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J Thorac Cardiovasc Surg 1998;115:1080-1084
© 1998 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
Supported in part by the British Heart Foundation. Magdi H. Yacoub is a British Heart Foundation Professor of Cardiothoracic Surgery and Emma J. Birks is a Research Fellow supported by the British Heart Foundation (Project Grant 96152).
Read at the Seventy-seventh Annual Meeting of The American Association for Thoracic Surgery, Washington, D.C., May 4-7, 1997.
Received for publication May 5, 1997. Revisions requested Sept. 9, 1997; revisions received Dec. 1, 1997. Accepted for publication Dec. 8, 1997. Address for reprints: Sir Magdi Yacoub, FRCS, Professor of Cardiothoracic Surgery, National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, Harefield, Middlesex, UB9 6JH, United Kingdom.
Abstract
Objectives: There is still no agreement about the best method of dealing with malfunction of the aortic valve caused by aneurysm or dissection of the aortic root. The experience, rationale, and development of a valve-preserving technique introduced and used since 1979 is described.
Methods: During this period 158 patients (78% of all patients undergoing resection of aneurysm of the ascending aorta) were operated on using this technique. Their ages ranged from 2 to 72 years (mean 46.6 years). Of the patients 107 were male and 51 were female. A total of 68 patients had skeletal manifestations of Marfan's syndrome. The original disease was chronic aneurysm of the ascending aorta or root in 92 (58.2%), chronic dissection in 17 (10.8%), and acute dissection in 49 (31%) patients. One hundred eleven additional procedures were performed in 84 patients. In all there were five early deaths (4.6% ± 2%) in the 109 patients with chronic aneurysm and one death in the 103 patients operated on electively (0.97% ± 0.9%). Actuarial survival for patients operated on for chronic aneurysm was 93.3%, 88.0%, 79.0%, and 57.9% at 1, 5, 10, and 15 years and 96.8%, 91.2%, 82.0%, and 60.0% for those operated on electively. Actuarial survival for patients operated on for acute dissection was 72.8%, 63.4%, and 53.3% at 1, 5, and 10 years. The probability of needing reoperation was 3.0% ± 2%, 11% ± 0.5%, and 11% ± 0.5% at 1, 5, and 10 years. There were no instances of infective endocarditis or thromboembolic complications except in two patients operated on early in the series who had cusp extension. No anticoagulants were used. Echocardiography showed reduction in left ventricular end-systolic and end-diastolic dimensions, which was maintained. At the end of follow-up trivial or no aortic regurgitation was demonstrated in 63.6%, mild to moderate in 33.3%, and severe in 3%.
Conclusions: Valve-sparing operations are possible in a large proportion of patients with aneurysms of the ascending aorta and the medium and long-term results are encouraging.
Aneurysm or dissection of the ascending aorta involving the aortic root results in varying degrees of anatomic and functional abnormalities of the aortic valve mechanism that need to be addressed at the time of operation. There is still no agreement about the best method of achieving this, with most of the patients undergoing composite replacement of the aortic root and valve with a mechanical valve.
1-5 We believe that the "ideal" operation for these patients is a valve-sparing procedure. 6-8 We believe this because the aortic valve is an extremely sophisticated, dynamic structure best suited for its hemodynamic performance to maintain optimal left ventricular function, coronary flow, and cardiac output under widely different physiologic and pathologic conditions while minimizing mechanical stress on the valve cusps and because all currently available valve substitutes have a significant incidence of valve-related complications in addition to the imperfect hemodynamic performance. If they are to gain wide acceptance, valve-conserving operations, however, need to be accurately defined and shown to be safe, effective, and durable. The early results of several small series of valve-conserving operations have been encouraging. 9-12 We have developed a valve-conserving operation on the basis of the functional anatomy of the aortic valve and the pathophysiology of aortic regurgitation in patients with aneurysm of the aortic valve. 6-8,13,14 This technique has been regularly used since 1979. The purpose of this article is to analyze our experience with this technique and describe the rationale, development, and certain technical aspects of the operation.
Rationale and development of the technique
Development of the technique was stimulated by the knowledge that, at least initially, aortic regurgitation in these patients is mainly or entirely caused by aortic wall disease with sparing of the other components of the valve mechanism. The components of the aortic valve include the sinuses of Valsalva, the sinotubular junction, the anulus, and cusps (Fig. 1). These components are closely integrated and tend to change their shape, size, and relation to each other during the different phases of the cardiac cycle. This interaction is essential for the smooth efficient functioning of the valve that results in the cusp movements frequently preceding movement of the blood inside the lumen, which have important implications for the heart and the valve. Preservation or recreation of the conditions that allow this interaction is important for the short- and long-term success of the valve-preserving operation. One of these conditions is the capacity of the aortic root to expand during systole, thus altering the opening and closing characteristics of the cusps. 15-17 This can be ensured by refashioning the Dacron tube to produce three separate tongue-shaped processes that act as individual sinuses (Fig. 2). Other anatomic features relevant to this operation include the fact that the aortic anulus is a definite anatomic structure that is preserved in both acute dissection and aneurysms 13,14 of the aorta and thus provides excellent material for suturing the tongue-shaped processes (sinuses) of the graft to the semilunar line of attachment of the cusps to the aortic wall without the use of pledgets or any foreign material. Finally, the three components of the aortic cusp (the hinge, body, and coapting surface) can be readily identified at the time of operation by inspection while elevating the commissures. Providing adequate coapting surfaces is an important objective of the operation. In principle, therefore, the technique consists of excision of all the diseased aortic wall with reconstitution of the aortic valve mechanism while attempting to preserve its sophisticated functional characteristics.
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This has been described elsewhere 13,14 and essentially consists of establishing cardiopulmonary bypass with arterial return to the aortic arch in a chronic aneurysm and the femoral artery in acute dissection (the site of cannulation in the aortic arch is later excised while performing an open distal anastomosis with replacement of the aortic cannula in the Dacron tube). The ascending aorta is clamped and opened. Antegrade or retrograde (or both) cardioplegia is used for myocardial protection. The aortic valve is inspected, and all the diseased aortic wall is excised to within 1 mm of the aortic anulus (Fig. 2
). The three commissures are stretched in a vertical direction by the use of three horizontal mattress sutures placed just above the top of each commissure. The position of the aortic cusps and their ability to coapt without prolapsing is tested using a blunt instrument. The size of the Dacron tube is determined by measuring the distance between the commissures, which produces maximal coaptation of the cusps. The distance between the three commissures is usually equal, and thus each represents one third of the circumference. Because the circumference of a tube is approximately three times the diameter, the measured distance between the commissures in their new position after excising the sinuses is a guide to the size of the tube to be chosen. Alternatively, an obturator is used to measure the "orifice" between the commissures after excising the sinuses. In this series tubes varying from 24 to 34 mm diameter were used (Table I).
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Patients and methods
Between September 1979 and April 1997, 158 patients with aneurysms of the ascending aorta underwent valve-sparing operations performed by one surgeon. This represents 78% of patients with aneurysms or dissection of the ascending aorta involving the aortic root. All patients were considered for a valve-sparing operation regardless of the size of the aneurysm or anulus. Patients with severe retraction or calcification of the aortic valve cusps were considered unsuitable for repair. The presence of a bicuspid valve in the absence of cusp retraction was not considered a contraindication for repair. Patient ages ranged from 2 to 72 years (mean 46.6 years). There were 107 male and 51 female patients. The original disease was chronic aneurysm of the ascending aorta or root in 92 (58.2%), chronic dissection in 17 (10.8%), and acute dissection in 49 (31%). Sixty-eight patients had skeletal manifestations of Marfan's syndrome. New York Heart Association (NYHA) status was class I in 14 (8.9%), class II in 32 (20.3%), class III in 71 (44.9%), and class IV in 41 (25.9%). The preoperative degree of aortic regurgitation was evaluated by a set of clinical and echocardiographic criteria 18,19 and judged to be trivial in 15 (9.5%), mild in 37 (23.4%), moderate in 78 (49.4%), and severe in 28 (17.7%). Cardiothoracic ratio on the preoperative chest x-ray film was less than 0.55 in 101 and more than 0.55 in 56. Pulmonary edema was present in 26. An echocardiogram was performed in all patients.
Coronary angiography was performed in those older than 40 years of age. The operation was performed as an emergency for acute dissection in 49 (31%) and for severe low cardiac output syndrome in 26 (16.4%). One hundred eleven additional procedures were performed in 84 patients (53.2%) (Table II). One hundred thirty (82%) patients were followed up regularly at our hospital, when a clinical examination, electrocardiogram, chest radiograph, and two-dimensional echocardiogram were performed. Twenty-four patients lived abroad; up-to-date information was obtained from their referring physician. Seven patients (4.43%) were lost to follow-up.
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Results
Mortality
The 30-day (early) mortality for patients operated on for chronic aneurysms during the whole period was 4.6% ± 2%. The causes of death are shown in Table III. Four of the five patients who died early were operated on as an emergency for low cardiac output syndrome. The early mortality for elective resection of chronic aneurysm was 0.97% ± 0.9% and 0% for those with Marfan's syndrome. Multiple regression analysis (Appendix 1) identified duration of symptoms, NYHA class, history of myocardial infarction, emergency operation, cardiopulmonary bypass time, and crossclamp time as incremental risk factors for early death in this group.
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During a period of follow-up varying from 30 to 6396 days, mean 2025 (median 1541), there were 12 late deaths in the chronic aneurysm group with an actuarial survival of 93.3%, 88.0%, 79.0%, and 57.9% at 1, 5, 10, and 15 years (Fig. 3) for the whole group and 96.8%, 91.2%, 82.0%, and 60.0% for those operated on electively (Fig. 3). The causes of late deaths are shown in Table IV.
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The late survival for patients operated on for acute dissection was significantly lower than that for those operated on for chronic aneurysm (Fig. 4) with the 1-, 5-, and 10-year actuarial survival being 72.8%.8%, 63.4%, and 53.3% for those with acute dissection. Overall survival for those with Marfan's syndrome was 90.9%, 85.3%, and 81.9% at 1, 5, and 10 years, better (p < 0.05) than 86.7%, 76.7%, and 60.7% for those without Marfan's syndrome.
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). The latter appeared to have a degree of "distensibility" in the region of the aortic root with approximately a 10% increase in systolic diameter when compared with the minimum diastolic dimension.
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18 in a total of 55, 39, 20, and 5 patients at 1, 5, 10, and 15 years, respectively, and at latest follow-up. At the end of follow-up it was judged to be absent or trivial in 63.6%, mild to moderate in 33.3%, and severe in 3.0%. Aortic valve function tended to be stable with progression occurring only in the patients who had more than mild residual regurgitation immediately after operation (Fig. 6). The first patient with a large aneurysm of the ascending aorta operated on in 1979 has normal aortic function (as assessed clinically and by echocardiography) 18 years after the operation and has recently retired from her job as a physician. Furthermore, after a major car accident 2 years after operation, she underwent aortic angiography, which showed "normal" aortic root, coronary ostia, and valve function.
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Symptomatic status
After operation an improvement in symptomatic status observed early, as assessed by NYHA class, was maintained in most patients, with 97.4% of those followed up for 10 years (n = 24) being in class I or II.
Cardiothoracic ratio
Postoperatively diminution in heart size as indicated by a reduction of the cardiothoracic ratio observed early tended to be maintained except in the patients who had aortic regurgitation develop.
Discussion
This study presents the rationale of a valve-preserving operation for patients with aortic aneurysm, dissection, or both, developed in the late seventies; it also serves to characterize the pattern of survival, aortic valve function, and valve-related complications over a period of up to 19 years. In addition, it has identified several incremental risk factors for either death or reoperation that could help to improve patient selection and timing of operation.
The concept of valve repair is extremely appealing and is now well established and widely practiced for the mitral and tricuspid valves. In contrast, aortic valve repair has tended to lag behind. 20-23 This could be due to the smaller size of the aortic outflow, its cylindric structure, and the presence of subtle interaction between components of the aortic valve mechanism. These factors make it difficult to render the aortic valve competent without plication, partial excision, or extension of the flimsy valve cusps. In addition, the materials used for cusp extension are thrombogenic and subject to degeneration and endocarditis, which defeats the purpose of the operation. These problems do not apply to patients with aortic aneurysm or dissection of the aortic root in which the disease process is largely or completely localized to the aortic wall. Although the term "annuloaortic ectasia," commonly used to describe the disease in these patients, implies gross dilatation of the anulus, in our experience the dilatation affects the sinuses and the sinotubular junction with sparing of the anulus. The latter is also completely spared in acute dissection. In addition, these patients have aortic valve cusps capable of functioning normally for long periods of time despite the presence of histologic abnormalities, particularly in patients with Marfan's syndrome. The technique used in this series aims at excising all the diseased aortic wall with reconstitution of the valve mechanism in a fashion to allow normal interaction between different components of the valve. This is achieved by preserving independent mobility of the aortic sinuses without "crowding" of the aortic cusps within the Dacron tube. This should prevent late degeneration of the cusps such as that described by Gallo and colleagues, 24 which was ascribed by the authors to "replacement of the normal dynamic aortic root with a noncompliant conduit which must affect the function of the aortic valve complex." Postoperative M-mode echocardiograms in our patients showed excellent mobility of the cusps, which opened fully without touching the Dacron sinuses at any stage with apparently normal opening and closing characteristics. In addition, preserved distensibility of the aortic root was observed after operation. These findings could explain the stable function in our series (Fig. 6) and the relatively low rate of reoperation over the follow-up period (Fig. 7). Reoperation was more common in patients with a longer duration of symptoms preoperatively; this strongly suggests that early operation before the onset of secondary changes in the cusps may reduce or eliminate the incidence of this complication. Furthermore, all the patients who required reoperation had at least mild to moderate aortic regurgitation shortly after operation, suggesting imperfect repair that could have been contributed to by secondary changes in the cusps caused by long-standing regurgitation. Valve competence can usually be achieved by resuspension of the aortic valve, particularly in patients operated on before shrinkage and further prolapse of the cusps produced by the turbulence of aortic regurgitation. In these patients several maneuvers aimed at producing sufficient coaption of the cusps can be used. These include controlled approximation of the right, noncoronary, and left coronary sinuses with a 4 mm band of Dacron graft material placed on the outside and fixed to the bottom of each sinus, plication of the thickened central border of the prolapsing cusps, or both. Insertion of a band was used in six patients in this series. Cusp extension is not recommended for the reasons mentioned earlier. We believe that postoperative bleeding can be minimized by ensuring wide excision of the diseased aortic sinuses with placement of the sutures in the firm aortic anulus along the line of attachment of the cusps coupled withensuring that the slightly rigid Dacron tube coapts to the patient's tissues. This obviates the need for the use of either fibrin sealants or adhesive glue (resorcinol), which we believe to be unnecessary.
The operation used in this series is safe as indicated by the fact that the early mortality for patients operated on electively in the entire series was 0.97%, with no mortality in those with the clinical manifestation of Marfan's syndrome. Multivariate analysis showed duration of symptoms, NYHA functional class, history of myocardial infarction, and emergency operation as incremental risk factors for early death.
In this series late survival depended on the original type of disease with an actuarial survival of patients undergoing resection of chronic aneurysm of 93.3%, 88.0%, 79.0, and 57.9% at 1, 5, 10, and 15 years and 96.8%, 91.2%, 82.0%, and 60% in those undergoing an elective procedure. These figures compare favorably to those reported for composite replacement of the aortic root using prosthetic valves. 1-5 In the absence of a randomized prospective trial or accurately matching patient characteristics any meaningful comparison is difficult, if not impossible. However, the valve-sparing operation should yield superior results in terms of late survival because of superior hemodynamics, virtual lack of valve-related complications, and the apparently stable aortic valve function. The pattern of early and late survival after repair can be expected to improve further because of increased experience and earlier operations; this is suggested by the multivariant analysis of predictors of survival in this series.
In this series routine anticoagulation was not used. Endocarditis and thromboembolism were not encountered except in two patients operated on early in the series in whom cusp extension using glutaraldehyde-tanned pericardium was used. The low incidence of valve-related complications and the lack of need for anticoagulation could have important implications on the quality of life in these patients.
Patients with the Marfan's syndrome are an important group that can benefit greatly from this operation. This applies to those who have acute dissections, chronic aneurysms, or both. This stems from the fact that these patients are usually younger and have a potentially compromised left ventricle, and the lack of anticoagulation and better hemodynamics can be particularly valuable. In addition, they could require orthopedic interventions that could be rendered hazardous by anticoagulation necessitated by the use of a prosthetic valve. In this series clinical manifestations of Marfan's syndrome were present in 68 patients. For these patients actuarial survival was 90.9%, 85.3%, 81.9%, and 63.8% at 1, 5, 10, and 15 years.
In conclusion, this study has shown that the valve-sparing operation designed to maintain mobility of the different valve components can be performed in most patients with chronic aneurysms or dissection of the aortic root. The early and long-term results are very encouraging, particularly in patients operated on early in the natural history of the disease. These findings warrant wider application of the technique.
Appendix: Discussion
Dr. Tirone E. David (Toronto, Ontario, Canada). Our experience with the aortic valve–sparing operations in patients with aortic aneurysms is more recent than yours. We only started doing them in 1988, and to date, we have operated on 105 patients.
During the same interval, we had done 111 composite replacements of the aortic valve and the ascending aorta. Therefore approximately half of our patients with aortic root aneurysms had this operation. The other ones who could not have it mostly had the bicuspid aortic valve, and that is the reason why we did not perform them.
Unlike what you described, we perform multiple different operations in these patients. Only about half of them had all three aortic sinuses replaced. The decision to replace the aortic sinuses was dependent on the pathologic condition and the mechanism of aortic insufficiency.
Many patients who have an ascending aortic aneurysm do not have a dilated aortic anulus or sinus of Valsalva, and aortic insufficiency is solely due to distortion of the sinotubular junction. By adjusting the sinotubular junction alone, we have been able to make these aortic valves competent.
I was surprised to hear you say that patients with Marfan's syndrome do not have annuloaortic ectasia and that this was a misnomer. Our patients with Marfan's syndrome and other patients as well, who had a dilated aortic root, almost consistently had a large aortic anulus. The dilatation is only in the fibrous component of the outflow tract, and I believe that in those patients, one has to perform a reduction annuloplasty to allow the leaflets to coapt better.
I have a few questions for Sir Magdi. The first one is, do you not believe that annuloplasty is necessary in patients with dilated aortic anulus?
Second, would you tell us which patients had their procedure fail? Of the 19 failures occurring in 158 patients, were they all Marfan's syndrome? How many had Marfan's syndrome? We have the impression, although our data do not support this yet, that they are more likely to fail. We have had only one failure; however, we have operated only on 28 patients with Marfan's syndrome.
Finally, how do you handle the patients who have a fairly good bicuspid aortic valve and an ascending aortic aneurysm?
Dr. Gerhard Ziemer (Tuebingen, Germany). Following your suggestion almost 10 years ago, I performed the same operation in appropriate patients; however, I was somewhat more choosy. I have two questions specifically regarding the management of patients with bicuspid aortic valves.
The first is, in acute aortic dissection and bicuspid aortic valves at any age, in Hannover before and at my institution now, we do not reconstruct the aortic root but perform a Bentall procedure. So my question is, do you differentiate your approach in aortic dissection according to whether there is a bicuspid or tricuspid aortic valve?
Second, your youngest patient was 2 years of age. I assume it was a child with Marfan's syndrome, as was my youngest patient at 3
years of age. There are more between 10 and 13 years of age. In these young patients with nondissecting Marfan's syndrome ascending aortic aneurysms, I preserve the aortic valve even if it is a bicuspid valve. Feeling somewhat insecure about the long-term function in these patients, however, I use a polytetrafluoroethylene* graft instead of a Dacron graft, possibly facilitating reoperation.
My question is, what is your approach to these patients and is your approach different related to age and whether or not Marfan's syndrome is present? Is there a functional follow-up difference in bicuspid valves?
Dr. Max B. Mitchell (Denver, Colo.). I was going to ask the same question regarding whether you would apply this operation to the patient with a bicuspid aortic valve.
Mr. Yacoub. Thank you. Dr. David, you asked several very relevant questions. The first has to do with whether we replace all sinuses routinely. Like you, we only routinely replace the three sinuses in patients with Marfan's syndrome because we know that the sinus tissue is abnormal; in the past, sparing any of the sinuses resulted in recurrence of the aneurysm. However, in patients with acute dissection, chronic aneurysm, or both, who do not have Marfan's syndrome, we would only replace the sinuses that are involved in the disease, be it dissection or dilatation.
The next point is about annuloaortic ectasia. I wanted to be slightly controversial to make the point. I agree, there is some dilatation that is not progressive. However, to put all the blame on the anulus, we believe, is wrong because the amount of cusp tissue in patients with Marfan's syndrome and other patients with aneurysms of the ascending aorta and root is sufficient for the size of the anulus. The anulus is spared in Marfan's syndrome largely because fibrillin seems to affect more elastic tissue than fibrous tissue.
The point we make is that in most patients with Marfan's syndrome and aneurysms, the problem is in the sinuses and the sinotubular junction. If we operate early enough, there will be no need to reduce the size of the anulus. We only reduce the size of the anulus if the cusp tissue has shrunken and retracted, and that is the point when we would try to reduce the size by approximating the bottom of the three sinuses after performing the operation to make sure that there is still mobility in the cusps.
As to your next point, the recurrence rate or the reoperation rate was not greater in the Marfan's syndrome patients. Only six patients were, and if one calculates the cumulative probability of reoperation, it was not higher in patients with Marfan's syndrome. We were quite pleased about that.
The final point I believe was about bicuspid aortic valves. In this series we have preserved valves in two patients, I believe, with bicuspid aortic valves. We believe that the presence of a bicuspid valve, per se, if the cusps are not diseased, is not a contraindication to the use of this operation, and that applies to Dr. Ziemer's and Dr. Mitchell's questions. Indeed, in the younger patients, we would preserve the valve, be it bicuspid or not. A similar situation exists in the arterial switch operation. We have had five or six patients who had bicuspid pulmonary valves (future aortic valves), and that did not stop us from performing the operation. Some of these patients have been followed up for nearly 10 years with no evidence of aortic valve malfunction, which supports the notion that the presence of a bicuspid valve is not necessarily a contraindication to the use of a valve-conserving operation.
Appendix 1. Variables examined in multivariant analyses of incremental risk factors for early death
Appendix 2. Variables examined in multivariant analyses of incremental risk factors for late death
Acknowledgments
We thank the Department of Mathematics and Statistics at Imperial College for performing the statistical analysis.
Footnotes
*Gore-Tex vascular graft, registered trademark of W. L. Gore & Associates, Inc., Newark, Del. 
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H. Jeanmart, L. de Kerchove, D. Glineur, J.-M. Goffinet, I. Rougui, M. Van Dyck, P. Noirhomme, and G. El Khoury Aortic Valve Repair: The Functional Approach to Leaflet Prolapse and Valve-Sparing Surgery Ann. Thorac. Surg., February 1, 2007; 83(2): S746 - S751. [Abstract] [Full Text] [PDF]
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K. Kallenbach, H. Baraki, N. Khaladj, H. Kamiya, C. Hagl, A. Haverich, and M. Karck Aortic Valve-Sparing Operation in Marfan Syndrome: What Do We Know After a Decade? Ann. Thorac. Surg., February 1, 2007; 83(2): S764 - S768. [Abstract] [Full Text] [PDF]
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F. Settepani, W. Y. Szeto, D. Pacini, R. De Paulis, L. Chiariello, R. Di Bartolomeo, R. Gallotti, and J. E. Bavaria Reimplantation Valve-Sparing Aortic Root Replacement in Marfan Syndrome Using the Valsalva Conduit: An Intercontinental Multicenter Study Ann. Thorac. Surg., February 1, 2007; 83(2): S769 - S773. [Abstract] [Full Text] [PDF]
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J. Bachet, F. Larrazet, B. Goudot, G. Dreyfus, T. Folliguet, F. Laborde, and D. Guilmet When Should the Aortic Arch Be Replaced in Marfan Patients? Ann. Thorac. Surg., February 1, 2007; 83(2): S774 - S779. [Abstract] [Full Text] [PDF]
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 V. Gariboldi, D. Grisoli, F. Kerbaul, R. Giorgi, A. Riberi, D. Metras, T. G. Mesana, and F. Collart Long-term outcomes after repaired acute type A aortic dissections Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 47 - 51. [Abstract] [Full Text] [PDF]
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 N C Radu, E W M Kirsch, M-L Hillion, F Lagneau, L Drouet, and D Loisance Embolic and bleeding events after modified Bentall procedure in selected patients Heart, January 1, 2007; 93(1): 107 - 112. [Abstract] [Full Text] [PDF]
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