Long-term outcome of patients with severe biventricular heart failure and severe mitral regurgitation after percutaneous edge-to-edge mitral valve repair.

OBJECTIVE: To assess long-term outcome and parameters associated with poor and favorable outcome in patients with a left ventricular ejection fraction (LV-EF) ≤25% and severe mitral regurgitation (MR) after percutaneous edge-to-edge mitral valve repair (pMVR). BACKGROUND: There is no data on long-term outcome in this cohort of patients. METHODS: We analyzed all 34 patients with a LV-EF ≤25% and severe MR treated with pMVR in 2 university hospitals from 2009 to 2012. RESULTS: Mitral regurgitation could be successfully reduced to grade ≤2 in 30 patients (88%). Long-term follow-up (up to 5 years) revealed a steep decline of the survival curve reaching 50% already 8 month after pMVR. In contrast, estimated survival of the remaining patients showed a favorable long-term outcome. Patients deceased during the first year presented with higher right ventricular tricuspid pressure gradient (RVTG) (44.5 ± 8.4 mmHg vs. 35.2 ± 15.4 mmHg, P = 0.035) and worse RV-function (P = 0.014) prior to the procedure. One-year mortality of patients with pulmonary hypertension and depressed RV-function (n = 22) was very high (77%) compared to the remaining patients (n = 12, mortality rate of 0%, P = 0.0001). CONCLUSIONS: Although pMVR lead to a successful reduction of MR in patients with a LV-EF ≤25%, 1-year mortality in this cohort was very high. However, a subgroup of patients showed a favorable long-term outcome after pMVR. Especially the right ventricular parameters sustained RV-function and absence of pulmonary hypertension-easily assessed with echocardiography-might be used to identify this subgroup and encourage pMVR in these patients.

Distribution of coronary calcifications in patients with suspected coronary heart disease.

BACKGROUND: Coronary calcifications are a marker of coronary atherosclerosis. The role of coronary calcium scoring (CS) as part of the initial evaluation of patients with suspected coronary heart disease (CHD) is controversially discussed. The primary goal of this study was to characterize the coronary calcium distribution in this particular patient population. In a second step, we aimed to establish a possible clinical implication using CS for the diagnosis of CHD. METHODS: Calcium scoring procedure was performed by either using a multidetector or a dual-source computed tomographic scanner. All patients underwent invasive coronary angiography (ICA) as the current criterion standard for CHD detection. A total of 4,137 (2,780 men, mean age 60.5 ± 12.4 years) consecutive patients were included. RESULTS: Mean CS was 288 ± 446 (range 0-5,252). Overall coronary artery calcifications significantly increased with patients' age. In 2,048 patients (mean CS 101 ± 239, range 0-5252), significant CHD (≥50% stenosis) was excluded by ICA (1,939 patients without calcifications). In remaining 2,089 patients (51%, mean CS 607 ± 821, range 0-5,252), significant CHD was documented leading to intervention in 732 patients. A threshold of zero calcifications (existence of calcified tissue) had the best overall sensitivity and negative predictive value with 99%. Overall specificity with 34% and overall positive predictive value with 24% were rather low. CONCLUSION: Coronary calcium scoring is able to exclude significant CHD in patients with suspected CHD with a high negative predictive value and, therefore, possibly reduce the number of invasive diagnostic examinations. Because of the low specificity and positive predictive value, CS cannot be used to indicate ICA.

Increased Pericardial Adipose Tissue in Smokers.

BACKGROUND: Pericardial adipose tissue (PAT), a visceral fat depot directly located to the heart, is associated with atherosclerotic and inflammatory processes. The extent of PAT is related to the prevalence of coronary heart disease and might be used for cardiovascular risk prediction. This study aimed to determine the effect of smoking on the extent of PAT. METHODS: We retrospectively examined 1217 asymptomatic patients (490 females, age 58.3 ± 8.3 years, smoker n = 573, non-smoker n = 644) with a multislice CT scanner and determined the PAT volume. Coronary risk factors were determined at inclusion, and a multivariate analysis was performed to evaluate the influence of smoking on PAT independent from accompanying risk factors. RESULTS: The mean PAT volume was 215 ± 107 mL in all patients. The PAT volume in smokers was significantly higher compared to PAT volume in non-smokers (231 ± 104 mL vs. 201 ± 99 mL, p = 0.03). Patients without cardiovascular risk factors showed a significantly lower PAT volume (153 ± 155 mL, p < 0.05) compared to patients with more than 1 risk factor. Odds ratio was 2.92 [2.31, 3.61; p < 0.001] for elevated PAT in smokers. CONCLUSION: PAT as an individual marker of atherosclerotic activity and inflammatory burden was elevated in smokers. The finding was independent from metabolic risk factors and might therefore illustrate the increased inflammatory activity in smokers in comparison to non-smokers.

Pericardial adipose tissue determined by dual source CT is a risk factor for coronary atherosclerosis.

OBJECTIVES: Pericardial fat as a visceral fat depot may be involved in the pathogenesis of coronary atherosclerosis. To gain evidence for that concept we sought to investigate the relation of pericardial fat volumes to risk factors, serum adiponectin levels, inflammatory biomarkers, and the quantity and morphology of coronary atherosclerosis. METHODS AND RESULTS: Using Dual source CT angiography pericardial fat volume and coronary atherosclerosis were assessed simultaneously. Plaques were classified as calcified, mixed, and noncalcified, and the number of affected segments served as quantitative score. Patients with atherosclerotic lesions had significant larger PAT volumes (226 cm3+/-92 cm3) than patients without atherosclerosis (134 cm3+/-56 cm3; P>0.001). No association was found between BMI and coronary atherosclerosis. PAT volumes >300 cm3 were the strongest independent risk factor for coronary atherosclerosis (odds ratio 4.1; CI 3.63 to 4.33) also significantly stronger compared to the Framingham score. We furthermore demonstrated that elevated PAT volumes are significantly associated with low adiponectin levels, low HDL levels, elevated TNF-alpha levels, and hsCRP. CONCLUSION: In the present study we demonstrated that elevated PAT volumes are associated with coronary atherosclerosis, hypoadiponectinemia, and inflammation and represent the strongest risk factor for the presence of atherosclerosis and may be important for risk stratification and monitoring.

MMP-1 serum levels predict coronary atherosclerosis in humans.

BACKGROUND: Myocardial infarction results as a consequence of atherosclerotic plaque rupture, with plaque stability largely depending on the lesion forming extracellular matrix components. Lipid enriched non-calcified lesions are considered more instable and rupture prone than calcified lesions. Matrix metalloproteinases (MMPs) are extracellular matrix degrading enzymes with plaque destabilisating characteristics which have been implicated in atherogenesis. We therefore hypothesised MMP-1 and MMP-9 serum levels to be associated with non-calcified lesions as determined by CT-angiography in patients with coronary artery disease. METHODS: 260 patients with typical or atypical chest pain underwent dual-source multi-slice CT-angiography (0.6-mm collimation, 330-ms gantry rotation time) to exclude coronary artery stenosis. Atherosclerotic plaques were classified as calcified, mixed or non-calcified. RESULTS: In multivariable regession analysis, MMP-1 serum levels were associated with total plaque burden (OR: 1.37 (CI: 1.02-1.85); p < 0.05) in a model adjusted for age, sex, BMI, classical cardiovascular risk factors, hsCRP, adiponectin, pericardial fat volume and medication. Specification of plaque morphology revealed significant association of MMP-1 serum levels with non-calcified plaques (OR: 1.16 (CI: 1.0-1.34); p = 0.05) and calcified plaques (OR: 1.22 (CI: 1,03-1.45); p < 0.05) while association with mixed plaques was lost in the fully adjusted model. No associations were found between MMP9 serum levels and total plaque burden or plaque morphology. CONCLUSION: MMP-1 serum levels are associated with total plaque burden but do not allow a specification of plaque morphology.

Predictive value of coronary calcifications for future cardiac events in asymptomatic patients with diabetes mellitus: a prospective study in 716 patients over 8 years.

BACKGROUND: To establish an efficient prophylaxis of coronary artery disease reliable risk stratification is crucial, especially in the high risk population of patients suffering from diabetes mellitus. This prospective study determined the predictive value of coronary calcifications for future cardiovascular events in asymptomatic patients with diabetes mellitus. METHODS: We included 716 patients suffering from diabetes mellitus (430 men, 286 women, age 55.2+/-15.2 years) in this study. On study entry all patients were asymptomatic and had no history of coronary artery disease. In addition, all patients showed no signs of coronary artery disease in ECG, stress ECG or echocardiography. Coronary calcifications were determined with the Imatron C 150 XP electron beam computed tomograph. For quantification of coronary calcifications we calculated the Agatston score. After a mean observation period of 8.1+/-1.1 years patients were contacted and the event rate of cardiac death (CD) and myocardial infarction (MI) was determined. RESULTS: During the observation period 40 patients suffered from MI, 36 patients died from acute CD. The initial Agatston score in patients that suffered from MI or died from CD (475+/-208) was significantly higher compared to those without cardiac events (236+/-199, p<0.01). An Agatston score above 400 was associated with a significantly higher annualised event rate for cardiovascular events (5.6% versus 0.7%, p<0.01). No cardiac events were observed in patients with exclusion of coronary calcifications. Compared to the Framingham risk score and the UKPDS score the Agatston score showed a significantly higher diagnostic accuracy in the prediction of MI with an area under the ROC curve of 0.77 versus 0.68, and 0.71, respectively, p<0.01. CONCLUSION: By determination of coronary calcifications patients at risk for future MI and CD could be identified within an asymptomatic high risk group of patients suffering from diabetes mellitus. On the other hand future events could be excluded in patients without coronary calcifications.

Omega-3 Index and Obstructive Sleep Apnea: A Cross-Sectional Study.

STUDY OBJECTIVES: Erythrocyte levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (Omega-3 Index) were previously found to be associated with obstructive sleep apnea (OSA) at very low levels (< 5.0%) in only one epidemiologic study. OSA has comorbidities, such as arterial hypertension, heart failure, or major depression, also associated with a low Omega-3 Index. These comorbidities can be improved by increasing intake of EPA and DHA, and thus the Omega-3 Index, preferably to its target range of 8% to 11%. Symptoms of OSA might improve by increasing the Omega-3 Index, but more research is needed. METHODS: In our sleep laboratory, 357 participants with OSA were recruited, and data from 315 participants were evaluated. Three categories of OSA (none/ mild, moderate, severe) were defined based on apnea-hypopnea index. Anthropometrics and lifestyle characteristics (smoking, alcohol, fish intake, omega-3 supplementation) were recorded. Erythrocyte fatty acid compositions were assessed with the HS-Omega-3 Index methodology. RESULTS: The mean Omega-3 Index in all 3 categories of OSA was 5.7%, and no association with OSA was found. There were more male participants with severe OSA (79.7%, P = .042) than females, and participants with severe OSA had a significantly higher body mass index (32.11 ± 6.39 kg/m2, P = .009) than participants with mild or moderate OSA. Lifestyle characteristics were not significantly different. CONCLUSIONS: In contrast to our hypothesis, an Omega-3 Index of 5.7% was not associated with OSA severity. Previously, an Omega-3 Index < 5.0% was associated. Although our results suggest aiming for an Omega-3 Index > 5.7% in an intervention trial with EPA and DHA in OSA, comorbidities of OSA suggest a target range of 8% to 11%.

Multislice spiral computed tomographic angiography of coronary arteries in patients with suspected coronary artery disease: an effective filter before catheter angiography?

BACKGROUND: Despite impressive image quality, it is unclear if noninvasive coronary angiography with multislice spiral computed tomography (CT) is powerful enough to act as a filter before invasive angiography (INV-A) in symptomatic patients. METHODS AND RESULTS: We therefore studied 133 consecutive symptomatic patients with suspected coronary artery disease (CAD) and an indication for INV-A (chest pain and signs of ischemia in conventional stress tests). Patients with known CAD, acute coronary syndrome, or a calcium volume score >1000 were excluded. In all patients, both INV-A and multislice CT angiography (MSCT-A) (Philips MX 8000 multislice spiral CT, scan time 250 milliseconds, slice thickness 1.3 mm, 120 mL of contrast agent, 4 mL/s, retrospective gating) were directly compared by 2 independent investigators using the American Heart Association 15-segment model. Altogether, we studied 1596 segments, 74% had diagnostic image quality. Multislice CT angiography correctly identified 68 significant stenoses of the 75 stenoses seen with INV-A (sensitivity 91%). In 945 of 1185 diagnostic segments, stenosis could correctly be ruled out with MSCT-A. There were 3 times more stenoses seen with MSCT-A compared with INV-A (positive predictive value 29%) mainly because of misclassification of nonobstructive plaques as stenosis. The per-patient analysis allowed to exclude significant CAD in 42 (32%) of 133 patients. In only 6 of 53 patients, MSCT-A failed to detect significant stenosis, 4 of those were in small segments not requiring intervention. Calcium scoring alone was less suited as a filter before angiography: 25 patients (18% of study group) had a calcium score = 0, and 8 of these patients turned out to have significant stenoses. CONCLUSION: Multislice CT angiography, but not calcium scoring alone, offers promise to reduce the number of INV-A in symptomatic patients with suspected CAD by up to one third with minimal risk for the patient.

Use of multi-slice computed tomography in patients with chest-pain submitted to the emergency department.

This study evaluates calcium scoring (CS) and computed tomography angiography (MSCTA) in patients >50 years with chest-pain submitted to the emergency department utilising CS as a "diagnostic filter" upfront. Results of CS and MSCTA performed by a 64-slice CT scanner were compared to invasive coronary angiography (ICA). 289 consecutive symptomatic patients (185 men, mean age 71.3 ± 6.4 years) were included. In patients with CS = 0 (Group I; n = 60) or CS > 400 (Group III; n = 95) we refrained from MSCTA, whereas patients with CS 1-400 (Group II; n = 134) underwent subsequent MSCTA. ICA detected significant coronary artery disease (CAD) in 162 patients (56.1%; male 98). None of Group I-patients showed CAD, but in Group III CAD prevalence increased to 82.1%. In Group II, MSCTA correctly identified 177/190 significantly diseased vessel segments. Compared to CS alone, our approach increased sensitivity to 98.1% (+1.8%), specificity to 82.6% (+27.5%) and negative predictive value (NPV) to 97.2% (+5.1%) as well as positive predictive value to 87.8% (+14.6%), respectively. Overall DA was 91.3%. Stratification of symptomatic patients into three different risk groups according to CS results with concomitantly increasing disease prevalence is possible. Zero calcium was found to exclude significant CAD, but needs further evaluation. Still server calcifications impair image quality in MSCTA. Thus direct referral to ICA might be a reasonable approach in case of high CS. In patients with intermediate CS, MSCTA is able to rule out significant CAD with a high NPV.

CT stress perfusion imaging for detection of haemodynamically relevant coronary stenosis as defined by FFR.

OBJECTIVES: To evaluate the diagnostic accuracy (DA) of CT-myocardial perfusion imaging (CT-MPI) and a combined approach with CT angiography (CTA) for the detection of haemodynamically relevant coronary stenoses in patients with both suspected and known coronary artery disease. DESIGN: Prospective, non-randomised, diagnostic study. SETTING: Academic hospital-based study. PATIENTS: 65 patients (42 men age 70.4±9) with typical or atypical chest pain. INTERVENTIONS: CTA and CT-MPI with adenosine stress using a fast dual-source CT system. At subsequent invasive angiography, FFR measurement was performed in coronary arteries to define haemodynamic relevance of stenosis. MAIN OUTCOME MEASURES: We tried to correlate haemodynamically relevant stenosis (FFR < 0.80) to a reduced myocardial blood flow (MBF) as assessed by CT-MPI and determined the DA of CT-MPI for the detection of haemodynamically relevant stenosis. RESULTS: Sensitivity and negative predictive value (NPV) of CTA alone were very high (100% respectively) for ruling out haemodynamically significant stenoses, specificity, Positive predictive value (PPV) and DA were low (43.8, 67.3 and 72%, respectively). CT-MPI showed a significant increase in specificity, PPV and DA for the detection of haemodynamically relevant stenoses (65.6, 74.4 and 81.5%, respectively) with persisting high sensitivity and NPV for ruling out haemodynamically relevant stenoses (97% and 95.5% respectively). The combination of CTA and CT-MPI showed no further increase in detection of haemodynamically significant stenosis compared with CT-MPI alone. CONCLUSIONS: Our data suggest that CT-MPI permits the detection of haemodynamically relevant coronary artery stenoses with a moderate DA. CT may, therefore, allow the simultaneous assessment of both coronary morphology and function.

Increased pericardial adipose tissue is correlated with atrial fibrillation and left atrial dilatation.

INTRODUCTION: Pericardial adipose tissue (PAT), a visceral fat depot surrounding the heart, serves as an endocrine active organ and is associated with inflammation. There is growing evidence that atrial fibrillation (AF) is linked with inflammation, which in turn can be a promoter of left atrial remodeling. The aim of this study was to evaluate a potential correlation of PAT to AF and left atrial structural remodeling represented by LA size. METHODS: PAT was measured in 1,288 patients who underwent coronary artery calcium-scanning for coronary risk stratification. LA size was determined by two independent readers. Patients were subdivided into patients without AF, patients with paroxysmal and persistent AF. RESULTS: PAT was independently correlated with AF, persistent AF, and LA size (all p values <0.001). No association could be observed between paroxysmal AF and PAT. These associations persisted after multivariate adjustment for AF risk factors such as age, hypertension, valvular disease, heart failure, and body mass index (AF: OR 1.52, 95 % CI 1.15-2.00, p = 0.003; persistent AF: OR 2.58, 95 % CI 1.69-3.99, p = 0.001; LA size: regression coefficient 0.15 with 95 % CI 0.10-0.20, p < 0.001). CONCLUSION: PAT is associated with AF, in particular with persistent AF and LA size. These findings suggest that PAT could be an independent risk factor for the development of AF and for LA remodeling.

Low adiponectin levels are an independent predictor of mixed and non-calcified coronary atherosclerotic plaques.

BACKGROUND: Atherosclerosis is the primary cause of coronary artery disease (CAD). There is increasing recognition that lesion composition rather than size determines the acute complications of atherosclerotic disease. Low serum adiponectin levels were reported to be associated with coronary artery disease and future incidence of acute coronary syndrome (ACS). The impact of adiponectin on lesion composition still remains to be determined. METHODOLOGY/PRINCIPAL FINDINGS: We measured serum adiponectin levels in 303 patients with stable typical or atypical chest pain, who underwent dual-source multi-slice CT-angiography to exclude coronary artery stenosis. Atherosclerotic plaques were classified as calcified, mixed or non-calcified. In bivariate analysis adiponectin levels were inversely correlated with total coronary plaque burden (r = -0.21, p = 0.0004), mixed (r = -0.20, p = 0.0007) and non-calcified plaques (r = -0.18, p = 0.003). No correlation was seen with calcified plaques (r = -0.05, p = 0.39). In a fully adjusted multivariate model adiponectin levels remained predictive of total plaque burden (estimate: -0.036, 95%CI: -0.052 to -0.020, p<0.0001), mixed (estimate: -0.087, 95%CI: -0.132 to -0.042, p = 0.0001) and non-calcified plaques (estimate: -0.076, 95%CI: -0.115 to -0.038, p = 0.0001). Adiponectin levels were not associated with calcified plaques (estimate: -0.021, 95% CI: -0.043 to -0.001, p = 0.06). Since the majority of coronary plaques was calcified, adiponectin levels account for only 3% of the variability in total plaque number. In contrast, adiponectin accounts for approximately 20% of the variability in mixed and non-calcified plaque burden. CONCLUSIONS/SIGNIFICANCE: Adiponectin levels predict mixed and non-calcified coronary atherosclerotic plaque burden. Low adiponectin levels may contribute to coronary plaque vulnerability and may thus play a role in the pathophysiology of ACS.

Detection of significant coronary artery stenosis with 64-slice computed tomography in heart transplant recipients: a comparative study with conventional coronary angiography.

PURPOSE: The present study evaluates clinical feasibility of cardiac multidetector computed tomography angiography (MDCTA) to detect significant stenosis of coronary vessels due to transplant vasculopathy (TVP) after heart transplantation (HTx). METHODS: Twenty-eight consecutive male HTx-recipients scheduled for their annual routine conventional coronary angiography (CCA) additionally underwent 64-slice MDCTA. RESULTS: Two patients were excluded from further MDCTA analysis. Out of 371 remaining coronary vessel segments evaluable by CCA, MDCTA was able to depict 302 (81.4%) in diagnostic image quality. On a segment based analysis, sensitivity, specificity, diagnostic accuracy (DA), negative predictive value (NPV), and positive predictive value (PPV) for detection of significant stenosis were calculated with 87.5%, 97.3%, 97.0%, 99.7%, and 46.7%, respectively. On a patient-based evaluation, sensitivity, specificity, DA, NPV, PPV were 100%, 81%, 84.6%, 100% and 55.6%, respectively. Evaluation of stenosis degree by MDCTA showed systematic overestimation of 4.4%. A moderate to good agreement comparing both modalities was found (Pearson's correlation coefficient: 0.64). CONCLUSION: High NPV suggesting 64-slice MDCTA being a reliable diagnostic tool for ruling out significant stenosis due to TVP in HTx patients. But its clinical value in these particular patients needs further investigation.

Chemerin is associated with markers of inflammation and components of the metabolic syndrome but does not predict coronary atherosclerosis.

OBJECTIVES: Chemerin is a recently discovered adipokine that regulates adipocyte differentiation and modulates chemotaxis and activation of dendritic cells and macrophages. Given the convergence of adipocyte and macrophage function, chemerin may provide an interesting link between obesity, inflammation and atherosclerosis in humans. We sought to examine the relationship of i) chemerin and markers of inflammation, ii) chemerin and components of the metabolic syndrome, and iii) chemerin and coronary atherosclerotic plaque burden and morphology. DESIGN: Serum chemerin levels were determined in 303 patients with stable typical or atypical chest pain who underwent dual-source multi-slice CT-angiography to exclude coronary artery stenosis. Atherosclerotic plaques were classified as calcified, mixed, or non-calcified. RESULTS: Chemerin levels were highly correlated with high sensitivity C-reactive protein (r=0.44, P<0.0001), interleukin-6 (r=0.18, P=0.002), tumor necrosis factor-alpha (r=0.24, P<0.0001), resistin (r=0.28, P<0.0001), and leptin (r=0.36, P<0.0001) concentrations. Furthermore, chemerin was associated with components of the metabolic syndrome including body mass index (r=0.23, P=0.0002), triglycerides (r=0.29, P<0.0001), HDL-cholesterol (r=-0.18, P=0.003), and hypertension (P<0.0001). In bivariate analysis, chemerin levels were weakly correlated with coronary plaque burden (r=0.16, P=0.006) and the number of non-calcified plaques (r=0.14, P=0.02). These associations, however, were lost after adjusting for established cardiovascular risk factors (odds ratio, OR 1.17, 95% confidence interval (CI) 0.97-1.41, P=0.11 for coronary plaque burden; OR 1.06, 95% CI 0.96-1.17, P=0.22 for non-calcified plaques). CONCLUSIONS: Chemerin is strongly associated with markers of inflammation and components of the metabolic syndrome. However, chemerin does not predict coronary atherosclerosis.

Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease.

AIMS: The aim of the present study was to assess the clinical performance of a dual X-ray source multi-slice CT (MSCT) with high temporal resolution to assess the coronary status in patients with an intermediate pretest likelihood for significant coronary artery disease (CAD) without using negative chronotropic pretreatment. METHODS AND RESULTS: Dual-source CT (DSCT) angiography (Siemens Definition) was performed in 90 patients with an intermediate likelihood for CAD who were referred for invasive coronary angiography. DSCT generated data sets with diagnostic image quality in 88 of the overall 90 patients. In six of seven patients with atrial fibrillation and in 46 of 48 patients with heart rates (HR)>65 b.p.m. image quality was diagnostic. In 20 of 21 patients with at least one stenosis>50% (sensitivity 95%) were correctly identified by DSCT-angiography. In 60 of 67 patients, a lesion>50% was correctly excluded (specificity 90%; positive predictive value 74%). The accuracy to detect patients with coronary stenoses>50% (sensitivity 92 vs. 100%; specificity 88 vs. 91%) was not significantly different among patients with HR>65 b.p.m. (n=46) and <65 b.p.m. The concordance of DSCT-derived stenosis quantification showed good correlation (r=0.76; P<0.001) to quantitative coronary angiography with a slight trend to overestimate the stenosis degree. CONCLUSION: DSCT is a non-invasive tool that allows to accurately rule out coronary stenoses in patients with an intermediate pretest likelihood for CAD, independent of the HR.