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259

Evaluation of Surgical Procedures for Cyanotic Congenital Heart Disease by Using MR Imaging

Barbara

A. Kersting-Sommerhoffi Klaus C. Seelos1 Christian Hardy2 Chisato Kondo1 Sarah S. Higgins2 Charles B. Higgins1

ECG-gated MR imaging has been shown to be effective for the diagnosis of congenital disease. In this study, we assessed its role in the postoperative evaluation of surgical procedures in patients with complex congenital heart disease. MR images of 26 patients with Rastelli (five), Fontan (three), Senning (three), Damus (one), Jatene (eight), Waterston (four), and Potts (two) procedures were evaluated retrospectively. The accuracy of MR imaging was compared with that of angiography in 20 patients. The surgical anastomoses were identified in all patients. Patency, atresia, or hypoplasia of central pulmonary arteries and postoperative complications (focal stenoses of pulmonary arteries, thrombosed conduit, peri-conduit abscess) were shown. Narrowing of the right ventricular outflow tract and focal compression of the proximal pulmonary arteries were recognized as specific complications of the Jatene procedure. MR imaging appears to be effective in the postoperative evaluation of surgical heart

procedures

used for congenital

heart disease.

It should

to repeated catheterization and angiography children with complex congenital heart disease.

AJR 155:259-266,

Aeceived February vision April 19, 1990. I

Department

16,

1990;

of Aadiology

accepted

(L308),

after reBox

0628,

University of California, San Francisco, Medical Center, San Francisco, CA 94143. Address reprint requests to C. B. Higgins. 2 Oakland Children’s Hospital, 51 05 Dover St., Oakland,

CA 94609.

0361 -803x/90/1 552-0259 Roentgen Ray Society

© American

August

be considered

for the

as an alternative

postoperative

examination

of

1990

Previous studies have established spin-echo MR imaging as an effective, noninvasive method for evaluating congenital disease of the heart [1 -7] and the great arteries [8-1 1]. When compared with echocardiography, one of the major advantages of MR imaging is its usefulness for evaluating great vessel abnormalities. Because a number of surgical procedures used in the treatment of cyanotic heart disease involve the great arteries or cardiovascular structures superior to the heart, MR imaging may be particularly useful in the assessment of these structures. Indeed, previous reports have shown the effectiveness of MR imaging for the evaluation of systemic to pulmonary shunts [12, 13]. The arterial switch (Jatene) procedure [14, 15], the Damus-Kaye-Stansel (Damus) procedure [16, 17], and the Rastelli procedure [1 8] are other surgical procedures involving structures above the base of the heart. The usefulness of MR imaging for evaluating these procedures has not yet been reported. The purposes of the current study were (1 ) to assess the effectiveness of spinecho MR imaging in the postoperative examination of patients with surgical procedures in the supracardiac region for the treatment of cyanotic congenital heart disease; (2) to compare the accuracy of MR imaging with that of angiography for identifying complications of the surgical procedures, including occlusion, stenosis, and aneurysm formation of conduits and anastomoses; and (3) to compare MR imaging with angiography for defining the status of the pulmonary arteries distal to various anastomoses and conduits. Subjects Twenty-six procedures

and Methods patients

(Rastelli,

with

congenital

five; Fontan, three;

heart

disease

Senning,

three;

and

palliative

Damus,

one;

or

corrective

Jatene,

eight;

surgical Water-

260

KERSTING-SOMMERHOFF

ston,

four;

imaging.

and

two)

description

underwent

ECG-gated,

of the surgical

procedures

spin-echo and

their

is given

to 28 years

patients

who

congenital

Images ing

were

were

magnet

ECG

acquired

was

in the transverse were

surgical

by using MT/S,

an echo

the AR interval images

after

a cryogenic

Milpitas,

(General

delay

applied

time

plane

in all patients; were

CA)

Electric (TE)

and thus depended acquired

procedures

for

0.35-T or

MR images reviewers

Signa,

of 25-30 the repetition

on the patient’s

obtained

depending

in all patients; on the

type

were time

anastomosis; WI).

obtained.

or coronal procedure

(in 17 and nine patients, of both

respectively). Images with a slice thickness 5 and 10 mm were obtained in 19 patients. In the last patients

TABLE

1: Surgical Procedure

Rastelli

did

of

not

retrospectively the

know

general the

by three reviewers.

diagnosis

results

of

other

definition

of the

central

pulmonary

Operative

Description from

Corrected

Lesion

RV to MPA

Pulmonary

atre-

sia, severe pulmonary stenosis Fontan

Conduit

or direct

anasto-

Tricuspid atresia, severe tricuspid ste-

of right atrial ap-

mosis pendage

to MPA

nosis, Senning

Surgically

created

baffle

teries

nary atrial chambers End-to-side anastomosis of MPA to ascending

Ao; shunt

Severe stenosis of LVOT; ob-

from Ao to

structing VSD in tncuspid atresia Transposition of great antenies

MPA

Jatene

Transsection

of great

ar-

teries above sinuses and switching of arteries to opposite

nuses:

Potts

hypo-

plastic RV Transposition of great ar-

dividing the atrium into systemic and pulmoDamus

si-

reimplantation

of coronary arteries from aortic sinuses to the switched ascending Ao Side-to-side anastomosis

of descending left PA

Pulmonary

Ao to

nosis

ste-

(tetnal-

ogy

of Fallot), pulmonary

atnesia, cuspid sia Waterston

Side-to-side

of ascending right

tnatne-

Pulmonary

anastomosis

Ao to

nosis

ogy

PA

ste-

(tetnalof Fallot),

pulmonary atnesia, tncuspid sia

=

Note.-RV ventricular

= right ventricle; MPA = main pulmonary septal defect; PA = pulmonary artery.

the

imaging

The

surgical studies

features: demof the site of

arteries;

Procedures

Conduit

and

and

identi-

fication of postoperative complications at valvar, anastomotic, and arterial levels. Successful studies had to meet the following criteria: depiction of the shunt or baffle on at least two images or in two different planes and direct visualization of the systemic-pulmonary arterial anast#{243}mosis. Patency of a shunt or conduit was determined by the absence of signal in the vessel lumen. The MR results were compared with the findings at surgery and angiography. Twenty of the patients had angiography to corroborate MR findings. In these 20 patients, MR and angiographic findings were

1 .5-T

(TR) equaled

sagittal

but

aware

or angiography). The MR images were evaluated for the following onstration of the shunt, conduit, or baffle; depiction

heart rate. Images

of surgical

1990

(echocardiography

superconductMilwaukee,

msec

were evaluated

were

procedure,

complex

a cryogenic

August

patients.

disease.

magnet

with gating

imaged heart

(Diasonics

superconducting Images

in Table

(mean,

cyanotic

AJR:155,

imaged who had had Jatene procedures, images of 3-mm thickness were acquired. In seven older children and adults, the slice thickness was 1 0 mm. Angiographic studies were available in 20 of the 26

MR major

1 . Patients ranged in age from 6 months 7 years). Twelve children were 3 years old or younger. Children under 6 years old were sedated 30 mm before the examination with 100 mg/kg chloral hydrate (maximum total dose, 1 500 mg) orally or rectally, or nembutal 5 mg/kg (maximum dose, 1 00 mg) intramuscularly. The subjects of the study were consecutive applications

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Potts,

A brief

ET AL.

artery;

Ao

=

aorta;

LVOT

=

atne-

left ventricular

outflow

tract;

VSD

AJR:155,

August

MR OF CYANOTIC

1990

CONGENITAL

compared. In the remaining patients, echocandiognaphy and surgical findings were used to corroborate the findings of MR imaging.

HEART

261

DISEASE

the one remaining case, a diminutive pulmonary artery was found during autopsy. All other pulmonary arterial segments were found to be normal with both techniques.

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Results Demonstration

of Anastomoses

with MR

Complications

The shunts, conduits, or baffles were successfully imaged in all 26 patients. In all 26 cases, the anastomoses could be visualized directly on transverse images. Waterston, Potts, Fontan, and Damus procedures were best visualized on transverse images: images in the coronal plane generally did not provide important additional information. Rastelli and Jatene procedures were depicted on transverse and sagittal images; images in the sagittal plane were especially valuable for detecting postoperative complications (Fig. 1). In all but four cases, the surgical connection could be seen on more than one image; in these four cases, the slice thickness was 1 0 mm. The Rastelli, Senning, and Damus procedures were visualized longitudinally on images in the sagittal or coronal plane (Figs. 2 and 3).

Comparison Central

of MR and Angiography

Pulmonary

Arteries

Pulmonary arterial segments of 20 patients were analyzed and compared with angiographic findings, with consideration of the main, left, and right pulmonary arteries as separate segments (Table 2). Three right and two left pulmonary arteries were diagnosed as stenotic on both MR and angiography. Eight pulmonary arterial segments (one right, one left, six main) were not visualized with MR imaging or angiography. On review of the patients’ surgical or autopsy reports, these vessels proved to be atretic in seven of eight segments. In

Fig. 1.-Adjacent transverse MR images of a patient A, Aorta (A) is located posterior to main pulmonary

Table 3 summarizes the number of complications evaluated by MR and angiography and the number of complications identified by the two techniques. Complications were seen in all four patients who had undergone the Rastelli procedure. In two patients, narrowing of the conduit was identified; in the third, a thrombus obstructing the conduit was detected with MR imaging. One of these patients had a stenosed right pulmonary arterial segment also. The fourth patient, with clinical symptoms of endocarditis, had an intramural abscess within the right ventricular wall (infectious pseudoaneurysm) and surrounding the conduit. Two of these patients were studied with angiography, and the complications were detected in both. The complications in all four patients were confirmed during subsequent surgery. Four complications of Fontan procedures were seen by MR in two different patients. However, only two of the four complications were identified by angiography. Considerable right atrial enlargement, with the atrial septum bulging into the left atrium, was present in both patients. This enlargement compressed the entrance of the right pulmonary veins into the left atrium. A thrombus adhering to the atrial septum was shown with MR in one of these patients. The bulging septum and compression of the ostium of the right pulmonary vein was confirmed with angiography, but the thrombus was not identified. The other patient had a cardiac mass that was diagnosed with MR imaging as a partially thrombosed pseu-

with transposition of great arteries and Jatene procedure. artery (P) and compresses proximal right (RP) and left (LP) pulmonary

arteries (arrows

= focal

stenoses). B, Aortic root (AR) is dilated and right ventricular outflow tract (asterisk) is hypertrophied. C, Sagittal MR image of a different patient who had undergone same procedure. Note severe carotid artery, A = aorta, asterisk = RV outflow tract, RV = right ventricle, LV = left ventricle.

right ventricular

outflow

tract

stenosis

(black

arrow).

C =

262

KERSTING-SOMMERHOFF

ET AL.

AJR:155,

Fig.

2.-A-D,

August

1990

(A, B) and coronal of patient with malaligned

Transverse

(C, D) MR images

atrioventricular canal and subaortic stenosis treated with Damus procedure (end-to-side anastomosis of proximal main pulmonary artery

[P] and ascending

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aorta [A]). Wide communica-

two vessels is clearly shown in both planes (A, C). B depicts narrowing of left ventricular outflow tract (curved arrow) as well

tion

between

as left and right ventricular hypertrophy. Note pulmonary veins entering left atrium (LA). Small arrows on A are pulmonary valve leaflets. RV = right ventricle, LV = left ventricle, RA = right atrium, I = innominate artery, C = carotid artery.

doaneurysm measuring 6 cm in diameter and arising from the right ventricle (Fig. 4). The presence of a pseudoaneurysm was not diagnosed with angiography but was confirmed at subsequent surgery. MR imaging and angiography in a patient with the Senning procedure showed stenosis at the superior limit of the baffle, causing superior vena caval obstruction (Fig. 5). Another patient had pulmonary arterial hypertension after surgery. This was shown on MR images by enlarged pulmonary arteres and an elliptical configuration of the left ventricle, rather than the crescentic shape usually observed after this procedune. The ventricular septum in this patient was bowed toward the right ventricle, which is the reverse of the usual appearance in patients with transposition of the great arteries. In the patient with the Damus procedure, MR imaging identified a thrombus obstructing the left pulmonary artery (Fig. 2). This complication was not detected on angiography; the angiographic finding was considered as poor opacification of the left pulmonary artery for unknown reasons. The thrombus appeared as an area of high signal intensity completely obstructing the lumen of the left pulmonary artery. The thrombus was removed at subsequent surgery, and a follow-up

MR study showed no residual obstruction of the pulmonary artery. The eight patients with Jatene procedures had 1 5 morphologic abnormalities that were all shown with MR imaging (Table 1) (Fig. 1). Dilatation of the aortic root (three patients), supravalvar aortic stenosis (one patient), and narrowing of the right ventricular outflow tract (six patients) were depicted on MR images in all cases. These were confirmed with angiography in the four patients who had this study. The remainder had identical findings on echocardiography. Proximal narrowing of the right and left pulmonary arteries as they coursed around the repositioned aorta was identified in six patients on transverse MR images (Fig. 1). There was complete agreement between MR imaging and angiography with regard to the nine abnormalities evaluated by both techniques. No complications were detected in the six patients with Waterston or Potts shunt.

Discussion This study assessed the echo MR imaging to evaluate

capability of ECG-gated, spinsurgical procedures used in the

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AJR:155,

August

MR OF CYANOTIC

1990

CONGENITAL

HEART

263

DISEASE

Fig. 3.-A-D, Transverse (A-C) and sagittal (D) MR images of patient with truncus arteriosus and uncomplicated Rastelli procedure. On transverse images, conduit (C) can be followed from right ventricle (RV) to its entrance into main pulmonary artery (P). Conduit is depicted longitudinally on sagittal image. A = aorta, LA left atrium, RA = right atrium, LV = left ventricle, RP = right pulmonary artery, LP = left pulmonary artery.

, ,

i.;i; I”-.’

‘u..J

C TABLE

2: Status

of Pulmonary Right (n =

Nonmal Stenotic Atnetic Note-PA

=

Arterial

PA

D (n

Segments

Left PA (n = 20)

20)

= 60)

Main (n =

PA

20)

MR

Angio

MR

Angio

MR

Angio

16 3 1

16

17

17

14

14

0 6

0 6

pulmonary

artery.

3 1

2 1 Angio

2 1 =

angiography.

treatment of cyanotic congenital heart disease. In comparison with angiography, the results show that MR imaging can reliably depict the anatomy of the surgical procedures, postoperative complications, and the status of the central pulmonary arteries. MR imaging is as effective as angiography for the identification of these complications and of the status of the pulmonary arteries. The results suggest that MR imaging could be used to monitor size, patency, and eventually the growth of the pulmonary arteries under improved perfusion conditions after construction of systemic-pulmonary shunts. In an earlier study, Jacobstein et al. [1 2] reported the usefulness of ECG-gated MR for the evaluation of systemic-

pulmonary artery shunts in a study population that consisted mostly of patients with Blalock-Taussig and Glenn shunts. The current study focused on patients with Rastelli, Fontan, and Senning procedures, and two of the newer surgical techniques, namely Damus and Jatene procedures, for connection on palliation of cyanotic congenital heart disease. In patients who underwent a Rastelli procedure, MR imaging displayed the conduit between the right ventricle and the pulmonary artery (Fig. 3) in the transverse and sagittal planes. The sagittal plane was found to be the most effective for showing the proximal anastomosis to the right ventricle and the distal anastomosis to the pulmonary artery. Narrowing of the conduit, stenosed origins of the right or left pulmonary arteries, and pseudoaneurysm were complications depicted with MR imaging. Compression of the graft by the sternum or other structures in an excessively narrowed space anterior to the right ventricle can be detected on sagittal MR images. Demonstration of valvular obstruction is limited with spinecho MR imaging. The Fontan procedure creates an anastomosis between the right atrium and pulmonary artery; it can generally be done either directly between the right atrial appendage and pulmonary artery or with graft material between the right

KERSTING-SOMMERHOFF

264

TABLE

3: Complications:

Comparison

ET AL.

AJR:155,

1990

of MR and Angiography

MR Imaging

Angiognaphy

Procedure

Specific Complications No. Studied

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August

No. Identified

No. Studied

No. Identified

Rastelli

4

4

2

2

Fontan

4

4

4

2

Senning Damus

1 1

1 1

1 1

1 0

15

15

9

9

Narrowing of conduit (n = 2), thnombosed conduit (n = 1), peniconduit abscess (n = 1) Aneunysmal dilatation of RA (n = 2), RA thnombus (n = 1), RV pseudoaneunysm(n=1)

Jatene

Note.-AA

=

right atrium;

RV

=

right ventricle;

PA

=

pulmonary

artery;

AVOT

Baffle stenosis (n = 1) Thrombus in left PA (n = 1) Aortic dilatation (n = 3), supravalvular aortic stenosis (n = 1), narrowing of RVOT (n = 6), proximal PA stenosis (n = 6) =

right ventricular

outflow

tract.

Fig. 4.-A-C, Transverse MR images of patient with tricuspid atresia and Fontan procedure. Right atrium (RA) is markedly enlarged, with atrial septum (arrowhead) bulging toward left and compression of entrance of pulmonary veins (arrow) into left atrium (LA). Conduit (C) originates from right atrium and enters the pulmonary artery (P). Phase-encoded imaging indicated slow flowing blood within a partially thrombosed pseudoaneurysm (asterisk) anterior to right ventricle. A = aorta.

atrium and pulmonary artery [1 9, 20]. Infrequently a valve may be included in the anastomosis. One recent report has described the effectiveness of MR imaging for the postoperative evaluation of the Fontan procedure [21 ], showing patency of the anastomosis and the size of the central and hilar pulmonary arteries. Complications [22] of this operation indude conduit obstruction, residual atrial septal defects, and systemic venous hypertension. Residual septal defects, however, may not be recognized with MR imaging and require Doppler or color flow echocardiography or angiography for detection and quantification. In the current study, an unusual complication, a pseudoaneurysm surrounding the anastomo-

sis, was characterized by a signal void within it due to flowing blood, along with some thrombus. This complication can be distinguished with MR imaging from hematoma and thrombus by using phase display images to identify the motion of blood [23]. The Damus-Kaye-Stansel procedure [1 6, 1 7], which is done for palliation of severe obstruction to aortic blood flow, entails an anastomosis that is constructed between the end of the transsected proximal main pulmonary artery and the side of the intact ascending aorta. Blood flow to the lungs is maintamed by a shunt from the aorta to the distal pulmonary artery or its main branches. Stenosis of the anastomosis is the most

AJR:155,

August

MR OF CYANOTIC

1990

CONGENITAL

HEART

DISEASE

265

Transverse (A-C) and sagittal of patient with transposition of great arteries and Senning procedure. Baffle (arFig. 5.-A-D, (D) MR images

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rowbeads)

Is visualized

on images

A-C

extend-

ing craniad to caudad. Pulmonary veins (straight solid arrows) enter portion of atrium outside baftIe. Baffle redirects flow from superior and inferior vena cava Into systemic atrial chamber, which drains (straight open arrow) into left vontricle (LV). Note narrowing of superior limb of baffle on transverse (asterisk) and on sagittal (curved arrow) Images. RV = right ventricle.

C

common complication [24]. MR images in the transverse and coronal planes seem to be the most effective for depicting the anastomosis (Fig. 2). However, further experience is needed to assess the role of MR imaging in the evaluation of this procedure. The Jatene procedure [1 4, 1 5, 25], or arterial switch openation, is an anatomic correction of transposition of the great vessels performed by transsecting both great arteries and connecting the proximal pulmonary artery to the sinus portion of the aorta and the proximal aorta to the sinus portion of the pulmonary artery. MR images in the transverse and sagittal planes are effective to assess the great vessel morphology after the Jatene procedure. Postoperatively, the aorta is situated posterior to the main pulmonary artery and between the right and the left pulmonary artery, sometimes resulting in diffuse as well as focal narrowing at the origin of the right and left pulmonary arteries (Fig. 1). This is shown with MR imaging. Because arteries are small in patients who undergo this procedure in the neonatal period, thin sections (3 mm) are useful. Other complications of the Jatene procedure are obstruction of the right ventricular outflow region (Fig. 1 C) and/or the supravalvular portion of the new pulmonary artery at the site where the coronary arteries were removed, and

D

supravalvular aortic stenosis [14, 1 5, 25]. Coronary arterial stenosis or occlusion also may occur after the Jatene procedune, but the diagnosis of these complications is beyond the current capability of MR imaging. The Senning procedure [26] is used to correct transposition of the great arteries by creating a baffle that divides the atrium into a systemic and pulmonary atrial chamber, rerouting the blood from the superior and inferior vena cava to the left ventricle. The blood from the pulmonary veins is channeled into the right ventricle, thus reestablishing a normal circulatory route. The baffle can be visualized on transverse and sagittal MR images, and the most frequent complication, obstruction of the superior limb of the baffle near the connection to the superior vena cava, was shown with MR imaging in this study (Fig. 5) and in a prior report [27]. However, depiction of baffle leaks may not be recognized with spin-echo MR imaging. This study shows that MR imaging is effective in the postoperative evaluation of patients with cyanotic congenital heart disease. It may obviate angiography in many cases, but further experience is needed to establish this notion. The role of MR imaging relative to echocardiography has yet to be determined. This was not the focus of the current study, but will be interesting to evaluate in the future. MR imaging

KERSTING-SOMMERHOFF

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266

depicts the great vessels and the effectively as intracardiac morphology,

supracardiac region as which makes it partic-

ularly

of patients.

useful

in the current

population

MR

studies

of infants have become feasible with reduction of slice thickness to 3 mm without a critical decrease in signal-to-noise ratio. However, in critically ill patients needing life-sustaining equipment, MR imaging may not be a realistic consideration, whereas echocardiography is effective. Cine MR imaging [28, 29], especially the new velocity-encoded technique, may significantly broaden the spectrum of MR diagnoses already

possible

by adding

information

on valvular

lesions

DW, et al. Magnetic

resonance

and flow

characteristics.

REFERENCES 1 . Higgins

CB, Byrd

patients 2. Fletcher

with congenital BD, Jacobstein

BF, Farmer

imaging

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Gated magnetic resonance

imaging of congenital

in AJ.

cardiac malformations.

Radiology 1984;150:137-140 3. Dicier D, Higgins CB, Fisher MA, Osaki L, Silverman NH, Cheitlin MD. Congenital heart disease: gated MA imaging in 72 patients. Radiology 1986;158:27-235 4. Mirowitz SA, Gutierrez FA, Canter CE, Vannier MW. Tetralogy of Fallot: MR findings.Radiology 1989;171:207-212 5. Link KM, Hen-era MA, D’Souza VJ, Formanek AG. MA imaging of Ebstein anomaly: results in four cases. AiR 1988;150:363-367 6. Akins EW, Martin TD, Alexander JA, et al. MR imaging of double outlet right ventricle. AJR 1989;152:128-130 7. Kersting-Sommerhoff BA, Diethelm L, Teitel DF, et al. Magnetic resonance imaging of congenital heart disease: sensitivity and specificity using receiver operating characteristic curve analysis. Am Heart J 1989;1 88: 155-1 63 8. Kerstlng-Sommerhoff BA, Sechtem UP, Higgins CB. Evaluation of pulmonary blood supply by nuclear magnetic resonance imaging in patients with pulmonary atresia. J Am coil Cardiol 1988;1 1:166-171 9. Formanek AG, Witcofski AL, D’Souza VJ, Link KM, Karstaedt N. MR imaging of the central pulmonary arterial tree in conotruncal malformation. AJR 1986;147:1127-1131 10. Fletcher BD, Jacobstein MD. MAI of congenital anomalies of the great arteries. AJR 1986;146:941-948 11. von Schulthess GK, Higashino SM, Higgins 55, et al. Coarctation of the

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Evaluation of surgical procedures for cyanotic congenital heart disease by using MR imaging.

ECG-gated MR imaging has been shown to be effective for the diagnosis of congenital heart disease. In this study, we assessed its role in the postoper...
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