心脏瓣膜病再次手术的治疗策略课件

心脏瓣膜病再次手术的心脏瓣膜病再次手术的 治疗策略治疗策略 广东省人民医院广东省人民医院 广东省心血管病研究所广东省心血管病研究所 卢聪卢聪 中国瓣膜外科发展史中的几个里程碑中国瓣膜外科发展史中的几个里程碑 1954 1954 第一例闭式扩张术第一例闭式扩张术 1958 1958 体外循环的首次应用体外循环的首次应用 1958 1958 第一例体外循环下二尖瓣直视分离术第一例体外循环下二尖瓣直视分离术 1965 1965 第一例瓣膜置换术第一例瓣膜置换术 瓣膜外科发展史中的领军人物瓣膜外科发展史中的领军人物 及科研院所及科研院所 蔡用之：长海医院蔡用之：长海医院 张宝仁：长海医院张宝仁：长海医院 郭加强：阜外心血管病医院郭加强：阜外心血管病医院 罗征祥：广东省人民医院罗征祥：广东省人民医院 手术数量及再次手术问题手术数量及再次手术问题 uu至至19991999年，每年瓣膜手术达年，每年瓣膜手术达60006000例例 uu经过近经过近1010年的发展，现在每年的瓣膜手术年的发展，现在每年的瓣膜手术 估计在估计在2-32-3万左右万左右 uu随着手术数量的增多，再次手术成为不可随着手术数量的增多，再次手术成为不可 避免的问题避免的问题 我院的经验我院的经验 我院我院19971997年至年至20072007年瓣膜手术情况年瓣膜手术情况 我院的经验我院的经验 19971997年至年至20072007年总瓣膜手术例数：年总瓣膜手术例数：67036703例例 其中再次手术例数：其中再次手术例数：499499例，占例，占 7.4% 7.4% 再手术病人围手术期死亡率：再手术病人围手术期死亡率：8.8%8.8% 再次手术的原因分析再次手术的原因分析 占比重最大的为：占比重最大的为： 二尖瓣闭式扩张术后（二尖瓣闭式扩张术后（64.5%64.5%） 国内其他医院再次手术的原因分析国内其他医院再次手术的原因分析 医院名称再次手术术例数原因 阜外医院333a,b,c,d,e,f 新桥桥医院187f,a,d,g 仁济济医院203f,a,g, 福建省立医院104f,e,g,d,a,h 包头头中心医院165f,a,g,c,d,b,e a:生物瓣失功能，b:瓣周漏，c:自然瓣膜损坏，d:机械 瓣功能障碍，e:感染性心内膜炎，f:二尖瓣闭式扩 张，g:二尖瓣直视分离，h:其他, 风险及对策风险及对策 再次瓣膜手术的风险比首次瓣膜手术再次瓣膜手术的风险比首次瓣膜手术 的风险高的风险高 病程长病程长 心功能差心功能差 粘连、手术时间长粘连、手术时间长 出血出血 针对不同的原因，其治疗方案及对策针对不同的原因，其治疗方案及对策 有所不同有所不同 闭式扩张及直视交界切开术后再狭窄闭式扩张及直视交界切开术后再狭窄 风湿性心脏病是导致瓣膜病变的首要原因风湿性心脏病是导致瓣膜病变的首要原因 再狭窄是必然结果，闭式扩张术后的症状缓解期再狭窄是必然结果，闭式扩张术后的症状缓解期 一般在一般在8-158-15年年 特点：病程长，常合并三尖瓣病变特点：病程长，常合并三尖瓣病变 策略：策略： 再次成形再次成形 换瓣换瓣 ：生物瓣（避免抗凝治疗）：生物瓣（避免抗凝治疗） 机械瓣机械瓣 机械瓣功能障碍机械瓣功能障碍 机械瓣结构原因机械瓣结构原因 机械瓣梗阻：机械瓣梗阻： 血管翳、纤维组织增生血管翳、纤维组织增生 血栓形成：多发生于血栓形成：多发生于3 3年内年内 梗阻原因MVRAVRTVR 血栓形成35(71%)8(33%)4(100%) 血管翳及纤维组织增生14(29%)16(67%) 机械瓣功能障碍机械瓣功能障碍 策略策略 血栓：内科溶栓血栓：内科溶栓 外科再次手术治疗外科再次手术治疗 血管翳、纤维组织增生：再次手术治疗血管翳、纤维组织增生：再次手术治疗 强调早期严格抗凝治疗，不同部位其抗凝标准有强调早期严格抗凝治疗，不同部位其抗凝标准有 所不同：所不同： AVRAVR：INR 1.8-2.0INR 1.8-2.0 MVRMVR：INR 2.0-2.5INR 2.0-2.5 TVRTVR：INR 2.5-3.0INR 2.5-3.0 妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍 原因：原因： （1 1）妊娠期高凝状态）妊娠期高凝状态 （2 2）担心华法林的副作用）担心华法林的副作用 （3 3）在妊娠早期停用或换用其他抗凝药物）在妊娠早期停用或换用其他抗凝药物 我院临床资料我院临床资料 20002000年年2 2月至月至20062006年年1212月，妊娠期发生机月，妊娠期发生机 械瓣功能障碍病人械瓣功能障碍病人7 7例，年龄例，年龄22-3222-32岁，平岁，平 均均26.4 26.4 22.6.6岁岁 风湿性心脏病风湿性心脏病5 5例，先天性心脏病例，先天性心脏病2 2例例 心功能心功能IVIV级级4 4例，例，IIIIII级级3 3例例 妊娠期妊娠期2828周周5 5例，例，66个月？个月？ 妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍 机械瓣梗阻程度机械瓣梗阻程度 心功能情况心功能情况 妊娠期周数及胎儿的情况妊娠期周数及胎儿的情况 患者及家属的意愿患者及家属的意愿 心脏外科医生的经验及业务水平心脏外科医生的经验及业务水平 涉及的有关专科的技术水平涉及的有关专科的技术水平 影响外科决策的因素影响外科决策的因素 妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍 面临的挑战面临的挑战 大批育龄妇女在换瓣术后有怀孕的需要大批育龄妇女在换瓣术后有怀孕的需要 孕期的抗凝不规律问题孕期的抗凝不规律问题 如何预防和处理妊娠期发生瓣膜失功能如何预防和处理妊娠期发生瓣膜失功能 低温体外循环对母体和胎儿的影响低温体外循环对母体和胎儿的影响 多学科如何协助治疗多学科如何协助治疗 妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍 左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流 是一个易受忽视的问题是一个易受忽视的问题 显著影响长期生存率显著影响长期生存率 Nath J,et al, J Am Coll Cardiol,2004;43,405 机制机制 肺动脉高压肺动脉高压 三尖瓣环扩张三尖瓣环扩张 心房纤颤心房纤颤 风湿性病变的进展风湿性病变的进展 成形技术的局限性成形技术的局限性 Xuejun X, et al. Heart Lung and Circul, 2004;13,65 Xuejun X, et al. Heart Lung and Circul, 2004;13,65 左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流 处理策略处理策略 再次成形：再次成形：DevegasDevegas， 瓣环成形，如何选择瓣环种类瓣环成形，如何选择瓣环种类 瓣膜置换：金属瓣：血栓风险瓣膜置换：金属瓣：血栓风险 生物瓣：近几年多采用生物瓣：近几年多采用 左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流 有待解决的问题有待解决的问题 l l 左心瓣膜置换术后三尖瓣返流的原因左心瓣膜置换术后三尖瓣返流的原因 l l 选择成形术的标准选择成形术的标准 l l 选用何种成形方法选用何种成形方法 l l 如何选择瓣环的种类和大小如何选择瓣环的种类和大小 l l 选择瓣膜置换术的标准选择瓣膜置换术的标准 l l 如何预防三尖瓣返流如何预防三尖瓣返流 左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流 二尖瓣成形失败二尖瓣成形失败 瓣膜成形术所占的比例不高瓣膜成形术所占的比例不高 在我国瓣膜病以风湿性病变为主，在我国瓣膜病以风湿性病变为主， 病人就诊晚病人就诊晚 成形技术未能普遍开展成形技术未能普遍开展 担心成形失败而需再次手术担心成形失败而需再次手术 外科治疗方法外科治疗方法 再次成形术再次成形术 瓣膜置换术瓣膜置换术 经导管瓣膜植入术经导管瓣膜植入术 “ “环中瓣环中瓣 ” ” 二尖瓣成形失败二尖瓣成形失败 如何预防如何预防 掌握二尖瓣成形术的指征掌握二尖瓣成形术的指征 采用合适的成形方法采用合适的成形方法 术中食道术中食道B B超检查超检查 二尖瓣成形失败二尖瓣成形失败 实时三维实时三维TEETEE在二尖成形术中的应用在二尖成形术中的应用 Post Repair Pre Repair 二尖瓣成形失败二尖瓣成形失败 展展 望望 随着外科技术及围手术期处理水平的提随着外科技术及围手术期处理水平的提 高，再次手术病人死亡率将下降高，再次手术病人死亡率将下降 介入及微创技术的进步可减少再次开胸介入及微创技术的进步可减少再次开胸 手术手术 Edwards Lifesciences 经导管主动脉瓣植入术的初步实验经导管主动脉瓣植入术的初步实验 THANK YOU Strategies of Re-operation in Heart Strategies of Re-operation in Heart Valve DiseaseValve Disease Cong Lu, MDCong Lu, MD Guangdong General HospitalGuangdong General Hospital Guangdong Provincial Cardiovascular InstituteGuangdong Provincial Cardiovascular Institute Guangzhou, ChinaGuangzhou, China Guangdong General Hospital Guangdong Provincial Cardiovascular Institute Relevant Historic Milestones in ChinaRelevant Historic Milestones in China 1954 1954 Closed mitral commissurotomy 1958 The first application of CPB1958 The first application of CPB 1958 1958 Open mitral commissurotomy by CPB 1965 Mitral valve replacement1965 Mitral valve replacement Eminent Pioneers and Institutions of China Eminent Pioneers and Institutions of China Cai YongzhiCai Yongzhi Changhai Hospital Changhai Hospital ShanghaiShanghai Zhang BaorenZhang Baoren Changhai Hospital Changhai Hospital ShanghaiShanghai Guo JiaqiangGuo Jiaqiang Fuwai Cardiovascular Hospital Fuwai Cardiovascular Hospital BeijingBeijing Luo ZhengxiangLuo Zhengxiang Guangdong General Hospital Guangdong General Hospital GuangzhouGuangzhou Operations and Re-operationsOperations and Re-operations By the late 1990s, 6000 heart valve operations performed each year In recent years, the number of valve In recent years, the number of valve operations per year is more than 20 000 operations per year is more than 20 000 With the number of heart valve surgeries With the number of heart valve surgeries increasing, re-operation of heart valve increasing, re-operation of heart valve disease becomes an unavoidable problemdisease becomes an unavoidable problem The Experience of Our HospitalThe Experience of Our Hospital Heart valve surgeries in Guangdong Heart valve surgeries in Guangdong General Hospital from 1997 to 2007General Hospital from 1997 to 2007 The Experience of Our HospitalThe Experience of Our Hospital The total operations from 1997 to 2007The total operations from 1997 to 2007： 6703 cases 6703 cases Re-operationsRe-operations：499 cases499 cases ( 7.4%)( 7.4%) Perioperative mortality of re-operations Perioperative mortality of re-operations ：8.8%8.8% Causes of Re-operationCauses of Re-operation The leading causeThe leading cause： Re-stenosis after closed mitral commissurotomyRe-stenosis after closed mitral commissurotomy（64.5%64.5% ） Causes of re-operation of other hospital Causes of re-operation of other hospital HospitalRe-operationcauses Fuwai Hospital333a,b,c,d,e,f Xinqiao Hospital187f,a,d,g Renji Hospital203f,a,g, Fujian Provincial Hospital104f,e,g,d,a,h Baotou Central Hospital165f,a,g,c,d,b,e a: bioprosthetic failure， b: perivalvular leakage， c: lesion of natural valve， d: dysfunction of mechanical valve， e: endocarditis， f: closed mitral commissurotomy， g: open mitral commissurotomy， h: others Risks and StrategiesRisks and Strategies Risks are higher of re-operation than Risks are higher of re-operation than initial operationinitial operation pro-longed history pro-longed history poor cardiac functionpoor cardiac function adhesionadhesion bleedingbleeding A variety of methods and strategies of A variety of methods and strategies of management should be applied according management should be applied according to different causes leading to re-operationto different causes leading to re-operation Restenosis after Closed or Open Mitral Restenosis after Closed or Open Mitral CommissurotomyCommissurotomy Was widely done with good results in China Restenosis is unavoidable Restenosis is unavoidable CharactersCharacters：pro-longed historypro-longed history，often often concomitant with tricuspid regurgitationconcomitant with tricuspid regurgitation StrategiesStrategies： re-repair re-repair prosthetic valve replacement prosthetic valve replacement ： bioprosthetic valve bioprosthetic valve mechanical prosthetic valve mechanical prosthetic valve Dysfunction of Mechanical Prosthetic ValveDysfunction of Mechanical Prosthetic Valve Prosthetic valve structureProsthetic valve structure Obstruction of mechanical prosthetic valveObstruction of mechanical prosthetic valve pannus, fibrous tissue accrementitionpannus, fibrous tissue accrementition thrombogenesis: most within 3 years thrombogenesis: most within 3 years postoperationpostoperation Causes of obstructionMVRAVRTVR thrombogenesis35(71%)8(33%)4(100%) pannus, fibrous tissuepannus, fibrous tissue14(29%)16(67%) Dysfunction of Mechanical Prosthetic ValveDysfunction of Mechanical Prosthetic Valve StrategiesStrategies ThrombusThrombus：thromblysisthromblysis reoperation reoperation Pannus, fibrous tissue Pannus, fibrous tissue ：reoperationreoperation Difference of the target value of INR Difference of the target value of INR among AVR, MVR and TVRamong AVR, MVR and TVR AVRAVR：INR 1.8-2.0INR 1.8-2.0 MVRMVR：INR 2.0-2.5INR 2.0-2.5 TVRTVR：INR 2.5-3.0INR 2.5-3.0 Mechanical valve dysfunction in pregnant Mechanical valve dysfunction in pregnant womenwomen Causes Causes （1 1）hemostasis changes in pregnancy Pregnancy is associated with a 20-200% increase in levels of fibrinogen and factors II, VII, VIII, X, and XII Lockwood CJ. Obstet Gynecol 2002;99:333. （2 2）worry about the side effect of warfarinworry about the side effect of warfarin （3 3）discontinue anticoagulation therapy in the discontinue anticoagulation therapy in the early stage of pregnancy or use other early stage of pregnancy or use other anticoagulants anticoagulants Mechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Experience of our hospitalExperience of our hospital Seven patients with mechanical valve Seven patients with mechanical valve dysfunction during pregnancy were dysfunction during pregnancy were retrospectively reviewed retrospectively reviewed NYHA at IV in 3, at III in 3NYHA at IV in 3, at III in 3 Gestation period 28 weeks in 4, 28 weeks in 4, 6 months 6 months？ Degree of obstruction of mechanical valveDegree of obstruction of mechanical valve Cardiac functionCardiac function Gestation period and condition of fetusGestation period and condition of fetus Desire of patients and family membersDesire of patients and family members Experience of cardiac surgeonExperience of cardiac surgeon Professional level of relevant departmentProfessional level of relevant department Mechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Factors impact on making decision Factors impact on making decision of managementof management Mechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Challenging Challenging Many young women who underwent valve Many young women who underwent valve replacement want to have babyreplacement want to have baby Irregular anticoagulation therapy during Irregular anticoagulation therapy during pregnancypregnancy The adverse impacts of hypothermia and CPB The adverse impacts of hypothermia and CPB on fetuson fetus How to prevent and manage mechanical valve How to prevent and manage mechanical valve dysfunction in pregnant patientsdysfunction in pregnant patients How to cooperate with other department ,eg. How to cooperate with other department ,eg. Neontology department, obstetrics departmentNeontology department, obstetrics department Late Tricuspid Regurgitation after Left Late Tricuspid Regurgitation after Left Cardiac Valve ReplacementCardiac Valve Replacement Tricuspid regurgitation is often neglectedTricuspid regurgitation is often neglected Adverse impact on survival Nath J,et al, J Am Coll Cardiol,2004;43,405 MechanismMechanism Persistent pulmonary hypertensionPersistent pulmonary hypertension Annular dilatationAnnular dilatation Atrial fibrillationAtrial fibrillation Progression or development of Progression or development of rheumatic lesionsrheumatic lesions Limitation of De Vegas procedureLimitation of De Vegas procedure Xuejun X, et al. Heart Lung and Circul, 2004;13,65 Xuejun X, et al. Heart Lung and Circul, 2004;13,65 TR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement TR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Strategies of managementStrategies of management Re-repairRe-repair De Vegas procedure De Vegas procedure annuloplasty ring annuloplasty ring Valve replacementValve replacement mechanical valve mechanical valve：risk of thrombogenesisrisk of thrombogenesis bioprosthetic valve bioprosthetic valve：widely used in recent widely used in recent years years TR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Remaining QuestionsRemaining Questions What is the mechanism of functional TR?What is the mechanism of functional TR? How to perform tricuspid repair?How to perform tricuspid repair? Which size and kind of ring for which patient?Which size and kind of ring for which patient? When should we perform a repair?When should we perform a repair? When should we think to valve replacement?When should we think to valve replacement? Why late development of tricuspid regurgitation Why late development of tricuspid regurgitation after successful mitral surgery?after successful mitral surgery? How to prevent it?How to prevent it? Failure and Complication of Valve Failure and Complication of Valve RepairRepair Valve repair is far less than valve replacement Valve repair is far less than valve replacement in Chinain China R Rheumatic heart disease is still the leading cause of valvular damage leading to surgery in China Patients often experienced pro-longed history before their first visits Techniques of valve repair are not applied widelyTechniques of valve repair are not applied widely Worry about reoperationWorry about reoperation Methods of surgical treatmentMethods of surgical treatment Re-repair Re-repair Valve replacement Valve replacement Transcatheter valve implantation Transcatheter valve implantation valve-in-ringvalve-in-ring Failure of Valve RepairFailure of Valve Repair Failure of Valve RepairFailure of Valve Repair How to prevent ?How to prevent ? Indication and contraindication of Indication and contraindication of mitral repairmitral repair Apply suitable methods of mitral Apply suitable methods of mitral repairrepair TEETEE Failure of Valve RepairFailure of Valve Repair Live 3D TEE for Mitral Repair SurgeryLive 3D TEE for Mitral Repair Surgery Post Repair Pre Repair ProspectionProspection With the development of surgical techniques With the development of surgical techniques ， the incidence of reoperation and the mortality of the incidence of reoperation and the mortality of reoperation will decreasereoperation will decrease With the improvement of interventional therapy, With the improvement of interventional therapy, reopen chest surgery will be avoided in some reopen chest surgery will be avoided in some patientspatients Edwards Lifesciences Our preliminary experiment of transcatheter aortic Our preliminary experiment of transcatheter aortic valve implantationvalve implantation THANK YOU K5eSIYADNxTbj(&3YqURrKwYEX-AC17KDX6)IY*d$PmcyXHY322zlP+p9S-J85GoQ30a8(WUxZ%M3Sn$KCbABhYp6dIk$1+6)ZWzMqXgSV&dh%c*3N9MJ-uL+h-GhO(QrsBqS3UjVmM%-nUz!3*2YHM-SzB-rtOYkp130D8Q!t!Vq2F7PKAbnsF(Fvr(!sM&yur#7OPIy&DM)56kRMCnO)5SGyrlT1&3hweymW8G%crD$&GVtoUf6M!- Trw1mHKxxdoA6&ScEuqh2AlwC$hfo39ZgG6U7r2&TJgYC$hdfKHnWRp9Vi!+8)+#u1aTXy7EtPv2FU&Cikvtw8lJWGPtGxpDVPzsxT4x6gpQl5UaJAuvBOj!xi6!e8vFn&TgTk5IyrSxjBx$xv3YzibeidoJZi0p5hLJJIP(cXE(dg2yjvAlyl70(60&6qu(*pv6#OZfLp5T8HMmNSqVMubAKF#A$vItvarX(iq7NNPqn)i*!Zgz4f6o9FM#W)!jx3MVuFOsABB3*X2%J3!oZGH0G!n73CrNBE3GXZaEmvH&3mtDqaReRMp+6IbMzesj0heScawKbbJ93YTRYqDoF&-B!hgUAtq9LgE%&nEkrw#JOn8JMT$f1I(p$uMwJrdecvSyV&KGrds0U*1eU$Wc5- yiq!%nCSmO(a*jk$Z6NgKT97LyG3#9+ae&C9*zYo3MTCMpNVdn8gG&CytcYUfOLDiiT5oF-d!VDTT6pL6#NF0oNo%5q50dsPvf+uV*$E3(FQtF+i-zdojZAWsagTYGl4LtGw$GZcMFX49$qy#DFE8Z!*3ON$U*p)zXO(8pe7DU&W7Llb3dd5%J2HTKJMhCNUWiCE6(2YOxH5nS&!4WbVJlz$6qv87(bFYmU9uMo5p#vwcWoYylx8En)oWl3WD7uyU0s-54$eoXkRaY4LnCkkGX$PbEnkdDwmByzc&Bo8nBIwh5CqbWNWs+hj6xLgZt9QLmyoQ$geUAgXZBsQH9nsytg!7boUeFPJYx#L+#J6QUFOecGNKS-2d4%#awmnHxRm$6F9rK%- K06zZU*tWcrr*m#XtxIaod#6cey#Ot9wpXHdkZzdlfR&wdOmofhS#3Qy10reDjMo6EfbPvF*$DaXHm&02O$1883TDav(mKT9TW4$(um91lakn(N9Vgx&8n)JQGyft8$Bgg$!Dlr+Kpk6#LuFJxnSWJkiNtHv-EAuFnCDh*QNmoKyMFunwr4cMCuTV)RkXRefCo-gYHGeX-gouR%oIEY#L57(q7rxs9A&Z6Xxu%PPFkUM9wpDV%&64(k3)wgk03kjcjuYQmWfU3ZI7Yu(9of*WqJR!Cj#rRCy!-41O&L!x1S+7B9&nTmHmbU)j8cn- DqxiJ%&jWA#BdLRD0ZGpr+%xyI3nb)1l!%WAn+hUtIYq#JEiyqsQ4%F+fcGB9ZJU3pN4I+6)u2ai$ZDdKqE5PT2NQ&zWtcJgiNHkV1eN&BXrZk8IkoX0he6M(cdIffcdFso4(bo1Lg+CcMXgr4a#8VpTo3Zeb&G-R2aGhWPiQofcEOMuUwstM$jT8h8aZW&jpZw3b3RgcFnbp5(kUX$+p+pVyECCmPF(Y-GGsA$kQ$joB3&2Uo-F6+E1RxLlxT2rgxFHXkAvGGg55)qqTsrKktuBCGb6COBIItyWOKysu39hmhETukVxutwYVpy9xx6+w#TzwffO)dAQB4VrIteA$gjThLHh*-$%FCQ9GXmCr4vBJbq(- VUMc%8MbLBQinkgaR%adVaBD8E62r&dK5Fke*IF4tucZS(wBwv9fOk*1vXq$ccbq3kR4lhjn(eRY4k9!Cj%7vQ0Q4CU-$uHUVz*oQvLzoRFbjMReih!QE5MmiJoC$*X+RA#QQL#muNO!w5qr!)5cIS8m-A55xF%SpqzpxWr-7b0(GIuB!#)PkQBEA6y&Ak4inYb1F!$Ovmnm54BzqE2Na%d!O&VnJ&#q$wOq3YtY7jwatzh4gwsh)jibFC*Yps)KP#&K*i2R(J9dEFGqxWW18cEB)- ziZDMoNNs2Vwev1!Rk+$WK7ms6Uf)N*b&$VBHeO832#WgP5ihPK4iF6AD92zE%)USsBsiE3TaTgzn1ZIDd5pS*gnIU8No#(3qRcRkz2g5#bGOq!KfDmMBj*C$5l9sTdWCPdhIUTti4bP+EyClhvtZoZ&1c2vyH73X&hlfTvLqVIIaBXxWY$oXXQMO-nfKn52gk&YV*N-*#slH)s2vmnyYjfxu3QCyQ(BE(!barIe2GqaHV2KFg2&0w8vATFvo&u(x9XMK6&LgZ&*d8*m&kxD5leUZD8u!WB%tZ2)dXcJfcpi%74guQlkV!6(b0oZKHLBeLOD%+0vbEWkXRTdJaj4ZbyxEfxa#Z6kFs4wKK$kwosVKPkgN#WfLi6XQ%gPv+E(dsds8ga6qes*bkIcNk*%!qbMDKca)*N6%r!u!vm(hqCfmE- G)+kYg&%BA+TvgQ90yTM6o!zm4Da-sT0AglqL(203Ega3W#KCQhXN%uNrsI61mZf86HuV0C+LMpA&dxiEAYAhjUdwXbWg$Z0l3&R3Rh2M8(+U%lk3VqG4WdOCQ)*BsQYDmTgP*1WgNdfyor+OcRo-rfRf02dYC(e!gKPnm%cxQTJrJ*h#c*M%)LQ*HPtvD9p$8d2KYol88caR9Lv)NohK7(18xI+TT%rVVVWF-+O5D74Nfd23ZWMrtFqe&yK8#z9H&v%Vio99MTCU7+*Ve&PUW-Y5UIJpkacDC9+IbBNF$m*3cmMQmm&nemC7gPzBoe67DyGznmOG3I)&Ye$8EWMm#fs8RknB0CLjBEe&myt(wOJz(Z1q4WtEHOPCDYkMFiMdL)*nroa#bcTfL!qwvW&eu- m9dy)NP!A2ERZ#XJ8kEFN-q7qM!9PIBn5iQ!UI83pGZMfzHB(0v0(Q%A&JqJHMBAZr9%d&dz&W)+HCsBnYbqdtrDk)1#dJ