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Design and Preliminary Results of Sensing and Detection for an Extravascular Implantable Cardioverter-Defibrillator. JACC Clin Electrophysiol 2021; 7:1387-1399. [PMID: 33933410 DOI: 10.1016/j.jacep.2021.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study reports the sensing and arrhythmia detection performance of a novel extravascular (EV) implantable cardioverter-defibrillator (ICD) in a first-in-human pilot study. BACKGROUND The EV ICD lead is implanted in the substernal space, resulting in novel sensing and detection challenges. It uses a programmable sensing profile with new or modified discrimination of oversensing and of ventricular tachycardia (VT) from supraventricular tachycardia (SVT). METHODS Electrograms were post-processed from induced ventricular fibrillation (VF) at implant to determine virtual detection times for each programmable sensitivity and the least-sensitive safe sensitivity setting. In ambulatory patients, programmed sensitivity provided at least a twofold safety margin for detecting induced VF. Noise discrimination was stress tested, and the effects of source, posture, and lead maturation were determined on electrogram amplitude. Telemetry Holter monitors were used to quantify undersensing and oversensing. RESULTS In 20 patients at implant, the least-sensitive safe sensitivity for VF detection ranged from 0.1 to 0.6 mV. Seventeen patients were followed up for a total of 16.6 patient-years. Electrogram amplitudes were stable over time, but there were significant differences among postures and sensing vectors. For the primary sensing vector, the weighted oversensing and undersensing rates were 1.03% and 0.40% respectively, on a beat-to-beat basis. Oversensing did not cause inappropriate therapy in patients with in situ leads. Oversensing discriminators withheld VF detection in 4 of 5 spontaneous, sustained oversensed episodes. SVT-VT discriminators correctly classified 93% of 128 sustained SVTs in monitor zones. CONCLUSIONS In the EV ICD pilot study, oversensing did not cause inappropriate therapy during ambulatory follow-up of stable leads.
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Signal-processing enhancement to reduce oversensing of T waves without increasing undersensing of ventricular fibrillation in the subcutaneous implantable cardioverter-defibrillator. Heart Rhythm 2018; 15:1523-1524. [DOI: 10.1016/j.hrthm.2018.06.001] [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: 05/26/2018] [Indexed: 11/17/2022]
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Swerdlow CD, Asirvatham SJ, Ellenbogen KA, Friedman PA. Troubleshooting implantable cardioverter-defibrillator sensing problems II. Circ Arrhythm Electrophysiol 2015; 8:212-20. [PMID: 25691555 DOI: 10.1161/circep.114.002514] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Charles D Swerdlow
- From the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.D.S.); Division of Cardiology, Mayo Clinic, Rochester, MN (S.J.A., P.A.F.); and Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.).
| | - Samuel J Asirvatham
- From the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.D.S.); Division of Cardiology, Mayo Clinic, Rochester, MN (S.J.A., P.A.F.); and Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.)
| | - Kenneth A Ellenbogen
- From the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.D.S.); Division of Cardiology, Mayo Clinic, Rochester, MN (S.J.A., P.A.F.); and Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.)
| | - Paul A Friedman
- From the Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (C.D.S.); Division of Cardiology, Mayo Clinic, Rochester, MN (S.J.A., P.A.F.); and Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (K.A.E.)
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Requena-Carrión J, Alonso-Atienza F, Everss E, Sánchez-Muñoz JJ, Ortiz M, García-Alberola A, Rojo-Álvarez JL. Analysis of the robustness of spectral indices during ventricular fibrillation. Biomed Signal Process Control 2013. [DOI: 10.1016/j.bspc.2013.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Omiya T, Shimizu A, Ueyama T, Yoshiga Y, Doi M, Hiratsuka A, Fukuda M, Yoshida M, Matsuzaki M. Effects of isoproterenol and propranolol on the inducibility and frequency of ventricular fibrillation in patients with Brugada syndrome. J Cardiol 2012; 60:47-54. [DOI: 10.1016/j.jjcc.2012.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Revised: 01/17/2012] [Accepted: 02/13/2012] [Indexed: 11/17/2022]
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Hiratsuka A, Shimizu A, Ueyama T, Yoshiga Y, Doi M, Ohmiya T, Yoshida M, Fukuda M, Matsuzaki M. Characteristics of Induced Ventricular Fibrillation Cycle Length in Symptomatic Brugada Syndrome Patients. Circ J 2012; 76:624-33. [DOI: 10.1253/circj.cj-11-1144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Atsushi Hiratsuka
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Akihiko Shimizu
- Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine
| | - Takeshi Ueyama
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Yasuhiro Yoshiga
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Masahiro Doi
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Toshihide Ohmiya
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Masaaki Yoshida
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Masakazu Fukuda
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Masunori Matsuzaki
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
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Suresh M, Benditt DG, Gold B, Joshi GP, Lurie KG. Suppression of Cautery-Induced Electromagnetic Interference of Cardiac Implantable Electrical Devices by Closely Spaced Bipolar Sensing. Anesth Analg 2011; 112:1358-61. [DOI: 10.1213/ane.0b013e3182172a18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Barquero-Pérez Ó, Rojo-Álvarez JL, Caamaño AJ, Goya-Esteban R, Everss E, Alonso-Atienza F, Sánchez-Muñoz JJ, García-Alberola A. Fundamental Frequency and Regularity of Cardiac Electrograms With Fourier Organization Analysis. IEEE Trans Biomed Eng 2010; 57:2168-77. [DOI: 10.1109/tbme.2010.2049574] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Panfilov I, Lever NA, Smaill BH, Larsen PD. Ventricular fibrillation frequency from implanted cardioverter defibrillator devices. Europace 2009; 11:1052-6. [DOI: 10.1093/europace/eup159] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chorro FJ, Guerrero J, Pelechano F, Trapero I, Mainar L, Cánoves J, Such-Miquel L, García-Alberola A, Ferrero Á, Sanchís J, Bodí V, Alberola A, Such L. Influencia del tipo de registro (unipolar o bipolar) en las características espectrales de los registros epicárdicos de la fibrilación ventricular. Estudio experimental. Rev Esp Cardiol 2007; 60:1059-69. [DOI: 10.1157/13111238] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Swerdlow CD, Shehata M, Chen PS. Using the Upper Limit of Vulnerability to Assess Defibrillation Efficacy at Implantation of ICDs. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:258-70. [PMID: 17338725 DOI: 10.1111/j.1540-8159.2007.00659.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The upper limit of vulnerability (ULV) is the weakest shock strength at or above which ventricular fibrillation (VF) is not induced when the shock is delivered during the vulnerable period. The ULV, a measurement made in regular rhythm, provides an estimate of the minimum shock strength required for reliable defibrillation that is as accurate or more accurate than the defibrillation threshold (DFT). The ULV hypothesis of defibrillation postulates a mechanistic relationship between the ULV-measured during regular rhythm-and the minimum shock strength that defibrillates reliably. Vulnerability testing can be applied at implantable cardioverter defibrillator (ICD) implant to confirm a clinically adequate defibrillation safety margin without inducing VF in 75%-95% of ICD recipients. Alternatively, the ULV provides an accurate patient-specific safety margin with a single fibrillation-defibrillation episode. Programming first ICD shocks based on patient-specific measurements of ULV rather than programming routinely to maximum output shortens charge time and may reduce the probability of syncope as ICDs age and charge times increase. Because the ULV is more reproducible than the DFT, it provides greater statistical power for clinical research with fewer episodes of VF. Limited evidence suggests that vulnerability testing is safer than conventional defibrillation testing.
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Affiliation(s)
- Charles D Swerdlow
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA.
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Nanthakumar K, Walcott GP, Melnick S, Rogers JM, Kay MW, Smith WM, Ideker RE, Holman W. Epicardial organization of human ventricular fibrillation. Heart Rhythm 2005; 1:14-23. [PMID: 15851110 DOI: 10.1016/j.hrthm.2004.01.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Accepted: 01/27/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to test the hypothesis that on the epicardium of the in vivo human heart, ventricular fibrillation (VF) consists of chaotic small wavefronts that constantly change paths. BACKGROUND Despite the significance of VF to cardiovascular mortality, little is known about the wavefronts that constitute VF in humans. METHODS In 9 patients undergoing cardiac surgery, a single VF episode was induced by rapid pacing immediately after institution of cardiopulmonary bypass while recordings were made from 504 electrodes spaced 2 mm apart in a 20 cm(2) plaque held against the anterior left ventricle epicardium. A total of 26 segments of VF, each 2 s long, were analyzed. A computer algorithm identified individual wavefronts and classified them into groups that followed similar activation sequences. RESULTS The mean activation rate was 5.8 +/- 1.8 (mean +/- SD) cycles/s. The wavefronts during each epoch were grouped into 9.4 +/- 7.1 different activation pathways, and 8.3 +/- 2.3 wavefronts followed each pathway. Individual wavefronts spread to activate an area of 5.1 +/- 3.0 cm(2) in the mapped region. The majority of the wavefronts propagated into the mapped region and/or propagated out of the mapped region into adjacent tissue, suggesting that the wavefronts were larger than 5.1 cm(2). Reentry was identified in only 16 of the 26 (62%) 2-s segments, always completed <2 cycles, and lasted for 9.5 +/- 6.6% of these 16 epochs, which is 5.8% of the total duration of all the segments analyzed. CONCLUSION VF wavefronts on the human epicardium are usually large, repeatedly follow distinct pathways, and only occasionally reenter. If these results for the left ventricular epicardium are representative of those for the entire ventricular mass, they do not support the hypothesis that human VF consists of small, constantly changing wavefronts, but rather suggest that there is significant organization of human VF.
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Kadish A, Johnson D, Choe W, Goldberger J, Horvath G. Characterization of fibrillatory rhythms by ensemble vector directional analysis. Am J Physiol Heart Circ Physiol 2003; 285:H1705-19. [PMID: 12791595 DOI: 10.1152/ajpheart.01108.2001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent studies have demonstrated that fibrillatory rhythms are not random phenomena but have definable patterns. However, standard mapping techniques may have limitations in their ability to identify the organization of fibrillation. The purpose of this study was to develop and apply a method, "ensemble vector mapping," for characterizing the spatiotemporal organization of fibrillation. Ventricular fibrillation was induced by burst pacing in normal mongrel dogs. In a separate protocol, atrial fibrillation was induced by epicardial aconitine application. Epicardial electrograms were recorded from a 112-electrode plaque array using a computerized mapping system. Vectors were created by summing orthogonal bipolar electrograms. The magnitude of the vectors was transformed using a logarithmic function, integrated over time, and normalized for local electrogram amplitude to produce an "ensemble vector" index whose magnitude is high when beat-to-beat activation direction is consistent and low when activation direction is variable. The mean index was 137 +/- 36 mV/s during ventricular pacing at a cycle length of 300 ms but only 39 +/- 23 mV/s during ventricular fibrillation (P < 0.001). The ensemble vector index was also lower during atrial fibrillation (60 +/- 54 mV/s) than during atrial pacing (115 +/- 27 mV/s, P < 0.01 vs. atrial fibrillation) but not as low as during ventricular fibrillation (P < 0.05, atrial vs. ventricular fibrillation). The index was also capable of distinguishing atrial tachycardia from atrial fibrillation. Ensemble vector mapping produces an objective assessment of the consistency of myocardial activation during fibrillation. The consistency of activation direction differs in different models of fibrillation and is higher during atrial than ventricular fibrillation. This technique has the potential to rapidly characterize repetitive activation patterns in fibrillatory rhythms and may help distinguish among different characteristics of fibrillatory rhythms.
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Affiliation(s)
- Alan Kadish
- Feinberg Cardiovascular Research Institute and Department of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Walcott GP, Kay GN, Plumb VJ, Smith WM, Rogers JM, Epstein AE, Ideker RE. Endocardial wave front organization during ventricular fibrillation in humans. J Am Coll Cardiol 2002; 39:109-15. [PMID: 11755295 DOI: 10.1016/s0735-1097(01)01696-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study was designed to characterize the organization of ventricular fibrillation (VF) on the endocardium of humans. BACKGROUND Most proposed mechanisms for the maintenance of VF postulate the propagation of a number of activation wave fronts that reenter to maintain the arrhythmia. We tested the hypothesis that, in patients undergoing internal cardioverter-defibrillator implantation, VF consists primarily of a few large wave fronts on the endocardium. METHODS Electrograms were recorded from a 36-electrode catheter in the left ventricle of 16 patients during VF. Activation times were chosen for a 2-s epoch for each fibrillation episode, and a two-dimensional Kolmogorov-Smirnov test was performed to determine if activation occurred randomly along the catheter over that time interval. The maximum cross-correlation was found for all possible pairs of electrodes on the catheter, and these values were plotted relative to the distance between the two electrodes. An exponential curve was then fit to the data, and a length constant was determined. Activation times were grouped into wave fronts along the catheter, and the lengths of the wave fronts were estimated. RESULTS The Kolmogorov-Smirnov test showed that activation was not random along the catheter in any of the patients studied. The correlation length determined was 9 +/- 2 cm. The number of wave fronts recorded by the catheter was 9.2 +/- 2.9 wave fronts/s. The length of the pathway of each wave front along the catheter was 6.5 +/- 4.5 cm. CONCLUSIONS Ventricular fibrillation is well organized on the endocardial surface of humans, consisting primarily of a few large wave fronts on the order of 6 to 9 cm.
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Affiliation(s)
- Gregory P Walcott
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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Abstract
BACKGROUND The upper limit of vulnerability (ULV) is the weakest shock at which ventricular fibrillation (VF) is not induced by a T-wave shock. This study tested the hypothesis that a vulnerability safety margin based on the ULV can be used as an implantable cardioverter-defibrillator implantation criterion. METHODS AND RESULTS Implantable cardioverter-defibrillators were implanted in 80 patients if T-wave shocks did not induce VF and the baseline-rhythm R wave was >/=7 mV. The T-wave shock was 10 J in the first 45 patients (group A) and 15 J in the last 35 patients (group B). After inductionless implantations, the first VF shock was programmed to the T-wave shock plus 5 J. If T-wave shocks induced VF, the ULV was measured and the first shock was programmed to the ULV+5 J. Inductionless implantations were performed in 58 patients (72%), 28 in group A (62%) and 30 in group B (86%; P=0.04). If T-wave scanning had been done at 15 J in group A patients, inductionless implantations could have been performed in 84% of them. At 3 months, VF was induced twice during electrophysiological study in 75 patients (94%). All VFs were detected in </=4.7 s and were terminated by the first shock. During follow-up, 197 of 198 appropriate first shocks for rapid ventricular tachycardia or VF (99%) were successful in patients who had inductionless implantations (95% confidence intervals, 97% to 100%). CONCLUSION Inductionless implantations can be performed in >80% of implantable cardioverter-defibrillator recipients using a vulnerability safety margin based on a T-wave scan at 15.
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Affiliation(s)
- C D Swerdlow
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Jacobson JT, Johnson D, Horvath G, Goldberger J, Kadish A. Effect of underlying heart disease on the frequency content of ventricular fibrillation in the dog heart. Pacing Clin Electrophysiol 2000; 23:243-52. [PMID: 10709233 DOI: 10.1111/j.1540-8159.2000.tb00806.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although prior studies have examined the frequency content of local electrogram characteristics during fibrillation, little is know about the effects of underlying heart disease on these parameters. This study was designed to compare the frequency content of local electrograms during VF in canine models of acute ischemia, subacute infarction, and chronic myocardial infarction (MI) to those in control animals to test the hypothesis that underlying heart disease can alter the basic characteristics of VF. VF was induced using burst pacing in three groups of mongrel dogs. Five dogs were evaluated 8 weeks after LAD occlusion MI, five were evaluated 5 days after experimental MI, and 5 had VF induced before (control) and immediately after LAD occlusion (ischemia). During VF, unipolar electrograms were recorded from 112 sites on the anterior LV and electrograms were evaluated 15 and 30 seconds after VF initiation in each group. Electrograms were analyzed by fast Fourier transform. No significant time dependent changes in VF characteristics were noted. The peak frequency was highest in control animals and 8-week MI, intermediate in 5-day MI, and lowest in acute ischemia (P < 0.01 for pairwise comparisons). In contrast, the fractional of energy within a bandwidth of 25% peak amplitude was highest in acute ischemia, (P < 0.001) and similar in the other three groups. Infarction decreased total energy by approximately 50%. In conclusion, the pressure of ischemia or infarction alters the frequency content of VF in a complex fashion. In addition to decreasing the peak frequency, the shape of the power spectral curve is altered in models of structural heart disease. These results suggest that the electrophysiological changes produced by infarction or ischemia alter the structural organization of ventricular fibrillation.
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Affiliation(s)
- J T Jacobson
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
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