
==== Front
JTCVS Open
JTCVS Open
JTCVS Open
2666-2736
Elsevier

S2666-2736(24)00171-2
10.1016/j.xjon.2024.06.011
Adult: Tricuspid Valve
Tricuspid valve surgery following septal myectomy in patients with a cardiac implantable electronic device
Sawma Tedy MD a
Schaff Hartzell V. MD Schaff@mayo.edu
a∗
Geske Jeffrey B. MD b
Dearani Joseph A. MD a
Ommen Steve R. MD b
a Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
b Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
∗ Address for reprints: Hartzell V. Schaff, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Schaff@mayo.edu
27 6 2024
8 2024
27 6 2024
20 2936
25 4 2024
20 5 2024
12 6 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of developing cardiac arrhythmias and have a high prevalence of cardiac implantable electronic device (CIED) use. Tricuspid regurgitation (TR) is a potential complication of device leads and can be severe enough to prompt surgical intervention.

Methods

We identified 21 consecutive patients who underwent tricuspid valve (TV) surgery for device lead-induced TR late following septal myectomy (SM) for obstructive HCM. The primary endpoint was long-term all-cause mortality.

Results

The median patient age was 63 years (range, 55-71 years), 19 patients (91%) had New York Heart Association class III or IV limitation, and all patients were receiving diuretics for right heart failure. The median interval between device implantation and TV surgery was 4 years (range, 1.5-8.5 years). Eight patients (38%) underwent pacemaker implantation due to complete heart block following SM. Preoperatively, TR was severe in 81% of the patients. The primary mechanism of lead-induced TR was leaflet impingement without adherence (n = 15; 75%). Nine patients (43%) underwent TV replacement, and 12 patients (57%) underwent repair. Only 1 patient died early postoperatively. Patients with lead-induced TR had markedly reduced long-term survival compared to the overall population of patients undergoing SM; 5-year survival was 58%, compared to 96% for the contemporary SM group.

Conclusions

Late lead-induced TR is a potential complication of CIEDs in patients with HCM who have undergone SM. Although TV repair and replacement can be done with acceptable early mortality, late patient survival is poor.

Graphical Abstract

Key Words

tricuspid valve regurgitation
cardiac implantable electronic device
pacemaker
device lead
implantable cardioverter defibrillator
hypertrophic cardiomyopathy
septal myectomy
tricuspid valve surgery
Abbreviations and Acronyms

CIED cardiac implantable electronic device

HCM hypertrophic cardiomyopathy

ICD implantable cardioverter defibrillator

IQR interquartile range

RV right ventricular

SCD sudden cardiac death

SM septal myectomy

TR tricuspid regurgitation

TV tricuspid valve
==== Body
pmc Main indications for device lead placement, surgical management of lead-induced tricuspid regurgitation, and the postoperative outcomes.

Central Message

Late lead-induced tricuspid regurgitation is a rare but significant complication of cardiac devices in hypertrophic cardiomyopathy patients after myectomy. Although early mortality for tricuspid valve repair or replacement is acceptable, late survival is poor.

Perspective

The findings of the present study emphasize the need to screen for tricuspid valve dysfunction prior to septal myectomy, as well as the use of meticulous surgical technique to reduce the risk of heart block and pacemaker dependency. Our results also support adherence to guidelines for the use of an implantable cardioverter defibrillator in patients with hypertrophic cardiomyopathy to minimize unnecessary lead-related complications.

Hypertrophic cardiomyopathy (HCM) is a common genetic disorder of cardiac myocytes, with a global prevalence of almost 1 in 200 individuals.1,2 Sudden cardiac death (SCD) from fatal arrhythmias remains one of the most important and feared complications of this disease. Numerous risk stratification scores have been devised to identify patients at higher risk of SCD.1,3, 4, 5 Better prediction of SCD enables physicians to intervene earlier in the disease process through the insertion of an implantable cardioverter-defibrillator (ICD) as a form of primary prevention, greatly reducing the incidence of fatal arrhythmic events.4 With this trend, however, the number of HCM patients with right ventricular (RV) lead insertion has increased significantly.

Additionally, many patients with left ventricular outflow tract obstruction and drug-refractory symptoms are managed by septal reduction therapy, and high-grade atrioventricular block requiring permanent pacing is a known complication of these procedures.6, 7, 8 Thus, an increasing incidence of device-related complications might be expected to accompany the growing numbers of HCM patients with a cardiac implantable electronic device (CIED).

The occurrence of tricuspid regurgitation (TR) following CIED implantation was first described 5 decades ago,9 and interest in this problem has increased because recent evidence suggests that lead-induced TR often is not a benign condition but rather may have a long-term detrimental impact on functional status and survival.10,11 Given the known prevalence of pulmonary hypertension in patients with obstructive HCM, the hemodynamic impact of TR may be especially severe and warrant tricuspid valve (TV) repair or replacement.12 Information on lead-induced TR and its surgical management in HCM patients is limited, however. Therefore, this study aimed to evaluate the outcomes of correction of lead-induced TR in patients with HCM who had undergone previous septal myectomy (SM).

Material and Methods

Study Design

The Mayo Clinic Institutional Review Board in Rochester, Minnesota approved the study (IRB 23-010210; approved October 26, 2023), and all patients authorized the use of their clinical data for research. Between 2003 and 2023, 36 patients underwent TV surgery (repair or replacement) following SM at our clinic. Patients with previous TV surgery and patients with concomitant SM were excluded from the study. Among patients undergoing TV surgery following SM, 21 (58.3%) had CIED and composed the study group.

Data Collection and Study Group

Relevant demographic characteristics, comorbidities, echocardiographic data, operative data, immediate postoperative outcomes, and long-term outcomes were collected from a prospectively maintained institutional cardiovascular surgery database. Variables were defined according to the criteria outlined by the Society of Thoracic Surgeons Adult Cardiac Surgery Database. A 5-point scale consistent with these definitions was adopted for the quantification of TR (0 = none, 1 = trivial, 2 = mild, 3 = moderate, 4 = severe). Lead-related details and echocardiographic parameters were collected manually from a review of electronic medical records. Comprehensive resting transthoracic echocardiography was performed in all patients. Data on long-term survival were gathered from LexisNexis Accurint and review of the medical records. Lead-induced TR was identified based on preoperative transthoracic echocardiography, intraoperative transesophageal echocardiography, and review of individual operative reports.

Operative Methods

The surgical management of TR in the context of a transvenous RV lead has been well described in previous studies.13, 14, 15 In summary, techniques for TV repair include suture and band annuloplasty. Regarding the RV lead, multiple techniques can be used depending on operative findings and surgeon preference. The most common technique involves repositioning the RV lead to prevent leaflet impingement and fixing it in place at a commissure between leaflets using tacking sutures or imbrication in a tissue fold. In cases where repair was not appropriate, valve replacement was performed, and the lead was exteriorized into the plane between the native annulus and the sewing ring of the prosthetic valve.

Outcomes of Interest

The primary endpoint of the study was long-term all-cause mortality. Secondary endpoints included the need for postoperative blood products, need for prolonged ventilation, need for dialysis, cardiogenic shock, length of intensive care unit stay at the index admission, length of hospital stay, and 30-day mortality.

Statistical Analysis

Categorical data are presented as frequency and percentage; continuous variables, as median and interquartile range (IQR). Long-term survival was estimated using the Kaplan-Meier method. We included a survival curve for the general SM population at the Mayo Clinic to allow for an informal comparison of outcomes, and also included 95% confidence bands for both curves. Given the limited sample size of 21 patients, survival curves were not truncated when the number at risk dropped below 10 and instead were truncated at the 5-year follow-up to avoid losing late survival information. Statistical analysis and data plotting were performed with BlueSky statistics (using R version 4.1.3).

Results

Baseline Characteristics

This study subset represents 58.3% of the total cohort of HCM patients who underwent TV surgery following SM (36 patients). The median patient age was 63.3 years (IQR, 55.3-71.1 years), and the median body mass index was 30.2 (IQR, 27.9-36.6). Fifteen patients were female (71.4%), 19 were in NYHA class III or IV (90.5%), and all (100%) required diuretics preoperatively. The patients’ baseline characteristics are listed in Table 1.Table 1 Baseline characteristics of patients undergoing tricuspid valve surgery due to lead-induced tricuspid regurgitation

Characteristic	Value	
Female sex, n (%)	15 (71.4)	
Age, y, median (IQR)	63.3 (55.3-71.1)	
BMI, kg/m2, median (IQR)	30.2 (27.9-36.6)	
Diabetes, n (%)	7 (33.3)	
Creatinine, mg/dL, median (IQR)	1.4 (0.8-1.9)	
Renal failure, n (%)	5 (23.8)	
Dyslipidemia, n (%)	12 (57.1)	
Cerebrovascular disease, n (%)	2 (9.5)	
Smoking, n (%)	1 (4.8)	
NYHA class III/IV, n (%)	19 (90.5)	
Recent atrial fibrillation, n (%)	7 (33.3)	
Complete heart block, n (%)	8 (38.1)	
Hypertension, n (%)	14 (66.7)	
Coronary artery disease, n (%)	2 (9.5)	
Previous mitral valve surgery, n (%)	9 (42.8)	
Use of beta-blockers, n (%)	19 (90.5)	
Use of calcium channel blockers, n (%)	2 (9.5)	
Use of diuretics, n (%)	21 (100)	
IQR, Interquartile range; BMI, body mass index; NYHA, New York Heart Association.

Echocardiographic Study

Preoperative and pre-dismissal echocardiographic assessments at the time of initial SM were available for 14 patients (66.6%) because not all individuals had their initial operation performed at our clinic. Among patients with available data, 6 (43%) had no TR prior to initial SM, 4 had trivial or mild TR (28.5%), and 4 had mild to moderate TR (28.5%). The median left ventricular outflow tract maximal instantaneous gradient prior to hospital dismissal following the SM was 0 (IQR, 0-0).

Preoperative echocardiography was performed in all patients undergoing TV surgery. The median left ventricular ejection fraction was 60% (IQR, 55%-65%). Seventeen patients (81%) had severe TR. The median RV systolic pressure was 50 mm Hg (IQR, 41-65 mm Hg), and the median right atrial pressure was estimated as 15 mm Hg (IQR, 14-20 mm Hg) (Table 2).Table 2 Preoperative echocardiographic parameters of patients undergoing tricuspid valve surgery for lead-induced tricuspid regurgitation

Echocardiographic parameter	Value	
Ejection fraction, %, median (IQR)	60 (55-65)	
Tricuspid regurgitation, n (%)		
 Mild	2 (9.5)	
 Moderate	2 (9.5)	
 Severe	17 (81)	
Right atrial pressure, mm Hg, median (IQR)	15 (14-20)	
Right ventricular systolic pressure, mm Hg, median (IQR)	50 (41-65)	
Right ventricular dysfunction, n (%)		
 None	8 (40)	
 Mild	7 (35)	
 Moderate or greater	5 (25)	
Mitral regurgitation, n (%)		
 None	1 (4.8)	
 Mild	4 (19)	
 Moderate	9 (42.9)	
 Severe	7 (33.3)	
Pulmonic regurgitation, n (%)		
 None	6 (28.6)	
 Mild	10 (47.6)	
 Moderate	2 (9.5)	
 Severe	3 (14.3)	
TR prior to initial myectomy, n (%)		
 None	6 (43)	
 Trivial	1 (7.1)	
 Mild	3 (21.4)	
 Mild to moderate	4 (28.5)	
Predismissal TR following TV surgery, n (%)		
 None	4 (19)	
 Trivial	11 (52.4)	
 Mild	6 (28.6)	
TR at last follow-up, n (%)∗		
 None	2 (16.7)	
 Trivial	2 (16.7)	
 Mild	3 (25)	
 Moderate	4 (33.3)	
Severe	1 (8.3)	
Predismissal resting LVOT gradient following initial septal myectomy, mm Hg, median (IQR)	0 (0-0)	
IQR, Interquartile range; TR, tricuspid regurgitation; TV, tricuspid valve; LVOT, left ventricular outflow tract.

∗ Only 12 patients had long-term echocardiographic follow-up, of whom 8 underwent TV repair and 4 underwent TV replacement.

Predismissal Doppler echocardiographic assessment was done in all patients; 4 (19%) had no regurgitation, 11 (52.4%) had trivial TR, and 6 (28.6%) had mild TR. Twelve patients had long-term follow-up studies (median, 1.8 years; IQR, 0.6-3.2 years). At the time of last echocardiographic assessment, 2 patients had no TR, 2 had trivial TR, 3 had mild TR, 3 had moderate TR, and 1 had severe TR. The latter patient had TV replacement as the primary intervention but presented with severe perivalvular leak 2 years following the cardiac surgery and was then treated with a transcatheter tricuspid valve-in-valve procedure.

Cardiac Device and RV Lead-Related Data

The median time between device insertion and TV surgery was 4 years (IQR, 1.5-8.5 years), and the median time between SM and TV surgery was 9 years (IQR, 3-15 years). Six patients (28.7%) had a pacemaker, 4 had an ICD (19%), 8 had both (38%), and the remaining 3 had a cardiac resynchronization device. Approximately 38% of the patients underwent CIED implantation due to complete heart block following SM. Lead-induced TR was determined by surgical inspection and/or echocardiography. Specifically, the RV lead was found to be contributing to TR in 14 patients (70%) based on both the operative note and echocardiographic assessment, in 4 patients (20%) based on the operative note only, and in 2 patients (10%) based on the echocardiography report only. The main mechanism of lead-induced TR was mechanical impingement without leaflet adherence (n = 15; 75%) (Table 3).Table 3 Cardiac implantable electronic device characteristics, indications, and outcomes in patients undergoing tricuspid valve surgery for lead-induced tricuspid regurgitation

Device-related information	Value	
Type of device, n (%)		
 Implantable cardioverter defibrillator only	4 (19)	
 Pacemaker only	6 (28.7)	
 Pacemaker and implantable cardioverter defibrillator	8 (38)	
 Cardiac resynchronization therapy device	3 (14.3)	
Reason for device placement, n (%)		
 Complete heart block postoperatively	8 (38.1)	
 Others (eg, sudden cardiac death prevention, syncopal episode, arrhythmias, chronotropic insufficiency)	13 (61.9)	
Mechanism of lead-induced tricuspid regurgitation, n (%)		
 Interference with adherence to the leaflet	3 (15)	
 Interference without adherence to the leaflet	15 (75)	
 Interference with adherence to the chordae	1 (5)	
 Perforation of the leaflet	1 (5)	
Time from device insertion to tricuspid valve surgery, y, median (IQR)	4 (1.5-8.5)	
IQR, Interquartile range.

Operative Data

Nine patients (42.9%) had concomitant mitral valve surgery. Information on the main indication for surgery was obtained from the operative notes and preoperative consult notes. TR was considered the primary indication for surgery in 12 patients (57.1%). In 8 patients, concomitant tricuspid and mitral valve diseases contributed equally to the decision for surgical intervention. Twelve patients underwent TV repair (57.1%), and 9 had TV replacement (42.9%). Operative management of the RV lead included exteriorization into the plane between the native and prosthetic valves in 5 patients (23.8%), removal from the right ventricle in 2 patients (9.5%), and fixation at the valve commissure in 5 patients (23.8%). In 9 patients (42.9%), the RV lead was left free-floating through the annulus (Table 4).Table 4 Operative variables

Variable	Value	
Primary indication for surgery, n (%)		
 Tricuspid valve	12 (57.1)	
 Mitral valve	1 (4.8)	
 Both	8 (38.1)	
TV repair, n (%)	12 (57.1)	
 Suture annuloplasty, n (%)	8 (66.7)	
 Band annuloplasty, n (%)	4 (33.3)	
TV replacement, n (%)	9 (42.9)	
 Bioprosthesis, n (%)	7 (77.7)	
 Mechanical prosthesis, n (%)	2 (22.3)	
Operative management of device leads, n (%)		
 Left free-floating through the annulus	9 (42.9)	
 Exteriorization into the plane between native and prosthetic valves	5 (23.8)	
 Removal from the right ventricle	2 (9.5)	
 Fixation at the valve commissure	5 (23.8)	
Concomitant CABG, n (%)	2 (8.7)	
Cross-clamp time, min, median (IQR)	37.5 (18.25-67.5)	
Perfusion time, min, median (IQR)	64 (48-102.5)	
TV, Tricuspid valve; CABG, coronary artery bypass grafting; IQR, interquartile range.

Outcomes

One patient died in the hospital due to multiorgan failure following surgery. Two patients experienced cardiogenic shock (9.5%) during their hospital stay, 2 needed dialysis (9.5%), and 4 required prolonged ventilation (19%). The median postoperative intensive care unit stay was 72 hours (IQR, 7-18 hours), and the median hospital stay from surgery to discharge was 10 days (IQR, 7-18 days) (Table 5).Table 5 Outcomes following tricuspid valve surgery for patients with lead-induced tricuspid regurgitation

Outcome	Value	
Congestive heart failure n (%)	1 (4.8)	
Cardiogenic shock, n (%)	2 (9.5)	
Prolonged ventilation, n (%)	4 (19)	
Need for postoperative blood transfusion, n (%)	12 (57.1%)	
Need for dialysis, n (%)	2 (9.5)	
Total ICU stay, h, median (IQR)	72 (32.7-155.4)	
Hospital stay from surgery to discharge, d, median (IQR)	10 (7-18)	
Hospital death, n (%)	1 (4.8)	
ICU, Intensive care unit; IQR, interquartile range.

During a median follow-up of 1.9 years (IQR, 0.7-5.9 years), 13 patients died. One-year survival was 68.6% (95% confidence interval [CI], 50.6%-93%), and 5-year survival was 57.6% (95% CI, 39%-83%). The long-term survival is illustrated in Figure 1, in which Kaplan-Meier survival curves show that patients with lead-induced TR who underwent TV surgery following SM have substantially worse survival compared to the overall SM population at our clinic. (Of note, the survival curve for the general SM population is added for illustrative and qualitative purposes only. Statistical conclusions cannot be generated by comparing the 2 curves, owing to sample size discrepancies and potential imbalances.) The 1-year and five-year survival rates for the general SM population were 99.2% (95% CI, 98.8%-99.5%) and 95.7% (95% CI, 94.8%-96.5%), respectively.Figure 1 Kaplan-Meier survival curves for patients with lead-induced tricuspid regurgitation undergoing surgery versus the overall septal myectomy population at our clinic. Time in years.

Figure 2 presents a graphical abstract of the study summarizing the main findings.Figure 2 Graphical abstract of the study.

Discussion

ICDs and permanent pacemakers are valuable medical devices that are integral to the treatment of a wide range of cardiac problems. In recent years, endocardial implantation of these devices has been increasing owing to significant technological advances that expanded their range of capabilities.16 Unfortunately, device lead implantation may be associated with multiple complications, including lead or pocket infection, lead failure, changes in pacing and defibrillator thresholds, and with ICDs, inappropriate shocks.17, 18, 19 TR is an important but incompletely studied complication of device lead insertion, and this complication requires focused investigation in HCM patients, in whom CIEDs are prevalent.

HCM patients are at increased risk of developing cardiac arrhythmias, which can be serious enough to cause SCD.1,20 With recent advancements in the management of heart rhythm disturbances, such outcomes can be greatly reduced through the implantation of ICDs.4,5 Specifically, the use of ICDs for primary and secondary prevention in HCM patients has been successful in decreasing the incidence of SCD by half and the overall HCM-related mortality by >10-fold over the last 30 years.1,21 Nonetheless, with the increasing use of ICDs, the prevalence of ICD lead-induced TR would be expected to increase as well. In the present study, 19% of patients undergoing TV surgery for lead-induced TR had an ICD implanted for prevention of SCD, and 38% had transvenous leads implanted for the purpose of both SCD prevention with the ICD and heart rate control with a pacemaker. This supports the importance of careful adherence to HCM practice guidelines for ICD implantation to avoid unnecessary lead-associated complications. Additionally, the use of subcutaneous ICDs for SCD prevention provides an alternative option to transvenous leads and should be considered in patients without the need for chronic pacing.22

Many patients with obstructive HCM and medically refractory symptoms undergo invasive septal reduction therapy with alcohol septal ablation and SM, and heart block with a subsequent need for pacemaker implantation is a well-known procedure-related complication.6,8 In the present study of surgery for lead-induced TR, 38% of the patients had a pacemaker placed as a result of heart block following SM. Unfortunately, the development of pacemaker lead-induced TR is unpredictable, and patients may present with valvular regurgitation several years following transvenous RV lead implantation. Alternative solutions, such as epicardial/leadless pacemaker systems, may offer some advantages by avoiding potential damage to the TV.23 However, leadless pacing does not allow for dual chamber pacing or defibrillation, and the long-term outcomes of these novel interventions remain unknown, especially in the HCM population.24 Thus, for HCM patients undergoing SM, it is important to avoid injury to the conduction system during muscle excision.7 Furthermore, clinicians should be aware of the increased risk of complete heart block and pacemaker requirement following SM, especially in patients who have had previous alcohol septal ablation with resulting right bundle branch block.7,25

Regarding overall long-term mortality, a recent study by Huang and colleagues13 reported a 5-year overall survival of 62% among patients with acquired heart diseases undergoing elective TV surgery for lead-induced TR. A similar study by the same group on lead-induced TR in patients with congenital heart disease showed a 5-year survival of 80.4%.15 In the present study, the 5-year survival was worse than both of those cohorts (57.6%). Furthermore, patients in the present study had dramatically reduced long-term survival compared to the general SM population, which has a 5-year overall survival of 95.7%. It should be noted, however, that this comparison is informal and qualitative, relying on visual inspection of survival curves rather than on formal statistical tests.7

The cause of the poor postoperative survival of HCM patients with lead-induced TR is unknown but may be explained in part by the tendency of these patients to have significant diastolic dysfunction at baseline,26,27 and TR can be a manifestation of the resultant biventricular heart failure that occurs with long-standing left heart disease. In addition, studies have shown that chronic RV pacing from the apex can cause ventricular desynchronization, which may result in abnormal left ventricular contraction, hypertrophy, and reduced pump function, further exacerbating the severity of TR in HCM patients with chronically implanted pacemakers.28,29

The device lead also can cause intrinsic damage to the TV apparatus, resulting in progressive and irreversible dilatation of the tricuspid annulus.11 In the present study, the median RV systolic pressure was relatively high (50 mm Hg; IQR, 41-65 mm Hg), suggesting that preexisting left heart pathology might be the initial trigger for RV failure. However, the presence of a device lead across the TV may accelerate the severity of TR and the subsequent decline in the RV function over time. Recent studies suggest that RV dysfunction is a poor prognostic factor in HCM patients and is associated with adverse cardiovascular events and reduced long-term survival.30, 31, 32

The negative association of lead-induced TR with survival of HCM patients emphasizes the importance of evaluating TV function preoperatively in those with transvenous leads and monitoring TV function during longitudinal follow-up. Early identification of lead-related TR is critical to selecting the most effective treatment, which may include percutaneous lead repositioning or extraction, or TV repair or replacement in severe cases.33 In the present study, all patients who underwent SM at our clinic had preoperative assessment of the TV and the majority of them had mild, trivial, or no TR. It is noteworthy that detection of lead-induced TR and accurate estimation of its severity on echocardiography can be challenging, potentially increasing the likelihood of missed diagnoses or misinterpretation of results.11

Limitations

The study findings are from a single tertiary center and might not be widely generalizable. The small size of the study group limits multivariable assessment of long-term survival. Additionally, granular echocardiographic data for patients prior to the initial myectomy were not available because many of the patients were referred to our clinic following SM at a different medical center.

Conclusions

Late lead-induced TR is an uncommon but important complication of CIED in patients with HCM who have undergone SM. Although early mortality rates for TV repair or replacement are acceptable, late patient survival is poor. These results underscore the importance of screening for TV dysfunction prior to initial SM as well as careful intraoperative technique during SM to avoid heart block and subsequent need for pacemaker insertion. Our findings also support adherence to HCM practice guidelines for ICD implantation to avoid unnecessary lead-associated complications.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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