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Journal of the American College of Cardiology Vol. 60, No. 15, 2012© 2012 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00

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STATE-OF-THE-ART PAPER

Surgical Approaches to Mitral Regurgitation

Donald D. Glower, MD

Durham, North Carolina

Surgical approaches to correct mitral regurgitation (MR) have evolved over 50 years and form much of the basisfor percutaneous approaches to the mitral valve. Surgical mitral repairs have been more durable with use of an-nuloplasty, but recurrent regurgitation not resulting in reoperation can occur. The mitral leaflets may be resectedor augmented, with recent trends to preserve leaflet coaptation surfaces if possible. Mitral chords tend to bereplaced or transferred instead of being shortened. Mitral replacement still has a role when more durable andreliable than repair. Surgical incisions have varied from full sternotomy down to percutaneous access only, withless invasiveness usually requiring a trade-off versus effectiveness or ease of application. Less invasive optionsin treating MR may encourage higher-risk patients to seek anatomic therapy, whether surgical or percutaneous.Rapidly evolving technology will continue to be a dominant driver of surgical approaches to MR, with increasingoverlap and interaction with percutaneous approaches. (J Am Coll Cardiol 2012;60:1315–22) © 2012 by theAmerican College of Cardiology Foundation

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2011.11.081

A successful surgical approach to mitral regurgitation (MR)was first reported as early as 1951 by Bailey et al. (1). Sincethat time, surgical and percutaneous interventions to treatMR have evolved tremendously. At present, percutaneousmeans to repair the mitral valve (MV) or even replacing theMV appears to be on the horizon and promises to dramat-ically alter the treatment and selection of patients with MR.The purpose of this review is to summarize current surgicalpractice in treating MR, and to suggest where treatment forMR might be heading in the near future.

A Brief History

Bailey et al. (1) first approached MR through a leftthoracotomy, and the mitral annulus was narrowed byexternal constriction of the base of the heart in an approachnot unlike recent attempts to perform mitral annuloplastythrough the coronary sinus. Lillehei et al. (2) performed thefirst direct suture annuloplasty of the MV in 1957 usingcardiopulmonary bypass (CPB), and Starr and Edwards (3)first replaced the mitral valve using a commercially success-ful device in 1960. Today, surgery for MR is performed in40,000 patients each year in the United States. One shouldbe aware that, in this age of rapidly advancing percutaneoustechnology that is used both by surgeons and nonsurgicalinterventionists, the term “surgical” could, in fact, be con-sidered an anachronism.

From the Department of Surgery, Duke University, Durham, North Carolina. Dr.Glower has received a research grant without funding from Abbott; and researchgrants from St. Jude Medical and Edwards Lifesciences.

Manuscript received July 11, 2011; revised manuscript received November 17,2011, accepted November 22, 2011.

ded From: http://content.onlinejacc.org/pdfAccess.ashx?url=/data/Journals

Anatomic Approaches to the Mitral Valve

The MV sits between the left atrium and the left ventricle, andcan therefore be approached from either of those 2 chambers.At present, nearly all surgical access to the MV is through theleft atrium. Rarely, the MV is approached through the leftventricle or the aortic root.

The left ventricular apex has previously been used toperform closed mitral commissurotomy. More recently, atransapical approach has been used to replace the MV usinga percutaneous, stented aortic valve device in a patient withfailed biological mitral prosthesis (4). Mitral chordae havealso been replaced through a transapical approach (5). Atransventricular approach to MV repair has been describedin patients having left ventriculotomy performed for leftventricular aneurysm (6,7). The transventricular approach atthe time of ventricular aneurysm repair is best suited forsimple replacement or commissural annuloplasty.

Surgical Incisions to Access the Mitral Valve

To access the anatomic approaches to MR listed above,several skin incisions have been used, including sternotomy,thoracotomy, or percutaneous access. With wide use ofCPB in the 1960s, median sternotomy replaced rightthoracotomy as the primary surgical approach to treat MRdue to reliability, speed, and excellent access to most of theheart. The skin incision for full sternotomy can be made assmall as 8 cm and can be a cosmetic inframammary incisionin women. Disadvantages to median sternotomy includeblood loss, slow sternal healing, potential for sternal non-union, and morbidity and mortality from deep sternal
infection, which may affect 1% to 2% of cases.
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Because of patient demand,marketing forces, and improvedtechnology, the percentage ofMV operations done with mini-mally invasive incisions otherthan sternotomy have steadily in-creased to 20% of all mitral op-erations in 2008 (8). Althoughlarge, controlled studies are lack-

ing, minimally invasive approaches to the MV have beenassociated with faster recovery, less blood loss, and lessinfection (9). Disadvantages can include increased operativedifficulty, increased procedure and pump times, limitedaccess to the rest of the heart, potentially more equipmentcosts, and possibly more stroke due to greater use of femoralarterial cannulation for CPB (8,10).

Partial superior sternotomy has been the most popularminimally invasive approach to the MV since the work ofGillinov and Cosgrove (11). Before median sternotomy,mitral operation for regurgitation was performed throughright thoracotomy by Lillehei et al. in 1956 (2). Many seriesnow describe smaller right thoracotomies termed “mini”thoracotomy or “port access” (12,13), with an incisionlength somewhere between full thoracotomy (20 cm) and anendoscopic port (0.5 cm to 1.5 cm).

Transapical access to the MV can be obtained through asmall left anterior thoracotomy and has been reported forvalve-in-valve redo mitral replacement using the Sapien(Edwards Lifesciences, Irvine, California) percutaneousvalve device (4). Inferior partial sternotomy, right paraster-nal incision, and left thoracotomy have all seen limited usedue to worse exposure or more chest trauma than otherapproaches.

To patients and to most surgeons, the term “totallyendoscopic” has generally implied no incision larger thanthe port for a 0.5 to 1.5 cm endoscope. However, in cardiacsurgical circles, “totally endoscopic” has also been used todescribe a right minithoracotomy in the 4 cm to 8 cm rangewith no rib spreading (14). To avoid confusion of termi-nology, Chitwood et al. (15) proposed a classification systemwhereby minimally invasive approaches are categorized, asin Table 1, on the basis of whether the surgeon uses directvision, thoracoscopic visualization, or robotics for any por-tion of the surgery. Totally endoscopic MV surgery with nochest incision �1.5 cm generally requires robotic assistanceand groin incision for femoral arterial and venous access.

Abbreviationsand Acronyms

CPB � cardiopulmonarybypass

LV � left ventricular

MV � mitral valve

MR � mitral regurgitation

Levels of Minimally Invasive Mitral Surgery*Table 1 Levels of Minimally Invasive Mitral Surgery*

Direct vision mini-incision (10 to 12 cm)

Video-assisted microincision (4 to 6 cm)

Video directed or robotic assisted (3 to 4 cm)

Robotic telemanipulation (1 cm)

Percutaneous

*Modified from Chitwood and Rodriguez (15).


Robotic assistance for MV surgery as currently practicedfirst became available in 2000 and has been championed byMohr, Chitwood, and others (16). The current daVincirobot (Intuitive Surgical, Sunnyvale, California) is aremotely controlled servo where 1 or 2 operating surgeonssit at a console away from the patient and manipulate 2 to4 servo-controlled arms. The robotic arms offer scalingwhere the instruments move smaller distances than theoperator’s hands, tremor reduction, stereoscopic vision,and �10 magnification. An additional bedside surgeon isneeded to load the various robotic arms, pass sutures inand out of the wound, cut, tie, and perform manipulationnot done by the robotic arms. The greatest merit torobotic assistance comes when surgical incisions aresufficiently small to prevent facile operating directlythrough the minithoracotomy (generally 4 cm or less)(Table 1). Disadvantages of a robotic approach includeequipment cost and complexity, size and bulk of currenttechnology, and difficulty with knot tying.

Percutaneous Access to the Mitral Valve

The only well-documented percutaneous approach to MRin the United States today is the MitraClip (AbbottLaboratories, Abbott Park, Illinois), which remains in trialin the United States (17). This is a 13-mm clip that isapplied to attach the anterior and posterior mitral leafletstogether, similar to the surgical edge-to-edge surgical repairtechnique (see following discussion). The MitraClip isplaced from the femoral vein and through the interatrialseptum.

Initial results of the North American EVEREST (Effi-cacy of Vasopressin Antagonism in Heart Failure: OutcomeStudy With Tolvaptan) trial and the European experienceshow that MitraClip can reduce MR, reduce left ventricularvolume, and improve quality of life and heart failuresymptoms at 1 to 2 years (17). Limitations of the MitraClipinclude the requirement of a localized regurgitant jet,technical challenges of the transseptal approach, and lack ofresults beyond 2 to 3 years.

Concern has been voiced that MitraClip placementwithout ring annuloplasty may duplicate surgical reports ofhigher recurrent MR due to lack of an annuloplasty ring(11). Conversely, Maisano et al. (18) reported a series ofpatients with surgical edge-to-edge repair without ring withfreedom from reoperation or �2� MR of 80% at 12 years.Many of these patients had annular calcification, which mayhave effectively served as an annuloplasty.

An additional concern voiced is that MitraClip place-ment may increase the likelihood of needing subsequentreplacement instead of repair. This concern is supported bydata from the EVEREST trial and from Germany, wherereplacement rates were higher than expected in patientsrequiring surgery after MitraClip placement (19,20). None-theless, more data will be needed, as these are small series
with short term follow-up and a relatively inexperienced
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1317JACC Vol. 60, No. 15, 2012 GlowerOctober 9, 2012:1315–22 Surgical Approaches to Mitral Regurgitation

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surgical community regarding repair of valves with aMitraClip in place (21). Most would interpret available dataas supporting the MitraClip in patients who are high riskfor surgery and have limited life expectancy (22).

Mitral Repair Techniques

Annuloplasty. Direct vision mitral annuloplasty was re-ported by Lillehei et al. in 1958 (2). Many studies haveshown that mitral repairs employing some form of ringmitral annuloplasty have better durability than do ringlessrepairs (Fig. 1A) (23). This observation may result from thefact that nearly all valves with significant chronic MR havesome degree of annular dilation. In addition, unlike normalhearts, failing hearts have permanent plasticity where theheart forever continues to deform favorably or unfavorablyunder changing loading conditions. That is not to say thatall ringless repairs fail (24), only that recurrent MR is morelikely if annuloplasty is not performed.

Mitral annuloplasty can be categorized as complete orpartial annuloplasty, as suture annuloplasty versus ringannuloplasty, and as rigid versus flexible ring annuloplasty.Partial annuloplasty and suture annuloplasty may be usefulin children because of the potential for the unsuturedannulus to grow and avoid mitral stenosis. For myxomatousMVs with prolapse, both rigid and flexible rings havesimilarly good results. Flexible rings theoretically have theadvantage of allowing the base of the heart to contract,whereas rigid rings are more resistant to central leakage inpatients with left ventricular (LV) dilation. In patients withfunctional MR, the net advantages of the complete rigidring exceed those of the flexible ring (25). One series ofprolapse patients suggests that flexible rings may have lessring dehiscence than rigid rings (26). Rigid rings may givemore predictable geometry after repair for lower volumesurgeons. The relative role for different ring shapes is

Figure 1 Common Established Surgical Techniques Used to Co

(A) Ring annuloplasty. (B) Quadrangular resection and sliding leaflet plasty. (C) Chord


unclear, except that narrowing the septal-free wall diameteris important in functional regurgitation (27). Concern hasbeen expressed that smaller under-sized (24 mm or 26 mm)mitral rings could cause mitral stenosis and/or LV diastolicdysfunction (28). However, most agree that a 4 to 6 mm Hgmean gradient across a 24 to 26 mm ring is of lessphysiologic importance than is recurrent MR. Large seriessuggest that both partial and complete rings can providegood results in myxomatous prolapse valves. Complete,rigid rings, again, are considered by most surgeons to havethe best results in patients with functional MR (25).Leaflet resection. In addition to the ring annuloplasty,Carpentier et al. (29) made the major contribution ofsuggesting quadrangular resection of redundant posteriorleaflet segments (Fig. 1B). By undermining the remainingposterior leaflet segments, more than one-half of the pos-terior leaflet can be resected. This “sliding leaflet plasty”reduces the height (annulus to free edge) of the remainingposterior leaflet to �1.5 cm to prevent anterior leafletsystolic anterior motion. A small triangular resection may beused for smaller segments of the posterior leaflet. Althoughposterior leaflet resection has been shown to be veryreproducible, concern has surfaced that, in some patients,resectional techniques can decrease coaptation between theremaining posterior and anterior leaflets with subsequentrecurrent regurgitation due to further valve remodeling (26).Equilateral triangular resections of the anterior leaflet up toapproximately 1 cm in length can be used to correct focalanterior leaflet pathology (29).Chordal replacement, shortening. Ruptured, elongated,or shortened primary chords can be replaced without leafletresection. Normal chords can be transferred from secondarychords on the same leaflet or from primary chords on theopposing posterior leaflet (Fig. 1C). Increasingly, surgeonshave been replacing chords with polytetrafluoroethylene

Mitral Regurgitation

sfer. (D) Cleft closure. (E) Mitral replacement. Figure illustration by Craig Skaggs.

rrect

al tran

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suture (Fig. 2A) (30,31). Disadvantages of chordal replace-ment remain difficulty getting chordal length right andstable chordal attachment to the mitral leaflet and papillarymuscle.Leaflet augmentation or patch. Leaflet perforations havelong been patched using fixed native or bovine pericardium.Recently, restricted posterior leaflets have been patch aug-mented with some early success (Fig. 2B) (32). Long-termresults of leaflet patching are unclear in any situation.Cleft closure. Large leaflet clefts can occur with congenitalleaflet variants and are easily closed (Fig. 1D). Manyregurgitant MVs of any etiology can have abnormally openclefts due to annular dilation. These also can be suturedclosed to improve the repair.Edge-to-edge repair. Alfieri et al. (33) described a tech-nique first applied in 1992 in which leaflet malappositionwas corrected by suturing the anterior leaflet to theposterior leaflet in 1 place (Fig. 2C). The name “edge-to-edge” is a bit of a misnomer because ideally 3 mm to5 mm of each leaflet edge is opposed to the other leafletto force an area with a coaptation height of at least 3 mmto 5 mm. The edge-to-edge repair also can preventsystolic anterior motion of the anterior leaflet with LVoutflow tract obstruction by fixing the anterior leaflet tothe posterior leaflet (34). The edge-to-edge technique isgenerally used in conjunction with annuloplasty, butannuloplasty may be omitted in patients with hypertro-phic obstructive cardiomyopathy to minimize outflowtract obstruction (24). Edge-to-edge repair may not beadvisable in patients with rheumatic or stiffened leafletsor in patients with ring size �30 mm to avoid significantmitral stenosis. Limited results up to 10 years have been

Figure 2 Newer Surgical Techniques Used to Repair Regurgitan

(A) chordal replacement. (B) Posterior leaflet augmentation. (C) Edge-to-edge Alfie(D) Papillary muscle approximation. (E) Posterior wall reduction. Figure illustration

published with edge-to-edge repairs (24).


Ventricular repairs. Functional MR results from LVdilation. As a result, many authors have attemptedventricular or papillary muscle based repairs for func-tional MR along with mitral annuloplasty. Posterior wallplication (Fig. 2E) (35) and papillary muscle approxima-tion (Fig. 2D) (36) have both been reported to have goodearly results.

Results of Mitral Repair

Many factors can diminish the likelihood of mitral repairversus mitral replacement. Factors predicting replacementinstead of repair include low surgeon/institution volume,anterior leaflet pathology or bileaflet pathology, rheumaticetiology, infectious etiology, functional/ischemic etiology,and secondary leaflet changes such as scarring and/orcalcification (37). Although surgeons are under pressure tohave high rates of MV repair, recurrent MR can often beworse than the consequences of initial mitral replacement.“Good” repairs are generally better than replacement, butreplacement is generally better than “bad” repair withrecurrent regurgitation.

Freedom from reoperation at 20 to 25 years has been 90%in several large series (38–42) (Fig. 3). Factors such asanterior leaflet pathology or bileaflet pathology, rheumaticetiology, infectious etiology, functional/ischemic etiology,secondary leaflet changes such as scarring and/or calcifica-tion, lack of ring annuloplasty, and low volume for thesurgeon or institution tend to predict a higher likelihood ofreoperation (43).

Only recently have several large studies with a high degree ofechocardiography follow-up reported residual/recurrent MR aftermitral repair (26,40,42,44,45). The goal of surgical mitral repair

tral Valve

h (valve shown in diastole with double orifice).ig Skaggs.

t Mi

ri stitcby Cra

has been to leave the operating room with no more than

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mild residual MR by transesophageal echocardiographyunder anesthesia, as more than that has been associated witha higher rate of reoperation (46). At 10 years, MR has beenreported as at least moderate in 15% to 30% of patientshaving myxomatous valve repaired and severe in 5% to 10%(Fig. 4) (26,40,42,44,45).

For patients with functional or ischemic etiology, mod-erate or more regurgitation has been reported in 20% to 30%of patients at 1 to 5 years (44), prompting some surgeons toconsider mitral replacement or not addressing the MV insome patients (47). Others have criticized these studiesbecause of their use of full-sized, partial, flexible rings,which many now think allow more unfavorable annularremodeling (48). Use of complete, rigid, and under-sized orreduced septal-free wall diameter rings is now favored forrepair of ischemic or functional MR by many authors (48).

Mitral Replacement

Mitral replacement had long been the standard surgicaltreatment for MR (Fig. 1E), but mitral repair is now favoredover replacement in most patients. Advantages of mitralrepair versus replacement include avoidance of mandatoryanticoagulation, potentially better durability than biopros-theses, less impairment of LV function, less risk of LVposterior wall rupture (ventricular-annular disruption), andlower early and late mortality (49). Some of the advantagesof mitral repair over replacement come from the fact thatprevious mitral replacements tended to resect all of thenative MV chords. However, many studies have now shownthat mitral replacement with chordal preservation nearlyeliminates the risk of ventricular-annular disruption andminimizes impairment of LV function (50). Indeed, to date,no definitive data exist to say that mitral repair has an

Figure 3 Freedom From Reoperation After Mitral Valve Repair

Data from Lawrie et al. (blue line) (26), Braunberger et al. (yellow line) (39),Salvador et al. (purple line) (40), David et al. (red line) (41), and Flameng et al.(green line) (42).

advantage over chordal sparing mitral replacement, beyond


the inherent issues of anticoagulation versus limited biolog-ical durability.

Mitral replacement does have some inherent advantagesover repair. The elimination of MR is more certain withreplacement, especially when the quality of repair is inquestion. Elderly patients with limited life expectancy mayhave little issue with anticoagulation therapy or limiteddurability using modern bioprostheses. Mechanical mitralreplacement with anterior leaflet resection was described byKrajcer et al. (51) for hypertrophic obstructive cardiomyop-athy with effective elimination of both MR and LV outflowtract obstruction. Some researchers believe that MV re-placement may be a more effective therapy than mitralrepair for patients with ischemic MR, especially if themitral leaflet is restricted �1 cm below the plane of themitral annulus (52).

The selection of biological versus mechanical prosthesesfor mitral replacement remains controversial. The last de-cade has seen a significant shift toward biological mitralprostheses due to an aging population, hope that reopera-tion can be less invasive or percutaneous, patient dislikeof anticoagulation therapy, and belief that modern bio-prostheses are more durable. Unfortunately, replacementof a failed biological prosthesis remains a morbid proce-dure, and a significant percentage of patients havingbiological mitral replacement will require anticoagulationtherapy for atrial fibrillation during their subsequentcourse. Data actually suggest that the durability ofcurrent bioprostheses in the mitral position remain lim-ited, especially in patients �60 years of age (Fig. 5)(53,54). Transapical replacement of failed biologicalmitral prostheses has been reported using percutaneousbioprostheses designed for the aortic position (4). Severalnew anticoagulants are on the horizon with the potential

Figure 4 Freedom From Mitral Regurgitation AfterMitral Valve Repair for DMR Versus IMR

Freedom from �2� (red lines) or �3� (blue lines) mitral regurgitation aftermitral valve repair for degenerative mitral regurgitation (DMR) versus ischemicmitral regurgitation (IMR) (26,40,42,44,45).

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to eliminate frequent testing and/or minimize bleedingcomplications with mechanical prostheses.

Indications for Mitral Repair or Replacement

As the results of surgery for MR have improved, thethreshold for operating on MR has been lowered. Today,the mortality for isolated mitral repair is 1% to 2%, and themortality for isolated mitral replacement is 6% (37). Pub-lished guidelines for management of valvular heart disease(55) are data driven and useful, but guidelines need to beadjusted for each individual patient. For patients with a 90%likelihood of obtaining a mitral repair, surgery today isseldom performed as an isolated procedure for less thansevere MR because of the low mortality and the low rate ofsymptoms for moderate MR.

The indications for operation on ischemic or functionalMR remain more controversial than those for degenerativedisease. Despite data that functional regurgitation is asso-ciated with impaired survival, nonrandomized studies havesuggested that survival is not improved by mitral repair forfunctional regurgitation when the ejection fraction is �30%(56). Most believe that heart failure symptoms can beimproved after repair of functional regurgitation in patientswith appropriate LV functional reserve (56).

Post-Operative Management

Two controversies in the early management of surgicalpatients are management of anticoagulation therapy andatrial fibrillation prophylaxis. Unless significant atrial fibril-lation occurs in the postoperative period, most mitral repairor biological replacement patients can be managed withaspirin alone. Short-term anticoagulation therapy with war-farin for 3 months is not uncommon, as mitral patients havea 30% to 70% incidence of new atrial fibrillation after mitralsurgery. Most large centers would use an antiarrhythmic likeamiodarone in patients for 1 to 3 months to minimize

Figure 5 Freedom From Structural ValveDeterioration or Reoperation

Freedom from structural valve deterioration or reoperation after biological mitralvalve replacement (53,54).

postoperative atrial fibrillation and subsequent anticoagula-


tion. Concurrent Maze procedure may have a role inminimizing but not eliminating atrial fibrillation in patientsat high risk for atrial fibrillation.

The Future

The next 10 years will see many changes in the surgicalapproach to MR. Certainly, the very early experience withpercutaneous MV repair will grow. The percutaneousMitraClip is a perfect example of how familiarity withlong-standing surgical approaches like edge-to-edge repaircan lead to new approaches for the interventional cardiolo-gist. Noninterventional cardiologists need to be familiarwith the changing options and indications for evolvingsurgical approaches to MR. Open surgical approaches toMR will become less morbid as facilitating technologydevelops and allows smaller incisions and/or eliminationof CPB. Stand-alone percutaneous therapies for MR willalways have the potential to be applied through opensurgical approaches also, thus blurring the distinctionbetween the interventional cardiologist and the cardio-vascular surgeon. Collaboration between the interven-tional cardiologist with percutaneous skills and the car-diovascular surgeon with open skills will create hybridapproaches to MR that would not be possible by purelypercutaneous or open procedures alone (57).

Perspective

Already today and increasingly in the future, the surgicaland interventional approaches to MR will be composed of aspectrum of approaches, spanning from maximally invasiveto percutaneous. Patient selection for the appropriate ap-proach will, therefore, become increasingly important oncewe have data regarding the outcomes of each approach indifferent patient subsets. To further complicate decisionmaking, procedure invasiveness/morbidity may often beinversely related to procedure effectiveness. Thus, we maytend to favor less invasive but less effective approaches totreating MR in patients who are at higher risk and withlimited life expectancy. Younger- and lower-risk patientsmay be more appropriate for more effective therapies whilebetter tolerating any morbidity or risk. As less invasiveapproaches to MR become more available, some of the largepool of patients receiving little or no therapy for MR maybecome more likely to refer themselves, or to be referred, forsome form of anatomic rather than medical treatment oftheir MR. Thus, technology continues to be a dominantdriver of medical care for MR, just like most other diseases.

Reprint requests and correspondence: Dr. Donald D. Glower,Duke University Medical Center, Box 3851, Durham, North
Carolina 27710. E-mail: [email protected].
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