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Hopman LHGA, Baalman SWE, de Groot JR, Knops RE, van Halm VP. Towards continuous optimization of CRT settings: the relationship between pulmonary artery dP/dt and Left ventricular dP/dt measurements. J Interv Card Electrophysiol 2024; 67:701-703. [PMID: 37991666 PMCID: PMC11166822 DOI: 10.1007/s10840-023-01700-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/13/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Sarah W E Baalman
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Reinoud E Knops
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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2
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Westphal P, Luo H, Shahmohammadi M, Prinzen FW, Delhaas T, Cornelussen RN. Machine learning-powered, device-embedded heart sound measurement can optimize AV delay in patients with CRT. Heart Rhythm 2023; 20:1316-1324. [PMID: 37247684 DOI: 10.1016/j.hrthm.2023.05.025] [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: 01/30/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Continuous optimization of atrioventricular (AV) delay for cardiac resynchronization therapy (CRT) is mainly performed by electrical means. OBJECTIVE The purpose of this study was to develop an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization. METHODS Electrocardiogram, left ventricular pressure (LVP), and heart sounds were simultaneously collected during CRT device implantation procedures. A piezoelectric alarm transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV delays. Machine learning (ML) was used to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVPmax) and maximal rise of LVP (LVdP/dtmax) using 3 heart sound-based features. To gauge the applicability of ML in AV delay optimization, polynomial curves were fitted to measured and estimated values. RESULTS In the data set of ∼30,000 heartbeats, ML indicated S1 amplitude, S2 amplitude, and S1 integral (S1 energy for LVdP/dtmax) as most prominent features for AV delay optimization. ML resulted in single-beat estimation precision for absolute values of LVPmax and LVdP/dtmax of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVPmax and LVdP/dtmax was 0.999 for both. The estimated optimal AV delays were not significantly different from those measured using invasive LVP (difference -5.6 ± 17.1 ms for LVPmax and +5.1 ± 6.7 ms for LVdP/dtmax). The difference in function at estimated and measured optimal AV delays was not statiscally significant (1 ± 3 mm Hg for LVPmax and 9 ± 57 mm Hg/s for LVdP/dtmax). CONCLUSION Heart sound sensors embedded in a CRT device, powered by a ML algorithm, provide a reliable assessment of optimal AV delays and absolute LVPmax and LVdP/dtmax.
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Affiliation(s)
- Philip Westphal
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands
| | - Hongxing Luo
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Mehrdad Shahmohammadi
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Richard N Cornelussen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands; Bakken Research Center, Medtronic, plc, Maastricht, The Netherlands.
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Butcher CJT, Cantor E, Sohaib A, Shun-Shin MJ, Haynes R, Khan H, Kyriacou A, Shi R, Chen Z, Haldar S, Cleland JGF, Hussain W, Markides V, Jones DG, Lane RE, Mason MJ, Whinnett ZI, Francis DP, Wong T. Variation in optimal hemodynamic atrio-ventricular delay of biventricular pacing with different endocardial left ventricular lead locations using precision hemodynamics. J Cardiovasc Electrophysiol 2023; 34:1431-1440. [PMID: 36786511 DOI: 10.1111/jce.15862] [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: 06/15/2022] [Revised: 01/11/2023] [Accepted: 02/05/2023] [Indexed: 02/15/2023]
Abstract
INTRODUCTION It is not known whether the optimal atrioventricular (AVopt ) delay varies between left ventricular (LV) pacing site during endocardial biventricular pacing (BiVP) and may therefore needs consideration. METHODS We assessed the hemodynamic AVopt in patients with chronic heart failure undergoing endocardial LV lead implantation. AVopt was assessed during atrio-BiVP with a "roving LV lead." Up to four locations were studied: mid-lateral wall, mid-septum (or a close alternative), site of greatest hemodynamic improvement, and LV lead implant site. The AVopt was compared to a fixed AV delay of 180 ms. RESULTS Seventeen patients were included (12 male, aged 66.5 ± 12.8 years, ejection fraction 26 ± 7%, 16 left bundle branch block or high percentage of right ventricular pacing [RVP], QRS duration 167 ± 27 ms). In most locations (62/63), AVopt increased systolic blood pressure during BiVP compared with RVP (relative improvement 6 mmHg, interquartile range [IQR] 4-9 mmHg). Compared to a fixed AV delay, the hemodynamic improvement at AVopt was higher (1 mmHg, IQR 0.2-2.6 mmHg, p < .001). Within most patients (16/17), we observed a difference in AVopt between pacing sites (median paced AVopt 209 ms, IQR 117-250). Within this range, the hemodynamic impact of these differences was small (median loss 0.6 mmHg, IQR 0.1-2.6 mmHg). CONCLUSION Within a patient, different endocardial LV lead locations have slightly different hemodynamic AVopt which are superior to a fixed AV delay. The hemodynamic consequence of applying an optimum from a different lead location is small.
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Affiliation(s)
- Charles J T Butcher
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Emily Cantor
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Afzal Sohaib
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Matthew J Shun-Shin
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Ross Haynes
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Habib Khan
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
| | - Adreas Kyriacou
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rui Shi
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zhong Chen
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shouvik Haldar
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Wajid Hussain
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vias Markides
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David G Jones
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca E Lane
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark J Mason
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zachary I Whinnett
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Darrel P Francis
- NHLI, Imperial College London, London, UK
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Tom Wong
- Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals Guy's and St Thomas' NHS Foundation Trust, London, UK
- NHLI, Imperial College London, London, UK
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Zweerink A, Burri H. His-Optimized and Left Bundle Branch-Optimized Cardiac Resynchronization Therapy: In Control of Fusion Pacing. Card Electrophysiol Clin 2022; 14:311-321. [PMID: 35715088 DOI: 10.1016/j.ccep.2021.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fusion pacing, which exploits conduction via the intrinsic His-Purkinje system, forms the basis of recent cardiac resynchronization therapy (CRT) optimization algorithms. However, settings need to be constantly adjusted to accommodate for changes in AV conduction, and the algorithms are not always available (eg, depending on the device, in case of AV block or with atrial fibrillation). His-optimized cardiac resynchronization therapy (HOT-CRT), and left-bundle branch optimized cardiac resynchronization therapy (LOT-CRT) which combines conduction system pacing with ventricular fusion pacing, provide constant fusion with ventricular activation (irrespective of intrinsic AV conduction). These modalities provide promising treatment strategies for patients with heart failure, especially in those with chronic atrial fibrillation who require CRT (in whom the atrial port is usually plugged and can be used to connect the conduction system pacing lead).
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Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland; Department of Cardiology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU Medical Center, Amsterdam, The Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland.
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Kabutoya T, Imai Y, Okuyama T, Watanabe H, Yokota A, Kamioka M, Watanabe T, Komori T, Kario K. Usefulness of Optimization of Interventricular Delay Using an Electrical Cardiometry Method in Patients with Cardiac Resynchronization Therapy Implantation. Int Heart J 2022; 63:241-246. [PMID: 35354746 DOI: 10.1536/ihj.21-711] [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: 11/18/2022]
Abstract
There are no studies examining interventricular (VV) delay optimization by an electrical cardiometry method in relation to subsequent cardiac function in cardiac resynchronization therapy (CRT) -implanted patients. This study aimed to compare the VV delay in CRT-implanted patients by the dp/dt and electrical cardiometry and to examine the optimization of VV delay and improvement of cardiac function. We examined 19 consecutive CRT-implanted patients. The protocol included biventricular stimulation with either simultaneous or sequential pacing, and we evaluated systolic volume (SV) using an electrical cardiometry and the dp/dt of the left ventricle. The optimal VV delay was determined by the maximum SV using the electrical cardiometry. Two groups were defined, those whose increase in SV was at or above the median and those whose SV increase was below the median; changes in left ventricular ejection fraction (LVEF). The correlation between the VV delay optimized by the electrical cardiometry and dp/dt methods was high (R = 0.61, P = 0.006). Compared to the baseline SV (43.4 mL), the SV increased to 47.8 mL with simultaneous biventricular pacing (versus baseline P = 0.008) and further increased to 49.8 mL with optimized VV delay (versus simultaneous biventricular pacing P = 0.020). LVEF after 6 months significantly improved in the above-median SV increase group (37.6 versus 28.2%, P = 0.041), but not in the below-median SV increase group (26.5 versus 26.5%, P = 0.985). In conclusion, the optimal VV delay by electrical cardiometry method was almost concordant with that by the dp/dt method. Cardiac function significantly improved in the group with the above-median SV increase.
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Affiliation(s)
- Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Takafumi Okuyama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Hiroaki Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Ayako Yokota
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Masashi Kamioka
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Tomonori Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
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Wouters PC, Vernooy K, Cramer MJ, Prinzen FW, Meine M. Optimizing lead placement for pacing in dyssynchronous heart failure: The patient in the lead. Heart Rhythm 2021; 18:1024-1032. [PMID: 33601035 DOI: 10.1016/j.hrthm.2021.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) greatly reduces morbidity and mortality in patients with dyssynchronous heart failure. However, despite tremendous efforts, response has been variable and can be further improved. Although optimizing left ventricular lead placement (LVLP) is arguably the cornerstone of CRT, the procedure of LVLP using the transvenous approach has remained largely unchanged for more than 2 decades. Improvements have been developed using scar location and electrical and/or mechanical mapping, and interest in conduction system pacing as an alternative to biventricular pacing has emerged recently. Conduction system pacing is promising but may not be suitable for all patients with dyssynchronous heart failure. This review underscores the importance of a patient-tailored approach and discusses the potential applications of both conduction system pacing and targeted biventricular CRT.
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Affiliation(s)
- Philippe C Wouters
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Wouters PC, Leenders GE, Cramer MJ, Meine M, Prinzen FW, Doevendans PA, De Boeck BWL. Acute recoordination rather than functional hemodynamic improvement determines reverse remodelling by cardiac resynchronisation therapy. Int J Cardiovasc Imaging 2021; 37:1903-1911. [PMID: 33547623 PMCID: PMC8255256 DOI: 10.1007/s10554-021-02174-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/22/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Cardiac resynchronisation therapy (CRT) improves left ventricular (LV) function acutely, with further improvements and reverse remodelling during chronic CRT. The current study investigated the relation between acute improvement of LV systolic function, acute mechanical recoordination, and long-term reverse remodelling after CRT. METHODS In 35 patients, LV speckle tracking longitudinal strain, LV volumes & ejection fraction (LVEF) were assessed by echocardiography before, acutely within three days, and 6 months after CRT. A subgroup of 25 patients underwent invasive assessment of the maximal rate of LV pressure rise (dP/dtmax,) during CRT-implantation. The acute change in dP/dtmax, LVEF, systolic discoordination (internal stretch fraction [ISF] and LV systolic rebound stretch [SRSlv]) and systolic dyssynchrony (standard deviation of peak strain times [2DS-SD18]) was studied, and their association with long-term reverse remodelling were determined. RESULTS CRT induced acute and ongoing recoordination (ISF from 45 ± 18 to 27 ± 11 and 23 ± 12%, p < 0.001; SRS from 2.27 ± 1.33 to 0.74 ± 0.50 and 0.71 ± 0.43%, p < 0.001) and improved LV function (dP/dtmax 668 ± 185 vs. 817 ± 198 mmHg/s, p < 0.001; stroke volume 46 ± 15 vs. 54 ± 20 and 52 ± 16 ml; LVEF 19 ± 7 vs. 23 ± 8 and 27 ± 10%, p < 0.001). Acute recoordination related to reverse remodelling (r = 0.601 and r = 0.765 for ISF & SRSlv, respectively, p < 0.001). Acute functional improvements of LV systolic function however, neither related to reverse remodelling nor to the extent of acute recoordination. CONCLUSION Long-term reverse remodelling after CRT is likely determined by (acute) recoordination rather than by acute hemodynamic improvements. Discoordination may therefore be a more important CRT-substrate that can be assessed and, acutely restored.
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Affiliation(s)
- Philippe C Wouters
- University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.
| | - Geert E Leenders
- University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Maarten J Cramer
- University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Mathias Meine
- University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - Frits W Prinzen
- Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | | | - Bart W L De Boeck
- University Medical Center Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands.,Luzerner Kantonsspital, 6000, Luzern, Switzerland
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If Only the Slope Could Tell*. Crit Care Med 2020; 48:1540-1542. [DOI: 10.1097/ccm.0000000000004534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zweerink A, Hopman LHGA, Allaart CP. Efficiency is key. Eur Heart J Cardiovasc Imaging 2020; 21:154-156. [PMID: 31630186 PMCID: PMC7029764 DOI: 10.1093/ehjci/jez260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Luuk H G A Hopman
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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