HEART PORTPort-Access® Operative Procedure UCI - Policlínica Gipuzkoa
Técnica                        Heart Port - PG                                              Port    Port: Robot-AssistedEs...
Técnica   Heart Port - PG
Técnica de Perfusión Estándar        PUMP      Oxygenator                       Lungs       Right     Right       Left    ...
Técnica de Perfusión Estándar   PUMP   Oxygenator           Cardioplegia           RA          RV   LA   LV
EndoClamp: Cardioplegia y ClampajeSVC Drainage                       Clamping       Right       Right       Left       Lef...
Técnica   By-pass cardiopulmonar 
Técnica   By-pass cardiopulmonar
Técnica   By-pass cardiopulmonar
Técnica   By-pass cardiopulmonar                    Canulación venosa                      Acceso Femoral
ClampajeAurícula   Ventrículo    Aurícula   VentrículoDerecha     Derecho     Izquierda   Izquierdo                    Car...
Técnica            By-pass cardiopulmonarCanulación arterial
Técnica   By-pass cardiopulmonar
Técnica   Heart Port - PG
Técnica   Campo Quirúrgico
Técnica   Campo Quirúrgico
Técnica   Campo Quirúrgico
Técnica   Campo Quirúrgico
Técnica   Campo Quirúrgico
Técnica   Campo Quirúrgico
TÉCNICA HEART-PORT                POLICLÍNICA
Resultados                                                           HEART PORT - PGü  Casos realizados                  ...
HEART PORT                            Tipo de cirugía                                                        Porcentaje   ...
HEART PORT" " " " " 
HEART PORT" " " 
Resultados                                    HEART PORT - PG  Periodo: ago-03 / jul-10                                   ...
Resultados                                HEART PORT - PG  Periodo: ago-03 / jul-10ü  Casos realizados: 200ü  Sexo: muje...
Resultados                                                         HEART PORT - PG  Periodo: ago-03 / jul-10ü  Estancia e...
Resultados                                                                           HEART PORT - PG  “PROBLEMAS”ü  Entre...
Resultados                                HEART PORT - PG   COMPLICACIONES - accesosü Complicaciones accesos vasculares a...
Resultados                                    HEART PORT - PGCOMPLICACIONES - globales           Complicaciones Heart-Port...
Conclusiones                      HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centroü  Pacientes seleccionad...
Comparaciones NO significativasResultados                                       HP vs nHP: 2003-2009          Heart-Port  ...
Comparaciones NO significativasResultados                                               HP vs nHP: 2003-2009         Tabla...
Comparaciones NO significativasResultados                                             HP vs nHP: 2003-2009Tabla de conting...
Comparaciones NO significativasResultados                                              HP vs nHP: 2003-2009               ...
Comparaciones NO significativasResultados                                                  HP vs nHP: 2003-2009           ...
Comparaciones NO significativasResultados                                                HP vs nHP: 2003-2009             ...
Conclusiones                      HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centro  Pacientes seleccionados...
HEART PORT ¿Factible y Seguro?Ann Thorac Surg 2002;74:660-4Minimally-Invasive Mitral Valve Surgery: A 6-Year Experience Wi...
HEART PORT ¿Factible y Seguro?The Journal of Heart Valve Disease 2008;17:48-53Video-Assisted Mitral Surgery through a Micr...
HEART PORT ¿Factible y Seguro?The Heart Surgery Forum # 2004-1143 8(5), 2005The Preferable Use of Port Access Surgical Tec...
HEART PORT ¿Factible y Seguro?J Thorac Cardiovasc Surg. 2009Quality of mitral valve repair: Median sternotomy versus port-...
HEART PORT: dolor y calidad de vidaAnn Thorac Surg 1999;67:1643-7Pain and Quality of Life After Minimally Invasive Versus ...
Conclusiones                      HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centro Pacientes seleccionados ...
Gracias
Técnica                   By-pass cardiopulmonar Canulación arterial femoral     EndoClamp
Manejo del paciente operados con técnica de heart port en el postoperatorio inmediato
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Manejo del paciente operados con técnica de heart port en el postoperatorio inmediato

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Manejo del paciente operados con técnica de heart port en el postoperatorio inmediato

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Manejo del paciente operados con técnica de heart port en el postoperatorio inmediato

  1. 1. HEART PORTPort-Access® Operative Procedure UCI - Policlínica Gipuzkoa
  2. 2. Técnica Heart Port - PG Port Port: Robot-AssistedEsternotomía   C.  Endoscópica   Experience  stages  
  3. 3. Técnica Heart Port - PG
  4. 4. Técnica de Perfusión Estándar PUMP Oxygenator Lungs Right Right Left Left Atrium Ventricle Atrium Ventricle
  5. 5. Técnica de Perfusión Estándar PUMP Oxygenator Cardioplegia RA RV LA LV
  6. 6. EndoClamp: Cardioplegia y ClampajeSVC Drainage Clamping Right Right Left Left Atrium Ventricle Atrium Ventricle Cardioplegia O²IVC Drainage
  7. 7. Técnica By-pass cardiopulmonar 
  8. 8. Técnica By-pass cardiopulmonar
  9. 9. Técnica By-pass cardiopulmonar
  10. 10. Técnica By-pass cardiopulmonar Canulación venosa Acceso Femoral
  11. 11. ClampajeAurícula Ventrículo Aurícula VentrículoDerecha Derecho Izquierda Izquierdo Cardioplegia O²
  12. 12. Técnica By-pass cardiopulmonarCanulación arterial
  13. 13. Técnica By-pass cardiopulmonar
  14. 14. Técnica Heart Port - PG
  15. 15. Técnica Campo Quirúrgico
  16. 16. Técnica Campo Quirúrgico
  17. 17. Técnica Campo Quirúrgico
  18. 18. Técnica Campo Quirúrgico
  19. 19. Técnica Campo Quirúrgico
  20. 20. Técnica Campo Quirúrgico
  21. 21. TÉCNICA HEART-PORT POLICLÍNICA
  22. 22. Resultados HEART PORT - PGü  Casos realizados Heart-Port (2003-2009)HP PorcentajeNo HP Frecuencia válido Si 192 5,5 94,5% 5,5% No 3329 94,5 Total 3521 100,0 Tabla de contingencia Heart-Port * Año Año 2003 2004 2005 2006 2007 2008 2009 Total Si Recuento 14 47 32 24 30 16 29 192 % de Año 2,6% 8,5% 6,2% 5,0% 6,2% 3,3% 6,2% 5,5%
  23. 23. HEART PORT Tipo de cirugía Porcentaje Frecuencia válido Valvular 363 91,4 CIA 23 5,8 Valv-CIA 9 2,3 Otros_Heart Port 2 ,5 Total 397 100,0" "  51,6% Heart-Port Porcentaje"  Frecuencia válido Si 192 48,4"  48,4% No 205 51,6 Total 397 100,0" " 
  24. 24. HEART PORT" " " " " 
  25. 25. HEART PORT" " " 
  26. 26. Resultados HEART PORT - PG Periodo: ago-03 / jul-10 Edad corregida (años) Stem-and-Leaf Plotü  Casos realizados: 200 Frequency Stem & Leaf 10,00 Extremes (=<36)ü  Sexo: mujeres 60% 2,00 3 . 77 7,00 4 . 0112244 5,00 4 . 56679 11,00 5 . 00112223444ü  Edad media: 64,9 años (16::86) 25,00 5 . 5556777778888889999999999 29,00 6 . 00000111111222222233333344444 29,00 6 . 55566666667777888888889999999 34,00 7 . 0000111111111222222223333344444444ü  2ª Intervención: 7% 31,00 7 . 5555556666667777777777888888899 16,00 8 . 0001111112223334 1,00 8. 6ü  F.E. Media: 62,6% (min. 31%) Stem width: 10 Each leaf: 1 case(s)ü  P. A. Pulmonar Media: 43 mm Hg. (max. 106)
  27. 27. Resultados HEART PORT - PG Periodo: ago-03 / jul-10ü  Casos realizados: 200ü  Sexo: mujeres 60%ü  Edad media: 64,9 años (16::86)ü  2ª Intervención: 7%ü  F.E. Media: 62,6% (min. 31%)ü  P. A. Pulmonar Media: 43 mm Hg. (max. 106)
  28. 28. Resultados HEART PORT - PG Periodo: ago-03 / jul-10ü  Estancia en UCI: 1,8 días / Md:1 díaü Estancia Hospitalaria: 8,5 días / Md: 7 díasü Mortalidad en UCI: 2,5%ü Mortalidad a los 30 días: 4,5% (Media EuroSCORE log.: 6,78%) Bajo riesgo (ES <= 2.94%) Porcentaje Frecuencia válido No 196 98,0 Si 4 2,0 Alto riesgo (ES >= 10.9%) Total 200 100,0 Porcentaje Frecuencia válido No 164 82,0 Si 36 18,0 Total 200 100,0
  29. 29. Resultados HEART PORT - PG “PROBLEMAS”ü  Entrenamiento / “curva de aprendizaje”ü  Tiempo y Paciencia Esternotomía Heart -Port Prueba de muestras independientes Estadísticos de grupo Desviación Error típ. de Heart-Port N Media típ. la mediaTiempo de isquemia (min.) Si 192 89,11 30,141 2,175 No 237 49,86 26,552 1,725 Prueba T para la igualdad de mediasTiempo de By-pass (min.) Si 192 128,47 35,752 2,580 95% Intervalo de No confianza para la 240 86,67 28,294 1,826 Diferencia diferencia de medias Inferior Superior Tiempo de isquemia (min.) 39,253 33,868 44,637 Tiempo de By-pass (min.) 41,802 35,585 48,019
  30. 30. Resultados HEART PORT - PG COMPLICACIONES - accesosü Complicaciones accesos vasculares arteriales: 2%ü  Complicaciones canulación venosa: 2%ü  Clampaje transtorácico - Novare: 8%ü  Adherencias pleurales: 2%
  31. 31. Resultados HEART PORT - PGCOMPLICACIONES - globales Complicaciones Heart-Port ACVA con secuelas 1,5% IAM peri-IQ 0,5% Shock 1,0% Daño renal agudo (RIFLE) 6% FRA con TDE ,0% H. Mediatínica SIN re-IQ 3,0% H. Medistínica CON re-IQ 1% Politrasfusión (> 6 C.H.) ,0% Taponamiento ,0% * 0% conversiones a esternotomía
  32. 32. Conclusiones HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centroü  Pacientes seleccionadosü  DIFICULTAD para realizar comparaciones
  33. 33. Comparaciones NO significativasResultados HP vs nHP: 2003-2009 Heart-Port Porcentaje Frecuencia válido Si 192 48,4 No 205 51,6 Total 397 100,0 Media Heart-Port Si No Prueba de muestras independientes Edad corregida (años) 65,12 65,96 Fraccion de eyeccion (%) Prueba T para la igualdad de medias 63,01 61,90 95% Intervalo de Hipertension pulmonar (mm Hg.) 41,97 46,12 confianza para la Diferencia diferencia Sig. (bilateral) de medias Inferior Superior Edad (años) ,511 -,839 -3,344 1,667 Edad corregida (años) ,511 -,8387 -3,3442 1,6667 Fraccion de eyeccion (%) ,307 1,110 -1,022 3,242 Hipertension pulmonar ,109 -4,146 -9,225 ,933 (mm Hg.)
  34. 34. Comparaciones NO significativasResultados HP vs nHP: 2003-2009 Tabla de contingencia Reintervenido * Heart-Port Heart-Port Si No Reintervenido Si Recuento 13 55 % de Heart-Port 6,8% 26,8% No Recuento 179 150 % de Heart-Port 93,2% 73,2% Total Recuento 192 205 Tabla de contingencia Tipo de prótesis mitral * Heart-Port Heart-Port Si No Tipo de Mecánica Recuento 109 133 prótesis mitral % de Heart-Port 56,8% 64,9% Biológica Recuento 4 21 % de Heart-Port 2,1% 10,2% Anuloplastia Recuento 63 20 % de Heart-Port 32,8% 9,8% No Recuento 16 31 % de Heart-Port 8,3% 15,1% Total Recuento 192 205
  35. 35. Comparaciones NO significativasResultados HP vs nHP: 2003-2009Tabla de contingencia IAM peri-IQ * Heart-Port Tabla de contingencia Shock * Heart-Port Heart-Port Heart-Port Si No Si NoIAM peri-IQ No 190 203 Shock No Recuento 189 199 99,5% 99,0% % de Heart-Port 99,0% 97,1% Si 1 2 Si Recuento 2 6 ,5% 1,0% % de Heart-Port 1,0% 2,9%Total 191 205 Total Recuento 191 205 Tabla de contingencia H. Mediatínica sin re-IQ * Heart-PortTabla de contingencia FRA con TDER * Heart-Port Heart-Port Heart-Port Si No Si No H. Mediatínica sin re-IQ No 185 197FRA con TDER No 191 205 96,9% 96,1% 100,0% 100,0% Si 6 8Total 191 205 3,1% 3,9% Total 191 205Port-Access®: tiempos de isquemia y CEC más prolongados
  36. 36. Comparaciones NO significativasResultados HP vs nHP: 2003-2009 Tabla de contingencia H. Medistínica con re-IQ * Heart-Port Heart-Port Si NoTabla de contingencia ACVA con secuelas * Heart-Port H. Medistínica con re-IQ No 189 195 Heart-Port 99,0% 95,1% Si No Si 2 10ACVA con secuelas No 188 194 1,0% 4,9% 98,4% 94,6% Total 191 205 Si 3 11 Tabla de contingencia Politrasfusión (> 6 C.H.) 1,6% 5,4%Total 191 205 Heart-Port Si No Politrasfusión No 51 50 (> 8 C.H.) 100,0% 92,6% Si 0 4 ,0% 7,4% Total 51 54 Tabla de contingencia Taponamiento * Heart-Port Heart-Port Si No Taponamiento No 191 201 100,0% 98,0% Si 0 4 ,0% 2,0% Total 191 205
  37. 37. Comparaciones NO significativasResultados HP vs nHP: 2003-2009 Heart-Port Porcentaje Tabla de contingencia Mortalidad a los 30 días * Heart-Port Frecuencia válido Si 192 48,4 Heart-Port No 205 51,6 Si No Total Total 397 100,0 Mortalidad a No Recuento 184 194 378 los 30 días % de Heart-Port 95,8% 94,6% 95,2% Si Recuento 8 11 19 % de Heart-Port 4,2% 5,4% 4,8% Total Recuento 192 205 397 48,4% 51,6% 100,0% Tabla de contingencia Alto riesgo (ES >= 10.9) * Heart-Port Heart-Port Estadísticos de grupo Si No Alto riesgo (ES >= 10.9) No 159 121 82,8% 59,6% Desviación Error típ. de Si 33 82 Heart-Port Media típ. la media 17,2% 40,4%EuroSCORE Log. (%) Si 6,5582 Prueba de muestras independientes Total 8,37325 ,60429 192 203 No 10,4865 9,05432 ,63549 Prueba T para la igualdad de medias 95% Intervalo de confianza para la Diferencia diferencia de medias Inferior Superior EuroSCORE Log. (%) Se han asumido -3,92828 -5,65610 -2,20045 varianzas iguales
  38. 38. Comparaciones NO significativasResultados HP vs nHP: 2003-2009 Desviación Error típ. de Heart-Port N Media de muestras independientes Prueba típ. la mediaEstancia Media (días) No 205 3,91 8,582 ,599 Prueba T para la igualdad de mediasen UCI Si 192 1,86 2,147 ,155 95% Intervalo de confianza para la Diferencia diferencia Sig. (bilateral) de medias Inferior Superior Estancia media (días) ,001 2,048 ,828 3,267
  39. 39. Conclusiones HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centro Pacientes seleccionados DIFICULTAD para realizar comparacionesü  HP es una técnica FACTIBLE y SEGURA Bibliografía
  40. 40. HEART PORT ¿Factible y Seguro?Ann Thorac Surg 2002;74:660-4Minimally-Invasive Mitral Valve Surgery: A 6-Year Experience With 714 PatientsEugene A. Grossi, MD, New York University School of Medicine. New York, USA.Objective:To analyze a single-institutional experience with minimally-invasive mitral valve operations of 6 years, reviewing short-term mortality andmorbidity and long-term echocardiographic data.Method:Between Nov 1995 and Nov 2001, 714 consecutive patients had minimally invasive mitral valve procedures. 561 patients had isolated mitral valveoperations (375 repairs, 186 replacements) . Mean age was 58.3 (30.1% > 70 years) and 15.4% had previous cardiac operations. Arterialcannulation was femoral in 79.0% and central in 21% with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugularretrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%Results:Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, medianventilation time was 11 hours, intensive care unit time was 19 hours and total hospital stay was 6 days. Complications for all patients includedpermanent neurologic deficit (2.9%), aortic dissection (0.3%), no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% ofthe repair patients had only trace or no residual mitral insufficiency.Conclusion:This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperativemorbidity and mortality and with late outcomes that are equivalent to conventional operations.
  41. 41. HEART PORT ¿Factible y Seguro?The Journal of Heart Valve Disease 2008;17:48-53Video-Assisted Mitral Surgery through a Micro-Access: A Safe and Reliable Reality in the Current EraErnesto Greco MD, Juan M. Zaballos MD, Luis Alvarez MD, Stefano Urso MD, Ivana Pulitani MD,Rafael Sàdaba MD, Arantxa Juaristi MD, Juan J. Goiti MDPoliclinica Gipuzkoa, San Sebastian.Objective:To describe the author´s experience with video-assisted mitral surgery through a micro-access.Method:Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-assisted port-access mitral valve surgery through a 4 to 6 cm anterior mini-thoracotomy. Mitral valve repair wascarried out in 36 patients (36%) andmitral valve replacement (MVR) in 64 (64%). Redo procedures were performed in 14 patients.Results:Endoclamp occlusion of the ascending aorta was used in 94%. The median intensive care unit and hospital stays were 20.0 ± 30.8h and 7.0 ± 5.9 days,respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. There were no perioperative myocardial infarctions,permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during thepostoperative course, and no wound infections were observed.Conclusion:Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results andquality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.
  42. 42. HEART PORT ¿Factible y Seguro?The Heart Surgery Forum # 2004-1143 8(5), 2005The Preferable Use of Port Access Surgical Technique for Right and Left Atrial ProceduresGersak B, Sostaric M, Kalisnik JM, Blaumamauer R.Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia.Objective:To analyze the results of mitral valve operations, either alone or in combination with the tricuspid valve surgeries.Method:From January 2001 till June 2004. The period was divided into two parts, classical sternotomy part (C) (110 patients) and minimally invasiveport access part (PA) (105 patients), later being used from December 2002 till now. Also, what we were interested in was the total hospital costof both types of the procedures and if there are any advantages of port access over the classical sternotomy. The mean age was 61.2 ± 10.2and 60.3 ± 12.4 (C versus PA) and mean additive Euroscore was 6.5 versus 4.8 (C versus PA).Results:There were statistically significant differences in cardiopulmonarybypass time (CPB) and aortic cross-clamp time (AXT) between both groups:CPB C versus PA: 98.3 ± 33.5 minutes versus 149.2 ± 44.2 minutes (mean ± sd), AXT C versus PA: 62.9 ± 20.6 minutes versus 88.3 ± 26.8minutes (mean ± sd). There were no statistically significant differences in mortality and stroke for both the groups There were statisticallysignificant differences in favor of the port access over the classical one for: intensive unit stay postoperative stay in days, bloodtransfusion, postoperative thoracic bleeding and extubation time in hours. Furthermore, costs analyses showed that the average totalpatient cost was less for port access. The differences between endo and classical type suggested that the port access type of surgery is 20%cheaper than the classical one.Conclusion:We may conclude that port access surgery is an acceptable alternative to classical type of surgery, also in complex pathology of the mitraland tricuspid valve.
  43. 43. HEART PORT ¿Factible y Seguro?J Thorac Cardiovasc Surg. 2009Quality of mitral valve repair: Median sternotomy versus port-access approach.Raanani E, Spiegelstein D, Sternik L, Preisman S, Moshkovitz Y, Smolinsky AK, Shinfeld A.Department of Cardiac Surgery, Chaim Sheba Med. Center, Tel Hashomer, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel.Objectives:We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means ofthe port-access and median sternotomy approaches. Methods: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwentsurgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group hadbetter preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Otherpreoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques.Results:Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that mostpatients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extendedfor up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) inthe port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11).Conclusion:In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with theconventional median sternotomy approach.
  44. 44. HEART PORT: dolor y calidad de vidaAnn Thorac Surg 1999;67:1643-7Pain and Quality of Life After Minimally Invasive Versus Conventional Cardiac SurgeryThomas Walther, MD, Herzzentrum LeipzigObjective:To evaluate pain and quality of life after minimally invasive cardiac operations in comparison with conventional cardiac operations.Method:From Oct 1996 to May 1997, a total of 338 patients were interviewed daily using standard scoring systems (myocardial revascularization n = 160;mitral valve reconstruction or replacement n = 58; aortic valve replacement n = 120).Results:There was no significant difference regarding ventricular function and intensive care and hospital stay. Pain decreased until the seventh postoperativeday in all patients. Patients with a lateral minithoracotomy had lower pain levels from the third postoperative day onward. There were nodifferences in quality of life, postoperative wound healing or stability of the bony thorax.Conclusion:After minimally invasive procedures with lateral minithoracotomy, earlier mobilization is possible because of a better stability of the bony thorax,resulting in lower pain levels.
  45. 45. Conclusiones HEART PORT - PGü  HP es una técnica HABITUAL en nuestro centro Pacientes seleccionados DIFICULTAD para realizar comparacionesü  HP es una técnica FACTIBLE y SEGURAü  Paso previo a la CIRUGÍA ROBÓTICA
  46. 46. Gracias
  47. 47. Técnica By-pass cardiopulmonar Canulación arterial femoral EndoClamp

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