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Chen J, Chen Q, Zhang F, Chen X, Xu Z, Jiang Q, Sun X, Li J, Chen L, Wang W. The Effect of the Enhanced Endpoint of Pulmonary Vein Isolation on the Long-Term Success Rate of Radiofrequency Ablation for Atrial Fibrillation. Int J Gen Med 2021; 14:697-707. [PMID: 33688241 PMCID: PMC7935441 DOI: 10.2147/ijgm.s294033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/18/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to investigate whether the enhanced endpoint of pulmonary vein isolation (PVI; intravenous injection of adenosine-triphosphate [ATP] + pacing capture + supplemental ablation) after initial PVI can reduce the long-term recurrence rate of atrial fibrillation (AF) after PVI. Methods Patients with paroxysmal or persistent AF undergoing catheter ablation treatment were enrolled in this study and divided into three groups according to the surgical endpoint: (1) group 1 (n = 92), in which patients were observed for 30 minutes after the initial PVI and pulmonary vein–left atrium (PV–LA) electrical conduction had not recovered; (2) group 2 (n = 99), in which patients were observed for 30 minutes after the initial PVI, then intravenously injected with ATP, and PV–LA electrical conduction had not recovered; and (3) group 3 (n = 102), in which patients were observed for 30 minutes after the initial PVI, then intravenously injected with ATP + treated with ablation line pacing, and the atrium could not be captured. Results Patients were followed up for 12 months after the operation. Twenty-eight patients in group 1 (30.4%), 19 patients in group 2 (19.2%), and 10 patients in group 3 (9.8%) developed a recurrence of AF. The difference between groups 1 and 3 was statistically significant (p < 0.001). At 12 months after the operation, the thickness of the left atrium, the posterior wall of the left ventricle, and the ventricular septum of the three groups of patients were significantly thinner than before the operation. Furthermore, the left ventricular ejection fraction had increased (p < 0.05 for all), and the pulmonary artery pressure had decreased (p < 0.001). Conclusion For patients with paroxysmal AF or persistent AF, the enhanced endpoint of PVI after the initial PVI can reduce the long-term recurrence rate of AF after PVI.
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Affiliation(s)
- Jianhua Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Quanhe Chen
- Union Clinic Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Xuehai Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Zhe Xu
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Qiong Jiang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Xudong Sun
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Jinguo Li
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
| | - Weiwei Wang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, People's Republic of China
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Jiang R, Chen M, Yang B, Liu Q, Zhang Z, Zhang F, Ju W, Li M, Sheng X, Sun Y, Zhang P, Yu L, Chen S, Zhu J, Cheng H, Fu G, Tung R, Jiang C. Intraprocedural endpoints to predict durable pulmonary vein isolation: a randomized trial of four post-ablation techniques. Europace 2020; 22:567-575. [PMID: 32249915 DOI: 10.1093/europace/euz301] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/26/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS The optimal procedural endpoint to achieve permanent pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) remains unknown. We aimed to compare the impact of prolonged waiting periods and adenosine triphosphate (ATP) testing after PVI on long-term freedom from AF. METHODS AND RESULTS In total, 538 patients (median age 61 years, 62% male) undergoing first-time radiofrequency ablation for paroxysmal AF were randomized into four groups: Group 1 [PVI (no testing), n = 121], Group 2 (PVI + 30min waiting phase, n = 151), Group 3 (PVI+ATP, n = 131), and Group 4 (PVI + 30min+ATP, n = 135). The primary endpoint was freedom from AF. Repeat mapping to assess for late pulmonary vein (PV) reconnection was performed in patients who remained AF-free for >3 years (n = 46) and in those who had repeat ablation for AF recurrence (n = 82). During initial procedure, acute PV reconnection was observed in 33%, 26%, and 42% of patients in Groups 2, 3, and 4, respectively. At 36 months, no significant differences in freedom from AF recurrence were observed among all four groups (55%, 61%, 50%, and 62% for Groups 1, 2, 3, and 4, respectively; P = 0.258). Late PV reconnection was commonly observed, with a similar incidence between patients with and without AF recurrence (74% vs. 83%; P = 0.224). CONCLUSION Although PVI remains the cornerstone for AF ablation, intraprocedural techniques to assess for PV reconnection did not improve long-term success. Patients without AF recurrence after 3 years exhibited similarly high rates of PV reconnection as those that underwent repeat ablation for AF recurrence. The therapeutic mechanisms of AF ablation may not be solely predicated upon durable PVI.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Bing Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Division of Cardiology, Department of Cardiology, Shanghai East Hospital, Tongji University, Shanghai 200120, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Zuwen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Fengxiang Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Jun Zhu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Hui Cheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Roderick Tung
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
- Center for Arrhythmia Care, Heart and Vascular Center, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
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Siontis KC, Noseworthy PA. Down but not out-addressing the scourge of late pulmonary vein reconnection. J Cardiovasc Electrophysiol 2019; 30:824-826. [PMID: 30887591 DOI: 10.1111/jce.13903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Konstantinos C Siontis
- Department of Cardiovascular Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, College of Medicine, Rochester, Minnesota.,Division of Health Care Policy and Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Ganesan P, Salmin A, Cherry EM, Huang DT, Pertsov AM, Ghoraani B. Iterative navigation of multipole diagnostic catheters to locate repeating-pattern atrial fibrillation drivers. J Cardiovasc Electrophysiol 2019; 30:758-768. [PMID: 30725499 PMCID: PMC6554033 DOI: 10.1111/jce.13872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 01/31/2019] [Indexed: 01/01/2023]
Abstract
Introduction Targeting repeating‐pattern atrial fibrillation (AF) sources (reentry or focal drivers) can help in patient‐specific ablation therapy for AF; however, the development of reliable and accurate tools for locating such sources remains a major challenge. We describe iterative catheter navigation (ICAN) algorithm to locate AF drivers using a conventional circular Lasso catheter. Methods and Results At each step, the algorithm analyzes 10 bipolar electrograms recoded at a given catheter location and the history of previous catheter movements to determine if the source is inside the catheter loop. If not, it calculates new coordinates and selects a new position for the catheter. The process continues until a source is located. The algorithm was evaluated in a computer model of atrial tissue with various degrees of fibrosis under a broad range of arrhythmia scenarios. The latter included slow and fast reentry, macroreentry, figure‐of‐eight reentry, and fibrillatory conduction. Depending on the initial distance of the catheter from the source and scenario, it took about 3 to 16 steps to localize an AF source. In 94% of cases, the identified location was within 4 mm from the source, independently of the initial position of the catheter. The algorithm worked equally well in the presence of patchy fibrosis, low‐voltage areas, fragmented electrograms, and dominant‐frequency gradients. Conclusions AF repeating‐pattern sources can be localized using circular catheters without the need to map the entire tissue. The proposed algorithm has the potential to become a useful tool for patient‐specific ablation of AF sources located outside the pulmonary veins.
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Affiliation(s)
- Prasanth Ganesan
- Computer and Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, Florida
| | - Anthony Salmin
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York
| | - Elizabeth M Cherry
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York
| | - David T Huang
- Department of Cardiology, University of Rochester Medical Center, Rochester, New York
| | - Arkady M Pertsov
- Department of Pharmacology, SUNY Upstate Medical Center, Syracuse, New York
| | - Behnaz Ghoraani
- Computer and Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, Florida
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Chen C, Li D, Ho J, Liu T, Li X, Wang Z, Lin Y, Zou F, Tse G, Xia Y. Clinical Implications of Unmasking Dormant Conduction After Circumferential Pulmonary Vein Isolation in Atrial Fibrillation Using Adenosine: A Systematic Review and Meta-Analysis. Front Physiol 2019; 9:1861. [PMID: 30705634 PMCID: PMC6345194 DOI: 10.3389/fphys.2018.01861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/11/2018] [Indexed: 12/04/2022] Open
Abstract
Purpose: Circumferential pulmonary vein isolation (CPVI) is a routine ablation strategy of atrial fibrillation (AF). The adenosine test can be used to unmask dormant conduction (DC) of pulmonary veins after CPVI, thereby demonstrating possible pulmonary vein re-connection and the need for further ablation. However, whether adenosine test could help improve the long term successful rate of CPVI is still controversial. This systemic review and meta-analysis was to determine the clinical utility of the adenosine test. Methods: PubMed, EMBASE, Web of Science and Cochrane Library database were searched through July 2016 to identify relevant studies using the keywords “dormant pulmonary vein conduction,” “adenosine test,” “circumferential pulmonary vein isolation,” and “atrial fibrillation.” A random-effects model was used to compare pooled outcomes and tested for heterogeneity. Results: A total of 17 studies including 5,169 participants were included in the final meta-analysis. Two groups of comparisons were classified: (1) Long-term successful rate in those AF patients underwent CPVI with and without adenosine test [Group A (+) and Group A (−)]; (2) Long-term successful rate in those patients who had adenosine test with and without dormant conduction [Group DC (+) and Group DC (−)]. The overall meta-analysis showed that no significant difference can be observed between Group A (+) and Group A (−) (RR 1.08; 95% CI 0.97–1.19; P = 0.16; I2 = 66%) and between Group DC (+) and Group DC (−) (RR 1.01; 95% CI 0.91–1.12; P = 0.88; I2 = 60%). Conclusion: Pooled meta-analysis suggested adenosine test may not improve long-term successful rate in AF patients underwent CPVI. Furthermore, AF recurrence may not be decreased by eliminating DC provoked by adenosine, even though adenosine test was applied after CPVI.
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Affiliation(s)
- Cheng Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Daobo Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jeffery Ho
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xintao Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhao Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yajuan Lin
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fuquan Zou
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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Afzal MR, Kahaly O, Weiss R, Houmsse M, Daoud EG, Hummel JD. Adenosine triphosphate/adenosine guided pulmonary vein isolation does not improve the outcomes of ablation: a meta-analysis of randomized controlled trials. Expert Rev Cardiovasc Ther 2018; 16:313-318. [PMID: 29561176 DOI: 10.1080/14779072.2018.1455500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs). OBJECTIVES To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis. METHODS AND RESULTS Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 s after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p = 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p = 0.98]. CONCLUSIONS ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.
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Affiliation(s)
- Muhammad R Afzal
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Omar Kahaly
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Raul Weiss
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Mahmoud Houmsse
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Emile G Daoud
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - John D Hummel
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
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McLellan AJ, Kumar S, Smith C, Ling LH, Prabhu S, Kalman JM, Kistler PM. The role of adenosine challenge in catheter ablation for atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2017; 236:253-261. [DOI: 10.1016/j.ijcard.2017.01.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
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Salmin AJ, Ganesan P, Shillieto KE, Cherry EM, Huang DT, Pertsov AM, Ghoraani B. A novel catheter-guidance algorithm for localization of atrial fibrillation rotor and focal sources. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:501-504. [PMID: 28268380 DOI: 10.1109/embc.2016.7590749] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Locating atrial fibrillation (AF) focal and rotor sources can help improve target ablation therapy for AF. However, it remains unclear how to use the information provided by multi-polar diagnostic catheters (MPDC) to locate AF sources. Our aim was to develop a catheter-guidance algorithm to locate AF focal and rotor sources using a conventional MPDC. We simulated a 10 cm × 10 cm atrial tissue with focal and rotor sources using the Nygren et al. ionic model. We modeled a Lasso MPDC with 20-unipole electrodes placed with a spacing of 4.5-1-4.5 mm (diameter, d=15 mm) along a circle to obtain 10-bipole electrograms. Staring from an initial location, the algorithm, which was blinded to the location and type of the AF source, iteratively advanced the MPDC by moving its center to the location of the first activated bipole (FAB). The algorithm located an AF source if a stopping condition for either source was satisfied using bipole electrogram characteristics extracted from the MPDC placement. We tested the algorithm for a single rotor and focal source for all possible initial positions on the simulated tissue and repeated it for a random placement with a maximum of 20 possible placements at every trial. The algorithm located the AF source for 100% of trials and on average required 5.99 ± 1.92 placements to an AF source. This algorithm may be used to iteratively direct an MPDC towards an AF source and allow the AF source to be localized for customized AF ablation.
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