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Kinami H, Morita K, Shinohara G, Uno Y. Echocardiographic Evaluation of Postoperative Coaptation Geometry of Left AV Valve in Complete Atrioventricular Septal Defect. CLINICAL MEDICINE. PEDIATRICS 2022; 16:11795565221139118. [PMCID: PMC9742689 DOI: 10.1177/11795565221139118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/28/2022] [Indexed: 12/13/2022]
Abstract
Background: We sought to determine the difference in geometric parameters in the left atrioventricular valve (LAVV) postoperative complete atrioventricular septal defect (CAVSD) compared to the normal heart, and the correlation between geometric and functional parameters for detecting the mechanism of LAVV regurgitation (LAVVR) in CAVSD. Methods: LAVV geometric parameters based on complete and acceptable quality echocardiograms of 18 patients with repaired CAVSD compared with 17 normal controls. LAVVR severity was also quantified by indexed vena contracta (I-VC) (mm) and % jet area/left atrium area (% Jet/LA), and the correlation with LAVV parameters in the CAVSD group was investigated. Results: In the CAVSD group, the posterior closing angle (Pc) was nearly the same as the anterior closing angle (Ac), yet in the normal heart, the Pc angle was double the Ac angle. The anterior opening angle (Ao) and posterior-to-anterior leaflet diameter ratio (a/p) in the CAVSD group was also significantly smaller. The CAVSD group also had a shorter indexed coaptation length (I-CL) and indexed tenting height (I-TH). Displacement length (ΔD) differed completely between the CAVSD and Normal groups, and also showed a strong positive correlation to the functional parameters of LAVVR (% Jet/LA: r = .70, P = .02; I-VC: r = .60, P = .02). Conclusions: The parameters in this study were applicable to CAVSD AV valve coaptation characteristics. We introduced 2 novel measures that may provide important insights into the differences in geometry and performance of the LAVV in repaired CAVSD as compared to normal hearts.
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Affiliation(s)
- Hiroo Kinami
- Hiroo Kinami, Department of Cardiac Surgery, Jikei University School of Medicine, 3-25-8 Nishinbashi, Minato-ku, Tokyo 105-8461, Japan.
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The effect of surgical technique, age, and Trisomy 21 on early outcome of surgical management of complete atrioventricular canal defect. Cardiol Young 2022; 32:869-873. [PMID: 34350818 DOI: 10.1017/s1047951121003139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The optimal timing, surgical technique, and the influence of Trisomy 21 on the outcome of surgical repair of Complete Atrioventricular Canal Defect remains uncertain. We reviewed our experience in the repair of CAVC to identify the influence of these factors on operative outcomes. METHODS A prospective study included 70 patients, who underwent repair of CAVC at our institute between July, 2016 and October, 2019. Primary endpoint was mortality and the secondary endpoint was a degree of left atrioventricular valve regurgitation. RESULTS No significant difference was noted between patients operated on, at the first 6 months of age versus later, regarding mortality or LAVV regurgitation. Surgical repair by modified single-patch technique showed a significant reduction in bypass time (71.13 ± 13.507 min versus 99.19 ± 27.092 min, p-value = 0.001). Compared to closure of cleft only, posterior annuloplasty used for repair of LAVV resulted in significant reduction in the occurrence of post-operative valve regurgitation during the early period (LAVV 2 + 43 versus 7 %, p-value = 0.03) and at 6 months of follow-up (LAVV 2 + 35.4 versus 0 %, p-value = 0.01), respectively. CONCLUSIONS Early intervention, in the first 6 months in patients with CAVC by surgical repair gives comparable acceptable results to later repair; Trisomy 21 was not found to be a risk factor for early intervention. Repair of common AV valve by cleft closure with posterior LAVV annuloplasty showed better results with a significant decrease in post-operative LAVV regurgitation and early mortality in comparison to the closure of cleft only.
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Surgical Management for Complete Atrioventricular Septal Defects: A Systematic Review and Meta-Analysis. Pediatr Cardiol 2020; 41:1445-1457. [PMID: 32583199 DOI: 10.1007/s00246-020-02397-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
A meta-analysis is performed for a comparison of outcomes between the modified one-patch repair (MPR) and two-patch repair (TPR) for complete atrioventricular septal defects (CAVSD). Electronic databases, including PubMed, Scopus, Embase, and Cochrane Library were searched systematically for the literature which aimed mainly at comparing the therapeutic effects for CAVSD administrated by MPR and TPR. Corresponding data sets were extracted and two reviewers independently assessed the risks of bias. Meta-analysis was performed using Revman 5.3 and Stata 12.0. Fifteen studies meeting the inclusion criteria were included, involving 2076 subjects in total. It was observed that MPR was associated with shorter cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times, as compared with TPR. However, no statistical differences were found in terms of size of ventricular septal defects (VSD), reoperation, mortality, implantation of permanent pacemakers, and length of ventilation, hospital and intensive care unit stay. As compared with TPR, MPR is superior in terms of ACC and CPB. However, with regard to reoperation, mortality, length of ventilation, ICU and hospital stay and permanent pacemakers implantation, no significant differences are found between these two procedures. MPR is likely to apply to younger infants with faster completion of surgery. Surgery is recommended between 3 and 6 months of age.
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Wang G, Ma K, Pang K, Hua Z, Zhang S, Qi L, Yang Y, Feng Z, Mao F, Zhang H, Li S. Modified Single Repair Technique for Complete Atrioventricular Septal Defect: A Propensity Score Matching Analysis. Pediatr Cardiol 2020; 41:615-623. [PMID: 31974717 DOI: 10.1007/s00246-020-02292-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/17/2020] [Indexed: 11/26/2022]
Abstract
There were controversies about the priority of modified single patch (MSP) technique compared with two-patch (TP) technique for patients with complete atrioventricular septal defect (CAVSD). From 2002 to 2013, patients who diagnosed as balanced CAVSD in our institution were retrospectively included. Patients with unbalanced ventricles or associated anomalies were excluded. The primary endpoint was all-cause mortality and the secondary endpoint consist of left atrioventricular dysfunction or left atrioventricular outflow tract obstruction (LVOTO). A total of 74 patients underwent MSP repair and 102 patients underwent TP repair. After 1:1 propensity matching, there were 46 Rastelli type A CAVSD patients in each group. Patients in MSP group had shorter cardiopulmonary bypass time [median (interquartile range) 73.5 (65.5-95.0) versus 105.0 (88.8-130.0) min, P < 0.001] and aortic cross-clamp time [105.5 (90.0-128.0) versus 143.0 (122.0-184.0) min, P < 0.001]. In total, the primary endpoint occurred in 12 patients, including 2/46 (4.3%) in MSP group and 10/46 (21.7%) in TP group. That 1-year, 3-year, 5-year survival rate can be calculated as 95.6%, 95.6%, 95.6% in MSP group and 92.6%, 80.4%, 78.2% in TP group, P = 0.015. No significant statistical difference found for the secondary endpoints that 7/46 (15.2%) patients occurred moderate or severe LAVVR in MSP group versus 11/46 (23.9%) patients in TP group, P = 0.293. No LVOTO occurred in both groups. Besides the simplicity of technique, MSP technique may be safer.
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Affiliation(s)
- Guanxi Wang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Kai Ma
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Kunjing Pang
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, The People's Republic of China
| | - Zhongdong Hua
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Sen Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Lei Qi
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Yang Yang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Zicong Feng
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | | | - Hao Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, 100037, The People's Republic of China.
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Loomba RS, Flores S, Villarreal EG, Bronicki RA, Anderson RH. Modified Single-Patch versus Two-Patch Repair for Atrioventricular Septal Defect: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2020; 10:616-623. [PMID: 31496417 DOI: 10.1177/2150135119859882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We performed a meta-analysis of studies to determine whether the modified single-patch technique offers benefits when compared to the two-patch repair. The postoperative outcomes examined in this study were cardiopulmonary bypass time, cross-clamp time, duration of mechanical ventilation, intensive care unit length of stay, total hospital length of stay, need for reoperation, need for reoperation for left ventricular outflow tract obstruction or left atrioventricular valve regurgitation, need for pacemaker implantation, and mortality during follow-up. METHODS A review was conducted to identify studies comparing a modified single-patch repair versus two-patch repair. A fixed-effects model was utilized for end points with low heterogeneity and a random-effects model for end points with significant heterogeneity. Meta-regression was also performed to determine the influence of other factors on the variables of interest. RESULTS A total of 964 unique manuscripts were screened, with 10 being included in the final analyses. There were a total of 724 patients, with 353 (49%) having undergone repair utilizing a modified single-patch repair. Mean age at repair for modified single-patch repair and two-patch repair was 8.81 and 9.03 months, respectively. Significant differences were noted in cardiopulmonary bypass time and cross-clamp time with mean difference of -28.53 and -22.69 minutes, respectively. In comparison to the two-patch repair, both times were decreased in modified single-patch repair. No significant difference was noted in any other variables. CONCLUSIONS Modified single-patch repair for atrioventricular septal defects requires less cardiopulmonary bypass and cross-clamp time but does not significantly impact the examined postoperative outcomes.
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Affiliation(s)
- Rohit S Loomba
- Cardiology, Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Saul Flores
- Critical Care and Cardiology, Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Enrique G Villarreal
- Critical Care and Cardiology, Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ronald A Bronicki
- Critical Care and Cardiology, Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Robert H Anderson
- Institute of Genetics, Newcastle University, Newcastle Upon Tyne, United Kingdom
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Geoffrion TR, Singappuli K, Murala JSK. A review of the Nunn modified single patch technique for atrioventricular septal defect repair. Transl Pediatr 2018; 7:91-103. [PMID: 29770291 PMCID: PMC5938247 DOI: 10.21037/tp.2018.02.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Atrioventricular septal defect (AVSD) is a common congenital cardiac surgical problem. Over the years, younger and smaller infants are having operations for this condition before irreversible cardio pulmonary changes occur. Traditionally a single or two patch techniques have been used to repair this defect. However, in the past two decades an innovative method of modified single patch technique popularized by Dr. Graham Nunn has gained worldwide popularity. This review discusses the origin, surgical principles, technique and outcomes of this method, popularly known as Nunn or Australian technique. Research comparing the modified single patch technique to classic single and double patch techniques has shown good preservation of atrioventricular valve function, no residual ventricular septal defect (VSDs), low incidence of left ventricular outflow obstruction, preserved conduction, easy reproducibility, and improved perioperative and long-term mortality.
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Affiliation(s)
- Tracy R Geoffrion
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kanchana Singappuli
- Department of Pediatric Cardiac Surgery, Lady Ridgeway Hospital for Children, Dr. Denister De Silva Mawatha, Colombo, Sri Lanka
| | - John S K Murala
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Li D, Fan Q, Iwase T, Hirata Y, An Q. Modified Single-Patch Technique Versus Two-Patch Technique for the Repair of Complete Atrioventricular Septal Defect: A Meta-Analysis. Pediatr Cardiol 2017; 38:1456-1464. [PMID: 28711966 DOI: 10.1007/s00246-017-1684-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
Abstract
Technical selection for surgical repair of complete atrioventricular septal defect (CAVSD) still remains controversial. This meta-analysis aimed to compare the modified single-patch (MP) technique with the two-patch (TP) technique for patients with CAVSD. Relevant studies comparing the MP technique with the TP technique were identified through a literature search using MEDLINE, EMBASE, Google Scholar, Cochrane Library, and the China National Knowledge Infrastructure databases. The variables were ventricular septal defect (VSD) size, cardiopulmonary bypass (CBP) time, aortic cross-clamp (ACC) time, intensive care unit stay, hospital stay, and other outcomes involving mortality, left ventricular outflow tract obstruction, atrioventricular valve regurgitation, residual septal shunt, atrioventricular block, and reoperation. A random-effect/fixed-effect model was used to summarize the estimates of mean difference/odds ratio with 95% confidence interval. Subgroup analysis stratified by region was performed. Fifteen publications involving 1034 patients were included. This meta-analysis demonstrated that (1) VSD size in the MP group was significantly smaller; (2) CBP time, ACC time, and hospital stay in the MP group experienced improvement; (3) Other postoperative outcomes showed no significant differences between two groups; and (4) The trends in China and other countries were close. The MP and TP techniques had comparable outcomes; however, the MP technique was performed with significantly shorter CBP and ACC times in patients with smaller VSDs. Given this limitation of data, the results of comparison of the two techniques in patients with larger VSDs remain unknown. Further studies are needed.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Qiang Fan
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Tomoyuki Iwase
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yasutaka Hirata
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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El-Rassi I, Charafeddine F, Tabbakh A, Aboutaka M, Khater D, Arabi M, Bitar F. Surgical repair of complete atrioventricular defect (Nunn technique). Multimed Man Cardiothorac Surg 2015; 2015:mmv023. [PMID: 26443542 DOI: 10.1093/mmcts/mmv023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/09/2015] [Indexed: 06/05/2023]
Abstract
Two procedures have been traditionally used for the surgical repair of complete atrioventricular canal. The single-patch technique includes the division of valve leaflets, and the use of one patch to close the ventricular and the atrial septal defects, whereas the double-patch technique uses two separate patches, without the division of the bridging leaflets. Between 1997 and 2007, another technique emerged, the modified single-patch technique, or the 'Australian' technique, whereby the ventricular septal defect (VSD) is closed by the direct apposition of the bridging leaflets against the crest of the defect. Because of the absence of the ventricular septal patch, concerns have been raised about the possible left ventricular outflow tract obstruction (LVOTO), or atrioventricular valve (AVV) distortion, especially in case of a deep VSD, or if the defect extends superiorly. The results of the modified single-patch technique in terms of mortality, immediate and long-term AVV function and LVOTO have been similar to the standard techniques in most reports. This article will describe in detail the operative technique and review the relevant literature.
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Affiliation(s)
- Issam El-Rassi
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Anas Tabbakh
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad Aboutaka
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Daniele Khater
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Cardiac Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Comparison of two surgical techniques for complete atrioventricular septal defect repair using two- and three-dimensional echocardiography. Pediatr Cardiol 2014; 35:393-8. [PMID: 24022512 DOI: 10.1007/s00246-013-0790-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
Different surgical techniques for complete atrioventricular septal defect (CAVSD) repair have been described, with the double-patch technique being most frequently employed. More recently a newer technique using a modified single-patch repair has been advocated. We hypothesized that the modified single-patch technique would result in an increased incidence of the two major post-repair comorbidities, namely, distortion of the left AV valve (LAVV) leaflets and narrowing of the left-ventricular outflow tract (LVOT). We studied 14 patients with CAVSD who underwent either traditional double-patch technique [group 1 (n = 7)] or modified single-patch technique [group 2 (n = 7)]. Preoperative and immediate postoperative two-dimensional (2D) echocardiograms, as well as follow-up 2D and three-dimensional (3D) studies, were reviewed. For group 1, the median age at repair was 4.1 months with a median duration from surgical repair and last echocardiogram of 44 months. For group 2, the median age at repair was 3 months with a median duration from surgical repair and last echocardiogram of 28 months. The two groups had similar demographics and ventricular septal defect size before surgery. For the LAVV, no significant difference was observed with respect to LAVV annulus size, tenting height, and the size of the vena contracta. Furthermore, there was no significant difference in the 2D echocardiographic areas and volumes of the LVOT between pre-repair and immediate post-repair studies for both groups. At the last evaluation, although there had been growth of the LVOT in both groups, no significant difference between areas and volumes were observed. Areas of the LVOT measured by 3D echocardiography on the final study showed no significant statistical difference between both groups. There was good correlation of the areas measured by 2D and 3D echocardiography within each group. In this small group, modified single-patch technique does not appear to tether the LAVV or promote an increase in regurgitation. In the short term, LVOT growth is unaffected, and the repair does not promote LVOT obstruction. 3D echocardiography is useful for area measurements of the LVOT and showed good correlation with areas measured by assumption of the LVOT shape as determined using 2D techniques.
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Pan G, Song L, Zhou X, Zhao J. Complete Atrioventricular Septal Defect: Comparison of Modified Single-Patch Technique with Two-Patch Technique in Infants. J Card Surg 2014; 29:251-5. [PMID: 24495040 DOI: 10.1111/jocs.12295] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gaofeng Pan
- Department of Thoracic and Cardiovascular Surgery; Zhongnan Hospital of Wuhan University; Wuhan, Hubei P.R. China
| | - Laichun Song
- Department of Cardiovascular Surgery; Wuhan Asia Heart Hospital; Wuhan P.R. China
| | - Xuefeng Zhou
- Department of Thoracic and Cardiovascular Surgery; Zhongnan Hospital of Wuhan University; Wuhan, Hubei P.R. China
| | - Jinping Zhao
- Department of Thoracic and Cardiovascular Surgery; Zhongnan Hospital of Wuhan University; Wuhan, Hubei P.R. China
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Harmandar B, Aydemir NA, Karaci AR, Sasmazel A, Saritas T, Bilal MS, Yekeler I. Results for Surgical Correction of Complete Atrioventricular Septal Defect: Associations with Age, Surgical Era, and Technique. J Card Surg 2012; 27:745-53. [DOI: 10.1111/jocs.12016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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