Rescue Pulsed-Field Ablation of Pro-Arrhythmic Multifocal Atrial Tachycardia Following Failed Conventional Ablation, A Case Report

Rescue Pulsed-Field Ablation of Pro-Arrhythmic Multifocal Atrial Tachycardia Following Failed Conventional Ablation, A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rescue Pulsed-Field Ablation of Pro-Arrhythmic Multifocal Atrial Tachycardia Following Failed Conventional Ablation, A Case Report Tudi Li, Yeji Zhuo, Jiaying Zhang, Rong Chen, Yanqun Zhao, Zhihuan Zeng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8318826/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Radiofrequency ablation of right atrial appendage tachycardias remains challenging due to anatomical constraints. We present a novel case where prior ablation led to pro-arrhythmic recurrence as multifocal atrial tachycardia, successfully rescued with pulsed-field ablation. Case Presentation: A 76-year-old woman presented with incessant multifocal atrial tachycardia two months after initially successful radiofrequency ablation for focal right atrial appendage tachycardia. Repeat electro anatomical mapping revealed earliest activation along the medial free wall of the appendage. Given the complex substrate and prior ablation failure, pulsed-field ablation was employed. The arrhythmia terminated after 2applications, though frequent premature complexes persisted from the posterior free wall. Additional pulsed-field ablation applications successfully eliminated all ectopic activity. No arrhythmias were inducible post-procedure, and the patient remained arrhythmia-free at 3-month follow-up. Conclusion: Conventional right atrial appendage ablation may rarely create pro-arrhythmic substrate manifesting as multifocal tachycardia. Pulsed-field ablation, with its ability to deliver broad, deep lesions safely, represents an ideal rescue therapy for such complex recurrences. This case expands the clinical application of pulsed-field ablation beyond straightforward cases to include management of iatrogenic arrhythmias in high-risk anatomical locations. Pulsed-field ablation Multifocal atrial tachycardia Right atrial appendage Pro-arrhythmic Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Focal atrial tachycardias originating from the right atrial appendage present significant challenges for conventional radiofrequency ablation due to the structure's thin walls, complex trabeculations, and difficulty achieving stable catheter contact. We present a novel case demonstrating how pulsed-field ablation can successfully rescue a pro-arrhythmic recurrence following initially successful conventional ablation. Case Presentation A 76-year-old woman with no significant cardiac history initially presented with symptomatic atrial premature complexes and paroxysmal atrial tachycardia(Figure 1 A, 1 B). The initial procedure successfully identified and ablated a focal source at the right atrial appendage using conventional radiofrequency energy (Fig. 1 C), with acute termination of the tachycardia and non-inducibility post-procedure. Two months later, she returned with incessant palpitations. Holter monitoring demonstrated a chaotic atrial rhythm with varying P-wave morphologies consistent with multifocal atrial tachycardia. Repeat electrophysiological study was performed using a high-density mapping system (Advisor™ HD Grid Mapping Catheter, Abbott). Activation mapping revealed the earliest activation site along the medial free wall of the RAA, occurring 104ms ahead of the reference signal (Figs. 2 A, 2 B, 2 C). Given the failure of prior radiofrequency ablation and the complex nature of the recurrence, we opted for pulsed-field ablation (PFA) (Farapulse® system, Boston Scientific). Under fluoroscopic guidance, a 31-mm Farawave® catheter was advanced into the RAA. Deployed in a "flower" configuration to maximize tissue contact, the catheter delivered two applications (1.8 kV × 2.5 s) (Fig. 3 ), resulting in termination of the clinical tachycardia. However, frequent premature atrial complexes persisted, characterized by negative deflections in inferior leads and V1, with the earliest activation now mapped to the posterior free wall of the right atrium. Four additional PFA applications at this site (1.8 kV × 2.5 s; two flower, two basket configurations) successfully eliminated all residual ectopic activity. Post-ablation, neither tachycardia nor premature complexes were inducible with aggressive atrial stimulation (Fig. 4 ). The procedure was completed without complications, and the patient was discharged the following day. At 3-month follow-up, she remained asymptomatic with no arrhythmia recurrence on 24-hour Holter monitoring. Technical Considerations This case underscores several unique advantages of PFA in managing recurrent RAA tachycardias: Broad Lesion Footprint: The 31-mm PFA catheter, used in multiple configurations, allowed efficient coverage of a wide arrhythmogenic area that would otherwise necessitate extensive point-by-point RFA. Deep Non-Thermal Lesions: PFA achieves deep, transmural lesions via a non-thermal mechanism, crucial in regions such as the RAA where thick pectinate muscles or convective cooling may limit the efficacy of RFA. Safety Profile: The tissue selectivity and non-thermal nature of PFA may reduce the risk of perforation in thin-walled structures like the RAA-a major concern during redo procedures. Procedural Efficiency: The short duration of each energy application (~ 2.5 s) and the rapid arrhythmia termination demonstrate the high efficiency of PFA for focal substrates. Conclusion Focal ATs originating from the RAA apex present a significant clinical challenge due to their often refractory nature to catheter ablation and potential to induce cardiomyopathy 1 . Furthermore, conventional RFA may in some cases create a pro-arrhythmic substrate leading to more complex arrhythmias such as multifocal atrial tachycardia. Although prior reports have established the feasibility of PFA for RAA AT in younger patients with straightforward anatomy 2 , this case provides critical evidence supporting its utility in more complex scenarios—specifically, as a rescue therapy after pro-arrhythmic recurrence. PFA, with its capacity to deliver broad, deep, and contiguous lesions safely, represents a promising therapeutic option for arrhythmias originating from challenging anatomical locations such as the RAA. Declarations Consent for publication: Written informed consent was obtained from the patient for publication of this case report and accompanying images. Funding: a. Medical Research Fund of Guangdong Province in 2024, B2024095 b. The 2024 College-level Educational Teaching Research and Reform Project, 2024JX09 c. 2025 Continuing Education High-Quality Development Construction Project of Guangdong Pharmaceutical University, 13 d. Guangzhou Municipal Science and Technology Project, 2025A03J3718 Author Contribution TDL, ZHZ and YQZ performed the PFA procedure on the patient. TDL wrote the main manuscript text. YJZ, JYZ and RC prepared figures. All authors reviewed the manuscript. References Nishizaki K, Itoh T, Kimura M, Tomita H (2022) Contrast injection into the right atrial appendage apex using an external irrigation catheter for focal atrial tachycardia ablation. J Arrhythm 38:157–159. 10.1002/joa3.12664 Urbanek L et al First pulse field ablation of an incessant atrial tachycardia from the right atrial appendage. (2022)J Interv Card Electrophysiol 65, 577–578, 10.1007/s10840-022-01345-3 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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10:22:48","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24666,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/ef5d98d949b8f9caf74512a0.html"},{"id":98767526,"identity":"059a7c63-77e9-47c7-a8d8-fa5b9ddc0289","added_by":"auto","created_at":"2025-12-22 10:22:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":459116,"visible":true,"origin":"","legend":"\u003cp\u003eA ECG showing multifocal atrial premature complexes, with negative p waves in the inferior leads.\u003c/p\u003e\n\u003cp\u003eB Intracardiac ECG showing multifocal atrial premature complexes arising from right atrium.\u003c/p\u003e\n\u003cp\u003eC Activation map showing early activation (red) at right atrial appendage.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/cb3fdd034641465f6f505b80.png"},{"id":98767527,"identity":"4d3e486b-1605-4802-8907-bca2a2e24ddf","added_by":"auto","created_at":"2025-12-22 10:22:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":582871,"visible":true,"origin":"","legend":"\u003cp\u003eA ECG showing atrial tachycardia（AT）, with negative p waves in the inferior leads.\u003c/p\u003e\n\u003cp\u003eB Intracardiac ECG showing AT arising from right atrium.\u003c/p\u003e\n\u003cp\u003eC Activation map showing early activation (red) at RAA, the same as before. And the earliest activation site to be localized to the lateral aspect of the RAA, preceding the reference electrogram by 104ms.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/bcac1340a71ccf27b03dda9d.png"},{"id":98779987,"identity":"0fd32334-c36d-4b37-947d-708efd473c9f","added_by":"auto","created_at":"2025-12-22 12:30:58","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":197281,"visible":true,"origin":"","legend":"\u003cp\u003eAfter PFA, no further AT or ectopy was induced.\u003c/p\u003e","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/d91478a60c51c0238ab421e7.jpeg"},{"id":98767531,"identity":"3b0b2399-b3be-4edf-a5a6-9028ce4820e1","added_by":"auto","created_at":"2025-12-22 10:22:48","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":760802,"visible":true,"origin":"","legend":"\u003cp\u003eThe catheter delivered two applications (1.8 kV ×2.5 s), resulting in termination of the clinical tachycardia.\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/6fee5e41bef4a1b5ed1ef027.jpeg"},{"id":105563933,"identity":"3b15e8ab-6631-4cea-942e-ba4bd18b7da2","added_by":"auto","created_at":"2026-03-27 12:48:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2278280,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8318826/v1/e03ac8f0-fdae-4032-949c-82f7e565dd06.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rescue Pulsed-Field Ablation of Pro-Arrhythmic Multifocal Atrial Tachycardia Following Failed Conventional Ablation, A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFocal atrial tachycardias originating from the right atrial appendage present significant challenges for conventional radiofrequency ablation due to the structure's thin walls, complex trabeculations, and difficulty achieving stable catheter contact. We present a novel case demonstrating how pulsed-field ablation can successfully rescue a pro-arrhythmic recurrence following initially successful conventional ablation.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 76-year-old woman with no significant cardiac history initially presented with symptomatic atrial premature complexes and paroxysmal atrial tachycardia(Figure\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The initial procedure successfully identified and ablated a focal source at the right atrial appendage using conventional radiofrequency energy (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eC), with acute termination of the tachycardia and non-inducibility post-procedure.\u003c/p\u003e\u003cp\u003eTwo months later, she returned with incessant palpitations. Holter monitoring demonstrated a chaotic atrial rhythm with varying P-wave morphologies consistent with multifocal atrial tachycardia. Repeat electrophysiological study was performed using a high-density mapping system (Advisor™ HD Grid Mapping Catheter, Abbott). Activation mapping revealed the earliest activation site along the medial free wall of the RAA, occurring 104ms ahead of the reference signal (Figs.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e\u003cp\u003eGiven the failure of prior radiofrequency ablation and the complex nature of the recurrence, we opted for pulsed-field ablation (PFA) (Farapulse® system, Boston Scientific). Under fluoroscopic guidance, a 31-mm Farawave® catheter was advanced into the RAA. Deployed in a \"flower\" configuration to maximize tissue contact, the catheter delivered two applications (1.8 kV × 2.5 s) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003e), resulting in termination of the clinical tachycardia.\u003c/p\u003e\u003cp\u003eHowever, frequent premature atrial complexes persisted, characterized by negative deflections in inferior leads and V1, with the earliest activation now mapped to the posterior free wall of the right atrium. Four additional PFA applications at this site (1.8 kV × 2.5 s; two flower, two basket configurations) successfully eliminated all residual ectopic activity. Post-ablation, neither tachycardia nor premature complexes were inducible with aggressive atrial stimulation (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe procedure was completed without complications, and the patient was discharged the following day. At 3-month follow-up, she remained asymptomatic with no arrhythmia recurrence on 24-hour Holter monitoring.\u003c/p\u003e\u003cp\u003eTechnical Considerations\u003c/p\u003e\u003cp\u003eThis case underscores several unique advantages of PFA in managing recurrent RAA tachycardias:\u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBroad Lesion Footprint: The 31-mm PFA catheter, used in multiple configurations, allowed efficient coverage of a wide arrhythmogenic area that would otherwise necessitate extensive point-by-point RFA.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDeep Non-Thermal Lesions: PFA achieves deep, transmural lesions via a non-thermal mechanism, crucial in regions such as the RAA where thick pectinate muscles or convective cooling may limit the efficacy of RFA.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSafety Profile: The tissue selectivity and non-thermal nature of PFA may reduce the risk of perforation in thin-walled structures like the RAA-a major concern during redo procedures.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProcedural Efficiency: The short duration of each energy application (~ 2.5 s) and the rapid arrhythmia termination demonstrate the high efficiency of PFA for focal substrates.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFocal ATs originating from the RAA apex present a significant clinical challenge due to their often refractory nature to catheter ablation and potential to induce cardiomyopathy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Furthermore, conventional RFA may in some cases create a pro-arrhythmic substrate leading to more complex arrhythmias such as multifocal atrial tachycardia. Although prior reports have established the feasibility of PFA for RAA AT in younger patients with straightforward anatomy\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, this case provides critical evidence supporting its utility in more complex scenarios\u0026mdash;specifically, as a rescue therapy after pro-arrhythmic recurrence. PFA, with its capacity to deliver broad, deep, and contiguous lesions safely, represents a promising therapeutic option for arrhythmias originating from challenging anatomical locations such as the RAA.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConsent for publication:\u003c/h2\u003e \u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003ea. Medical Research Fund of Guangdong Province in 2024, B2024095\u003c/p\u003e \u003cp\u003eb. The 2024 College-level Educational Teaching Research and Reform Project, 2024JX09\u003c/p\u003e \u003cp\u003ec. 2025 Continuing Education High-Quality Development Construction Project of Guangdong Pharmaceutical University, 13\u003c/p\u003e \u003cp\u003ed. Guangzhou Municipal Science and Technology Project, 2025A03J3718\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTDL, ZHZ and YQZ performed the PFA procedure on the patient. TDL wrote the main manuscript text. YJZ, JYZ and RC prepared figures. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNishizaki K, Itoh T, Kimura M, Tomita H (2022) Contrast injection into the right atrial appendage apex using an external irrigation catheter for focal atrial tachycardia ablation. J Arrhythm 38:157\u0026ndash;159. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/joa3.12664\u003c/span\u003e\u003cspan address=\"10.1002/joa3.12664\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrbanek L et al First pulse field ablation of an incessant atrial tachycardia from the right atrial appendage. (2022)J Interv Card Electrophysiol 65, 577\u0026ndash;578, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10840-022-01345-3\u003c/span\u003e\u003cspan address=\"10.1007/s10840-022-01345-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pulsed-field ablation, Multifocal atrial tachycardia, Right atrial appendage, Pro-arrhythmic, Case report","lastPublishedDoi":"10.21203/rs.3.rs-8318826/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8318826/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Radiofrequency ablation of right atrial appendage tachycardias remains challenging due to anatomical constraints. We present a novel case where prior ablation led to pro-arrhythmic recurrence as multifocal atrial tachycardia, successfully rescued with pulsed-field ablation.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 76-year-old woman presented with incessant multifocal atrial tachycardia two months after initially successful radiofrequency ablation for focal right atrial appendage tachycardia. Repeat electro anatomical mapping revealed earliest activation along the medial free wall of the appendage. Given the complex substrate and prior ablation failure, pulsed-field ablation was employed. The arrhythmia terminated after 2applications, though frequent premature complexes persisted from the posterior free wall. Additional pulsed-field ablation applications successfully eliminated all ectopic activity. No arrhythmias were inducible post-procedure, and the patient remained arrhythmia-free at 3-month follow-up.\u003c/p\u003e\n\u003cp\u003eConclusion: Conventional right atrial appendage ablation may rarely create pro-arrhythmic substrate manifesting as multifocal tachycardia. Pulsed-field ablation, with its ability to deliver broad, deep lesions safely, represents an ideal rescue therapy for such complex recurrences. This case expands the clinical application of pulsed-field ablation beyond straightforward cases to include management of iatrogenic arrhythmias in high-risk anatomical locations.\u003c/p\u003e","manuscriptTitle":"Rescue Pulsed-Field Ablation of Pro-Arrhythmic Multifocal Atrial Tachycardia Following Failed Conventional Ablation, A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:22:40","doi":"10.21203/rs.3.rs-8318826/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20e90182-954f-4d87-8030-6d0a99f0a1d1","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T22:54:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 10:22:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8318826","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8318826","identity":"rs-8318826","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}