JACC. Clinical electrophysiology最新文献

{"title":"Heritable Burden of Community Sudden Death by Autopsy and Molecular Phenotyping for Precision Genotype Correlation.","authors":"Zian H Tseng, James W Salazar, Julianne Wojciak, W Patrick Devine, Brielle A Kinkead, Matthew Yee, David Eik, Jean Feng, Andrew J Connolly, Ellen Moffatt","doi":"10.1016/j.jacep.2024.10.027","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.027","url":null,"abstract":"<p><strong>Background: </strong>Sudden cardiac death (SCD) genetic studies neglect the majority occurring in older decedents with cardiovascular pathology.</p><p><strong>Objectives: </strong>This study sought to determine the burden of genetic disease in unselected adult sudden deaths by precision genotype-postmortem phenotype correlation.</p><p><strong>Methods: </strong>The authors used autopsy, histology, and toxicology to adjudicate cause and identify high-suspicion phenotypes (eg, hypertrophic cardiomyopathy) among presumed SCDs aged 18 to 90 years referred to the county medical examiner from February 2011 to January 2018. They tested 231 genes associated with sudden death and correlated genotype with postmortem phenotypes, including myocardial analysis. Family history in high-suspicion phenotype cases was obtained.</p><p><strong>Results: </strong>Of 856 autopsied presumed SCDs, families of 359 consented and 306 cases (66% cardiac cause) ultimately underwent genetic testing (mean age 62 years, 74% male). Seventy-five cases met high-suspicion phenotype criteria (8.8%), of which 36 underwent testing; 18 families met with a genetic counselor. We found 14 cases with autosomal dominant or X-linked pathogenic/likely pathogenic (P/LP) variants (apparent yield 4.6%); 6 had concordant cause (corrected yield 2%). Yields restricted to autopsy-confirmed cardiac causes (2.5%) and high-suspicion phenotypes (2.7%) were similar. Myocardial genotyping in 14 high-suspicion decedents matched negative blood genotyping, thus did not support somatic mosaicism. Myocardial RNA in a P/LP PKP2 carrier without phenotype demonstrated nonsense-mediated escape as potential mechanism for incomplete penetrance. One-half of high-suspicion cases had a family history of a related condition or sudden death.</p><p><strong>Conclusions: </strong>In this 7-year countywide study, 2% of total sudden deaths and 2.5% of confirmed SCDs had identifiable genetic cause, corrected for genotype-phenotype concordance. These results do not support routine genetic testing for community sudden deaths, particularly without autopsy.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142871843","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Temporal Trends of Ischemic Stroke Risk in Patients With Incident Atrial Fibrillation Before Anticoagulation.","authors":"Konsta Teppo, K E Juhani Airaksinen, Olli Halminen, Jussi Jaakkola, Jari Haukka, Elis Kouki, Alex Luojus, Jukka Putaala, Birgitta Salmela, Miika Linna, Aapo L Aro, Pirjo Mustonen, Juha Hartikainen, Gregory Y H Lip, Mika Lehto","doi":"10.1016/j.jacep.2024.10.029","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.029","url":null,"abstract":"<p><strong>Background: </strong>Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS), but whether the magnitude of this risk has changed over time is unknown.</p><p><strong>Objectives: </strong>This study sought to investigate temporal trends in IS rates in patients with incident AF before oral anticoagulant agent (OAC) therapy.</p><p><strong>Methods: </strong>The nationwide FinACAF (Finnish Anticoagulation in Atrial Fibrillation) study covers patients with AF at all levels of care in Finland from 2007 to 2018. A 4-week quarantine period from AF diagnosis was applied, and only follow-up time without OAC therapy was included. Incidence rates of IS were computed in 4-year intervals in relation to sex and non-sex CHA₂DS₂-VASc (ie, CHA₂DS₂-VA) score values.</p><p><strong>Results: </strong>In total, 129,789 patients with new-onset AF were identified (49.2% women; mean age: 71.4 ± 14.5 years). Between the calendar year intervals of 2007-2010 and 2015-2018, the patients' mean CHA₂DS₂-VA score increased from 2.5 to 3.0, and concurrently the overall IS rate decreased by 25% from 36.7 to 27.6 events per 1,000 patient-years. This trend was driven by a 32% decrease of IS rate in women, particularly among those with higher age and CHA₂DS₂-VA scores. The IS rate in patients with a CHA₂DS₂-VA score of 1 was 8.2 events per 1,000 patient-years and remained stable across the study period.</p><p><strong>Conclusions: </strong>The initial IS risk in AF patients, before the initiation of OAC therapy, has decreased by 25% between 2007 and 2018 despite an increase in both age and stroke risk scores. The decrease has been most pronounced in older women with high stroke risk scores.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142871998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Restitution Threshold Index Characterizes the Association Between Atrial Fibrillation Ventricular Rate and Ejection Fraction.","authors":"Nikhil Ahluwalia, Shohreh Honarbakhsh, Abhishek Joshi, Hakam Abbass, Anthony W Chow, Mehul Dhinoja, Steffen E Petersen, Guy Lloyd, Ross J Hunter, Richard J Schilling","doi":"10.1016/j.jacep.2024.10.020","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.020","url":null,"abstract":"<p><strong>Background: </strong>Patients with reduced left ventricular ejection fraction (LVEF) and rate-controlled atrial fibrillation (AF) may improve after restoring sinus rhythm. This may be due to the elimination of the short R-R intervals during AF even when mean heart rate is acceptable.</p><p><strong>Objectives: </strong>This work aims to evaluate a novel parameter representing the burden of short R-R intervals during AF and its association with reduced LVEF and LVEF recovery after catheter ablation (CA).</p><p><strong>Methods: </strong>Patients with persistent AF were prospectively enrolled pre-CA and grouped as having reduced (LVEF ≤50%) or preserved LVEF. Sequential R-R intervals on resting Holter monitoring were measured. We sought to define a threshold R-R interval at which the difference in the percentage of short R-R intervals is greatest when comparing patients with reduced and preserved ejection fraction. We termed this threshold the restitution threshold (RT) in the belief that this may be possible to apply as a threshold to identify patients with AF-mediated cardiomyopathy. This percentage burden of intervals shorter than the RT was defined as the restitution threshold index (RTI). The association with reduced LVEF in AF and predicting improvement in LVEF after CA was then evaluated.</p><p><strong>Results: </strong>One hundred four patients were enrolled; 53 (51%) had a reduced LVEF. There was no difference in mean heart rate; however, at an RT of 660 ms, the RTI was higher in the reduced LVEF arm (56.1% ± 23.1% vs 39.5% ± 26.0%; P < 0.001). It was an independent predictor of left ventricular systolic dysfunction. The RTI in the reduced LVEF arm had an area under the receiver operating characteristic of 0.74 (95% CI: 0.47-0.95) and positive predictive value of 0.97 for LVEF improvement after CA, which was observed in 39 of 47 (83.0%) participants in sinus rhythm.</p><p><strong>Conclusions: </strong>The RTI in persistent AF was associated with a reduced LVEF, whereas mean heart rate was not. The RTI could be used to predict LVEF improvement after CA.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142813046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical and Electrophysiological Characteristics of Marshall Bundle-Related Atrial Tachycardia: Considerations Based on a Definitive Diagnosis.","authors":"Yasuaki Tanaka, Atsushi Takahashi, Hirotaka Yano, Naohiko Kawaguchi, Emiko Nakashima, Kenji Okubo, Hiroyuki Hikita, Tetsuo Sasano","doi":"10.1016/j.jacep.2024.10.019","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.019","url":null,"abstract":"<p><strong>Background: </strong>Conventional endocardial mapping cannot fully elucidate Marshall bundle (MB)-related atrial tachycardia (AT).</p><p><strong>Objectives: </strong>This study aimed to clarify the clinical and electrophysiological characteristics of MB-related AT definitively diagnosed using catheter insertion.</p><p><strong>Methods: </strong>Forty-eight patients with AT who had previously undergone mitral isthmus ablation were enrolled in this study. A 1.6-F hexapolar electrode catheter was inserted into the vein of Marshall (VOM) if endocardial left atrial mapping showed centrifugal propagation and post-pacing intervals after entrainment pacing suggested a macro-re-entrant mechanism. MB-related AT was diagnosed only when activation along the VOM was consistent with the propagation of the AT circuit, and post pacing interval within the VOM approximated the tachycardia cycle length.</p><p><strong>Results: </strong>Among 48 patients, 20 were diagnosed with MB-related AT. The activation direction along the VOM was predominantly descending (n = 13), rather than ascending (n = 7). There were diverse breakthrough sites to the endocardium along the course of the VOM. Two patients experienced persistent AT despite a conduction block in the VOM. Thirteen patients underwent chemical ablation with ethanol injection, and the remaining 7 underwent radiofrequency ablation at the earliest endocardial activation sites or mitral isthmus areas. Acute termination of AT was observed in 20 patients. No recurrence was observed in the group that underwent chemical ablation; however, 4 patients in the radiofrequency group experienced recurrence (n = 0 of 13 vs n = 4 of 7).</p><p><strong>Conclusions: </strong>Understanding the distinct clinical and electrophysiological characteristics of MB-related AT can facilitate the diagnosis and treatment of this AT type.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142871215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Contact Force Increases During Radiofrequency Ablation: A Novel Catheter Assessment of Myocardial Response to Thermal Injury.","authors":"Keita Watanabe, Moritz Nies, Steffy Rodrigues, Vivek Y Reddy, Jacob S Koruth","doi":"10.1016/j.jacep.2024.10.010","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.010","url":null,"abstract":"<p><strong>Background: </strong>Contact force (CF) changes after onset of radiofrequency (RF) delivery are not well understood and often ascribed to catheter instability.</p><p><strong>Objectives: </strong>This study sought to characterize CF changes during RF-based pulmonary vein (PV) isolation.</p><p><strong>Methods: </strong>Catheter-tip parameters including CF for all RF sessions were extracted from a novel catheter-mapping system from 6 patients undergoing PV isolation.</p><p><strong>Results: </strong>Of a total 416 RF sessions, 241 demonstrated progressive increases in CF during RF delivery (group 1). Zero to 5 seconds of RF delivery demonstrated the greatest increase in CF, with no differences between right and left PV sites (2.2 ± 2.2 vs 1.9 ± 2.3 g, P = 0.26). Subsequent 5-second intervals demonstrated greater increases for right vs left PV sites (eg, 1.2 ± 1.3 vs 0.5 ± 0.3 g, P = 0.01 for 20 to 25 seconds). CF increment was greater for posterior vs anterior PV sites (3.4 ± 3.1 vs 1.4 ± 1.4 g, P < 0.001), but similar for roof and floor sites. Higher power and greater impedance drops were associated with greater CF increases. Perpendicular contact had greater CF increases, followed by diagonal and parallel contact. The remaining 175 of 416 sessions demonstrated at least 1 CF decrement, typically occurring after 15 seconds of RF (group 2). This was observed least frequently at inferior PV sites. Except for minor differences in power, there were no differences in CF, tip excursion, and impedance drop between groups.</p><p><strong>Conclusions: </strong>Progressive CF increase during RF ablation is a distinct phenomenon that likely reflects the \"push-back\" effect of local myocardial swelling against the catheter tip. This may explain certain catheter-tip behaviors such as tip displacement and instability during ablation.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142785438","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pseudo Peridevice Leak After LAA Closure Device Implantation Unmasking a Persistent Left Superior Vena Cava.","authors":"Fatima M Ezzeddine, Ammar M Killu, Rachel C Haagensen, Xiaoke Liu","doi":"10.1016/j.jacep.2024.10.021","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.021","url":null,"abstract":"","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142813037","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Novel Pericardial Access Technique Facilitated by Direct Visualization and Vacuum Suction.","authors":"Hina Amin, Arman Arghami, Alan M Sugrue, Ammar M Killu","doi":"10.1016/j.jacep.2024.10.002","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.002","url":null,"abstract":"","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142785435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Atrial Tachyarrhythmias With Ultra-Rapid Ventricular Response and Sudden Death in Patients Without Structural Heart Disease.","authors":"Maarten A J De Smet, Benjamin De Becker, Clara François, Jean-Benoit le Polain de Waroux, Sebastien Knecht, Mattias Duytschaever, Rene Tavernier","doi":"10.1016/j.jacep.2024.10.025","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.10.025","url":null,"abstract":"<p><strong>Background: </strong>Sudden cardiac death (SCD) is generally associated with life-threatening ventricular arrhythmias. Supraventricular arrhythmias are an accepted cause of SCD in Wolff-Parkinson-White syndrome and complex congenital heart disease. However, the role of atrial tachyarrhythmias (ATAs) in SCD in patients with structurally normal hearts is unclear.</p><p><strong>Objectives: </strong>The goal of this study was to present data on resuscitated patients without structural heart disease (SHD), experiencing recurrent implantable cardioverter-defibrillator (ICD) shocks, who share common clinical and electrical features suggesting that ATAs can cause SCD.</p><p><strong>Methods: </strong>We describe the clinical characteristics and ICD analysis of syncopal events terminated with shock delivery in 5 young SCD survivors without SHD. Details on the follow-up after ablation of the arrhythmia causing the syncopal episode are also reported.</p><p><strong>Results: </strong>In all patients (4 male, 1 female; median age 23 years; age range 15-47 years), a surface electrocardiogram recording in the resuscitation setting suggested ventricular fibrillation. After the index event, all patients exhibited recurrent arrhythmic syncopal episodes in a setting of elevated adrenergic tone, treated with ICD shocks. ICD interrogation suggested ATAs (atrial fibrillation in 4 patients, atrial tachycardia in 1 patient), conducting to the ventricles at rates approaching 300 beats/min, as the underlying arrhythmia leading to the syncopal events. ATA ablation abolished episodes of arrhythmic syncope and shock delivery in all patients after a median follow-up of 34 months. No patient died suddenly during follow-up.</p><p><strong>Conclusions: </strong>Common clinical and electrical features define a distinct entity of SCD caused by ATAs with ultra-rapid ventricular response in otherwise healthy patients. Catheter ablation of the ATA is an effective treatment in these patients.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142870839","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"TTN Variants, Dilated Cardiomyopathy, and Arrhythmic Causes by Autopsy Among Countywide Sudden Deaths.","authors":"Matthew Yee, James W Salazar, Julianne Wojciak, W Patrick Devine, Ellen Moffatt, Zian H Tseng","doi":"10.1016/j.jacep.2024.09.040","DOIUrl":"https://doi.org/10.1016/j.jacep.2024.09.040","url":null,"abstract":"","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142785530","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety and Feasibility of Pulsed Field Ablation in Patients With Mechanical Prosthetic Valves.","authors":"Roberto Scacciavillani, Domenico G Della Rocca, Devi Nair, Michele Magnocavallo, Andrzej Głowniak, Sanghamitra Mohanty, Antonio Sorgente, Roberto Mené, Alexandre Almorad, Giampaolo Vetta, Luigi Pannone, Katarzyna Wojewoda, Lorenzo Marcon, Erwin Stroker, Gezim Bala, Aleksander Konopka, Juan Sieira, Stefano Bianchi, Kirollos Gabrah, Pietro Rossi, Andrea Sarkozy, Serge Boveda, Andrea Natale, Carlo de Asmundis, Gian-Battista Chierchia","doi":"10.1016/j.jacep.2024.09.025","DOIUrl":"10.1016/j.jacep.2024.09.025","url":null,"abstract":"<p><strong>Background: </strong>Pulsed field ablation (PFA) is a novel ablation energy source, which leads to selective and irreversible electroporation of cardiomyocytes with no collateral damage to adjacent tissues. The presence of mechanical prosthetic valves may pose some issues related to catheter manipulation and risk of electromagnetic interference.</p><p><strong>Objectives: </strong>The purpose of this study was to assess the feasibility of PFA in patients with mechanical prosthetic valves.</p><p><strong>Methods: </strong>The authors enrolled 30 consecutive patients (age 64.7 ± 11.4 years; 43% men) with mitral and/or aortic valve replacement with mechanical substitutes undergoing endocardial AF ablation via a PFA technology at 6 institutions.</p><p><strong>Results: </strong>Time between valve surgery and ablation was 6.6 ± 6.5 years; 14 (46.7%) patients had an aortic mechanical valve, 10 (33.3%) a mitral, and 6 (20.0%) both. The following PFA technologies were used: FARAWAVE in 25 patients, Sphere-9 in 2, PulseSelect in 2, and the CENTAURI System in 1. No periprocedural and 1-month postablation major and minor complications were observed. Postprocedural transthoracic echocardiography did not identify any prosthetic valve dysfunction. One patient showed electromagnetic interference of the PFA catheter adjacent to the mitral prosthesis without clinical implications. No energy delivery to the mitral edge of the isthmus was possible despite multiple attempts to reposition the catheter. Mean procedural time was 77.5 ± 29.9 minutes, whereas mean left atrial dwell and fluoroscopy times were 43.1 ± 21.4 and 14.0 ± 6.4 minutes, respectively.</p><p><strong>Conclusions: </strong>PFA in patients with mechanical valves appears safe, but careful catheter handling is essential to avoid electromagnetic interference hindering PFA delivery.</p>","PeriodicalId":14573,"journal":{"name":"JACC. Clinical electrophysiology","volume":" ","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142681952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}