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Beyer SE, Imnadze G, Sommer P. [New pacing strategies for heart failure]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024:10.1007/s00108-024-01747-7. [PMID: 38967707 DOI: 10.1007/s00108-024-01747-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Abstract
In patients with a reduced left ventricular (LV) systolic function (ejection fraction < 35%) and a left bundle branch block with a QRS duration > 130 ms, cardiac resynchronization therapy (CRT) can contribute to an improvement in the quality of life and a reduction in mortality. The resynchronization is mostly achieved by pacing via an epicardial LV lead in the coronary sinus; however, this approach is often limited by the patient's venous anatomy and an increase in the stimulation threshold over time. In addition, up to 30% of patients do not respond to the intervention. New treatment approaches involve direct stimulation of the conduction system by pacing of the bundle of His or left bundle branch. This enables a more physiological propagation of the stimulus. Pacing of the left bundle branch is achieved by advancing the lead into the right ventricle and screwing it deep into the interventricular septum. Due to the relatively large target area of the left bundle branch the success rate is very high (currently > 90%). Observational studies have shown a greater reduction in the QRS duration, a more pronounced improvement in systolic function and a lower hospitalization rate for heart failure associated with conduction system pacing compared to CRT using a coronary sinus lead. These findings have been confirmed in small randomized trials. Therefore, the use of left bundle branch pacing should be considered not only as a bail out in the case of failed resynchronization using coronary sinus lead placement but increasingly also as an initial pacing strategy. The results of the first large randomized trials are expected to be released in late 2024.
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Affiliation(s)
- Sebastian E Beyer
- Klinik für Elektrophysiologie, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Guram Imnadze
- Klinik für Elektrophysiologie, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Philipp Sommer
- Klinik für Elektrophysiologie, Herz- und Diabeteszentrum NRW, Ruhr Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland.
- Herz- und Diabeteszentrum NRW, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland.
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Chokesuwattanaskul R, Tokavanich N, Srimahachota S. Challenging coronary sinus lead placement for CRT: A modified "Anchoring balloon" technique. Pacing Clin Electrophysiol 2024; 47:914-917. [PMID: 37932890 DOI: 10.1111/pace.14869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/20/2023] [Accepted: 10/29/2023] [Indexed: 11/08/2023]
Abstract
An 80-year-old man with a history of complete heart block underwent dual chamber pacemaker implantation about a year ago. He returned to the hospital due to de novo heart failure caused by pacing-induced cardiomyopathy; hence, we planned to upgrade his pacemaker to a biventricular device. The initial strategy was to perform left bundle branch area pacing-optimized cardiac resynchronization therapy (LOT-CRT) with left bundle branch area pacing (LBBAP) combined with a coronary sinus (CS) lead. In this challenging case, the successful placement of a CS lead was hindered by a complicated combination of a large CS body linked to the left superior vena cava and a winding CS branch. However, utilizing readily available tools, such as the coronary balloon and Guide Plus II ST catheter, proved instrumental in overcoming these obstacles. As a result, LOT-CRT provided the patient with a safe alternative to surgical LV lead placement.
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Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Department of Medicine, Faculty of Medicine, Cardiac Center, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Thai Red Cross Society, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Center of Excellence in Arrhythmia Research Chulalongkorn University, Chulalongkorn University, Bangkok, Thailand
| | - Nithi Tokavanich
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Suphot Srimahachota
- Department of Medicine, Faculty of Medicine, Cardiac Center, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Thai Red Cross Society, Bangkok, Thailand
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Yoshida K, Yoshino M, Kawabata T, Tasaka H, Kadota K. Cardiac resynchronization therapy-defibrillator implantation with shock lead placement in the left bundle branch area: a case report. Eur Heart J Case Rep 2024; 8:ytae323. [PMID: 39035259 PMCID: PMC11259192 DOI: 10.1093/ehjcr/ytae323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/22/2024] [Accepted: 07/01/2024] [Indexed: 07/23/2024]
Abstract
Background Cardiac resynchronization therapy (CRT) with biventricular pacing is a well-established therapy. Left bundle branch area pacing (LBBAP) is a safe technique providing physiological pacing, and LBBAP-optimized CRT (LOT-CRT) has been shown to provide better electrical resynchronization than traditional CRT. However, there are few reports on shock lead placement in the left bundle branch area (LBBA) during CRT-defibrillator (CRT-D) implantation. Case summary A 76-year-old woman with heart failure from dilated cardiomyopathy presented with left bundle branch block pattern (QRS duration, 160 ms). Left ventricular ejection fraction was 21%. Cardiac resynchronization therapy-defibrillator implantation was performed due to worsening symptoms. By reshaping the Agilis HisPro catheter and adding a septal curve, the shock lead was placed deep into the ventricular septum, narrowing QRS duration to 114 ms. Left ventricular activation time was 84 ms. A defibrillation threshold test confirmed successful treatment without adverse events. At 6-month follow-up, left ventricular ejection fraction improved from 21 to 63%, with the patient's condition improving from New York Heart Association class III to class I. Discussion It was reported that QRS narrowing in CRT was related to long-term mortality, and LOT-CRT further decreased QRS duration as compared with LBBP only or biventricular pacing and increased the response rate. Combining LBBAP with coronary sinus pacing can potentially achieve superior electrical resynchronization. Lack of a suitable tool for direct shock lead placement in LBBA necessitated additional LBBAP lead in conventional LOT-CRT. Our successful LOT-CRT-D procedure with minimal number of leads through Agilis HisPro catheter reshaping enabled direct LBBA shock lead placement.
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Affiliation(s)
- Kenta Yoshida
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Mitsuru Yoshino
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Tokuma Kawabata
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Hiroshi Tasaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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Kamalathasan S, Paton M, Gierula J, Straw S, Witte KK. Is conduction system pacing a panacea for pacemaker therapy? Expert Rev Med Devices 2024:1-11. [PMID: 38913600 DOI: 10.1080/17434440.2024.2370827] [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: 04/04/2024] [Accepted: 06/18/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION While supported by robust evidence and decades of clinical experience, right ventricular apical pacing for bradycardia is associated with a risk of progressive left ventricular dysfunction. Cardiac resynchronization therapy for heart failure with reduced ejection fraction can result in limited electrical resynchronization due to anatomical constraints and epicardial stimulation. In both settings, directly stimulating the conduction system below the atrio-ventricular node (either the bundle of His or the left bundle branch area) has potential to overcome these limitations. Conduction system pacing has met with considerable enthusiasm in view of the more physiological electrical conduction pattern, is rapidly becoming the preferred option of pacing for bradycardia, and is gaining momentum as an alternative to conventional biventricular pacing. AREAS COVERED This article provides a review of the current efficacy and safety data for both people requiring treatment for bradycardia and the management of heart failure with conduction delay and discusses the possible future roles for conduction system pacing in routine clinical practice. EXPERT OPINION Conduction system pacing might be the holy grail of pacemaker therapy without the disadvantages of current approaches. However, hypothesis and enthusiasm are no match for robust data, demonstrating at least equivalent efficacy and safety to standard approaches.
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Affiliation(s)
- Stephe Kamalathasan
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiometabolic Medicine, University of Leeds, Leeds, UK
| | - Maria Paton
- Cardiology Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiometabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiometabolic Medicine, University of Leeds, Leeds, UK
| | - Sam Straw
- Leeds Institute of Cardiometabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiometabolic Medicine, University of Leeds, Leeds, UK
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Ponnusamy SS, Ramalingam V, Mariappan S, Ganesan V, Anand V, Syed T, Murugan S, Kumar M, Vijayaraman P. Left bundle branch pacing lead for sensing ventricular arrhythmias in implantable cardioverter-defibrillator: A pilot study (LBBP-ICD study). Heart Rhythm 2024; 21:419-426. [PMID: 38142831 DOI: 10.1016/j.hrthm.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) has been suggested as an alternative modality for biventricular pacing in cardiac resynchronization therapy (CRT)-eligible patients. As it provides stable R-wave sensing, LBBP has been recently used to provide sensing of ventricular arrhythmia in patients receiving implantable cardioverter-defibrillator (ICD) with CRT. OBJECTIVE The aim of this study was to analyze the long-term safety and efficacy of the LBBP lead for appropriate detection of ventricular arrhythmia and delivery of antitachycardia pacing (ATP) in patients requiring defibrillator therapy with CRT. METHODS CRT-eligible patients who underwent successful LBBP-optimized ICD and LBBP-optimized CRT with defibrillator were enrolled. The LBBP lead was connected to the right ventricular-P/S port after capping the IS-1 connector plug of the DF-1-ICD lead. LBBP-optimized ICD or LBBP-optimized CRT with defibrillator was decided on the basis of correction of conduction system disease. Documented arrhythmic episodes and therapy delivered were analyzed. RESULTS Thirty patients were enrolled. The mean age was 59.7 ± 10.5 years. LBBP resulted in an increase in left ventricular ejection fraction from 29.9% ± 4.6% to 43.9% ± 11.2% (P < .0001). During a mean follow-up of 22.9 ± 12.5 months, 254 ventricular arrhythmic events were documented. Appropriate events (n = 225 [89%]) included nonsustained ventricular tachycardia (VT) (n = 212 episodes [94%]), VT (n = 8 [3.5%]), and ventricular fibrillation (n = 5 [2.5%]). ATP efficacy in terminating VT was 75%. Eleven percent of episodes (n = 29) were inappropriately detected because of T-wave oversensing. Inappropriate therapy (ATP) was delivered for 14 episodes (5.5%). Three patients (10%) had worsening of tricuspid regurgitation. CONCLUSION Sensing from the LBBP lead for arrhythmia detection is safe as ∼90% of the episodes were detected appropriately. Future studies with a dedicated LBBP-defibrillator lead along with algorithms to avoid oversensing can help in combining defibrillation with conduction system pacing.
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Affiliation(s)
- Shunmuga Sundaram Ponnusamy
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India.
| | - Vadivelu Ramalingam
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Selvaganesh Mariappan
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Vithiya Ganesan
- Department of Microbiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Vijesh Anand
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Thabish Syed
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Senthil Murugan
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Mahesh Kumar
- Department of Cardiology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
| | - Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania
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Chen X, Jin Q, Qiu Z, Qian C, Liang Y, Wang J, Qin S, Bai J, Wang W, Chen H, Dong Y, Huang W, Su Y. Outcomes of Upgrading to LBBP in CRT Nonresponders: A Prospective, Multicenter, Nonrandomized, Case-Control Study. JACC Clin Electrophysiol 2024; 10:108-120. [PMID: 37943191 DOI: 10.1016/j.jacep.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) nonresponders account for nearly 30% of CRT candidates. Left-bundle branch pacing (LBBP) is an alternative to CRT. OBJECTIVES This study aimed to evaluate the feasibility, clinical efficacy, and outcomes of upgrading to LBBP in CRT nonresponders, using propensity-score matching (PSM) analysis. METHODS CRT nonresponders were defined as those with an implantable CRT-pacemaker or CRT-defibrillator for more than 12 months who remained nonresponsive (a decrease in left ventricular end-systolic volume of <15% or a left ventricular ejection fraction [LVEF] absolute increase of <5%) after optimal medical therapy and device optimization compared with baseline. In total, 145 CRT nonresponders were prospectively enrolled and randomly divided into 2 groups: upgraded to LBBP (n = 48), and continuing biventricular pacing (BVP) (control; n = 97). PSM was performed at a 1:1 ratio, and clinical evaluation and echocardiographic assessments were compared at baseline and follow-up in paired cohorts. The primary composite endpoint for clinical outcomes (heart failure-related rehospitalization events, all-cause death, or heart transplantation) was analyzed. RESULTS Successful upgrading to LBBP was achieved in 48/49 patients (97.96%), with a significant decrease in QRS duration (P < 0.001). In the paired LBBP group, LVEF significantly increased (baseline: 29.75% ± 7.79%; 6 months: 37.78% ± 9.25% [P < 0.001]; 12 months: 38.84% ± 12.13% [P < 0.001]) with 21/44 patients (47.73%) classified as echocardiographically responsive, whereas in the BVP control group, no significant improvement was observed (29.55% ± 6.74% vs 29.22% ± 8.10%; P = 0.840). In a multivariate logistic regression model, LV end-diastolic volume and baseline LBBB QRS morphology were independent predictors of echocardiographic response after upgrading to LBBP. At a median 24 months, the primary composite endpoint was significantly lower in the LBBP group (HR: 0.31; 95% CI: 0.14-0.72; log-rank P = 0.007). CONCLUSIONS Upgrading to LBBP is feasible and effective in achieving significant heart function improvement and better clinical outcomes in CRT nonresponders, making it a reasonable and promising pacing strategy. (LBBP in CRT Non-Response patients; ChiCTR1900028131).
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Affiliation(s)
- Xueying Chen
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhaohui Qiu
- Division of Cardiology, TongRen Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Caizhen Qian
- Zhuji People's Hospital Affiliated of Wenzhou Medical University, Wenzhou, China
| | - Yixiu Liang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Jingfeng Wang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shengmei Qin
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Jin Bai
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Wei Wang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Haiyan Chen
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yingxue Dong
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China.
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Yangang Su
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China.
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Diaz JC, Duque M, Aristizabal J, Marin J, Niño C, Bastidas O, Ruiz LM, Matos CD, Hoyos C, Hincapie D, Velasco A, Romero JE. The Emerging Role of Left Bundle Branch Area Pacing for Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2023; 12:e29. [PMID: 38173800 PMCID: PMC10762674 DOI: 10.15420/aer.2023.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/04/2023] [Indexed: 01/05/2024] Open
Abstract
Cardiac resynchronisation therapy (CRT) reduces the risk of heart failure-related hospitalisations and all-cause mortality, as well as improving quality of life and functional status in patients with persistent heart failure symptoms despite optimal medical treatment and left bundle branch block. CRT has traditionally been delivered by implanting a lead through the coronary sinus to capture the left ventricular epicardium; however, this approach is associated with significant drawbacks, including a high rate of procedural failure, phrenic nerve stimulation, high pacing thresholds and lead dislodgement. Moreover, a significant proportion of patients fail to derive any significant benefit. Left bundle branch area pacing (LBBAP) has recently emerged as a suitable alternative to traditional CRT. By stimulating the cardiac conduction system physiologically, LBBAP can result in a more homogeneous left ventricular contraction and relaxation, thus having the potential to improve outcomes compared with conventional CRT strategies. In this article, the evidence supporting the use of LBBAP in patients with heart failure is reviewed.
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Affiliation(s)
- Juan Carlos Diaz
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical SchoolMedellin, Colombia
| | - Mauricio Duque
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical SchoolMedellin, Colombia
| | - Julian Aristizabal
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las AmericasMedellin, Colombia
| | - Jorge Marin
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las AmericasMedellin, Colombia
| | - Cesar Niño
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobón UribeMedellin, Colombia
| | - Oriana Bastidas
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobón UribeMedellin, Colombia
| | | | - Carlos D Matos
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Daniela Hincapie
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
| | - Alejandro Velasco
- Electrophysiology Section, University of Texas Health Sciences CentreSan Antonio, TX, US
| | - Jorge E Romero
- Cardiac Arrhythmia Service, Brigham and Women’s Hospital, Harvard Medical SchoolBoston, MA, US
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