ST elevation myocardial infarction coronary artery bypass grafting

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Despite the guidelines, emergency bypass surgery for the treatment of an acute myocardial infarction (MI) is less common then PCI or medical management. In an analysis of patients in the U.S. National Registry of Myocardial Infarction (NRMI) from January 1995 to May 2004, the percentage of patients with cardiogenic shock treated with primary PCI rose from 27.4% to 54.4%, while the increase in CABG treatment was only from 2.1% to 3.2%.[1]

Coronary Artery Bypass Surgery in STEMI

Coronary artery bypass surgery during mobilization (freeing) of the right coronary artery from its surrounding tissue, adipose tissue (yellow). The tube visible at the bottom is the aortic cannula (returns blood from the HLM). The tube above it (obscured by the surgeon on the right) is the venous cannula (receives blood from the body). The patient's heart is stopped and the aorta is cross-clamped. The patient's head (not seen) is at the bottom.

Emergency coronary artery bypass graft surgery (CABG) is usually undertaken to simultaneously treat a mechanical complication, such as a ruptured papillary muscle, or a ventricular septal defect, with ensueing cardiogenic shock.[2] In uncomplicated MI, the mortality rate can be high when the surgery is performed immediately following the infarction.[3] If this option is entertained, the patient should be stabilized prior to surgery, with supportive interventions such as the use of an intra-aortic balloon pump.[4] In patients developing cardiogenic shock after a myocardial infarction, both PCI and CABG are satisfactory treatment options, with similar survival rates.[5][6]

Coronary artery bypass surgery involves an artery or vein from the patient being implanted to bypass narrowings or occlusions on the coronary arteries. Several arteries and veins can be used, however internal mammary artery grafts have demonstrated significantly better long-term patency rates than great saphenous vein grafts.[7] In patients with two or more coronary arteries affected, bypass surgery is associated with higher long-term survival rates compared to percutaneous interventions.[8] In patients with single vessel disease, surgery is comparably safe and effective, and may be a treatment option in selected cases.[9] Bypass surgery has higher costs initially, but becomes cost-effective in the long term.[10] A surgical bypass graft is more invasive initially but bears less risk of recurrent procedures (but these may be again minimally invasive).


2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease

Recommendations for duration of DAPT in patients undergoing CABG

Class I
"1. In patients treated with DAPT after coronary stent implantation who subsequently undergo CABG, P2Y12 inhibitor therapy should be resumed postoperatively so that DAPT continues until the recommended duration of therapy is completed.(Level of Evidence: C-EO)"
"2. In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS(Level of Evidence: C-EO)"
"2. In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)"
Class IIb
"1. In patients with SIHD, DAPT (with clopidogrel initiated early postoperatively) for 12 months after CABG may be reasonable to improve vein graft patency (Level of Evidence: B-NR)"

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary(DO NOT EDIT)[11]

Coronary Artery Bypass Graft Surgery: Recommendations(DO NOT EDIT)

CABG in Patients With STEMI

Class I
"1. Urgent CABG is indicated in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features(Level of Evidence: B)"
"2. CABG is recommended in patients with STEMI at time of operative repair of mechanical defects (Level of Evidence: B)"
Class IIa
"1. The use of mechanical circulatory support is reasonable in patients with STEMI who are hemodynamically unstable and require urgent CABG (Level of Evidence: C)"
Class IIb
"1. Emergency CABG within 6 hours of symptom onset may be considered in patients with STEMI who do not have cardiogenic shock and are not candidates for PCI or fibrinolytic therapy (Level of Evidence: C)"

Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents

Class I
"1. Aspirin should not be withheld before urgent CABG (Level of Evidence: C)"
"2. Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible(Level of Evidence: B)"
"3. Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG (Level of Evidence: B)"
"4. Abciximab should be discontinued at least 12 hours before urgent CABG (Level of Evidence: B)"
Class IIb
"1. Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding (Level of Evidence: B)"
"2. Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding (Level of Evidence: C)"

2013 Revised and 2009 and 2004 ACC/AHA Guidelines for Management of Patients with ST-Elevation Myocardial Infarction and Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[12][13][14]

PCI in patients with Prior Coronary Bypass Surgery (DO NOT EDIT)[13]

Class I
"1. When technically feasible, PCI should be performed in patients with early ischemia (usually within 30 days) after CABG. (Level of Evidence: B)"
"2. It is recommended that distal embolic protection devices be used when technically feasible in patients undergoing PCI to saphenous vein grafts. (Level of Evidence: B)"
Class III (No Benefit)
"1. PCI is not recommended in patients with prior CABG for chronic total vein graft occlusions.(Level of Evidence: B)"
"2. PCI is not recommended in patients who have multiple target lesions with prior CABG and who have multi-vessel disease failure of multiple SVGs, and impaired LV function unless repeat CABG poses excessive risk due to severe comorbid conditions. (Level of Evidence: B)"
Class IIa
"1. PCI is reasonable in patients with ischemia that occurs 1 to 3 years after CABG and who have preserved LV function with discrete lesions in graft conduits. (Level of Evidence: B)"
"2. PCI is reasonable in patients with disabling angina secondary to new disease in a native coronary circulation after CABG. (If angina is not typical, objective evidence of ischemia should be obtained.) (Level of Evidence: B)"
"3. PCI is reasonable in patients with diseased vein grafts more than 3 years after CABG. (Level of Evidence: B)"
"4. PCI is reasonable when technically feasible in patients with a patent left internal mammary artery graft who have clinically significant obstructions in other vessels. (Level of Evidence: C)"

PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion (DO NOT EDIT) [14]

Class I
"1. Emergency or urgent CABG in patients with STEMI should be undertaken in the following circumstances: "
"a. Failed PCI with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery. (Level of Evidence: B)"
"b. Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, have a significant area of myocardium at risk, and are not candidates for PCI or fibrinolytic therapy. (Level of Evidence: B)"
"c. At the time of surgical repair of post infarction ventricular septal rupture (VSR) or mitral valve insufficiency. (Level of Evidence: B)"
"d. Cardiogenic shock in patients less than 75 years old with ST elevation or LBBB or posterior MI who develop shock within 36 hours of STEMI, have severe multivessel or left main disease, and are suitable forrevascularization that can be performed within 18 hours of shock, unless further support is futile because of the patient’s wishes or contraindications/unsuitability for further invasive care. (Level of Evidence: A)"
"e. Life-threatening ventricular arrhythmias in the presence of greater than or equal to 50% left main stenosis and/or triple-vessel disease. (Level of Evidence: B)"
Class III (Harm)
"1. Emergency CABG should not be performed in patients with persistent angina and a small area of risk who are hemodynamically stable. (Level of Evidence: C)"
"1. Emergency CABG should not be performed in patients with successful epicardial reperfusion but unsuccessful microvascular reperfusion. (Level of Evidence: C)"
Class IIa
"1. Emergency CABG can be useful as the primary reperfusion strategy in patients who have suitable anatomy and who are not candidates for fibrinolysis or PCI and who are in the early hours (6 to 12 hours) of an evolvingSTEMI, especially if severe multivessel or left main disease is present. (Level of Evidence: B)"
"2. Emergency CABG can be effective in selected patients 75 years or older with ST elevation, LBBB, or posterior MI who develop shock within 36 hours of STEMI, have severe triple-vessel or left main disease, and are suitable for revascularization that can be performed within 18 hours of shock. Patients with good prior functional status who are suitable for revascularization and agree to invasive care may be selected for such an invasive strategy. (Level of Evidence: B)"

CABG in Patients With STEMI (DO NOT EDIT)[12]

Class I
"1. Urgent CABG is indicated in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features.[15][16][17](Level of Evidence: B)"
"2. CABG is recommended in patients with STEMI at time of operative repair of mechanical defects.[17][18][19][20][21](Level of Evidence: B)"
Class IIa
"1. The use of mechanical circulatory support is reasonable in patients with STEMI who are hemodynamically unstable and require urgent CABG. (Level of Evidence: C)"
Class IIb
"1. Emergency CABG within 6 hours of symptom onset may be considered in patients with STEMI who do not have cardiogenic shock and are not candidates for PCI or fibrinolytic therapy. (Level of Evidence: C)"

Timing of Urgent CABG in Patients With STEMI in Relation to Use of Antiplatelet Agents (DO NOT EDIT)[12]

Class I
"1. Aspirin should not be withheld before urgent CABG.[22](Level of Evidence: C)"
"2. Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible.[23][24][25][26][17](Level of Evidence: B)"
"3. Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG.[17][27](Level of Evidence: B)"
"4. Abciximab should be discontinued at least 12 hours before urgent CABG.[17](Level of Evidence: B)"
Class IIb
"1. Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding. [24][28][17][29](Level of Evidence: B)"
"2. Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.(Level of Evidence: C)"

Sources

  • The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [30]
  • The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [31]
  • 2013 Revised ACC/AHA Guidelines for Management of Patients with ST-Elevation Myocardial Infarction and Guidelines for Percutaneous Coronary Intervention[12]

References

  1. ↑ Babaev A, Frederick PD, Pasta DJ, Every N, Sichrovsky T, Hochman JS (2005). "Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock". JAMA. 294 (4): 448–54. doi:10.1001/jama.294.4.448. PMID 16046651. Unknown parameter |month= ignored (help)
  2. ↑ Townsend, Courtney M. (2004). Sabiston Textbook of Surgery - The Biological Basis of Modern Surgical Practice. Philadelphia, Pennsylvania: Elsevier Saunders. p. 1871. ISBN 0-7216-0409-9. Unknown parameter |coauthors= ignored (help)
  3. ↑ Kaul TK, Fields BL, Riggins SL, Dacumos GC, Wyatt DA, Jones CR (1995). "Coronary artery bypass grafting within 30 days of an acute myocardial infarction". Ann. Thorac. Surg. 59 (5): 1169–76. PMID 7733715. Unknown parameter |month= ignored (help)
  4. ↑ Creswell LL, Moulton MJ, Cox JL, Rosenbloom M (1995). "Revascularization after acute myocardial infarction". Ann. Thorac. Surg. 60 (1): 19–26. PMID 7598589. Unknown parameter |month= ignored (help)
  5. ↑ White HD, Assmann SF, Sanborn TA; et al. (2005). "Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial". Circulation. 112 (13): 1992–2001. doi:10.1161/CIRCULATIONAHA.105.540948. PMID 16186436. Unknown parameter |month= ignored (help)
  6. ↑ Hochman JS, Sleeper LA, Webb JG; et al. (2006). "Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction". JAMA. 295 (21): 2511–5. doi:10.1001/jama.295.21.2511. PMC 1782030. PMID 16757723. Unknown parameter |month= ignored (help)
  7. ↑ Raja SG, Haider Z, Ahmad M, Zaman H (2004). "Saphenous vein grafts: to use or not to use?". Heart Lung Circ. 13 (4): 403–9. doi:10.1016/j.hlc.2004.04.004. PMID 16352226. Unknown parameter |month= ignored (help)
  8. ↑ Hannan EL, Racz MJ, Walford G; et al. (2005). "Long-term outcomes of coronary-artery bypass grafting versus stent implantation". N. Engl. J. Med. 352 (21): 2174–83. doi:10.1056/NEJMoa040316. PMID 15917382. Unknown parameter |month= ignored (help)
  9. ↑ Bourassa MG (2000). "Clinical trials of coronary revascularization: coronary angioplasty vs. coronary bypass grafting". Curr. Opin. Cardiol. 15 (4): 281–6. PMID 11139092. Unknown parameter |month= ignored (help)
  10. ↑ Hlatky MA, Boothroyd DB, Melsop KA; et al. (2004). "Medical costs and quality of life 10 to 12 years after randomization to angioplasty or bypass surgery for multivessel coronary artery disease". Circulation. 110 (14): 1960–6. doi:10.1161/01.CIR.0000143379.26342.5C. PMID 15451795. Unknown parameter |month= ignored (help)
  11. ↑ American College of Emergency Physicians. Society for Cardiovascular Angiography and Interventions. O'Gara PT, Kushner FG, Ascheim DD, Casey DE; et al. (2013). "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (4): 485–510. doi:10.1016/j.jacc.2012.11.018. PMID 23256913.
  12. ↑ 12.0 12.1 12.2 12.3 O'Gara PT, Kushner FG, Ascheim DD; et al. (2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e3182742c84. PMID 23247303. Unknown parameter |month= ignored (help)
  13. ↑ 13.0 13.1 Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO (2009). "2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Journal of the American College of Cardiology. 54 (23): 2205–41. doi:10.1016/j.jacc.2009.10.015. PMID 19942100. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  14. ↑ 14.0 14.1 Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M; et al. (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)". Circulation. 110 (5): 588–636. doi:10.1161/01.CIR.0000134791.68010.FA. PMID 15289388.
  15. ↑ Caracciolo EA, Davis KB, Sopko G; et al. (1995). "Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience". Circulation. 91 (9): 2325–34. PMID 7729018. Unknown parameter |month= ignored (help)
  16. ↑ Hochman JS, Buller CE, Sleeper LA; et al. (2000). "Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?". J. Am. Coll. Cardiol. 36 (3 Suppl A): 1063–70. PMID 10985706. Unknown parameter |month= ignored (help)
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 Hillis LD, Smith PK, Anderson JL; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 124 (23): e652–735. doi:10.1161/CIR.0b013e31823c074e. Unknown parameter |month= ignored (help)
  18. ↑ Menon V, Webb JG, Hillis LD; et al. (2000). "Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?". J. Am. Coll. Cardiol. 36 (3 Suppl A): 1110–6. PMID 10985713. Unknown parameter |month= ignored (help)
  19. ↑ Slater J, Brown RJ, Antonelli TA; et al. (2000). "Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?". J. Am. Coll. Cardiol. 36 (3 Suppl A): 1117–22. PMID 10985714. Unknown parameter |month= ignored (help)
  20. ↑ Tavakoli R, Weber A, Vogt P, Brunner HP, Pretre R, Turina M (2002). "Surgical management of acute mitral valve regurgitation due to post-infarction papillary muscle rupture". J. Heart Valve Dis. 11 (1): 20–5, discussion 26. PMID 11843502. Unknown parameter |month= ignored (help)
  21. ↑ Thompson CR, Buller CE, Sleeper LA; et al. (2000). "Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we use emergently revascularize Occluded Coronaries in cardiogenic shocK?". J. Am. Coll. Cardiol. 36 (3 Suppl A): 1104–9. PMID 10985712. Unknown parameter |month= ignored (help)
  22. ↑ Jacob M, Smedira N, Blackstone E, Williams S, Cho L (2011). "Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery". Circulation. 123 (6): 577–83. doi:10.1161/CIRCULATIONAHA.110.957373. PMID 21282503. Unknown parameter |month= ignored (help)
  23. ↑ Kim JH, Newby LK, Clare RM; et al. (2008). "Clopidogrel use and bleeding after coronary artery bypass graft surgery". Am. Heart J. 156 (5): 886–92. doi:10.1016/j.ahj.2008.06.034. PMID 19061702. Unknown parameter |month= ignored (help)
  24. ↑ 24.0 24.1 Held C, Asenblad N, Bassand JP; et al. (2011). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial". J. Am. Coll. Cardiol. 57 (6): 672–84. doi:10.1016/j.jacc.2010.10.029. PMID 21194870. Unknown parameter |month= ignored (help)
  25. ↑ Nijjer SS, Watson G, Athanasiou T, Malik IS (2011). "Safety of clopidogrel being continued until the time of coronary artery bypass grafting in patients with acute coronary syndrome: a meta-analysis of 34 studies". Eur. Heart J. 32 (23): 2970–88. doi:10.1093/eurheartj/ehr151. PMID 21609973. Unknown parameter |month= ignored (help)
  26. ↑ Barker CM, Anderson HV (2009). "Acute coronary syndromes: don't bypass the clopidogrel". J. Am. Coll. Cardiol. 53 (21): 1973–4. doi:10.1016/j.jacc.2009.02.029. PMID 19460610. Unknown parameter |month= ignored (help)
  27. ↑ Dyke CM, Bhatia D, Lorenz TJ; et al. (2000). "Immediate coronary artery bypass surgery after platelet inhibition with eptifibatide: results from PURSUIT. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrelin Therapy". Ann. Thorac. Surg. 70 (3): 866–71, discussion 871–2. PMID 11016325. Unknown parameter |month= ignored (help)
  28. ↑ Shim JK, Choi YS, Oh YJ, Bang SO, Yoo KJ, Kwak YL (2007). "Effects of preoperative aspirin and clopidogrel therapy on perioperative blood loss and blood transfusion requirements in patients undergoing off-pump coronary artery bypass graft surgery". J. Thorac. Cardiovasc. Surg. 134 (1): 59–64. doi:10.1016/j.jtcvs.2007.03.013. PMID 17599487. Unknown parameter |month= ignored (help)
  29. ↑ Maltais S, Perrault LP, Do QB (2008). "Effect of clopidogrel on bleeding and transfusions after off-pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery". Eur J Cardiothorac Surg. 34 (1): 127–31. doi:10.1016/j.ejcts.2008.03.052. PMID 18455412. Unknown parameter |month= ignored (help)
  30. ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter |month= ignored (help)
  31. ↑ Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter |month= ignored (help)


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