MDCT evaluation of the cardiac venous system ... - Springer

840 Radiol med (2009) 114:837–851Table 1 Clinical characteristics of the study populationStudy populationDemographic characteristicsNumber of patients (M/F) 89 (73/16)Included patients 84 (71/13)Age (average±SD; range) 62.5±8.9; 31–79Heart rate (bpm) (average±SD; range) 62.2±4.3; 52–70SymptomsStable angina (%) 25 (29.8%)Unstable angina (%) 4 (4.8%)Atypical chest pain 19 (22.6%)Stent follow-up 10 (11.9%)By-pass follow-up 15 (17.8%)Suspected coronary abnormalities 2 (2.4%)Valve replacement planning 9 (10.7%)Cardiovascular risk factorsHypertension (%) 63 (75%)Hyperlipidaemia (%) 39 (46%)Diabetes (%) 46 (55%)Smoke (%) 24 (29%)Familial (%) 37 (44%)Obesity (%) 15 (18%)NYHA classificationNYHA I (absence of dyspnoea, chestpain or palpitations after severe physicalexertion) 45NYHA II (dyspnoea, chest pain orpalpitations after sustained physical exertion) 28NYHA III (dyspnoea, chest pain orpalpitations after mild physical exertion) 10NYHA IV (dyspnoea, chest pain orpalpitations at rest) 1Ejection fraction of the ventricle (LVEF)Normal (≥50%) 53Moderately impaired (35%–50%) 29Impaired (

842 Radiol med (2009) 114:837–851abcdFig. 1a-d Normal anatomy of the coronaryveins (3D VR reconstruction). The AIV arisesfrom the cardiac apex and runs in the anteriorinterventricular groove parallel to the left anteriordescending artery. Near the LM bifurcation,it opens into the GCV, which lies in theleft atrioventricular groove close to the leftcircumflex artery and in turn opens into theCS. Tributaries of the GCV are the lateral(LCV) and posterior (PCV) cardiac veinsrunning across the posterolateral wall of theleft ventricle. The MCV lies in the posteriorinterventricular groove and opens into the CS.CS, coronary sinus; GCV, great cardiac vein;AIV, anterior interventricular vein; MCV,middle cardiac vein; LCV, lateral (alsomarginal) cardiac vein; PCV, posterior cardiacvein; SCV, small cardiac vein; LM, left maincoronary artery; D1, first diagonal; MO, obtusemarginal.Fig. 1a-d Anatomia normale delle vene coronariche(ricostruzioni 3D VR). L’AIV originadall’apice cardiaco, decorrendo nel solcointerventricolare anteriore parallelamenteall’arteria discendente anteriore. A livellodella biforcazione del LM termina nella GCV,che giace nel solco atrio-ventricolare sinistroin vicinanza dell’arteria circonflessa fino aterminare nel CS. Tributarie della GCV sonola vene laterali (LCV) e posteriori (PCV), chedecorrono sulla faccia postero-laterale delventricolo sinistro. La MCV giace nel solcointerventricolare posteriore e sbocca nel CS.CS, seno coronario; GCV, grande venacardiaca; AIV, vena inter-ventricolare anteriore;MCV, vena cardiaca media; LCV, venacardiaca laterale; PCV, vena cardiaca posteriore;SCV, piccola vena cardiaca; LM, troncocomune; D1, primo diagonale; MO, marginaleottuso.The distance between the postero-lateral veins and the CSwas 62.51±32.5 mm for the PCV and 58.66±32.0 mm for theLCV. The angle between the postero-lateral veins and theGCV resulted 90° in four patients(6.3%) for the PCV and in three patients (5.4%) for the LCV.The mean diameters of CS and GCV were 15.3 mm and 7.6mm, respectively. The mean diameters of the other tributariesof the CS were as follows: AIV 3.2 mm, MCV 4.6mm, LCV 2.6 mm, PCV 3.4 mm and SCV 2.2 mm (Table 3).Therefore, in 79 of the 84 patients (94%) who underwentMDCT coronary angiography for suspected CAD, at leastone venous branch with good diameter and regular coursewas identified along the postero-lateral wall of the leftventricle. In 5/84 patients (6%), the postero-lateral branchhad a short course (

Radiol med (2009) 114:837–851 843Fig. 2 Multiplanar reconstruction (MPR) of the coronary venous system. The image displays the coronary sinus (CS), the great cardiac vein (GCV), theanterior interventricular vein (AIV) and the middle cardiac vein (MCV). Mean diameters are calculated on multiplanar reconstruction (MPR) images (asshown in the figure).Fig. 2 Ricostruzione multiplanare (MPR) del sistema venoso coronarico. La figura mostra il seno coronarico (CS), la grande vena cardiaca (GCV), lavena interventricolare anteriore (AIV) e la vena cardiaca media (MCV). I diametri principali sono calcolati sulle immagini MPR (come mostrato infigura).abcFig. 3a-c Cardiac resynchronisation therapy (CRT): MDCT planning and balloonvenography during the procedure. a) 3D VR reconstruction: presence of a good diameterPCV. b) Balloon retrograde angiography during the lead placement procedure for CRT(angiographic view of the coronary sinus and its tributaries filled with contrast media). c)Angiography: correct lead placement at the end of the procedure. CS, coronary sinus;GCV, great cardiac vein; AIV, anterior interventricular vein; MCV, middle cardiac vein;LCV, lateral cardiac vein; PCV, posterior cardiac vein.Fig. 3a-c Terapia di resincronizzazione cardiaca (CRT): planning TCMS e venografia conpallone occludente durante la procedura. a) Ricostruzione 3D-VR: presenza di una PCV dibuon calibro. b) Venografia retrograda con pallone occludente durante la procedura diimpianto dell’elettrocatetere per la CRT (visualizzazione angiografica del seno coronaricoe delle sue vene tributarie opacizzate dal mezzo di contrasto). c) Immagine angiografica:corretto posizionamento dell’elettrocatetere al termine della procedura. CS, seno coronario;GCV, grande vena cardiaca; AIV, vena interventricolare anteriore; MCV, venacardiaca media; LCV, vena cardiaca laterale; PCV, vena cardiaca posteriore.

844 Radiol med (2009) 114:837–851abLa distanza delle vene della parete postero-laterale dalCS è risultata 62,51±32,5 cm per la PCV e di 58,66±32 cmper la LCV. L’angolo di raccordo dei rami venosi dellaparete postero-laterale è apparso inferiore a 90° in 59pazienti (93,7%) in corrispondenza della PCV e in 53pazienti (94,6%) in corrispondenza della LCV, superiore a90° in 4 pazienti (6,3%) in corrispondenza della PCV e in 3pazienti (5,4%) in corrispondenza della LCV. Il diametromedio del CS è risultato 15,3 mm, quello della GCV 7,6 mm.I diametri medi delle altre vene tributarie del seno coronaricosono risultati rispettivamente: AIV 3,2 mm, MCV4,6 mm, LCV 2,6 mm, PCV 3,4 mm e PVC 2,2 mm (Tabella3). Quindi in 79 degli 84 pazienti (94%) sottoposti adangio-TCMS coronarica per sospetta CAD, è stato possibilevisualizzare almeno un ramo venoso di buon calibro edecorso regolare in corrispondenza della parete posterolateraledel ventricolo sinistro; in 5/84 pazienti (6%) ilramo venoso postero-laterale visualizzato presentava brevedecorso (

Radiol med (2009) 114:837–851 845Table 3 Detection rates and mean diameters of the coronary sinus and its tributaries in the personal series and data reported in the LitteratureVeins Personal series LiteratureNumber Diameter Number DiameterCS 84/84 (100%) 15.3 333/340 (98%) 13.2GCV 84/84 (100%) 7.6 160/161 (98%) 6.8MCV 84/84 (100%) 4.6 332/340 (98%) 5.2AIV 84/84 (100%) 3.2 210/211 (99%) 3.9PCV 63/84 (75%) 3.4 302/340 (89%) 3.9LCV 56/84 (67%) 2.6 250/340 (73%) 3.7SCV 11/84 (13%) 2.2 47/340 (14%) –CS, coronary sinus; GCV, great cardiac vein; MCV, middle cardiac vein; AIV, anterior interventricular vein; PCV, posterior cardiac vein; LCV, lateral cardiacvein; SCV, small cardiac veinTabella 3 Percentuali di visualizzazione e diametri medi delle vene tributarie del seno coronarico nella casistica personale e dati riportati in LetteraturaVene Casistica LetteraturaNumero Diametro Numero DiametroCS 84/84 (100%) 15,3 333/340 (98%) 13,2GCV 84/84 (100%) 7,6 160/161 (98%) 6,8MCV 84/84 (100%) 4,6 332/340 (98%) 5,2AIV 84/84 (100%) 3,2 210/211 (99%) 3,9PCV 63/84 (75%) 3,4 302/340 (89%) 3,9LCV 56/84 (67%) 2,6 250/340 (73%) 3,7SCV 11/84 (13%) 2,2 47/340 (14%) –CS, seno coronarico; GCV, grande vena cardiaca; MCV, vena cardiaca media; AIV, vena interventricolare anteriore; PCV, vena cardiaca posteriore;LCV, vena cardiaca laterale; SCV, piccola vena cardiacasatisfactory results, and the association of several drugs maybe poorly tolerated by elderly patients. This has led to thedevelopment of alternative treatments [11, 14].CRT is an innovative approach to the patient affected bychronic heart failure [9, 10, 12]. CRT acts on cardiacmechanics through the implantation of a biventricular pacemakerthat restores the correct synchronisation of theactivity of the atria and ventricles. The results are improvedclinical condition, quality of life and outcome of patientsaffected by advanced chronic heart failure associated withincreased QRS duration. The technique involves implantationof three pacing leads to stimulate the right atrium, theright ventricle and the left ventricle [9, 15–18].For lead implantation, an intravascular approach withvenous access is preferable to minimally invasive thoracicsurgery because of the obvious advantage of sparing generalanaesthesia and surgical trauma for patients with unstablehaemodynamic status. The pacing leads destined for theright heart chambers can be positioned through a centralvenous catheter, generally with access from the left subclavianvein. Stimulation of the left ventricle is performed witha usually bipolar pacing lead specially developed for placementin a cardiac vein, which is reached through catheterisationof the CS.The CS is a large vein that runs across the diaphragmaticsviluppato per l’impianto in una vena cardiaca, che vieneraggiunta mediante cateterizzazione del CS.Il CS è una grossa vena che decorre sulla facciadiaframmatica del cuore (Fig. 1) nella metà sinistra delsolco atrio-ventricolare posteriore [15]. L’ostio del CS èprovvisto di un residuo valvolare di forma semilunare, lavalvola di Tebesio [16, 17]. La maggiore tra le veneaffluenti del seno coronarico è la GCV (Fig. 1) chedall’apice cardiaco decorre nel solco interventricolareanteriore e il solco atrio-ventricolare sinistro sino aconfluire nel CS [17]. La MCV (Fig. 1a) decorre lungo ilsolco interventricolare posteriore sino a raggiungereanch’essa nella maggioranza dei casi il CS poco prima delsuo sbocco. Il CS riceve inferiormente la PCV, che originadalla parete posteriore del ventricolo stesso, e superiormentela vena obliqua dell’atrio sinistro (o di Marshall), laquale discende medialmente dalla parete posteriore di taleatrio [15–17]. La LCV drena la parete laterale del ventricolosinistro confluendo nella GCV. La PCV e la LCV nonsono presenti in tutti i pazienti. La SCV (Fig. 1a) prendeorigine dal margine acuto del cuore e decorre sulla suafaccia diaframmatica, confluendo nel CS in prossimità delsuo sbocco in atrio destro [18].La presenza di un appropriato ramo venoso del senocoronarico è quindi cruciale per un corretto approccio

846 Radiol med (2009) 114:837–851surface of the heart (Fig. 1) in the left half of the posterioratrio-ventricular groove [15]. The ostium of the CS isguarded by a rudimentary semicircular valve, the Thebesianvalve [16, 17]. The largest of the CS tributaries is the GCV(Fig. 1), which arises from the cardiac apex and runs acrossthe anterior interventricular groove and the left atrioventriculargroove to open into the CS [17]. The MCV (Fig.2a) runs along the posterior interventricular groove and inmost cases also opens into the CS just prior to its outlet.The CS also receives inferiorly the PCV, which arises fromthe posterior wall of the left ventricle, and superiorly theoblique vein of the left atrium (Marshall veins), whichdescends medially from the posterior wall of the atrium [15,17]. The LCV drains the lateral wall of the left ventricle andopens into the GCV. The PCV and the LCV are not presentin all subjects. The SCV (Fig. 1a) arises from the acutemargin of the heart, runs along its diaphragmatic surfaceand opens into the CS near its outlet into the right atrium[18].The presence of an appropriate venous branch of the CSis therefore crucial for correct transvenous approach andplacement of the pacing lead in the medial or basal region ofthe free wall of the left ventricle, either in a lateral orpostero-lateral vein, which is the area of the left ventriclemost commonly affected by desynchronisation [13].For this reason not all patients are candidates for CRTdue to the absence of a cardiac vein with a sufficiently largediameter or a sufficient length to accommodate the pacinglead, or due to impediments to the catheterisation procedure.The possibility of obtaining a detailed visualisation of thecardiac venous system is therefore a valuable aid duringplanning for implantation of biventricular pacemakers [19].Retrograde venous angiography with occlusive balloon iscurrently the conventional technique for studying the coronaryveins [9, 20]. This technique is performed with theinjection of contrast agent during selective catheterisation ofthe CS and tributary veins. A complete study requires atleast two fluoroscopic views in order to clearly visualise theanatomy, the angulation and the course of each vein [16].The limitations of this technique include invasiveness,examination duration, a not always optimal depiction of thecardiac veins, an inability to visualise both the vessels andthe cardiac wall at the same time, a need for large amountsof contrast agent (in some cases up to 500 ml per examination)and the impossibility to selectively catheterise the CSand its tributaries in 4%–5% of patients [10, 16, 20–22].In recent years, MDCT has been taking on an increasinglyimportant role as a noninvasive modality for studyingthe cardiac veins, thanks to its high spatial and temporalresolution, cardiac gating and sophisticated image postprocessingand reconstruction techniques, which are able toproduce detailed visualisation of the cardiac venous system[20–27].trans-venoso ed impianto dell’elettrocatetere in corrispondenzadella regione mediale o basale della parete libera delventricolo di sinistra, in una vena laterale o postero-laterale,zona del ventricolo sinistro che risulta essere quella maggiormentecolpita dal processo di desincronizzazione [13].Non tutti i pazienti risultano candidabili alla CRT, acausa dell’assenza di una vena cardiaca di calibro olunghezza adeguata ad alloggiare l’elettrocatetere o per lapresenza di ostacoli alla procedura di cateterizzazione. Lapossibilità di ottenere una visualizzazione dettagliata delsistema venoso cardiaco risulta perciò preziosa nella pianificazionedella procedura di impianto dei pacemaker biventricolari[19].L’angiografia venosa retrograda con pallone occludente,attualmente rappresenta la metodica convenzionaledi studio delle vene coronariche [9, 20]: viene ottenutamediante iniezione di MdC durante cateterizzazione selettivadel seno coronarico e delle vene tributarie. Per unostudio completo sono necessarie almeno due proiezionifluoroscopiche, in modo da evidenziare chiaramentel’anatomia, l’angolazione ed il decorso di ogni vena [16]. Ilimiti di questa metodica sono da ricercare nell’invasivitàdella procedura, nella durata dell’esame, nella visualizzazionenon sempre ottimale delle vene cardiache, nell’impossibilitàdi visualizzare contemporaneamente i vasi e laparete cardiaca, nella necessità di impiegare grandi quantitàdi MdC (in alcuni casi fino a 500 ml per esame) edinfine nell’impossibilità, riscontrata nel 4%–5% deipazienti, di procedere al cateterismo selettivo del seno coronaricoe delle vene tributarie [10, 16, 20–22].In questi ultimi anni la TCMS, grazie all’elevata risoluzionespaziale e temporale, alle tecniche di gating cardiaco,alle sofisticate capacità di processazione e ricostruzionedelle immagini, che consentono di ottenere una visualizzazionedettagliata dell’anatomia del sistema venoso coronarico,si sta proponendo come metodica non invasiva per lostudio delle vene cardiache [20–27].L’esame TCMS nel planning di CRT permette una preliminarevalutazione dell’anatomia del sistema venoso coronarico,del calibro del seno coronario, del calibro edell’estensione delle vene coronariche passibili di cateterizzazioneed impianto di elettrodo stimolatore; deve essereinfatti esclusa la presenza di condizioni anatomiche chepossono creare un possibile ostacolo al corretto posizionamentodell’elettrodo bipolare, come la presenza nel senocoronarico di lembi valvolari accessori (Tebesio o Vieussens),la presenza di particolari configurazioni del senocoronarico (bifido, “high riding”, varicoide, filiforme,“windsock” o ectasico, diverticolare, atresico) (Fig. 5), lapresenza di un decorso dell’arteria circonflessa che“scavalca” la GVC determinandone la sua compressione“ab estrinseco” ed infine la presenza angoli di confluenzadelle vene cardiache della parete postero-laterale con la

Radiol med (2009) 114:837–851 847a b cd e fFig. 5a-f Normal anatomy and variants of the coronary sinus (MDCT 3D volume-rendered reconstruction): normal anatomy (a), bifid CS (b), high-ridingCS (c), varicoid CS (d), filiform CS (e), CS windsock or ectatic CS (f). CS: coronary sinus.Fig. 5a-f Anatomia normale e varianti del sistema venoso del seno coronarico (TCMS ricostruzioni 3DVR): anatomia normale (a), SC bifido (b), SC “highriding” (c), SC varicoide (d), SC filiforme (e), SC “windsock” o ectasico (f). CS: seno coronario.In the planning of CRT, the MDCT examination enablesa preliminary evaluation of the anatomy of the cardiacvenous system, of the diameter of the CS, and of the diameterand length of the cardiac veins suitable for catheterisationand pacing lead implantation. The presence of anatomicalconditions unsuitable for correct placement of thebipolar lead needs to be ruled out, such as accessory valveleaflets (Thebesian or Vieussens) in the CS, certain anatomicalconfigurations of the CS (bifid, high riding, varicoid,filiform, windsock or ectatic, diverticular, atresic) (Fig.5a–f), a left circumflex artery crossing the GCV and causingexternal compression, and unfavourable angles between theGCV non favorevoli (≥90°) ad un’agevole cateterizzazione.L’intento del nostro lavoro non è quello di analizzarel’accuratezza diagnostica della TCMS nei confronti dellavenografia, ma di far risaltare i vantaggi che possono derivaredall’utilizzo routinario della TCMS nella valutazionedel sistema venoso coronarico. In letteratura sono riportatepercentuali di visualizzazione dei diversi segmenti venosicoronarici, variabili in relazione al calibro dei vasi considerati:il CS è stato visualizzato nel 98% dei casi, la GCVnel 99% dei casi, la AIV nel 99% dei casi, la MCV nel 98%dei casi, la PVC nel 89% dei casi, la LCV nel 73% dei casi,la PVC nel 14% dei casi. Il diametro medio del CS è

848 Radiol med (2009) 114:837–851postero-lateral veins and the GCV (≥90°).The aim of our study was not to analyse the diagnosticaccuracy of MDCT compared with venography but, rather, tohighlight the advantages of the routine use of MDCT in theevaluation of the coronary venous system. The Literaturereports detection rates of the various venous segments thatvary in relation to the diameter of the vessels considered. TheCS was visualised in 98% of cases, the GCV in 99%, theAIV in 99%, the MCV in 98%, the PCV in 89%, the LCV in73% and the SCV in 14% of cases. The mean diameters ofthe CS tributaries were 3.9 mm for the IAV, 5.2 mm for theMCV, 3.9 mm for the PCV and 3.7 mm for the LCV [20–27].The reported detection rates of the cardiac veins are, to alarge extent, similar to those in our study with the exceptionof the LCV (73% vs. 67% in our series) and more notably ofthe PCV (89% vs. 75%). Possible explanations for thisdiscrepancy include nonoptimal timing of contrast enhancement,much faster scan times with respect to the earlier multislicescanners (4- 8- and 16 slices) and interobserver variabilityin the linear measurements of vessel diameter.Even though postprocessing of new-generation angiographicimages makes possible the creation of 3D volumerendering (VR) reconstructions immediately after retrogradevenography [28] and linear measurements on 2Dimages, the VR and MPR images created from MDCTacquisitions with isotropic voxels may provide additionaladvantages. In addition to clearly depicting the courseof the vessel in relation to the left ventricular free wall andthe left circumflex artery [28], these reconstructions offerthe possibility of evaluating the anatomy of the mitralvalve and enable precise measurement of the diameter, orbetter of the section, of the CS and its branches.The presence of reduced diameters, short vessels orsharp vascular angles can in fact make difficult or evenimpossible the insertion of the bipolar pacing [10, 16,21–23].Normally the anatomy of the cardiac veins is not optimallyvisualised with the contrast-enhancement protocolused for the coronary arteries, with the exception of thejuxta-atrial portions (CS and MCV). This occurs becausethe veins situated more cranially, when the acquisitions areperformed in the cranio-caudal direction, show validcontrast enhancement towards the end of the scan [1].Undoubtedly, the visibility of the cardiac veins on thepostero-lateral wall of the left ventricle could be improved byperforming the scan in the caudo-cranial direction or by usingan additional delay of 12–15 s after reaching the enhancementthreshold in the ascending aorta (baseline HU+100 HU)[1, 2, 17]. Another expedient, which is the subject of astudy at our centre, is the simultaneous use of two ROIscorresponding to the CS and the ascending aorta. Althroughour experience is still limited, this bolus-tracking method,which does not appear to be reported in the Literature,risultato 13,2 mm, quello della GCV 6,8 mm. I diametrimedi delle altre vene tributarie del seno coronarico sonorisultati rispettivamente: AIV 3,9 mm, MCV 5,2 mm, PVC3,9 mm e LCV 3,7 mm [20–27]. I dati riguardanti la percentualedi visualizzazione delle vene cardiache riportati inletteratura sono in buona parte sovrapponibili ai dati estrapolatidalla nostra esperienza fatta eccezione per la visualizzazionedella LCV (73% vs 67% letteratura vs nostracasistica) ed in maniera ancora più significativa della PVC(89% vs 75%). È possibile che il motivo di tali discrepanzerisieda in un timing contrastografico non ottimizzato, intempi di scansione estremamente più veloci rispetto ai primiscanner multi-slice (4-8-16 strati) ed infine nella variabilitàinter-osservatore delle misure lineari del diametro vasale.Nonostante le implementazioni degli angiografi di nuovagenerazione permettano di creare in post-processing immagini3D volume rendering (VR) subito dopo l’esecuzionedella venografia retrograda [28] e di eseguire misurazionilineari su immagini bidimensionali, le ricostruzioni VR eMPR ricavate da acquisizioni TCMS con voxel isotropico,possono fornire ulteriori vantaggi. Queste ricostruzioni,oltre che mettere bene in evidenza il decorso dei vasi inrelazione alla parete libera del ventricolo di sinistra eall’arteria circonflessa [28] offrono la possibilità di valutarel’anatomia dell’anello mitralico e consentono di misurarein maniera precisa il diametro, o ancor meglio lasezione, del seno coronarico e dei suoi rami; la presenza dicalibri ridotti, di vasi a breve decorso o di brusche angolazionivasali, possono infatti rendere difficoltoso, o addiritturaimpossibile, l’inserimento dell’elettrocatetere bipolaredurante la procedura di CRT [10, 16, 21–23].Normalmente l’anatomia delle vene cardiache non vienevisualizzata in maniera ottimale applicando il protocollo distudio contrastografico utilizzato per le arterie coronarie,ad eccezione delle porzioni iuxta-atriali (seno coronarico evena cardiaca media). Questo avviene perché le venesituate più cranialmente, quando l’acquisizione viene effettuatain senso cranio-caudale, presentano un validocontrast enhancement verso il termine della scansione [1].Sicuramente effettuare l’acquisizione della scansione indirezione caudo-craniale o l’utilizzo di un ritardo aggiuntivodi 12–15 secondi dal raggiungimento della soglia di attenuazionein aorta ascendente [HU basale+100 HU], consente dimigliorare la visibilità delle vene cardiache lungo la paretepostero-laterale del ventricolo sinistro [1, 2, 17]. Un ulterioreaccorgimento, attualmente oggetto di studio presso ilnostro centro, è l’utilizzo contemporaneo di due regioni diinteresse (ROI) in corrispondenza del seno coronarico edell’aorta discendente; questa modalità di bolus tracking,che non ci risulta essere mai stata descritta, nella nostra casisticaseppure ancor limitata, permetterebbe di ridurre alminimo la criticità del timing contrastografico del sistemavenoso coronarico, specie in pazienti che a causa della

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