
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

39252282
MD-D-23-09653
00069
10.1097/MD.0000000000039491
3
3300
Research Article
Observational Study
An observational study on the application of fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol in valve replacement surgery
Su Mingping BM 15908470660@163.com
a
https://orcid.org/0009-0000-0283-3119
Ju Jifeng MD b*
a Department of Anesthesiology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan, China
b Department of Anesthesiology, The 960th Hospital of the PLA Joint Logistic Support Force, Jinan, Shandong, China.
* Correspondence: Jifeng Ju, Department of Anesthesiology, The 960th Hospital of the PLA Joint Logistic Support Force, No. 25, Tianqiao District, Jinan 250000, Shandong, China (e-mail: jujifeng@tom.com).
06 9 2024
06 9 2024
103 36 e3949101 11 2023
07 8 2024
08 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

The aim of this study was to evaluate the efficacy of fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol in valve replacement surgery. The clinical data of 88 patients with rheumatic heart disease undergoing valve replacement surgery were retrospectively analyzed and grouped based on different treatment methods. Among them, 44 cases received fast-track cardiac anesthesia using target-controlled infusion of fentanyl and propofol from November 2019 to July 2021 were set as the control group, and 44 cases received fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol from August 2021 to February 2022 were set as the study group. The study group showed shorter postoperative awakening time, extubation time, and hospital stay duration, and lower dosage of dopamine and nitroglycerin consumption compared to the control group (P < .05). At T5 and T6, both groups exhibited higher ACTH, cortisol (Cor), and C3a than at T0, and the study group showed significantly lower ACTH, Cor, and C3a at T5 and T6 than the control group (P < .05). At T7, the control group showed higher ACTH, Cor, and C3a than at T0, and ACTH, Cor, and C3a were significantly lower in the study group than in the control group at T7 (P < .05). Fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol in valve replacement surgery has demonstrated favorable application effects, which stabilizes hemodynamics, alleviates myocardial damage, suppresses endocrine stress responses, and does not increase adverse reactions, thereby exhibiting good safety.

cardiac anesthesia
hemodynamics
myocardial injury
propofol
Rheumatic heart disease
stress response
sufentanil
valve replacement
OPEN-ACCESSTRUE
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pmc 1. Introduction

Rheumatic heart disease is a prevalent clinical cardiac condition with a high incidence rate, primarily resulting from mitral stenosis caused by Group A hemolytic streptococcal infections. Patients often exhibit clinical manifestations such as shortness of breath, palpitations, loss of appetite, and dyspnea, significantly reducing their quality of life.[1] Without timely and effective therapeutic interventions for individuals with rheumatic heart disease, the continuous progression of the disease can lead to complications such as arrhythmias, thromboembolism, and heart failure, and may even prove fatal.[2] Currently, clinical treatments for rheumatic heart disease encompass pharmacological and surgical approaches, with valve replacement surgery being a common and highly effective procedure.[3] However, valve replacement can cause hemodynamic fluctuations and myocardial injury, impacting the safety of the surgery and patients’ postoperative recovery.[4] Therefore, maintaining hemodynamic stability and minimizing myocardial injury in valve replacement patients are crucial for improving patient outcomes.

For early postoperative extubation and early recovery, fast-track cardiac anesthesia is used during cardiac surgery anesthesia. Fast-track cardiac anesthesia refers to the selection of appropriate anesthesia management protocols, aiming to remove the tracheal intubation at an early stage (<6 hours) after cardiac surgery and shorten ICU stay duration, so as to improve patient prognosis and reduce medical expenses. Early postoperative extubation and mobilization facilitate enhanced thoracic blood circulation, expedite the healing of thoracic surgical wounds, reduce ICU stay and hospitalization duration, and accelerate physical recovery. Relevant research has demonstrated that the appropriate selection of anesthetic agents can effectively stabilize hemodynamics in patients undergoing valve replacement, and certain anesthetics possess myocardial protective properties.[5] Historically, fast-track anesthesia using target-controlled infusion of fentanyl and propofol has been predominantly employed in valve replacement surgeries, but the outcomes have been suboptimal.[6] Sufentanil, an opioid analgesic, more readily crosses the blood-brain barrier than fentanyl, exhibits a stronger analgesic effect and a longer duration of action, and can effectively reduce cardiac load and myocardial injury when combined with propofol.[7,8] In light of these findings, this study investigates the application of fast-track cardiac anesthesia with target-controlled infusion of sufentanil and propofol in valve replacement surgery, as well as its effects on patients’ hemodynamics, endocrine stress response, and myocardial injury markers. The aim is to provide a reference for the clinical development of anesthetic regimens for this patient population. The results are presented below.

2. Methods

2.1. Clinical data

The clinical data of 88 patients with rheumatic heart disease undergoing valve replacement surgery at our hospital from November 2019 to February 2022 were selected for retrospective analysis, including 50 males and 38 females; ages ranged from 24 to 68 years, with a mean age of (46.71 ± 4.61) years; ASA classification: 32 cases of class II and 56 cases of class III; New York Heart Association (NYHA) cardiac function classification: 40 cases of class II and 48 cases of class III; surgical procedures: 18 cases of aortic valve replacement, 33 cases of mitral valve replacement, and 37 cases of combined aortic and mitral valve replacement. Patients were grouped according to different treatment methods. Among them, 44 cases received fast-track cardiac anesthesia using target-controlled infusion of fentanyl and propofol from November 2019 to July 2021 were set as the control group, and 44 cases received fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol from August 2021 to February 2022 were set as the study group. This study has been approved by the Ethics Committee of the 960th Hospital of the PLA Joint Logistic Support Force. The flow diagram for study design is shown in Figure 1.

Figure 1. The flow diagram of the study design.

2.2. Inclusion and exclusion criteria

Inclusion criteria included the following: patients who met the diagnostic criteria for rheumatic heart disease[9]; those with indications for surgery and elective valve replacement treatment; those with NYHA cardiac function class II-III; those aged between 20 and 70 years; and those with ASA class II-III.

Exclusion criteria included the following: patients with allergies to drugs used in this study, such as sufentanil and propofol; those with coagulation dysfunction, malignant tumors, severe aortic stenosis, or severe liver and kidney diseases; those who had experienced serious heart diseases such as heart failure and acute myocardial infarction within 3 months before enrollment; pregnant and lactating women; and those with a history of valve replacement or coronary artery surgery.

2.3. Study methods

The control group received fast-track cardiac anesthesia using target-controlled infusion of fentanyl and propofol, and the study group received fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol. All patients underwent preoperative examinations, received 0.3 mg intramuscular injections of atropine (Hunan Wuzhoutong Pharmaceutical Co., Ltd., H43020903, Xiangtan, China) and 0.2 mg/kg morphine before anesthesia, and were provided with a facial mask for oxygen intake while undergoing regular monitoring of heart rate (HR), blood oxygen saturation (SpO2), and electrocardiogram (ECG) upon admission to the operating room. The peripheral venous access was opened, and the catheterizations of the right internal jugular vein and left radial artery were performed under local anesthesia. The central venous pressure (CVP) and invasive arterial blood pressure (ABP) were monitored. The anesthesia induction involved the administration of 0.05 mg/kg midazolam, 0.1 mg/kg vecuronium bromide, and 0.3 mg/kg etomidate. The control group was administered with 5.0 μg/kg fentanyl (Yichang Renfu Pharmaceutical Co., Ltd. , Yichang, China, H20003688). The study group was administered with sufentanil (Yichang Renfu Pharmaceutical Co., Ltd., Yichang, China, H20054256), followed by tracheal intubation, mechanical ventilation, and maintaining PETCO2 between 35–45 mm Hg (1 mm Hg = 0.133 kPa). Anesthesia was maintained using target-controlled infusion of propofol at 1.5–2.0 μg/mL, and intermittent intravenous injections of vecuronium bromide at 0.05 mg/kg were administered to ensure muscle relaxation. The control group received intermittent bolus of fentanyl and was no longer administered within the last half hour before the end of the procedure; the study group received continuous infusion of 2 μg/mL sufentanil until the end of the procedure. Hemodynamic stabilization during the induction period was defined as a decrease in MAP ≤ 20% of the pre-induction value.

2.4. Observation indexes

(1) Clinical data: Comparison of clinical data between the 2 groups, including gender, age, American Society of Anesthesiologists (ASA) classification, NYHA cardiac function classification, surgical mode, and mean body mass index.

(2) Anesthesia efficacy: Comparison of postoperative awakening and extubation time, dopamine and nitroglycerin dosage, and hospitalization duration between the 2 groups.

(3) Intraoperative parameters: Comparison of intraoperative blood loss, urine output, crystalloid intake, colloid intake, and total fluid intake between the 2 groups.

(4) Hemodynamics: Comparison of mean arterial pressure (MAP) and HR changes at the following time points between the 2 groups: before induction (T0), after induction (T1), following tracheal intubation (T2), post-skin incision (T3), and after sternal splitting (T4).

(5) Endocrine stress response: Central venous blood samples were collected at T0, post-surgery (T5), 12 hours post-surgery (T6), and 24 hours post-surgery (T7) from both groups. Complement C3a (C3a) levels were measured.

(6) Markers of myocardial injury: Central venous blood samples were obtained at T0, T5, T6, and T7 from both groups. Creatine kinase isoenzyme (CK-MB) levels were measured using the immunosuppression method, and cardiac troponin I (cTnI) levels were determined using the chemiluminescence method. The reagent kits were provided by Shanghai Shu Hua Biotechnology Co.

(7) Adverse reactions: Comparison of the occurrence of respiratory depression, nausea and vomiting, tachycardia, and hypotension between the 2 groups. Respiratory depression is indicated when a patient has an abnormally low frequency, specifically at a low respiratory rate of <12 breaths/min. Tachycardia refers to a heart rate exceeding 100 beats/min. Blood pressure below the standard level, i.e., lower than 90/60 mm Hg, is considered hypotension.

2.5. Statistical analysis

SPSS 23.0 software was employed for data analysis in this study. The measurement data were expressed as mean (χ ± S) and analyzed using one-way analysis of variance (ANOVA), with F values representing differences between multiple groups. The repeated measures ANOVA was used for intragroup comparisons. Count data were expressed as percentages and analyzed using the χ2 test. A P value <.05 was considered statistically significant.

3. Results

3.1. Comparison of clinical data

There were no statistically significant differences in clinical data, such as gender, age, ASA classification, NYHA cardiac function classification, surgical method, and mean body mass index between the 2 groups (P > .05; Table 1). Thus, the clinical data of the 2 groups were comparable.

Table 1 Comparison of clinical data n (%)/(χ ± S).

Clinical data	Control group (n = 44)	Study group (n = 44)	χ2/t	P	
Gender	Male	27 (61.36)	23 (52.27)	0.741	.389	
Female	17 (38.64)	21 (47.73)	
Age (yr)	46.36 ± 4.39	47.12 ± 5.03	0.755	.452	
ASA classification	Class II	15 (34.09)	17 (38.64)	0.196	.658	
Class III	29 (65.91)	27 (61.36)	
NYHA heart function classification	Class II	22 (50.00)	18 (40.91)	0.733	.392	
Class III	22 (50.00)	26 (59.09)	
Surgical modality	Aortic valve replacement	10 (22.73)	8 (18.18)	0.280	.870	
Mitral valve replacement	16 (36.36)	17 (38.64)	
Aortic and mitral valve replacement	18 (40.91)	19 (43.18)	
Body mass index (kg/m2)	23.85 ± 1.37	23.61 ± 1.52	0.778	.439	
ASA = American Society of Anesthesiologists, NYHA = New York Heart Association.

3.2. Anesthetic effects

Postoperative awakening, extubation, and hospitalization time were shorter in the study group than in the control group, while the consumption of dopamine and nitroglycerin were lower in the study group (P < .05). See Table 2. These findings suggest that sufentanil combined with propofol target-controlled infusion in fast-track cardiac anesthesia is more effective and promotes patients’ postoperative recovery.

Table 2 Comparison of anesthetic effects (χ ± S).

Anesthetic effect	Control group (n = 44)	Study group (n = 44)	t	P	
Time to awaken (h)	4.78 ± 1.26	2.35 ± 1.12	9.561	<.001	
Extubation time (h)	8.75 ± 2.14	4.48 ± 1.41	11.052	<.001	
Dopamine dosage (mg)	98.65 ± 8.45	72.36 ± 7.12	15.782	<.001	
Nitroglycerin dosage (mg)	10.02 ± 2.05	7.31 ± 1.63	6.864	<.001	
Length of hospitalization (d)	8.45 ± 1.74	6.48 ± 1.41	5.835	<.001	

3.3. Intraoperative volumes

There was no statistically significant difference (P > .05) between the 2 groups compared with each intraoperative access volume. See Table 3. It can be seen that sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia had no significant effect on intraoperative volumes.

Table 3 Comparison of fluids balance (χ ± S).

Parameters	Control group (n = 44)	Study group (n = 44)	t	P	
Intraoperative bleeding volume (mL)	385.65 ± 32.25	384.15 ± 31.18	0.222	.825	
Urine volume (L)	1.58 ± 0.75	1.45 ± 0.66	0.863	.391	
Crystal fluids (L)	2.21 ± 0.82	2.12 ± 0.76	0.534	.595	
Colloid fluids (mL)	884.62 ± 54.65	881.24 ± 56.62	0.285	.776	
Total fluids (L)	3.02 ± 1.42	2.91 ± 1.52	0.351	.727	

3.4. Hemodynamics

Compared with MAP and HR at T0 in both groups, the difference was not statistically significant (P > .05); at T1, MAP and HR were lower in both groups than at T0, and MAP was lower in the study group than in the control group (P < .05); at T2, MAP was lower in both groups than at T0, HR was higher in the control group than at T0, and HR was lower in the study group than in the control group (P < .05); at T3, MAP was lower in the control group than in T0, and MAP was lower in the study group than in the control group, while HR was higher in both groups than at T0, and HR was lower in the study group than in the control group (P < .05); at T4, HR was higher in both groups than at T0 (P < .05). See Table 4. It can be seen that sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia has less hemodynamic impact on the patient and contributes to the smooth performance of the procedure.

Table 4 Comparison of hemodynamics (χ ± S).

Indicator	Group	T0	T1	T2	T3	T4	
MAP (mm Hg)	Control group (n = 44)	84.02 ± 5.15	69.02 ± 4.89*	76.02 ± 6.05*	90.77 ± 6.34*	84.35 ± 6.64	
Study group (n = 44)	84.31 ± 5.22	75.25 ± 5.03*,**	77.31 ± 5.63*	85.62 ± 6.05**	86.02 ± 7.41	
HR (times/min)	Control group (n = 44)	82.26 ± 5.36	75.21 ± 5.03*	90.55 ± 7.65*	96.57 ± 8.02*	87.32 ± 5.82*	
Study group (n = 44)	81.25 ± 4.67	76.52 ± 5.16*	83.45 ± 5.74**	90.01 ± 7.72*,**	86.41 ± 6.02*	
Note: Compared with T0 within this group,

* P<.0; Compared with control group,

** P<.05.

3.5. Endocrine stress response

There was no statistically significant difference in adrenocorticotrophic hormone (ACTH), cortisol (Cor), and C3a at T0 compared with the 2 groups (P > .05); at T5 and T6, ACTH, Cor, and C3a were higher in both groups than at T0, and they were lower in the study group than in the control group (P < .05); at T7, ACTH, Cor, and C3a were higher in the control group than at T0, and they were lower in the study group than in the control group (P < .05). See Figure 2. It can be seen that sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia can effectively reduce the endocrine stress response and contribute to the smooth operation.

Figure 2. Effect of sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia on endocrine stress response in patients undergoing valve replacement. This figure illustrates that the combination of sufentanil and propofol in target-controlled infusion of fast-track cardiac anesthesia effectively reduces the levels of (A) ACTH, (B) cortisol, and (C) C3a, which are key indicators of endocrine stress response. ACTH = adrenocorticotrophic hormone; Cor = cortisol; C3a = complement C3a. In comparison to T0 within the same group, *P < .05; in comparison to the control group, **P < .05.

3.6. Markers of myocardial injury

Compared with CK-MB and cTnI at T0 in both groups, the difference was not statistically significant (P > .05); at T5, T6, and T7, CK-MB and cTnI were higher in both groups than at T0, and they were lower in the study group than in the control group (P < .05). See Figure 3. It can be seen that sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia can effectively reduce myocardial injury and promote postoperative recovery in patients.

Figure 3. Effect of sufentanil compounded with propofol target-controlled infusion of fast-track cardiac anesthesia on markers of myocardial injury in patients undergoing valve replacement. This figure demonstrates that the combination of sufentanil and propofol in target-controlled infusion of fast-track cardiac anesthesia effectively reduces the levels of myocardial injury markers (A) CK-MB and (B) cTnI. CK-MB = creatine kinase isoenzyme, cTnI = cardiac troponin I. In comparison to T0 within the same group, *P < .05; in comparison to the control group, **P < .05.

3.7. Adverse reactions

The incidence of adverse reactions, such as respiratory depression, nausea and vomiting, tachycardia, and hypotension, were compared between the 2 groups. Following Fisher’s exact probability test, there was no statistically significant difference in each adverse reaction between the 2 groups. The total incidence of adverse reactions in the study group (4.55%) was slightly lower than that in the control group (9.09%), but the difference was not statistically significant (P > .05), indicating that sufentanil combined with propofol target-controlled infusion in fast-track cardiac anesthesia did not increase adverse reactions, demonstrating favorable safety profile. See Table 5.

Table 5 Comparison of adverse reactions n (%).

Group	Respiratory depression	Nausea and vomiting	Tachycardia	Hypotension	Total incidence	
Control group (n = 44)	1 (2.27)	1 (2.27)	1 (2.27)	1 (2.27)	4 (9.09)	
Study group (n = 44)	0	1 (2.27)	0	1 (2.27)	2 (4.55)	
χ2	–	–	–	–	0.179	
P	1.000	1.000	1.000	1.000	.672	

4. Discussion

Valve replacement is a prevalent treatment for patients with rheumatic heart disease, demonstrating significant efficacy. However, the procedure is complex and associated with risks, such as bleeding and thrombosis, which can lead to hemodynamic changes and exacerbate myocardial injury.[10] Previously, high doses of fentanyl were primarily used as the main anesthetic regimen for valve replacement. This approach had limitations, as it affected the patient’s ventilatory function and caused bradycardia and hypotension, hindering the surgical procedure.[11,12] With the advancement of anesthesia technology, target-controlled infusion techniques have been widely adopted in clinical anesthesia due to their simplicity and effective anesthetic outcomes.[13] This method relies on pharmacodynamics and pharmacokinetics, using drug concentration as an indicator to regulate anesthesia depth, analgesia, and sedation through computer-controlled drug delivery infusion rates.[14]

In this study, patients undergoing valve replacement received sufentanil compounded with propofol target-controlled infusion for fast-track cardiac anesthesia. The results demonstrated that postoperative awakening, extubation, and hospitalization times were shorter in the study group compared to the control group. Moreover, the consumption of dopamine and nitroglycerin was lower in the study group. Hemodynamic indicators, such as MAP and HR, were more stable in the study group at various time points (T1, T2, T3, and T4). Furthermore, the incidence of adverse reactions between the 2 groups did not significantly differ (P > .05). These findings align with the results from Song Leijun’s study,[15] indicating that sufentanil compounded with propofol target-controlled infusion for fast-track cardiac anesthesia is more effective, can efficiently stabilize patient hemodynamics, and exhibits a favorable safety profile.

Sufentanil is potent opioid analgesic drug acting primarily on mu-opioid receptors. It possesses greater lipophilicity and a higher binding rate to plasma proteins than fentanyl, allowing it to provide stronger analgesic effects at lower doses, thus reducing cardiac load and ensuring drug safety.[16,17] Propofol, characterized by its potent action and rapid onset, effectively dilates blood vessels, further reducing cardiac load. When combined with sufentanil, it can effectively maintain hemodynamic stability in patients.[18,19]

Surgical procedures and anesthesia can trigger stress responses in patients, leading to increased levels of endocrine stress indicators such as ACTH, Cor, and C3a.[20,21] The stress response can cause intraoperative hemodynamic instability and increase surgical risk. Patients with rheumatic heart disease are predisposed to myocardial hypoxia and ischemia due to their compromised cardiac function. Anesthesia and perioperative blood pressure fluctuations exacerbate this imbalance in myocardial oxygen supply and demand, aggravating myocardial injury.[2] CK-MB and cTnI, sensitive clinical indicators for diagnosing myocardial injury, are typically low in serum under normal conditions but rapidly released into circulation when myocardial injury occurs.[22]

This study found that sufentanil compounded with propofol target-controlled infusion for fast-track cardiac anesthesia effectively inhibited the endocrine stress response and reduced myocardial injury. This may be attributed to propofol’s ability to reduce lipid peroxidation damage to the myocardial cell membrane by inhibiting oxygen-free radical production. When combined with sufentanil, the cardiac load is further reduced, thereby minimizing stress response and myocardial injury.

In conclusion, sufentanil combined with propofol target-controlled infusion for fast-track cardiac anesthesia is effective in valve replacement, stabilizing hemodynamics, reducing myocardial injury, inhibiting endocrine stress, and maintaining a favorable safety profile without increasing adverse effects. However, this study has some limitations, such as a small sample size and a single source, which may introduce bias in the results. Additionally, the long-term myocardial injury of patients undergoing fast-track cardiac anesthesia with sufentanil compounded with propofol target-controlled infusion has not been analyzed. Further research with extended follow-up periods and larger sample sizes is necessary to confirm the findings of this study.

The overall cutoff point for case selection in this study was from November 2019 to February 2022. The administration of anesthetic drugs in our hospital must adhere to the hospital’s clinical treatment guidelines, and patients with the same condition should be treated according to the same anesthesia regimen outlined in the guidelines. Before July 2021, our hospital mainly used fentanyl combined with propofol for anesthesia. In August 2021, we introduced sufentanil and subsequently modified the clinical pathway to use sufentanil combined with propofol for all cases. Therefore, the case selection was divided into 2 phases. Additionally, through strict inclusion and exclusion criteria, the number of cases for each group was exactly the same, which may lead readers to question whether this is a randomized controlled study, which is understandable. In the next step of our research, we will further expand the number of cases to observe the efficacy.

Author contributions

Conceptualization: Mingping Su, Jifeng Ju.

Data curation: Mingping Su.

Formal analysis: Mingping Su, Jifeng Ju.

Investigation: Jifeng Ju.

Methodology: Mingping Su, Jifeng Ju.

Project administration: Mingping Su, Jifeng Ju.

Resources: Mingping Su, Jifeng Ju.

Writing – original draft: Mingping Su, Jifeng Ju.

Writing – review & editing: Jifeng Ju.

Abbreviations:

ACTH adrenocorticotrophic hormone

ASA American Society of Anesthesiologists

C3a complement C3a

CK-MB creatine kinase isoenzyme

Cor cortisol

cTnI cardiac troponin I

HR heart rate

MAP mean arterial pressure

NYHA New York Heart Association.

The authors have no conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

How to cite this article: Su M, Ju J. An observational study on the application of fast-track cardiac anesthesia using target-controlled infusion of sufentanil and propofol in valve replacement surgery. Medicine 2024;103:36(e39491).
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