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Maher T, Vegh A, Uretsky S. Mitral Regurgitation: Advanced Imaging Parameters and Changing Treatment Landscape. Heart Fail Clin 2023; 19:525-530. [PMID: 37714591 DOI: 10.1016/j.hfc.2023.05.001] [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] [Indexed: 09/17/2023]
Abstract
Mitral regurgitation is a common valvular heart disease with increasing prevalence due to the aging population. In degenerative (primary) mitral regurgitation, medical therapies are limited and the mainstay of treatment is mitral valve surgery. Patients are referred for mitral valve surgery based on the American College of Cardiology/American Heart Association guidelines, which recommend surgery in patients with severe mitral regurgitation. Echocardiography uses multiple parameters that lack reproducibility and accuracy. Studies comparing cardiovascular magnetic resonance (CMR) and echocardiography have shown that CMR is a better predictor of clinical outcome and postsurgical left ventricular remodeling than echocardiography.
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Affiliation(s)
- Thomas Maher
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Andrea Vegh
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Avenue, Morristown, NJ 07960, USA.
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2
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Uretsky S, Aldaia L, Marcoff L, Koulogiannis K, Ignacio J, Vegh A, Sakul S, Gillam LD. The relationship between mitral regurgitant severity, symptoms, and exercise capacity in primary degenerative mitral regurgitation. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1677-1685. [PMID: 37347380 DOI: 10.1007/s10554-023-02881-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/16/2023] [Indexed: 06/23/2023]
Abstract
Although it is assumed that more severe MR is associated with a greater burden of symptoms and lower exercise capacity, the relationship between symptoms, exercise capacity, and mitral regurgitant severity has not been well studied. We prospectively studied 67 (63 ± 11 years, 72% male) patients with at least mild degenerative MR and left ventricular ejection fraction ≥ 50% who underwent stress echocardiography, CMR, and evaluation with the Kansas City Cardiomyopathy questionnaire (KCCQ). Symptoms and exercise capacity were evaluated in the context of MR severity. Patients reporting dyspnea had lower KCCQ symptom scores (79 ± 23 vs. 96 ± 9, p = 0.01) and achieved lower percentage of age and gender predicted METs (114 ± 37 vs. 152 ± 43%, p < 0.001) compared to those without dyspnea. There was no significant difference in MR volume between those with vs. without dyspnea by CMR (43 ± 26 ml vs. 51 ± 28 ml, p = 0.3) or echocardiography (64 ± 28 vs. 73 ± 41ml, p = 0.4). Those with severe MR by CMR had similar KCCQ symptom scores (96 ± 10 vs. 89 ± 17, p = 0.04) and percentage of age and gender predicted METs (148 ± 42 vs. 133 ± 47%, p = 0.2) to those without severe MR. Those with severe MR by echocardiography had similar KCCQ symptom score (93 ± 15 vs. 89 ± 16, p = 0.3) and percentage of age and gender predicted METs (138 ± 43 vs. 153 ± 46%, p = 0.2) to those without severe MR. Patients with degenerative MR assessed by CMR and stress echocardiography, there was no relationship between MR severity and either symptoms or exercise capacity. These findings highlight the disconnect between symptoms and the severity of MR and challenge the assumption that correcting MR can be counted on to improve symptom status in patients with degenerative MR.
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Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA.
| | - Lillian Aldaia
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
| | - Konstatinos Koulogiannis
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
| | - Jonathan Ignacio
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
| | - Andrea Vegh
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
| | - Sakul Sakul
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, NY, USA
| | - Linda D Gillam
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, 100 Madison Ave, Morristown, NJ, 07960, USA
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Altes A, Vermes E, Levy F, Vancraeynest D, Pasquet A, Vincentelli A, Gerber BL, Tribouilloy C, Maréchaux S. Quantification of primary mitral regurgitation by echocardiography: A practical appraisal. Front Cardiovasc Med 2023; 10:1107724. [PMID: 36970355 PMCID: PMC10036770 DOI: 10.3389/fcvm.2023.1107724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed “moderate” MR.
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Affiliation(s)
- Alexandre Altes
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - André Vincentelli
- Cardiac Surgery Department, Centre Hospitalier Régional et Universitaire de Lille, Lille, France
| | - Bernhard L. Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | | | - Sylvestre Maréchaux
- GCS-Groupement des Hôpitaux de l’Institut Catholique de Lille/Lille Catholic Hospitals, Heart Valve Center, Cardiology Department, ETHICS EA 7446, Lille Catholic University, Lille, France
- Correspondence: Sylvestre Maréchaux
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The Role of Cardiovascular Magnetic Resonance in Patients with Mitral Regurgitation. J Cardiovasc Dev Dis 2022; 9:jcdd9110399. [DOI: 10.3390/jcdd9110399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
The 2019 Global Burden of Disease (GBD) study estimated that there were approximately 24.2 million people affected worldwide by degenerative mitral regurgitation (MR), resulting in 34,200 deaths. After aortic stenosis, MR is the most prevalent VHD in Europe and the second-most common VHD to pose indications for surgery in western countries. Current ESC and AHA/ACC guidelines for the management of VHD emphasize the importance of an integrative approach for the assessment of MR severity, which is of paramount importance in dictating the timing for surgery. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are the first-line imaging modalities; however, despite the technological advancement, sometimes, the final diagnosis on the degree of the disease may still be challenging. In the last 20 years, CMR has emerged as a robust technique in the assessment of patients with cardiac disease, and, recently, its role is gaining more and more importance in the field of VHD. In fact, CMR is the gold standard in the assessment of cardiac volumes, and it is possible to accurately evaluate the regurgitant volume. The purpose of this review is to outline the current state-of-the-art management of MR by using Cardiac Magnetic Resonance (CMR).
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Uretsky S, Animashaun IB, Sakul S, Aldaia L, Marcoff L, Koulogiannis K, Argulian E, Rosenthal M, Wolff SD, Gillam LD. American Society of Echocardiography Algorithm for Degenerative Mitral Regurgitation: Comparison With CMR. JACC. CARDIOVASCULAR IMAGING 2022; 15:747-760. [PMID: 35324429 DOI: 10.1016/j.jcmg.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the American Society of Echocardiography (ASE) algorithm for assessing mitral regurgitation (MR) to cardiac magnetic resonance (CMR) and left ventricular (LV) remodeling following mitral intervention. BACKGROUND The ASE recommends integrating multiple echocardiographic parameters for assessing MR. The ASE guidelines include an algorithm that weighs the parameters and highlights those considered indicative of definitely mild or definitely severe MR. METHODS We prospectively enrolled 152 (age 62 ± 13 years; 59% male) patients with degenerative MR who underwent ASE algorithm-guided echocardiographic and CMR grading of MR severity. Using the ASE algorithm, patients were graded as definitely mild, grade I, grade II, grade III, grade IV, or definitely severe MR. CMR MR volume was graded as mild (<30 mL), grade II moderate (30-44 mL), grade III moderate (45-59 mL), or severe (≥60 mL). A subgroup of 63 patients underwent successful mitral intervention, of whom 48 had postintervention CMR. RESULTS Only 52% of patients with definitely severe MR by the ASE algorithm had severe MR by CMR, and 10% had mild MR by CMR. There was an increase in post mitral intervention LV reverse remodeling with worsening MR severity using CMR (P < 0.0001) but not the ASE algorithm (P = 0.07). Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling and definitely severe MR by the ASE algorithm was not. CONCLUSIONS In patients with degenerative MR, agreement between CMR and the ASE algorithm was suboptimal. Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling, whereas definitely severe MR by the ASE algorithm was not. These findings suggest an important role for CMR in surgical decision making in degenerative MR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).
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Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA.
| | - Islamiyat Babs Animashaun
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Sakul Sakul
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, New York, USA
| | - Lillian Aldaia
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Konstantinos Koulogiannis
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Edgar Argulian
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, New York, USA
| | - Mark Rosenthal
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | | | - Linda D Gillam
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
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Altes A, Levy F, Iacuzio L, Dumortier H, Toledano M, Tartar J, Tribouilloy C, Maréchaux S. Comparison of mitral regurgitant volume assessment between proximal flow convergence and volumetric methods in patients with significant primary mitral regurgitation: an echocardiographic and CMR study. J Am Soc Echocardiogr 2022; 35:671-681. [DOI: 10.1016/j.echo.2022.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/04/2022] [Accepted: 03/04/2022] [Indexed: 11/25/2022]
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Characterization of Primary Mitral Regurgitation With Flail Leaflet and/or Wall-Impinging Flow. J Am Coll Cardiol 2021; 78:2537-2546. [PMID: 34915984 DOI: 10.1016/j.jacc.2021.09.1382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Echocardiography guidelines note that a flail leaflet is a specific criterion for severe mitral regurgitation (MR) and that regurgitant severity is underestimated in wall-impinging jets (Coandă effect). Both findings are often considered to be pathognomonic of severe MR. OBJECTIVES In this study, the authors sought to determine the association of flail leaflet and Coandă effect with MR severity quantified by means of cardiac magnetic resonance (CMR). METHODS The authors enrolled 158 consecutive patients with primary MR according to echocardiography and CMR. The presence of a flail leaflet or Coandă was determined for each patient. CMR regurgitant volume (RV) and regurgitant fraction (RF) were quantified for all patients. RESULTS There were 55 patients (35%) with a flail leaflet, 52 (33%) with Coandă, and 22 (14%) with a flail leaflet and Coandă. The mean CMR mitral RV and RF progressively increased in patients without a Coandă or flail, a Coandă, a flail, or a Coandă and a flail (RV: 28 ± 21 mL vs 43 ± 23 mL vs 58 ± 29 mL vs 64 ± 25 mL [P < 0.001]; RF: 25% ± 16% vs 34% ± 14% vs 41% ± 12% vs 45% ± 12% [P < 0.001]). With the use of CMR RV, 35%, 46%, and 59% of patients had severe MR with the presence of a Coandă, flail leaflet, or both, respectively. With the use of CMR RF, 25%, 31%, and 40% of patients had severe MR with the presence of a Coandă, flail leaflet, or both, respectively. CONCLUSIONS While the presence of a flail leaflet and Coandă effect on echocardiography are associated with higher regurgitant volumes and fractions, they are frequently not associated with severe MR as assessed by means of CMR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).
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Wang W, Jiang Y, Li J, Gong K, Zhao L, Tang G, Meng Y, Wang Z. Diagnostic value of mitral regurgitant jet volume in the assessment of mitral regurgitation severity by general imaging three-dimensional quantification. Int J Cardiovasc Imaging 2020; 36:1963-1972. [DOI: 10.1007/s10554-020-01916-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/07/2020] [Indexed: 10/24/2022]
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Tarasoutchi F, Montera MW, Ramos AIDO, Sampaio RO, Rosa VEE, Accorsi TAD, Santis AD, Fernandes JRC, Pires LJT, Spina GS, Vieira MLC, Lavitola PDL, Ávila WS, Paixão MR, Bignoto T, Togna DJD, Mesquita ET, Esteves WADM, Atik F, Colafranceschi AS, Moises VA, Kiyose AT, Pomerantzeff PMA, Lemos PA, Brito Junior FSD, Weksler C, Brandão CMDA, Poffo R, Simões R, Rassi S, Leães PE, Mourilhe-Rocha R, Pena JLB, Jatene FB, Barbosa MDM, Abizaid A, Ribeiro HB, Bacal F, Rochitte CE, Fonseca JHDAPD, Ghorayeb SKN, Lopes MACQ, Spina SV, Pignatelli RH, Saraiva JFK. Update of the Brazilian Guidelines for Valvular Heart Disease - 2020. Arq Bras Cardiol 2020; 115:720-775. [PMID: 33111877 PMCID: PMC8386977 DOI: 10.36660/abc.20201047] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Roney Orismar Sampaio
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Vitor Emer Egypto Rosa
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tarso Augusto Duenhas Accorsi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Antonio de Santis
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - João Ricardo Cordeiro Fernandes
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Lucas José Tachotti Pires
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Guilherme S Spina
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Marcelo Luiz Campos Vieira
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Paulo de Lara Lavitola
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Walkiria Samuel Ávila
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Milena Ribeiro Paixão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tiago Bignoto
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | | | - Fernando Atik
- Fundação Universitária de Cardiologia (FUC), São Paulo, SP - Brasil
| | | | | | | | | | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | | | - Clara Weksler
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Carlos Manuel de Almeida Brandão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Robinson Poffo
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Ricardo Simões
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
| | | | | | - Ricardo Mourilhe-Rocha
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Alexandre Abizaid
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Fernando Bacal
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e Instrução Mantenedora da Pontifícia Universidade Católica de Campinas, Campinas, SP - Brasil
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Capron T, Cautela J, Scemama U, Miola C, Bartoli A, Theron A, Pinto J, Porto A, Collart F, Lepidi H, Bernard M, Guye M, Thuny F, Avierinos JF, Jacquier A. Cardiac magnetic resonance assessment of left ventricular dilatation in chronic severe left-sided regurgitations: comparison with standard echocardiography. Diagn Interv Imaging 2020; 101:657-665. [DOI: 10.1016/j.diii.2020.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/05/2020] [Accepted: 04/18/2020] [Indexed: 12/19/2022]
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Maffeis C, Inciardi RM, Benfari G, Bergamini C, Ribichini FL, Cicoira M, Rossi A. Mitral regurgitation and dyspnoea: the expanding role of mitral effective regurgitant orifice among un-selected patients. J Cardiovasc Med (Hagerstown) 2020; 21:503-509. [PMID: 32443135 DOI: 10.2459/jcm.0000000000000975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Mitral regurgitation is frequent in the general population and among suspected heart failure patients; however, to what extent it contributes to dyspnoea is unclear. We hypothesized mitral regurgitation to have a role in determining dyspnoea in unselected ambulatory patients. METHODS Consecutive outpatients referred for echocardiography were retrospectively screened and included. We excluded patients with mitral stenosis or prosthesis, congenital heart disease, cardiac surgery (previous 6 months) and atrial fibrillation. Patients were classified into four dyspnoea grades based on how they perceived their disability. We assessed mitral regurgitation severity through the effective regurgitant orifice area (ERO). RESULTS One hundred and fifty-four patients (58% men; age 67 ± 14 years; mean ejection fraction 54 ± 12%) formed the study population; 76 (49%) classified asymptomatic (grade I), 63 (41%) dyspnoea grade II and 15 (10%) grade III; none was in grade IV. Mitral regurgitation was present in 102 patients (66%): primary in 14 (14%) and secondary in 88 (86%); among grades I, II and III patients, mitral regurgitation was present in 35 (46%; ERO 0.05 ± 0.10 cm), 52 (82%; ERO 0.10 ± 0.13 cm) and 15 (100%; ERO 0.20 ± 0.11 cm) patients, respectively (P < 0.0001). After adjusting for clinical (age, hypertension, ischemic heart disease, chronic kidney injury, chronic pulmonary disease) and echocardiographic confounders (ejection fraction, E/e'), ERO remained associated with symptoms presence (grade I versus II - III; P = 0.01 and P = 0.03, respectively). CONCLUSION Among unselected heterogeneous ambulatory patients, mitral ERO was associated with the presence of dyspnoea and could therefore help in identifying symptomatic patients and in clinical characterization of patients with perceived dyspnoea.
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Affiliation(s)
- Caterina Maffeis
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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12
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Watanabe N. Lost in the Woods? Then We Need a Bird's-Eye View: Integrative Approach for the Doppler Assessment of Mitral Regurgitation. Circ Cardiovasc Imaging 2020; 13:e010788. [PMID: 32408825 DOI: 10.1161/circimaging.120.010788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nozomi Watanabe
- Miyazaki Medical Association Hospital Cardiovascular Center, Miyazaki, Japan
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13
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Uretsky S, Aldaia L, Marcoff L, Koulogiannis K, Argulian E, Lasam G, Gillam L. Concordance and Discordance of Echocardiographic Parameters Recommended for Assessing the Severity of Mitral Regurgitation. Circ Cardiovasc Imaging 2020; 13:e010278. [PMID: 32408828 DOI: 10.1161/circimaging.119.010278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The American College of Cardiology/American Heart Association and American Society of Echocardiography guidelines recommend assessing several echocardiographic parameters when evaluating mitral regurgitation (MR) severity. These parameters can be discordant, making the assessment of MR challenging. The degree to which echocardiographic parameters of MR severity are concordant is not well studied. METHODS We enrolled 159 patients in a prospective multicenter study. Eight parameters were included in this analysis: proximal isovelocity surface area (PISA)-derived regurgitant volume, PISA-derived effective regurgitant orifice area, vena contracta, color Doppler jet/left atrial area, left atrial volume index, left ventricular end-diastolic volume index, peak E wave, and the presence of pulmonary vein systolic reversal. Each echocardiographic parameter was determined to represent severe or nonsevere MR according to the American Society of Echocardiography guidelines. A concordance score was calculated as [Formula: see text] so that a higher score reflects greater concordance. There was no discordance when all the echocardiographic parameters agreed and high discordance when 3 or 4 parameters were discordant. RESULTS The mean concordance score was 75±14% for the entire cohort. There were 9 (6%) patients with complete agreement of all parameters and 61 (38%) with high discordance. There was greater discordance in patients with severe MR but no difference between primary versus secondary or central versus eccentric jets. There was an improvement in concordance when only considering PISA-based regurgitant volume, PISA-based effective regurgitant orifice area, and vena contracta with agreement in 68% of patients. CONCLUSIONS There was limited concordance between the echocardiographic parameters of MR severity, and the discordance was worse with more severe MR. Concordance improved when considering only 3 quantitative measures of vena contracta and PISA-based effective regurgitant orifice area and regurgitant volume. These findings highlight the challenges facing echocardiographers when assessing the severity of MR and emphasize the difficulty of using an integrated approach that incorporates multiple components. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04038879.
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Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, NJ (S.U., L.A., L.M., K.K., L.G.)
| | - Lillian Aldaia
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, NJ (S.U., L.A., L.M., K.K., L.G.)
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, NJ (S.U., L.A., L.M., K.K., L.G.)
| | - Konstantinos Koulogiannis
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, NJ (S.U., L.A., L.M., K.K., L.G.)
| | - Edgar Argulian
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, NY (E.A., G.L.)
| | - Glenmore Lasam
- Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center/Atlantic Health System, NJ (S.U., L.A., L.M., K.K., L.G.)
| | - Linda Gillam
- Department of Medicine, Division of Cardiology, Mount Sinai St. Luke's Hospital, Mount Sinai School of Medicine, New York, NY (E.A., G.L.)
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Validation of Semiautomated Quantification of Mitral Valve Regurgitation by Three-Dimensional Color Doppler Transesophageal Echocardiography. J Am Soc Echocardiogr 2020; 33:342-354. [DOI: 10.1016/j.echo.2019.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/27/2019] [Accepted: 10/31/2019] [Indexed: 11/18/2022]
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15
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Cardiac magnetic resonance assessment of mitral regurgitation severity appears better than echocardiographic imaging. Int J Cardiovasc Imaging 2020; 36:889-897. [DOI: 10.1007/s10554-020-01772-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/07/2020] [Indexed: 01/03/2023]
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16
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Kreidel F, Ruf T, Tamm A, Geyer M, Emrich T, von Bardeleben RS. [Evaluation of mitral regurgitation : How much quantification do we need?]. Herz 2019; 44:574-585. [PMID: 31555893 DOI: 10.1007/s00059-019-04857-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Severe mitral regurgitation (MR) is associated with increased morbidity and mortality. Thus, the correct evaluation of the underlying etiology, pathomechanism and severity is crucial for optimal treatment. Echocardiography is the predominant diagnostic modality in the clinical routine as it enables grading of mitral regurgitation, which can frequently be achieved by readily available qualitative parameters. Additionally, echocardiography provides several methods to quantify the hemodynamic significance of MR. The effective regurgitation orifice area (EROA) is the quantitative parameter best correlated with clinical events. American and European imaging guidelines both recommend the use of quantitative parameters even though they disagree on the cut-off values for secondary MR. The evaluation of MR should always include an assessment of the adjacent heart chambers in order to be able to assess the impact of volume overload on size and function of the left ventricle and left atrium. The final interpretation of the quantitative parameters requires knowledge of left ventricular volume and ejection fraction. Newer 3D-echocardiographic approaches to quantify MR are less dependent on mathematical assumptions and have shown convincing results in several studies but still lack sufficient clinical validation. As an alternative to echocardiography, for specific indications cardiac magnetic resonance imaging (MRI) has proven to be a systematic and observer-independent method for quantification of MR.
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Affiliation(s)
- F Kreidel
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
| | - T Ruf
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - A Tamm
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - M Geyer
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
| | - T Emrich
- Klinik für Radiologie der Universitätsmedizin Main, Mainz, Deutschland
| | - R S von Bardeleben
- Department of Cardiology, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland
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17
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Kamoen V, El Haddad M, De Backer T, De Buyzere M, Timmermans F. The Average Pixel Intensity Method and Outcome of Mitral Regurgitation in Mitral Valve Prolapse. J Am Soc Echocardiogr 2019; 33:54-63. [PMID: 31619368 DOI: 10.1016/j.echo.2019.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) is a frequent consequence of mitral valve prolapse (MVP). However, the echocardiographic grading of MR is challenging, and the recommended grading parameters have several limitations. The authors developed a novel echocardiographic parameter to grade MR, the average pixel intensity (API) method, on the basis of pixel intensity analysis of the continuous-wave Doppler signal. METHODS Transthoracic echocardiography was performed prospectively in consecutive patients with MVP (N = 149). MR was quantitatively assessed using the API method, vena contracta width, effective regurgitant orifice area, and regurgitant volume. The primary clinical events were cardiovascular mortality, mitral valve surgery, percutaneous mitral intervention, and heart failure hospitalization. RESULTS The API method was feasible in 90% of all patients with MVP, which was significantly higher than vena contracta width, effective regurgitant orifice area, and regurgitant volume. During a median follow-up period of 17 months, 44 patients (32%) had major adverse cardiac events, and the majority of events occurred in the holosystolic MVP subgroup. The degree of MR severity by the API method was highly significant for the prediction of events. An API cutoff of 111 arbitrary units was defined as "severe" MR due to MVP, with overall superior sensitivity and specificity compared with cutoffs for established MR grading parameters. In patients who did not have major adverse cardiac events during the follow-up period (n = 92), no significant changes in measures of MR severity were found on follow-up echocardiography. CONCLUSIONS The API method is predictive of clinical events and outcomes in MR due to MVP. Therefore, the API method may be considered for grading the severity of MR due to MVP in clinical practice.
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Affiliation(s)
- Victor Kamoen
- Department of Cardiology, Heart Center, Gent University Hospital, Gent, Belgium.
| | - Milad El Haddad
- Department of Cardiology, Heart Center, Gent University Hospital, Gent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Center, Gent University Hospital, Gent, Belgium
| | - Marc De Buyzere
- Department of Cardiology, Heart Center, Gent University Hospital, Gent, Belgium
| | - Frank Timmermans
- Department of Cardiology, Heart Center, Gent University Hospital, Gent, Belgium
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18
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Kampaktsis PN, Albert BJ, Kim J, Xie LX, Brouwer LR, Tehrani NH, Villanueva M, Choi DY, Szulc M, Ratcliffe MB, Levine RA, Devereux R, Weinsaft JW. Impact of Mitral Regurgitation Severity and Cause on Effort Tolerance-Integrated Stress Myocardial Perfusion Imaging and Echocardiographic Assessment of Patients With Known or Suspected Coronary Artery Disease Undergoing Exercise Treadmill Testing. J Am Heart Assoc 2019; 8:e010974. [PMID: 30808228 PMCID: PMC6474934 DOI: 10.1161/jaha.118.010974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/30/2019] [Indexed: 01/19/2023]
Abstract
Background Mitral regurgitation ( MR ) has the potential to impede exercise capacity; it is uncertain whether this is because of regurgitation itself or the underlying cause of valvular insufficiency. Methods and Results The population comprised 3267 patients who underwent exercise treadmill myocardial perfusion imaging and transthoracic echocardiography within 6±8 days. MR was present in 28%, including 176 patients (5%) with moderate or greater MR . Left ventricular systolic function significantly decreased and chamber size increased in relation to MR , paralleling increments in stress and rest myocardial perfusion deficits (all P<0.001). Exercise tolerance (metabolic equivalents of task) decreased stepwise in relation to graded MR severity ( P<0.05). Workload was significantly lower with mild versus no MR (mean±SD, 9.8±3.0 versus 10.1±3.0; P=0.02); magnitude of workload reduction significantly increased among patients with advanced versus those with mild MR (mean±SD, 8.6±3.0 versus 9.8±3.0; P<0.001). MR -associated exercise impairment was accompanied by lower heart rate and blood pressure augmentation and greater dyspnea (all P<0.05). Both functional and nonfunctional MR subgroups demonstrated significantly decreased effort tolerance in relation to MR severity ( P≤0.01); impairment was greater with functional MR ( P=0.04) corresponding to more advanced left ventricular dysfunction and dilation (both P<0.001). Functional MR predicted reduced metabolic equivalent of task-based effort (B=-0.39 [95% CI, -0.62 to -0.17]; P=0.001) independent of MR severity. Among the overall cohort, advanced (moderate or greater) MR was associated with reduced effort tolerance (B=-1.36 [95% CI, -1.80 to -0.93]; P<0.001) and remained significant ( P=0.01) after controlling for age, clinical indexes, stress perfusion defects, and left ventricular dysfunction. Conclusions MR impairs exercise tolerance independent of left ventricular ischemia, dysfunction, and clinical indexes. Magnitude of exercise impairment parallels severity of MR .
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Affiliation(s)
| | | | - Jiwon Kim
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
- Department of Medicine and RadiologyWeill Cornell Medical CollegeNew YorkNY
| | - Lola X. Xie
- Memorial Sloan Kettering Cancer CenterNew YorkNY
| | | | | | | | - Daniel Y. Choi
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
| | | | - Mark B. Ratcliffe
- Veterans Affairs Medical CenterUniversity of CaliforniaSan FranciscoCA
| | | | | | - Jonathan W. Weinsaft
- Department of MedicineWeill Cornell Medical CollegeNew YorkNY
- Department of Medicine and RadiologyWeill Cornell Medical CollegeNew YorkNY
- Memorial Sloan Kettering Cancer CenterNew YorkNY
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19
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Uretsky S, Gillam LD. Authors Reply. J Am Soc Echocardiogr 2019; 32:163-165. [DOI: 10.1016/j.echo.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 10/27/2022]
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20
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Is Cardiac Magnetic Resonance Imaging the New “Gold Standard” for Quantitation of Mitral Regurgitation? A Critical Appraisal. J Am Soc Echocardiogr 2019; 32:163. [DOI: 10.1016/j.echo.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Indexed: 11/20/2022]
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21
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Hung J, Zeng X, Little SH. Quantifying Mitral Regurgitation: How Much Should We Lean on PISA? J Am Soc Echocardiogr 2018; 31:1000-1001. [DOI: 10.1016/j.echo.2018.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Indexed: 10/28/2022]
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