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Novel insights into myocardial fibrosis in patients with new onset ST-elevation myocardial infarction following percutaneous coronary intervention through enhanced cardiac magnetic resonance imaging: a prospective cohort study

BMC Cardiovascular Disorders volume 25, Article number: 274 (2025) Cite this article

Abstract

Background

Myocardial fibrosis is a prevalent pathological hallmark of a diverse range of chronic and acute cardiovascular disorders. However, the relevant literature currently provides limited evidence regarding the determinants of myocardial fibrosis severity in patients with new-onset ST-elevation myocardial infarction (STEMI) following successful emergent percutaneous coronary intervention (PCI) utilizing contrast-enhanced cardiac magnetic resonance imaging (CE-CMR).

Methods

We prospectively enrolled a cohort of 78 patients who presented with new-onset ST-segment elevation myocardial infarction and who underwent successful emergent PCI within 12 h from the onset of symptoms. Late gadolinium-enhanced LGE (LGE) was quantified via CE-CMR, and patients were categorized into two groups on the basis of the median LGE value.

Results

The median LGE was 16% (IQR 12 to 24). Compared with patients with LGE below the median (n = 37), those with LGE above the median (n = 41) presented significantly reduced left ventricular global radial strain(GRS), global circumferential strain(GCS), and global longitudinal strain(GLS) (all p < 0.05). The infarcted radial segment (IRS), infarcted circumferential segment (ICS) and infarcted longitudinal segment (ILS) were significantly reduced in patients with greater LGE (all p < 0.05). The occurrence rates of microvascular obstruction (MVO) (p < 0.001) and wall motion abnormality (WMA) (p < 0.01) were significantly greater in patients with a greater extent of LGE, despite successful reperfusion therapy. LGE exhibited a moderate negative correlation with the global circumferential segment (r=-0.547, p < 0.001) and a weak negative correlation with both the global radial segment and the global longitudinal segment (r=-0.434, p < 0.001; r=-0.437, p < 0.001). In the multivariable linear regression analysis model, the Gensini score (β = 0.258; p < 0.01), LVEF% (β=-0.269; p < 0.05), MVO (β = 0.343; p < 0.001) and GRS (β = 0.227; p < 0.05) emerged as robust predictors of myocardial fibrosis.

Conclusion

The present study revealed a correlation of cardiac pathological structure, microcirculation, and myocardial fibrosis in the context of acute myocardial infarction. Therefore, this study provides theoretical evidence from a pathological perspective regarding the progression of myocardial fibrosis in patients with new-onset STEMI following successful PCI.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2400080282; January 25th, 2024).

Peer Review reports

Introduction

The mechanisms underlying acute myocardial infarction (AMI) have been extensively investigated, and significant advancements have been made in recent decades [1]. Currently, our focus should be shifted from targeting a single “vulnerable plaque” as the primary intervention target, which can result in myocardial ischemia and coronary artery stenosis, to implementing a comprehensive intervention strategy for “vulnerable patients” [2,3,4,5,6,7]. Notably, according to the most recent Fingesture study, a significant number of individuals (97%) who were examined postmortem exhibited concomitant myocardial disease, specifically cardiac hypertrophy or myocardial fibrosis [8]. Thus, tissue characterization and the presence of myocardial fibrosis could help in identifying at-risk patients, especially those with ST-elevation myocardial infarction (STEMI) after successful percutaneous coronary intervention (PCI).

Clinically, imaging techniques are invaluable for identifying additional features of coronary atherosclerosis, including myocardial fibrosis, that precede adverse outcomes. Contrast-enhanced cardiac magnetic resonance imaging (CE-CMR) plays a crucial role in the diagnosis of myocardial fibrosis, and its ability to predict sudden cardiac death in patients with coronary artery disease is well established [9]. Moreover, the extent of myocardial fibrosis following STEMI can be precisely evaluated through late gadolinium enhancement (LGE) on CE-CMR [10]. Previous studies have provided clinical evidence demonstrating a correlation between the extent of LGE on CE-CMR during the acute phase and the outcomes of patients with STEMI [11, 12]. Additionally, CMR has emerged as a pivotal noninvasive imaging technique enabling the visualization and quantification of various prognostic cardiac pathological structures, including myocardial strain, microvascular obstruction (MVO), myocardial fibrosis, intramyocardial hemorrhage (IMH), left ventricular ejection fraction (LVEF), and wall motion abnormality (WMA) [13, 14]. However, the literature offers limited evidence on the factors influencing the severity of myocardial fibrosis in patients with newly diagnosed STEMI after PCI. Thus, in this study, we explored the relationship between cardiac physiological structures and myocardial fibrosis in patients with new-onset STEMI following successful PCI utilizing CE-CMR (Figs 1, 2, 3, 4, 5, 6, 7 and 8).

Fig. 1
figure 1

Flow diagram of the patient population

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Fig. 2
figure 2

Correlation analysis between the percentage of late gadolinium enhancement (LGE) and global circumferential strain (GCS)

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Fig. 3
figure 3

Correlation analysis between the percentage of late gadolinium enhancement (LGE) and global radial strain (GRS)

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Fig. 4
figure 4

Correlation analysis between the percentage of late gadolinium enhancement (LGE) and global longitudinal strain (GLS)

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Fig. 5
figure 5

A. A 65-year-old female patient with acute anterior and interventricular septal ST-elevation myocardial infarction (STEMI). Cardiac magnetic resonance imaging (CMR) revealed a high-intensity signal area (red arrow) of late gadolinium enhancement (%LGE = 26.23%) and a low-intensity area (white arrow) indicating microvascular obstruction (MVO) with a volume of 9.63 mL%. B. The corresponding left ventricular myocardial radial strain, circumferential strain, and longitudinal strain of the patient

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Fig. 6
figure 6

A. A 66-year-old female patient with acute ST-elevation myocardial infarction (STEMI). Cardiac magnetic resonance imaging (CMR) examination revealed a high-intensity signal area of late gadolinium enhancement (LGE) (Patient’s %LGE = 24.77%). B. The corresponding left ventricular myocardial radial strain, the left ventricular myocardial circumferential strain and the left ventricular myocardial longitudinal strain of the patient

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Fig. 7
figure 7

A. A 65-year-old male patient with acute anterior wall ST-elevation myocardial infarction (STEMI) underwent a cardiac magnetic resonance imaging (CMR) examination 7 days after interventional percutaneous transluminal coronary intervention (PCI). CMR revealed a high-intensity signal area (red arrow) of late gadolinium enhancement (LGE) (patient’s %LGE = 47.76%) and a low-intensity signal area (white arrow) of microvascular obstruction (MVO). B. The corresponding left ventricular myocardial radial strain, the left ventricular myocardial circumferential strain and the left ventricular myocardial longitudinal strain of the patient

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Fig. 8
figure 8

A 50-year-old patient with an anterior wall and interventricular septum myocardial infarction accompanied by microvascular obstruction (MVO). In the image, blue represents normal myocardium, yellow indicates infarcted myocardium, and orange–red highlights MVO within the infarct zone. CVI42 software was used to segment each myocardial layer, allowing precise determination of the infarct area and quantification of the volume of microcirculatory dysfunction

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Methods

Study population

We prospectively included patients with new-onset STEMI who were admitted to the First Affiliated Hospital of Bengbu Medical University between June 2022 and June 2024. All enrolled patients underwent emergent PCI for STEMI within 12 h of symptom onset. CMR was subsequently conducted between 5 and 7 days postsurgery for each patient. The patients were categorized into two distinct groups on the basis of their LGE with respect to the median LGE: the LGE < median group (n = 41) and the LGE ≥ median group (n = 37). STEMI was diagnosed according to the guidelines outlined by the European Society of Cardiology/American College of Cardiology (ESC/ACC) committee [15]. The exclusion criteria were as follows: a history of cardiac surgery, concomitant atrial fibrillation, frequent premature contractions, severe heart failure, sustained ventricular tachycardia, other tachyarrhythmias, previous myocardial infarction, valvular heart disease, severe hepatic or renal dysfunction, malignant neoplasm, life expectancy less than one year, infectious disease within the previous month, pregnancy, poor mental health, poor cooperation, significant chronic obstructive airway disease or inability to hold breath in expiration during image acquisition, presence of gadolinium contrast agent allergy, presence of ferromagnetic objects in the body, and claustrophobia. Informed consent was obtained from all participants. Our work is reported in line with the.

TRIPOD guidelines (Table S1).

Laboratory examination

Upon admission, detailed clinical data were collected, and peripheral venous blood samples were taken for laboratory examinations, including a complete blood count, routine biochemical parameters, troponin-I (TNI), D-dimer, creatine kinase isoenzymes, N-terminal pro-brain natriuretic peptide (NT-pro-BNP).

Coronary arteriography

A group of experienced attending physicians meticulously assessed the coronary anatomy and clinical condition of each patient to determine the appropriate revascularization method. The Gensini system was used to score the severity of vascular lesions on the basis of coronary angiography findings [16]. Two expert cardiologists independently performed the evaluation and calculations, seeking consultation from a third independent cardiologist when any discrepancies arose. All patients achieved Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow after PCI. Following successful revascularization, standardized medications for secondary prevention of coronary artery disease were administered to all patients prior to discharge.

CMR

CMR was performed by an accredited CMR operator using a Siemens 1.5 T MRI system. The agent used was gadopentetate dimeglumine injection (Gd-DTPA) [17] (Beijing Beilu Pharmaceutical Co., Ltd., National Drug Approval Number: H10960045) at a concentration of 469 mg/mL × 20 mL or 0.9% sodium chloride injection (normal saline; China Otsuka Pharmaceutical Co., Ltd., National Drug Approval Number: H12020010) at a concentration of 4.5 g/500mL.

Images were acquired at end expiration to obtain steady-state free precession cine sequences for each section. Gd-DTPA (469 mg/mL × 20 mL) was injected intravenously at a dose of 0.2 mmol/kg and a rate of 4.0 mL/s, followed by an equal volume of 0.9% normal saline solution.

For quantitative analysis of myocardial fibrosis, the percentage of late gadolinium enhancement (%LGE) was calculated. LGE images were acquired ten minutes after intravenous injection of Gd-DTPA using a breath-hold phase-sensitive segmented inversion recovery (PSIR) fast field echo sequence. The image acquisition parameters typically included a slice thickness of 6 mm, an interslice gap of 4 mm, and an in-plane resolution of 1.5 × 1.5 mm² [18]. All the images were postprocessed via cvi42 software for cardiac function analysis. Left ventricular functional and structural parameters were obtained through an automated feature-tracking method. The delineation of myocardial contours and the identification of LGE were performed with visual confirmation and, where necessary, manual adjustments were made to ensure accuracy. LGE quantification was based on the extent of enhancement relative to remote myocardium, and myocardial segments were evaluated according to the 17-segment model recommended by the American Heart Association (AHA). MVO was defined as an area of hypoenhancement within the hyperenhanced infarct region and was manually delineated on LGE images. The size of the MVO was not combined with the %LGE but was treated as a distinct area of interest, and its relationship with infarct size was assessed through independent analysis. Parameters such as left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), LVEF, and left ventricular mass were obtained according to the postprocessing standards published by the American Society of Cardiovascular Magnetic Resonance in 2013 [19]. The 3D global, segmental, radial, circumferential, and longitudinal strains of the myocardium were obtained using automated tracking technology [20].

Statistical analysis

All the data were analyzed using the IBM SPSS Statistics software (version 27.0). For categorical variables, comparisons between groups were performed via the chi-square test. For continuous data with a normal and nonnormal distribution, the t test and Mann‒Whitney U test were used for comparisons between groups, respectively. The results are presented as the means ± standard deviations for variables with a normal distribution and medians and interquartile ranges for variables with nonnormal distributions. Correlation analyses were conducted using Pearson and Spearman tests.

Univariable and multivariable linear regression analyses were conducted to determine the predictors of LGE. Multivariable regression was performed using only variables with a probability value < 0.05 in the univariable regression analyses.

Results

Baseline characteristics

A total of 78 patients (55 males and 23 females) with new-onset STEMI who underwent successful PCI were enrolled in the study. The mean age of the participants was 60.14 ± 12.35 years. Among the 78 patients, 37 patients (47.4%) had LGE values that were lower than the median value (LGE < median group), while 41 patients (52.6%) had LGE values that were greater than or equal to the median value (LGE ≥ median group). An overview of the baseline characteristics of these patients is provided in Table 1.

Table 1 Baseline characteristics
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Patients in the LGE ≥ median group had a significantly higher percentage of patients who were current smokers; low-density lipoprotein cholesterol (LDL-C), creatine kinase-MB (CK-MB) and TN-I levels; a longer symptom onset to reperfusion time; elevated NT pro-BNP levels; and increased Gensini scores (p < 0.05).

Comparisons of CMR parameters between the two groups

As shown in Table 2, the LGE ≥ median group presented significantly greater LVEDV and LVESV values (p < 0.05), lower LVEF values (p < 0.01), and greater myocardial masses, as well as significantly higher rates of MVO (p < 0.001) and WMA (p < 0.01). Patients in the LGE ≥ median group had lower global radial strain (GRS; p < 0.05), global circumferential strain (GCS) and global longitudinal strain (GLS; p < 0.01). Additionally, patients in the LGE ≥ median group had lower infarcted radial and circumferential strain (p < 0.01) as well as infarcted longitudinal strain (p < 0.05). The correlations between LGE and global strain were explored further. LGE was moderately negatively correlated with the GCS (r= -0.547, p < 0.001) and weakly negatively correlated with both the GRS and GLS (r= -0.434, p < 0.001; r= -0.437, p < 0.001).

Table 2 Analysis of the CMR parameters of the two groups
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Predictors of myocardial fibrosis

The results of the univariable and multivariable linear regression analyses for the prediction of myocardial fibrosis are presented in Table 3. Univariable linear regression analysis revealed significant associations between greater myocardial fibrosis and the following factors: TN-I level (β = 0.349; p < 0.01), NT-proBNP (β=-2.444; p < 0.01), Gensini score (β = 0.456; p < 0.001), LVEDV (β = 0.300; p < 0.01), LVESV (β = 0.496; p = 0.001), LVEF% (β=-0.589; p = 0.001), left ventricle myocardial mass (β = 0.379; p = 0.001), presence of MVO (β = 0.523; p < 0.001), WMA (β = 0.336; p < 0.01), GRS (β=-0.434; p < 0.001), GCS (β=-0.547; p < 0.001), GLS (β=-0.437; p = 0.001), infarcted radial segment (IRS) (β=-0.380; p < 0.001), infarcted circumferential segment (ICS) (β=-0.517; p = 0.001) and infarcted longitudinal segment (ILS) (β=-0.424; p < 0.001). The multivariable linear regression model was adjusted by incorporating variables found to be significant in the univariable analysis, with LGE serving as the dependent variable. Variables with probability values < 0.05 were selected for multivariable analysis (Table 3). In the multivariable analysis model, the Gensini score (β = 0.258; p < 0.01), LVEF% (β=-0.269; p < 0.05), MVO (β = 0.343; p < 0.001) and GRS (β = 0.227; p < 0.05) were the independent predictors of the extent of myocardial fibrosis.

Table 3 Univariable and multivariable linear regression analyses for the prediction of myocardial fibrosis
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Discussion

We comprehensively investigated multiple clinical aspects, including the overall and regional functioning of the left ventricle, as well as tissue characteristics, via CE-CMR in patients who experienced new-onset STEMI following successful PCI. We explored the complex interplay among cardiac pathological structures, microcirculatory function, and myocardial fibrosis in patients who developed new-onset STEMI after undergoing successful PCI. Despite the significant progress made in AMI management, the findings of this study emphasize the importance of adopting a comprehensive approach that extends beyond focusing solely on individual “vulnerable plaques” to encompassing a broader understanding of a “vulnerable myocardium”.

Myocardial fibrosis is a pathological process characterized by excessive deposition of extracellular matrix components, primarily collagen, within the myocardial tissue [21]. This phenomenon frequently occurs after myocardial injury, such as that induced by ischemic events such as AMI. Myocardial fibrosis can result in myocardial tissue stiffening, impaired contractility, and ultimately heart failure [21]. The presence and extent of myocardial fibrosis are critical determinants of patient outcomes, influencing both functional recovery and long-term outcomes.

CE-CMR has emerged as the gold-standard method for the noninvasive assessment of myocardial fibrosis [22]. LGE involves the acquisition of CMR images following the administration of a gadolinium contrast agent, which accumulates in tissues with increased extracellular space; this technique serves as an indicator of fibrosis in the ventricles [23]. LGE-CMR, in particular, allows precise quantification of fibrotic tissue, providing valuable insights into the extent and severity of myocardial damage. Understanding the factors that influence myocardial fibrosis is essential for improving patient management and outcomes following AMI. After AMI, myocardial tissue undergoes a dynamic and evolving response characterized by inflammation and edema. Previous studies have demonstrated that myocardial edema following AMI is closely associated with increased infarct size, contributing to adverse myocardial remodeling and the development of myocardial fibrosis, which can further impair myocardial function and long-term outcomes [24, 25]. Studies have shown that myocardial fibrosis after AMI, as observed by LGE-CMR, alters the structure of the heart, creating a substrate that is conducive to arrhythmias. Ongoing remodeling of the myocardium, driven by both structural and functional changes, further worsens cardiac function and contributes to long-term complications such as heart failure and persistent ventricular arrhythmias, which reinforces the importance of assessing infarct size as an important factor in identifying high-risk patients [32,33,38,29].

Importantly, the utilization of CE-CMR has become increasingly prevalent in the detection and evaluation of AMI. This technique facilitates the quantification of both the extent and transmurality of the infarct. LGE holds significant value, as it serves as a predictor of functional recovery following the restoration of blood flow in patients [30, 31]. Our findings indicated that individuals with greater LGE exhibited increased LVESV, LVEDV and left ventricular myocardial mass index, along with more pronounced impairments in LVEF and global peak strains [26,27,34]. In contemporary studies, myocardial strain analysis is recognized as a potent tool for precisely quantifying subtle and regional myocardial dysfunction, surpassing the limitations associated with ejection fraction assessment [35]. In this study, we compared the strain characteristics of the infarct zones of patients in the two groups. Our study revealed that patients with greater LGE exhibited lower IRS, ICS, and ILS, aligning with the findings of Podlesnikar et al. [36]. Furthermore, our study confirmed that the Gensini score, LVEF%, GCS and MVO are independent predictors of LGE in patients with AMI. Previous studies have shown that the occurrence of MVO after PCI in STEMI patients is closely related to mortality and hospitalization rates within 1 year [28, 37]. Another study revealed that among patients who underwent PCI for STEMI, those with MVO exhibited less favorable outcomes [38].

In our study, despite successful PCI, MVO and WMA were prevalent among patients with higher levels of LGE, and various studies have shown a robust correlation of infarct size, the presence of MVO within the infarcted area, and clinical outcomes in patients [29, 36,40,41]. Moreover, increased LGE was associated with both impaired function in the infarct zone and impaired global left ventricular function. Our study identified MVO, GCS, LVEF% and the Gensini score as independent predictors of infarct size in STEMI patients who underwent successful PCI. The findings of this study demonstrate that traditional risk stratification factors, such as the Gensini score and LVEF%, complement imaging-based parameters, including MVO and myocardial strain capacity. This integrated approach provides a more comprehensive evaluation of coronary disease burden, thereby improving clinical decision-making and risk prediction.

By employing CMR in combination with conventional risk assessment methods, we can more precisely evaluate the location and extent of myocardial infarction as well as the presence of viable myocardium. LGE-CMR enables the visualization of MVO and the quantification of its volume. Through tissue tracking technology, we can clearly delineate the structural changes in each myocardial segment in the radial, longitudinal, and circumferential directions; therefore, CMR offers a superior approach to the assessment of myocardial remodeling. The identification of independent predictors of myocardial fibrosis, including the Gensini score, LVEF%, MVO, and GCS, provides valuable insights for tailoring post-PCI management strategies. Early identification of patients at high risk for extensive fibrosis could facilitate targeted interventions aimed at mitigating adverse remodeling and improving long-term outcomes.

Study limitations

The present study was conducted at a single center and had a limited sample size, potentially limiting the generalizability of the findings to broader populations. Second, while efforts were made to control for confounding factors through rigorous multivariate analysis, it is important to acknowledge the potential presence of residual selection bias that may not have been entirely mitigated. Third, the duration of patient follow-up in the study was not long enough to sufficiently evaluate their risk.

Conclusion

This study revealed a significant relationship of cardiac pathological structures, microcirculatory function, and the extent of myocardial fibrosis in the setting of AMI after successful PCI.

Data availability

Individual participant data that underlie the results reported in this article, after de-identification can be obtained from the corresponding author upon reasonable request.

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Acknowledgements

None.

Funding

This work was supported by grants from the Clinical Research Transformation Project of Anhui Province (202304295107020086), the Key Project of Natural Science Research of the Anhui Provincial Department of Education (2022AH051477), and the First Affiliated Hospital of Bengbu Medical University 2022 high-tech (2022050) and 512 Talent Cultivation Program (No. 51201317).

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Authors and Affiliations

  1. Department of Cardiovascular Diseases, The First Affiliated Hospital of Bengbu Medical University, Bengbu, 233004, China

    Temilola J. Oketunbi, Jun Wang, Bin Ding, Xilong Song, Yao Li, Xiaojun Shi, Sigang Hu, Dasheng Gao, Hongju Wang & Miaonan Li

  2. Department of Radiology, The First Affiliated Hospital of Bengbu Medical University, Bengbu, 233004, China

    Hongwei Song

Authors
  1. Temilola J. Oketunbi
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Contributions

H.W. and M.L. conceived and performed the study. B.D., X.S., Y.L., H.S., X.S, S.H, D.G. participated in the design of the study and performed the clinical study. T.O. and W.J. wrote the manuscript and analysis and interpretation of the data. All authors agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Miaonan Li.

Ethics declarations

Ethical approval

This study was approved by the Ethics Committee of the First Affiliated Hospital of Bengbu Medical University ([2023]KY046).

Informed consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patients. A copy of the consent form is available for review by the editor of this journal.

Guarantor

The scientific guarantor of this publication is Hongju Wang.

Statistics and biometry

Miaonan Li and Jun Wang kindly provided statistical advice for this manuscript. No complex statistical methods were necessary for this study.

Study subject or cohort overlap

None.

Methodology

Methodology: Prospective. prognostic study/observational. Performed at one institution.

Competing interests

The authors declare no competing interests.

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Oketunbi, T.J., Wang, J., Ding, B. et al. Novel insights into myocardial fibrosis in patients with new onset ST-elevation myocardial infarction following percutaneous coronary intervention through enhanced cardiac magnetic resonance imaging: a prospective cohort study. BMC Cardiovasc Disord 25, 274 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12872-025-04719-3

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Keywords

BMC Cardiovascular Disorders

ISSN: 1471-2261

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