Difference between revisions of "COVID-19-associated myocarditis"

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==Overview==
 
==Overview==
Studies have demonstrated that [[COVID-19]] interacts with the [[cardiovascular system]], thereby causing [[myocardial injury]] and dysfunction as well as increasing [[morbidity]] among patients with underlying cardiovascular conditions.
+
[[COVID-19]] is caused by the [[novel coronavirus]], also known as [[SARS-CoV-2]]. It mainly affects the lungs, causing [[severe acute respiratory syndrome]]. It invades through the [[Angiotensin-converting enzyme 2]] (ACE2) receptors present abundantly not only in the [[lungs]] but also in the [[heart]], [[kidneys]], [[intestine]], [[brain]], [[skin]] thus causing [[multiorgan dysfunction]]. Studies have demonstrated that [[COVID-19]] interacts with the [[cardiovascular system]], thereby causing [[myocardial injury]] and dysfunction as well as increasing [[morbidity]] among patients with underlying cardiovascular conditions.
  
 
==Historical Perspective==
 
==Historical Perspective==
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*Elevations of both [[troponin]] and [[NT-proBNP]] levels were observed in the [[COVID-19–related myocarditis]] cases.<ref name="ZengLiu2020">{{cite journal|last1=Zeng|first1=Jia-Hui|last2=Liu|first2=Ying-Xia|last3=Yuan|first3=Jing|last4=Wang|first4=Fu-Xiang|last5=Wu|first5=Wei-Bo|last6=Li|first6=Jin-Xiu|last7=Wang|first7=Li-Fei|last8=Gao|first8=Hong|last9=Wang|first9=Yao|last10=Dong|first10=Chang-Feng|last11=Li|first11=Yi-Jun|last12=Xie|first12=Xiao-Juan|last13=Feng|first13=Cheng|last14=Liu|first14=Lei|title=First case of COVID-19 complicated with fulminant myocarditis: a case report and insights|journal=Infection|year=2020|issn=0300-8126|doi=10.1007/s15010-020-01424-5}}</ref><ref name="InciardiLupi2020">{{cite journal|last1=Inciardi|first1=Riccardo M.|last2=Lupi|first2=Laura|last3=Zaccone|first3=Gregorio|last4=Italia|first4=Leonardo|last5=Raffo|first5=Michela|last6=Tomasoni|first6=Daniela|last7=Cani|first7=Dario S.|last8=Cerini|first8=Manuel|last9=Farina|first9=Davide|last10=Gavazzi|first10=Emanuele|last11=Maroldi|first11=Roberto|last12=Adamo|first12=Marianna|last13=Ammirati|first13=Enrico|last14=Sinagra|first14=Gianfranco|last15=Lombardi|first15=Carlo M.|last16=Metra|first16=Marco|title=Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)|journal=JAMA Cardiology|year=2020|issn=2380-6583|doi=10.1001/jamacardio.2020.1096}}</ref><ref name="HanKim2020">{{cite journal|last1=Han|first1=Seongwook|last2=Kim|first2=Hyun Ah|last3=Kim|first3=Jin Young|last4=Kim|first4=In-Cheol|title=COVID-19-related myocarditis in a 21-year-old female patient|journal=European Heart Journal|volume=41|issue=19|year=2020|pages=1859–1859|issn=0195-668X|doi=10.1093/eurheartj/ehaa288}}</ref><ref name="EspositoGodino2020">{{cite journal|last1=Esposito|first1=Antonio|last2=Godino|first2=Cosmo|last3=Basso|first3=Cristina|last4=Cappelletti|first4=Alberto Maria|last5=Tresoldi|first5=Moreno|last6=De Cobelli|first6=Francesco|last7=Vignale|first7=Davide|last8=Villatore|first8=Andrea|last9=Palmisano|first9=Anna|last10=Gramegna|first10=Mario|last11=Peretto|first11=Giovanni|last12=Sala|first12=Simone|title=Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection|journal=European Heart Journal|volume=41|issue=19|year=2020|pages=1861–1862|issn=0195-668X|doi=10.1093/eurheartj/ehaa286}}</ref><ref name="Irabien-OrtizCarreras-Mora2020">{{cite journal|last1=Irabien-Ortiz|first1=Ángela|last2=Carreras-Mora|first2=José|last3=Sionis|first3=Alessandro|last4=Pàmies|first4=Julia|last5=Montiel|first5=José|last6=Tauron|first6=Manel|title=Fulminant myocarditis due to COVID-19|journal=Revista Española de Cardiología (English Edition)|volume=73|issue=6|year=2020|pages=503–504|issn=18855857|doi=10.1016/j.rec.2020.04.005}}</ref><ref name="DoyenMoceri2020">{{cite journal|last1=Doyen|first1=Denis|last2=Moceri|first2=Pamela|last3=Ducreux|first3=Dorothée|last4=Dellamonica|first4=Jean|title=Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes|journal=The Lancet|volume=395|issue=10235|year=2020|pages=1516|issn=01406736|doi=10.1016/S0140-6736(20)30912-0}}</ref>
 
*Elevations of both [[troponin]] and [[NT-proBNP]] levels were observed in the [[COVID-19–related myocarditis]] cases.<ref name="ZengLiu2020">{{cite journal|last1=Zeng|first1=Jia-Hui|last2=Liu|first2=Ying-Xia|last3=Yuan|first3=Jing|last4=Wang|first4=Fu-Xiang|last5=Wu|first5=Wei-Bo|last6=Li|first6=Jin-Xiu|last7=Wang|first7=Li-Fei|last8=Gao|first8=Hong|last9=Wang|first9=Yao|last10=Dong|first10=Chang-Feng|last11=Li|first11=Yi-Jun|last12=Xie|first12=Xiao-Juan|last13=Feng|first13=Cheng|last14=Liu|first14=Lei|title=First case of COVID-19 complicated with fulminant myocarditis: a case report and insights|journal=Infection|year=2020|issn=0300-8126|doi=10.1007/s15010-020-01424-5}}</ref><ref name="InciardiLupi2020">{{cite journal|last1=Inciardi|first1=Riccardo M.|last2=Lupi|first2=Laura|last3=Zaccone|first3=Gregorio|last4=Italia|first4=Leonardo|last5=Raffo|first5=Michela|last6=Tomasoni|first6=Daniela|last7=Cani|first7=Dario S.|last8=Cerini|first8=Manuel|last9=Farina|first9=Davide|last10=Gavazzi|first10=Emanuele|last11=Maroldi|first11=Roberto|last12=Adamo|first12=Marianna|last13=Ammirati|first13=Enrico|last14=Sinagra|first14=Gianfranco|last15=Lombardi|first15=Carlo M.|last16=Metra|first16=Marco|title=Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)|journal=JAMA Cardiology|year=2020|issn=2380-6583|doi=10.1001/jamacardio.2020.1096}}</ref><ref name="HanKim2020">{{cite journal|last1=Han|first1=Seongwook|last2=Kim|first2=Hyun Ah|last3=Kim|first3=Jin Young|last4=Kim|first4=In-Cheol|title=COVID-19-related myocarditis in a 21-year-old female patient|journal=European Heart Journal|volume=41|issue=19|year=2020|pages=1859–1859|issn=0195-668X|doi=10.1093/eurheartj/ehaa288}}</ref><ref name="EspositoGodino2020">{{cite journal|last1=Esposito|first1=Antonio|last2=Godino|first2=Cosmo|last3=Basso|first3=Cristina|last4=Cappelletti|first4=Alberto Maria|last5=Tresoldi|first5=Moreno|last6=De Cobelli|first6=Francesco|last7=Vignale|first7=Davide|last8=Villatore|first8=Andrea|last9=Palmisano|first9=Anna|last10=Gramegna|first10=Mario|last11=Peretto|first11=Giovanni|last12=Sala|first12=Simone|title=Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection|journal=European Heart Journal|volume=41|issue=19|year=2020|pages=1861–1862|issn=0195-668X|doi=10.1093/eurheartj/ehaa286}}</ref><ref name="Irabien-OrtizCarreras-Mora2020">{{cite journal|last1=Irabien-Ortiz|first1=Ángela|last2=Carreras-Mora|first2=José|last3=Sionis|first3=Alessandro|last4=Pàmies|first4=Julia|last5=Montiel|first5=José|last6=Tauron|first6=Manel|title=Fulminant myocarditis due to COVID-19|journal=Revista Española de Cardiología (English Edition)|volume=73|issue=6|year=2020|pages=503–504|issn=18855857|doi=10.1016/j.rec.2020.04.005}}</ref><ref name="DoyenMoceri2020">{{cite journal|last1=Doyen|first1=Denis|last2=Moceri|first2=Pamela|last3=Ducreux|first3=Dorothée|last4=Dellamonica|first4=Jean|title=Myocarditis in a patient with COVID-19: a cause of raised troponin and ECG changes|journal=The Lancet|volume=395|issue=10235|year=2020|pages=1516|issn=01406736|doi=10.1016/S0140-6736(20)30912-0}}</ref>
 
*Elevated NT-pro-BNP level has been associated with worse clinical outcomes in severe [[COVID-19]] patients.<ref name="GaoJiang2020">{{cite journal|last1=Gao|first1=Lei|last2=Jiang|first2=Dan|last3=Wen|first3=Xue-song|last4=Cheng|first4=Xiao-cheng|last5=Sun|first5=Min|last6=He|first6=Bin|last7=You|first7=Lin-na|last8=Lei|first8=Peng|last9=Tan|first9=Xiao-wei|last10=Qin|first10=Shu|last11=Cai|first11=Guo-qiang|last12=Zhang|first12=Dong-ying|title=Prognostic value of NT-proBNP in patients with severe COVID-19|journal=Respiratory Research|volume=21|issue=1|year=2020|issn=1465-993X|doi=10.1186/s12931-020-01352-w}}</ref><ref name="HanXie2020">{{cite journal|last1=Han|first1=Huan|last2=Xie|first2=Linlin|last3=Liu|first3=Rui|last4=Yang|first4=Jie|last5=Liu|first5=Fang|last6=Wu|first6=Kailang|last7=Chen|first7=Lang|last8=Hou|first8=Wei|last9=Feng|first9=Yong|last10=Zhu|first10=Chengliang|title=Analysis of heart injury laboratory parameters in 273 COVID‐19 patients in one hospital in Wuhan, China|journal=Journal of Medical Virology|volume=92|issue=7|year=2020|pages=819–823|issn=0146-6615|doi=10.1002/jmv.25809}}</ref>
 
*Elevated NT-pro-BNP level has been associated with worse clinical outcomes in severe [[COVID-19]] patients.<ref name="GaoJiang2020">{{cite journal|last1=Gao|first1=Lei|last2=Jiang|first2=Dan|last3=Wen|first3=Xue-song|last4=Cheng|first4=Xiao-cheng|last5=Sun|first5=Min|last6=He|first6=Bin|last7=You|first7=Lin-na|last8=Lei|first8=Peng|last9=Tan|first9=Xiao-wei|last10=Qin|first10=Shu|last11=Cai|first11=Guo-qiang|last12=Zhang|first12=Dong-ying|title=Prognostic value of NT-proBNP in patients with severe COVID-19|journal=Respiratory Research|volume=21|issue=1|year=2020|issn=1465-993X|doi=10.1186/s12931-020-01352-w}}</ref><ref name="HanXie2020">{{cite journal|last1=Han|first1=Huan|last2=Xie|first2=Linlin|last3=Liu|first3=Rui|last4=Yang|first4=Jie|last5=Liu|first5=Fang|last6=Wu|first6=Kailang|last7=Chen|first7=Lang|last8=Hou|first8=Wei|last9=Feng|first9=Yong|last10=Zhu|first10=Chengliang|title=Analysis of heart injury laboratory parameters in 273 COVID‐19 patients in one hospital in Wuhan, China|journal=Journal of Medical Virology|volume=92|issue=7|year=2020|pages=819–823|issn=0146-6615|doi=10.1002/jmv.25809}}</ref>
*Cardiac troponins and brain natriuretic peptides are sensitive but non-specific in the diagnosis of myocarditis.<ref name="LauerNiederau1997">{{cite journal|last1=Lauer|first1=Bernward|last2=Niederau|first2=Christoph|last3=Kühl|first3=Uwe|last4=Schannwell|first4=Mira|last5=Pauschinger|first5=Matthias|last6=Strauer|first6=Bodo-Eckhard|last7=Schultheiss|first7=Heinz-Peter|title=Cardiac Troponin T in Patients With Clinically Suspected Myocarditis|journal=Journal of the American College of Cardiology|volume=30|issue=5|year=1997|pages=1354–1359|issn=07351097|doi=10.1016/S0735-1097(97)00317-3}}</ref><ref name="Heymans2007">{{cite journal|last1=Heymans|first1=S.|title=Myocarditis and heart failure: need for better diagnostic, predictive, and therapeutic tools|journal=European Heart Journal|volume=28|issue=11|year=2007|pages=1279–1280|issn=0195-668X|doi=10.1093/eurheartj/ehm111}}</ref><ref name="JensenMa2010">{{cite journal|last1=Jensen|first1=Juliana|last2=Ma|first2=Li-Ping|last3=Fu|first3=Michael L. X.|last4=Svaninger|first4=David|last5=Lundberg|first5=Per-Arne|last6=Hammarsten|first6=Ola|title=Inflammation increases NT-proBNP and the NT-proBNP/BNP ratio|journal=Clinical Research in Cardiology|volume=99|issue=7|year=2010|pages=445–452|issn=1861-0684|doi=10.1007/s00392-010-0140-z}}</ref>
+
*Cardiac troponins and brain natriuretic peptides are sensitive but non-specific in the diagnosis of myocarditis. It requires other supplementary findings and investigations.<ref name="LauerNiederau1997">{{cite journal|last1=Lauer|first1=Bernward|last2=Niederau|first2=Christoph|last3=Kühl|first3=Uwe|last4=Schannwell|first4=Mira|last5=Pauschinger|first5=Matthias|last6=Strauer|first6=Bodo-Eckhard|last7=Schultheiss|first7=Heinz-Peter|title=Cardiac Troponin T in Patients With Clinically Suspected Myocarditis|journal=Journal of the American College of Cardiology|volume=30|issue=5|year=1997|pages=1354–1359|issn=07351097|doi=10.1016/S0735-1097(97)00317-3}}</ref><ref name="Heymans2007">{{cite journal|last1=Heymans|first1=S.|title=Myocarditis and heart failure: need for better diagnostic, predictive, and therapeutic tools|journal=European Heart Journal|volume=28|issue=11|year=2007|pages=1279–1280|issn=0195-668X|doi=10.1093/eurheartj/ehm111}}</ref><ref name="JensenMa2010">{{cite journal|last1=Jensen|first1=Juliana|last2=Ma|first2=Li-Ping|last3=Fu|first3=Michael L. X.|last4=Svaninger|first4=David|last5=Lundberg|first5=Per-Arne|last6=Hammarsten|first6=Ola|title=Inflammation increases NT-proBNP and the NT-proBNP/BNP ratio|journal=Clinical Research in Cardiology|volume=99|issue=7|year=2010|pages=445–452|issn=1861-0684|doi=10.1007/s00392-010-0140-z}}</ref>
 
*Although a negative troponin result cannot exclude myocarditis, negative serial [[high-sensitivity cardiac troponin]] (hs-cTn) still is helpful in the acute phase and makes the diagnosis of acute myocarditis significantly less likely.<ref name="SiripanthongNazarian2020">{{cite journal|last1=Siripanthong|first1=Bhurint|last2=Nazarian|first2=Saman|last3=Muser|first3=Daniele|last4=Deo|first4=Rajat|last5=Santangeli|first5=Pasquale|last6=Khanji|first6=Mohammed Y.|last7=Cooper|first7=Leslie T.|last8=Chahal|first8=C. Anwar A.|title=Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management|journal=Heart Rhythm|year=2020|issn=15475271|doi=10.1016/j.hrthm.2020.05.001}}</ref>
 
*Although a negative troponin result cannot exclude myocarditis, negative serial [[high-sensitivity cardiac troponin]] (hs-cTn) still is helpful in the acute phase and makes the diagnosis of acute myocarditis significantly less likely.<ref name="SiripanthongNazarian2020">{{cite journal|last1=Siripanthong|first1=Bhurint|last2=Nazarian|first2=Saman|last3=Muser|first3=Daniele|last4=Deo|first4=Rajat|last5=Santangeli|first5=Pasquale|last6=Khanji|first6=Mohammed Y.|last7=Cooper|first7=Leslie T.|last8=Chahal|first8=C. Anwar A.|title=Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management|journal=Heart Rhythm|year=2020|issn=15475271|doi=10.1016/j.hrthm.2020.05.001}}</ref>
  

Revision as of 12:49, 1 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Synonyms and Keywords: Novel coronavirus, COVID-19, Wuhan Coronavirus, Coronavirus Disease-19, Coronavirus Disease 2019, SARS-CoV-2, COVID-19, COVID-19, 2019-nCoV, 2019 novel coronavirus, Cardiovascular finding in COVID-19, Myocardial injury in COVID-19, Myocarditis, Myocarditis in COVID-19, COVID-19-associated Myocarditis, SARS-CoV2-associated Myocarditis, Myocardial injury in COVID-19, COVID-19 myocarditis

Overview

COVID-19 is caused by the novel coronavirus, also known as SARS-CoV-2. It mainly affects the lungs, causing severe acute respiratory syndrome. It invades through the Angiotensin-converting enzyme 2 (ACE2) receptors present abundantly not only in the lungs but also in the heart, kidneys, intestine, brain, skin thus causing multiorgan dysfunction. Studies have demonstrated that COVID-19 interacts with the cardiovascular system, thereby causing myocardial injury and dysfunction as well as increasing morbidity among patients with underlying cardiovascular conditions.

Historical Perspective

Classification

Pathophysiology

  • Myocarditis is an inflammatory disease of the heart characterized by inflammatory infiltrates and myocardial injury without an ischemic cause.[8]
  • The major cause of myocarditis in the United States and other developed countries is viral.[9] [10]
  • The exact mechanisms of COVID-19 induced myocarditis are not yet well known, although several have been proposed based on the limited data outside of case reports.

Proposed pathophysiologies of SARS-CoV-2 myocarditis

Pathological changes in the myocardium

Causes

Myocarditis in COVID-19 is caused by:

Differentiating COVID-19 associated myocarditis from other Diseases

Myocarditis in COVID-19 must be differentiated from other diseases that cause chest pain, dyspnea, elevated cardiac biomarkers, ventricular dysfunction, such as:

Epidemiology and Demographics

Age

Gender

  • There is no data on gender predilection to myocarditis in COVID-19.

Race

  • There is no data on racial predilection to myocarditis in COVID-19.

Risk Factors

Screening

There is insufficient evidence to recommend routine screening for myocarditis in COVID-19 patients.

Natural History, Complications and Prognosis

Natural history

If left untreated, myocarditis of patients with COVID-19 may progress to develop cardiogenic shock, heart failure, and succumb to death.[32]

Complications

Common complications of [myocarditis] include:

Prognosis

Diagnosis

Diagnostic Criteria

  • The diagnosis of myocarditis cannot be made with a single test or examination. When indicated, the diagnosis requires a combination of:

Signs and Symptoms

Clinical presentations have varied in the reported COVID-19 cases with myocarditis in the literature with a potential overlap in symptomatology in patients with primary COVID-19 infection and COVID-19 patients with clinically suspected myocarditis. Clinical presentation of SARS-CoV-2 myocarditis varies among cases from mild to severe to fulminant.

According to a study, ventricular arrhythmias are also seen in the patients of myocarditis.[37]

Physical Examination

  • Physical examination of patients with severe myocarditis may be remarkable for:
  • Physical examination of patients with fulminant myocarditis may be remarkable for:

Laboratory Findings

Inflammatory biomarkers

Cardiac biomarkers

Electrocardiogram

The American Heart Association (AHA) recommends further testing with 1 or more cardiac imaging methods such as an echocardiogram or cardiovascular magnetic resonance (CMR) for patients having signs consistent with myocarditis.[10] However, echocardiogram or cardiac imaging can be avoided or delayed until recovery from COVID-19 in the patients with COVID-19 and myocardial injury who are hemodynamically and electrophysiologically stable with mild to moderate elevations of troponin unless the patient clinically deteriorates and develops hemodynamic instability, shock, ventricular arrhythmias, or a severely elevated or rapidly rising troponins.[46]

Echocardiography

Cardiac Magnetic Resonance

  • Cardiac Magnetic resonance (CMR) has major imaging advantages with highest diagnostic accuracy over echocardiography[49], but it has limitations of availability, the requirement for some breath-holding, the requirement for deep cleaning after use given the high contagious risk of COVID-19 and slower throughput.
  • If CMR is performed, revised Lake Louise consensus criteria are used to interpret the results.[50] 1) edema 2) irreversible cell injury 3) hyperemia or capillary leak.
  • In all of the SARS-CoV-2–related myocarditis cases for which CMR results were reported, myocardial edema and/or scarring were observed.[29][18][30]

Cardiac Computed Tomography

Endomyocardial biopsy

  • Endomyocardial biopsy (EMB) has been recommended as the definitive diagnostic tool for myocarditis by the American Heart Association (AHA) and European Society of Cardiology (ESC).[51] In non–COVID-19 cases, endomyocardial biopsy has traditionally been recommended in fulminant presentations to exclude the rare presentation of eosinophilic, hypersensitive,and giant-cell myocarditis.[52] However, in COVID-19, it may not be feasible because of the instability of the patient, requirement of expertise, false-negative rate and risk of contagiousness, especially if the biopsy results would not change clinical management.[9][10][49]
  • EMB samples if obtained should be tested for inflammatory infiltrates and for the presence of viral genomes by DNA/RNA extraction.[9]
  • In a COVID-19 case reported, EMB showed diffuse T-lymphocytic inflammatory infiltrates with huge interstitial edema and no replacement fibrosis, suggesting an acute inflammatory process. SARS-CoV-2 genome was absent within the myocardium in molecular analysis.[30]

Treatment

Medical Therapy

Prevention

References

  1. https://www.cdc.gov/coronavirus/2019-ncov/about/index.html. Missing or empty |title= (help)
  2. Lu, Jian; Cui, Jie; Qian, Zhaohui; Wang, Yirong; Zhang, Hong; Duan, Yuange; Wu, Xinkai; Yao, Xinmin; Song, Yuhe; Li, Xiang; Wu, Changcheng; Tang, Xiaolu (2020). "On the origin and continuing evolution of SARS-CoV-2". National Science Review. doi:10.1093/nsr/nwaa036. ISSN 2095-5138.
  3. Huang, Chaolin; Wang, Yeming; Li, Xingwang; Ren, Lili; Zhao, Jianping; Hu, Yi; Zhang, Li; Fan, Guohui; Xu, Jiuyang; Gu, Xiaoying; Cheng, Zhenshun; Yu, Ting; Xia, Jiaan; Wei, Yuan; Wu, Wenjuan; Xie, Xuelei; Yin, Wen; Li, Hui; Liu, Min; Xiao, Yan; Gao, Hong; Guo, Li; Xie, Jungang; Wang, Guangfa; Jiang, Rongmeng; Gao, Zhancheng; Jin, Qi; Wang, Jianwei; Cao, Bin (2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". The Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. ISSN 0140-6736.
  4. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Missing or empty |title= (help)
  5. "WHO | Novel Coronavirus – China".
  6. "Coronavirus (COVID-19) events as they happen".
  7. "Coronavirus (COVID-19) events as they happen".
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