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PROUDLY HOSTED BY

ISSN: 1883-2148

19-22 NOVEMBER 2015 |

| Abstract Book | Abstract Book

THE VOLUME OF LEFT ATRIUM MEASURED BY MULTI-

DETECTOR COMPUTED TOMOGRAPHY CAN PREDICT

OF LONG TERM OUTCOME IN CATHETER ABLATION OF

ATRIAL FIBRILLATION

Yoo Ri Kim, Jong Pil Yun, Jung Hae Kwon, Jun Kim, Gi-Byoung Nam, Kee- Joon Choi and You-Ho Kim. Incheon St. Mary's Hospital, Incheon, Korea, Republic of, Asan Medical Center, Seoul, Korea, Republic of None. None. None. None. None. None. None. This study will identify the left atrium (LA) and left atrial appendage (LAA) volumes calculated by multidetector computed tomography (MDCT) is related to the long term out come of radiofrequency We analyzed data from 99 consecutive patients who referred for RFCA of drug-refractory symptomatic AF (age 56±10 years; 74% men; 64% paroxysmal AF[PAF]). Prior to the procedure, all patients underwent ECG- gated 128 channels MDCT scan for assessment for PV anatomy, LA and LAA volume estimation, and electro-anatomical mapping intergration. The volume of LA and LAA were 142.6±32.2 mL and 14.7±6.0 mL, respectively. LA volume was smaller in PAF than persistent AF(PeAF) (133.9±29.3mL vs. 158.0±31.4mL, p<0.0001) but LAA volume was not group 1 (LA volume < 160mL,n=73) and group 2 (LA volume

160mL,

n=26). After a mean follow up 12.6 ± 5.3 months, 78.8% of the patients maintained sinus rhythm after the index ablation. AF free survival was No relationship was found between LAA volume and the outcome of RFCA. Multivariate analysis showed that the LA volume >160mL was an independent predictor of arrhythmia-free after ablation (Hazard ration Higher LA volume is independent risk factor for AF recurrence after RFCA but not LAA volume. The LA volume quickly assessed by MDCT could be a good predictor of long term recurrence after AF abltion.

THE IMPACT OF NONPAROXYSMAL ATRIAL FIBRILLATION

ON STROKE, BLEEDING AND DEATH: A SYSTEMATIC

REVIEW AND META-ANALYSIS

Anand Ganesan, Derek Chew, Trent Hartshorne, Joseph Selvanayagam, Prashanthan Sanders and Andrew McGavigan. Flinders Medical Centre, Bedford Park, Australia, University of Adelaide, Adelaide, Australia None. None. None. None. None. None. a systematic review and meta-analysis evaluating the impact of AF type on thromboembolism, bleeding and mortality.

Pubmed was searched through November 27 2014 for

randomized controlled trials, cohort studies, and case series reporting incidence of thromboembolism, mortality and bleeding was extracted. AF clinical outcome data was extracted from 12 studies containing 99,996 patients. The pooled unadjusted risk ratio (RR) for thromboembolism in NPAF vs. PAF was RR 1.369 (95% CI: 1.140-1.644, P<0.001). In studies providing estimates of thromboembolism risk adjusted for baseline clinical risk factors, the pooled adjusted hazard ratio (HR) in NPAF vs. PAF was HR 1.384 (95% CI, 1.191-1.608, P<0.001). The pooled unadjusted risk ratio for all-cause mortality in NPAF vs. PAF was RR 1.462 (95% CI: 1.255-1.703 P<0.001). The pooled adjusted HR for all-cause mortality in NPAF vs. PAF was HR 1.217 (95% CI: 1.085-1.365, P<0.001. Rates of bleeding in NPAF and PAF were similar, unadjusted RR

1.00 (95% CI 0.919-1.087, P=0.994), pooled adjusted HR 1.025 (95% CI:

0.898-1.170, P=0.715).

These data suggest a need for re-evaluation of the paradigm of thromboembolic risk equivalence between PAF and NPAF, and emphasize AF type as a powerful predictor of AF-related morbidity and mortality. Future studies exploring integration of AF type into thromboembolic risk models are needed.

Oral abstracts

ABSTRACT SESSION 1

| Abstract Book Young-Ah Park, Tae-Hoon Kim, Jae-Sun Uhm, Jong-yun Kim, Boyoung Joung, Moon-Hyoung Lee and Hui-Nam Pak. Yonsei University, Severance

Hospital, Seoul, Korea, Republic of

None. None. None. None. None. None. None. Although it has been vaguely considered that linear ablation gap or low atrial critical mass are related to atrial tachycardia (AT) recurrence after radiofrequency catheter ablation (RFCA) for atrial of this study is to discriminate the clinical factors associated with AT recurrence compared with recurrence as AF after RFCA. Among 1425 patients who underwent AF ablation, we included

283 patients (72% male, 58±11 years old, 62% paroxysmal AF) who showed

electrocardiogram (ECG)-documented clinical recurrence 3 months after RFCA. We excluded all the patients who were taking antiarrhythmic drug pulmonary vein isolation (CPVI) only group (n=127) and PVI with additional linear ablation (CPVI+Line) group (n=156), and clinical, imaging parameters, and the number of linear lesions were determined.

1. The timing of clinical recurrence was 13±9 months after RFCA,

and 37.5% (36/96) recurred as AT. The proportion of AT recurrence was

29.1% (37/127) in CPVI only group and 33.3% (52/156) in CPVI+Line group

(p=0.520).

2. Patients with AT recurrence were more likely to have smaller left atrial

(LA) volume index measured by CT (LAVI; 70.4±22.1 vs 82.2±27.3cm3, p=0.002) and left ventricular mass index (LVMI; 88.0±19.1 vs 95.1±23.4g/ m2, p=0.026), and higher LA voltage (1.23±0.61 vs 0.98±0.57mV, p=0.008) than patients with AF recurrence. In logistic regression analysis, Anterior LAVI (OR 0.97, 95% CI 0.94~1.00, p=0.048) and LA voltage during procedure (OR 2.85, 95% CI 1.25~6.51, p=0.013) were independently associated with AT recurrence. However, the presence or the number of linear ablation line was not associated with AT recurrence (1.73±1.73 vs 1.51±1.62, p=0.299).

3. In subgroup analysis, there was no predictor for AT recurrence in CPVI

only group, whereas LAVI (OR 0.97, 95% CI 0.95~1.00, p=0.036) and LA voltage during procedure (OR 5.77, 95% CI 1.80~18.45, p=0.003) were associated with AT recurrence in CPVI+Line group. AT recurrence after AF ablation was more likely to be associated with less remodeled LA and higher LA voltage, rather than the number of linear ablation lesion. Melissa Middeldorp, Rajeev Pathak, Megan Meredith, Abhinav Mehta, Rajiv Mahajan, Adrian Elliott, Dennis Lau and Prashanthan Sanders. University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia, Australian National University, Canberra, Australia None. None. None. None. None. None. None.

A - Consulting Fees/Honoraria;

Medtronic, Biosense-Webster, St Jude

Medical. I - Research Grants;

Sorin, Biotronik. I - Research Grants;

Atrial Fibrillation (AF) is a progressive disease. The LEGACY study demonstrated a dose-response effect on AF of weight reduction. In the current study, we aim to look at the impact of weight loss on the progression of the AF disease.

Of 1415 consecutive patients with AF, 825 had BMI

27 kg/

m2 and were offered weight management. After screening for exclusion criteria, 355 were included in this analysis. Weight-loss was categorized as: Group-1 (>10%); Group-2 (3-9%); and Group-3 (<3%). Change in AF type was determined by clinic review and 7-day Holter monitoring at 12 monthly intervals. AF type was categorized as per HRS consensus. There were no differences in baseline characteristic or follow (86%) in Group 1 were free from AF (40% without ablation, 37%: 1 ablation & 23%: multiple ablation); 69 patients (67%) in Group 2 were free from AF (37% without ablation, 36%: 1 ablation & 27%: multiple ablation); and 45 patients (39%) in Group 3 were free from AF (11% without ablation, 36%:

1 ablation & 53%: multiple ablation). The table shows the change in AF

disease state in each of the groups. There was no difference in number of patients requiring AV node ablation or pacemaker implantation between the 3 groups (p=NS). burden and improved maintenance of sinus rhythm. This study shows that weight loss and risk factor management can reverse disease progression, underscoring its pivotal role to treat and prevent the growing epidemic of AF. Clinical Trial Registration: ACTRN12614001123639. | Abstract Book

PREDICTORS ASSOCIATED WITH ATRIAL FIBRILLATION

RECURRENCE 2-YEARS AFTER RADIOFREQUENCY

CATHETER ABLATION

Yong-Soo Baek, Tae-Hoon Kim, Jae-Sun Uhm, Jong-Youn Kim, Boyoung Joung, Moon-Hyoung Lee and Hui-Nam Pak. Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea, Republic of None. None. None. None. None. None. None. late delayed recurrence of AF after catheter ablation is technical issue or AF progression is uncertain. Therefore, we sought predictors for very late clinical of AF 2-years after radiofrequency catheter ablation. Among 1394 patients who underwent AF catheter ablation, we included 433 patients who had experienced AF recurrence (mean age

57 ± 10 years, 114 (26.3%) female, 57.6% paroxysmal AF) 3 months after

ablation procedure. We divided them into two groups according to the timing of initial AF recurrence: the clinical recurrence (CR) group (AF recurrence at 3~24 months after ablation) and the very late CR group (AF recurrence >24 months after ablation), and compared clinical and imaging parameters, 3- and 12-month follow-up heart rate variability (HRV), and pre-ablation polysomnogram (PSG).

1. During 38±17 months follow-up, 346 (79.9%) patients recurred

AF within 24 months (CR group) and 87 (20.0%) patients recurred

2-years after procedure (very late CR group). Very late CR group included

higher proportions of obesity (BMI>25Kg/m2, 58.6% vs. 41.6%, p=0.009), hypertension (74.6% vs. 63.5%, p8mg/L (9.2% vs. 3.8%, p=0.035) and metabolic syndrome score (2.17±0.98 vs. 1.80±1.07, p=0.007) than those in PSG (87.9 ± 3.9% vs. 85.4 ± 5.5%, p=0.019), whereas there were no groups. 3. In a multivariate analysis, obesity (OR=1.819, 95% CI: 1.119-

2.955, p=0.016), dyslipidemia (OR=1.677, 95% CI: 1.028-2.737, P=0.038)

or metabolic syndrome score (OR=1.466, 95% CI: 1.136-1.891, P=0.003) were independently associated with very late CR 2-years of catheter ablation for AF. Our data suggests that overweight/obesity, dyslipidemia and metabolic syndrome score are independent predictors of very late CR 2-years after catheter ablation of AF. Very late CR is more likely to be affected by metabolic factors related, suggesting contribution of AF progression.

COMPREHENSIVE ANALYSIS IDENTIFIES COMMON

MICRORNA INVOLVED IN DIFFERENT MURINE MODELS OF

ATRIAL FIBRILLATION AND CLINICAL SAMPLES

Tetsuo Sasano, Kentaro Takahashi, Kensuke Ihara, Koji Sugiyama, Kenzo Hirao and Tetsushi Furukawa. Tokyo Medical and Dental University, Tokyo, Japan, Tokyo Medical and Dental University, Medical Research Institute,

Tokyo, Japan

None. None. None. None. None. None. Epidemiologic studies revealed hypertension, heart failure, diabetes mellitus, and metabolic syndrome were the risk factor for enhanced atrial structural remodeling. However, the mechanism linking atrial remodeling and these risk factors has not been fully elucidated. Recent studies showed that microRNA plays pleiotropic actions in many pathological conditions. We studied the progression of atrial remodeling and arrhythmogenicity in 3 pathological models relating AF, focusing on the involvement of microRNA. We produced three murine models: pressure overload by transverse aortic constriction (TAC), diabetes mellitus (DM) by injection of Streptozocin, and obesity by high fat diet (HFD). Eight weeks after each procedure, mice were evaluated by histology, quantitative RT-PCR for mRNA, and electrophysiological study (EPS). We also screened the atrial expression of 754 microRNAs utilizing microRNA array card. In clinical settings, we collected serum from 6 persistent AF patients, 6 paroxysmal AF patients, and 7 healthy controls. We also performed comprehensive analysis for circulating microRNA using same system. revealed inducibility of atrial tachycardia was 67% in TAC, 22% in DM, decreased microRNAs in TAC model, 11 and 37 in DM model, and 24 and

6 in HFD model. Three microRNAs among them were overlapped in all 3

models (2 up-regulated and 1 down-regulated). These commonly changed stress. In clinical samples, we found 2 up-regulated and 28 down- regulated microRNAs in persistent AF patients. We found 1 microRNA was overlapped among 3 murine models and clinical analysis. In comprehensive analysis, we found common microRNA involved in three pathological murine models relating AF and serum from AF patients. The commonly involved microRNA may play a pivotal role in atrial remodeling, and may be critical target for novel treatment strategy. | Abstract Book

DISEASE MODELING OF ANDERSEN-TAWIL SYNDROME

USING PATIENT-SPECIFIC IPS CELLS

Yusuke Kuroda, Shinsuke Yuasa, Yasuhide Watanabe, Tetsuhisa Hattori, Kaichiro Kamiya and Keiich Fukuda. Chutoen General Medical Center, Kakegawa, Japan, Keio University School of Medicine, Tokyo, Japan, Hamamatsu University School of Medicine, Hamamatsu, Japan, Shiga University of Medical Science, Otsu, Japan, Research Institute of Environmental Medicine,Nagoya University, Nagoya, Japan, Keio

University school of Medicine, Tokyo, Japan

None. None. None. None. None. None.

Andersen-Tawil syndrome (ATS) is a rare inherited

channelopathy characterized by periodic paralysis, dysmorphic feature and ventricular arrhythmia. Cardiac phenotype is characterized as prominent U wave and ventricular arrhythmia, and the effective treatment for this disease remain unestablished.The aim of this study is to establish to investigate cardiac disease mechanisms that remain incompletely understood. We reprogrammed somatic cells from three ATS patients carrying the KCNJ2 mutations (R218W, R218Q, R67W) to generate iPSCs. Multi-electrode arrays could record extracellular electrograms of iPSC- derived cardiomyocytes. Ca2+ imaging of iPSC-derived cardiomyocytes loaded with the Ca2+ indicator Fluo-4 showed intracellular Ca2+ handling measure NCX current of isolated guinea-pig cardiac ventricular myocytes ATS-iPSC-derived cardiomyocytes highly exhibited irregular higher in the ATS-iPSC-derived cardiomyocytes compared with that that intracellular calcium overload and triggered activity can be the mechanisms for the arrhythmias associated with the ATS. Drug testing using ATS-iPSC-derived cardiomyocytes revealed that these irregular mode Na+/Ca2+exchanger (NCX) inhibitor, KB-R7943 suppressed the has direct effect on NCX current ATS-iPSC-derived cardiomyocytes recapitulate abnormal electrophysiological phenotypes and serve as a useful model for exploring disease mechanisms and drug screening. Takashi Ashihara, Kensuke Sakata, Tomoya Ozawa, Koichi Kato, Takeshi Tsuchiya, Ryo Haraguchi, Shin Inada, Kazuo Nakazawa and Minoru Horie. Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan, EP Expert Doctors-Team Tsuchiya, Kumamoto, Japan, National Cerebral and Cardiovascular Center, Suita, Japan None. None. None. None. None. None. None. None. None. Recently, electrogram-based catheter ablation, targeting areas of complex fractionated atrial electrogram (CFAE), is empirically However, the exact mechanisms of the CFAE in relation to the rotor distribution are not fully understood because existing mapping systems available for clinical use are not able to detect both CFAE and rotors simultaneously. To clarify this issue, we conducted a clinical study to analyze the continuous AF wave dynamics and to compare with the distribution of CFAE recorded simultaneously in 9 patients with non-paroxysmal AF just before and after the pulmonary vein isolation (PVI) by ablation. To quickly map and remap the entire left atrium during AF, we recently developed a real-time phase mapping system called "ExTRa Mapping" based on 41 bipolar signals recorded by a 20-pole spiral-shaped ring catheter. (1) The novel mapping system demonstrated meandering and/or short-lived unstable rotors in all cases. (2) The regions where such rotors frequently observed did not always match with the CFAE regions (rotors were often observed outside the CFAE regions) (Figure). (3) The CFAEs in most parts were associated with wave collisions or complex wave dynamics in the form of multiple wavelets. (4) PVI not only diminished the CFAE regions but also moved the regions of rotors most highly-observed to another positions if the AF sustained after the PVI.

The ExTRa Mapping system uncovered the various

relationships between the rotor distribution and the CFAE distribution. This study gives us important clues for both CFAE ablation and rotor ablation. | Abstract Book

COMBINED USE OF FAST-FOURIER TRANSFORM

ANALYSIS AND VOLTAGE LIMIT ADJUSTMENT TO

DETECT TRUE CRITICAL ISTHMUSES OF VENTRICULAR

TACHYCARDIA CIRCUIT IN POST-MYOCARDIAL

INFARCTION.

Kenji Kuroki, Akihiko nogami, Miyako Igarashi, Yuki Komatsu, Shinya Kowase, Kenji Kurosaki, Eiko Sai, Yasutoshi Shinoda, Chihiro Ota, Fumi Yamagami, Tomoaki Hasegawa, Keita Masuda, Takeshi Machino, Dongzhu Xu, Nobuyuki Murakoshi, Yukio Sekiguchi and Kazutaka Aonuma. University of Tsukuba, Tsukuba, Japan, Yokohama Rosai Hospital,

Yokohama, Japan

None. None. None. None. None. None. None. None. None. None. None. None. None. None. None. None. None. It is known that conducting channels in the circuit of limits of substrate mapping. However, they might include the bystander intramural circuit. Voltage limit adjustment (VLA) and fast-Fourier transform (FFT) analyses of the local ventricular bipolar electrograms were performed during sinus rhythm in 9 postinfarction patients with 12 monomorphic the relative contributions of 40-100 Hz frequencies. The high AR areas between the low AR areas on a 3-dimensional map were regarded as high frequency channels (HFC). We examined the relationship among HFC, relatively high voltage channels (HVC) by VLA, and true VT isthmuses. Eight VT isthmuses were included in 15 HVC, consisting of 9 HVC identical to HFC and 6 HVC not identical to HFC. Seven VT isthmuses were found in the 9 HVC (+)/HFC (+) sites, while only 1 true VT isthmus was found in the 6 HVC (+)/HFC (-) sites. On the other hand, 4 true VT isthmuses were not revealed by VLA. FFT analysis in the low-voltage area could reveal true VT isthmuses in these VTs. Ten HFC were detected, and 6 of the 10 HFC were identical to a constricted pattern (CP) of the low voltage area. Four VT isthmuses were found in the 6 HFC (+)/CP (+) sites, while no VT isthmus were found in the 4 HFC (+)/CP (-) sites. The combined use of FFT analysis and VLA predicted true VT isthmuses with a Combined use of FFT analysis and VLA may be useful to detect true VT isthmuses even in the intramural substrate. | Abstract Book

TARGETING THE ATRIAL SUBSTRATE DUE TO

HYPERTENSION: TRANILAST VERSUS ANTI-

HYPERTENSIVE THERAPIES

Shivshankar Thanigaimani, Anthony Brooks, Pawel Kuklik, Jim Manavis, Timothy Kuchel, Darragh Twomey, Rajiv Mahajan, Prashanthan Sanders and Dennis Lau. University of Adelaide, Adelaide, Australia, South Australian health and medical research institute, Adelaide, Australia

S. Thanigaimani: None.

A. Brooks: None.

P. Kuklik: None.

J. Manavis:

None.

T. Kuchel: None.

D. Twomey: None.

R. Mahajan: None.

P. Sanders:

None.

D. Lau: None.

Hypertension is a major independent risk factor for the effects of Tranilast against blood pressure lowering therapies on the

AF substrate in hypertensive sheep.

: Thirty nine sheep with induced 'one-kidney, one-clip' (1K1C) hypertension was studied: Normotensive controls (n=7); hypertensive controls (n=7) and Tranilast (600mg, orally, BD, n=7) treatment for 12 weeks; remaining sheep were sequentially assigned to treatment with Amlodipine (10mg daily, n=6) or Atenolol (100mg daily, n=6) or clamp removal (n=6) for a further 16 weeks. Open chest epicardial mapping was performed to assess atrial electrophysiological parameters: effective refractory period (ERP), conduction velocity/heterogeneity and AF inducibility. Detailed histological and immunohistochemistry analysis were also performed. All 1K1C animals developed hypertension with mean systolic blood pressure (SBP) of 156±7 mmHg from baseline mean of 114±8 mmHg. Sixteen weeks of Amlodipine, Atenolol and clamp removal treatment reduced SBP to 133±3 mmHg (p<0.001), 131±11 mmHg (p=0.007) and 125±7 mmHg (p<0.001) respectively, while SBP was unchanged in the Tranilast group 162±5 mmHg (p=NS). Atrial ERP improvement in: atrial conduction velocity/heterogeneity (p<0.001); endothelin1, all p<0.001); Connexin 43 expression (p<0.001), interstitial above effects resulted in reduced AF susceptibility in all treatment groups (p<0.05). Despite higher blood pressure levels, preventive atrial remodeling effects of Tranilast are comparable to the reverse remodeling effects of blood pressure lowering therapies both electrically and structurally.

RENAL SYMPATHETIC DENERVATION SUPPRESSES

ATRIAL FIBRILLATION INDUCED BY ACUTE ISCHEMIA/

INFARCTION BY INHIBITING CARDIAC SYMPATHETIC

ACTIVITY

Qina Zhou and Xianhui Zhou. First Teaching Hospital, Xinjiang Medical

University, Urumuqi, China

Q. Zhou: None.

X. Zhou: None.

Whether renal sympathetic denervation(RSD) can reduce induced by acute ischemia/infarction is not known. In this study, we aimed to explore the effects of renal sympathetic denervation(RSD) on atrial acute ischemia/infarction. : Acute ischemia/infarction was created in 12 beagle dogs by ischemia/infarction and left ventricular infarction, occlusion of the right atrial anterior branch and intermediate branch of atrium to induce right atrial ischemia/infarction in addition to sinus node and right ventricular infarction. Six dogs in sham-RSD group did not undergo renal sympathetic denervation. Six dogs without coronary artery ligation served as controls. AF induction rate, sympathetic discharge, catecholamine concentration and densities of tyrosine hydroxylase-positive nerves were measured. The AF induction rate in the RSD group and Sham-RSD group was 95.8% and 90.0%, respectively. Acute ischemia/infarction resulted in sympathetic denervation compared to Sham(P<0.05). The number of to baseline and control(P<0.05). The number of sympathetic discharge compared to control and Sham(P<0.05). Norepinephrine and epinephrine concentration in atria, ventricle and kidney were elevated by ischemia/ infarction, while reduced by renal sympathetic denervation (P<0.05). : Sympathetic hyperactivity and hyperinnervation are associated with pacing-induced AF after acute ischemia/infarction. Renal sympathetic denervation have the potential to reduce the incidence of new-onset AF after acute ischemia/infarction. The inhibition of cardiac sympathetic activity, rather than innervation by renal sympathetic denervation may be one of the major underlying mechanisms on the marked reduction of AF inducibility.

YIA abstracts

| Abstract Book

ACHIEVEMENT OF SUCCESSFUL PULMONARY VEIN

ISOLATION; METHODS OF ADENOSINE TESTING AND

INCREMENTAL BENEFIT OF EXIT BLOCK

Ju Youn Kim, Sung-Hwan Kim, Young Choi, Yeongsu Yi, In Geol Song, Yoo Ri Kim, Tae-Suk Kim, Ji-Hoon Kim, Sung-Won Jang, Man-Young Lee, Tai-Ho Rho and Yong-Seog Oh. Seoul St. Mary's hospital, Seoul, Korea, Republic of, The Catholic University of Korea, Seoul, Korea, Republic of

J. Kim: None.

S. Kim: None.

Y. Choi: None.

Y. Yi: None.

I. Song: None.

Y.

Kim: None.

T. Kim: None.

J. Kim: None.

S. Jang: None.

M. Lee: None.

T.

Rho: None.

Y. Oh: None.

Several approaches were tried to achieve complete

pulmonary vein isolation (PVI). The aims of this study were to: 1) compare adenosine-induced PV conduction and exit conduction, 2) identify the location of incomplete isolation, 3) determine the adequate adenosine dose. A total of 378 consecutive patients who underwent PVI from

318 [84.1%] and a redo procedure in 60 [15.9%]). After the exit block was

assessed, 20 mg adenosine was injected into the left atrium. If dormant conduction was observed, 12 and 6 mg of adenosine were injectedquotesdbs_dbs48.pdfusesText_48

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