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Erschienen in: Arthritis Research & Therapy 2/2005

01.12.2005 | Review

Anti-SSA/Ro antibodies and the heart: more than complete congenital heart block? A review of electrocardiographic and myocardial abnormalities and of treatment options

verfasst von: Nathalie Costedoat-Chalumeau, Zahir Amoura, Elisabeth Villain, Laurence Cohen, Jean-Charles Piette

Erschienen in: Arthritis Research & Therapy | Ausgabe 2/2005

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Abstract

Apart from complete and incomplete congenital heart block (CHB), new cardiac manifestations related to anti-SSA/Ro antibodies have been reported in children born to mothers bearing these antibodies. These manifestations include transient fetal first-degree heart block, prolongation of corrected QT (QTc) interval, sinus bradycardia, late-onset cardiomyopathy, endocardial fibroelastosis and cardiac malformations. Anti-SSA/Ro antibodies are not considered pathogenic to the adult heart, but a prolongation of the QTc interval has recently been reported in adult patients and is still a matter of debate. Treatment of CHB is not well established and needs to be assessed carefully. The risks and benefits of prenatal fluorinated steroids are discussed.
Literatur
1.
Zurück zum Zitat Sonesson SE, Salomonsson S, Jacobsson LA, Bremme K, Wahren-Herlenius M: Signs of first-degree heart block occur in one-third of fetuses of pregnant women with anti-SSA/Ro 52-kd antibodies. Arthritis Rheum . 2004, 50: 1253-1261. 10.1002/art.20126.CrossRefPubMed Sonesson SE, Salomonsson S, Jacobsson LA, Bremme K, Wahren-Herlenius M: Signs of first-degree heart block occur in one-third of fetuses of pregnant women with anti-SSA/Ro 52-kd antibodies. Arthritis Rheum . 2004, 50: 1253-1261. 10.1002/art.20126.CrossRefPubMed
2.
Zurück zum Zitat Cimaz R, Stramba-Badiale M, Brucato A, Catelli L, Panzeri P, Meroni PL: QT interval prolongation in asymptomatic anti-SSA/Ro-positive infants without congenital heart block. Arthritis Rheum. 2000, 43: 1049-1053. 10.1002/1529-0131(200005)43:5<1049::AID-ANR13>3.0.CO;2-X.CrossRefPubMed Cimaz R, Stramba-Badiale M, Brucato A, Catelli L, Panzeri P, Meroni PL: QT interval prolongation in asymptomatic anti-SSA/Ro-positive infants without congenital heart block. Arthritis Rheum. 2000, 43: 1049-1053. 10.1002/1529-0131(200005)43:5<1049::AID-ANR13>3.0.CO;2-X.CrossRefPubMed
3.
Zurück zum Zitat Gordon PA, Khamashta MA, Hughes GR, Rosenthal E: Increase in the heart rate-corrected QT interval in children of anti-Ro-positive mothers, with a further increase in those with siblings with congenital heart block: comment on the article by Cimaz et al. Arthritis Rheum. 2001, 44: 242-243. 10.1002/1529-0131(200101)44:1<242::AID-ANR34>3.0.CO;2-S.CrossRefPubMed Gordon PA, Khamashta MA, Hughes GR, Rosenthal E: Increase in the heart rate-corrected QT interval in children of anti-Ro-positive mothers, with a further increase in those with siblings with congenital heart block: comment on the article by Cimaz et al. Arthritis Rheum. 2001, 44: 242-243. 10.1002/1529-0131(200101)44:1<242::AID-ANR34>3.0.CO;2-S.CrossRefPubMed
4.
Zurück zum Zitat Brucato A, Frassi M, Franceschini F, Cimaz R, Faden D, Pisoni MP, Muscara M, Vignati G, Stramba-Badiale M, Catelli L, et al: Risk of congenital complete heart block in newborns of mothers with anti-Ro/SSA antibodies detected by counterimmunoelectrophoresis: a prospective study of 100 women. Arthritis Rheum. 2001, 44: 1832-1835. 10.1002/1529-0131(200108)44:8<1832::AID-ART320>3.0.CO;2-C.CrossRefPubMed Brucato A, Frassi M, Franceschini F, Cimaz R, Faden D, Pisoni MP, Muscara M, Vignati G, Stramba-Badiale M, Catelli L, et al: Risk of congenital complete heart block in newborns of mothers with anti-Ro/SSA antibodies detected by counterimmunoelectrophoresis: a prospective study of 100 women. Arthritis Rheum. 2001, 44: 1832-1835. 10.1002/1529-0131(200108)44:8<1832::AID-ART320>3.0.CO;2-C.CrossRefPubMed
5.
Zurück zum Zitat Moak JP, Barron KS, Hougen TJ, Wiles HB, Balaji S, Sreeram N, Cohen MH, Nordenberg A, Van Hare GF, Friedman RA, et al: Congenital heart block: development of late-onset cardiomyopathy, a previously underappreciated sequela. J Am Coll Cardiol. 2001, 37: 238-242. 10.1016/S0735-1097(00)01048-2.CrossRefPubMed Moak JP, Barron KS, Hougen TJ, Wiles HB, Balaji S, Sreeram N, Cohen MH, Nordenberg A, Van Hare GF, Friedman RA, et al: Congenital heart block: development of late-onset cardiomyopathy, a previously underappreciated sequela. J Am Coll Cardiol. 2001, 37: 238-242. 10.1016/S0735-1097(00)01048-2.CrossRefPubMed
6.
Zurück zum Zitat Nield LE, Silverman ED, Taylor GP, Smallhorn JF, Mullen JB, Silverman NH, Finley JP, Law YM, Human DG, Seaward PG, et al: Maternal anti-Ro and anti-La antibody-associated endocardial fibroelastosis. Circulation. 2002, 105: 843-848. 10.1161/hc0702.104182.CrossRefPubMed Nield LE, Silverman ED, Taylor GP, Smallhorn JF, Mullen JB, Silverman NH, Finley JP, Law YM, Human DG, Seaward PG, et al: Maternal anti-Ro and anti-La antibody-associated endocardial fibroelastosis. Circulation. 2002, 105: 843-848. 10.1161/hc0702.104182.CrossRefPubMed
7.
Zurück zum Zitat Nield LE, Silverman ED, Smallhorn JF, Taylor GP, Mullen JB, Benson LN, Hornberger LK: Endocardial fibroelastosis associated with maternal anti-Ro and anti-La antibodies in the absence of atrioventricular block. J Am Coll Cardiol. 2002, 40: 796-802. 10.1016/S0735-1097(02)02004-1.CrossRefPubMed Nield LE, Silverman ED, Smallhorn JF, Taylor GP, Mullen JB, Benson LN, Hornberger LK: Endocardial fibroelastosis associated with maternal anti-Ro and anti-La antibodies in the absence of atrioventricular block. J Am Coll Cardiol. 2002, 40: 796-802. 10.1016/S0735-1097(02)02004-1.CrossRefPubMed
8.
Zurück zum Zitat Costedoat-Chalumeau N, Amoura Z, Lupoglazoff JM, Thi Huong du L, Denjoy I, Vauthier D, Sebbouh D, Fain O, Georgin-Lavialle S, Ghillani P, et al: Outcome of pregnancies in patients with anti-SSA/Ro antibodies: a study of 165 pregnancies, with special focus on electrocardiographic variations in the children and comparison with a control group. Arthritis Rheum. 2004, 50: 3187-3194. 10.1002/art.20554.CrossRefPubMed Costedoat-Chalumeau N, Amoura Z, Lupoglazoff JM, Thi Huong du L, Denjoy I, Vauthier D, Sebbouh D, Fain O, Georgin-Lavialle S, Ghillani P, et al: Outcome of pregnancies in patients with anti-SSA/Ro antibodies: a study of 165 pregnancies, with special focus on electrocardiographic variations in the children and comparison with a control group. Arthritis Rheum. 2004, 50: 3187-3194. 10.1002/art.20554.CrossRefPubMed
9.
Zurück zum Zitat Lazzerini PE, Acampa M, Guideri F, Capecchi PL, Campanella V, Morozzi G, Galeazzi M, Marcolongo R, Laghi-Pasini F: Prolongation of the corrected QT interval in adult patients with anti-Ro/SSA-positive connective tissue diseases. Arthritis Rheum. 2004, 50: 1248-1252. 10.1002/art.20130.CrossRefPubMed Lazzerini PE, Acampa M, Guideri F, Capecchi PL, Campanella V, Morozzi G, Galeazzi M, Marcolongo R, Laghi-Pasini F: Prolongation of the corrected QT interval in adult patients with anti-Ro/SSA-positive connective tissue diseases. Arthritis Rheum. 2004, 50: 1248-1252. 10.1002/art.20130.CrossRefPubMed
10.
Zurück zum Zitat Buyon JP, Hiebert R, Copel J, Craft J, Friedman D, Katholi M, Lee LA, Provost TT, Reichlin M, Rider L, et al: Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry. J Am Coll Cardiol. 1998, 31: 1658-1666. 10.1016/S0735-1097(98)00161-2.CrossRefPubMed Buyon JP, Hiebert R, Copel J, Craft J, Friedman D, Katholi M, Lee LA, Provost TT, Reichlin M, Rider L, et al: Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry. J Am Coll Cardiol. 1998, 31: 1658-1666. 10.1016/S0735-1097(98)00161-2.CrossRefPubMed
11.
Zurück zum Zitat Eronen M, Siren MK, Ekblad H, Tikanoja T, Julkunen H, Paavilainen T: Short- and long-term outcome of children with congenital complete heart block diagnosed in utero or as a newborn. Pediatrics. 2000, 106: 86-91. 10.1542/peds.106.1.86.CrossRefPubMed Eronen M, Siren MK, Ekblad H, Tikanoja T, Julkunen H, Paavilainen T: Short- and long-term outcome of children with congenital complete heart block diagnosed in utero or as a newborn. Pediatrics. 2000, 106: 86-91. 10.1542/peds.106.1.86.CrossRefPubMed
12.
Zurück zum Zitat Brucato A, Gasparini M, Vignati G, Riccobono S, De Juli E, Quinzanini M, Bortolon C, Coluccio E, Massari D: Isolated congenital complete heart block: longterm outcome of children and immunogenetic study. J Rheumatol. 1995, 22: 541-543.PubMed Brucato A, Gasparini M, Vignati G, Riccobono S, De Juli E, Quinzanini M, Bortolon C, Coluccio E, Massari D: Isolated congenital complete heart block: longterm outcome of children and immunogenetic study. J Rheumatol. 1995, 22: 541-543.PubMed
13.
Zurück zum Zitat Askanase AD, Friedman DM, Copel J, Dische MR, Dubin A, Starc TJ, Katholi MC, Buyon JP: Spectrum and progression of conduction abnormalities in infants born to mothers with anti-SSA/Ro-SSB/La antibodies. Lupus. 2002, 11: 145-151. 10.1191/0961203302lu173oa.CrossRefPubMed Askanase AD, Friedman DM, Copel J, Dische MR, Dubin A, Starc TJ, Katholi MC, Buyon JP: Spectrum and progression of conduction abnormalities in infants born to mothers with anti-SSA/Ro-SSB/La antibodies. Lupus. 2002, 11: 145-151. 10.1191/0961203302lu173oa.CrossRefPubMed
14.
Zurück zum Zitat Glickstein JS, Buyon J, Friedman D: Pulsed Doppler echocardiographic assessment of the fetal PR interval. Am J Cardiol. 2000, 86: 236-239. 10.1016/S0002-9149(00)00867-5.CrossRefPubMed Glickstein JS, Buyon J, Friedman D: Pulsed Doppler echocardiographic assessment of the fetal PR interval. Am J Cardiol. 2000, 86: 236-239. 10.1016/S0002-9149(00)00867-5.CrossRefPubMed
15.
Zurück zum Zitat Glickstein J, Buyon J, Kim M, Friedman D: The fetal Doppler mechanical PR interval: a validation study. Fetal Diagn Ther. 2004, 19: 31-34. 10.1159/000074256.CrossRefPubMed Glickstein J, Buyon J, Kim M, Friedman D: The fetal Doppler mechanical PR interval: a validation study. Fetal Diagn Ther. 2004, 19: 31-34. 10.1159/000074256.CrossRefPubMed
16.
Zurück zum Zitat Andelfinger G, Fouron JC, Sonesson SE, Proulx F: Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques. Am J Cardiol. 2001, 88: 1433-1436. 10.1016/S0002-9149(01)02130-0. A1438CrossRefPubMed Andelfinger G, Fouron JC, Sonesson SE, Proulx F: Reference values for time intervals between atrial and ventricular contractions of the fetal heart measured by two Doppler techniques. Am J Cardiol. 2001, 88: 1433-1436. 10.1016/S0002-9149(01)02130-0. A1438CrossRefPubMed
17.
Zurück zum Zitat Friedman D, Buyon J, Copel J, Kim M: PR interval and dexamethasone evaluation: an ongoing prospective fetal echocardiographic study in neonatal lupus. I – observational. [Abstract]. Lupus . 2004, 13: 760- Friedman D, Buyon J, Copel J, Kim M: PR interval and dexamethasone evaluation: an ongoing prospective fetal echocardiographic study in neonatal lupus. I – observational. [Abstract]. Lupus . 2004, 13: 760-
18.
Zurück zum Zitat Cimaz R, Meroni PL, Brucato A, Fesstova VV, Panzeri P, Goulene K, Stramba-Badiale M: Concomitant disappearance of electrocardiographic abnormalities and of acquired maternal autoantibodies during the first year of life in infants who had QT interval prolongation and anti-SSA/Ro positivity without congenital heart block at birth. Arthritis Rheum . 2003, 48: 266-268. 10.1002/art.10700.CrossRefPubMed Cimaz R, Meroni PL, Brucato A, Fesstova VV, Panzeri P, Goulene K, Stramba-Badiale M: Concomitant disappearance of electrocardiographic abnormalities and of acquired maternal autoantibodies during the first year of life in infants who had QT interval prolongation and anti-SSA/Ro positivity without congenital heart block at birth. Arthritis Rheum . 2003, 48: 266-268. 10.1002/art.10700.CrossRefPubMed
19.
Zurück zum Zitat Schwartz PJ, Montemerlo M, Facchini M, Salice P, Rosti D, Poggio G, Giorgetti R: The QT interval throughout the first 6 months of life: a prospective study. Circulation. 1982, 66: 496-501.CrossRefPubMed Schwartz PJ, Montemerlo M, Facchini M, Salice P, Rosti D, Poggio G, Giorgetti R: The QT interval throughout the first 6 months of life: a prospective study. Circulation. 1982, 66: 496-501.CrossRefPubMed
20.
Zurück zum Zitat Gordon PA, Rosenthal E, Khamashta MA, Hughes GR: Absence of conduction defects in the electrocardiograms of mothers with children with congenital complete heart block. J Rheumatol. 2001, 28: 366-369.PubMed Gordon PA, Rosenthal E, Khamashta MA, Hughes GR: Absence of conduction defects in the electrocardiograms of mothers with children with congenital complete heart block. J Rheumatol. 2001, 28: 366-369.PubMed
21.
Zurück zum Zitat Costedoat-Chalumeau N, Amoura Z, Hulot JS, Ghillani P, Funck-Brentano C, Lechat P, Piette JC: Letter in response to 'Prolongation of the corrected QT interval in adult patients with anti-Ro/SSA-positive connective tissue diseases' by Lazzerini et al. in Arthritis Rheum2004, 50:1248–1252. Arthritis Rheum. 2005, Costedoat-Chalumeau N, Amoura Z, Hulot JS, Ghillani P, Funck-Brentano C, Lechat P, Piette JC: Letter in response to 'Prolongation of the corrected QT interval in adult patients with anti-Ro/SSA-positive connective tissue diseases' by Lazzerini et al. in Arthritis Rheum2004, 50:1248–1252. Arthritis Rheum. 2005,
22.
Zurück zum Zitat Menon A, Silverman ED, Gow RM, Hamilton RM: Chronotropic competence of the sinus node in congenital complete heart block. Am J Cardiol. 1998, 82: 1119-1121. 10.1016/S0002-9149(98)00569-4.CrossRefPubMed Menon A, Silverman ED, Gow RM, Hamilton RM: Chronotropic competence of the sinus node in congenital complete heart block. Am J Cardiol. 1998, 82: 1119-1121. 10.1016/S0002-9149(98)00569-4.CrossRefPubMed
23.
Zurück zum Zitat Mazel JA, El-Sherif N, Buyon J, Boutjdir M: Electrocardiographic abnormalities in a murine model injected with IgG from mothers of children with congenital heart block. Circulation. 1999, 99: 1914-1918.CrossRefPubMed Mazel JA, El-Sherif N, Buyon J, Boutjdir M: Electrocardiographic abnormalities in a murine model injected with IgG from mothers of children with congenital heart block. Circulation. 1999, 99: 1914-1918.CrossRefPubMed
24.
Zurück zum Zitat Hu K, Qu Y, Yue Y, Boutjdir M: Functional basis of sinus bradycardia in congenital heart block. Circ Res. 2004, 94: e32-e38. 10.1161/01.RES.0000121566.01778.06.CrossRefPubMed Hu K, Qu Y, Yue Y, Boutjdir M: Functional basis of sinus bradycardia in congenital heart block. Circ Res. 2004, 94: e32-e38. 10.1161/01.RES.0000121566.01778.06.CrossRefPubMed
25.
Zurück zum Zitat Southall DP, Richards J, Brown DJ, Johnston PG, de Swiet M, Shinebourne EA: 24-hour tape recordings of ECG and respiration in the newborn infant with findings related to sudden death and unexplained brain damage in infancy. Arch Dis Child. 1980, 55: 7-16.PubMedCentralCrossRefPubMed Southall DP, Richards J, Brown DJ, Johnston PG, de Swiet M, Shinebourne EA: 24-hour tape recordings of ECG and respiration in the newborn infant with findings related to sudden death and unexplained brain damage in infancy. Arch Dis Child. 1980, 55: 7-16.PubMedCentralCrossRefPubMed
26.
Zurück zum Zitat Hogg GR: Congenital, acute lupus erythematosus associated with subendocardial fibroelastosis. Report of a case. Am J Clin Pathol . 1957, 28: 648-654.PubMed Hogg GR: Congenital, acute lupus erythematosus associated with subendocardial fibroelastosis. Report of a case. Am J Clin Pathol . 1957, 28: 648-654.PubMed
28.
Zurück zum Zitat Saleeb S, Copel J, Friedman D, Buyon JP: Comparison of treatment with fluorinated glucocorticoids to the natural history of autoantibody-associated congenital heart block: retrospective review of the research registry for neonatal lupus. Arthritis Rheum. 1999, 42: 2335-2345. 10.1002/1529-0131(199911)42:11<2335::AID-ANR12>3.0.CO;2-3.CrossRefPubMed Saleeb S, Copel J, Friedman D, Buyon JP: Comparison of treatment with fluorinated glucocorticoids to the natural history of autoantibody-associated congenital heart block: retrospective review of the research registry for neonatal lupus. Arthritis Rheum. 1999, 42: 2335-2345. 10.1002/1529-0131(199911)42:11<2335::AID-ANR12>3.0.CO;2-3.CrossRefPubMed
29.
Zurück zum Zitat Jaeggi ET, Fouron JC, Silverman ED, Ryan G, Smallhorn J, Hornberger LK: Transplacental fetal treatment improves the outcome of prenatally diagnosed complete atrioventricular block without structural heart disease. Circulation. 2004, 110: 1542-1548. 10.1161/01.CIR.0000142046.58632.3A.CrossRefPubMed Jaeggi ET, Fouron JC, Silverman ED, Ryan G, Smallhorn J, Hornberger LK: Transplacental fetal treatment improves the outcome of prenatally diagnosed complete atrioventricular block without structural heart disease. Circulation. 2004, 110: 1542-1548. 10.1161/01.CIR.0000142046.58632.3A.CrossRefPubMed
30.
Zurück zum Zitat Buyon JP, Rupel A, Clancy RM: Neonatal lupus syndromes. Lupus. 2004, 13: 705-712. 10.1191/0961203304lu2008oa.CrossRefPubMed Buyon JP, Rupel A, Clancy RM: Neonatal lupus syndromes. Lupus. 2004, 13: 705-712. 10.1191/0961203304lu2008oa.CrossRefPubMed
31.
Zurück zum Zitat Baud O, Foix-L'Helias L, Kaminski M, Audibert F, Jarreau PH, Papiernik E, Huon C, Lepercq J, Dehan M, Lacaze-Masmonteil T: Antenatal glucocorticoid treatment and cystic periventricular leukomalacia in very premature infants. N Engl J Med. 1999, 341: 1190-1196. 10.1056/NEJM199910143411604.CrossRefPubMed Baud O, Foix-L'Helias L, Kaminski M, Audibert F, Jarreau PH, Papiernik E, Huon C, Lepercq J, Dehan M, Lacaze-Masmonteil T: Antenatal glucocorticoid treatment and cystic periventricular leukomalacia in very premature infants. N Engl J Med. 1999, 341: 1190-1196. 10.1056/NEJM199910143411604.CrossRefPubMed
32.
Zurück zum Zitat Costedoat-Chalumeau N, Amoura Z, Le Thi Hong D, Wechsler B, Vauthier D, Ghillani P, Papo T, Fain O, Musset L, Piette JC: Questions about dexamethasone use for the prevention of anti-SSA related congenital heart block. Ann Rheum Dis. 2003, 62: 1010-1012. 10.1136/ard.62.10.1010.CrossRefPubMed Costedoat-Chalumeau N, Amoura Z, Le Thi Hong D, Wechsler B, Vauthier D, Ghillani P, Papo T, Fain O, Musset L, Piette JC: Questions about dexamethasone use for the prevention of anti-SSA related congenital heart block. Ann Rheum Dis. 2003, 62: 1010-1012. 10.1136/ard.62.10.1010.CrossRefPubMed
33.
Zurück zum Zitat Chico A, Manzanares JM, Halperin I, Martinez de Osaba MJ, Adelantado J, Webb SM: Cushing's disease and pregnancy: report of six cases. Eur J Obstet Gynecol Reprod Biol. 1996, 64: 143-146. 10.1016/0301-2115(95)02258-9.CrossRefPubMed Chico A, Manzanares JM, Halperin I, Martinez de Osaba MJ, Adelantado J, Webb SM: Cushing's disease and pregnancy: report of six cases. Eur J Obstet Gynecol Reprod Biol. 1996, 64: 143-146. 10.1016/0301-2115(95)02258-9.CrossRefPubMed
34.
Zurück zum Zitat Buyon JP, Clancy RM: Maternal autoantibodies and congenital heart block: mediators, markers, and therapeutic approach. Semin Arthritis Rheum. 2003, 33: 140-154. 10.1016/j.semarthrit.2003.09.002.CrossRefPubMed Buyon JP, Clancy RM: Maternal autoantibodies and congenital heart block: mediators, markers, and therapeutic approach. Semin Arthritis Rheum. 2003, 33: 140-154. 10.1016/j.semarthrit.2003.09.002.CrossRefPubMed
35.
Zurück zum Zitat Costedoat-Chalumeau N, Amoura Z, Le Thi Hong D, Georgin S, Vauthier D, Sebbouh D, Frances C, Villain E, Wechsler B, Piette JC: Neonatal lupus syndrome: review of the literature. [In French]. Rev Med Interne. 2003, 24: 659-671. 10.1016/S0248-8663(03)00211-X.CrossRefPubMed Costedoat-Chalumeau N, Amoura Z, Le Thi Hong D, Georgin S, Vauthier D, Sebbouh D, Frances C, Villain E, Wechsler B, Piette JC: Neonatal lupus syndrome: review of the literature. [In French]. Rev Med Interne. 2003, 24: 659-671. 10.1016/S0248-8663(03)00211-X.CrossRefPubMed
Metadaten
Titel
Anti-SSA/Ro antibodies and the heart: more than complete congenital heart block? A review of electrocardiographic and myocardial abnormalities and of treatment options
verfasst von
Nathalie Costedoat-Chalumeau
Zahir Amoura
Elisabeth Villain
Laurence Cohen
Jean-Charles Piette
Publikationsdatum
01.12.2005
Verlag
BioMed Central
Erschienen in
Arthritis Research & Therapy / Ausgabe 2/2005
Elektronische ISSN: 1478-6362
DOI
https://doi.org/10.1186/ar1690

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