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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ebstein anomaly &#40;EA&#41; is a rare congenital heart disease consisting of a low implantation of the tricuspid valve&#44; with hypoplasia of the right ventricle and other anomalies such as pulmonary valve stenosis and ventricular preexcitation&#46; Additionally&#44; in 80-94&#37; of patients&#44; an atrial septal defect &#40;ASD&#41; is present and can generate a right-to-left shunt due to high pressure in the right cavities and tricuspid insufficiency&#46; This shunt generates systemic desaturation&#59; however&#44; it also contributes to the right-side overload discharge enabling a hemodynamic balance in these patients&#46; The percutaneous closure of these defects may contribute to improving systemic saturation&#44; after having ensured that the right ventricle can tolerate the pressure increase&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 68-year-old man with metastatic parotid carcinoma and central cyanosis &#40;oxygen saturation of 75&#37; at baseline with domiciliary oxygen therapy&#41; with EA and a patent foramen oval &#40;PFO&#41;&#46; A previous transesophageal echocardiogram &#40;TEE&#41; described a severely dilated right ventricle with moderate systolic dysfunction and an atrial septal aneurysm check with a PFO generating a right-to-left shunt&#46; Magnetic resonance imaging demonstrated an incompletely developed tricuspid septal leaflet&#44; with a low implantation of the valve&#44; moderate tricuspid insufficiency&#44; and a PFO with a long membrane&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We planned the percutaneous closure of the PFO with transitory balloon occlusion to ensure accurate right ventricular tolerance of the PFO closure&#46; Due to the clinical characteristics of the patient&#44; with difficult intubation secondary to the parotid tumor&#44; transthoracic echocardiogram &#40;TTE&#41; was used to motorize the procedure&#46; After canalizing the right femoral vein and the right radial artery&#44; pulmonary artery pressure was measured&#44; ruling out significant pulmonary hypertension&#46; Balloon occlusion of the PFO was then performed&#44; maintaining an inflated 18 mm balloon for 10 minutes through the foramen&#46; A significant improvement in peripheral oxygen saturation was observed&#44; with good hemodynamic tolerance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We then decided to perform the percutaneous closure of the PFO using a cribriform occluder&#46; A 9 French sheath was placed in the left atrium and a 25 mm Amplatzer Multi-Fenestrated Septal Occluder - &#8220;Cribriform&#8221; &#40;AGA Medical Corporation&#44; Golden Valley&#44; MN&#44; USA&#41; was advanced through the PFO&#44; with good apposition of the discs before delivery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After release&#44; the device was embolized into the left atrium and descending aorta&#46; The right femoral artery was then canalized and the device was captured with a 30 mm gooseneck snare and externalized through the femoral artery&#46; TEE was then performed under superficial sedation&#44; showing an atrial septal aneurysm&#44; with a wide PFO&#44; and a large membrane distance generating an effective orifice of 18-20 mm&#46; Finally&#44; a 24 mm Amplatzer Septal Occluder &#40;AGA Medical Corporation&#44; Golden Valley&#44; MN&#44; USA&#41; was implanted&#46; Absence of shunt was confirmed via angiography and TTE before delivery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The procedure was concluded successfully and the patient was discharged the following day and prescribed treatment with 100 mg aspirin and 75 mg clopidogrel&#46; In the following weeks there was a progressive improvement in his oxygen saturation&#44; maintaining baseline levels over 90&#37; and he was able to manage without domiciliary oxygen therapy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">There are few publications on the percutaneous closure of ASD in patients with right-to-left shunt&#46; The first reported cases were in pediatric patients&#44; in whom a significant improvement in oxygen saturation and exercise tolerance was confirmed after percutaneous closure&#44; even in the presence of a hypoplastic right ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Jategoankar et al&#46; described nine adults with EA and ASD defects&#44; four of whom had right-to-left shunt and in whom a percutaneous closure of the defect was performed after a prolonged test occlusion of the interatrial communication at rest and under catecholamine stimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> These authors recommended an exhaustive pre-procedure study of the patient&#44; avoiding the closure of the defect in the presence of severe tricuspid regurgitation or pulmonary hypertension&#46; In this series&#44; two of the nine patients presented a PFO&#44; which was closed using ASD devices&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Silva et al&#46; described nine cases of EA with right-to-left shunt&#44; in which temporary test occlusion was performed before the percutaneous closure&#44; resulting in a significant improvement in oxygen saturation and functional capacity in all cases&#59; mean follow-up was of five years&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this kind of patient&#44; the anatomy of the interatrial septum must be analyzed exhaustively to select the appropriate device&#46; Given the high right pressure&#44; the PFO can present a large inter-membrane defect&#44; generating large effective orifices&#44; which should preferably be occluded using ASD defect devices&#46; In this case&#44; the TEE was initially avoided due to the high risk associated with intubation and the previous TEE&#59; an intracardiac echo would have been very useful in this patient&#46; In the reported cases&#44; ASD devices are only occasionally used for PFO closures&#46; The design of the ASD occluders&#44; with longer discs and a wider waist&#44; may also provide better stability against an increase in right pressure after the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Percutaneous closure of ASD in the presence of a right-to-left shunt can offer significant clinical improvement in selected cases&#46; In these patients&#44; a balloon occlusion test is essential to evaluate the individual response to the ASD closure and to guarantee procedure safety&#46; Additionally&#44; the anatomy of the interatrial septum must be exhaustively analyzed to select the appropriate device for each case&#46; The implantation of an ASD closure device may be desirable over the PFO devices in this kind of patients due to their design&#44; characterized by longer disc length which may provide better stability against an increase in right pressure after the procedure&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Percutaneous closure of an atrial septal defect in a patient with Ebstein anomaly and right-to-left shunt
Encerramento percutâneo de comunicação interauricular em doente com anomalia de Ebstein e shunt direito-esquerdo
Leire Unzuéa,b,
Autor para correspondência
leireunzue@yahoo.es

Corresponding author.
, Eulogio Garcíaa, Jorge Solísc, Ángel Sánchez Recalded, Juan Manuel Barcelóe, Javier Parraf
a Interventional Cardiology Unit, HM CIEC, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
b San Pablo CEU University, Madrid, Spain
c Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
d Interventional Cardiology, Hospital Universitario Ramón y Cajal, Madrid, Spain
e Clinical Cardiology, HM CIEC, Hospital Universitario HM Norte Sanchinarro, HM Hospitales, Madrid, Spain
f Clinical Cardiology Unit, HM CIEC, Hospital Universitario HM Montepríncipe, Hospital Universitario HM Sanchinarro, Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
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        "titulo" => "Encerramento percut&#226;neo de comunica&#231;&#227;o interauricular em doente com anomalia de Ebstein e <span class="elsevierStyleItalic">shunt</span> direito-esquerdo"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Initial closure of the defect using a cribriform patent foramen ovale &#40;PFO&#41; device&#46; A&#58; Transesophageal echocardiogram image where a PFO can be observed&#44; with right-to-left shunt &#40;arrow&#41; and hypertrabeculation of the right atrium &#40;RA&#41; &#40;ventricularization of the RA&#41; &#40;asterisk&#41;&#46; B&#58; Transitory occlusion test&#46; C&#38;D&#58; Cribiform PFO closure device released at the PFO&#44; radioscopy image &#40;C&#41; and three-dimensional transesophageal echocardiogram &#40;D&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ebstein anomaly &#40;EA&#41; is a rare congenital heart disease consisting of a low implantation of the tricuspid valve&#44; with hypoplasia of the right ventricle and other anomalies such as pulmonary valve stenosis and ventricular preexcitation&#46; Additionally&#44; in 80-94&#37; of patients&#44; an atrial septal defect &#40;ASD&#41; is present and can generate a right-to-left shunt due to high pressure in the right cavities and tricuspid insufficiency&#46; This shunt generates systemic desaturation&#59; however&#44; it also contributes to the right-side overload discharge enabling a hemodynamic balance in these patients&#46; The percutaneous closure of these defects may contribute to improving systemic saturation&#44; after having ensured that the right ventricle can tolerate the pressure increase&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 68-year-old man with metastatic parotid carcinoma and central cyanosis &#40;oxygen saturation of 75&#37; at baseline with domiciliary oxygen therapy&#41; with EA and a patent foramen oval &#40;PFO&#41;&#46; A previous transesophageal echocardiogram &#40;TEE&#41; described a severely dilated right ventricle with moderate systolic dysfunction and an atrial septal aneurysm check with a PFO generating a right-to-left shunt&#46; Magnetic resonance imaging demonstrated an incompletely developed tricuspid septal leaflet&#44; with a low implantation of the valve&#44; moderate tricuspid insufficiency&#44; and a PFO with a long membrane&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We planned the percutaneous closure of the PFO with transitory balloon occlusion to ensure accurate right ventricular tolerance of the PFO closure&#46; Due to the clinical characteristics of the patient&#44; with difficult intubation secondary to the parotid tumor&#44; transthoracic echocardiogram &#40;TTE&#41; was used to motorize the procedure&#46; After canalizing the right femoral vein and the right radial artery&#44; pulmonary artery pressure was measured&#44; ruling out significant pulmonary hypertension&#46; Balloon occlusion of the PFO was then performed&#44; maintaining an inflated 18 mm balloon for 10 minutes through the foramen&#46; A significant improvement in peripheral oxygen saturation was observed&#44; with good hemodynamic tolerance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We then decided to perform the percutaneous closure of the PFO using a cribriform occluder&#46; A 9 French sheath was placed in the left atrium and a 25 mm Amplatzer Multi-Fenestrated Septal Occluder - &#8220;Cribriform&#8221; &#40;AGA Medical Corporation&#44; Golden Valley&#44; MN&#44; USA&#41; was advanced through the PFO&#44; with good apposition of the discs before delivery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After release&#44; the device was embolized into the left atrium and descending aorta&#46; The right femoral artery was then canalized and the device was captured with a 30 mm gooseneck snare and externalized through the femoral artery&#46; TEE was then performed under superficial sedation&#44; showing an atrial septal aneurysm&#44; with a wide PFO&#44; and a large membrane distance generating an effective orifice of 18-20 mm&#46; Finally&#44; a 24 mm Amplatzer Septal Occluder &#40;AGA Medical Corporation&#44; Golden Valley&#44; MN&#44; USA&#41; was implanted&#46; Absence of shunt was confirmed via angiography and TTE before delivery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The procedure was concluded successfully and the patient was discharged the following day and prescribed treatment with 100 mg aspirin and 75 mg clopidogrel&#46; In the following weeks there was a progressive improvement in his oxygen saturation&#44; maintaining baseline levels over 90&#37; and he was able to manage without domiciliary oxygen therapy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">There are few publications on the percutaneous closure of ASD in patients with right-to-left shunt&#46; The first reported cases were in pediatric patients&#44; in whom a significant improvement in oxygen saturation and exercise tolerance was confirmed after percutaneous closure&#44; even in the presence of a hypoplastic right ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Jategoankar et al&#46; described nine adults with EA and ASD defects&#44; four of whom had right-to-left shunt and in whom a percutaneous closure of the defect was performed after a prolonged test occlusion of the interatrial communication at rest and under catecholamine stimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> These authors recommended an exhaustive pre-procedure study of the patient&#44; avoiding the closure of the defect in the presence of severe tricuspid regurgitation or pulmonary hypertension&#46; In this series&#44; two of the nine patients presented a PFO&#44; which was closed using ASD devices&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Silva et al&#46; described nine cases of EA with right-to-left shunt&#44; in which temporary test occlusion was performed before the percutaneous closure&#44; resulting in a significant improvement in oxygen saturation and functional capacity in all cases&#59; mean follow-up was of five years&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this kind of patient&#44; the anatomy of the interatrial septum must be analyzed exhaustively to select the appropriate device&#46; Given the high right pressure&#44; the PFO can present a large inter-membrane defect&#44; generating large effective orifices&#44; which should preferably be occluded using ASD defect devices&#46; In this case&#44; the TEE was initially avoided due to the high risk associated with intubation and the previous TEE&#59; an intracardiac echo would have been very useful in this patient&#46; In the reported cases&#44; ASD devices are only occasionally used for PFO closures&#46; The design of the ASD occluders&#44; with longer discs and a wider waist&#44; may also provide better stability against an increase in right pressure after the procedure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Percutaneous closure of ASD in the presence of a right-to-left shunt can offer significant clinical improvement in selected cases&#46; In these patients&#44; a balloon occlusion test is essential to evaluate the individual response to the ASD closure and to guarantee procedure safety&#46; Additionally&#44; the anatomy of the interatrial septum must be exhaustively analyzed to select the appropriate device for each case&#46; The implantation of an ASD closure device may be desirable over the PFO devices in this kind of patients due to their design&#44; characterized by longer disc length which may provide better stability against an increase in right pressure after the procedure&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ebstein anomaly is a congenital disease frequently associated with atrial septal defects&#44; which can generate a right-to-left shunt&#44; leading to systemic desaturation and right ventricular failure&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a 68-year-old man with central cyanosis due to Ebstein anomaly and a patent foramen ovale&#46; An atrial septal occluder was initially implanted after having performed prolonged test occlusion of the interatrial communication&#46; In this case&#44; device embolization occurred due to high right pressure&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Percutaneous closure of atrial septal defects in the presence of a right-to-left shunt can offer a significant clinical improvement in selected cases&#46; In patients with Ebstein anomaly&#44; the implantation of atrial septal defect closure devices may be desirable&#44; due to the larger size of the waist&#44; which may provide better stability in the event of an increase in right pressure&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A anomalia de Ebstein &#233; uma cardiopatia cong&#233;nita complexa frequentemente associada a comunica&#231;&#227;o interauricular&#44; com <span class="elsevierStyleItalic">shunt</span> direito-esquerdo&#44; provocando desatura&#231;&#227;o sist&#233;mica e fal&#234;ncia ventricular direita&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de um doente de 68 anos&#44; com cianose central devido a anomalia de Ebstein e <span class="elsevierStyleItalic">Foramen ovale</span> patente&#44; em que foi implantado um dispositivo de encerramento de comunica&#231;&#227;o interauricular&#44; ap&#243;s teste de oclus&#227;o de comunica&#231;&#227;o interauricular&#46; Neste caso&#44; utilizou-se inicialmente um dispositivo do encerramento do <span class="elsevierStyleItalic">Foramen</span><span class="elsevierStyleItalic">ovale</span>&#44; que embolizou no contexto de press&#245;es elevadas &#224; direita&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O encerramento percut&#226;neo das comunica&#231;&#245;es interauriculares na presen&#231;a de <span class="elsevierStyleItalic">shunt</span> direito-esquerdo pode oferecer uma melhoria cl&#237;nica significativa em casos selecionados&#46; Em doentes com anomalia de Ebstein&#44; a implanta&#231;&#227;o de dispositivos de encerramento da comunica&#231;&#227;o interauricular pode ser prefer&#237;vel&#44; devido &#224;s suas caracter&#237;ticas morfol&#243;gicas&#44; permitindo maior estabilidade contra o aumento de press&#245;es &#224; direita&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Initial closure of the defect using a cribriform patent foramen ovale &#40;PFO&#41; device&#46; A&#58; Transesophageal echocardiogram image where a PFO can be observed&#44; with right-to-left shunt &#40;arrow&#41; and hypertrabeculation of the right atrium &#40;RA&#41; &#40;ventricularization of the RA&#41; &#40;asterisk&#41;&#46; B&#58; Transitory occlusion test&#46; C&#38;D&#58; Cribiform PFO closure device released at the PFO&#44; radioscopy image &#40;C&#41; and three-dimensional transesophageal echocardiogram &#40;D&#41;&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cribriform patent foramen ovale occluder embolization and extraction with final implant of the atrial septal defect &#40;ASD&#41; device&#46; A&#58; Transesophageal echography image where the device can be visualized with free movement at the left atrium&#46; B&#58; Device capture at the descending aorta&#46; C&#58; Device extraction through the right femoral artery&#46; D&#58; Final implant of the ASD device&#46;</p>"
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                      "titulo" => "Transcatheter closure of atrial septal defects in children with a hypoplastic right ventricle"
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                          "autores" => array:3 [
                            0 => "M&#46; Atiq"
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                      "doi" => "10.1002/ccd.20245"
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                        "tituloSerie" => "Catheter Cardiovasc Interv"
                        "fecha" => "2005"
                        "volumen" => "64"
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                      "titulo" => "Right to left shunt through interatrial septal defects in patients with congenital heart disease&#58; results of interventional closure"
                      "autores" => array:1 [
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                          "autores" => array:3 [
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                      "titulo" => "Interventional closure of atrial septal defects in adult patients with Ebstein&#39;s anomaly"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46;R&#46; Jategaonkar"
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                      "Revista" => array:5 [
                        "tituloSerie" => "Congenit Heart Dis"
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                    0 => array:2 [
                      "titulo" => "Percutaneous closure of atrial right-to-left shunt in patients with Ebstein&#39;s anomaly of the tricuspid valve"
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