57c7482b2a4537575fd4dbed545090dc  335899.pdf
c8d83b261f539ee02c89d92005b51e8411233441  335899.pdf
7f7ce3f382ca70b83978c18eeff50f3a7614a09089c2ccd6e33c6543e2723266  335899.pdf

Title:           Lipomatous metaplasia in cardiac CT: when ‘normal’ extracellular volume does not indicate myocardial viability - a case report
Subject:         DOI: 10.1093/ehjcr/ytaf612; European Heart Journal - Case Reports, 9, 12, 2025-12-01.; Abstract:  Background: Extracellular-volume (ECV) mapping derived from dual-energy cardiac computed tomography (DE-CT) demonstrates potential for informing myocardial-viability assessment. However, intramyocardial lipomatous metaplasia (LM)—a frequent sequel of chronic infarction—contains little or no interstitial space and may therefore normalize ECV values, falsely suggesting viable tissue. Case Summary: A 65-year-old man with chronic total occlusion of the left anterior descending (LAD) artery underwent multimodality imaging to guide revascularisation. Cardiac magnetic resonance (CMR) demonstrated a transmural, thinned scar in the antero-septal apex and sub-endocardial fibrosis in basal–mid anterior segments. DE-CT demonstrated low attenuation in the same territory, whereas ECV mapping revealed normal values in the scarred apex (comparable to non-infarcted myocardium) and mildly elevated ECV in the basal–mid anterior segments with non-transmural scar. The presence of chemical-shift artefacts on cine CMR, along with further attenuation reduction on DE-CT, confirmed intramyocardial fat, explaining the paradoxically low ECV in this region. Ultimately, the integrated assessment of limited viability, extensive scar remodelling, and high-risk procedural features led to the decision to defer revascularization. Discussion: LM can obscure chronic infarcted myocardium on CT-derived ECV maps by abolishing extracellular expansion and generating deceptively normal values. Reliable interpretation mandates correlation with tissue attenuation, mono-energetic reconstructions, or fat-sensitive CMR sequences. DE-CT affords single-acquisition, high-resolution characterization of both ECV and tissue composition, but its quantitative outputs must be contextualized to avoid misclassification of viability. Awareness of this pitfall is essential for accurate decision-making in chronic ischaemic heart 
Keywords:        Dual Energy CT; Cardiac Magnetic Resonance; Multimodal Imaging; Lipomatous Metaplasia; Coronary Artery Disease; Case Report
Author:          Konrad Pieszko
Creator:         Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64
Producer:        PDFlib+PDI 9.0.7p3 (C++/Win64); modified using iTextSharp.LGPLv2.Core 3.7.4.0
CreationDate:    Tue Dec  9 13:55:51 2025 CET
ModDate:         Mon Sep  7 10:55:49 2026 CEST
Custom Metadata: yes
Metadata Stream: yes
Tagged:          yes
UserProperties:  no
Suspects:        no
Form:            none
JavaScript:      no
Pages:           5
Encrypted:       no
Page size:       595.276 x 793.701 pts
Page rot:        0
File size:       685615 bytes
Optimized:       no
PDF version:     1.6


name                                 type              encoding         emb sub uni object ID
------------------------------------ ----------------- ---------------- --- --- --- ---------
VXQSDO+GillSansNova-Book             CID TrueType      Identity-H       yes yes yes     21  0
PYITUA+GillSansNova-Bold             CID TrueType      Identity-H       yes yes yes     20  0
CVJEOI+GillSansNova-BookItalic       CID TrueType      Identity-H       yes yes yes     22  0
XWVHXF+GillSansNova-Heavy            CID TrueType      Identity-H       yes yes yes     29  0
MDTHLN+TimesNewRomanPSMT             CID TrueType      Identity-H       yes yes yes     23  0
EZXNOW+SourceSansPro-Regular         Type 1C           Custom           yes yes yes    344  0
VFGSVI+ArialMT                       TrueType          WinAnsi          yes yes no       1  0
AURERM+STIXGeneral-Regular           Type 1C           Custom           yes yes yes     24  0


Jhove (Rel. 1.28.0, 2023-05-18)
 Date: 2026-09-08 04:12:43 CEST
 RepresentationInformation: 335899.pdf
  ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16)
  LastModified: 2026-09-07 11:01:42 CEST
  Size: 685615
  Format: PDF
  Version: 1.6
  Status: Well-Formed and valid
  SignatureMatches:
   PDF-hul
  MIMEtype: application/pdf
  Profile: Tagged PDF
  PDFMetadata: 
   Objects: 392
   FreeObjects: 1
   IncrementalUpdates: 0
   DocumentCatalog: 
    ViewerPreferences: 
     HideToolbar: false
     HideMenubar: false
     HideWindowUI: false
     FitWindow: false
     CenterWindow: false
     DisplayDocTitle: true
     NonFullScreenPageMode: UseNone
     Direction: L2R
     ViewArea: CropBox
     ViewClip: CropBox
     PrintArea: CropBox
     PageClip: CropBox
    PageLayout: OneColumn
    PageMode: UseOutlines
    Language: en
    Outlines: 
     Item: 
      Title: Lipomatous metaplasia in cardiac CT: when ‘normal’ extracellular volume does not indicate myocardial viability - a case report
      Destination: head1
      Children: 
       Item: 
        Title: Introduction
        Destination: secytaf612-s1
       Item: 
        Title: Summary figure
        Destination: secytaf612-s2
       Item: 
        Title: Case presentation
        Destination: secytaf612-s4
       Item: 
        Title: Discussion
        Destination: secytaf612-s5
       Item: 
        Title: Conclusions
        Destination: secytaf612-s6
       Item: 
        Title: Lead author biography
        Destination: secytaf612-s3
       Item: 
        Title: Supplementary material
        Destination: secytaf612-s7
       Item: 
        Title: Author contributions
        Destination: secytaf612-s8
       Item: 
        Title: Funding
        Destination: secytaf612-s10
       Item: 
        Title: Data availability
        Destination: secytaf612-s11
       Item: 
        Title: References
        Destination: reflist
   Info: 
    Title: Lipomatous metaplasia in cardiac CT: when ‘normal’ extracellular volume does not indicate myocardial viability - a case report
    Author: Konrad Pieszko
    Subject: DOI: 10.1093/ehjcr/ytaf612; European Heart Journal - Case Reports, 9, 12, 2025-12-01.; Abstract:  Background: Extracellular-volume (ECV) mapping derived from dual-energy cardiac computed tomography (DE-CT) demonstrates potential for informing myocardial-viability assessment. However, intramyocardial lipomatous metaplasia (LM) a frequent sequel of chronic infarction contains little or no interstitial space and may therefore normalize ECV values, falsely suggesting viable tissue. Case Summary: A 65-year-old man with chronic total occlusion of the left anterior descending (LAD) artery underwent multimodality imaging to guide revascularisation. Cardiac magnetic resonance (CMR) demonstrated a transmural, thinned scar in the antero-septal apex and sub-endocardial fibrosis in basal mid anterior segments. DE-CT demonstrated low attenuation in the same territory, whereas ECV mapping revealed normal values in the scarred apex (comparable to non-infarcted myocardium) and mildly elevated ECV in the basal mid anterior segments with non-transmural scar. The presence of chemical-shift artefacts on cine CMR, along with further attenuation reduction on DE-CT, confirmed intramyocardial fat, explaining the paradoxically low ECV in this region. Ultimately, the integrated assessment of limited viability, extensive scar remodelling, and high-risk procedural features led to the decision to defer revascularization. Discussion: LM can obscure chronic infarcted myocardium on CT-derived ECV maps by abolishing extracellular expansion and generating deceptively normal values. Reliable interpretation mandates correlation with tissue attenuation, mono-energetic reconstructions, or fat-sensitive CMR sequences. DE-CT affords single-acquisition, high-resolution characterization of both ECV and tissue composition, but its quantitative outputs must be contextualized to avoid misclassification of viability. Awareness of this pitfall is essential for accurate decision-making in chronic ischaemic heart 
    Keywords: Dual Energy CT; Cardiac Magnetic Resonance; Multimodal Imaging; Lipomatous Metaplasia; Coronary Artery Disease; Case Report
    Creator: Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64
    Producer: PDFlib+PDI 9.0.7p3 (C++/Win64); modified using iTextSharp.LGPLv2.Core 3.7.4.0
    CreationDate: Tue Dec 09 14:25:51 CET 2025
    ModDate: Mon Sep 07 10:55:49 CEST 2026
   ID: 0x1dfe293d9a7ea9a57377977d67ef889c, 0x3cfcf7adf48da241d490984d3defdc35
   Filters: 
    FilterPipeline: FlateDecode
    FilterPipeline: DCTDecode
   Images: 
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 1360
      ImageHeight: 730
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 1200
      ImageHeight: 944
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 1032
      ImageHeight: 812
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 860
      ImageHeight: 631
      BitsPerSample: 8
      BitsPerSampleUnit: integer
    Image: 
     NisoImageMetadata: 
      FormatName: image/jpg
      CompressionScheme: JPEG
      ImageWidth: 275
      ImageHeight: 354
      BitsPerSample: 8
      BitsPerSampleUnit: integer
   Fonts: 
    Type0: 
     Font: 
      BaseFont: PYITUA+GillSansNova-Bold
      Encoding: Identity-H
      ToUnicode: true
     Font: 
      BaseFont: VXQSDO+GillSansNova-Book
      Encoding: Identity-H
      ToUnicode: true
     Font: 
      BaseFont: CVJEOI+GillSansNova-BookItalic
      Encoding: Identity-H
      ToUnicode: true
     Font: 
      BaseFont: MDTHLN+TimesNewRomanPSMT
      Encoding: Identity-H
      ToUnicode: true
     Font: 
      BaseFont: XWVHXF+GillSansNova-Heavy
      Encoding: Identity-H
      ToUnicode: true
    Type1: 
     Font: 
      BaseFont: EZXNOW+SourceSansPro-Regular
      FontSubset: true
      FirstChar: 1
      LastChar: 1
      FontDescriptor: 
       FontName: EZXNOW+SourceSansPro-Regular
       Flags: Nonsymbolic
       FontBBox: -192, -323, 1160, 952
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: AURERM+STIXGeneral-Regular
      FontSubset: true
      FirstChar: 1
      LastChar: 3
      FontDescriptor: 
       FontName: AURERM+STIXGeneral-Regular
       Flags: Nonsymbolic
       FontBBox: -995, -455, 2000, 1055
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
    TrueType: 
     Font: 
      BaseFont: VFGSVI+ArialMT
      FontSubset: true
      FirstChar: 32
      LastChar: 121
      FontDescriptor: 
       FontName: VFGSVI+ArialMT
       Flags: Nonsymbolic
       FontBBox: -664, -324, 2000, 1039
       FontFile2: true
      Encoding: WinAnsiEncoding
    CIDFontType2: 
     Font: 
      BaseFont: VXQSDO+GillSansNova-Book
      CIDSystemInfo: 
       Registry: Adobe
       Registry: Identity
       Supplement: 0
      FontDescriptor: 
       FontName: VXQSDO+GillSansNova-Book
       Flags: Nonsymbolic
       FontBBox: -420, -251, 1219, 950
       FontFile2: true
     Font: 
      BaseFont: PYITUA+GillSansNova-Bold
      CIDSystemInfo: 
       Registry: Adobe
       Registry: Identity
       Supplement: 0
      FontDescriptor: 
       FontName: PYITUA+GillSansNova-Bold
       Flags: Nonsymbolic, ForceBold
       FontBBox: -476, -276, 1276, 961
       FontFile2: true
     Font: 
      BaseFont: CVJEOI+GillSansNova-BookItalic
      CIDSystemInfo: 
       Registry: Adobe
       Registry: Identity
       Supplement: 0
      FontDescriptor: 
       FontName: CVJEOI+GillSansNova-BookItalic
       Flags: Nonsymbolic, Italic
       FontBBox: -316, -235, 1219, 950
       FontFile2: true
     Font: 
      BaseFont: XWVHXF+GillSansNova-Heavy
      CIDSystemInfo: 
       Registry: Adobe
       Registry: Identity
       Supplement: 0
      FontDescriptor: 
       FontName: XWVHXF+GillSansNova-Heavy
       Flags: Nonsymbolic, ForceBold
       FontBBox: -504, -287, 1375, 966
       FontFile2: true
     Font: 
      BaseFont: MDTHLN+TimesNewRomanPSMT
      CIDSystemInfo: 
       Registry: Adobe
       Registry: Identity
       Supplement: 0
      FontDescriptor: 
       FontName: MDTHLN+TimesNewRomanPSMT
       Flags: Nonsymbolic
       FontBBox: -568, -307, 2046, 1040
       FontFile2: true
   XMP: <x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="Adobe XMP Core 5.4-c006 80.159825, 2016/09/16-03:31:08        ">
   <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#">
      <rdf:Description rdf:about="" xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/" xmlns:xmpRights="http://ns.adobe.com/xap/1.0/rights/" xmlns:pdf="http://ns.adobe.com/pdf/1.3/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:prism="http://prismstandard.org/namespaces/basic/2.0/" xmlns:xmp="http://ns.adobe.com/xap/1.0/" xmlns:pdfx="http://ns.adobe.com/pdfx/1.3/" xmlns:pdfuaid="http://www.aiim.org/pdfua/ns/id/" xmlns:pdfaExtension="http://www.aiim.org/pdfa/ns/extension/" xmlns:pdfaSchema="http://www.aiim.org/pdfa/ns/schema#" xmlns:pdfaProperty="http://www.aiim.org/pdfa/ns/property#">
         <xmpMM:InstanceID>uuid:8eaa174d-be76-4c50-b17b-c86543ce760c</xmpMM:InstanceID>
         <xmpMM:DocumentID>uuid:F827FB1A-6748-23A3-CE67-467B129BF222</xmpMM:DocumentID>
         <xmpRights:Marked>True</xmpRights:Marked>
         <pdf:Keywords>Dual Energy CT; Cardiac Magnetic Resonance; Multimodal Imaging; Lipomatous Metaplasia; Coronary Artery Disease; Case Report</pdf:Keywords>
         <pdf:Producer>PDFlib+PDI 9.0.7p3 (C++/Win64); modified using iTextSharp.LGPLv2.Core 3.7.4.0</pdf:Producer>
         <dc:format>application/pdf</dc:format>
         <dc:identifier>10.1093/ehjcr/ytaf612</dc:identifier>
         <dc:lang>en</dc:lang>
         <dc:publisher>
            <rdf:Bag>
               <rdf:li>Oxford University Press</rdf:li>
            </rdf:Bag>
         </dc:publisher>
         <dc:title>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Lipomatous metaplasia in cardiac CT: when ‘normal’ extracellular volume does not indicate myocardial viability - a case report</rdf:li>
            </rdf:Alt>
         </dc:title>
         <dc:creator>
            <rdf:Seq>
               <rdf:li>Konrad Pieszko</rdf:li>
               <rdf:li>Clara Rodríguez González</rdf:li>
               <rdf:li>Rubén Leta Petracca</rdf:li>
               <rdf:li>David Viladés Medel</rdf:li>
            </rdf:Seq>
         </dc:creator>
         <dc:description>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">DOI: 10.1093/ehjcr/ytaf612; European Heart Journal - Case Reports, 9, 12, 2025-12-01.; Abstract:  Background: Extracellular-volume (ECV) mapping derived from dual-energy cardiac computed tomography (DE-CT) demonstrates potential for informing myocardial-viability assessment. However, intramyocardial lipomatous metaplasia (LM)—a frequent sequel of chronic infarction—contains little or no interstitial space and may therefore normalize ECV values, falsely suggesting viable tissue. Case Summary: A 65-year-old man with chronic total occlusion of the left anterior descending (LAD) artery underwent multimodality imaging to guide revascularisation. Cardiac magnetic resonance (CMR) demonstrated a transmural, thinned scar in the antero-septal apex and sub-endocardial fibrosis in basal–mid anterior segments. DE-CT demonstrated low attenuation in the same territory, whereas ECV mapping revealed normal values in the scarred apex (comparable to non-infarcted myocardium) and mildly elevated ECV in the basal–mid anterior segments with non-transmural scar. The presence of chemical-shift artefacts on cine CMR, along with further attenuation reduction on DE-CT, confirmed intramyocardial fat, explaining the paradoxically low ECV in this region. Ultimately, the integrated assessment of limited viability, extensive scar remodelling, and high-risk procedural features led to the decision to defer revascularization. Discussion: LM can obscure chronic infarcted myocardium on CT-derived ECV maps by abolishing extracellular expansion and generating deceptively normal values. Reliable interpretation mandates correlation with tissue attenuation, mono-energetic reconstructions, or fat-sensitive CMR sequences. DE-CT affords single-acquisition, high-resolution characterization of both ECV and tissue composition, but its quantitative outputs must be contextualized to avoid misclassification of viability. Awareness of this pitfall is essential for accurate decision-making in chronic ischaemic heart </rdf:li>
            </rdf:Alt>
         </dc:description>
         <dc:rights>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.</rdf:li>
            </rdf:Alt>
         </dc:rights>
         <dc:subject>
            <rdf:Bag>
               <rdf:li>Dual Energy CT</rdf:li>
               <rdf:li>Cardiac Magnetic Resonance</rdf:li>
               <rdf:li>Multimodal Imaging</rdf:li>
               <rdf:li>Lipomatous Metaplasia</rdf:li>
               <rdf:li>Coronary Artery Disease</rdf:li>
               <rdf:li>Case Report</rdf:li>
            </rdf:Bag>
         </dc:subject>
         <prism:aggregationType>Journal</prism:aggregationType>
         <prism:publicationName>European Heart Journal - Case Reports</prism:publicationName>
         <prism:copyright>© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.</prism:copyright>
         <prism:issn />
         <prism:elssn>2514-2119</prism:elssn>
         <prism:volume>9</prism:volume>
         <prism:number>12</prism:number>
         <prism:issueName />
         <prism:startingPage>1</prism:startingPage>
         <prism:endingPage>5</prism:endingPage>
         <prism:doi>10.1093/ehjcr/ytaf612</prism:doi>
         <prism:url>https://doi.org/10.1093/ehjcr/ytaf612</prism:url>
         <xmp:CreateDate>2025-12-09T18:25:51+05:30</xmp:CreateDate>
         <xmp:ModifyDate>2026-09-07T08:55:49+00:00</xmp:ModifyDate>
         <xmp:CreatorTool>Servigistics Arbortext Advanced Print Publisher 11.1.4546/W-x64</xmp:CreatorTool>
         <xmp:MetadataDate>2026-09-07T08:55:49+00:00</xmp:MetadataDate>
         <pdfx:EPSprocessor>PStill version 1.84.42</pdfx:EPSprocessor>
         <pdfuaid:part>1</pdfuaid:part>
         <pdfaExtension:schemas>
            <rdf:Bag>
               <rdf:li rdf:parseType="Resource">
                  <pdfaSchema:schema>PDF/UA Universal Accessibility Schema</pdfaSchema:schema>
                  <pdfaSchema:namespaceURI>http://www.aiim.org/pdfua/ns/id/</pdfaSchema:namespaceURI>
                  <pdfaSchema:prefix>pdfuaid</pdfaSchema:prefix>
                  <pdfaSchema:property>
                     <rdf:Seq>
                        <rdf:li rdf:parseType="Resource">
                           <pdfaProperty:name>part</pdfaProperty:name>
                           <pdfaProperty:valueType>Integer</pdfaProperty:valueType>
                           <pdfaProperty:category>internal</pdfaProperty:category>
                           <pdfaProperty:description>Indicates, which part of ISO 14289 standard is followed</pdfaProperty:description>
                        </rdf:li>
                     </rdf:Seq>
                  </pdfaSchema:property>
               </rdf:li>
            </rdf:Bag>
         </pdfaExtension:schemas>
      </rdf:Description>
   </rdf:RDF>
</x:xmpmeta>
   Pages: 
    Page: 
     Sequence: 1
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 143, 581, 153, 591
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 156, 585, 161, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 164, 585, 169, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 172, 585, 178, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 178, 579, 185, 592
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 355, 581, 365, 591
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 368, 585, 373, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 513, 581, 523, 591
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 525, 585, 531, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 533, 585, 539, 598
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 196, 565, 206, 575
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 208, 569, 214, 582
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 217, 569, 222, 582
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 225, 569, 230, 582
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 42, 549, 45, 556
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 436, 549, 439, 556
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 296, 540, 298, 547
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 151, 531, 154, 538
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 42, 108, 47, 115
       Flags: Print
       Destination: 238
      Annotation: 
       Subtype: Link
       Rect: 197, 108, 258, 115
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 261, 108, 333, 115
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 336, 63, 458, 70
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 138, 727, 261, 735
       Flags: Print
    Page: 
     Sequence: 2
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 161, 75, 192, 84
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 212, 75, 217, 84
       Flags: Print
       Destination: 31
      Annotation: 
       Subtype: Link
       Rect: 306, 558, 337, 567
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 356, 558, 360, 567
       Flags: Print
       Destination: 31
      Annotation: 
       Subtype: Link
       Rect: 482, 169, 509, 178
       Flags: Print
       Destination: 31
      Annotation: 
       Subtype: Link
       Rect: 337, 106, 480, 115
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 376, 89, 379, 98
       Flags: Print
       Destination: 35
    Page: 
     Sequence: 3
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 288, 184, 291, 193
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 99, 152, 102, 161
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 186, 142, 189, 151
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 91, 121, 94, 130
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 95, 100, 99, 109
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 62, 58, 66, 67
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 481, 289, 485, 298
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 394, 236, 398, 245
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 346, 194, 350, 203
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 428, 163, 434, 172
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 366, 131, 372, 140
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 517, 110, 523, 119
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 416, 58, 420, 67
       Flags: Print
       Destination: 35
    Page: 
     Sequence: 4
    Page: 
     Sequence: 5
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 77, 730, 80, 739
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 74, 688, 81, 697
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 209, 646, 216, 655
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 113, 551, 116, 560
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 164, 541, 170, 550
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 182, 166, 291, 175
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 42, 155, 67, 164
       Flags: Print
      Annotation: 
       Subtype: Link
       Rect: 313, 473, 316, 480
       Flags: Print
       Destination: 15
      Annotation: 
       Subtype: Link
       Rect: 313, 446, 316, 453
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 428, 316, 435
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 401, 316, 408
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 374, 316, 381
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 356, 316, 363
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 338, 316, 345
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 311, 316, 318
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 313, 284, 316, 291
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 309, 257, 316, 264
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 309, 230, 316, 237
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 309, 203, 316, 210
       Flags: Print
       Destination: 26
      Annotation: 
       Subtype: Link
       Rect: 309, 167, 316, 174
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 309, 140, 316, 147
       Flags: Print
       Destination: 35
      Annotation: 
       Subtype: Link
       Rect: 309, 104, 316, 111
       Flags: Print
       Destination: 35
  Checksum: cbe86e4f
   Type: CRC32
  Checksum: 57c7482b2a4537575fd4dbed545090dc
   Type: MD5
  Checksum: c8d83b261f539ee02c89d92005b51e8411233441
   Type: SHA-1
  Checksum: 7f7ce3f382ca70b83978c18eeff50f3a7614a09089c2ccd6e33c6543e2723266
   Type: SHA-256