3. 3 | P a g e
Elham Ali Ahmed Ali
Holds a Bachelor's degree
in Nursing,
Ain Shams University,
holds a diploma in therapeutic nutrition
approved by the Arab Studies Center and accredited by the
foreign consulate,
and
holds a diploma in a medical quality
approved by the Arab Studies Center and accredited by the
foreign consulate
and
holds a diploma in an infection control
approved by the Arab Studies Center and accredited by the
foreign consulate
and
holds a Mini master’s in Medical administration
approved by the Arab Studies Center and accredited by the
foreign consulate.
4. 4 | P a g e
subject
Introduction
Reviewabout coronary vein
Definition CABG
Propose of CABG
Indication of CABG
Contraindication ofCABG
Coronary artery bypass graft sides
Types of CABG
Traditional
procedure
Off pump
Minimally invasive CABG
MIDCAB
Port-access coronary artery bypass
Robot-Assistedtechnique
Complication
Diagnosis evaluation
Recovery
Recovery at hospital
Recovery at home
Followup
rehabilitation
Nursing management for CABG
Preoperative
Intraoperative
Postoperative
Nurse care plan
Summary
Reference
Introduction
The heart is amazing organ and have amazing power and
the functions of its many parts.
5. 5 | P a g e
How is the organs in your body nourished?
By the blood carry oxygen and minerals that needed it
How is arrive blood to organs?
By circulatory system
What is circulatory system?
Is pulmonary circulation and systemic circulation through
cardiovascular system.
Cardiovascular system
Arteries in the body:-
Carry oxygenationblood from aorta to organs.
Veins in the body:-
Carry deoxygenationblood from body to inferior and superior
vena cava.
How is the heart nourished?
By coronary circulation.
What is coronary circulation and how is nourished
the heart?
Pulmonary circulation
Enter Deoxygenationblood toinferior and superior vena cava to
RT atrium RT ventricle pulmonary artery
lung (change gases)
Systemic circulation
Exit oxygenation blood from lung to LT atrium LT
ventricle Aorta to all system tissuesfrom head to toe.
6. 6 | P a g e
The coronary circulation ispart from of the systemic
circulatorysystem
that suppliesblood to the heart through coronaryartery
Provide drainage from tissuesof the heart is coronary veins.
Coronary artery
Coronary arteries arise from the ascending aorta,
immediately above aortic valve
The coronary arteriesand their branches runon the surface of
the heart
Lying withinthe sub pericardial fibber fattytissue
The heart content on coronary artery and coronary vein
Coronary arteries:-
is responsible for supplies oxygenationblood to heart
muscle
Coronary veins:-
is responsible for drainage deoxygenationblood to RT
atrium.
7. 7 | P a g e
Anatomically coronaryarteriesare not end-arteries
But functionally they like end arteries.
Why is anatomically the coronary arteries are not
end-arteries but functionally they like end arteries?
Because the coronary artery content on anastomoses
The coronary artery divide to RT coronary artery
and LT coronary artery
Anastomoses
is connectionbetweenterminatesofartery with terminates
another artery
but
functionboth arteries have functionespecialto hem.
9. 9 | P a g e
Arise from the anterior aortic sinus of ascending aorta,
immediately above the aortic valve.
Course:-
After arising from ascending aorta the right coronary artery
first run forwardsbetween pulmonary trunk and the right
auricle
thenit almost ventricle into the right atrioventricular groove (
also called the right anterior coronarysulcus)
Up to junctionof the right and inferior borders of the heart at
the inferior bordersof the heart
Thenturn posteriorly
Run up to the posterior atrioventricular groove and
terminatesby anastomosingwith the left coronary artery.
Branches and distribution:-
Right couns artery :-
It supplies the anterior surface of the pulmonary couns
Anterior ventricularbranches :-
They are two or three and suppliesthe anterior of the right
ventricle
The marginal artery :-
Is the largest and sup lies along the lower marginof the
sternal surface to reach the apex
10. 10 | P a g e
Atrial branches :-
They supply the atria
The Sino atrial node artery:-
Is one of atrialbranches,
supplies the SA node in the 60% of cases in 40% of individuals
it is arisesfrom the left coronary artery.
Posteriorventricular branches :-
they are supply the diaphragmaticsurface ofright and left
ventricles
Posteriorinterventricularartery :-
It runs in the posterior interventricular groove up to the apex
It supplies the posterior part of the interventricular septum,
AV node in 60% casesand RT and LT ventricles.
Left coronary artery
Origin:-
11. 11 | P a g e
Arise from the posterior aortic sinusof ascending aorta,
immediately above the aortic valve.
Course:-
After arising from ascending aorta the left coronary artery
run forwardsbetween pulmonary trunk and the left auricle.
It then divide in to an anterior interventricular artery(also
called left anterior descending) and circumflex artery
left anterior descending isrun downward in the anterior
interventricular groove tothe apex of the heart
thenpasses posteriorly around the apex of the heart
To enter the posterior interventricular groove toterminate by
anastomosing with the posterior interventricularartery a
branch from right coronary artery.
the circumflex artery:-
passes around the left margin of the heart and continuesin left
posterior coronary sulcus
Up to the posterior atrioventricular groove where it
terminatesby anastomosingwith rightcoronary artery.
Branches and distribution:-
anterior interventricularartery ( also called left anterior
descending artery ) :-
it supply anterior interventricularseptum
12. 12 | P a g e
greater part of the left ventricle and
part of the right ventricle , and
a part of left bundle branch .
circumflex artery :-
it givesa left marginalartery that suppliesthe left marginof
the left ventricle up to the apex of the heart
diagonal artery :-
it may arise directly from the trunk of left coronary artery.
Couns artery :-
it suppliesthe pulmonary couns
Atrial branches :-
they supply the left atrium
Over time, these arteriescanbecome narrowed and hardened by
the build-up of fatty depositscalled plaques.
Thisprocess is knownas atherosclerosis.
People with atherosclerosisofthe coronary arteriesare said to
have coronary heart disease.
How does the heart maintain its normal
function?
Regulate the timing of heart beat.
Keep the heart muscle healthy.
Keep blood flowing efficiently.
13. 13 | P a g e
It happenswhen the supply of oxygen-rich blood tothe heart
becomes restricted.
Risk associated with coronary heartdisease isthe possibility of
one of the plaques in the coronary artery rupturing (splitting),
creating a blood clot.
If the blood clot blocks the blood supply to the heart, it can trigger
a heart attack.
A coronary artery bypass graft may be recommended
To reduce your chances of having a heart attack.
Definition
A coronary artery bypass graft (CABG)
A surgicalprocedure used totreat coronary heart disease.
It divertsblood around narrowed or clogged partsof the major
arteriestoimprove blood flow and oxygensupply to the heart.
14. 14 | P a g e
CABG-CORONARY ARTERY BYPASS GRAFTING
A cardiothoracicsurgeon doesthe surgery with support from
an anesthesiologist, perfusionist (heart-lung bypassmachine
specialist), other surgeons, and nurses.
There are several typesof CABG .
Propose
1. Restore blood flow to the heart.
2. Relieve chest pain& ischemia.
3. Improves the patient’squalityoflife.
4. Enables the patient toresumea normal life cycle.
5. Lower the risk of a heart attack.
Indication
1. Left mainarterydiseaseor equivalent
15. 15 | P a g e
2. Triplevessel disease
3. AbnormalLeft Ventricularfunction.
4. Failed PTCA.
5. Immediatelyafter MyocardialInfarction(tohelp perfusionof the
viablemyocardium).
6. Life threatening arrhythmiascaused bya previousmyocardial
infarction.
7. Occlusionof graftsfrom previous CABG.
Contraindication
1. Abdominalaortic aneurysm
2. Hemorrhagediseases
3. congenitalheart diseases
4. Lower extremitiesedema
5. Severe hypertension
6. Uncontrolled arrhythmias
7. patient refusal
8. coronaryarteriesincompatiblewith grafting
9. The absenceof viablemyocardium tograft.
Coronary artery bypasses graft sites
Internal mammaryarteries
Radialarteries
Greater saphenousveins
16. 16 | P a g e
The number of blood vessels used will depend on how severe a
coronary heart disease isand how many of the coronary blood
vessels have become narrowed.
If you need 2, 3 or 4 grafts, you may hear the operationreferred
to as a double, triple or quadruple bypass.
Double bypass means twocoronary arteriesare
bypassed (e.g. the left anterior descending (LAD) coronary
artery and right coronary artery (RCA)
17. 17 | P a g e
Triple bypass meansthree arteriesare bypassed (e.g.
LAD, RCA, left circumflex artery(LCX)
Quadruple bypass meansfour vessels are bypassed
(e.g. LAD, RCA, LCX, first diagonalartery of the LAD)
One of the graft vessels is usually takenfrom your chest (internal
mammary artery).
Surgeonsprefer to use thisvessel because it doesn't narrow over
time, unlike the blood vessels takenfrom your leg or arm.
Types of CABG
Traditional Coronary Artery Bypass Grafting
On-pump CABG
Nontraditional Coronary Artery Bypass Grafting
off-pump CABG
Minimally invasive CABG.
Uncommonly type
MIDCAB procedure.
Port-access coronaryartery bypass
Robot-assisted technique
18. 18 | P a g e
Traditional Coronary Artery Bypass Grafting
On-pump CABG
the heart is stopped, and a heart-lung bypassmachine isused .
Thisis the most commontype of coronary artery bypassgrafting
(CABG).
It's used whenat least one major artery needsto be bypassed.
Procedure
Thistype of surgery usually lasts 3 to 5 hours, depending on the
number of arteriesbeing bypassed.
Numerousstepstake place during traditionalCABG.
The pt will' be under general anesthesia for the surgery.
During the surgery, the anesthesiologist checksyour heartbeat,
blood pressure, oxygenlevels, and breathing.
A breathing tube isplaced and the tube is connected toa
ventilator (a machine that helpsyou breathe).
An incisionis made down the center of the chest, at least 6 to 8
incheslong.
The chest bone is thencut and the ribcage isopened so that the
surgeoncan get to the heart.
19. 19 | P a g e
Medicinesare used to stop the heart, which allowsthe surgeonto
operate on it while it's not beating.
The pt also given medicinestoprotect your heart function during
the time that it'snot beating.
A heart-lung bypassmachine keepsoxygen-rich blood moving
throughout your body during the surgery.
An artery or vein is taken from your body—for example, from
your chest or leg—and prepared to be used as a graft for the
bypass.
In surgery with severalbypasses, both artery and veingraftsare
commonly used
After the grafting is done,
Blood flow to the heart isrestored.
Usually, the heart startsbeating againonitsown.
In some cases, mild electric shocksare used to restart the heart.
The pt thendisconnected from the heart-lung bypassmachine.
Tubesare inserted intothe chest to drainfluid.
The surgeon uses wiresto close your chest bone (much like how a
brokenbone is repaired).
The wiresstay in your body permanently.
After your chest bone heals, it will be as strong as it wasbefore
the surgery.
Stitchesor staplesare used to close the skin incision.
The breathing tube isremoved whenyou're able to breathe
without it
20. 20 | P a g e
Off-pump CABG
Thistype of CABG is similar to traditionalCABG because the
chest bone is opened to accessthe heart.
However, the heart isn't stopped, and a heart-lung bypass
machine isn't used.
Off-pump CABG is sometimes calledbeating heart bypass
grafting.
A member of the surgicalteam uses a device to stabilize just the
portionof the heart where the bypassis needed, while the
remainder ofthe heart keepspumping and circulatingblood to
the body.
With a particular area of the heart steadied, a surgeonis able to
bypassthe blocked artery in a controlled environment.
21. 21 | P a g e
Minimally Invasive Coronary Artery Bypass Grafting
There are several typesof minimally invasive coronary artery
bypassgrafting.
These typesof surgery differ from traditionalbypasssurgery.
They only require small incisionsrather thanopening the chest
bone to get to the heart.
These proceduressometimes use a heart-lung bypassmachine.
22. 22 | P a g e
MIDCAB
Thisprocedure isused when only one or two coronary arteries
need to be bypassed.
23. 23 | P a g e
A seriesof small incisions is made betweenyour ribs on the left
side of your chest, directly over the artery tobe bypassed.
The incisionsusually are about 3 incheslong.
A heart-lung bypassmachine isn't used during thisprocedure.
Port-access coronary artery bypass procedure
Thisprocedure isdone through smallincisions(ports) made in
the chest.
Artery or vein graftsare used.
A heart-lung bypassmachine isused during thisprocedure
24. 24 | P a g e
Robot-assisted technique
Thistype of procedure allows for even smaller, keyhole-sized
incisions.
A small video camera isinserted in one incision toshow the
heart,
Whilethe surgeon uses remote-controlled surgicalinstruments
to do the surgery.
A heart-lung bypassmachine issometimesused during this
procedure.
25. 25 | P a g e
Types of CABG
traditi
onal
Non-
traditi
onal
Non-
traditional
uncommon
On-
pump
CABG
off-
pump
CABG
Minimally
invasive
CABG.
MIDCAB Port-access
coronary
artery
bypass
Robot-
assisted
technique
incision Made
center
of
chest
at least
6 to 8
inches
Made
center
of
chest
at least
6 to 8
inches
Small
incision
about 3
inchesin
heart
located
Small
incision
about 3
inchesin
heart
located
And
Many of
small
incision
(ports)
Many of
small
incision
(ports)
Many of
small
incision
(ports)
Heart-lung
bypass
machine
used Isn`t
used
sometimes Isn`t
used
used sometimes
26. 26 | P a g e
Complication
Although complications from coronary artery bypass
grafting (CABG) are uncommon,
Risk to complication also is higher if you have other
diseases or conditions, such as diabetes, kidney disease,
lung disease, or peripheral arterial disease
Or
If the pt older than 60, or if and have a history of smoking
Wound infection
bleeding
Reactionsto
anesthesia
Decrease C/O
Bradycardia
Electrolyte
imbalance
Arrhythmia
Heart failure
Fever
Stroke
Pleuraleffusions )develop fluid buildup
around the heart)
Renal failure
Pain
heart attack
death
Some patientsdevelop a fever
associated with chest pain, irritability,
decreased appetite
Thisis due to inflammationinvolving
the lung and heart sac.
28. 28 | P a g e
Recovery
Recovery in the Hospital
After surgery, the pt will typically spend 1 or 2 days in an
intensive care unit (ICU).
Assess heart rate, blood pressure, and oxygenlevels will be
checked regularly during thistime.
An intravenousline (IV) will likely be inserted intoa vein in your
arm.
Through the IV line, may get medicines to
controlblood circulationand blood pressure and
manage pain
And lower cholesterol
and medicationtoreduce the risk of blood clots forming
and medicationmanage diabetes;
Or treat depression.
Also will likely have a tube in the bladder to drainurine and a
tube to drainfluid from the chest.
May receive oxygentherapy (oxygengiventhroughnasalprongs
or a mask or connect with ventilation) and a temporary
pacemaker while inthe ICU.
(A pacemaker is a small device that's placed in the chest or
abdomen to help control abnormal heart rhythm)
Doctor may recommend that wear compressionstockingsonthe
legs as well.
(These stockingsare tight at the ankle and become looser as they
go up the leg)
29. 29 | P a g e
(This creates gentle pressure up the leg)
(The pressure keeps blood from pooling and clotting)
While in the ICU, the pt will also have bandageson your chest
incision (cut) and on the areaswhere an artery or vein was
removed for grafting.
After the pt leave the ICU, the pt will be moved to a less intensive
care area of the hospitalfor 3 to 5 daysbefore going home.
30. 30 | P a g e
Recovery at Home
the doctor will give to pt specific instructionsfor recovering at
home, especially concerning:
How to care for healing incisions
What is medicationtotaken
How to recognize signsof infectionor other
complications
Whento call the doctor right away
Whento make follow up appointments
And also may get instructionsonhow to deal with
commonside effectsfrom surgery.
The doctor will tell to whenhe canstart physicalactivityagain.
It varies from person to person, but there are some
typicaltimeframes.
Most people can resume sexual activitywithinabout 4
weeksand driving after 3 to 8 weeks.
Returning to work after 6 weeks is commonunless your
job involves specific and demanding physicalactivity.
Some people may need to find less physically demanding
typesof work or work a reduced schedule at first.
Follow up
31. 31 | P a g e
Care after surgery may include periodic checkupswith doctors.
During these visits, testsmay be done to see how the heart is
working.
Testsmay include ECG (electrocardiogram), stresstesting,
echocardiography, and cardiacCT.
CABG is not a cure for coronary heart disease (CHD), coronary
heart disease is a chronic disease.
Must be maintaintake the medicationafter surgery.
The pt and the doctor may develop a treatmentplanthat includes
lifestyle changesto help the pt stay healthy and reduce the chance
of CHD getting worse.
Lifestyle changesmay include making changesto the diet,
quitting smoking, doing physicalactivityregularly, and lowering
and managing stress.
The doctor also may refer you to cardiac rehabilitation(rehab).
Rehabilitation
32. 32 | P a g e
(Cardiac rehab is a medically supervised program that helps
improve the health and well-being of people who have heart
problem)
Rehab programsinclude exercise training, educationonheart
healthy living, and counseling to reduce stressand help you
returnto an active life.
Doctorssupervise these programs, which may be offered in
hospitalsand other community facilities.
Talk to your doctor about whether cardiac rehabmightbenefit
you.
Taking medicinesasprescribed alsois an important part of care
after surgery.
The doctor may prescribe medicinestomanage painduring
recovery;
lower cholesteroland blood pressure;reduce the risk of blood
clots forming;
Manage diabetes;or treat depression.
NURSING MANAGEMENT OF CABG PATIENT
NURSINGMANAGEMENT
Preoperative Nursing Management.
Intraoperative NursingManagement.
Postoperative NursingManagement
33. 33 | P a g e
PREOPERATIVE NURSING MANAGEMENT
The preoperative nursing management
Usually beginsbefore hospitalization.
Patientswith non-acute heartdisease
may be admitted tohospitalthe day
Before or the day of their surgery.
PREOPERATIVE ASSESSMENT
History Physicalexamination
Radiographicexamination
Electrocardiogram
Laboratory analysis
Typing and cross-matching ofblood.
Assessing patient’sfunctionallevel
Psychosocialassessment.
Family support system
PHYSICAL EXAMINATION
Generalappearance and behavior
Vitalsigns
Nutritionaland fluid status, weight and Height
Inspectionand palpationof heart
Auscultationofheart
JVP
Peripheralpulses.
Peripheraledema.
PSYCHOSOCIAL ASSESSMENT
Meaning of surgery to patient
Coping mechanismsbeing used.
Anticipated changesinlifestyle
Support system ineffect
Fear regarding present & future
34. 34 | P a g e
Knowledge & understanding ofsurgicalprocedure
INTRAOPERATIVE NURSINGMANAGEMENT
Assisting in surgicalprocedure
Continuousmonitoring
Monitoring for complications:dysrhythmias, hemorrhage,
MI, CVA, embolizationetc.
POST OPERATIVE NURSINGMANAGEMENT
ASSESSMENT:
Neurologicalstatus
Cardiac status
Respiratory status
Peripheralvascular status
Renal function
Fluid & electrolyte status
Pain
Assessment of equipment and tubing
Psychologicaland emotionalstatusas patient regains
consciousness
Assessing for complications.
Nurse care plan
NURSINGDIAGNOSIS
Fear related to surgicalprocedure, itsuncertainoutcome, and
the threat of well-being.
Goal:
35. 35 | P a g e
To reduce fear.
INTERVENTIONS
Allowing patient and family to expresstheir fears.
Explainthe patient regarding surgeryand sensationsthat are
expected during and after the surgery.
Reassuring the patient that fear of painis normal and explain
that some pain will be experienced but certainmeasureswill
help to relieve the pain.
COMMUNICATION
INTERVENTIONS
Encourage the patient totalk about the fear of dying.
Patient should be reassured and misconceptionsshould be
corrected.
NURSINGDIAGNOSIS
Knowledge deficit regarding the surgicalprocedure and the
postoperative course.
Goal:
To provide the knowledge regarding surgery
INTERVENTIONS
Patient and family teaching about
Hospitalization
Surgery
Length of surgery
Expected painand discomfort
Criticalcare phase
Recovery phase
PATIENT TEACHING
INTERVENTIONS
Physicalpreparationbefore surgery
36. 36 | P a g e
Medicationsbefore surgery
Informationregarding equipment, tubesthatwillbe present
postoperatively
Teaching the postoperative exercises.
Outcome of the surgery
NURSINGDIAGNOSIS
Potentialfor complicationsrelated tothe stress of impending
surgery (Angina, Severe anxiety, Cardiacarrest)
Goal:
To monitor and manage the complications
INTERVENTIONS
Assess for complicationsAngina:oxygentherapyand
nitroglycerinetherapy.
Severe anxiety:emotionalsupport
Cardiac arrest:cardiaclife support
NURSINGDIAGNOSIS
Decreased cardiac output related toblood loss and
compromised myocardialfunction
Goal:
To restore cardiac output
INTEREVENTIONS
Monitor cardiovascularstatus
Assess arterialpressure every 15 min. untilstable
Auscultate for heart sounds and rhythms
Assess all peripheralpulses
Hemodynamic monitoring
ECG monitoring
37. 37 | P a g e
Assess cardiac enzymes
Monitor urinary output
Observe for persistent bleeding
Observe for cardiac temponade
Observe for cardiac failure
Observe for myocardialinfarction.
NURSINGDIAGNOSIS
Risk for impaired gasexchange related totrauma of
extensive chest surgery
Goal:
To maintainadequategasexchange
INTERVENTIONS
Maintainproper ventilation
Monitor arterialblood gases, tidalvolumes, peek inspiratory
pressuresand extubationparameters
Auscultate chest for breath sounds
Provide chest physiotherapyasprescribed
Promote deep breathing coughing and turning, use of
incentive spirometer.
Teach incisionalsplinting with a cough pillow to decrease
discomfort during deep breathingand coughing
Suctiontracheobronchialsecretionsasneeded, using aseptic
technique
EARLY AMBULATION
NURSINGDIAGNOSIS
Risk for alterationin fluid volume and electrolyte balance
related to alterationinblood volume
Goal:
To maintainfluid and electrolyte balance
INTERVENTIONS
38. 38 | P a g e
Maintainintake and output chart
Assess the following parameters:LAP, BP, CVP, PAWP,
weight, electrolyte levels, hematocrit, JVP, tissue turgor,
breath sounds, urinary output etc.
Measure post operative chest drainage
Be alert to serum electrolyte levels
NURSINGDIAGNOSIS
Painrelated to operative trauma and pleuralirritation
caused by chest tubes
Goal:
To relieve pain
INTERVENTION
Record nature, type, locationand duration
Providing comfortable position
Assist patient to differentiatebetweensurgicaland angina
pain Administerprescribed painmedication
Encourage relaxationtechniques
PAIN MEDICATION
NURSINGDIAGNOSIS
Risk for alterationin renal perfusionrelated to decreased
cardiac output, hemolysis, or vasopressor therapy
Goal:
To maintainadequaterenalperfusion
INTERVENTION
Measure urine output strictly
Monitor renal functiontests
Report to physicianifurine output less
Administer medicationsasprescribed
NURSINGDIAGNOSIS
39. 39 | P a g e
Risk for hypothermia/hyperthermiarelated to
cardiopulmonarybypasssurgery, infectionsetc.
Goal:
To maintainnormalbody temperature
INTERVENTIONS
Warm the patient gradually with warmair or warm
blanketsor heat lamps
Assess for dysrhythmiasdue tohypothermia
Assess for elevated body temperature
Assess for infection( lungs, urinary tract, incisionsand
intravascular catheter
Use the aseptic technique while dressing and other
procedure
Using proper hand washing technique Meticulouscare tobe
takento prevent contaminationat the sites of catheterand
tube insertion
CARE OF THE GRAFT DONOR SITE RADIAL ARTERY
CARE OF CHEST TUBE
NURSINGDIAGNOSIS
Risk for sensory- perceptualalterationsrelated tosensory
overload
Goal:
to prevent postcardiotomysyndrome
INTERVENTIONS
Explainall proceduresto patient
Plan nursing care to provide for periodsof uninterrupted
sleep with day-night pattern
Decrease sleep preventing environmentalstimuli asmuch
as possible
Promote continuityofcare from nurse to nurse
40. 40 | P a g e
Orient the patient totime, place and person.
Encourage the family to visit at regular times
Teach relaxationand divisionaltechniques
Observe for signs of pericardiotomy syndrome
NURSINGDIAGNOSIS
Knowledge deficit about self-care activities
Goal:
to help the patient in the performance of self-care activities
INTERVENTIONS
Develop teaching planfor patient and family specifically
about:
Diet
Activity progression
Exercise
Deep breathing, coughing exercises
Medicationregimenand Follow up
52. 52 | P a g e
Reference
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a-human-heart
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