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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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Kis Z, Muka T, Franco OH, Bramer WM, De Vries LJ, Kardos A, Szili-Torok T. The Short and Long-Term Efficacy of Pulmonary Vein Isolation as a Sole Treatment Strategy for Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis. Curr Cardiol Rev 2017; 13:199-208. [PMID: 28124593 PMCID: PMC5633714 DOI: 10.2174/1573403x13666170117125124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Pulmonary vein isolation (PVI) is an accepted treatment strategy for catheter ablation (CA) of paroxysmal atrial fibrillation (PAF). In this study, we aimed to assess the short, mid- and long-term outcome of PVI as a sole treatment strategy for PAF. Methods: Six bibliographic electronic databases were searched to identify all published relevant stud-ies until December 14, 2015. Search of the scientific literature was performed for studies describing outcomes with mean follow-up > 24 months after PAF ablation. Only articles with 1, 3 or 5-year fol-low up were included, from the same group of investigators. Results: Of the 2398 references reviewed for eligibility, 13 articles (enrolling a total of 1774 patients) were included in the final analysis. Pooled analysis showed that the 12- and 62 -month success rate of a single CA procedure was 78% (95% CI 0.76% to 0.855) and 59% (95% CI 0.56% to 0.64%), re-spectively. The results did not differ by type of CA performed. Major complications mentioned in the enrolled studies were cerebrovascular event, pericardial tamponade and PV stenosis. Conclusion: There is a progressive and significant decline in freedom from AF between 1, 3 and 5-year after successful PVI in patients with PAF. Our analysis suggests that a high short-time success rate after PVI does not necessarily result in high chronic success rate.
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Affiliation(s)
- Zsuzsanna Kis
- Erasmus Medical Center, Department of Cardiology, Electrophysiology, Rotterdam, Netherlands
| | - Taulant Muka
- Erasmus Medical Center, Department of Epidemiology, Rotterdam, Netherlands
| | - Oscar H Franco
- Erasmus Medical Center, Department of Epidemiology, Rotterdam, Netherlands
| | - Wichor M Bramer
- Erasmus Medical Center, Department of Biomedicine, Rotterdam, Netherlands
| | - Lennart J De Vries
- Erasmus Medical Center, Department of Cardiology, Electrophysiology, Rotterdam, Netherlands
| | - Attila Kardos
- Gottsegen György National Cardiology Institute, Department of Electrophysiology, Budapest, Hungary
| | - Tamas Szili-Torok
- Department of Clinical Electrophysiology, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, Netherlands
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Arbelo E, Guiu E, Ramos P, Bisbal F, Borras R, Andreu D, Tolosana JM, Berruezo A, Brugada J, Mont L. Benefit of left atrial roof linear ablation in paroxysmal atrial fibrillation: a prospective, randomized study. J Am Heart Assoc 2014; 3:e000877. [PMID: 25193295 PMCID: PMC4323787 DOI: 10.1161/jaha.114.000877] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Isolation of the pulmonary veins (PVs) for the treatment of atrial fibrillation (AF) is often supplemented with linear lesions within the left atrium (LA). However, there are conflicting data on the effects of creating a roof line (RL) joining the superior PVs in paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS A cohort of 120 patients with drug-refractory PAF referred for ablation were prospectively randomized into 2 strategies: (1) PV isolation in combination with RL ablation (LA roof ablation [LARA]-1: 59 patients) or (2) PV isolation (LARA-2: 61 patients). Follow-up was performed at 1, 3, and 6 months after the procedure and every 6 months thereafter. After a 3-month blanking period, recurrence was defined as the ocurrence of any atrial tachyarrhythmia lasting ≥30 seconds. PV isolation was achieved in 89% and complete RL block in 81%. RF duration, fluoroscopy, and procedural times were slightly, but not significantly, longer in the LARA-1 group. After 15±10 months, there was no difference in the arrhythmia-free survival after a single AF ablation procedure (LARA-1: 59% vs. LARA-2: 56% at 12 months; log rank P=0.77). The achievement of complete RL block did not influence the results. The incidence of LA macroreentrant tachycardias was 5.1% in the LARA-1 group (n=3) versus 8.2% in the LARA-2 (n=5) (P=ns). Univariate analysis only identified AF duration as a covariate associated with arrhythmia recurrence (hazard ratio, 1.01 [95% confidence interval, 1.002 to 1.012]; P<0.01). CONCLUSION The linear block at the LA roof is not associated with an improved clinical outcome compared with PV isolation alone. CLINICAL TRIAL REGISTRATION URL ClinicalTrials.gov. Unique identifier: NCT01203241.
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Affiliation(s)
- Elena Arbelo
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Esther Guiu
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Pablo Ramos
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Felipe Bisbal
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Roger Borras
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - David Andreu
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - José María Tolosana
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Antonio Berruezo
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Josep Brugada
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Lluís Mont
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
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Shim J, Joung B, Park JH, Uhm JS, Lee MH, Pak HN. Long duration of radiofrequency energy delivery is an independent predictor of clinical recurrence after catheter ablation of atrial fibrillation: Over 500 cases experience. Int J Cardiol 2013; 167:2667-72. [DOI: 10.1016/j.ijcard.2012.06.120] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 05/31/2012] [Accepted: 06/24/2012] [Indexed: 10/28/2022]
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Solheim E, Off MK, Hoff PI, De Bortoli A, Schuster P, Ohm OJ, Chen J. Remote magnetic versus manual catheters: evaluation of ablation effect in atrial fibrillation by myocardial marker levels. J Interv Card Electrophysiol 2011; 32:37-43. [PMID: 21476086 PMCID: PMC3184221 DOI: 10.1007/s10840-011-9567-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 03/09/2011] [Indexed: 11/28/2022]
Abstract
Background A remote magnetic navigation (MN) system is available for radiofrequency ablation of atrial fibrillation (AF), challenging the conventional manual ablation technique. The myocardial markers were measured to compare the effects of the two types of MN catheters with those of a manual-irrigated catheter in AF ablation. Methods AF patients underwent an ablation procedure using either a conventional manual-irrigated catheter (CIR, n = 65) or an MN system utilizing either an irrigated (RMI, n = 23) or non-irrigated catheter (RMN, n = 26). Levels of troponin T (TnT) and the cardiac isoform of creatin kinase (CKMB) were measured before and after ablation. Results Mean procedure times and total ablation times were longer employing the remote magnetic system. In all groups, there were pronounced increases in markers of myocardial injury after ablation, demonstrating a significant correlation between total ablation time and post-ablation levels of TnT and CKMB (CIR r = 0.61 and 0.53, p < 0.001; RMI r = 0.74 and 0.73, p < 0.001; and RMN r = 0.51 and 0.59, p < 0.01). Time-corrected release of TnT was significantly higher in the CIR group than in the other groups. Of the patients, 59.6% were free from AF at follow-up (12.2 ± 5.4 months) and there were no differences in success rate between the three groups. Conclusions Remote magnetic catheters may create more discrete and predictable ablation lesions measured by myocardial enzymes and may require longer total ablation time to reach the procedural endpoints. Remote magnetic non-irrigated catheters do not appear to be inferior to magnetic irrigated catheters in terms of myocardial enzyme release and clinical outcome.
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Affiliation(s)
- Eivind Solheim
- Institute of Medicine, University of Bergen, Bergen, Norway.
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Govindan M, Savelieva I, Catanchin A, Camm AJ. Atrial fibrillation-the final frontier. J Cardiovasc Pharmacol Ther 2010; 15:36S-50S. [PMID: 20940451 DOI: 10.1177/1074248410371947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and represents a significant health care issue. The diagnosis and management of AF uses a significant proportion of the health care budget and is responsible for substantial morbidity and mortality. Restoration and maintenance of sinus rhythm is still an important treatment option for symptomatic AF. Anti-arrhythmic drugs (AADs) have had inconsistent results for the prevention of recurrent AF and have been hampered by significant adverse effects. Catheter ablation has rapidly evolved and is fast becoming an alternative for AF prevention. Although multiple treatment options exist, no single modality is effective for all patients. This review outlines best current practice for AF prevention and future perspectives, focusing on new and promising developments in antiarrhythmic drug therapy, strategies for ablation therapy, and forms of hybrid therapy that may offer improved outcomes in selected patients.
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Affiliation(s)
- Malini Govindan
- Division of Cardiac & Vascular Sciences, St George's University of London, London, UK
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POKUSHALOV EVGENY, ROMANOV ALEXANDER, ARTYOMENKO SERGEY, TUROV ALEX, SHIROKOVA NATALYA, KATRITSIS DEMOSTHENESG. Left Atrial Ablation at the Anatomic Areas of Ganglionated Plexi for Paroxysmal Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1231-8. [DOI: 10.1111/j.1540-8159.2010.02800.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Katritsis D, Merchant FM, Mela T, Singh JP, Heist EK, Armoundas AA. Catheter Ablation of Atrial Fibrillation. J Am Coll Cardiol 2010; 55:2293-8. [PMID: 20488298 DOI: 10.1016/j.jacc.2010.03.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/21/2010] [Accepted: 03/01/2010] [Indexed: 11/18/2022]
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DE GREEF YVES, TAVERNIER RENE, VANDEKERCKHOVE YVES, DUYTSCHAEVER MATTIAS. Triggering Pulmonary Veins: A Paradoxical Predictor for Atrial Fibrillation Recurrence After PV Isolation. J Cardiovasc Electrophysiol 2010; 21:381-8. [DOI: 10.1111/j.1540-8167.2009.01646.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Pokushalov E, Romanov A, Artyomenko S, Turov A, Shugayev P, Shirokova N, Katritsis DG. Ganglionated plexi ablation for longstanding persistent atrial fibrillation. Europace 2010; 12:342-6. [DOI: 10.1093/europace/euq014] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Halperin HR, Nazarian S. Damage assessment after ablation role of cardiovascular magnetic resonance. J Am Coll Cardiol 2008; 52:1272-3. [PMID: 18926332 DOI: 10.1016/j.jacc.2008.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022]
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