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Lachmann M, Hesse A, Trenkwalder T, Xhepa E, Rheude T, von Scheidt M, Covarrubias HAA, Rippen E, Hramiak O, Pellegrini C, Schuster T, Yuasa S, Schunkert H, Kastrati A, Kupatt C, Laugwitz KL, Joner M. Invasive Assessment of Right Ventricular to Pulmonary Artery Coupling Improves 1-year Mortality Prediction After Transcatheter Aortic Valve Replacement and Anticipates the Persistence of Extra-Aortic Valve Cardiac Damage. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100282. [PMID: 38799808 PMCID: PMC11121747 DOI: 10.1016/j.shj.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/04/2023] [Accepted: 01/03/2024] [Indexed: 05/29/2024]
Abstract
Background The interplay between the right ventricle and the pulmonary artery, known as right ventricular to pulmonary artery (RV-PA) coupling, is crucial for assessing right ventricular systolic function against the afterload from the pulmonary circulation. Pulmonary artery pressure levels are ideally measured by right heart catheterization. Yet, echocardiography represents the most utilized method for evaluating pulmonary artery pressure levels, albeit with limitations in accuracy. This study therefore aims to evaluate the prognostic significance of right ventricular to pulmonary artery (RV-PA) coupling expressed as tricuspid annular plane systolic excursion (TAPSE) related to systolic pulmonary artery pressure (sPAP) levels measured by right heart catheterization (TAPSE/sPAPinvasive) or estimated by transthoracic echocardiography (TAPSE/sPAPechocardiography) in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Methods Using data from a bicentric registry, this study compares TAPSE/sPAPinvasive vs. TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR. Results Among 333 patients with complete echocardiography and right heart catheterization data obtained before TAVR, their mean age was 79.8 ± 6.74 years, 39.6% were female, and general 1-year survival was 89.8%. sPAPinvasive and sPAPechocardiography showed only moderate correlation (Pearson correlation coefficient R: 0.53, p value: <0.0001). TAPSE/sPAPinvasive was superior to TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR (area under the curve: 0.662 vs. 0.569, p value: 0.025). Patients with reduced TAPSE/sPAPinvasive levels (< 0.365 mm/mmHg) evidenced significantly lower 1-year survival rates than patients with preserved TAPSE/sPAPinvasive levels (81.8 vs. 93.6%, p value: 0.001; hazard ratio for 1-year mortality: 3.09 [95% confidence interval: 1.55-6.17]). Echocardiographic follow-up data revealed that patients with reduced RV-PA coupling suffer from persistent right ventricular dysfunction (TAPSE: 16.6 ± 4.05 mm vs. 21.6 ± 4.81 mm in patients with preserved RV-PA coupling) and severe tricuspid regurgitation (diagnosed in 19.7 vs. 6.58% in patients with preserved RV-PA coupling). Conclusions RV-PA coupling expressed as TAPSE/sPAPinvasive can refine stratification of severe aortic stenosis patients into low-risk and high-risk cohorts for mortality after TAVR. Moreover, it can help to anticipate persistent extra-aortic valve cardiac damage, which will demand further treatment.
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Affiliation(s)
- Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Amelie Hesse
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Teresa Trenkwalder
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Erion Xhepa
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Moritz von Scheidt
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | | | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Oksana Hramiak
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Specialized Department of Cardiology, Ternopil City Communal Hospital №2, Ternopil National Medical University, Ternopil, Ukraine
| | - Costanza Pellegrini
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Canada
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Heribert Schunkert
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Adnan Kastrati
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Christian Kupatt
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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Dadarlat-Pop A, Molnar A, Serban A, Tomoaia R, Hagiu C, Manole S, Oprea A, Mocanu L, Picos A, Mot S. Prognostic Value of Myocardial Function Imaging Markers in Elderly Patients Undergoing Transcatheter Aortic Valve Replacement. Clin Interv Aging 2023; 18:1597-1606. [PMID: 37786426 PMCID: PMC10541530 DOI: 10.2147/cia.s413426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/12/2023] [Indexed: 10/04/2023] Open
Abstract
Background Transcatheter aortic valve replacement (TAVR) became the leading therapeutic strategy for aortic valve replacement in older patients with severe symptomatic aortic stenosis. Echocardiographic parameters that mark the left ventricle and right ventricle reverse remodeling after the TAVR are not well established. The aim of the current study is to describe the dynamics of both left ventricle (LV) and right ventricle (RV) strain derived from speckle tracking echocardiography in elderly patients at 3-months after the TAVR procedure. Methods We enrolled 52 consecutive patients (77 ± 4.9 years old, median STS score of 3.1) who underwent transfemoral TAVR at our tertiary care center. All patients were evaluated at baseline and 3 months following TAVR. Results The LV global longitudinal strain (GLS) 3-month following TAVR was significantly improved compared with baseline values (-16 ±4.2% vs -16 ±4.2%; p < 0.001) but no significant changes in the RV GLS 3 and 6 segments model following TAVR were registered. The LV ejection fraction was significantly improved 3-months after the TAVR procedure. LV-GLS at baseline demonstrated a strong positive correlation with LV-GLS at 3 months (r = 0.69) and a moderate correlation with RV strain parameters (r = 0.38 and r = 0.56), but also a negative correlation with LVEF at follow-up (r=-0.61). Interestingly, in contrast to LVEF, none of the strain parameters correlated with age. NT-proBNP values were correlated with both LV-GLS (r = 0.37) and LVEF (r=-0.5) at baseline. However, at follow-up, baseline NT-proBNP values remained correlated only to LV-GLS at 3-months (r = 0.24), but the correlation was weak.
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Affiliation(s)
- Alexandra Dadarlat-Pop
- Cardiology Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
- Cardiology Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adrian Molnar
- Cardiovascular Surgery Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
- Cardiovascular Surgery Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adela Serban
- Cardiology Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
- Cardiology Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Raluca Tomoaia
- Cardiology Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Cardiology Department, Clinical Rehabilitation Hospital, Cluj-Napoca, Romania
| | - Claudia Hagiu
- Gastroenterology Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- “Prof. Dr. Octavian Fodor” Regional Gastroenterology-Hepatology Institute, Cluj-Napoca, Romania
| | - Simona Manole
- Radiology and Medical Imaging Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Radiology and Medical Imaging, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
| | - Alexandru Oprea
- Cardiovascular Surgery Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
- Cardiovascular Surgery Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lorena Mocanu
- Cardiology Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
| | - Andrei Picos
- Department of Prevention in Dental Medicine, ‘Iuliu Hatieganu’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Stefan Mot
- Cardiology Department, Heart Institute Niculae Stăncioiu, Cluj-Napoca, Romania
- Cardiology Department, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Angellotti D, Manzo R, Castiello DS, Immobile Molaro M, Mariani A, Iapicca C, Nappa D, Simonetti F, Avvedimento M, Leone A, Canonico ME, Spaccarotella CAM, Franzone A, Ilardi F, Esposito G, Piccolo R. Echocardiographic Evaluation after Transcatheter Aortic Valve Implantation: A Comprehensive Review. Life (Basel) 2023; 13:1079. [PMID: 37240724 PMCID: PMC10221682 DOI: 10.3390/life13051079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is an increasingly popular treatment option for patients with severe aortic stenosis. Recent advancements in technology and imaging tools have significantly contributed to the success of TAVI procedures. Echocardiography plays a pivotal role in the evaluation of TAVI patients, both before and after the procedure. This review aims to provide an overview of the most recent technical advancements in echocardiography and their use in the follow-up of TAVI patients. In particular, the focus will be on the examination of the influence of TAVI on left and right ventricular function, which is frequently accompanied by other structural and functional alterations. Echocardiography has proven to be key also in detecting valve deterioration during extended follow-up. This review will provide valuable insights into the technical advancements in echocardiography and their role in the follow-up of TAVI patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
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Grinstein J, Blanco PJ, Bulant CA, Torii R, Bourantas CV, Lemos PA, Garcia-Garcia HM. A computational study of aortic insufficiency in patients supported with continuous flow left ventricular assist devices: Is it time for a paradigm shift in management? Front Cardiovasc Med 2022; 9:933321. [PMID: 36337891 PMCID: PMC9631475 DOI: 10.3389/fcvm.2022.933321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/29/2022] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND De novo aortic insufficiency (AI) following continuous flow left ventricular assist device (CF-LVAD) implantation is a common complication. Traditional early management utilizes speed augmentation to overcome the regurgitant flow in an attempt to augment net forward flow, but this strategy increases the aortic transvalvular gradient which predisposes the patient to progressive aortic valve pathology and may have deleterious effects on aortic shear stress and right ventricular (RV) function. MATERIALS AND METHODS We employed a closed-loop lumped-parameter mathematical model of the cardiovascular system including the four cardiac chambers with corresponding valves, pulmonary and systemic circulations, and the LVAD. The model is used to generate boundary conditions which are prescribed in blood flow simulations performed in a three-dimensional (3D) model of the ascending aorta, aortic arch, and thoracic descending aorta. Using the models, impact of various patient management strategies, including speed augmentation and pharmacological treatment on systemic and pulmonary (PA) vasculature, were investigated for four typical phenotypes of LVAD patients with varying degrees of RV to PA coupling and AI severity. RESULTS The introduction of mild/moderate or severe AI to the coupled RV and pulmonary artery at a speed of 5,500 RPM led to a reduction in net flow from 5.4 L/min (no AI) to 4.5 L/min (mild/moderate) to 2.1 L/min (severe). RV coupling ratio (Ees/Ea) decreased from 1.01 (no AI) to 0.96 (mild/moderate) to 0.76 (severe). Increasing LVAD speed to 6,400 RPM in the severe AI and coupled scenario, led to a 42% increase in net flow and a 16% increase in regurgitant flow (RF) with a nominal decrease of 1.6% in RV myocardial oxygen consumption (MVO2). Blood pressure control with the coupled RV with severe AI at 5,500 RPM led to an 81% increase in net flow with a 15% reduction of RF and an 8% reduction in RV MVO2. With an uncoupled RV, the introduction of mild/moderate or severe AI at a speed of 5,500 RPM led to a reduction in net flow from 5.0 L/min (no AI) to 4.0 L/min (mild/moderate) to 1.8 L/min (severe). Increasing the speed to 6,400 RPM with severe AI and an uncoupled RV increased net flow by 45%, RF by 15% and reduced RV MVO2 by 1.1%. For the uncoupled RV with severe AI, blood pressure control alone led to a 22% increase in net flow, 4.2% reduction in RF, and 3.9% reduction in RV MVO2; pulmonary vasodilation alone led to a 18% increase in net flow, 7% reduction in RF, and 26% reduction in RV MVO2; whereas, combined BP control and pulmonary vasodilation led to a 113% increase in net flow, 20% reduction in RF and 31% reduction in RV MVO2. Compared to speed augmentation, blood pressure control consistently resulted in a reduction in WSS throughout the proximal regions of the arterial system. CONCLUSION Speed augmentation to overcome AI in patients supported by CF-LVAD appears to augment flow but also increases RF and WSS in the aorta, and reduces RV MVO2. Aggressive blood pressure control and pulmonary vasodilation, particularly in those patients with an uncoupled RV can improve net flow with more advantageous effects on the RV and AI RF.
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Affiliation(s)
- Jonathan Grinstein
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Pablo J. Blanco
- National Laboratory for Scientific Computing, Petrópolis, Brazil
| | - Carlos A. Bulant
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Ryo Torii
- Department of Mechanical Engineering, University College of London, London, United Kingdom
| | | | - Pedro A. Lemos
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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Lachmann M, Rippen E, Schuster T, Xhepa E, von Scheidt M, Trenkwalder T, Pellegrini C, Rheude T, Hesse A, Stundl A, Harmsen G, Yuasa S, Schunkert H, Kastrati A, Laugwitz KL, Joner M, Kupatt C. Artificial intelligence-enabled phenotyping of patients with severe aortic stenosis: on the recovery of extra-aortic valve cardiac damage after transcatheter aortic valve replacement. Open Heart 2022; 9:e002068. [PMID: 36261218 PMCID: PMC9582320 DOI: 10.1136/openhrt-2022-002068] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/26/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE A novel artificial intelligence-based phenotyping approach to stratify patients with severe aortic stenosis (AS) prior to transcatheter aortic valve replacement (TAVR) has been proposed, based on echocardiographic and haemodynamic data. This study aimed to analyse the recovery of extra-aortic valve cardiac damage in accordance with this novel stratification system following TAVR. METHODS The proposed phenotyping approach was previously established employing data from 366 patients with severe AS from a bicentric registry. For this consecutive study, echocardiographic follow-up data, obtained on day 147±75.1 after TAVR, were available from 247 patients (67.5%). RESULTS Correction of severe AS by TAVR significantly reduced the proportion of patients suffering from concurrent severe mitral regurgitation (from 9.29% to 3.64%, p value: 0.0015). Moreover, pulmonary artery pressures were ameliorated (estimated systolic pulmonary artery pressure: from 47.2±15.8 to 43.3±15.1 mm Hg, p value: 0.0079). However, right heart dysfunction as well as the proportion of patients with severe tricuspid regurgitation remained unchanged. Clusters with persistent right heart dysfunction ultimately displayed 2-year survival rates of 69.2% (95% CI 56.6% to 84.7%) and 74.6% (95% CI 65.9% to 84.4%), which were significantly lower compared with clusters with little or no persistent cardiopulmonary impairment (88.3% (95% CI 83.3% to 93.5%) and 85.5% (95% CI 77.1% to 94.8%)). CONCLUSIONS This phenotyping approach preprocedurally identifies patients with severe AS, who will not recover from extra-aortic valve cardiac damage following TAVR and whose survival is therefore significantly reduced. Importantly, not the degree of pulmonary hypertension at initial presentation, but the irreversibility of right heart dysfunction determines prognosis.
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Affiliation(s)
- Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Erion Xhepa
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Moritz von Scheidt
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Teresa Trenkwalder
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Costanza Pellegrini
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Amelie Hesse
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Anja Stundl
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gerhard Harmsen
- Department of Physics, University of Johannesburg, Auckland Park, South Africa
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Heribert Schunkert
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Adnan Kastrati
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Christian Kupatt
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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