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At least 19 recordsLinked to original sources

PubMed1987

[ECG-gated magnetic resonance imaging of the left ventricle: visualization of anatomical characteristics and quantification of wall thickness and ventricular volume in left ventricular hypertrophy].

Electrocardiography- and respiration-gated magnetic resonance imaging (MRI) was performed using a 0.15-Tesla resistive magnet system in 54 patients with left ventricular hypertrophy to define the site and extent of abnormal wall thickness and to estimate left ventricular function. Because the major cardiac axes are not orthogonal to the conventional transverse, sagittal or coronal planes, the long-axis and short-axis images of the left ventricle were obtained at the end-diastolic and end-systolic phases. The anatomic characteristics of concentric hypertrophy, asymmetric septal hypertrophy, and asymmetric apical hypertrophy were clearly demonstrated by MRI, even in patients with poor echocardiographic images. Quantitatively, left ventricular wall thicknesses obtained from MR images correlated well with those obtained from echocardiography (r = 0.95), and regression was y = 0.99x + 0.39, and so did the ratios of wall thickness of the interventricular septum to the left ventricular posterior wall (r = 0.91, y = 0.80x + 0.24). Left ventricular volumes calculated by the area-length method from MRI and those from left ventriculography also correlated well (r = 0.98, y = 1.13x + 24.5). In conclusion, using the gated long-axis and short-axis MR images of the left ventricle, the anatomical location and extent of hypertrophy and left ventricular volumes are noninvasively demonstrated.

Aged↗

PubMed1976

Right ventricular volume characteristics in ventricular septal defect.

Right and left ventricular volume characteristics were determined from biplane cineangiocardiography in 37 patients with isolated ventricular septal defects. Patients were divided into three categories as determined by the degree of left-to-right shunt: small shunt-less than 35% of pulmonary blood flow (N=9); moderate shunt-35-49% (N=8), and large shunt-greater than 50% (N=20). Right ventricular (RV) end-diastolic volume was increased above normal in 15 of 20 studies performed in patients with large left-to-right shunts and averaged 159 +/- 10% of normal (P less than 0.001). In contrast, only one of the patients in the small shunt group and only half of the patients in the moderate shunt group showed increases in RV end-diastolic volume. The increase in RV volume was proportional to the corresponding increase in left ventricular end-diastolic volume, with the right ventricle ranging from 48 to 116% of LV end-diastolic volume (average 83%). Right ventricular ejection fraction was normal in all patient groups. Right ventricular outpur was increased commensurate with the increases in the RV end-diastolic volume. These data indicate that substantial augmentation in RV end-diastolic volume does occur in patients with isolated ventricular septal defects and large left-to-right shunts. These data can be explained by the significant diastolic and "isovolumic" shunting from left ventricle to right ventricle which occurs in these patients.

Cardiac Output↗

PubMed1989

Effect of left ventricular volume on right ventricular end-systolic pressure-volume relation. Resetting of regional preload in right ventricular free wall.

Effect of left ventricular (LV) volume on right ventricular (RV) end-systolic pressure-volume relation (ESPVR) was investigated, and the mechanism was examined from a standpoint of the alteration of RV free wall mean fiber length. Twelve cross-circulated isovolumically contracting canine hearts in which both ventricular volumes were controlled independently were used, and RV-ESPVR was determined at three different LV volume levels. At small (10.2 +/- 0.6 ml), middle (15.3 +/- 1.0 ml), and large (20.5 +/- 1.4 ml) LV volume, the slope of the RV-ESPVR was 2.63 +/- 0.13, 2.74 +/- 0.13, and 2.89 +/- 0.12 mm Hg/ml, respectively, and each value was significantly different from the others (p less than 0.01). The volume intercept (V0) of the relation (RV-V0) was significantly decreased with the increment of LV volume (RV-V0 in small, middle, and large LV volume; 3.92 +/- 0.68, 3.39 +/- 0.67, and 2.87 +/- 0.71 ml, respectively; p less than 0.01). In nine hearts, RV free wall lengths in latitudinal and meridional direction were measured at three LV volume levels when RV volume was held constant (16.1 +/- 1.1 ml). RV latitudinal end-diastolic length was significantly augmented with increasing LV volume (latitudinal length in small, middle, and large LV volume; 9.68 +/- 0.55, 9.81 +/- 0.56, and 9.92 +/- 0.55 mm, respectively). RV meridional end-diastolic length also increased significantly with increasing LV volume.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1977

QRS voltage of the electrocardiogram and Frank vectorcardiogram in relation to ventricular volume.

Left ventricular volumes were estimated in 59 patients, who were investigated by single plane ventriculography and coronary arteriography. The relation of the left ventricular end-diastolic volumes to the QRS voltage of the 12-lead electrocardiograms and Frank vectorcardiograms was examined. It was found that the maximum spatial QRS voltage and the R wave voltage of leads V5 and V6 in patients without left ventricular hypertrophy were inversely correlated with end-diastolic volume. This inverse relation of QRS voltage and left ventricular volume may explain loss of QRS voltage with dilatation of the heart. In patients with left ventricular hypertropy QRS voltage is usually positively correlated with the degree of hypertrophy, but there is no significant correlation in the presence of cardiac dilatation. If the results of this study are extrapolated to patients with left ventricular hypertrophy and cardiac dilatation, then the inverse correlation of volume and QRS voltage may reduce the diagnostic sensitivity of unipolar chest lead and vectorcardiographic criteria of left ventricular hypertrophy.

Cardiac Volume↗

PubMed1988

Stability of radionuclide left ventricular volume measurements.

Left ventricular volume measurements are useful in the evaluation of cardiac function and are important in the long-term management of patients with various cardiac diseases. Although there are many methods of measuring left ventricular volumes, a non invasive and reproducible method relies on radionuclide techniques. The errors in estimation of left ventricular volumes have previously been well studied. To date there is little information on the reproducibility of left ventricular volume measurements made by this technique at different points in time. This study evaluated 61 patients with stable coronary artery disease over a period of approximately 1 year. All patients had two resting radionuclide gated blood pool studies. Patients had no changes in symptoms, electrocardiographic findings or medication between studies. Using +/- 2 SD as 95% confidence limits for a true change, an end diastolic volume index change greater than -34 ml m-2 and +38 ml m-2 or an end systolic volume index change greater than -24 ml m-2 and +26 ml m-2 are required to state with confidence that a change has occurred between two examinations. These data provide guidelines to assess whether interval changes in left ventricular volumes are real or are due to variations within the technique.

Adult↗

PubMed1992

The conductance volume catheter technique for measurement of left ventricular volume in young piglets.

The conductance catheter has been used extensively in the adult for instantaneous and continuous measurement of left ventricular volumes, but has not been validated for use in the small heart. To determine the accuracy of this technique, we simultaneously measured left ventricular volume by the conductance catheter and biplane cineangiography in nine piglets (2-5 wk of age) over a wide range of volumes experimentally altered by volume infusion, hemorrhage, inferior vena caval occlusion, or administration of phenylephrine, isoproterenol, or propranolol. We performed 110 comparisons and determined parallel conductance of contiguous structures (alpha Vc) for each comparison using the saline technique. End-systole and end-diastole volumes were estimated by angiography using Simpson's rule. Raw and alpha Vc-corrected conductance volumes were compared to simultaneously obtained angiographic volumes by multiple regression analyses, using dummy variable coding for the effects of the interanimal variability and the phase of the cardiac cycle. Raw conductance volumes correlated highly with the cineangiographic volumes (r = 0.97), and the coefficient of angiographic volumes was near identity (1.11 +/- 0.04). The phase of the cardiac cycle did not have a significant effect. However, alpha Vc-corrected conductance volumes correlated less (well (r = 0.85), probably related to the fact that estimated alpha Vc was found to vary with ventricular volume. Thus, the conductance catheter affords a very accurate technique for measuring instantaneous changes in ventricular volume in the small heart, although correction to absolute volumes using the saline technique for estimation of alpha Vc may induce some inaccuracy.

Animals↗

PubMed1992

Left ventricular volume determined echocardiographically by assuming a constant left ventricular epicardial long-axis/short-axis dimension ratio throughout the cardiac cycle.

OBJECTIVES: The purpose of this study was to develop and test a simplified echocardiographic method to calculate left ventricular volume. BACKGROUND: This method was based on the assumption that the ratio of the left ventricular epicardial long-axis dimension to the epicardial short-axis dimension was constant throughout the cardiac cycle. With use of this constant ratio, the method developed to calculate left ventricular volume at a given point in the cardiac cycle required the left ventricular endocardial long-axis dimension to be measured at only one point in the cardiac cycle. METHODS: Studies were performed in 13 normal dogs, 8 normal puppies, 9 normal pigs, 12 dogs with aortic stenosis, 13 dogs with acute mitral regurgitation, 12 dogs with chronic mitral regurgitation, 7 dogs that had undergone mitral valve replacement and 6 pigs that had had chronic supraventricular tachycardia. Animals with aortic stenosis developed left ventricular pressure overload hypertrophy with a 60% increase in left ventricular mass; chronic mitral regurgitation caused left ventricular volume overload hypertrophy with a 46% increase in left ventricular volume; supraventricular tachycardia caused a dilated cardiomyopathy with a 55% decrease in left ventricular ejection fraction. RESULTS: The left ventricular epicardial long-axis/short-axis dimension ratio remained constant throughout the cardiac cycle in each animal group. End-diastolic and end-systolic volumes calculated with the simplified echocardiographic method correlated closely with angiographically measured volumes; for end-diastolic volume, echocardiographic end-diastolic volume = 1.0 (angiographic end-diastolic volume) -1.8 ml, r = 0.96; for end-systolic volume, echocardiographic end-systolic volume = 0.98 (angiographic end-systolic volume) -0.7 ml, r = 0.95. CONCLUSIONS: Thus the left ventricular epicardial long-axis/short-axis dimension ratio was constant throughout the cardiac cycle in a variety of animal species and age groups and in the presence of cardiac diseases that significantly altered left ventricular geometry and function. The simplified echocardiographic method examined provided an accurate determination of left ventricular volumes.

Animals↗

PubMed1991

Validation of ultrafast computed tomographic left ventricular volume measurement.

Left ventricular volume has been measured with ultrafast computed tomography. However, the accuracy with which this can be done is unknown. We therefore imaged with ultrafast computed tomography 11 rectangular phantoms, 20 to 225 ml, and 17 left ventricular casts, 15 to 112 ml. Two observers planimetered serial tomographic images and computed volume from sequential tomograms. There was no significant inter- or intraobserver difference in measurement of phantoms. Deviation of ultrafast computed tomographic volume from true phantom volume was -0.1 +/- 3.5% SD, range 9.0 to -7.6%. Correlation of true phantom volume with ultrafast computed tomographic volume was 0.99, SEE = 1.9 ml. No significant difference was observed between merged and single ultrafast computed tomographic scanning sequences. Left ventricular cast volume determined by ultrafast computed tomography deviated from true volume by 6% +/- 20%, range 54% to -45%. Correlation of true volume with ultrafast computed tomographic volume was 0.99, SEE = 5.1 ml. There was no interobserver significant difference in measurement of left ventricular cast volume. Correlation between ultrafast computed tomographic volume and cineradiographic volume of the same left ventricular casts was 0.99, SEE = 4.4 ml. Thus, phantom volumes can be measured accurately without significant intra- or interobserver variation. Merged scanning sequences did not influence volume determination. Left ventricular cast volume determination was comparable to that obtained with cineradiography.

Cardiac Volume↗

PubMed1991

Echocardiographic prediction of left ventricular volume after myocardial infarction.

Left ventricular volume is a strong determinant of survival after acute myocardial infarction. The aim of this study was to determine which clinical and echocardiographic criteria assessed early after myocardial infarction would predict later left ventricular dilation. Forty-eight patients with uncomplicated transmural myocardial infarction had echocardiography 5 to 10 days after myocardial infarction and assessment of clinical variables including peak creatine kinase and sum of electrocardiographic ST segment elevation. Left ventricular dimensions were measured from the echocardiogram in the parasternal view and also in the apical four and two chamber views at the level of the mitral leaflets, papillary muscles and apex. A cardiac wall motion score was obtained by segmental analysis of the apical views. Echocardiographic left ventricular volume was measured after 1 year from the apical views with use of a Simpson's rule method. Initial clinical and echocardiographic variables were correlated with the left ventricular volume at 1 year. There was a significant relation between the initial four and two chamber end-diastolic dimensions and the left ventricular volume at 1 year, particularly for dimensions measured at the apical level (four chamber R2 = 0.66, p = 0.0001, two chamber R2 = 0.61, p = 0.0001). Other clinical variables, parasternal left ventricular dimensions and cardiac wall motion score were not significantly related to left ventricular volume. A powerful three variable model obtained by multiple regression and including the initial two chamber apical dimension, cardiac wall motion score and body surface area accounted for 82% of the variation in left ventricular volume at 1 year.

Cardiac Volume↗

PubMed1988

Quantitative cineangiographic analysis of ventricular volume and mass in patients with single ventricle: relation to ventricular morphologies.

With the use of biplane selective ventriculography, the ventricular volume, ejection fraction, and ventricular mass were evaluated in 28 patients with a single ventricle, and those with the left ventricular type (LV type, 12 patients) and right ventricular type (RV type, 16 patients) were compared. There were no significant differences in terms of age, hemoglobin, systemic oxygen saturation, or pulmonary-to-systemic flow ratio in the two groups. No patients with atrioventricular valve regurgitation were included. The ventricular cavity volume was calculated by the area-length method. The ventricular mass volume was determined as the shell volume created by subtracting the ventricular cavity volume from the total ventricular volume calculated by adding the free wall thickness to the chamber dimensions. The ventricular mass volume was converted to mass by multiplying by the gravity of the heart muscle. There was no significant difference between patients with the LV type and RV type of single ventricle with respect to the end-diastolic ventricular volume (188 +/- 53 and 179 +/- 61 ml/m2 in LV and RV types, respectively), end-systolic volume (88 +/- 31 and 84 +/- 27 ml/m2), or ejection fraction (0.54 +/- 0.06 and 0.52 +/- 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Volume↗

PubMed1989

Left ventricular volume measurement by conductance catheter in intact dogs. Parallel conductance volume depends on left ventricular size.

The conductance catheter is a promising new instrument for continuously measuring left ventricular (LV) volume. Absolute LV volume (V[t]) is related to uncorrected conductance volume, B(t), according to the equation: V(t) = (1/alpha)(B(t) - alpha Vc). The alpha Vc factor represents parallel-conductance volume due to conducting material outside the LV blood pool, and may be estimated by transiently changing blood conductivity using a bolus injection of hypertonic saline. alpha is the slope in the relation between B(t) and true LV volume. We tested the assumption that alpha Vc and alpha are constant over a range of hemodynamic conditions. We performed multiple hypertonic saline alpha Vc determinations in seven intact dogs during control conditions and subsequent temporary balloon occlusions of inferior vena cava (IVCO), aorta (AO), and pulmonary artery (PAO). We also compared B(t) with simultaneous biplane angiographic LV volume during similar control and intervention conditions. The saline-derived alpha Vc was 76 +/- 2 ml during control and fell significantly by -7 +/- 2 ml during IVCO (p less than 0.001) but not during AO or PAO. According to multiple linear regression analyses, the strongest predictor of saline-derived alpha Vc was uncorrected end-systolic Bes, with a sensitivity coefficient of 0.60 +/- 0.06 ml/ml (p less than 0.001). Angiographically derived alpha Vc showed a similar dependence on Bes, with a coefficient of 0.77 +/- 0.14 ml/ml (p less than 0.001). Angiographically determined alpha also showed significant variation with hemodynamic interventions, largely reflecting an underlying dependence on alpha Vc. The variation in alpha Vc and alpha with LV size may stem from nonlinearity in the B(t)-V(t) relation. Although the conductance catheter provides a useful measure of relative LV volume, measurement of absolute LV volume over a wide hemodynamic range using constant alpha Vc and alpha factors is unrealistic. This result calls into question the current use of this technique for the measurement of the absolute end-systolic--pressure-volume relation.

Animals↗

PubMed1978

Partial volume summation: a simple approach to ventricular volume determination from CT.

The accurate determination of ventricular volume from computed tomography (CT) is not a trivial problem. The direct approach of measuring the area within a visually determined boundary or contour level and multiplying by the nominal slice thickness may be subject to large errors because such boundaries are not, in general, well defined. When the ventricles are filled with a high-contrast material such as metrizamide, we may use the technique of 'partial volume summation,' a simple but accurate, clinically applicable method which may be performed on a standard DeltaScan-50 or similar system.

Cerebral Ventricles↗

PubMed1988

Correlation of right ventricular volume using axial angulated ventriculography to known right ventricular cast volumes in infants and children with congenital heart disease.

To calculate right ventricular (RV) volumes from biplane cineangiography obtained in nonstandard views, regression equations were developed from RV casts of known volume. Volumes were calculated using Simpson's rule from casts ranging from 2 to 42 ml from 25 postmortem specimens with various congenital heart diseases. The casts were divided into 2 groups: group 1 (n = 15) with abnormal or group 2 (n = 10) with normal RV hemodynamic measurements. Biplane cinegrams were taken in the anterolateral, anterior and long axis oblique, hepatoclavicular and sitting up projections. The true volume of each cast was determined from its weight and specific gravity. Excellent correlations were obtained between measured and true volumes (r = 0.92 to 0.96) in all projections, although each projection overestimated the true volume (slope value less than 1). The regression equations obtained from group 1 were not statistically different from those in group 2 in any view. Although the application of different regression equations is required in measuring RV volumes by multiple angulated angiography, these regression equations appear not to be affected by the hemodynamic state of the ventricle. These results are important in assessing RV volume in pediatric patients with congenital heart disease using axial angulated ventriculography.

Cineangiography↗

PubMed1986

A new three-dimensional echocardiographic method of right ventricular volume measurement: in vitro validation.

Right ventricular volume is difficult to measure accurately from one or two views because the complexity of right ventricular shape invalidates simplifying geometric assumptions. This article describes a new three-dimensional echocardiographic reconstruction method of right ventricular volume calculation, and reports the results of testing this method in vitro using normal animal hearts and pathologic specimens from infants and children who died with aortic stenosis or hypoplastic left heart. The correlation with reference volumes was excellent for both groups (r = 0.98, n = 25 for the animal data; r = 0.97, n = 15 for the human data). Given the calculated echocardiographic volume (Vc), the reference volume (Vr) was best estimated by the equation Vr = 1.16 Vc for the animal data and Vr = 0.92 Vc for the human data. Three-dimensional echocardiographic measurement of right ventricular volume is an accurate method that deserves further study and application in a clinical setting.

Animals↗

PubMed1988

Alterations in left ventricular compliance due to changes in right ventricular volume, pressure and compliance.

Because of ventricular interdependence, part of the measured left ventricular diastolic pressure can be attributed to the right ventricle. Therefore, we examined the hypothesis that left ventricular diastolic properties are modified by alterations in right ventricular compliance and pressure even without a change in right ventricular volume. To examine this hypothesis, the hearts were removed from six dogs, the coronary arteries perfused with cool cardioplegic solution, and the hearts submerged in cool cardioplegic solution. Balloons were inserted into each ventricle. Left ventricular pressure-volume curves were recorded and approximated by an exponential equation. With no fluid in the right ventricular balloon (control), the exponential coefficient and constant were 0.038 (SD 0.004) ml-1 and 2.38(0.75) mm Hg respectively. With right ventricular pressure held constant at 20 mm Hg, the exponential coefficient and constant were 0.035(0.002) ml-1 and 3.71(1.64) mm Hg (p less than 0.05 v control constant), respectively. With a fixed right ventricular volume, the exponential coefficient and constant were significantly different (p less than 0.05 v control values) at 0.040(0.006) ml-1 and 2.81(0.96) mm Hg, respectively. After decreasing right ventricular free wall compliance by injecting glutaraldehyde into the right coronary artery, the exponential coefficient and constant were significantly different (p less than 0.01 v control values) at 0.058(0.010) ml-1 and 1.86(0.60) mm Hg, respectively. Thus, even with a constant right ventricular pressure or volume, a significant upward shift in the left ventricular pressure-volume relation occurred. Decreasing right ventricular free wall compliance further increased left ventricular pressure. The results of these studies indicate that the diastolic properties of the left ventricle can be modified by changes in right ventricular pressure and compliance even without a change right ventricular volume. Thus indices of left ventricular diastolic properties may be altered by changes in the characteristics of the right ventricle.

Animals↗

PubMed1988

Evaluation of right ventricular volumes measured by magnetic resonance imaging.

Right ventricular volumes were determined in 12 patients with different levels of right and left ventricular function by magnetic resonance imaging (MRI) using an ECG gated multisection technique in planes perpendicular to the diastolic position of the interventricular septum. Right ventricular stroke volume was calculated as the difference between end-diastolic and end-systolic volume and compared to left ventricular stroke volume and to stroke volume determined simultaneously by a classical indicator dilution technique. There was good agreement between right ventricular stroke volume determined by MRI and by the indicator dilution method and between right and left ventricular stroke volume determined by MRI. Thus, MRI gives reliable values not only for left ventricular volumes, but also for right ventricular volumes. By MRI it is possible to obtain volumes from both ventricles simultaneously in a noninvasive way and without exposing the patient to radiation.

Adult↗

PubMed1985

Comparative angiographic right and left ventricular volumes.

Comparative angiographic right and left ventricular volumes and right and left ventricular ejection fractions have been reported in the same normal infants and children. This relationship was assessed in adult patients to determine if these pediatric observations persist in later life. Seventeen adults, who had both right and left ventricular angiograms and who had no demonstrable organic heart disease, were studied. Right ventricular end-diastolic volume ranged from 54 to 98 (76 +/- 14, mean +/- SD) cc/m2 and left ventricular end-diastolic volume ranged from 48 to 90 (70 +/- 12) cc/m2; p less than 0.03. Right ventricular end-systolic volume ranged from 22 to 47 (33 +/- 8.0) cc/m2 and left ventricular end-systolic volume ranged from 13 to 34 (22 +/- 5.3) cc/m2; p less than 0.00005. Calculated right ventricular stroke volume ranged from 31 to 60 (43 +/- 8.3) cc/m2 and left ventricular stroke volume ranged from 29 to 70 (48 +/- 11) cc/m2; p = NS. Calculated right ventricular ejection fraction ranged from 0.48 to 0.62 (0.57 +/- 0.04) and the left ventricular ejection fraction ranged from 0.57 to 0.84 (0.68 +/- 0.07; p less than 0.00005. Both right ventricular end-systolic and end-diastolic volumes were greater than left ventricular end-systolic and end-diastolic volumes. This resulted in decreased right ventricular ejection fraction compared to left ventricular ejection fraction. The difference between the two ventricles may be due to compliance, muscle mass, and anatomic configuration with a net result of one chamber more completely emptying than the other. Thus it appears that the relationships between right and left ventricular volumes noted in infancy and childhood persist in adult life.

Adolescent↗

PubMed1989

[Left ventricular volume characteristics and its relationship with right ventricle after repair of tetralogy of Fallot].

In order to study the left ventricular volume characteristics and right ventricular influence on left ventricle, cardiac catheterization and biplane cineangiography was performed in 61 patients after repair of tetralogy of Fallot. Preoperative left ventricular volume size was also measured in 25 patients. Postoperative left ventricular end-diastolic volume index (LVEDVI) was 93 +/- 22 ml/m2 (mean +/- standard deviation) and it was 140 +/- 29% of normal left ventricular volume. Left ventricular ejection fraction (LVEF) was 60 +/- 6%. Left ventricular size significantly increased from 109 +/- 25% to 140 +/- 23% of normal by corrective surgery (p less than 0.001). Left ventricular volume characteristics are correlated with right ventricle. LVEDVI increased with increasing right ventricular end-diastolic volume index (RVEDVI) and decreased right ventricular ejection fraction (RVEF). LVEDVI (ml/m2) = 60 + 0.29 RVEDVI (ml/m2), r = 0.52, p less than 0.001, LVEDVI (ml/m2) = 141 - 0.90 RVEF (%), r = -0.30, p less than 0.02. LVEF decreased with increasing RVEDVI and decreased RVEF. LVEF (%) = 68 - 0.075 RVEDVI (ml/m2), r = -0.51, p less than 0.001, LVEF (%) = 43 + 0.32 RVEF (%), r = 0.40, p less than 0.001. On the contrary there was no relationship between right ventricular volume characteristics and right ventricular systolic pressure. There were two cases whose LVEF was less than 50%. In one case right ventricular systolic pressure was as high as 98 mmHg. In the other patient RVEDVI was 299 ml/m2 (453% of normal right ventricular volume) because of severe pulmonary regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗