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\begin{document}

\title{Added value of three dimensional transesophageal echocardiography in
percutaneous closure of atrial septal defect.}



\author[1]{faten Abdelghani}%
\author[2]{Hala ElMarsafawy}%
\author[2]{Ahmad Wafa}%
\author[2]{Mahmoud Youssof}%
\author[1]{Wei Li}%
\author[1]{Michael Gatzoulis}%
\affil[1]{Royal Brompton Hospital}%
\affil[2]{Mansoura University Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 22, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Unrepaired secundum ASD (atrial septal defect) is the commonest
congenital heart disease encountered in adulthood. In this study we try
to correlate the three-dimensional size of a secundum ASD to the device
size. We did a retrospective analysis to 36 patients who underwent
successful transcatheter closure of atrial septal defect guided by
balloon sizing and correlated this to the device size. The device size
was correlated significantly with all the maximal ASD diameter by
2D-TTE, 2D-TEE and 3D-TEE. However, the most significant correlation was
between three-dimensional maximal diameter and device. 3D TEE is a
promising and reliable tool that can be used to determine the size,
number and shape of ASD and to accurately select the suitable device
size during percutaneous closure.%
\end{abstract}%



\sloppy


\textbf{Added value of three dimensional transesophageal
echocardiography in percutaneous closure of atrial septal defect.}

\textbf{Authors}

Faten Abdelghani, Hala Elmarsafawy, Ahmad Wafa, Mahmoud Youssof, Wei Li,
Michael Gatzoulis.

\textbf{Corresponding author}

Faten Abdelghani

Email:Faten.ezzat88@gmail.com

Mobile phone number:+447394893768

\textbf{Institutions}

Royal Brompton Hospital, London

Children Hospital, Mansoura University, Egypt.

\textbf{Addresses of authors}

Faten Abdelghani: Faculty of Medicine Mansoura University, Egypt / Royal
Brompton Hospital , London

Hala Elmarsafawy : Faculty of Medicine Mansoura University , Egypt
Faculty of Medicine New Mansoura, Egypt

Ahmad Wafa : Faculty of Medicine Mansoura University , Egypt

Mahmoud Youssof : Faculty of Medicine Mansoura University , Egypt

Wei Li : Royal Brompton Hospital , London

Michael Gatzoulis : Royal Brompton Hospital , London

\textbf{Abstract:}

Unrepaired secundum ASD (atrial septal defect) is the commonest
congenital heart disease encountered in adulthood. In this study we try
to correlate the three-dimensional size of a secundum ASD to the device
size. We did a retrospective analysis to 36 patients who underwent
successful transcatheter closure of atrial septal defect guided by
balloon sizing and correlated this to the device size. The device size
was correlated significantly with all the maximal ASD diameter by
2D-TTE, 2D-TEE and 3D-TEE. However, the most significant correlation was
between three-dimensional maximal diameter and device. 3D TEE is a
promising and reliable tool that can be used to determine the size,
number and shape of ASD and to accurately select the suitable device
size during percutaneous closure.



\textbf{Introduction}

Unrepaired secundum ASD is the commonest congenital defect seen in adult
congenital heart disease population. Transcatheter closure of secundum
ASD has been proven safe, very effective and become preferred method of
choice for the treatment. It avoids the prolonged hospital stay and the
unpreferred sternotomy that are associated with surgical closure.
Accurate assessment of the ASD shape and size is the cornerstone of a
successful transcatheter closure of an ASD. Both under sizing and
oversizing the defect could lead to serious complications. At present
balloon sizing is the preferable technique adopted by most of the
cardiac interventionists to assess the defect size and select the
device. Although it proved to be a reliable method, balloon sizing
prolongs exposure to fluoroscopy and adds cost. Some authors have
mentioned that an overstretched balloon can lead to distortion of the
defect margins leading to enlarging the defect size and probably losing
a pre-existing tiny rim (Ooi et al., 2016).

Three dimensional transesophageal echocardiography (3D-TEE) is a
promising tool to guide different cardiac interventional procedures. It
is widely available, easy and reproducible imaging modality that has the
ability to overcome geometric assumption which is considered one of the
major limitations of the two dimensional echocardiography.(Balzer et
al., 2013)

Nowadays, image acquisition and processing using the 3D TEE have become
more applicable during different cardiac interventional procedures
(references) (Balzer et al., 2013)The 3D TEE obtained en face view of
interatrial septum provides accurate information about the number, shape
and size of the defect. Moreover, it provides additional valuable
information about the relation between the defect and the surrounding
structures and confirms the adequacy of the surrounding rims. (Balzer et
al., 2013)

We conducted this retrospective analysis to assess the efficacy and
reliability of 3D TEE as a reproducible imaging modality to accurately
determine the size of ASD and selection of the device.

\textbf{Patients and methods:}

We retrospectively reviewed thirty-eight patients who underwent a
transcatheter closure of atrial septal defect from November 2018 to
December 2019. In this study 28 patients were done at The Royal Brompton
Hospital in London and 10 patients were done at The Children Hospital,
Mansoura University, Egypt. There was no patients with significant
residual shunts. However, we excluded two patients one of them had a
major complication (device dislodgement) and the other one had multiple
defects. A total of 36 patients composed study group.

All our patients had a percutaneous ASD closure under 3D TOE guidance as
the presence of haemodynamically significant ASD and suitable anatomic
characters. The device selection was done according to balloon sizing
using the flow stopping technique.

We considered a procedure to be successful in all patients with no
residual shunt or with residual shunt of less than 2 mm and without
encroachment on the surrounding structures or other major complications
(device dislodgement) Subsequently, we assumed that the device size was
appropriate among those patients.

Echocardiographic assessment was conducted in all patients, using an IE
33 Philips machine and TEE probe X7-2t.

From transthoracic echocardiogram both color and 2D images of ASD were
obtained in the standard subcostal view and the modified apical four
chamber view, maximal dimensions of the ASD were measured.

During the transesophageal Echocardiography the ASD diameters were
assessed using the standard views including a mid-oesophageal
four-chamber view (0), a short-axis view (35 -- 60) and a long-axis view
(90 -- 130). Continuous rotation was performed to track the maximal
diameter and both colour and 2D pictures were obtained.

The 3D images were obtained in the mid-oesophageal bicaval view at
around 90 degrees, the 3D zoom mode was activated and the zoom box was
optimized in the lateral plane to include the opening of the SVC and
IVC. The whole septum was included by optimizing the depth settings. A
full volume for the IAS was obtained and then rotated anticlockwise for
90 degrees and turn the image leftwards, the SVC opening is directed
upwards. This was considered anatomically oriented en face view of ASD
from the RA perspective. Gain optimization was done to remove all blood
shadows and optimise the image for accurate identification of defect
border then the image was acquired.

An offline MPR was performed moving each axis to obtain an image, which
included the whole ASD. Measurements of the minimal and maximal
diameters were performed using two axes on the 2D images obtained by MPR
(figure 1)

The maximal diameters were all compared with the device size. Three
types of devices were encountered in this study which were Occulotech,
Hyperion and Amplatzer according to the availability of the selected
size.

\textbf{Statistical analysis:}

Data were analysed using the Statistical Package of Social Science
(SPSS) program for Windows (Standard version 24). The normality of data
was first tested with one-sample Kolmogorov-Smirnov test.

Continuous variables were presented as mean \selectlanguage{ngerman}± SD (standard deviation)
while qualitative data were described using number and percent. Pearson
correlation was used to correlate continuous variables.

Significant variables in correlation entered into linear regression
models using the enter statistical technique to predict the most
significant determinants and to control for possible interactions and
confounding effects.

Level of significance:

For all above mentioned statistical tests done, the threshold of
significance is fixed at 5\% level (p-value). The results were
considered:

Non-significant when the probability of error is more than 5\% (p
\textgreater{} 0.05).

Significant when the probability of error is less than 5\% (p \selectlanguage{english}[?] 0.05).

The smaller the p-value obtained, the more significant are the results.



\textbf{Results:}

\textbf{Study population:}

Thirty-six patients (18 males and 18 females) who underwent successful
transcatheter closure of atrial septal defect from November 2017 to
December 2019 were studied. Mean age of the patients was 31.5+-19.1 (min
3, max 74). The demographic data of our study population are shown in
Table (1).

\textbf{Echocardiographic measurements}

The device size was correlated significantly with all the maximal ASD
diameter by 2D-TTE (R 0.64, P \selectlanguage{english}[?]0.001), by 2D-TEE (R 0.78, P \selectlanguage{english}[?]0.001) and
3D-TEE (R 0.80 P \selectlanguage{english}[?]0.001). The correlations between maximal ASD diameters
by echocardiography and device size are reported in Table (2). The
strongest correlation was noted with 3D TEE maximal diameter R 0.80.
Mean device size 24.04 +- 6.53, Mean 3D TEE maximal diameter 19.52+-6.01,
and mean TEE maximal diameter 17.42+-5.86.Maximal ASD diameters by 3D-TEE
were larger than maximal ASD diameters by 2D-TEE and by 2D-TTE The mean
difference was 2 mm P \selectlanguage{english}[?] 0.001 , and 2.25 mm , P 0.008).

The device size was larger than all echocardiographic ASD diameters. The
mean difference between Device size and 3D-TEE maximal diameter, 2D-TEE
maximal diameter, and 2D-TTE maximal diameter was 4.0 mm P \selectlanguage{english}[?]0.001, 6 mm,
P \selectlanguage{english}[?] 0.001- and 6.5-mm P \selectlanguage{english}[?] 0.001 respectively. (Table 4).

With multiple linear regression analysis, one formula was suggested to
predict device size using the different echocardiographic measurements.
The suggested formula was y = c + b*x where y = estimated dependent
variable score (device size) c = constant, b = beta coefficient, and x =
score on the independent variable .This model was more predictive with
3D maximal diameter with R 72\%.The values for this suggested formula
are presented in (Table 3) Using the 3D maximal diameter (Device size =
6.9 + 0.87 x 3D max diameter ) R2 = 0.72 P \selectlanguage{english}[?] 0.001.Using 2D TEE maximal
diameter ( Device size =8.9 +0.87 x 2D TEE max diameters ) R2=0.69 P \selectlanguage{english}[?]
0.001.However, all these formulas needs to be validated on a larger
number of patients.

Using the first and second formulas there was no significant difference
between the suggested device and the actual device. Mean difference was
23.97+-5.31 for equation 1 and 24.03+-5.08 for equation 2 with P 0.919 and
0.984 respectively.

\textbf{Discussion:}

In this study, 3D TEE and 2D maximal ASD diameters were found to be
correlated with the device size. 3D Echocardiography has a good ability
to overcome geometric assumptions and the variability in the ASD
measurements.

3D Echocardiography is now widely available and validated protocols for
accurate measurement of different cardiac defects are now established.

Balloon sizing is the widely used and approved technique till the
moment. However, it is thought to overestimate the defect size due
outstretching the defect margins. At the meantime it adds an extra cost
to the procedure besides the prolonged exposure to fluoroscopy.(Zhu et
al., 2000)

Underestimation of the defect size could lead to serious complications
for example device dislodgment. Meanwhile, overestimation of the defect
size is not appropriate too. The routine use of a bigger device has a
safety concerns as it could lead to encroachment on the surrounding
structures. It may result in serious complications like heart block and
aortic erosion.(Zhu et al., 2000)

The main result of this study is the good correlation between the
maximal ASD measurement assessed by 3D-TEE and the device size. We
assumed that the device size was accurate in cases where there was no
residual leak , encroachment on surrounding structures or any major
complications e.g., device dislodgement. We correlated the device size
with the different Echocardiographic maximal diameters.

The correlation between the device size and the Echocardiographic
maximal diameters was higher with 3D TEE than other maximal diameters.
R2 0.72, P \selectlanguage{english}[?]0.001

With multiple linear regression analysis, we suggest a formula that can
predict the device size according to the 3D TEE maximal diameter: Device
size = 6.9 + 0.87 x 3D maximal diameter with R2 = 0.72, P \selectlanguage{english}[?]0.001 .We can
use 2D TEE maximal diameters but this could have a lower predictive
value than the 3D measurement: Device size =8.9 +0.87 x 2D TEE maximal
diameters R2=0.69, P \selectlanguage{english}[?]0.001, However, all these formulas needs to be
validated on a larger number of patients.

Hajizeinali et al compared the 2D TEE maximal diameter with the device
size and suggested a formula to predict the device size using the 2D
maximal diameter. They proposed the following equations to calculate a
device size:

Device size = 2.76 + 1.16 x TEE defect size, R2 = 0.91

Device size = 4.08 + 1.05 x TEE defect size, R2 = 0.91 (Hajizeinali et
al., 2013)

There is some difference between this result and our results. We
attribute this to the difference in sample size, and some technical
aspects; for example, the variability in selecting the device size to be
1-4 mm larger than the defect size.

Hascoet et al suggested that 3D TEE maximal diameter was correlated to
the balloon size. They suggested two formulas BS = 1.07 x 3D TEE max-
0.1 when the ASD shape was oval and BS =1.07 x 3D TEE max+3 when the ASD
shape was round. (P, 0.0001). R2 was 0.78. (Hascoet et al., 2015)

We thought that correlating the 3D maximal diameter directly to the
device size would have an added benefit if the 3D proved efficacy in
accurately assessing the defect size. It reduces the time of the
procedure and minimize radiation exposure and more importantly decreases
the cost.

Another model which was described by (Hascoet et al., 2015) is BS = 4.5
x ASD area+11.5 (P , 0.0001). R2 was 0.74.

Roushdy et al. suggested a formula which used the 3D area and
circumference to predict the device size (Roushdy et al., 2020) . The
suggested formulas were:

a-Device size = 10.8 + 3.95 x 3D ASD area.

b-Device size = 3.85 x 3D ASD circumference \selectlanguage{english}-1.02.

However, we used the 3D maximal diameter as it is the previously known
practice and it is easier to apply.

Based upon our results we suggest that 3D TEE can be used solely to
choose the suitable device without the need for balloon sizing .This
will reduce the duration of the procedure, minimize the radiation
exposure, avoid the defect margins distortion that is probable with the
overstretched balloon and more importantly reduces the cost of the
procedure. However, this needs to be validated by a larger study.

\textbf{Limitations}

The main limitation of this study is the small sample size. Further
studies with bigger sample size are suggested to validate the 3D TEE as
the appropriate method to choose the ASD device size without the use of
the balloon.

\textbf{Conclusion:}

3D TEE is a promising and reliable tool that can be used to determine
the size, number and shape of ASD and to accurately select the suitable
device size during percutaneous closure. However, this needs to be
validated on long-term.

Table (1): Patients' characteristics among the studied group:\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Patients' characteristics\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Cases group (n=36)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Age (years) Mean \selectlanguage{ngerman}± SD Median (Min-Max)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
31.5\selectlanguage{ngerman}±19.17 27 (3-74)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Gender Male Female\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
18 (50\%) 18 (50\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Weight (kg) Mean \selectlanguage{ngerman}± SD\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
61.83\selectlanguage{ngerman}±21.81\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Height (cm) Mean ± SD\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
159.8\selectlanguage{ngerman}±2.32\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

Table (2): Pearson correlation between 3D TEE maximal diameter, 2D TEE
maximal diameter, TTE maximal diameter and device size.\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Variables & Device size & Device size\tabularnewline
\midrule
\endhead
& r & P\tabularnewline
Maximal diameters 2D TTE Maximal diameter 2D TEE Maximal diameter 3D TEE
Maximal diameter & 0.640 0.780 \textbf{0.80} & [?]0.001 [?]0.001
\textbf{[?]0.001}\tabularnewline
\bottomrule
\end{longtable}

Table (3): Linear regression analysis for different Echocardiographic
diameters as independent predictors of device size:\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
& Constant & Constant & \selectlanguage{greek}β & SE & P - value & R2 \% & Adjusted
R\textsuperscript{2} \%\tabularnewline
\midrule
\endhead
2D TTE Maximal diameter 2D TEE Maximal diameter 3D TEE Maximal diameter
& 2D TTE Maximal diameter 2D TEE Maximal diameter 3D TEE Maximal
diameter & 9.03 8.91 6.91 & 0.859 0.87 0.87 & 3.21 0.12 0.11 & 0.008
[?]0.001 [?]0.001 & 41\% 69.8\% \textbf{72.3\%} & 39.2\% 68.6\%
\textbf{71.2\%}\tabularnewline
\bottomrule
\end{longtable}

Table (4): The difference between the device size and 3D TEE , 2D TEE
and TTE maximal diameters.\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Difference Median (Min-Max)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Paired t test\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Device size\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{2D TTE maximal diameter}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.04 \selectlanguage{ngerman}± 6.53\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17.48\selectlanguage{ngerman}±4.87\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.0 (-1-17)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.76\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]0.001*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Device size\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{2D TEE maximal diameter}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.04 \selectlanguage{ngerman}± 6.53\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17.42\selectlanguage{ngerman}±5.86\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.5 (-1-19)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9.45\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]0.001*\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Device size\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textbf{3D TEE maximal diameter}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.04 \selectlanguage{ngerman}± 6.53\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
19.52\selectlanguage{ngerman}±6.01\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.0 (-3-12)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
6.92\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
[?]0.001*\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure (1): Measurements of the minimal and maximal diameters of ASD
using offline MPR

D1 maximal diameter , D2 minimal diameter

ASD Atrial septal defect. MPR multiplanar reconstruction

\textbf{References:}

Balzer, J., van Hall, S., B\selectlanguage{ngerman}öring, Y.-C., \& Kelm, M. (2013). New role of
echocardiography in the Cath Lab: novel approaches of
peri-interventional 3D echocardiography. \emph{Current Cardiovascular
Imaging Reports} , \emph{6} (6), 445--453.

Hajizeinali, A., Alidoosti, M., Sadeghian, H., Zoroufian, A.,
Rezvanfard, M., \& Volman, M. A. (2013). A comparison between size of
the occluder device and two-dimensional transoesophageal
echocardiographic sizing of the ostium secundum atrial septal
defect.\emph{Cardiovascular Journal of Africa} , \emph{24} (5), 161.

Hascoet, S., Hadeed, K., Marchal, P., Dulac, Y., Alacoque, X., Heitz,
F., \& Acar, P. (2015). The relation between atrial septal defect shape,
diameter, and area using three-dimensional transoesophageal
echocardiography and balloon sizing during percutaneous closure in
children. \emph{European Heart Journal-Cardiovascular Imaging}
,\emph{16} (7), 747--755.

Ooi, Y. K., Kelleman, M., Ehrlich, A., Glanville, M., Porter, A., Kim,
D., Kogon, B., \& Oster, M. E. (2016). Transcatheter versus surgical
closure of atrial septal defects in children: a value
comparison.\emph{JACC: Cardiovascular Interventions} , \emph{9} (1),
79--86.

Roushdy, A., Ali, Y. A., \& Attia, H. (2020). A novel three-dimensional
echocardiographic method for device size selection in patients
undergoing ASD trans-catheter closure. \emph{The Egyptian Heart Journal}
, \emph{72} (1), 1.

Zhu, W., Cao, Q.-L., Rhodes, J., \& Hijazi, Z. M. (2000). Measurement of
atrial septal defect size: a comparative study between three-dimensional
transesophageal echocardiography and the standard balloon sizing
methods. \emph{Pediatric Cardiology} , \emph{21} (5), 465--469.

\selectlanguage{english}
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