Medical & Biological Engineering & Computing

, Volume 52, Issue 4, pp 375–391 | Cite as

Evaluation of ventricular repolarization dispersion during acute myocardial ischemia: spatial and temporal ECG indices

  • Pedro David AriniEmail author
  • Fabricio Hugo Baglivo
  • Juan Pablo Martínez
  • Pablo Laguna
Original Article


In this work, we studied the evolution of different electrocardiogram (ECG) indices of ventricular repolarization dispersion (VRD) during acute transmural myocardial ischemia in 95 patients undergoing percutaneous coronary intervention (PCI). We studied both temporal indices of VRD (T-VRD), based on the time intervals of the ECG wave, and spatial indices of VRD (S-VRD), based on the eigenvalues of the spatial correlation matrix of the ECG. The T-wave peak-to-end interval I TPE index showed statistically significant differences during left anterior descending artery and right coronary artery (RCA) occlusion for almost the complete time course of the PCI procedure with respect to the control recording. Regarding S-VRD indices, we observed statistically significant increases in the ratio of second to the first eigenvalue I T21, the ratio of the third to the first eigenvalue I T31 and the T-wave residuum I TWR during RCA occlusions. We also found a statistically significant increase in the I T31 during left circumflex artery occlusions. To evaluate the evolution of VRD indices during acute ischemia, we calculated the relative change parameter R I for each index I. Maximal relative changes (R I ) during acute ischemia were found for the S-VRD indices I T21, the first eigenvalue I λ1 and the second eigenvalue I λ2, with changes 64, 57 and 52 times their baseline range of variation during the control recording, respectively. Also, we found that relative changes with respect to the baseline were higher in patients with T-wave alternans (TWA) than in those without TWA. In conclusion, results suggest that I TPE as well as I T21, I T31 and I TWR are very responsive to dispersion changes induced by ischemia, but with a behavior which very much depends on the occluded artery.


Ischemia Repolarization dispersion PCA 



Two dimensional


Three dimensional


Acute myocardial infarction


Action potential duration


Coronary artery disease






Left anterior descending artery


Left circumflex artery


Left main artery


Monophasic action potential


Myocardial infarction


Principal component analysis


Percutaneous coronary intervention


Right coronary artery


Sudden cardiac death


Standard error mean


Single-photon emission computed tomography


Database of the ECG signals


ST-segment elevation myocardial infarction


Singular value decomposition


Spatial indices of ventricular repolarization dispersion


Total population


Temporal indices of ventricular repolarization dispersion


T-wave alternans




Ventricular repolarization dispersion


Standard deviation of I index at control recording




First eigenvalue


Second eigenvalue


Third eigenvalue


Ratio of the second to the first eigenvalues


Ratio of the third to the first eigenvalues


Multilead T-wave width


Total energy of the T-wave


T-wave peak-to-end in the lead with maximal level of ST-segment


T-wave width in the lead with maximal level of ST-segment


T-wave residuum


Relative variation of the index I

\(\hbox{ST}_{\rm J+60}\)

ST level measured at J-point plus 60 ms


T-wave end


T-wave onset


T-wave peak



This work was supported by the Ministerio de Ciencia e Innovación, Spain, under Projects TEC2010-21703-C03-02, by the Diputación General de Aragón, Spain, through Grupos Consolidados GTC and Fondo Social Europeo ref: T30, by Instituto de Salud Carlos III, Spain, through CIBER CB06/01/0062. This work was also funded by the Consejo Nacional de Investigaciones Científicas y Técnicas (PIP-538) and Agencia Nacional de Promoción Científica y Tecnológica (PICT 2008 nro. 2108), Argentina.


  1. 1.
    Acar B, Yi G, Hnatkova K, Malik M (1999) Spatial, temporal and wavefront direction characteristics of 12-lead T-wave morphology. Med Biol Eng Comput 37:574–584CrossRefPubMedGoogle Scholar
  2. 2.
    Antzelevitch C, Shimizu W, Yan GX, Sicouri S, Weissenburger J, Nesterenko VV, Burashnikov A, Di Diego J, Saffitz J, Thomas GP (1999) The M cell: its contribution to ECG and to normal and abnormal electrical function of the heart. J Cardiovasc Electrophysiol 10:1124–1152CrossRefPubMedGoogle Scholar
  3. 3.
    Arini PD, Bertrán GC, Valverde ER, Laguna P (2008) T-wave width as an index for quantification of ventricular repolarization dispersion: evaluation in an isolated rabbit heart model. Biomed Signal Proc Control 3:67–77CrossRefGoogle Scholar
  4. 4.
    Arini PD, Quinteiro RA, Valverde ER, Bertrán GC, Biagetti MO (2000) Evaluation of QT interval dispersion in a multiple electrodes recording system versus 12-lead standard ECG in an in vitro model. Ann Noninvasive Electrocardiol 5(2):125–132CrossRefGoogle Scholar
  5. 5.
    Arini PD, Quinteiro RA, Valverde ER, Bertrán GC, Biagetti MO (2001) Differential modulation of electrocardiographic indices of ventricular repolarization dispersion depending on the site of pacing during premature stimulation. J Cardiovasc Electrophysiol 12:36–42CrossRefPubMedGoogle Scholar
  6. 6.
    Ashman R, Byer E (1943) The normal human ventricular gradient. II. Factors which affect its manifiest area and its relationship to the manifest area of the QRS complex. Am Heart J 25:36–57CrossRefGoogle Scholar
  7. 7.
    Aufderheide TP, Reddy S, Dhala A, Thakur RK, Brady WJ, Rowlandson I (1997) QT dispersion and principal component analysis on prehospital patients with chest pain. In: Computers in cardiology, vol 24. IEEE Computer Society Press, Lund, pp 665–668Google Scholar
  8. 8.
    Badilini F, Fayn J, Maison-Blanche P (1997) Quantitative aspects of ventricular repolarization: relationship between three dimensional T-wave loop morphology and scalar QT dispersion. Ann Noninvasive Electrocardiol 2(2):146–157CrossRefGoogle Scholar
  9. 9.
    Badilini F, Maison-Blanche P, Fayn J, Forlini MC, Rubel P, Coumel P (1995) Relationship between 12-lead ECG QT dispersion and 3D-ECG repolarization loop. In: Computers in cardiology, vol 22. IEEE Computer Society Press, Michigan, pp 785–788Google Scholar
  10. 10.
    Batdorf BH, Feiveson AH, Schlegel TT (2006) The effect of signal averaging on the reproducibility and reliability of measures of T- wave morphology. J Cardiovasc Electrophysiol 39:266–270Google Scholar
  11. 11.
    Bidoggia H, Maciel J, Capalozza N, Mosca S, Blaksley E, Valverde E, Bertrán G, Arini PD, Biagetti M, Quinteiro R (2000) Sex-dependent electrocardiographic pattern of cardiac repolarization. Am Heart J 140:430–436CrossRefPubMedGoogle Scholar
  12. 12.
    Bortolan G, Cristov I (2001) Myocardial infarction and ischemia characterization from T-loop morphology in VCG. In: Computers in cardiology, vol 28. IEEE Computer Society Press, Rotterdam, pp 633–636Google Scholar
  13. 13.
    Brennan TP, Tarassenko L (2012) Review of T-wave morphology-based biomarkers of ventricular repolarization using the surface electrocardiogram. Biomed Signal Proc Control 7:278–284CrossRefGoogle Scholar
  14. 14.
    Coronel R, Fiolet JW, Wilms-Schopman FJ, Schaapherder AF, Johnson TA, Gettes LS, Janse MJ (1988) Distribution of extracellular potassium and its relations to electrophysiologic changes during acute myocardial ischemia in the isolated perfused porcine heart. Circulation 77:1125–1138CrossRefPubMedGoogle Scholar
  15. 15.
    Downar E, Janse MJ, Durrer D (1977) The effect of acute coronary artery occlusion on subepicardial transmembrane potentials in the intact porcine heart. Circulation 56:217–223CrossRefPubMedGoogle Scholar
  16. 16.
    Franz MR, Flaherty JT, Platia EV, Bulkley BH, Weisfeldt ML (1984) Localization of regional myocardial ischemia by recording monophasic action potentials. Circulation 69:593–604CrossRefPubMedGoogle Scholar
  17. 17.
    Fuller MS, Sándor G, Punske B, Taccardi B, MacLeod R, Ershler PR, Green LS, Lux RL (2000) Estimation of repolarization dispersion from electrocardiographic measurements. Circulation 102:685–691CrossRefPubMedGoogle Scholar
  18. 18.
    García J, Lander P, Sörnmo L, Olmos S, Wagner G, Laguna P (1998) Comparative study of local and Karhunen–Loève-based ST-T indexes in recording from human subjects with induced myocardial ischemia. Comp Biomed Res 31:271–292CrossRefGoogle Scholar
  19. 19.
    Haarmark C, Hansen PR, Vedel-Larsen E, Pedersen SH, Graff C, Andersen MP, Toft E, Wang F, Struijk JJ, Kanters JK (2009) The prognostic value of T peakT end in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. J. Electrocardiol 42:555Google Scholar
  20. 20.
    Hohnloser SH, Klingenheben T, Yi-Gang L, Zabel M, Peetermans J, Cohen RJ (1998) T-wave alternans as a predictor of recurrent ventricular tachyarrhythmias in ICD recipients: prospective comparison with conventional risk markers. J Cardiovasc Electrophysiol 9:1258–1268CrossRefPubMedGoogle Scholar
  21. 21.
    Huebner T, Schuepbach WM, Seeck A, Sanz E, Meier B, Voss A, Pilgram R (2010) Cardiogoniometric parameters for detection of coronary artery disease at rest as a function of stenosis localization and distribution. Med Biol Eng Comput 48:435–446CrossRefPubMedGoogle Scholar
  22. 22.
    Janse MJ, Capucci A, Coronel R, Fabius MA (1985) Variability of recovery of excitability in the normal and ischaemic porcine heart. Eur Heart J 6(Suppl):41–52Google Scholar
  23. 23.
    Janse MJ, Wit AL (1989) Electrophysiological mechanisms of ventricular arrhythmias resulting from myocardial ischemia and infarction. Physiol Rev 69:1049–1069PubMedGoogle Scholar
  24. 24.
    John RM, Taggart P, Sutton PM, Ell PJ, Swanton H (1992) Direct effect of dobutamine on action potential duration in ischemic compared to normal areas in the human ventricle. J Am Coll Cardiol 20:896–903CrossRefPubMedGoogle Scholar
  25. 25.
    Karjalainen J, Viitasalo M, Manttari M, Manninen V (1994) Relation between QT intervals and heart rates from 40 to 120 beats min in rest electrocardiograms of men and a simple method to adjust QT interval values. J Am Coll Cardiol 23(7):1547–1553CrossRefPubMedGoogle Scholar
  26. 26.
    Kimura S, Bassett AL, Kohya T, Kozolovskis PL, Myerburg RJ (1986) Simultaneous recording of action potential from endocardium and epicardium during ischemia in the isolated cat ventricle: relation of temporal electrophysiologic heterogeneities to arrhytmias. Circulation 2:401–409CrossRefGoogle Scholar
  27. 27.
    Kingaby RO, Lab MJ, Cole AW, Palmer TN (1986) Relation between monophasic action potential duration, ST segment elevation and regional myocardial blood flow after coronary occlusion in the pig. Cardiovasc Res 20:740–751CrossRefPubMedGoogle Scholar
  28. 28.
    Kuo CS, Munakata K, Reddy P, Surawicz B (1983) Characteristics and possible mechanism of ventricular arrhythmia dependent on the dispersion of action potential. Circulation 67:1356–1367CrossRefPubMedGoogle Scholar
  29. 29.
    Laguna P, Jané R, Caminal P (1994) Automatic detection of wave boundaries in multilead ECG signals: validation with the CSE. Comp Biomed Res 27:45–60CrossRefGoogle Scholar
  30. 30.
    Lemire D, Pharand C, Rajaonah JC, Dube B, LeBlanc AR (2000) Wavelet time entropy, T wave morphology and myocardial ischemia. IEEE Trans Biomed Eng 47:967–970CrossRefPubMedGoogle Scholar
  31. 31.
    Letsas KP, Weber R, Astheimer K, Kalusche D, Arentz T (2010) T peakT end interval and T peakT end/QT ratio as markers of ventricular tachycardia inducibility in subjects with Brugada ECG phenotype. Europace 12:271CrossRefPubMedGoogle Scholar
  32. 32.
    Lukas A, Antzelevitch C (1993) Differences in the electrophysiological response of canine ventricular epicardium and endocardium to ischemia: role of the transient outward current. Circulation 88:2903–2915CrossRefPubMedGoogle Scholar
  33. 33.
    Malik M, Acar B, Gang Y, Yap YG, Hnatkova K, Camm AJ (2000) QT dispersion does not represent electrocardiographic interlead heterogeneity of ventricular repolarization. J Cardiovasc Electrophysiol 11:835–843CrossRefPubMedGoogle Scholar
  34. 34.
    Martínez JP, Almeida R, Olmos S, Rocha AP, Laguna P (2004) A wavelet-based ECG delineator: evaluation on standard databases. IEEE Trans Biomed Eng 4:570–581CrossRefGoogle Scholar
  35. 35.
    Martínez JP, Olmos S, Wagner G, Laguna P (2005) Characterization of repolarization alternans during ischemia: time-course and spatial analysis. IEEE Trans Biomed Eng 53(4):701–711CrossRefGoogle Scholar
  36. 36.
    Merri M, Benhorin J, Alberti M, Locati E, Moss AJ (1989) Electrocardiographic quantitation of ventricular repolarization. Circulation 80:1301–1308CrossRefPubMedGoogle Scholar
  37. 37.
    Mincholé A, Pueyo E, Rodriguez JF, Zacur E, Doblaré M, Laguna P (2011) Quantification of restitution dispersion from the dynamic changes of the T wave peak to end, measured at the surface ECG. IEEE Trans Biomed Eng 58(5):1172–1182CrossRefPubMedGoogle Scholar
  38. 38.
    Moody GB, Mark RG (1982) Development and evaluation of a 2 lead ECG analysis program. In: Computers in cardiology, vol 9. IEEE Computer Society Press, Seattle, Washington, pp 39–44Google Scholar
  39. 39.
    Okada J, Washio T, Maehara A, Momomura S, Sugiura S, Hisada T (2011) Transmural and apicobasal gradients in repolarization contribute to T-wave genesis in human surface ECG. Am J Physiol Heart Circ Physiol 301:H200–H208CrossRefPubMedGoogle Scholar
  40. 40.
    Okin PM, Devereux RB, Lee ET, Galloway JM, Howard BV (2004) Electrocardiographic repolarization complexity and abnormality predict all-cause and cardiovascular mortality in diabetes: the strong heart study. Diabetes 53:434–440CrossRefPubMedGoogle Scholar
  41. 41.
    Okin PM, Xue Q, Reddy S, Kligfield P (2000) Electrocardiographic quantitation of heterogeneity of ventricular repolarization. Ann Noninvasive Electrocardiol 5(1):79–87CrossRefGoogle Scholar
  42. 42.
    Perry RA, Seth A, Hunt A, Smith SC, Westwood E, Woolgar N, Shiu MF (1989) Balloon occlusion during coronary angioplasty as a model of myocardial ischaemia: reproducibility of sequential inflations. Eur Heart J 10:791–800PubMedGoogle Scholar
  43. 43.
    Priori S, Mortara D, Napolitano C, Diehl L, Paganini V, Cantu F, Cantu G, Schwartz P (1997) Evaluation of the spatial aspects of T wave complexity in the long-QT syndrome. Circulation 96:3006–3012CrossRefPubMedGoogle Scholar
  44. 44.
    Ringborn M, Pettersson J, Persson E, Warren SG, Platonov P, Pahlm O, Wagner GS (2010) Comparison of high-frequency QRS components and ST-segment elevation to detect and quantify acute myocardial ischemia. J Electrocardiol 43(2):113–120CrossRefPubMedGoogle Scholar
  45. 45.
    Romero D, Ringborn M, Laguna P, Pahlm O, Pueyo E (2011) Depolarization changes during acute myocardial ischemia by evaluation of QRS slopes: standard lead and vectorial approach. IEEE Trans Biomed Eng 58:110–120CrossRefPubMedGoogle Scholar
  46. 46.
    Rubulis A, Jensen J, Lundahl G, Tapanainen J, Wecke L, Bergfeldt L (2004) T vector and loop characteristics in coronary artery disease and during acute ischemia. Heart Rhythm 3:317–325CrossRefGoogle Scholar
  47. 47.
    Rubulis A, Jensen SM, Näslund U, Lundahl G, Jensen J, Bergfeldt L (2010) Ischemia-induced repolarization response in relation to the size and location of the ischemic myocardium during short-lasting coronary occlusion in humans. J Electrocardiol 43:104–112CrossRefPubMedGoogle Scholar
  48. 48.
    Saba MM, Arain SA, Lavie CI, Abi-Samra FM, Ibrahim SS, Ventura HO, Milani RV (2005) Relation between left ventricular geometry and transmural dispersion of repolarization. Am J Cardiol 96:952–955CrossRefPubMedGoogle Scholar
  49. 49.
    Savelieva I, Yap YG, Yi G, Guo X, Camm AJ, Malik M (1998) Comparative reproducibility of QT, QT peak, and T peakT end intervals and dispersion in normal subjects, patients with myocardial infarction, and patients with hypertrophic cardiomyopathy. Pacing Clin Electrophysiol 21:2376–2382CrossRefPubMedGoogle Scholar
  50. 50.
    Schupbach WM, Emese B, Loretan P, Mallet A, Duru F, Sanz E, Meier B (2008) Non-invasive diagnosis of coronary artery disease using cardiogoniometry performed at rest. Swiss Med Wkly 138(15):210–218Google Scholar
  51. 51.
    Shimizu W, Antzelevitch C (1997) Sodium channel block with mexiletine is effective in reducing dispersion of repolarization and preventing torsades de pointes in LQT2 and LQT3 models of the long-QT syndrome. Circulation 96:2038–2047CrossRefPubMedGoogle Scholar
  52. 52.
    Shimizu W, Antzelevitch C (1998) Cellular basis for the ECG features of the LQT1 form of the long QT syndrome. Efects of β adrenergic agonist and antagonist and sodium channel blockers on transmural dispersion of repolarization and torsades de pointes. Circulation 98:2314–2322CrossRefPubMedGoogle Scholar
  53. 53.
    Smetana P, Batchvarov V, Hnatkova K, Camm AJ, Malik M (2004) Ventricular gradient and nondipolar repolarization components increase at higher heart rate. Am J Physiol Heart Circ Physiol 286:H131–H136CrossRefPubMedGoogle Scholar
  54. 54.
    Smetana P, Batchvarov VN, Hnatkova K, Camm J, Malik M (2002) Sex differences in repolarization homogeneity and its circadian pattern. Am J Physiol Heart Circ Physiol 282:H1889–H1897PubMedGoogle Scholar
  55. 55.
    Smetana P, Schmidt A, Zabel M, Hnatkova K, Franz M, Huber K, Malik M (2011) Assessment of repolarization heterogeneity for prediction of mortality in cardiovascular disease: peak to the end of the T wave interval and nondipolar repolarization components. J Electrocardiol 44:301–308CrossRefPubMedGoogle Scholar
  56. 56.
    Surawicz B (1997) Ventricular fibrillation and dispersion of repolarization. J Cardiovasc Electrophysiol 8:1009–1012CrossRefPubMedGoogle Scholar
  57. 57.
    Taggart P, Sutton P (2000) Role of ischemia on dispersion of repolarization. In: Dispersion of ventricular repolarization: state of the art. Futura, Armonk, NYGoogle Scholar
  58. 58.
    Taggart P, Sutton P, Runnalls M, O’Brien W, Donaldson R, Hayward R, Swanton H, Emanuel R, Treasure T (1986) Use of monophasic action potential recordings during routine coronary artery bypass surgery as an index of localised myocardial ischaemia. Lancet 1:1462–1464CrossRefPubMedGoogle Scholar
  59. 59.
    Taggart P, Sutton PM, Boyett MR, Swanton H (1996) Human ventricular action potential duration during short and long cycles. Rapid modulation by ischemia. Circulation 94:2526–2534CrossRefPubMedGoogle Scholar
  60. 60.
    Taggart P, Sutton PM, Spear DW, Drake HF, Swanton RH, Emanuel RW (1988) Simultaneous endocardial and epicardial monophasic action potential recordings during brief periods of coronary artery ligation in the dog: influence of adrenaline, beta blockade and alpha blockade. Cardiovasc Res 12:900–909CrossRefGoogle Scholar
  61. 61.
    Taggart P, Sutton PM, John R, Hayward R, Swanton H (1989) The epicardial electrogram: a quantitative assessment during balloon angioplasty incorporating monophasic action potentials recordings. Br Heart J 62:342–352CrossRefPubMedCentralPubMedGoogle Scholar
  62. 62.
    Noble D, Cohen I (1978) The interpretation of the T wave of the electrocardiogram. Cardiovasc Res 12:13–27CrossRefPubMedGoogle Scholar
  63. 63.
    Vassallo JA, Cassidy DM, Kindwall KE, Marchlinski FE, Josephon ME (1988) Nonuniform recovery of excitability in the left ventricle. Circulation 78:1365–1372CrossRefPubMedGoogle Scholar
  64. 64.
    Viitasalo M, Oikarinen L, Swan H, Väänänen H, Glatter K, Laitinen PJ, Kontula K, Barron HV, Toivonen L, Scheinman MM (2002) Ambulatory electrocardiographic evidence of transmural dispersion of repolarization in patients with long-QT syndrome types 1 and 2. Circulation 106:2073–2079CrossRefGoogle Scholar
  65. 65.
    Watanabe N, Kobayashi Y, Tanno K, Miyoshi F, Asano T, Kawamaru M, Mikami Y, Adachi T, Ryu S, Miyata A, Katagiri T (2004) Transmural dispersion of repolarization and ventricular tachyarrhythmias. J Electrocardiol 37:191–200CrossRefPubMedGoogle Scholar
  66. 66.
    Xue J, Farrell R, Wright S, Kesek M (2005) Are nondipolar components of electrocardiogram correlated to repolarization abnormality in ischemic patients or to noise? J Electrocardiol 33:39–45CrossRefGoogle Scholar
  67. 67.
    Yan G, Antzelevitch C (1998) Cellular basis for the normal T wave and the electrocardiographic manifestation of the long-QT syndrome. Circulation 98:1928–1936CrossRefPubMedGoogle Scholar
  68. 68.
    Yan G, Jack M (2003) Electrocardiographic T wave: a symbol of transmural dispersion of repolarization in the ventricles. J Cardiovasc Electrophysiol 14:639–640CrossRefPubMedGoogle Scholar
  69. 69.
    Yang TF, Macfarlane PW (1994) Comparison of the derived vectorcardiogram in apparently healthy whites and Chinese. Chest 106:1014–1020CrossRefPubMedGoogle Scholar
  70. 70.
    Zabel M, Acar B, Klingenheben T, Franz MR, Hohnloser SH, Malik M (2000) Analysis of 12-lead T wave morphology for risk stratification after myocardial infarction. Circulation 102:1252–1257CrossRefPubMedGoogle Scholar
  71. 71.
    Zabel M, Malik M, Hnatkova K, Papademetriou MD, Pittaras A, Fletcher RD, Franz MR (2002) Analysis of T-wave morphology from the 12-lead electrocardiogram for prediction of long-term prognosis in male US veterans. Circulation 105:1066–1070CrossRefPubMedGoogle Scholar
  72. 72.
    Zareba W, Couderc J, Moss A (2000) Automatic detection of spatial and temporal heterogeneity of repolarization. In: Dispersion of ventricular repolarization: state of the art. Futura, Armonk, NY, pp 85–107Google Scholar

Copyright information

© International Federation for Medical and Biological Engineering 2014

Authors and Affiliations

  • Pedro David Arini
    • 1
    • 2
    Email author
  • Fabricio Hugo Baglivo
    • 3
  • Juan Pablo Martínez
    • 4
    • 5
  • Pablo Laguna
    • 4
    • 5
  1. 1.Argentine Institute of Mathematics‘Alberto P. Calderón’ (CONICET)Buenos AiresArgentina
  2. 2.Biomedical Engineering Institute, School of EngineeringUniversity of Buenos Aires (UBA)Buenos AiresArgentina
  3. 3.Electronic Engineering Department, School of EngineeringUniversity of Buenos Aires (UBA)Buenos AiresArgentina
  4. 4.Communications Technology Group (GTC), Aragón Institute of Engineering Research (I3A), IIS AragónUniversity of ZaragozaZaragozaSpain
  5. 5.Biomedical Research Networking Center in BioengineeringBiomaterials and Nanomedicine (CIBER-BBN)ZaragozaSpain

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