Basic and Clinical Aspects

source and its scan rate is 30,000 A scan/s.

the SPAC in the glaucoma screening.

**2. Ultrasound biomicroscopy (UBM) (Fig. 1)**

The UBM measurement requires trained and experienced technicians and is time consuming. In addition, UBM require contact with the globe, and as a result, UBM can induce artifacts by inadvertent compression of the globe. Consequently, UBM is not suitable for glaucoma screening examination.

**Figure 1. (a)** UBM image of the normal anterior segment. This scan demonstrates all anterior segment structures, in‐ cluding anterior lens surface, iris, and ciliary body. In UBM, frequencies of 35-50 MHz and above provide over a three‐ fold improvement in resolution compared with conventional ophthalmic ultrasound systems **(b)**. **b.** Conventional Bmode ultrasound image of the posterior segment. **c and d.** UBM image of the normal **(c)** and the PAC anterior segment **(d)**. Note the shallow anterior chamber depth of the PAC compared with the normal. **e and f.** UBM image of the anterior segment of the PACG patient before **(e)** and after laser iridotomy **(f)**. Note the increase of anterior cham‐ ber depth after laser iridotomy (LI). Arrow indicates the portion of the LI. **g and h.** UBM image of the anterior segment of the PACG patient before **(g)** and after cataract surgery (phacoemulsification and intraocular lens implantation) **(h)**. Note the increase of anterior chamber depth after cataract surgery.


*3.3. Stage 3—Secondary Analysis*

Once the initial analysis of data had been undertaken using the pre-determined categories identified through the focus group, significant amounts of data remained uncoded. Accordingly, a secondary stage of analysis was undertaken to code and analyse these uncoded data, using an inductive coding approach with Nvivo software in order to allow themes and categories to emerge. This approach yielded four additional main themes with dependent sub-themes, which illustrated more of the complexity under discussion, as represented in the following tree map of the theme density (Figure 2). *3.3. Stage 3—Secondary Analysis*  Once the initial analysis of data had been undertaken using the pre-determined categories identified through the focus group, significant amounts of data remained uncoded. Accordingly, a secondary stage of analysis was undertaken to code and analyse these uncoded data, using an inductive coding approach with Nvivo software in order to allow themes and categories to emerge. This approach yielded four additional main themes with dependent sub-themes, which illustrated more of the complexity under discussion, as represented in the following tree map of the theme density (Figure 2).

**Figure 2.** Emergent themes: coding density. Source: Graphic by author. **Figure 2.** Emergent themes: coding density. Source: Graphic by author.

#### 3.3.1. Epistemological Issues 3.3.1. Epistemological Issues

• Quality

musical quality is revealed:

The most significant of these complexities related to epistemological issues of "thinking differently" about music and what it "means" from the perspective of participation: The most significant of these complexities related to epistemological issues of "thinking differently" about music and what it "means" from the perspective of participation:

*It's given me an awareness of the importance of knowing how others see music, and that everyone experiences music differently; trying to understand that creates a better experience for all involved. (Q-2)*  It's given me an awareness of the importance of knowing how others see music, and that everyone experiences music differently; trying to understand that creates a better experience for all involved. (Q-2)

At the heart of these epistemological shifts is an awareness of the complexity of the notion of "quality" in musical contexts, which can be an especially tough shift to make for conservatoire students steeped in a culture of perfectionism. Elsewhere, I suggest that musical quality is contingent on its situation (Camlin 2015b, Camlin 2018), and it is in grappling with these contingencies that more of the complexity of

*happy with that. In some ways it's terrifying but incredibly helpful. (FG-7)*

*What this kind of work is doing is bringing you into contact with more of the*

14

What this kind of work is doing is bringing you into contact with more of the complexity of what music actually is in the world. It's more than what you might get within a training environment, [where] it's very easy to stay in a box and be happy with that. In some ways it's terrifying but incredibly helpful. (FG-7)

• Quality

At the heart of these epistemological shifts is an awareness of the complexity of the notion of "quality" in musical contexts, which can be an especially tough shift to make for conservatoire students steeped in a culture of perfectionism. Elsewhere, I suggest that musical quality is contingent on its situation (Camlin 2015b, 2018), and it is in grappling with these contingencies that more of the complexity of musical quality is revealed:

As a professional musician, realising the actual impact of music rather than the strive for perfection [is beneficial]. I think that the quality is different. There is less dependency on getting every individual note absolutely perfect and it's more to do with the overall feel and yourself as an educator as opposed to your ability to play any flat in tune. (FG-6)

There was also a recognition that quality is understood in different ways in different musical situations:

I disagree with [participatory music] being lesser [and the idea that] you don't have to audition to be a community musician. You do. It's just different skills. You have to be able to entertain an audience as a community musician, you have to connect. You have to have the chops and to be able to connect—it's a different audition. (FG-3)

Similarly, there was also a recognition that these standards of quality are not fixed, but they vary as the context changes between more presentational and more participatory dimensions of performance (Camlin 2015b, 2018):

I think if you have [an] ensemble that get[s] together just for the community aspect or a bit of therapy or stress relief, that's got a very different dynamic to "okay we've got this community based ensemble, and we're all from the local area, but we've got a concert in three weeks. We need to deliver this concert. All of a sudden the dynamic changes because you're showcasing what you've got. You leave the safety of your space, your room. You're opening up to the public and everyone wants it to be good. (FG-7)


*4.2.1 Methods*

Yeast alpha-glucosidase inhibitory activity was measured using methods reported before [52] with modifications as described in Suruga et al. [10]. Briefly, yeast alpha-glucosidase was incubated with fermented soybean extract solutions and then p-nitrophenyl α-D-glucopyranoside (pNP-glucoside) was added and absorbance was determined at 400 nm. For the mammalian reaction, alpha glucosidase from rat

*Medicinal Mushroom Mycelia: Characteristics, Benefits, and Utility in Soybean Fermentation DOI: http://dx.doi.org/10.5772/intechopen.102522*

**Table 1.**

*Total phenolic content and antioxidant activity of soybeans fermented by mushroom mycelia [10].*

intestinal acetone powder [53] was incubated with fermented soybean extract and the amount of glucose released was measured. We also used maltose as the substrate and calculated the % inhibition rate of alpha glucosidase [54].