1 CARDIAC SURGERY A Guide for Patients and Their Families HEART & VALVE CENTER
2 Table of Contents My Personal Information Baptist Health Lexington A. Services B. Our Cardiac Nurse Navigators The Heart and Heart Disease A. The Function of the Heart B. Coronary Artery Disease and Treatment C. Heart Surgery D. Valve Surgery E. TAVR Surgery F Minimally Invasive Heart Surgery G. Atrial Fibrillation The Day of Surgery A. Preparing for Surgery B. The Morning of Surgery After Surgery A. Intensive Care Unit B. Telemetry Unit Going Home After Surgery A. General B. Incision Care C. Medication D. Activity E. Diet F. Emotions G. Cardiac Risk Factors H. Follow-Up Appointments I. Things to Remember President, William G. Sisson Thank you for choosing one of the top-ranked cardiac surgery programs in the country. According to the Society of Thoracic Surgeons (STS), Baptist Health Lexington s cardiac surgery program ranks within the top 14% of programs in the country for quality and successful patient outcomes. We want our community to know world-class health care is right here at home. Our basis for success is built upon a foundation of expertly skilled physicians, nursing and support staff and leading-edge technology. The Heart and Valve Center brings together skilled specialists in cardiology, cardiac surgery and interventional cardiology to provide unsurpassed care. This cardiac surgery educational guide provides an overview for you and your family. It is designed to offer answers to questions and concerns you may have about your surgery. In addition to this guide, our cardiac surgery nurse navigator, physicians, nurses and staff will give you instructions and information regarding your surgery or procedure.
4 My Personal Information Use this worksheet to keep a list of your primary care physician and other health providers, as well as their contact information. You may include dentists, eye doctors and other specialists, as well as pharmacists. My Primary Care Physician Physician Name Office Address City State Zip Office Phone Number Date of Next Appointment Nurse/PA Receptionist Other Doctors Doctor Name Office Address City State Zip Office Phone Number Date of Next Appointment Doctor Name Office Address City State Zip Office Phone Number Date of Next Appointment Cardiac Surgery Nurse Navigator Name Phone Number: (VALV) or (CABG) My Pharmacy Store Name Address City State Zip Phone Number Pharmacist s Name Store Name Address City State Zip Phone Number Pharmacist s Name My Allergies
5 My Personal Information Use this chart to keep track of key information from your doctor s appointments. You can fill it in yourself, or ask your doctor or a nurse for assistance. Date of Visit Age Weight Height Blood Pressure Cholesterol Use this worksheet to keep track of any medications you are currently taking. Medication Name Prescribed By Strength Dosage Date started/how long taking Supplements Supplement Name Reason for taking Be sure to ask your doctor about substituting generic drugs for any brand-name prescription drugs you take. Generic drugs have the same active ingredients as brand-name drugs, but your cost is usually lower.
6 Services At Baptist Health Lexington, we strive to provide the best quality care for our patients. Our Heart & Valve Program offers the skills and experience of board-certified cardiovascular physicians, nurse practitioners (APRNs), cardiac nurses and other healthcare professionals allowing: Collaborative management of the patient with the referring physician Evaluation by board-certified cardiologists in valve imaging Treatment recommendations, including medical therapy and anticoagulation for high-risk patients Intervention options, including catheter-based interventions, minimally invasive surgery, open heart surgery and transcatheter aortic valve replacement (TAVR) Second opinions regarding diagnosis of heart and valve disease severity and the timing and type of recommended intervention Cardiac genetic screening Cutting-edge imaging technology including heart catheterization lab At Baptist Health Lexington, we evaluate, treat and manage patients with a broad spectrum of heart diseases, focusing on patients with advanced disease states or coexisting medical conditions. Our Awards and accreditations illustrate our emphasis on quality.
7 Our Cardiac Nurse Navigators Serving as a link between physicians and patients and their families, our nurse navigators are nurse practitioners who follow you through the continuum of care. By supporting and guiding, the nurse navigators ease the stress and help with questions and education after diagnosis and throughout treatment. Our nurse navigators also ensure easy access and convenience for you and your referring physician by coordinating: A prompt and thorough evaluation of your condition Immediate access to our physicians/surgeons Your progress through the program Detailed reporting to, and follow-up with, your primary referring physician and/or cardiologist
8 The Function of the Heart Your heart is an amazing organ. Shaped like an upside-down pear, this fist-sized powerhouse pumps 5 or 6 quarts of blood each minute to all parts of the body. Your heart pumps blood through a network of blood vessels that carry the blood through the body. The heart and network of blood vessels is called the circulatory system. Blood is essential because it carries oxygen and nutrients to your body s tissues. Blood is needed to keep your body s tissues alive and functioning.
9 What does a normal heart look like? Outside View The walls of the heart are made of muscle. The strong muscular walls squeeze, pumping blood into the arteries. Inside View The heart is a four-chambered, hollow organ. The septum is a muscular wall that divides the heart into the right and left sides. The heart consists of: Two atria which are the top chambers of the heart that receive blood from the veins. Two ventricles which are the bottom chambers of the heart that pump blood into the arteries. The left ventricle is the major pumping chamber of the heart.
10 How Heart Function is Evaluated Feel your pulse Your healthcare provider feels your pulse in order to check your heart s rate, rhythm and regularity. Each pulse matches up with a heartbeat that pumps blood into the arteries. The force of the pulse also helps evaluate the strength of blood flow to different areas of your body. Listen to your heart Your doctor listens to your heart with a stethoscope. The opening and closing of your valves make sounds known as the heart sounds. The doctor can check your heart and valve function and hear your heart s rate and rhythm by listening to your heart sounds. Check your blood pressure Blood pressure measures the force of the blood in the arteries as it is pumped throughout the body by the heart. It is recorded as two measurements: Systolic Pressure: Pressure in the arteries when the heart pumps blood (the top number) Diastolic Pressure: Pressure in the arteries when the heart relaxes between heartbeats (the bottom number) Measure your ejection fraction Ejection Fraction (EF) is a test that determines how well your heart pumps with each beat. An echocardiogram, an ultrasound of the heart, can determine your ejection fraction. A normal heart pumps a little more than half the heart s blood with each beat. The EF may be lower than normal when the heart muscle has become damaged due to a Ejection Fraction Measurement What it means 50-70% Normal 41-49% Below normal 35-40% May confirm diagnosis of systolic heart failure Less than 35% You may be at risk of life-threatening heartbeats heart attack or heart muscle disease. The lower your EF, the weaker your heart is pumping. Your EF can go up and down, based on your heart condition, procedures that have been performed, and the medications that have been prescribed. Medications or surgery can help.
11 Coronary Artery Disease and Treatment The Coronary Arteries The heart receives its own supply of blood from the coronary arteries. Two major coronary arteries branch off from the aorta (the largest artery in the body) near the point where the aorta and the left ventricle (the main pumping chamber of the heart) meet. These arteries and their branches supply all parts of the heart muscle with blood. Some coronary arteries are larger and provide the heart more blood. Coronary Artery Disease What is coronary artery disease? Coronary artery disease is a thickening of the walls of the blood vessels due to a buildup of plaque which decreases blood flow to the heart. This can be compared to rust and sludge building up in plumbing. Normal artery Narrowing of artery Normal blood flow Plaque Artery Wall Plaque What causes coronary artery disease? Some causes (risk factors) of coronary artery disease are classified as changeable or unchangeable. Abnormal blood flow Narrowed artery Changeable Risk Factors Tobacco use High blood pressure High cholesterol Diabetes control Obesity Lack of regular exercise Stress Unchangeable Risk Factors Family history of coronary artery disease Age
12 Why do you need heart surgery? You may have one or more of the following: A blood vessel or artery to the heart is completely or partially blocked and can t be fixed by a stent, a device made of expandable metal mesh placed to keep the artery open Critical narrowing in the coronary arteries that decreases the blood flow to a significant portion of the heart muscle, placing you at risk for a disabling heart attack Multiple blocked arteries Blocked arteries that are not appropriate for stents or angioplasty (a procedure used to open blocked or narrowed arteries) either because of size of artery or location of blockage Re-occurring blockage in arteries with stents Significant blockage in a coronary artery A heart valve that needs to be repaired or replaced
13 Heart Surgery Coronary Artery Bypass Graft Surgery (CABG, also called cabbage) Coronary artery bypass graft (CABG) surgery is done to provide detours around the partially or completely blocked arteries. With a new open bypass system the heart can now receive its much needed blood supply. The blockages in the coronary artery are not removed but will be bypassed using the saphenous vein from the leg and/or the internal mammary artery from the chest. The saphenous vein is removed from the leg and is used to bypass the blocked artery. The internal mammary artery is also used to bypass the blocked artery. These procedures can be compared to a road detour. Will my chest muscles function without the internal mammary artery? Removing the internal mammary artery for use in the heart s circulation has not been shown to cause any injury to the chest muscles. Some patients may have numbness of the chest that decreases over time but may not completely disappear. Will my leg(s) function properly without the saphenous vein? How will I get circulation to my leg if a vein is removed? This vein can be taken from your leg without causing problems. Removal of the saphenous vein will not affect normal circulation in the leg(s). The blood that previously flowed through the saphenous vein will change its course of travel. You may have swelling in your leg, but this will get better with time. Segment of blood vessel, usually the saphenous vein in the leg, is taken from the patient to be used as the bypass graft.
14 Valve Surgery The heart is divided into four main areas, or chambers two upper chambers (called the left and right atrium) and two lower chambers (called the left and right ventricle). There are four valves that control the flow of blood through your heart. They are called the aortic, mitral, pulmonary, and tricuspid valves, and each is made of flaps of tissue called leaflets. Pulmonary Valve Aortic Valve Each time your heart beats, it pumps blood through these valves by contracting (squeezing) its chambers. These valves open in one direction, like one-way gates, allowing blood to flow forward. In between beats, the heart s chambers quickly relax, and its valves close, preventing blood from flowing backward. Mitral Valve When your valve does not fully close and allows blood to leak backwards through the valve, this is called regurgitation. Tricuspid Valve There are two common problems that can develop in heart valves: When your valve is narrowed and does not completely open because of things like a buildup of calcium (mineral deposits), high cholesterol (a waxy fat), age, or genetics (such as a birth defect), this is called stenosis. With either problem, your heart needs to work harder and may not pump enough oxygen-rich blood to your body. During heart valve surgery, one or more heart valves can be repaired or replaced. Repair means that your own valve is modified to help it work better. Replacement means your valve is removed
15 and a new valve is inserted in its place. The decision whether to repair or replace a valve often can t be made until after surgery has begun. You and your surgeon can discuss plans for surgery and any other procedures you may need. If a valve cannot be repaired, it will be replaced with a new valve, which is called a prosthetic valve. There are two kinds of prosthetic heart valves available: Mechanical valves are created from man-made materials and require you to take a blood thinner (anticoagulant) called warfarin (Coumadin). This prevents blood clots from forming on your valve. Biological (tissue) valves are taken from pigs, cows, or humans. These valves do not last as long as mechanical valves. Aspirin is the only blood-thinning medication needed long term. You and your doctor can discuss which type of valve is best for you. Factors that are looked at are your age, the type of work you do, the size of your valve, your heart s rhythm, your ability to take blood-thinning medications, and the number of new valves you need. What is Transcatheter Aortic Valve Replacement (TAVR)? If a cardiac surgeon determines that you are at high risk or too sick for open-heart surgery or for replacement of your aortic valve, and if medicine is not helping you feel better, TAVR may be an alternative. This less invasive procedure allows a new valve to be inserted within your diseased aortic valve while your heart is still beating. Cardiopulmonary bypass is usually not required. The TAVR procedure can be performed through two different approaches transfemoral or transapical. Your doctor will decide which approach is best for you based on your medical condition and other factors. A transfemoral approach is done by making a small incision in the large femoral artery in your upper leg. A short hollow tube or sheath is threaded into the artery and up to the heart. The heart valve is threaded through this tube to the heart and placed inside your diseased aortic valve.
16 A transapical approach is done by making a small incision in your left chest between your ribs to get to the apex (the lowest portion) of your heart. A short hollow tube is inserted into your heart through the incision. The heart valve is threaded through the tube and placed inside your diseased aortic valve. Following a TAVR, you will take a blood thinner (i.e. Plavix or Effient) for 3 months to a year. You will also take aspirin every day for the rest of your life. You will receive specific information about your medications from your nurse and doctor before you leave the hospital. Protecting Your Heart Valves Your valves can become infected and damage the lining in your heart. This is called endocarditis. If the infection isn t treated with antibiotics it can make you very sick and could cause you to die. This infection is caused by bacteria. To reduce your chance of infective endocarditis: Brush and floss your teeth at least two times a day. Get your teeth cleaned by a dentist every six months and make sure your dentures fit correctly. Call your doctor if you have: Temperature over 100 degrees Fahrenheit Sweats or chills Skin rash A cut that won t heal Red, warm or draining wound Sore throat or scratchy throat or pain when swallowing A cold, headache or tenderness in your face that won t go away Dry or moist cough that lasts more than two days White patches in your mouth or on your tongue Nausea, vomiting or diarrhea Don t wait to get treatment. Colds and the flu do not cause endocarditis, but infections, which may have the same symptoms, do cause endocarditis. To be safe, call your doctor.
17 Who is at risk? People at risk for an infection in the heart are those who: Have an artificial (prosthetic) heart valve Have had previous bacterial endocarditis Have certain heart diseases you are born with (congenital) Have had a heart transplant Use IV drugs (i.e., heroin, cocaine, etc.) If you have any of the conditions listed above, please talk to your doctor about the type and amount of antibiotics you should take, and for what procedures you should take them. Your doctor will talk to you about whether or not you need to take antibiotics before procedures such as dental work, colonoscopy, and surgeries. A bacterial endocarditis identification card is available from the American Heart Association and should be carried with you. You should be given an infective (bacterial) endocarditis card and handout before you leave the hospital. Minimally Invasive Heart Surgery Important Note: Not everyone can have this type of surgery. Your doctor will determine if you are a candidate for minimally invasive surgery. The surgical team will carefully compare the advantages and disadvantages of minimally invasive techniques versus regular surgery. Minimally invasive heart surgery is performed through smaller incisions, sometimes using specialized surgical instruments, and can result in less bleeding and a faster recovery. Your incision is about 3 to 4 inches instead of the 6- to 8-inch incision required for regular surgery.
18 Off-Pump or Beating Heart Bypass Surgery Off-pump or beating heart bypass surgery allows surgeons to perform surgery on the heart while it is beating. This surgery may be an option for patients with single-vessel disease (such as disease of the left anterior descending artery or right coronary artery) who only have one blood vessel that is blocked. Coronary artery bypass graft surgery (CABG, called cabbage) surgery is usually done with the use of a machine that pumps blood outside the heart during the surgery called the cardiopulmonary bypass (heart-lung machine). The heart-lung machine allows the heart s beating to be stopped so the surgeon can operate on a surface which is free of blood. The heart-lung machine maintains life despite the lack of a heartbeat, removing carbon dioxide from the blood and replacing it with oxygen before pumping it throughout the body. During off-pump or beating heart surgery, the heart-lung machine is not used. The surgeon uses advanced operating equipment to hold portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body.
19 Who is a Candidate for This Type of Surgery? Your surgeon will talk to you about whether or not this type of surgery can be done or what type of surgery is best for you. The surgical team will carefully compare the advantages and disadvantages of these techniques with those of traditional surgery. The type of treatment recommended for your condition depends on several factors, including the type and severity of heart disease, your age, medical history and lifestyle. Benefits of Minimally Invasive Surgical Techniques The benefits of minimally invasive and robotic heart surgery techniques typically include: A smaller incision A smaller scar Decreased risk of infection Less bleeding Less pain Shorter hospital stay after surgery Shorter recovery time What you need to know about Atrial Fibrillation (A-Fib) If you develop atrial fibrillation after surgery: Atrial fibrillation (A-Fib) is a heart rhythm disorder in which the heart s two upper chambers (the atria) beat irregularly and out of coordination with the two lower chambers (the ventricles). Sometimes people who have never had A-Fib before can develop it after heart surgery. In fact, atrial fibrillation is one of the most frequent problems or complications after heart surgery. The presence of A-Fib can prolong a patient s hospital stay in some cases. If you develop A-Fib after surgery, your doctor will prescribe medications to correct it. One medication that is often used is called amiodarone.
20 The good news is that if you develop A-Fib after surgery and did not have it before, there is a very good chance that the A-Fib will go away once your heart is healed. You may only need to take the A-Fib medication for a few months or less after you go home. What if you have A-Fib before surgery? There is a surgical treatment for atrial fibrillation called the MAZE procedure. It is most commonly done for patients who have A-Fib and also need heart surgery for another reason, such as bypass or valve repair/replacement. During a MAZE procedure, energy is delivered to certain areas in the top chambers of the heart (the atria) to disrupt the electrical abnormality that causes A-Fib. As these areas heal, they form scar tissue which blocks the abnormal electrical impulses from being conducted through the heart. This promotes the normal conduction of impulses through the proper pathways, leading to a regular heartbeat. During the surgery, the area of the heart where clots from A-Fib most frequently form (the left atrial appendage) can be closed off. This helps to reduce the risk of stroke. Normal heart rhythm Atrial fibrillation
22 Preparing for Surgery What can I do to get ready for my operation? Medications Aspirin: If you are currently taking aspirin, continue to take your daily aspirin unless your surgeon instructs you not to take it. Do not take any additional doses of aspirin or products containing aspirin (above your normal daily dosage) for two weeks prior to your surgery. Keep in mind that over-the-counter (OTC) medication may have aspirin in it so it is best to not take any OTC medication except acetaminophen (i.e., Tylenol) in the two weeks prior to your surgery. Stop the following blood thinning medications as instructed by your surgeon: Aggrenox Prasugrel (Effient) Apixaban (Eliquis) Rivaroxaban (Xarelto) Clopidogrel (Plavix) Ticlopidine (Ticlid) Dipyridamole (Persantine) Ticagrelor (Brilinta) Dabigatran (Pradaxa) Warfarin (Coumadin or Jantoven) Enoxaparin (Lovenox) Note: This may not be a complete list of all medications you should stop. Please follow the advice of your physician. Stop all herbal supplements 24 hours before surgery.
23 Medication Disclaimer: If you have been told you have liver disease, you should not take any medication with acetaminophen (i.e., Tylenol) without checking with your doctor. If you are allergic to any medications listed in this booklet, do not take without checking with your doctor. Smoking It is extremely important that you STOP SMOKING as soon as possible. People who smoke will have more mucous accumulation in their lungs, which is harder to remove after surgery and may slow down recovery. Please consult your primary care physician about stop smoking aides. Patients who smoke may require additional breathing treatments during the postoperative period and may have to stay in the hospital longer.
24 The Morning of Surgery Before arriving at Baptist Health Lexington: DO NOT eat or drink anything after midnight the night before your surgery. You will take all of your routine prescribed medications (except diabetic medication) with a sip of water unless otherwise instructed by your physician or the cardiac surgery nurse navigator. You may brush your teeth and rinse your mouth. Do not wear any makeup, jewelry or dark nail polish. For your safety, all rings and body piercings must be removed. Do not wear contact lenses. Leave anything you consider valuable at home or with your family. Female patients need to pack a bra to wear after surgery. If you have obstructive sleep apnea, bring your tubing, mask and settings with you, but do not bring the CPAP/BiPap machine. You will need to bring the following with you: Driver s license or picture ID Insurance, Medicare, Medicaid cards All medications you are currently taking in their original bottles Completed pre-operative skin prep instruction form Copy of your advance directive, living will or power of attorney if you did not bring it to your pre-op appointment at the Heart and Valve Center Eyeglasses if needed Denture container labeled with your name if needed
25 Pre-Op Area: You will be taken to a private curtained area and given a hospital gown to wear. You will need to remove all your clothing, including undergarments, except your socks. You will need to remove any hair pins, or any hair containment items that have metal parts. You may have one family member at a time accompany you in this area. Your other family members may wait in the waiting room. The nurse will insert an IV. Any tests ordered by your surgeon such as a chest X-ray, EKG (checks for problems with electrical activity of your heart), or blood tests will be performed if they were not done during a pre-op appointment at the Heart & Valve Center Consents will be signed if they were not signed during a pre-op appointment at the Heart & Valve Center. Hair on your chest and legs (if applicable) will be shaved with an electric clipper. You will be instructed on breathing exercises to do after your surgery. You will be asked to remove dentures and glasses prior to going in the operating room. A medical history will be taken or updated. An antibacterial ointment will be placed in your nose to prevent infection. You will have an opportunity to speak with the anesthesiologist, the physician who will administer anesthesia and pain medication and monitor your vital signs during surgery.
26 Operating Room (OR) Your family will be asked to wait in the surgery waiting room while you are in surgery. Your family will receive updates during the surgery, and the surgeon will speak with your family soon after the surgery is completed. You will be taken by stretcher to the Operating Room and moved over to the operating table. Your anesthesiologist will begin general anesthesia. After you are asleep: A breathing tube will be placed and a breathing machine (ventilator) will breathe for you. You will be cleaned from chin to toes with an antibacterial soap. A Foley catheter will be placed to drain urine. An arterial line will be placed in your wrist or groin for blood pressure monitoring and blood drawing. A Swan Ganz catheter will be placed in a vein in your neck through which medication will be administered and your heart function will be monitored during and after surgery.
28 After Surgery Intensive Care Unit (often called ICU): Immediately after surgery, you will be transferred directly to the ICU. There will be a lot of equipment in the room connected to you to monitor the heart, oxygen level, and blood pressure closely. The breathing tube will still be in place and a ventilator (breathing machine) will provide breaths or air. You will have a Foley catheter (a drain placed in your bladder) for a day or two in order to monitor urine output. Your family will typically be able to visit within the first hour of your arrival in ICU, but this depends on your condition at time of arrival. A nurse will be at your bedside and will watch your condition closely. As you begin to wake up from anesthesia, the nurse and respiratory therapist will begin to work with you to take the breathing tube out. The goal is to have you off the ventilator in about 6 to 12 hours. This may be longer depending on the extent of your heart surgery, your general health or if you smoke or have ever smoked. Once the breathing tube is removed, you will be given oxygen by a mask and later by nasal cannula (plastic tubing inserted into the nostrils). If you have sleep apnea you will need to wear your mask.
29 You will be instructed to turn, cough, take deep breaths and use the incentive spirometer (device used to help patients improve the function of their lungs) every hour. This is important to keep you from developing lung problems, such as pneumonia. Comfort: Your nurse will administer pain medications to keep you comfortable. Inform your nurse of any pain. You will be asked to rate your pain on the 0 to 10 scale, with 0 being none and 10 being the worst pain you have ever had. You will be given a heart pillow to place against your chest incision when moving around or coughing. This will decrease the amount of pain you experience with these activities. It is very important to treat your pain so that you can walk and move more easily. Do not be afraid to ask for or take pain medication. Diet: Once off the breathing machine, you will be given ice chips. Your diet will be advanced as tolerated to clear liquids, and then to solid food. Nausea and loss of appetite may occur. It may take several weeks to get your appetite back. Activity: Physical therapy and nursing staff will work with you throughout your hospital stay. You will be helped to sit on the side of the bed after being taken off the breathing machine. You will be helped to sit up in a chair several times, as soon as possible, after surgery. It is important for you to sit in a chair for every meal if possible. Physical therapy staff will either assist you in walking in your room or the hallway. You will be asked to do leg exercises while in bed. Your activity level will increase each day. You should be able to walk by yourself before you are sent home. You may need a walker to help you get around and avoid falling.
30 Visitation The ICU has open visitation. However, it may be necessary at times for us to ask family or visitors to step out of the room so we can give your loved one the care he or she needs. Two visitors (immediate family only) are permitted in a room at one time. Children younger than 10 years of age are not allowed to visit due to infection control reasons. Post-surgery patients will have an initial short visit approximately one hour after arriving in the ICU. More extended visits will begin approximately 3-4 hours after arriving in the ICU. Staff will notify family when the patient is ready for visiting. To obtain access to the unit or patient information, use the phone on the wall past the Surgery/ ICU waiting area desk or the ICU door. This is to protect the privacy of your family as well as the other patients. Telephone patient information: Select one family member as a spokesperson. The spokesperson will be responsible to relay patient information to other family and friends. We ask phone calls be limited to avoid interruption of patient care. We limit information over the phone to the spokesperson only to protect patient privacy. There are times that visiting may be adjusted, held or cancelled due to patient care activities or emergencies. Please do not let a delay alarm you. Your patience is greatly appreciated. Restrooms are located in the waiting area for visitors. Food and drink are not permitted in the unit. Please do not visit if you do not feel well. Telephone numbers: Main hospital: (859) Surgery/ICU waiting room: (859) ICU Nursing Station: (859)
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