**1. Multivessel disease**

### **1.1 Introduction**

The revascularization of multivessel disease (MVD) has advanced considerably and has gone through periods where angioplasty with the advent of conventional stents (BMS) was competitive with surgery [1]. After the incorporation of drugeluting stents (DES) with the significant reduction of the revascularization of the treated vessel, it was thought that the percutaneous coronary intervention (PCI) would be superior to coronary artery bypass graph (CABG), with the advent of the SYNTAX trial [2], which also incorporated an anatomical score that revolutionized the way of stratifying the patients. Although this trial used stents that are not

currently marketed, called first-generation DES, later came trials with secondgeneration stents that also failed to achieve the desired results [3]. An important element was the incorporation of the in vivo functional study of the lesion and its relation with the prognosis, which is the fractional flow of reserve (FFR) [4] and their instantaneous wave-free ratio (iwFR) [5], which gave a physiological view of the coronary disease and its treatment, although its use in stable patients such as the ORBITA trial [6] failed both by design and by results, since 85% of patients are finally revascularized, and the first randomized trial to assess functional lesion testing before CABG found patients who underwent FFR before CABG experienced similar rates of graft failure at 6 months as those who received angiography-guided by surgery [7]. We re-evaluated the SYNTAX score [8] first, and thus we generated an ERACI score [9] more in line with the modern treatment of severe and rational injuries at the time of complete revascularization, targeting medium-to-large caliber vessels, since only 70% lesions were included and vessel lesions larger than 2 mm were included.

#### **1.2 Main trails of PCI vs. CABG and meta-analysis in MVD**

In our Argentine Randomized Trial of Coronary Angioplasty With Stenting vs. Coronary Bypass Surgery in Patients With Multivessel Disease (ERACI II) 1, where patients were randomized to PCI with BMS vs. CABG after 5 years of follow-up, there were no significant differences in the mortality of all causes, PCI 7.1% vs. CABG 11.5%, p = 0.182. In terms of nonfatal MI, the incidence was 6.2% in the CABG group and 2.8% in the PCI group (p = 0.128), where a significant difference was observed in the need for new revascularization, 7.2% in the CABG group and 28.4% in the PCI group (p = 0.0002). MACCE was also larger in the PCI group than in the CABG, 24.5% vs. 34.7% (p = 0.019). A high rate of patients was asymptomatic without significant differences in both groups. The first randomized trial of patients with first-generation DES vs. CABG and with the creation of an anatomical score to assess severity divided the patients into three groups. This score was based on obstructions of at least 50% in vessels greater than 1.5 mm. Although this very basic score served to stratify patients, the SYNTAX study [2] compared CABG and PCI, followed by placement of paclitaxel-eluting stent in patients with MVD or left main disease (LMCA) or both. At 5 years of follow-up, it was observed that the MACCE between the two groups was significantly higher for the PCI group 37.3% than with the 26.9% CABG (p < 0.0001). The MI and the TVR was significantly higher in the PCI group than with surgery, but the mortality of all causes as well as the stroke was not significantly different between the two groups. When analyzed by groups, in the SYNTAX of low score ≤ 22, the MACCE was similar between both groups, but when analyzing intermediate scores 23–32 and high ≥33, it was significantly higher with PCI commensurate with CABG. The randomized trial was subsequently carried out with the so-called second-generation DES. In the Randomized CABG and Everolimus-Eluting Stent EES Implantation in the Treatment of Patients with MVD, the BEST trial [3] was performed in 27 sites in East Asia and showed PCI with placement of EES. This study had as its primary end point the composite events of death, MI, and TVR. At 2 years of follow-up, it was observed that there were no significant differences with 11% events in the PCI group compared with 7.9% in the CABG group (p = 0.32 for non-inferiority). In the long-term follow-up (4.6 years on average), the events of the primary end point occurred in 15.3% of patients in the PCI group and in 10.6% of those in the CABG group (p = 0.04). This is due to an excess of new interventions in the PCI group, since the TVR was significantly higher in the PCI group (11.0% vs. 5.4%, p = 0.003). There were no significant differences in mortality between the two groups, 6.6% in the PCI group and

**5**

**1.4 ERACI risk score**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

5% in the CABG group (p = 0.30), as well as with the stroke (2.5 and 2.9%, respectively; p = 0.72). The MI was higher in the PCI group than the CABG 4.3% vs. 1.6%, respectively p = 0.02. A recent meta-analysis of Brazilian origin [10] that includes randomized clinical trials (RCT) of multivessel disease performed a group analysis. They identified a total of 15 RCT that satisfied the requirements. The following results were obtained in the pooled data (n = 12,781). Thirty-day mortality and stroke were lower with PCI (1% vs. 1.7%, p = 0.01; and 0.6% vs. 1.7%, p < 0.0001). There was no difference in 1- and 2-year mortality (3.3% vs. 3.7%, p = 0.25; 6.3% vs. 6.0%, p = 0.5). Long-term mortality favored CABG (10.6% vs. 9.4%, p = 0.04), particularly in trials of DES era (10.1% vs. 8.5%, p = 0.01). In diabetics (DM) (n = 3274) long-term mortality favored CABG (13.7% vs. 10.3%, p < 0.0001). In six trials of LMCA (n = 4700), there was no difference in 30-day mortality (0.6% vs. 1.1%, p = 0.15), 1-year mortality (3% vs. 3.7%, p = 0.18), and long-term mortality (8.1% vs. 8.1%) between PCI and CABG. The incidence of stroke was lower with PCI (0.3% vs. 1.5%, p < 0.001). DM and a high SYNTAX score were the subgroups

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

that influenced more adversely the results of PCI (**Table 1**).

**1.3 "Functional" complete or anatomic complete revascularization**

The fractional flow reserve allows to measure the functional capacity of a stenosis, and if it establishes a threshold of 0.80 (which is equivalent to a maximum intracoronary pressure drop of 20%), it determines a degree of ischemia. In fact, the use of this guide in patients with MVD showed that residual angiographic lesions that were functionally nonsignificant did not cause worse evolution [11] and thus indicated that they do not need treatment, giving a complete revascularization (CR) functional rather than anatomical, since the degree of injury is less important than its functional impact, as well as the magnitude of the territory that irrigates. However, the concept of "functional" CR with PCI was introduced many years ago even when FFR was not available. The ERACI I one of the first randomized clinical trials between PCI and CABG in MVD [12] showed similar outcomes in patients with complete "functional" revascularization achieved with PCI and guided by noninvasive tests and in those with complete "anatomic" revascularization achieved with CABG.

The ERACI IV study [13] was a multicenter, observational, and prospective registry with a second-generation DES in patients with MVD and LMCA. We built a score based on our experience in the treatment of patients with more realistic MVD; since our group led by Dr Rodriguez et al. aimed to treat more critical vessel lesions that irrigate a significant territory, based on this concept we created the ERACI score (ES) by modifying the SYNTAX score (SS), as well as the difference between the treated and residual lesions, their corresponding residual ES or residual SS. This reformulated score included lesions greater than or equal to 70% in vessels larger than 2 mm. The analysis of the bifurcations and CTO was preserved as in the previous score. We included in a novel way the restenosis of the treated vessel that was cataloged as a severely calcified lesion. The rest of the variables were preserved as in the previous score [9] (**Figure 1**). The rationality of this revised score was previously published in our *Journal of Interventional Cardiology* of Argentina (RACI) 3 years ago [9]. With this new modality of scoring with the ES in the ERACI IV study, more than half of the patients had a low ES, and only 17% of the patients had a high score, in contrast to the SS that 34% of the patients were with a high score. The first analysis of this data is that with this score patients are re-categorized into a lower-risk group so they could be treated with either PCI or CABG. When we analyzed the residual untreated

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

5% in the CABG group (p = 0.30), as well as with the stroke (2.5 and 2.9%, respectively; p = 0.72). The MI was higher in the PCI group than the CABG 4.3% vs. 1.6%, respectively p = 0.02. A recent meta-analysis of Brazilian origin [10] that includes randomized clinical trials (RCT) of multivessel disease performed a group analysis. They identified a total of 15 RCT that satisfied the requirements. The following results were obtained in the pooled data (n = 12,781). Thirty-day mortality and stroke were lower with PCI (1% vs. 1.7%, p = 0.01; and 0.6% vs. 1.7%, p < 0.0001). There was no difference in 1- and 2-year mortality (3.3% vs. 3.7%, p = 0.25; 6.3% vs. 6.0%, p = 0.5). Long-term mortality favored CABG (10.6% vs. 9.4%, p = 0.04), particularly in trials of DES era (10.1% vs. 8.5%, p = 0.01). In diabetics (DM) (n = 3274) long-term mortality favored CABG (13.7% vs. 10.3%, p < 0.0001). In six trials of LMCA (n = 4700), there was no difference in 30-day mortality (0.6% vs. 1.1%, p = 0.15), 1-year mortality (3% vs. 3.7%, p = 0.18), and long-term mortality (8.1% vs. 8.1%) between PCI and CABG. The incidence of stroke was lower with PCI (0.3% vs. 1.5%, p < 0.001). DM and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI (**Table 1**).

#### **1.3 "Functional" complete or anatomic complete revascularization**

The fractional flow reserve allows to measure the functional capacity of a stenosis, and if it establishes a threshold of 0.80 (which is equivalent to a maximum intracoronary pressure drop of 20%), it determines a degree of ischemia. In fact, the use of this guide in patients with MVD showed that residual angiographic lesions that were functionally nonsignificant did not cause worse evolution [11] and thus indicated that they do not need treatment, giving a complete revascularization (CR) functional rather than anatomical, since the degree of injury is less important than its functional impact, as well as the magnitude of the territory that irrigates. However, the concept of "functional" CR with PCI was introduced many years ago even when FFR was not available. The ERACI I one of the first randomized clinical trials between PCI and CABG in MVD [12] showed similar outcomes in patients with complete "functional" revascularization achieved with PCI and guided by noninvasive tests and in those with complete "anatomic" revascularization achieved with CABG.

#### **1.4 ERACI risk score**

*The Current Perspectives on Coronary Artery Bypass Grafting*

**1.2 Main trails of PCI vs. CABG and meta-analysis in MVD**

In our Argentine Randomized Trial of Coronary Angioplasty With Stenting vs. Coronary Bypass Surgery in Patients With Multivessel Disease (ERACI II) 1, where patients were randomized to PCI with BMS vs. CABG after 5 years of follow-up, there were no significant differences in the mortality of all causes, PCI 7.1% vs. CABG 11.5%, p = 0.182. In terms of nonfatal MI, the incidence was 6.2% in the CABG group and 2.8% in the PCI group (p = 0.128), where a significant difference was observed in the need for new revascularization, 7.2% in the CABG group and 28.4% in the PCI group (p = 0.0002). MACCE was also larger in the PCI group than in the CABG, 24.5% vs. 34.7% (p = 0.019). A high rate of patients was asymptomatic without significant differences in both groups. The first randomized trial of patients with first-generation DES vs. CABG and with the creation of an anatomical score to assess severity divided the patients into three groups. This score was based on obstructions of at least 50% in vessels greater than 1.5 mm. Although this very basic score served to stratify patients, the SYNTAX study [2] compared CABG and PCI, followed by placement of paclitaxel-eluting stent in patients with MVD or left main disease (LMCA) or both. At 5 years of follow-up, it was observed that the MACCE between the two groups was significantly higher for the PCI group 37.3% than with the 26.9% CABG (p < 0.0001). The MI and the TVR was significantly higher in the PCI group than with surgery, but the mortality of all causes as well as the stroke was not significantly different between the two groups. When analyzed by groups, in the SYNTAX of low score ≤ 22, the MACCE was similar between both groups, but when analyzing intermediate scores 23–32 and high ≥33, it was significantly higher with PCI commensurate with CABG. The randomized trial was subsequently carried out with the so-called second-generation DES. In the Randomized CABG and Everolimus-Eluting Stent EES Implantation in the Treatment of Patients with MVD, the BEST trial [3] was performed in 27 sites in East Asia and showed PCI with placement of EES. This study had as its primary end point the composite events of death, MI, and TVR. At 2 years of follow-up, it was observed that there were no significant differences with 11% events in the PCI group compared with 7.9% in the CABG group (p = 0.32 for non-inferiority). In the long-term follow-up (4.6 years on average), the events of the primary end point occurred in 15.3% of patients in the PCI group and in 10.6% of those in the CABG group (p = 0.04). This is due to an excess of new interventions in the PCI group, since the TVR was significantly higher in the PCI group (11.0% vs. 5.4%, p = 0.003). There were no significant differences in mortality between the two groups, 6.6% in the PCI group and

2 mm were included.

currently marketed, called first-generation DES, later came trials with secondgeneration stents that also failed to achieve the desired results [3]. An important element was the incorporation of the in vivo functional study of the lesion and its relation with the prognosis, which is the fractional flow of reserve (FFR) [4] and their instantaneous wave-free ratio (iwFR) [5], which gave a physiological view of the coronary disease and its treatment, although its use in stable patients such as the ORBITA trial [6] failed both by design and by results, since 85% of patients are finally revascularized, and the first randomized trial to assess functional lesion testing before CABG found patients who underwent FFR before CABG experienced similar rates of graft failure at 6 months as those who received angiography-guided by surgery [7]. We re-evaluated the SYNTAX score [8] first, and thus we generated an ERACI score [9] more in line with the modern treatment of severe and rational injuries at the time of complete revascularization, targeting medium-to-large caliber vessels, since only 70% lesions were included and vessel lesions larger than

**4**

The ERACI IV study [13] was a multicenter, observational, and prospective registry with a second-generation DES in patients with MVD and LMCA. We built a score based on our experience in the treatment of patients with more realistic MVD; since our group led by Dr Rodriguez et al. aimed to treat more critical vessel lesions that irrigate a significant territory, based on this concept we created the ERACI score (ES) by modifying the SYNTAX score (SS), as well as the difference between the treated and residual lesions, their corresponding residual ES or residual SS. This reformulated score included lesions greater than or equal to 70% in vessels larger than 2 mm. The analysis of the bifurcations and CTO was preserved as in the previous score. We included in a novel way the restenosis of the treated vessel that was cataloged as a severely calcified lesion. The rest of the variables were preserved as in the previous score [9] (**Figure 1**). The rationality of this revised score was previously published in our *Journal of Interventional Cardiology* of Argentina (RACI) 3 years ago [9]. With this new modality of scoring with the ES in the ERACI IV study, more than half of the patients had a low ES, and only 17% of the patients had a high score, in contrast to the SS that 34% of the patients were with a high score. The first analysis of this data is that with this score patients are re-categorized into a lower-risk group so they could be treated with either PCI or CABG. When we analyzed the residual untreated

**7**

**Study** FREEDOM [67]

Va-Cards [73]

BEST [3] EXCEL [31] NOBLE [30]

Europe

2008–2015

982

LMCAD

DES (Biolimus)

*AWESOME, Angina With Extremely Severe Outcomes; ERACI II, Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multivessel Disease;*

*MASS II, Medicine, Angioplasty, or Surgery Study; ARTS, Arterial Revascularization Therapies Study; SOS, Stent or Surgery trial. SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery;*

*CARDia: Coronary Artery Revascularization in Diabetes; Le Mans, Left Main Coronary Artery Stenting; FREEDOM, Future Revascularization Evaluation in Patients with Diabetes Mellitus; Va-Cards,*

*Coronary Artery Revascularization in Diabetes in VA Hospitals; BEST, Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease;*

*PRECOMBAT, Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; EXCEL, Coronary Artery*

*Bypass Surgery for Effectiveness of Left Main Revascularization; NOBLE, Nordic-Baltic-British Left Main Revascularization Study [81]. DES, drug-eluting stents; BMS, bare-metal stent.*

*Modified from "Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation" (Pedro José Negreiros*

*de Andrade, João Luiz de Alencar Araripe Falcão, Breno de Alencar Araripe Falcão, Hermano Alexandre Lima Rocha)*

**Table 1.**

*Overview of the main trials of MVCAD and LMCAD.*

18

60

16

18

International

2010–2014

1905

LMCAD

DES (Everolimus)

37

57

29

25

Korea

2008–2013

880

2v and 3v

DES (Everolimus)

42

59

64

45

USA

2006–2010

198

2v and 3v

DES, only DBT

Nd

Nd

Nd

100

International

2005–2010

1900

2v and 3v

DES, only DBT

30

65

19

100

The primary outcome occurred more frequently in the PCI

group (p = 0.005), with 5-year rates of 26.6% in the PCI

group and 18.7% in the CABG group

At 2 years, all-cause mortality was 5.0% for CABG and

21% for PCI (HR, 0.30; 95% CI, 0.11–0.80); nonfatal

myocardial infarction was 15% for CABG and 6.2% for

PCI (HR, 3.32; 95% CI, 1.07–10.30)

MACE at 4.6 years: 15.3% for PCI vs. 10.6% for CABG

(p = 0.04)

At 3 years, a primary end-point event had occurred in

15.4% in the PCI group and in 14.7% in the CABG group

(p = 0.02 for non-inferiority; HR, 1.00; 95% CI, 0.79–1.26;

p = 0.98 for superiority)

Kaplan-Meier 5-year MACCE was 28% for PCI and 18%

for CABG (HR, 1·51; 95% CI, 1·13–2·00; p = 0·0044)

**Origin**

**Date**

**N**

**MVD**

**Characteristics**

**UA**

**EF**

**Offpump**

**DM**

**Outcome**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

**Table 1.** *Overview of the main trials of MVCAD and LMCAD.*

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

*The Current Perspectives on Coronary Artery Bypass Grafting*

**6**

**Study** AWESOME [76]

ARTS [77, 78]

ERACI II [1]

SOS [79] MASS II [80] LEMANS [29]

SYNTAX [2] CARDia [74] Boudriot et al.

Germany

2003–2009

201

LMCAD

DES (Sirolimus)

ND

ND

46

30

[81]

PRECOMBAT

Korea

2003–2009

600

LMCAD

DES (Everolimus)

45

60

64

42

[28]

UK

2002–2007

510

2v and 3v

BMS and DES, only

22

59

31

100

DBT

Europe and

2005–2007

1800

LM and 3v

DES Taxus

28

Nd

15

35

USA

Poland

2001–2004

105

LMCAD

BMS and DES, DES

32

53

0

25

if LM < 3.8

Brazil

1995–2000

408

2v and 3v

BMS, clinical arm

36

65

0

30

Europe and

1995–1999

988

2v and 3v

BMS, majority 2v

33

Nd

3

15

Canada

Argentina

1196–1998

450

2v and 3v

BMS, majority UA

92

ND

0

17

International

1997–2000

1205

2v and 3v

BMS, majority 2v

30

61

0

21

USA

1995–2000

454

2v and 3v

BMS, CABG

36

45

0

32

Survival rates for CABG and PCI were 79% versus 80% at

36 months (log-rank test, p = 0.46)

Event-free survival at 5 years: 58.3% for PCI vs. 78.2% for

CABG (p < 0.0001)

Freedom from MACE at 5 years was lower with PCI than

with CABG (65.3% vs. 76.4%; p = 0.013)

At a median follow-up of 6 years, 53 patients (10.9%)

died in the percutaneous coronary intervention group

compared with 34 (6.8%) in the CABG group (HR, 1.66;

95% CI, 1.08–2.55; p = 0.022)

The 10-year survival rates were 74.9% with CABG, 75.1%

with PCI, and 69% with MT (p = 0.089)

At 10 years, the mortality of PCI vs. CABG was (21.6% vs.

30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28)

5-year MACCE in all: 37.3% for PCI vs. 26.9% for CABG

(p < 0.001)

5-year MACCE in 3 VD: 37.5% for PCI vs. 24.2% for CABG

(p < 0.001)

At 1 year of follow-up, the composite rate of death, MI,

and stroke was 10.5% in the CABG group and 13.0% in the

PCI group (HR, 1.25; 95% CI, 0.75–2.09; p = 0.39)

At 1 year of follow-up, the combined primary end point

was 13.9% of patients after surgery, as opposed to 19.0%

after PCI (p = 0.19 for non-inferiority)

At 5 years, MACCE in PCI group and the CABG group

(cumulative event rates of 17.5% and 14.3%, respectively;

HR, 1.27; 95% CI, 0.84–1.90; p = 0.26)

previous

**Origin**

**Date**

**N**

**MVD**

**Characteristics**

**UA**

**EF**

**Offpump**

**DM**

**Outcome**

#### **Figure 1.**

*Modification of the SYNTAX score by ERACI score, with residual SYNTAX and ERACI scores and its implications. SYNTAX score = 28 points (red and white arrows). Hypothetically the patients need 4 DES. Modified ERACI score, in the ERACI IV, the SYNTAX score (only the red arrows) was 16 points = patient received 2 DES. The residual ERACI score was 3.5. If the patient was scored with the SYNTAX score, he would have had 17 residual SYNTAX score.*

lesions between these two scores, we also found significant differences between these two groups of patients since with RSS it was 8.7 ± 5.9 vs. and with RES it was 3.5 ± 4.6, p = 0.003. In addition, reasonably incomplete revascularization was defined, defined by a residual of ≤5 (**Table 2**). If we take the RSS, only 35% of the patients reached this goal, but if we analyze it with the RES, they reached 80%, which suggests that most patients achieved a functional rather than an anatomical revascularization (**Table 2**). This could be corroborated in the long-term follow-up where these patients had a MACCE less than 10% at 3 years of follow-up. In addition, this score was validated in another trial of our group called the WALTZ registry [14]. A total of 201 real-life patients were included prospectively, in 11 centers in the Argentine Republic using the same criteria of ERACI IV. The study design, as well as the rationale, was previously published [15]. When we performed the analysis regarding the scores, we found a significant difference with respect to the baseline (SS 11.8 + 6.8 vs. ES 7.8 + 5.3, p = 0.0016), and the same happened with the residual (RSS 5.4 + 5.6 vs. RES 1.3 + 2.9, p < 0.001). The analysis that we carry out is that the presence of

**9**

**1.5 Guidelines**

**Table 2.**

**1.6 Ongoing trials**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

Low group 33.8% 54.8% < 0.001 Intermediate group 32.4% 27.9% = 0.35 High group 33.8% 17.2% <0.001 Baseline mean 27.7 ± 11.3 22 ± 11.02 =0.0004 Residual mean 8.7 ± 5.9 3.5 ± 4.6 =0.003 Residual ≤5 35% 80% <0.001 Residual <8 48% 93.5% =0.002 *From "Lowering Risk Score Profile During PCI in Multiple Disease is Associated with Low Adverse Events: The ERACI Risk Score" (Alfredo E. Rodriguez, Carlos Fernandez-Pereira, Juan Mieres, Hernan Pavlovsky, Juan del Pozo,*

Number of patients (n) 225 225

*Alfredo M. Rodriguez-Granillo, David Antoniucci, On behalf of ERACI IV Investigators)*

*Differences in baseline and residual risk scores: ERACI IV registry.*

**SYNTAX score ERACI score P value**

neoatherosclerosis [16] that we believe is also present in the second- and thirdgeneration stents is a growing concern, which is why this more rational strategy of the use of these devices can lead to better results long term. When we look closely at the results of the Syntax II study where iwFR was used, we can verify that the conservative strategy is beneficial [17]. When we compare the PCI group guided by the iwFR with the SYNTAX I in the PCI group, we find a decrease in MI and MACCE, similar to the SYNTAX I CABG group. SYNTAX II treated fewer lesions per patient than SYNTAX I (2.6 vs. 4, p < 0.001) and then implanted fewer stents per patient (3.8% vs. 5.2%, p < 0.001) despite the fact that the two groups of patients were scored similarly, with SS (p = 0.16). These results are consistent with our ERACI IV trial. We also have to recognize that the FFR analysis has numerous limitations, among them it can be technically difficult in segments of diffuse disease, tandem lesions and bifurcation lesions. When performed in patients with severe aortic stenosis, the evaluation is more complex to analyze. Also you have to assume the cost of catheters that cannot be ignored. It is also important to mention that studies of CABG guided by FFR [18] have not achieved the expected results when compared when guided by angiography, and studies such as FAME 2 comparing optimal medical treatment vs. guided PCI

have not observed reduction in MI or long-term mortality [19].

The evidence suggests that in MVD without DM and low anatomical complexity, PCI and CABG achieve similar long-term outcomes with respect to survival and the composite of death, MI, and stroke, justifying a class I recommendation for PCI. Consistent results were also obtained for patients with MVD in the recent individual patient-level meta-analysis. Thus, the previous class III recommendation for PCI in MVD and intermediate-to-high complexity was maintained [20]. The intermediate and high SYNTAX scores are associated with better evolution with the CABG. Although this score is very limited and impractical for its application, its use for making decisions in patients with MVD is reasonable [21]. The ERACI score could be more rational for making decisions due to being more realistic and conservative [9].

The Prospective Multicenter Registry of Hybrid Coronary Artery Revascularization

Combined with Surgical Bypass and Percutaneous Coronary Intervention Using

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

*From "Lowering Risk Score Profile During PCI in Multiple Disease is Associated with Low Adverse Events: The ERACI Risk Score" (Alfredo E. Rodriguez, Carlos Fernandez-Pereira, Juan Mieres, Hernan Pavlovsky, Juan del Pozo, Alfredo M. Rodriguez-Granillo, David Antoniucci, On behalf of ERACI IV Investigators)*

#### **Table 2.**

*The Current Perspectives on Coronary Artery Bypass Grafting*

lesions between these two scores, we also found significant differences between these two groups of patients since with RSS it was 8.7 ± 5.9 vs. and with RES it was 3.5 ± 4.6, p = 0.003. In addition, reasonably incomplete revascularization was defined, defined by a residual of ≤5 (**Table 2**). If we take the RSS, only 35% of the patients reached this goal, but if we analyze it with the RES, they reached 80%, which suggests that most patients achieved a functional rather than an anatomical revascularization (**Table 2**). This could be corroborated in the long-term follow-up where these patients had a MACCE less than 10% at 3 years of follow-up. In addition, this score was validated in another trial of our group called the WALTZ registry [14]. A total of 201 real-life patients were included prospectively, in 11 centers in the Argentine Republic using the same criteria of ERACI IV. The study design, as well as the rationale, was previously published [15]. When we performed the analysis regarding the scores, we found a significant difference with respect to the baseline (SS 11.8 + 6.8 vs. ES 7.8 + 5.3, p = 0.0016), and the same happened with the residual (RSS 5.4 + 5.6 vs. RES 1.3 + 2.9, p < 0.001). The analysis that we carry out is that the presence of

*points = patient received 2 DES. The residual ERACI score was 3.5. If the patient was scored with the SYNTAX*

*Modification of the SYNTAX score by ERACI score, with residual SYNTAX and ERACI scores and its implications. SYNTAX score = 28 points (red and white arrows). Hypothetically the patients need 4 DES. Modified ERACI score, in the ERACI IV, the SYNTAX score (only the red arrows) was 16*

**8**

**Figure 1.**

*score, he would have had 17 residual SYNTAX score.*

*Differences in baseline and residual risk scores: ERACI IV registry.*

neoatherosclerosis [16] that we believe is also present in the second- and thirdgeneration stents is a growing concern, which is why this more rational strategy of the use of these devices can lead to better results long term. When we look closely at the results of the Syntax II study where iwFR was used, we can verify that the conservative strategy is beneficial [17]. When we compare the PCI group guided by the iwFR with the SYNTAX I in the PCI group, we find a decrease in MI and MACCE, similar to the SYNTAX I CABG group. SYNTAX II treated fewer lesions per patient than SYNTAX I (2.6 vs. 4, p < 0.001) and then implanted fewer stents per patient (3.8% vs. 5.2%, p < 0.001) despite the fact that the two groups of patients were scored similarly, with SS (p = 0.16). These results are consistent with our ERACI IV trial. We also have to recognize that the FFR analysis has numerous limitations, among them it can be technically difficult in segments of diffuse disease, tandem lesions and bifurcation lesions. When performed in patients with severe aortic stenosis, the evaluation is more complex to analyze. Also you have to assume the cost of catheters that cannot be ignored. It is also important to mention that studies of CABG guided by FFR [18] have not achieved the expected results when compared when guided by angiography, and studies such as FAME 2 comparing optimal medical treatment vs. guided PCI have not observed reduction in MI or long-term mortality [19].

#### **1.5 Guidelines**

The evidence suggests that in MVD without DM and low anatomical complexity, PCI and CABG achieve similar long-term outcomes with respect to survival and the composite of death, MI, and stroke, justifying a class I recommendation for PCI. Consistent results were also obtained for patients with MVD in the recent individual patient-level meta-analysis. Thus, the previous class III recommendation for PCI in MVD and intermediate-to-high complexity was maintained [20]. The intermediate and high SYNTAX scores are associated with better evolution with the CABG. Although this score is very limited and impractical for its application, its use for making decisions in patients with MVD is reasonable [21]. The ERACI score could be more rational for making decisions due to being more realistic and conservative [9].

#### **1.6 Ongoing trials**

The Prospective Multicenter Registry of Hybrid Coronary Artery Revascularization Combined with Surgical Bypass and Percutaneous Coronary Intervention Using

Everolimus-Eluting Metallic Stents evaluates the efficacy of hybrid coronary revascularization (HCR) combining CABG and PCI in the treatment of MVD. CABG is to be performed in the left anterior descending artery and the left circumflex artery using only arterial grafts, whereas PCI is to be conducted for the treatment of the right coronary artery with everolimus-eluting stents (EESs) [22]. The Comparison of One-stop Hybrid Revascularization vs. Off-pump Coronary Artery Bypass for the Treatment of Multi-vessel Disease combines minimally invasive direct CABG and PCI to be performed in the hybrid operating suite, an enhanced operating room equipped with radiographic capability [23].

### **1.7 Conclusions**

In our long experience in the treatment of MVD for more than two decades and according to our score, we believe that the stratified treatment can be divided into two groups, patients with low and intermediate scores in whom the results of PCI are comparable with surgery. The other group of patients are those with high scores, we think that the current state-of-the-art CABG is the treatment of choice. However, with the increase in stent technology this difference can be reduced.


3.3.2. Residual Compressive Strength

The residual compressive strength of Csample and Asample at different temperature and cooling regimes is shown in Table 8. For both cooling types, the residual compressive strength increases at 200 ◦C and achieved a maximum strength for Csample and Asample. At 400 ◦C, the Csample has the least strength loss of 41% and 43% for AC and WC, respectively. For 600 ◦C, the loss trend continues to increase for both types of samples and achieved a maximum loss of compressive strength at 800 ◦C. 78% (AC) and 80% (WC) of strength loss gained by Csample which is the highest loss of compressive strength, compared with Asample with 65% (A/C) and 66% (W/C) loss.

**Table 8.** Residual compressive strength of samples exposed at different temperature.

According to a previous researcher [40], geopolymer concrete strength was enhanced in heat conditions. Changes in chemical structure and the dehydration of free and chemically-bound water was caused from the exposure to high temperature. As the temperature increases, the moisture particles inside the samples tend to escape to the surface.

In this research, it was proved that fly ash geopolymer concrete (Asample and Csample) does not complete a geopolymerization process until 28 days have passed. Within 200 ◦C exposure, both type of samples gain an improvement in terms of strength and also the matrix structure. These are associated with the reported changes in the value of compressive strength after exposure.

It is seen that the water molecule is expelled from the geopolymer concrete during the presence of heat, which improves the strength of the concrete and also leads to the discontinuous nano-pores of the matrix. It is possible that not all water molecules were expelled due to high temperature, especially in a larger sample. Higher surface tensions in larger samples will dissipate moisture at slower rates compared to in smaller samples.

Starting from 400 ◦C, 600 ◦C and 800 ◦C levels of heat exposure, the the compressive strength decreased for both type of samples. But in the presence of bamboo ash, the residual compressive strength of Asample tends to show a positive result at 800 ◦C where the strength is higher compared to Csample.

This clearly shows that at 800 ◦C, the presence of bamboo ash contains potassium oxide, thus producing a significant compressive strength compared to Csample. If alkali metal oxides content is above a certain limit, it exhibits a high coefficient of thermal expansion. With the presence of bamboo ash at high temperature, the tendency of the oxides lead to change its shape to have a higher area and volume. Thus, more solid and packed molecules are formed and provide better structural components for the geopolymer concrete.

#### 3.3.3. Ultrasonic Pulse Velocity (UPV) Value after Exposure

The change in UPV value due to exposure to high temperature is depicted in Table 9. The UPV values at the initial temperature (27 ◦C) were 3854 m/s (AC) and 3850 m/s (WC) for Csample, and 3810 m/s (AC) and 3802 m/s (WC) for Asample. UPV value increases at 200 ◦C yielded values of 4451 m/s (AC) and 4417 m/s (W/C) for Csample, and 4438 m/s (AC) and 4394 m/s (WC) for Asample, which is the highest value among all studied temperature. At 400 ◦C, the trends changed, after which the Csample experienced UPV losses of 13.3% (AC) and 14.0% (WC) compared to Asample, which experienced 12.9% (AC) and 16.1% (WC) UPV losses. At 600 ◦C, the loss trends continued to increase and achieved a maximum loss at 800 ◦C for both types of samples. 67.8% (AC) and 64.7% (WC) losses was achieved by Csample, while 42.8% (WC) and 45.1% (AC) were achieved for Asample. The Asample exhibited a smaller loss of UPV compared to Csample. Generally, the reduction of the velocity in the concrete was due to the deformation of the microstructure in the geopolymer concrete. A rise in the temperature increases the amount of air voids in the concrete samples. Thus, the transmission speed of sound waves decreased with the increase in the traveling time of the ultrasonic pulse transmission.

**Table 9.** UPV value after exposure to different temperatures.

The quality of the concrete can be classified based on Table 10 [47]. Based on Table 10 values, good quality concrete can be produced at 200 ◦C. It was proven that the highest compressive strength

corresponded with the highest UPV value. Apart from that, at 800 ◦C, Asample gained a higher UPV value compared to Csample, which corresponded with the residual compressive strength results.

**Table 10.** Quality of concrete based on UPV.


**2. Proposed techniques**

We have proposed a blind invisible watermarking technique for copyright protection of the colored images.

In blind techniques, during the extraction process original image is not required. Watermarking systems which involve marking imperceptible alteration on the cover data to convey the hidden information, is called invisible watermarking. Here 512\*512 grayscale image of 'peppers' is taken as host image and 32\*32 binary image is taken as watermark image.

Then implement second level wavelet transform on host image using wavelet function 'haar' and extracted middle level components (HL2, LH2) for embedding watermark. Middle level components are selected for embedding watermark as much of the signal energy lies at low-frequencies sub-band which contains the most important visual parts of the image and high frequency components of the image are usually removed through compression and noise attacks.

We have divided the HL2 and LH2 bands in to 4x4 blocks and applied DFT in these blocks and used to two highly uncorrelated pseudo random sequences (treated as key: key1) to embed watermarking message according to template matrix. We reshaped watermark image of 32x32 into a row vector of size 1024, called watermark message.

A template matrix is such a matrix whose size is 4x4 and elements are 0 and 1. Watermarking message is embedded into image blocks only in the position where the template matrix's element is 1. Through amounts of experiments, we found when the template matrix is set to [1,1,1,1;1,0,0,1;0,0,0,1;0,0,0,1]T,imperceptibility and robustness of the algorithm can get better balance. Here template matrix is used as a key2.

We have embedded watermark according to the (9) given below.

$$\mathbf{I}\_{\mathbf{w}}(\mathbf{x}, \mathbf{y}) = \mathbf{I}(\mathbf{x}, \mathbf{y}) + \mathbf{k} \ast \mathbf{W}(\mathbf{x}, \mathbf{y}) \tag{9}$$

In (9), *k* denotes a gain factor, and IW the resulting watermarked image, *I* the cover image and W the watermark to be embedded. Increasing *k* increases the robustness of the watermark at the expense of the quality of the watermarked image.

The algorithm for the proposed method is given below:

The watermark embedding steps are as follows:

We have proposed a blind invisible watermarking technique for copyright protection of the

In blind techniques, during the extraction process original image is not required. Watermarking systems which involve marking imperceptible alteration on the cover data to convey the hidden information, is called invisible watermarking. Here 512\*512 grayscale image of 'peppers' is taken as host image and 32\*32 binary image is taken as watermark

Then implement second level wavelet transform on host image using wavelet function 'haar' and extracted middle level components (HL2, LH2) for embedding watermark. Middle level components are selected for embedding watermark as much of the signal energy lies at low-frequencies sub-band which contains the most important visual parts of the image and high frequency components of the image are usually removed through compression and

We have divided the HL2 and LH2 bands in to 4x4 blocks and applied DFT in these blocks and used to two highly uncorrelated pseudo random sequences (treated as key: key1) to embed watermarking message according to template matrix. We reshaped watermark

A template matrix is such a matrix whose size is 4x4 and elements are 0 and 1. Watermarking message is embedded into image blocks only in the position where the template matrix's element is 1. Through amounts of experiments, we found when the template matrix is set to [1,1,1,1;1,0,0,1;0,0,0,1;0,0,0,1]T,imperceptibility and robustness of the

In (9), *k* denotes a gain factor, and IW the resulting watermarked image, *I* the cover image and W the watermark to be embedded. Increasing *k* increases the robustness of the

Implement second level wavelet transform on host Image H using wavelet function

Divide the HL2, LH2 components in several blocks of size 4x4 and DFT is applied to

Perform search to find highly uncorrelated pseudo random (PN) sequences (seq\_zero

Set gain factor K and embed the watermark to the cover image under the following

I x, y I x, y k W x, y w (9)

image of 32x32 into a row vector of size 1024, called watermark message.

algorithm can get better balance. Here template matrix is used as a key2.

We have embedded watermark according to the (9) given below.

watermark at the expense of the quality of the watermarked image.

'Haar' and Extract middle frequency components (LH2, HL2).

The algorithm for the proposed method is given below:

The watermark embedding steps are as follows:

and seq\_one) and use these as a key1. Defines the template matrix of an 4x4.

these blocks.

If wa(i,j) ==0 then

rule:

**2. Proposed techniques**

colored images.

image.

noise attacks.

```
If template(m,n)==1 then
I(m,n)=I(m,n) + K*seq_zero(m,n)
End
Else
if template(m,n)==1 then
I(m,n)=I(m,n)+K*seq_one(m,n)
End
End
Where 1≤ i ≤ M, 1≤ j ≤ N, and 1≤ m,n ≤ 4
Here I denotes to 4x4 DFT blocks.
```

The watermark extraction steps of this technique are as follows:

```
If corr_zero(i) > corr_one(i) then
watermark_detected(i)=0;
Else
watermark_detected(i)=1
```
End


*2.4. Primer Selection*

After Tandem repeat detection, a total of 13,264 SSRs were obtained. Then, after lobSTR processing, a total of 145 high quality SSRs and ranges were finally selected. Based on the predicted results of the SSRs, 12 pairs of specific primers were selected from the developed primer sequences, namely primer pairs Cun463, Cun378, Cun500, Cun626, Cun672, Cun586, Cun148, Cun752, Cun230, Cun27, Cun485, and Cun484 following the principle of high polymorphism at the loci. Each primer pair consisted of one forward primer and one reverse primer. The dosage ratio of the forward and reverse primers was 1:4 [27]. Furthermore, two fluorescently labeled universal primers M13 and PQE-F were included: the fluorescent marker that is compatible with the universal primer M13 is 5-FAM, and the fluorescent marker that is compatible with the universal primer PQE-F

is 5-HEX [28]. The 12 primer pairs were divided into two groups: G1 group primers, including Cun463, Cun378, Cun500, Cun626, Cun672, Cun586, and Cun148, and G2 group primers, including primer pairs Cun752, Cun230, Cun27, Cun485, and Cun484. Primers were synthesized by Beijing Rui Bo Xing Ke Biotechnology Co. Site names and primer sequences are listed, and the generic primer names and primer sequence information are shown in Table 1.

**Table 1.** Information about site combination and primer concentration of Multiplex PCR1 and Multiplex PCR2.

#### *2.5. Establishment of a Microsatellite Multiplex PCR Amplification System*

The reaction volume for multiplex PCR in both G1 and G2 groups was 25 μL. Specific information is shown in Table 2. For PCR amplification, the amplification procedure used was as follows: 98 ◦C for 10 s, 57 ◦C for 40 s, 72 ◦C for 60 s, 35 cycles; 98 ◦C for 10 s, 53 ◦C for 40 s, 72 ◦C for 60 s, 15 cycles; and 72 ◦C for 30 min for extension [26]. After PCR, 5 μL was taken on an agarose gel to detect bright bands of the desired size. Gel electrophoresis was used to confirm that the primers amplified the target bands. The remaining samples were sent to a commercial company (Beijing Ruibio BioTech Co., Ltd., Beijing, China) for genotyping using an ABI 3730XL sequencer.

**Table 2.** Group G1 and Group G2 multiplex PCR reaction system.

**Table 2.** *Cont.*

#### *2.6. Polymorphism Analysis*

The amplification products were subjected to capillary electrophoresis usingABI3730XL. Peak types were converted to alleles using GeneMarker (version <IP_ADDRESS>, SoftGenetics, Pennsylvania, USA) [29]. Genotype data were counted using GenAlex (version 6.5, ANU, Canberra, Australia) [30] and population genetics parameters were calculated including the number of individuals (N), number of different alleles (Na), number of effective alleles (Ne), observed heterozygosity (Ho), expected heterozygosity (He), unbiased expected heterozygosity(uHe), fixation index (F) and Hardy–Weinberg equilibrium (HW). The null allele frequency (F(null)) and polymorphism information content (PIC) were calculated using the software Cervus (version 3.0.7, Field Genetics, London, UK).


**5.2 Blood glucose and platelet functions in T1DM**

Although platelet hyperactivity in T1DM has partly been ascribed to hyperglycemia, however, empirical evidence has been conflicting. Study results have ranged from no effects, decreased to increased platelet functions. The ambiguity may be attributed to confounders, depending on study designs, dose, and duration of exposure. Specifically, non-diabetic or healthy controls do not have the coexisting inflammatory biomarker seen in diabetics (T1DM from T2DM) who additionally have hyperlipidemia. Thus, in diabetics, duration of disease determines the level of nonenzymatic glycation. The route of glucose administration also matters. Oral intake

is accompanied by post-prandial secretion of gut and counter regulatory hormones while direct or parenteral administration bypasses the gut, with *in vitro* mixing with platelet-rich plasma excluding the leukocytes contribution.

Bridges and coworkers [19] first demonstrated the link between blood glucose and platelet function. They showed that either a postprandial oral glucose load or intravenous infusion increased platelet stickiness in both diabetics and nob-diabetics. The observation has since been confirmed by others mostly in T2DM [68–71]. Surprisingly, in one study of hyperglycemia platelet p-selectin expression was decreased during hyperglycemia compared with levels before oral intake [72]. These results are confounded other factors concurrently activating platelets such as postprandial hyperglycemia on counter regulatory hormones [73], procoagulant platelet microparticles [74], combined effect with insulin [75, 76], neutrophil-megakaryocyte thrombopoiesis [16], and hyperlipidemia [25, 77, 78].

In order to avoid the many confounders inherent in *in vivo* hyperglycaemia, *in vitro* studies designed to define the particular role of glucose have yielded mixed results. It has been shown that *in vitro* incubation of healthy PRP platelets with glucose upto 50 mmol has no effect on agonist-induced aggregation to ADP, AA or collagen, secretion of MDA or TXB2 [79] indicating no direct effects on platelets. Many *in vitro* studies involving short incubation periods with varying concentrations of glucose have shown no effects [80, 81]. However, studies have shown that glucose paradoxically increases platelet aggregation or surface P-selectin expression depending on the type of agonist [82–85].

The discordance in effects of glucose on platelets can be explained by the duration of exposure. While acute or short duration of exposure is associated with no or minimal effects, longer duration or chronic exposure stimulates thrombopoiesis in which reticulocytes increase adhesive receptors and are hyperactive to agonists [16]. The duration of glucose exposure correlates with HbA1c levels [86]. Contrary to popular belief, hyperactive platelets are evident even before observable metabolic features in individuals predisposed to T1DM with normal blood [41]. Early evidence of the influence of glucose on platelet functions via metabolic reactions was provided by Murer et al. [87] and Chaudhry et al. [88]. The two groups reported the presence of aggregation in media containing glucose or substitute substrates, the extent of which was related to glucose consumption and carbon dioxide production due to metabolism. In these experiments, addition of metabolic inhibitors inhibited aggregation. Moreover, alterations of membrane properties and energy requiring processes have been noted upon incubation of platelets with varying glucose concentrations [18] suggesting other mechanisms are at play.

Several preclinical animal studies have confirmed the dependency of platelet functions on glucose uptake and subsequent metabolism [33, 89]. Under resting conditions, the plasma membrane localized GLUT-1 glucose transporter facilitates glucose entry into platelets, activation glycolysis, and ATP production [90]. Upon stimulation with agonists such as thrombin, alpha granules containing both P-selectin and GLUT-3 translocate and fuse with plasma membrane to increase glucose uptake [91]. The resulting alpha granules degranulation, glucose influx, and increased ATP synthesis lead to P-selectin expression and aggregation [33, 92].

It appears that hyperglycemia in itself has little bearing on platelet activation unless accompanied by other changes. In a study of T1DM and T2DM, despite postprandial elevation of blood glucose in both types, however, markers of platelet activation were only increased in T2DM. Interestingly, insulin levels did not change in T1DM unlike in T2DM. Administration of insulin pre-meal was accompanied

by increase of postprandial platelet activation markers [74, 76, 93]. However, platelet-activating effects of insulin in T1DM are evident only when there is concurrent hypoglycemia [94]. At low extracellular glucose, insulin potentiates action of thrombin to increase glucose entry via Glut-3 with concomitant increase in surface expression of P-selectin and aggregation. Conversely, at high glucose concentrations, insulin becomes inhibitory through its action on protein kinase B (PKB) and hampers thrombin activation mechanisms leading to decreased platelet activation and aggregation [92].


**4. Slovenian water protection legislation—the theory**

Slovenia is not a very old state. For centuries, it was a part of different Germanic kingdoms like Austro-Hungarian Empire, but in twentieth century, it mostly existed as a state in different connections of South Slavic federations (most recently in the socialistic Yugoslavia). In 1991, Slovenians finally managed to form our own state, and in 2004, we decided to join the European Union. Since the secession from Yugoslavia, a lot of legislation was taken over from Yugoslavian, but in terms of water protection, major improvements were done since the accession negotiations with European Union (**Figure 4**).

The main piece of legislation concerning the subject is the Water Framework Directive (Directive 2000/60/EC of the European Parliament and of the Council)

**Figure 4.**

*Surface water and topography in Slovenia.*

 in force since October 23, 2000. Its main objective was establishing a framework for Community action in the field of water policy. Member states had to implement the necessary measures to prevent deterioration of the status of all bodies of surface water (art. 4.1(a)(i)); and protect, enhance, and restore all bodies of surface water to achieve good water status (art. 4.1(a)(ii)).

In Slovenia, Water Framework Directive resonated in acceptance of Waters Act [7]. Waters Act defines rules for management of waters (both surface and subsurface) in Slovenia, specifically for protection of waters, sustainable use of waters, good management of water use facilities, and other water-related questions. Waters Act imposes the formulation of a Program of Measures which is used to define measures needed to meet the objectives set for protection, development, and use of waters. A state-wide Program of Measures needs to be formulated every 6 years by the government with the help of interested public. More locally specific programs should be formulated for river-basins or other vulnerable areas when necessary. Different daughter rules were also brought to act, for example:

 They offer more specific limitations concerning the subjects. Specific water protection zones are defined by decrees that define locally specific areas around drinking water reservoirs, which are shown in **Figure 5**. Red areas mark the inner-most part of the zone directly around the pumping station. Strictest measures apply here. Transitioning from red across orange, and yellow to green, less and less strict measures apply. The size of each zone was determined by different factors; for example, by aquifer type, speed of groundwater recharge, response time, pollutant retention time, dilutive capacities of groundwater body, etc. Different modeling approaches were also used in the process to help determine groundwater flow, dilutive properties etc. A common criterion for definition is the time it takes for pollutants to reach the well. Time for the first zone is usually 50 days and second zone is 400 days, while the third zone encircles the whole connected aquifer.

 Another important piece of legislation is the decree on groundwater status [11]. It was transposed from European Union Ground Water Directive with the aim to define procedures for determining of groundwater quality, standards of quality, and corresponding threshold values, but also other demands concerning preparation of groundwater protection action plans, etc. For any given groundwater body, investigation of pollution was executed, and bodies with good chemical status were determined. Bodies that were not recognized as such are considered vulnerable and a program of measures has to be formed with an aim to prevent further pollution and restore the body to good chemical state.

A groundwater body is considered to be of good chemical status when:

Threshold values for pollutants in groundwater are presented in **Table 1**. Note that values are similar to European Union Drinking water directive (Council Directive 98/83/EC of 3 November 1998 on the quality of water intended for human consumption). In Slovenia, as mentioned before, groundwater is used extensively for drinking (98% of drinking water comes from ground water), so EU drinking water values apply to all groundwater.

Apart from legislation that is more directly bound to groundwater issues, other legislation pieces are also important for our topic. Agriculture and industry influence groundwater quality significantly, so some relevant regulations also concern these sectors. Let us only concentrate on the agricultural part. For the most part, the framework for these regulations is the following European Union directives:

*Groundwater Protection Legislation in Slovenia: Theory and Practice DOI: http://dx.doi.org/10.5772/intechopen.83664*

• Sewage Sludge Directive (Council Directive 86/278/EEC of June 12, 1986 on the protection of the environment, and in particular of the soil, when sewage sludge is used in agriculture).

In Slovenia, Environmental Protection Act [12] is the framework act concerning protection of the environment. Its aim is to set up a framework of principles, measures, monitoring, etc., to ensure sustainable environment protection. It refers to other, more specific regulations, though, and these are listed below:

Main emphases are collected in **Table 2**.

#### **Figure 5.**

*Water protection zones in Slovenia—colors go from strictest (red) to least strict (dark green).*

**Table 1.**

*Threshold values for pollutants from the decree on groundwater status [11].*

#### **Table 2.**

*Main emphases from nitrates decree, PPP act, and sewage sludge decree [13–15].*

 Apart from these state-wide valid limitations, special rules also apply to water protection zones. Three main zones are used (see **Figure 5** for reference) to divide land around groundwater reservoir depending on risk of harmful pollution. Such rules valid for water protection zones are:

 Apart from what was already mentioned, there are also many other minor or locally valid pieces of legislation, but these major laws present the main structure of Slovenia's legislation on groundwater protection.

## **5. Slovenian water protective measures—the practice**

 Legislation is very important when it comes to protecting the environment, but without the knowledge of how to meet the prescribed criteria, stakeholders would have a hard time meeting it. This is where the more practical part of water protection comes in. Based on scientific research, trials, and experimenting, several instructive manuals with guidelines have been published for Slovenian farmers. Several institutions are a part of collective effort to discover locally efficient measures and practices in Slovenia; listed below are just a few:

Collecting the most recent knowledge in the field, Ministry of Agriculture, Forestry and Food publishes (with advice from above-listed research institutions) a yearly issue of technological instructions for different agricultural sectors:

 Periodically, similar instructions are also issued for organic production. These manuals are not meant to address only the issue of groundwater protection, though. They are written to give farmers a framework for integrated, that is an environmentally friendly, sustainable production, which, as it happens, already helps in terms of groundwater protection. But—as stated in the beginning of this chapter, Slovenia has several areas, where just some generic measures are not sufficient. For this reason, more specialized guidelines are also issued to showcase the stricter solutions. Only recent publications are presented below, as older practices may no longer be relevant. A good representation of such a guidelines manual is "Fertilization with Nitrogen on Water Protection Areas (Example of Aquifer Apače Field)" [16] written in 2017. Important thing to stress out at this point is that only farms that are a part of either integrated or organic production scheme are certified and therefore under state control. In practice, this means that other farms, which are not a part of certified schemes and use conventional practices often, do not comply with legislation standards, because they are not stimulated or controlled enough to do so. Stimulation program exists, though, as a system of direct payments from European Union is available to farmers who enter into integrated or organic scheme, and only then, they enter into control mechanisms as well. Measures that need to be implemented in order to qualify for funding change every 6 years and have to do with animal welfare, cover-crops, good agricultural practices, water-sources protection, biodiversity, etc.

Authors of the manual note that for their example, area almost half of the farms in second and third vulnerable zone are not a part of official certified schemes, and

 therefore, are not subjected to control from state officials. Not that these farmers want to be polluters, sometimes they are just not willing to adapt to the new ways and just stick to what their forefathers taught them. Dealing with the lack of knowledge, practical tips for farmers that do not know how to deal with fertilizing plans and balanced fertilizing are presented in the manual. Some tips are listed below:

 Another work on fertilizing is the "Guidelines for realization of water protection claims in regards to nitrates from agricultural sources" [17] written in 2016, with updates from 2017. This is a very farmer-focused publication, written in a question-and-answer form, and is intended to explain legislation claims in a clear and easy-to-understand manner. Farmers are becoming more and more knowledgeable and eager for education, but long and complicated legislation pieces are not very easy nor enjoyable to read. Guidelines are not focused only on water protection areas, but rather include the good practices from legislation concerning the whole Slovenia. In many points, this is similar to the previous work, but at some it goes into more practical details, that farmers are interested in, like for example: "What is the animal-based equivalent of the yearly maximum of nitrogen

## *Groundwater Protection Legislation in Slovenia: Theory and Practice DOI: http://dx.doi.org/10.5772/intechopen.83664*

**Table 3.**

*Average yearly nitrogen yield from animal manure by species [17].*

 input (170 kg N/ha)?" A table with average yearly nitrogen yield for different species manure as well as a calculation example is included. Part of the table values is presented in **Table 3**. If farm animals produce more than 170 kg of nitrogen per hectare, excess manure should not be used on the farm, but sold or disposed elsewhere to prevent overloading of soil with nutrients.

Apart from this, other tips are included, for example, formulas to calculate:

Manual also offers clarifications of legislation, like "Is it allowed to temporarily store manure on frozen ground?" (Yes), "Is anyone allowed to make a fertilizing plan?" (Yes, as long as he knows how to do it), "Is there a specific type of fertilizing implement supposed to be used?" (No, but those that incorporate the fertilizer into the ground are preferable), etc.

 Moving from the topic of fertilizer pollution into the plant protection products territory, we have another recent (2017) manual on use of phytopharmaceutical substances in water protection areas [18]. At the beginning of the document, the author makes a very important statement about what it means to cause pollution: "Advances in measuring technology have made detection of plant protection products very sensible." Author gives us the following example: "When filling a spraying implement, a farmer drops the lid of a pesticide bottle, and it ends up in the nearby stream. Even if it only had a couple drops of pesticide on it, this can still be detected up to 40 km away in drought season, and even exceed the threshold values. If even such small mistakes or carelessness of a single user can be detected, it is not hard to imagine how important it is that every single user knows the principles of good agricultural practices, or his deeds can give bad results for whole area. The thinking in terms of 'this drop can't make any difference' or 'nobody will see me if I do it' is not helpful, as detection of pesticide in waters must, by law, be sanctioned by restrictive measures of some sort in the area of concern. This of course inflicts all the farmers in the area, not just the polluter."

 In the manual, there is a good explanation of what is going on in the soil that is subject to leaching, but practical considerations are also included. Attached is the list of pesticides that are not acceptable or should only be used every couple years in water protection zones because of their chemophysical properties when in contact with soil (unacceptable active substances are bromacil, propaklor, triklorpyr, terbutryn, piloram, haloxyfop, terbacil, hexazinone, norflurazon, heptachlor, terbumeton). Just as with crop rotations, pesticide rotations should also be considered to minimize constant exposure to the same active substance, but also to allow for less frequent use of more dangerous pesticides in favor of using a similar but less hazardous active substance.

 Another important topic is preparation of spraying mixture and dealing with its residuals after use. Care should be taken to prepare the right amount, a certified sprayer with good nozzles should be used (as discussed in the theory chapter), and a water-tight system for cleaning the sprayer should be used afterward. There is no urgent need to buy expensive devices, the author gives farmers an easy, cheap, and effective solution: If using a dedicated commercial cleaning system is not an option, smaller farmers can also create an improvised pool out of durable foil with a small quantity of soil in it—the soil works as a reactive substance in which, under sunlight, pesticide is decomposed. Another option is to empty the sprayer into the manure lagoon, where active substances also get decomposed quickly, especially with small quantities that remain after use. A big part of the document deals with surface drift into streams though, which is not our point if interest here.

### **6. Perspectives and improvements for future**

Several projects on the topic of groundwater protection were recently concluded or are still in progress. Some of them are briefly described in the next lines.

*Groundwater Protection Legislation in Slovenia: Theory and Practice DOI: http://dx.doi.org/10.5772/intechopen.83664*

"SI-MUR-AT" project [16, 17], dealing with ecological and sustainable agriculture in accordance to a contemporary water management is an interregional between Austria and Slovenia. The project is still underway, but one of the interesting interim propositions was to prepare a wholesome regulation on topic of proper cleaning of spraying equipment which is not set by Slovenian law yet. A good recommendation is also to give more emphasis to conservation management of soils, which in other countries shows promising results in terms of better soil properties. Also, just as crop rotation plans are mandatory for integrated or organic agriculture, plant protection products rotation plans would also be a good idea to have in order to gain a better view of the actual farming practices.

Another project, funded by Slovenian research fund and titled "Possibilities of farming in water protection areas" [19], offered some valuable insight into possible improvements of current state. Its aim was to discover measures to improve groundwater quality, and the final propositions were the following:

"UraViVo" project [20], aimed to improve land management regime in order to improve groundwater quality, is another project that is still underway. Three most interesting goals are to develop and test a new formulation of fertilizer made from pig manure to minimize leaching possibilities, test a deficit irrigation practice to save water and minimize leaching possibilities and to use nitrate-polluted groundwater for fertigation in order to reduce nitrate concentration. Use of modeling to test more long-term results is also planned.

Workshops and lectures on topic of groundwater protection are also organized frequently by Chamber of Agriculture and Forestry of Slovenia's regional offices and also other institutions to extend the knowledge and make it available to farmers and interested public.

 In the end though, even if scientists and researchers figure out good ways and effective measures, it is still on the legislators to legalize them, and on farmers or industry to implement them. Without the interest in implementation, even a very effective measure is not effective, as nobody implements it. Subsidies and funding seem to help in this regard significantly though.


**3. Cell intrinsic roles for ecdysone, EcR and USP in cell growth and division**

The *Drosophila* imaginal discs (see also Introduction 1.1), which form the adult head structures (eyes and antenna), appendages (wings and legs) and genitalia, have provided an excellent model for studying developmental signals controlling cell proliferation. The imaginal disc precursor cells arise early in embryonic development from invaginations of the embryonic epithelium (Alberts 2002). By the early larval stage each disc consists of a ball

Steroid Hormones in *Drosophila*:

How Ecdysone Coordinates Developmental Signalling with Cell Growth and Division 151

**A B**  Fig. 4. **A - Eye imaginal disc differentiation occurs in a wave that moves from posterior (P) to anterior (A)**. The margin between the asynchronously dividing anterior cells and the differentiated posterior cells is marked by the morphogenetic furrow (MF), where cells are delayed in G1. Mitotic division cycles become synchronized in the "Second Mitotic Wave" (SMW), which is composed of a tight band of DNA synthesis (Marked by BrdU in red) and mitosis (marked by PH3 in green). **B - The Hedgehog (Hh) and Dpp pathways control cell division in the larval eye.** *Drosophila* eye development is dependent on *hedgehog* (*hh*) expression posterior to the MF and *decapentaplegic* (*dpp*) expression within the MF. Hh and Dpp regulate key cell cycle genes to coordinate cell cycle and differentiation. Dpp and Hh act redundantly to ensure G1 arrest, thus cells unable to respond to Dpp will arrest later in response to Hh. Dpp and Hh inhibit Cyclin E and dE2F1 in the cells comprising the MF. In the anterior of the MF, Hh acts to promote cell division in the SMW by upregulating Cyclin

and Dpp, suggests there might be many connections between ecdysone, developmental pathways and cell cycle regulation during metamorphosis in *Drosophila* (Li and White 2003). The first evidence for these connections in the *Drosophila* larval eye imaginal disc came from studies implicating the ecdysone pathway in regulation of MF progression via effects on Hh and Dpp (Brennan, Ashburner, and Moses 1998; Brennan et al. 2001). In *Drosophila*, eye development is dependent on *hedgehog* (*hh*) expression posterior to the MF (Heberlein,

D to promote cell growth and Cyclin E to drive S-phase entry.

of around 10-50 undifferentiated stem cells, which undergo extensive growth and proliferation to comprise up to 100,000 cells by the end of the third larval instar. The imaginal discs start differentiation at the end of third instar and complete the process by the end of pupariation, when all adult structures such as the wings, legs and eyes have developed (Fristrom and Fristrom 1993). The third instar larval stage is a critical stage of *Drosophila* development, containing the major growth and proliferation of all tissues required to form the adult fly (Church and Robertson 1966). Indeed the size of the adult fly is determined at the time when the pupal case is formed, as after this the animal cannot feed again until eclosion. Here we will discuss the developmental signals (including Wingless, Dpp, Hedgehog, Notch) controlling growth of the eye and wing imaginal discs, and how ecdysone impacts on these signalling pathways to control cell division.


Meet the editors

Dr. Luigi Cocco is a professional engineer with fifteen years of experience in the automotive industry. He worked in the Electrical and Electronic R&D and Supply Quality departments of racing/luxury/premium Italian vehicle manufacturers, such as Ferrari F1 Team, Automobili Lamborghini, and Maserati. Currently, he is Head of Global Value Optimization for Passive Safety, Active Chassis and ADAS systems for all former FCA brands.

After obtaining a master's degree in Telecommunication Engineering, Dr. Cocco obtained a Ph.D. in Information Engineering. Since 2019, he has been a member of the Coordination Board of MotorVehicle University of Emilia-Romagna (MUN-ER). He has published several papers and three books: *Modern Metrology Concerns* (2012), *New Trends and Developments in Metrology* (2016), and *Standards, Methods, and Solutions of Metrology* (2018).

Dr. Muhammad Aziz is currently an Associate Professor at the Institute of Industrial Science, The University of Tokyo, Tokyo, Japan. He received a BEng, MEng, and DEng in Mechanical Engineering from Kyushu University, Japan, in 2004, 2006, and 2008, respectively. His research interests include power generation, renewable energy utilization, process modeling, smart grids, electric vehicles, batteries, and hydrogen production and

utilization. He has published more than 125 peer-reviewed journals, 22 books and book chapters, and more than 200 proceedings. In addition, Dr. Aziz is also an active reviewer for more than sixty distinguished journals related to energy research.


*3.2. ITS-Based Phylogeny*

Our new ITS tree with 1325 sequences contained 1091 unique samples, collected from 29 different countries (Figures 5 and S1). By utilizing historical specimens, we were able to add records for an additional 11 countries for which the diversity of *Cora* and *Corella* species was previously unknown (Figure 2; a singular fresh collection from Sri Lanka not mapped, see [33]).

**Figure 5.** ITS fungal barcoding tree inferred by maximum likelihood for the genus *Cora*, including the *Acantholichen*-*Corella* clade as outgroup (1325 terminals), and two examples of the results of species delimitation approaches. *Cora hawksworthiana* (**a**) is currently considered a single species, but could potentially be further divided into two—one from Brazil and another for Chile, Colombia, and Costa Rica—based on the ad hoc, GMYC, DNADIST, and ABGD-231 approaches. In contrast, *Cora reticulifera* (**b**), an abundant common species from southeastern Brazil and Uruguay, with a uniform phenotype and ecology, was delimited as a single species by all methods, except in bPTP, which recovered each sample as a separated species. For the full-length tree as well as species delimitations for all specimens, see Figure S1 and Table S4.

Given this information, we were able to extend the distribution of six species in *Corella* and 28 in *Cora*; for example, *Cora davibogotana* previously only known from Colombia, is now also reported from Venezuela; and *Cora* spec-84, before known exclusively from Brazil, is now also known from Uruguay (Figure S1). In all cases, range extensions were to adjacent countries. Countries such as Ecuador, Jamaica, Mexico, Colombia, and Brazil, continue to be well represented by fresh specimens, while for other countries, the addition of new specimens from the herbarium was invaluable. For example, for Panama, we added 18 herbarium collections to compliment the one available fresh specimen, now corresponding to seven or eight species as opposed to just one previously known from the country. Overall, approximately 25–30 additional novel lineages were detected among the herbarium collections alone; however, since these require further studies to be formally described (as either species or at infraspecific level, following the approach proposed by Lücking et al. [34]), they will be treated in a separate publication.

### *3.3. Comparison between ITS and Astral Six-Marker Tree*

Our microfluidics PCR followed by Illumina sequences yielded 239 novel sequences belonging to *EF3*, mtLSU, nuLSU and nuSSU. ITS data were also highly successful with this approach; however, we already had those sequenced with other methods. Our ITS-based ML tree and the ASTRAL six-marker coalescent tree exhibited very similar topologies (Figure 6), with a normalized Robinson–Foulds distance of 0.0278, suggesting that an ITS-based phylogeny reliably recovers a multi-marker phylogeny in this particular genus.

**Figure 6.** Comparison between inferred ASTRAL six-marker species tree (**a**) and ITS maximum likelihood tree (**b**). The different colors simply denote the two major clades in *Cora*, with *Corella* in black as the outgroup.


**3. Al2O3 for Insulated-Gate GaN Devices**

Table 1 reports the physical parameters of the energy bandgap (EG), conduction band offset (∆EC) and valence band offset (∆EV) obtained experimentally from amorphous Al2O3 films deposited on GaN and AlGaN by various deposition methods. Note that the bandgap of the amorphous Al2O3 ranges between 6.7 eV and 7.6 eV depending on the method of the oxide film growth, and it is lower than the value for the crystalline bulk α-Al2O3 (8.8 eV–9 eV) considered in the theoretical calculations (Figure 3). In fact, it is well known that the EG of Al2O3 compounds strongly depends on its crystallographic phase [96,97]. Momida et al. investigated the structure of amorphous Al2O3 by first-principles calculations, concluding that the reduction of the bandgap of amorphous Al2O3 compared to crystalline Al2O3 could be related to the changes in the density of the Al2O3 compounds and the average coordination number of Al atoms [98]. Toyoda et al. showed that annealing at temperatures of 800 ◦C led to phase transformations of the Al2O3 films from amorphous to crystalline, which correlated to a significant increase in the energy bandgap and the modification of the conduction band discontinuity [99]. Afanas'ev et al. pointed out that for Al2O3 films treated at temperatures above 800 ◦C, the widening of the Al2O3 bandgap with the phase transformation from amorphous to crystalline mostly occurred at the valence band side [96,97]. Differently, Yang et al. revealed that the annealing processes at a lower temperature of 650 ◦C can affect the band bending of GaN but has almost no effect on the Al2O3/GaN band offset [100]. The decrease of the bandgap of amorphous Al2O3 has also been associated with defect-induced states located in the bandgap [101]. This could explain the large discrepancy between the theoretical (Figure 3) and experimental (Table 1) values of ∆EV. In fact, since in the case of Al2O3 the valence band maximum states are associated with the O 2p states, and the conduction band minimum states are associated with the Al 3s, 3p states [102], the rehybridization between Al 3s, 3p and O 2p modifies the charge transfer between Al and O and consequently decreases the bandgap, thus increasing the valence band maximum [51]. In contrast to ∆EV, the experimental values of ∆EC obtained for the Al2O3/(Al)GaN system are consistent with the theoretical predictions and make Al2O3 a suitable dielectric for insulated-gate GaN-based transistors.

In addition to the physical properties of the bandgap of Al2O3 and the band offsets in the Al2O3/(Al)GaN system, high-quality dielectric layers in terms of defects and bulk traps and an Al2O3/(Al)GaN interface with a low interface trap density are required to deliver a high performance and highly efficient MIS gate structure, as discussed above. It is important to mention that these properties strongly depend on the deposition technique and temperature, the crystalline structure of the film and the surface and annealing treatments [51]. Among the techniques explored for the deposition of Al2O3 films, such as sputtering [103], the oxidation of a thin Al layer [53] and MOCVD [104–106], the ALD technique is widely used. The main advantages of the ALD method are the low deposition temperature (<350 ◦C), the excellent film thickness control as well as the high uniformity and conformality, which have enabled the deposition of high-quality Al2O3 films and Al2O3/(Al)GaN interfaces compared to other methods. Nevertheless, despite substantial progress in the ALD technology, large amounts of defects in the as-deposited Al2O3 bulk material and interface traps at the Al2O3/(Al)GaN interface are still present and still hinder the success of the insulated-gate GaN devices [1].

**Table 1.** Energy bandgap (EG), conduction band offset (∆EC) and valence band offset (∆EV) measured for Al2O3 films on GaN and AlGaN. The deposition method is reported in the second column, where ALD = atomic layer deposition; PEALD = plasma-enhanced atomic layer deposition; CVD = chemical vapor deposition; MBD = molecular beam epitaxy; ECR = electron cyclotron resonance. In addition, the measurement method is noted in column 3, where C–V = capacitance–voltage measurements; F–N = Fowler–Nordheim characteristics; IPE = internal photoemission; XPS = X-ray photoelectron spectroscopy; UPS = ultraviolet photoelectron spectroscopy; XAS = X-ray absorption spectroscopy.


Petersburg: St. Petersburg university press) (in Russian) **Part 4**

**Recent Developments**

252 Chemical Kinetics

Zhiglinski A G 1994 *Handbook of Rate Constants of Process of Atoms, Electrons and Photons* (St.

**12**

*P.R.China*

**Recent Developments on the Mechanism and**

*Institute of Chemical Engineering, East China University of Science and Technology,*

Esters have played a significant role in daily living and chemical industry, such as plasticizers, fragrance, adhesive and lubricants (Joseph et al., 2005; Mbaraka & Shanks, 2006; Krause et al., 2009; Martínez et al., 2011). The vast majority of esters can be prepared using esterification reaction in the chemical engineering industry. Esterification has acquired further improvement from the engineering side; this mainly depends on the research of esterification kinetics. On the other hand, the need to control chemical reactions at the molecular level, which depends critically on the catalytic mechanism, is rapidly increasing

In the recent years, various esterification mechanisms were proposed for homogeneous and heterogeneous systems. Base on the mechanism, numerous kinetic models have been developed to represent the kinetic behaviors of esterification, such as simple orders or the power-law model, the pseudo-homogeneous model, the L-H model, the E-R model, etc.

Herein, we review the mechanisms of esterification catalyzed by inorganic acid, Lewis acid, metallic compounds, solid acids, ion-exchange resin, respectively. Meanwhile, the kinetics for each esterification is also conducted in detail. The study on the mechanism of various catalysts is not only useful in the present applications but it is required to enhance the scope of their applications. Therefore, it is desired to research and develop more efficient catalysts for high yield ester production, under mild reaction conditions. The esterification kinetics is

A literature survey more than 90 relevant references has been done in this chapter. The studies on esterification are mainly focused on the following aspects: (1) establishing the adequate reaction mechanism according to the research papers, and (2) evaluating the

Inorganic acids, such as H2SO4, HCl and HI, are still being widely applied in the chemical industry (Liu et al., 2006; Schmitt et al., 2008). Under this condition, they are used as

**1. Introduction**

(Salciccioli et al., 2011).

important for simulation and design of a reactor.

**2. Esterification mechanism and kinetic model**

available esterification kinetics.

**2.1 Inorganic acids**

**Kinetics of Esterification Reaction**

Zuoxiang Zeng, Li Cui, Weilan Xue, Jing Chen and Yu Che

 **Promoted by Various Catalysts**


**Section 1**

**Landscape Planning**

**1**

**Protected Areas**

*Namk Kemal University, Faculty of Agriculture,*

Protected areas are essential for biodiversity conservation. They are the cornerstones of virtually all national and international conservation strategies, set aside to maintain functioning natural ecosystems, to act as refuges for species and to maintain ecological processes that cannot survive in most intensely managed landscapes and seascapes. Protected areas act as benchmarks against which we understand human interactions with the natural world. Today they are often the only hope we have of stopping many threatened

The original intent of the IUCN Protected Area Management Categories system was to create a common understanding of protected areas, both within and between countries. This is set out in the introduction to the Guidelines by the then Chair of CNPPA (Commission on National Parks and Protected Areas, now known as the World Commission on Protected Areas), P.H.C. (Bing) Lucas who wrote: "*These guidelines have a special significance as they are intended for everyone involved in protected areas, providing a common language by which managers, planners, researchers, politicians and citizens groups in all countries can exchange information and*

*"An area of land and/or sea especially dedicated to the protection of biological diversity, and of natural and associated cultural resources, and managed through legal or other effective means"*

Protected areas can be categorized into six types, according to their management objectives

*Protected area managed mainly for science or wilderness protection (I(a) Strict Nature Reserves, and*

An area of land and/or sea possessing some outstanding or representative ecosystems, geological or physiological features and/or species available primarily for research and/or environmental monitoring. A wilderness area is a large area of unmodified or slightly modified land and/or sea retaining its natural character and influence without permanent or significant habitation which is protected and managed so as to preserve its natural condition.

*views*" (The International Union For Conservation of Nature [IUCN], 1994).

or endemic species from becoming extinct (Dudley, 2008).

IUCN defines a protected area as:

(IUCN 1994).

*Category I*

(IUCN, 1994; 2003):

*I(b) Wilderness Areas).*

**1. Introduction**

*Department of Landscape Architecture*

Murat Özyavuz

*Turkey*