Pub Date : 2023-08-25DOI: 10.1177/26324636231194886
Sudipta Mondal, Richard R. Raj, S. Harikrishnan
Extensive myocardial dystrophic calcification is rare and indicates a poor prognosis with a risk of arrhythmia and recurrent heart failure. We present a long term survivor of extensive myocardial infarction presenting as myocardial calcification related unstable ventricular tachycardia needing an implantable cardioverter defibrillator.
{"title":"Calcium Jacket of Left Ventricle: An Aristocracy of the Monster","authors":"Sudipta Mondal, Richard R. Raj, S. Harikrishnan","doi":"10.1177/26324636231194886","DOIUrl":"https://doi.org/10.1177/26324636231194886","url":null,"abstract":"Extensive myocardial dystrophic calcification is rare and indicates a poor prognosis with a risk of arrhythmia and recurrent heart failure. We present a long term survivor of extensive myocardial infarction presenting as myocardial calcification related unstable ventricular tachycardia needing an implantable cardioverter defibrillator.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"152 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127314351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-18DOI: 10.1177/26324636231193999
Anish Pabba, K. Parvathareddy, Praveen Nagula, Susruth Bandaru
A pulmonary artery aneurysm is defined as focal dilation of the pulmonary artery beyond a diameter of 29 mm. The reported incidence is 1 in 14,000 as per the autopsy studies. A diameter of more than 55 mm is defined as a massive pulmonary artery aneurysm which is very rare. These are commonly associated with patent ductus arteriosus. No distinct features for identification and guidelines for their management warrant a detailed evaluation for etiology and close follow-up in this entity fearing fatal rupture. We present a case of a massive pulmonary artery aneurysm associated with the ventricular septal defect.
{"title":"Massive Pulmonary Artery Aneurysm in a Patient with Ventricular Septal Defect: Case Report of a Rare Association","authors":"Anish Pabba, K. Parvathareddy, Praveen Nagula, Susruth Bandaru","doi":"10.1177/26324636231193999","DOIUrl":"https://doi.org/10.1177/26324636231193999","url":null,"abstract":"A pulmonary artery aneurysm is defined as focal dilation of the pulmonary artery beyond a diameter of 29 mm. The reported incidence is 1 in 14,000 as per the autopsy studies. A diameter of more than 55 mm is defined as a massive pulmonary artery aneurysm which is very rare. These are commonly associated with patent ductus arteriosus. No distinct features for identification and guidelines for their management warrant a detailed evaluation for etiology and close follow-up in this entity fearing fatal rupture. We present a case of a massive pulmonary artery aneurysm associated with the ventricular septal defect.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133352222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-13DOI: 10.1177/26324636231191313
P. Jariwala, Venugopal Rao Joginpalli, Venkateswaralu Jampala
A high-grade stenosis of the inferior vena cava (IVC) can cause swelling, discoloration of the lower extremities, and the development of venous ulcers. These patients may be unable to participate in physical activities as well. Although anticoagulation and compression therapy may help alleviate symptoms and prevent repeated thrombosis, few patients develop progressive symptoms. We present a case of an elderly female who had progressive venous claudication, edema, heaviness, and discoloration of both lower limbs. Despite endovascular laser therapy for varicose veins, the symptoms worsened, jeopardizing her quality of life. Endovenous intervention with a stent to treat high-grade stenosis at the junction of the suprahepatic IVC and right atrium (RA) could completely relieve her symptoms and improve her quality of life. Isolated severe stenosis of the IVC at the confluence with the RA is a rare cause of chronic venous congestion. Its leads to refractory venous congestion with secondary skin change with an adverse impact on quality of life. Endovenous intervention using an appropriate endovascular prosthesis is the treatment of choice.
{"title":"Endovenous Intervention for Isolated Idiopathic Non-Malignant High-Grade Stenosis of the Suprahepatic Inferior Vena Cava for Chronic Venous Congestion","authors":"P. Jariwala, Venugopal Rao Joginpalli, Venkateswaralu Jampala","doi":"10.1177/26324636231191313","DOIUrl":"https://doi.org/10.1177/26324636231191313","url":null,"abstract":"A high-grade stenosis of the inferior vena cava (IVC) can cause swelling, discoloration of the lower extremities, and the development of venous ulcers. These patients may be unable to participate in physical activities as well. Although anticoagulation and compression therapy may help alleviate symptoms and prevent repeated thrombosis, few patients develop progressive symptoms. We present a case of an elderly female who had progressive venous claudication, edema, heaviness, and discoloration of both lower limbs. Despite endovascular laser therapy for varicose veins, the symptoms worsened, jeopardizing her quality of life. Endovenous intervention with a stent to treat high-grade stenosis at the junction of the suprahepatic IVC and right atrium (RA) could completely relieve her symptoms and improve her quality of life. Isolated severe stenosis of the IVC at the confluence with the RA is a rare cause of chronic venous congestion. Its leads to refractory venous congestion with secondary skin change with an adverse impact on quality of life. Endovenous intervention using an appropriate endovascular prosthesis is the treatment of choice.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"64 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122895965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-07DOI: 10.1177/26324636231190247
Tammiraju Iragavarapu, K. Krishna
Introduction Torsades de pointes (TdP), a form of polymorphic ventricular tachycardia that manifests in the setting of an acquired or congenital QT interval prolongation. Polymorphic VT can occur in hyper acute phase or healing phase of an acute myocardial infarction. The presence of necrotic area caused by the infarction explains the existence of a possible circuit as well as the appearance of a re-entry arrhythmia. Aims and Objectives Our aim is to study the incidence of long Qt induced TdP in acute MI patients and its prognostic implications. We also want to analyze the impact of primary percutaneous transluminal coronary angioplasty in the management of these subset of patients. Methods In this cross-sectional observational study done from May 2021 to May 2022, We have studied 320 cases of acute MI, of which 6 were found to have TdP (1.9%). Four patients had inferior wall myocardial infarction and 2 patients had Non-ST elevation MI. Thrombolysis was done in 2 cases. Two cases underwent primary angioplasty. One case was recommended for coronary artery bypass grafting. All cases underwent appropriate electrolyte correction, besides cardioversion, as needed. Results All patients with TdP had prolonged QT interval. 50% of patients had mild hypokalemia. Two patients had complete heart block. Three patients had severe left ventricular dysfunction. Patients who underwent primary angioplasty survived. Thrombolysis had less impact on survival in Acute Mi with TdP. Conclusion Early percutaneous coronary angioplasty, combined with electrolyte correction, improves the prognosis in TdP complicating acute MI.
{"title":"Torsades De Pointes Complicating Acute Myocardial Infarction, Twisting the Prognosis","authors":"Tammiraju Iragavarapu, K. Krishna","doi":"10.1177/26324636231190247","DOIUrl":"https://doi.org/10.1177/26324636231190247","url":null,"abstract":"Introduction Torsades de pointes (TdP), a form of polymorphic ventricular tachycardia that manifests in the setting of an acquired or congenital QT interval prolongation. Polymorphic VT can occur in hyper acute phase or healing phase of an acute myocardial infarction. The presence of necrotic area caused by the infarction explains the existence of a possible circuit as well as the appearance of a re-entry arrhythmia. Aims and Objectives Our aim is to study the incidence of long Qt induced TdP in acute MI patients and its prognostic implications. We also want to analyze the impact of primary percutaneous transluminal coronary angioplasty in the management of these subset of patients. Methods In this cross-sectional observational study done from May 2021 to May 2022, We have studied 320 cases of acute MI, of which 6 were found to have TdP (1.9%). Four patients had inferior wall myocardial infarction and 2 patients had Non-ST elevation MI. Thrombolysis was done in 2 cases. Two cases underwent primary angioplasty. One case was recommended for coronary artery bypass grafting. All cases underwent appropriate electrolyte correction, besides cardioversion, as needed. Results All patients with TdP had prolonged QT interval. 50% of patients had mild hypokalemia. Two patients had complete heart block. Three patients had severe left ventricular dysfunction. Patients who underwent primary angioplasty survived. Thrombolysis had less impact on survival in Acute Mi with TdP. Conclusion Early percutaneous coronary angioplasty, combined with electrolyte correction, improves the prognosis in TdP complicating acute MI.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"6 42","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114046164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-07DOI: 10.1177/26324636231190170
Sudipta Mondal, Harikrishnan Sivadasanpillai
Acute aortic dissection is a life-threatening condition with high mortality if not treated immediately. We present a case of acute aortic dissection presenting as acute ST elevation myocardial infarction causing Cath Lab misadventure and delay in the definitive management.
{"title":"STEMI: Wolf in Sheep’s Clothing With Double-Barrel Aorta","authors":"Sudipta Mondal, Harikrishnan Sivadasanpillai","doi":"10.1177/26324636231190170","DOIUrl":"https://doi.org/10.1177/26324636231190170","url":null,"abstract":"Acute aortic dissection is a life-threatening condition with high mortality if not treated immediately. We present a case of acute aortic dissection presenting as acute ST elevation myocardial infarction causing Cath Lab misadventure and delay in the definitive management.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"48 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116007217","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-27DOI: 10.1177/26324636231185645
K. Parvathareddy, Praveen Nagula
Introduction Prevalence of heart failure (HF) is increasing, and right ventricular (RV) dysfunction is an independent predictor of mortality. Accurate echocardiographic evaluation of RV function is challenging and novel parameters which can aid in prediction RV function are required. Pulmonary artery Pulsatility index (PAPi) is one such parameter. Patients and Methods We conducted a prospective study in 33 patients admitted with symptoms of HF and severe LV dysfunction (EF < 35) who underwent right heart catheterization and followed them for 6 months. Primary objective was to determine the association of PAPi with hospitalizations and mortality in short-term follow-up in HF patients. Clinical, demographic, echocardiographic, and catheterization data were recorded. PAPi was calculated as a ratio of pulmonary artery pulse pressure and right atrial pressure. Results The mean age of population was 47 years (±12). Males were 20(61%) and females were 13(39%). Median PAPi in the study population was 2.42 (IQR-1.83). The study population were stratified into 3 groups based on 10th, 50th, and 90th percentile PAPi and on comparisons between groups PAPi was significantly associated with hospitalization at 1 and 6 months in univariate (P = .03 and P = .03 respectively) and in multivariate analysis (P = .04). PAPi was not found to be associated with mortality at 1 month or 6 months. However, the absolute mortality was low in the study population (n = 4). Conclusion PAPi has been found to be a strong and an independent predictor of hospitalization at 1 month and 6 months. Comments Advanced HF is seen in 1 out of 5 patients with HF. It is characterized by refractory symptoms, multiple hospitalizations, fluid retention, elevated natriuretic peptides, and decreased cardiac output often requiring inotropes. The survival rate is poor. The presence of right ventricular dysfunction is an independent predictor of mortality in these patients. Hemodynamic assessment is of importance in these patients to guide regarding further management, ie, use of inotropes, left ventricular assist devices, etc. The PAPi is a marker derived from the formula (PASP-PADP/RAP). 1 The outcome worsens as the PAPi decreases. However, the stroke volume, pulmonary artery capacitance (PAC), and right atrial pressure all have an impact on PAPi. Patients with high PAC will have better PAPi compared to those with low PAC with the stroke volume being constant. 2 Different subsets of HF population have varying PAPI thresholds, with isolated RV infarction having the lowest (0.9) and severe HF having the highest (3.2). 2 Future research should examine the impact of exercise, inotropes, and vasodilators.
{"title":"Hemodynamic and Management Perspectives in Heart Failure Patients","authors":"K. Parvathareddy, Praveen Nagula","doi":"10.1177/26324636231185645","DOIUrl":"https://doi.org/10.1177/26324636231185645","url":null,"abstract":"Introduction Prevalence of heart failure (HF) is increasing, and right ventricular (RV) dysfunction is an independent predictor of mortality. Accurate echocardiographic evaluation of RV function is challenging and novel parameters which can aid in prediction RV function are required. Pulmonary artery Pulsatility index (PAPi) is one such parameter. Patients and Methods We conducted a prospective study in 33 patients admitted with symptoms of HF and severe LV dysfunction (EF < 35) who underwent right heart catheterization and followed them for 6 months. Primary objective was to determine the association of PAPi with hospitalizations and mortality in short-term follow-up in HF patients. Clinical, demographic, echocardiographic, and catheterization data were recorded. PAPi was calculated as a ratio of pulmonary artery pulse pressure and right atrial pressure. Results The mean age of population was 47 years (±12). Males were 20(61%) and females were 13(39%). Median PAPi in the study population was 2.42 (IQR-1.83). The study population were stratified into 3 groups based on 10th, 50th, and 90th percentile PAPi and on comparisons between groups PAPi was significantly associated with hospitalization at 1 and 6 months in univariate (P = .03 and P = .03 respectively) and in multivariate analysis (P = .04). PAPi was not found to be associated with mortality at 1 month or 6 months. However, the absolute mortality was low in the study population (n = 4). Conclusion PAPi has been found to be a strong and an independent predictor of hospitalization at 1 month and 6 months. Comments Advanced HF is seen in 1 out of 5 patients with HF. It is characterized by refractory symptoms, multiple hospitalizations, fluid retention, elevated natriuretic peptides, and decreased cardiac output often requiring inotropes. The survival rate is poor. The presence of right ventricular dysfunction is an independent predictor of mortality in these patients. Hemodynamic assessment is of importance in these patients to guide regarding further management, ie, use of inotropes, left ventricular assist devices, etc. The PAPi is a marker derived from the formula (PASP-PADP/RAP). 1 The outcome worsens as the PAPi decreases. However, the stroke volume, pulmonary artery capacitance (PAC), and right atrial pressure all have an impact on PAPi. Patients with high PAC will have better PAPi compared to those with low PAC with the stroke volume being constant. 2 Different subsets of HF population have varying PAPI thresholds, with isolated RV infarction having the lowest (0.9) and severe HF having the highest (3.2). 2 Future research should examine the impact of exercise, inotropes, and vasodilators.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"59 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132832091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-21DOI: 10.1177/26324636231186910
B. Vivek, Ashish Kumar Jain, J. Sawhney, R. Jain, R. Passey, A. Mohanty
Aim To highlight the prevailing lack of suspicion of cardiac amyloidosis (CA) amongst physicians, leading to preventable delay in management of patients of heart failure (HF). Methods Six patients of CA diagnosed in 6 months were retrospectively analyzed. Clinical history, investigations, treatment, and follow-up data is analyzed. Result A speckled interventricular septum on echo favored CA. Speckle tracking showed reduced global longitudinal strain with typical left ventricular apical sparing in all patients. Bone marrow study confirmed light chain amyloidosis (AL) in all patients. Conclusion CA, a frequently missed diagnosis, can be detected early with the help of clinical red flag signs, echocardiogram, serum and urine immune electrophoresis and bone scan.
{"title":"Missed Cardiac Amyloidosis: A Potentially Treatable Disease","authors":"B. Vivek, Ashish Kumar Jain, J. Sawhney, R. Jain, R. Passey, A. Mohanty","doi":"10.1177/26324636231186910","DOIUrl":"https://doi.org/10.1177/26324636231186910","url":null,"abstract":"Aim To highlight the prevailing lack of suspicion of cardiac amyloidosis (CA) amongst physicians, leading to preventable delay in management of patients of heart failure (HF). Methods Six patients of CA diagnosed in 6 months were retrospectively analyzed. Clinical history, investigations, treatment, and follow-up data is analyzed. Result A speckled interventricular septum on echo favored CA. Speckle tracking showed reduced global longitudinal strain with typical left ventricular apical sparing in all patients. Bone marrow study confirmed light chain amyloidosis (AL) in all patients. Conclusion CA, a frequently missed diagnosis, can be detected early with the help of clinical red flag signs, echocardiogram, serum and urine immune electrophoresis and bone scan.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122833857","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-23DOI: 10.1177/26324636231173790
Sharath Reddy Annam, Anil Krishna, Amjad Ali
With growing expertise and evolving hardware chronic total occlusion (CTO) percutaneous coronary intervention (PCI) success and safety has been improved remarkably. The nuances of CTO wiring help operators to find novel solutions to the complications created during percutaneous coronary interventions. Accidental coronary perforations caused during CTO interventions can be sealed by wiring from other side and shifting interposing plaque or flap onto perforation. We report a case of saccular aneurysm around the proximal cap formed by antegrade wire escalation in earlier failed percutaneous coronary interventions, which is excluded by “retrograde plaque lift and shift.”
{"title":"“Retrograde Plaque/Flap Lift-and-Shift” Technique to Exclude Coronary Artery Aneurysm at the Proximal Cap of Chronic Total Occlusion of the Right Coronary Artery: A Case Report","authors":"Sharath Reddy Annam, Anil Krishna, Amjad Ali","doi":"10.1177/26324636231173790","DOIUrl":"https://doi.org/10.1177/26324636231173790","url":null,"abstract":"With growing expertise and evolving hardware chronic total occlusion (CTO) percutaneous coronary intervention (PCI) success and safety has been improved remarkably. The nuances of CTO wiring help operators to find novel solutions to the complications created during percutaneous coronary interventions. Accidental coronary perforations caused during CTO interventions can be sealed by wiring from other side and shifting interposing plaque or flap onto perforation. We report a case of saccular aneurysm around the proximal cap formed by antegrade wire escalation in earlier failed percutaneous coronary interventions, which is excluded by “retrograde plaque lift and shift.”","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"49 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130243192","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1177/26324636231178191
S. Madivada, Angella Patnaik
There are several recent trials that are burgeoning at a rapid pace in the field of cardiology. We picked up 5 trials that impacted our practice: CLEAR OUTCOMES trial, REVIVED BCIS2 trial, DELIVER trial, ADVOR trial, and EBC MAIN trial. After a brief description of the results of these trials, we gave our perspective of their impact on our practice.
{"title":"Five Recent Trials That Are Changing Cardiology Practice Across the World","authors":"S. Madivada, Angella Patnaik","doi":"10.1177/26324636231178191","DOIUrl":"https://doi.org/10.1177/26324636231178191","url":null,"abstract":"There are several recent trials that are burgeoning at a rapid pace in the field of cardiology. We picked up 5 trials that impacted our practice: CLEAR OUTCOMES trial, REVIVED BCIS2 trial, DELIVER trial, ADVOR trial, and EBC MAIN trial. After a brief description of the results of these trials, we gave our perspective of their impact on our practice.","PeriodicalId":429933,"journal":{"name":"Indian Journal of Clinical Cardiology","volume":"84 4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122660210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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