Surgical treatment of ischemic Heart disease

Surgical treatment of myocardial ischemiaThe 1, 2, 3, 4 of carcinoid heart disease: Comprehensive

Treatment for patients with ischemic heart disease and hypothyroidism contains many difficulties, such as a dilemma that thyroid hormone to hypothyroid patients may worsen angina. The purpose of this study is to propose an appropriate control of thyroid function in these patients before coronary artery bypass grafting (CABG), and to clarify the. History of surgical treatment of ischemic heart disease--pre-'coronary bypass grafting' era Historically various innovative concepts existed and a variety of procedures were performed for treating ischemic myocardium, with variable results. These procedures continued till the evolution of direct coronary artery bypass grafting

[Surgical treatment of ischemic heart disease combined

  1. The STICH trial showed that in patients with ischemic cardiomyopathy, coronary artery bypass grafting (CABG) + medical therapy resulted in higher mortality at 30 days, but with a significant improvement in long-term mortality (out to 10 years) compared with medical therapy alone
  2. [Surgical treatment of ischemic heart disease associated with lesions of the valvular apparatus of the heart]. [Article in Russian] Ursulenko VI, Knyshov GV, Slabchenko AP, Furkalo SN, Krikunov AA. Every fourth patient over 45 years of age in a group of patients with valvular heart diseases suffers from affection of the coronary arteries
  3. 1. Kardiologiia. 1982;22(6):5-9. [Indications for the surgical treatment of ischemic heart disease]. [Article in Russian] Kniazev MD, Kirichenko AA

Coronary revascularisation or heart bypass surgery. Sometimes more than one coronary artery is blocked or there are multiple lesions which are difficult to treat with an angioplasty. An alternative solution for such cases is to perform heart bypass surgery. It is performed in an operating theatre under general anaesthetic We have learned new lessons about both the successes and limitations of surgical treatment for coronary disease in this population. Patients who, just one decade ago, would not have been considered suitable surgical candidates are enjoying good outcomes today. Surgical Treatment of Ischemic Heart Disease in the Elderly. In: Edwards N.M. The goal of treatment for ischemic heart disease is to prevent myocardial infarction (heart attack), reduce symptoms and improve overall quality of life. Our cardiologists are involved in refining current heart disease therapy and pioneering new treatment options, including New therapy options such as drug-eluting stent Surgical procedures used to treat ischemic heart disease Severe symptoms that are not relieved by medication alone are treated with surgical procedures including: Angioplasty and stent placement (procedure to remove plaque and restore blood flow in clogged arteries Conclusion: Surgical treatment of patients with severe ischaemic disease as a result of myocardial infarction can be performed with minimal operative and post-operative compli- cations, especially.

History of surgical treatment of ischemic heart disease

Coronary artery bypass surgery. A surgeon uses a vessel from another part of your body to create a graft that allows blood to flow around the blocked or narrowed coronary artery. This type of open-heart surgery is usually used only for people who have several narrowed coronary arteries Coronary artery disease (CAD) is a significant source of morbidity and mortality in developed countries. The landmark Surgical Treatment for Ischemic Heart Failure (STICH) trial has provided greatly needed evidence in the management of patients with severe left ventricle (LV) dysfunction (LVEF ≤ 35%) and CAD amenable to revascularization

In July 2014 the American College of Cardiology, the American Heart Association and other cardiovascular organizations updated standards on the evaluation and treatment of stable ischemic heart disease. These guidelines apply to most patients, but also give your doctor the flexibility to tailor treatment to your specific clinical needs Ischemic Heart Disease Surgery. 3. IHD IHD Surgical management of complicationsSurgical Management Mitral valve reflux Post-MI VSD Acute Coronary Syndrome Left ventricular aneurysm. 6. History• Symptoms• Risk factors• Family Hx• Medical Hx• Surgical Hx• Drug HxExaminationInvestigation. 7 Invasive treatments involve catheterization, a procedure in which a tube-like catheter is slipped into an artery in the groin or arm and is threaded through blood vessels to the heart Ischemic cardiomyopathy (IC) is a condition when your heart muscle is weakened as a result of a heart attack or coronary artery disease.. In coronary artery disease, the arteries that supply blood. Results confirm necessity of differential surgical policy for ischemic heart disease that permits to use adequate method of myocardium revascularisation for each patient. Similar Articles To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation

Surgical Treatment for Ischemic Heart Failure - American

  1. Few surgical treatments for ischemic heart disease are as follows: Angioplasty and Stent Placement or Percutaneous Coronary Revascularization Surgery for Ischemic Heart Disease Angioplasty and stent placement or percutaneous coronary revascularization surgery can aid in treating ischemic heart disease
  2. Heart failure resulting from ischaemic heart disease is associated with a poor prognosis despite optimal medical treatment. Despite this, patients with ischaemic cardiomyopathy have been largely excluded from randomised trials of revascularisation in stable coronary artery disease. Revascularisation has multiple potential mechanisms of benefit, including the reversal of myocardial hibernation.
  3. Medical treatment of ischemic heart disease. The main antianginal drugs include nitrates, beta-blockers and calcium antagonists. Nitrates. The effectiveness of nitrates is well known in the management of angina attacks and in the prevention of pre-exercise
  4. ation of animal and human development efforts, Alexis Carrell presents paper.
  5. Patients with ischemic heart disease undergoing noncardiac surgery are at increased risk for perioperative cardiovascular events, such as myocardial infarction, heart failure, and mortality. Those with recent myocardial infarction or unstable angina are at very high risk if they require urgent or emergency surgery

[Surgical treatment of ischemic heart disease associated

According to mayo clinic, ischemic heart disease can be treated successfully with lifestyle changes, medicines, and surgical procedures Coronary artery bypass grafting (CABG) is also known as bypass surgery, a heart bypass, or coronary artery bypass surgery. It's carried out in people whose arteries are narrowed or blocked. A coronary angiogram will determine if you're suitable for treatment. Off-pump coronary artery bypass (OPCAB) is a type of coronary artery bypass surgery Ischemic Heart Disease refers to a condition of recurring chest pain or discomfort that occurs when a part of the heart does not receive enough blood. Visit Indian Cardiac Surgery Site for further details and get a free consultation from the specialist

A common symptom of coronary artery disease (CAD) is angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back Cardiologists of the private clinic of Herzliya Medical Center specialize in advanced methods for the diagnosis and treatment of ischemic heart disease. The use of innovative technologies and modern protocols of conservative, minimally invasive and surgical treatment, for the analysis of coronary circulation has significantly improved the prognosis of the disease, preventing the development of. Summer Sale At Swell UK Is On Now - Save Up To 30% On Thousands Of Products. Shop Now. Pond Pumps, Liners, Electricals, Lighting, Treatments, Food, Test Kits And Much More DOI: 10.1159/000157977 Corpus ID: 84259524. Surgical Treatment of Ischemic Heart Disease @article{Barto1973SurgicalTO, title={Surgical Treatment of Ischemic Heart Disease}, author={J. Barto{\vs} and J. Pokorny and R. Petz and J. Van{\vc}ura and V. Volek and E. Mildeov{\'a}}, journal={Journal of Vascular Research}, year={1973}, volume={10}, pages={221-232} Surgical Treatment of Ischemic Heart Failure The Dor Procedure treatment of the underlying disease. To date, the technique described by Dor has been applied to all kinds of dilatation involving all segments (anterior, apical and septal). More recently, Menicanti et al14 introduced the use of

Ischemic Heart Disease - Surgical Treatment Approximately 12% - 15% of US hospitals received the STS 3 star rating for CABG surgery. This denotes the highest category of quality. In the current analysis of national data covering the period from July 1, 2013, through June 30, 2014, the CABG surgery performance at Cleveland Clinic was foun of coronary artery disease during life, countless investigations, remedies and surgical procedures have been proposed for ischemic heart disease. It seems that the larger the island of investigation and knowledge of ischemic heart disease, the greater is ourshoreline of wonder. Recently, however, improved exercise, electrocar The Surgical Treatment for Ischemic Heart Failure (STICH) study consisted of two trials — a surgical revascularization component and a surgical ventricular reconstruction component

Since than, over 20,000 patients with ischemic heart disease were provided with emergency care. Since 2000, coronary artery bypass grafting is performed by the off-pump technique . For over 18 years, more than 14,000 surgeries have been completed, this is one of the largest experiences in the world Treatment of Ischemic Heart Disease Mechanism Categories Angina Control of SM Contraction Ischemic Heart Disease Imbalance of the ratio of O2 Supply (Coronary Blood Flow) & O2 Demand (Work of the Heart) Factors of O2 Supply: O2 extraction (%), coronary blood flow, aortic diastolic pressure, coronary arteriolar resistance Abstract Background and aim: To review the various concepts, surgical experiments, and actual procedures performed for the treatment of ischemic heart disease, which eventually led to the evolution of direct coronary artery bypass surgery. Methods: References were collected from original articles and through pubmed search.Results: Various concepts and procedures were introduced, all with the. Post-operative management: Most perioperative myocardial injury in noncardiac surgery (MINS) occurs during the postoperative period. For patients with ischemic heart disease at high cardiac risk, reasonable precautions include continuous electrocardiography (ECG) monitoring and troponin measurements if needed in the post-anesthesia care unit

[Indications for the surgical treatment of ischemic heart

  1. Ischemic heart disease treatment does not always require surgery. There are other methods to help treat coronary artery disease, such as heart-healthy lifestyle changes, maintaining a healthy weight. managing stress and taking part in routine physical activity, as well as quitting habits such as smoking and drinking
  2. Mortality in Korea related to ischemic heart disease has been decreasing rapidly since 1990 • The mortality rate due to ischemic heart disease in Korea has decreased 60% on average every year since 1990, thanks to the development of a revolutionary treatment. Factors in the development of cardiac infarction treatment
  3. [Surgical treatment of ischemic heart disease] Ishikura Y, Takizawa H, Kawada S, Inoue T. Kyobu geka. The Japanese Journal of Thoracic Surgery, 01 Mar 1970, 23(3): 192-198 Language: jpn PMID: 5461915 . Share this article Share with email Share with twitter Share with linkedin.
  4. The term ischemic cardiomyopathy has been used to describe significantly impaired left ventricular function (left ventricular ejection fraction [LVEF] ≤35 to 40 percent) that results from coronary artery disease. Despite the common clinical use of the term ischemic cardiomyopathy, there is no consensus of the term ischemic cardiomyopathy [ 1-3 ]
  6. The human results of coronary heart disease surgery are promising: there has been a substantial decrease in the pain of angina pectoris, and an increase in the work capacity of the coronary heart disease patient; and there is some evidence that the eventual life expectancy of patients undergoing surgery has been increased

Ischemic heart disease treatments PortalCLÍNI

Surgical Treatment of Ischemic Heart Disease in the

Ischemic Heart Disease Treatment - The University of

Diagnosis and Treatment: Ischemic Heart Disease. Symptoms of ischemic heart disease include chest pain and difficulty breathing. Treatment options may include lifestyle changes, medication or surgery. Learn more about ischemic heart disease diagnosis and treatment. Find a doctor or specialist at The UVM Medical Center or call us at 802-847. Complicated forms of ischemic heart disease (ICD) develop in delayed treatment of acute myocardial infarction (MI). Severe mitral insufficiency develops in 10-20% of patients after acute MI Ischemic Mitral Regurgitation: Indications for Surgery. Many patients with ischemic heart disease have ischemic mitral regurgitation, and the presence of ischemic mitral regurgitation has subsequently been shown to have a significant impact on prognosis (Figure 17-21). 89-91 There is some degree of ischemic mitral regurgitation detected in as.

Ischemic Heart Disease - Symptoms, Causes, Treatment

  1. The most famous modern ways of surgical treatment of heart disease: Coronary angioplasty is one of the leading methods by which it has been possible to save and improve the quality of life of many patients with ischemic heart disease
  2. The Surgical Treatment of Ischemic Heart failure trial (STICH) was supposed to answer the question whether there was a real benefit of SVR added to revascularization in patients with end-stage CAD . Some methodological concerns, such as changing enrollment criteria during prolonged patient recruitment or lacking identification of scared.
  3. Background Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some.
  4. Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries).Its risk increases with age, smoking, hypercholesterolaemia (high cholesterol levels), diabetes, hypertension (high blood pressure) and is more common in men and those who.
  5. The Heart in Spondylitis. In addition to well-known extra-articular manifestations, ankylosing spondylitis (AS) has been reported to be associated with a number of cardiovascular diseases, including aortitis, aortic valve disease, conduction disturbances, cardiomyopathy, and ischemic heart disease. Cardiac issues are found in an estimated two.

NOTE: For coronary artery disease, myocardial infarction, or hypertensive disease, complete VA Form 21-0960A-1, Ischemic Heart Disease Disability Benefits Questionnaire. SECTION I - DIAGNOSIS HEART CONDITIONS (INCLUDING ISCHEMIC AND NON-ISCHEMIC HEART DISEASE, ARRHYTHMIAS, VALVULAR DISEASE AND CARDIAC SURGERY 1. Introduction. Current statistics from the British Heart Foundation and the American Heart Association show that cardiovascular disease is still the leading cause of deaths in Europe and the US, accounting for 49% and 37.3% of all deaths, respectively. Out of all cardiovascular deaths in Europe and in the US, coronary heart disease (CHD) is the single largest killer: More than 1 in 5 deaths. Background— Health status is a key outcome for comparing treatments, particularly when mortality does not differ significantly. Methods and Results— Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) randomized 2368 patients with type 2 diabetes mellitus and stable ischemic heart disease to (1) prompt revascularization versus medical therapy and (2) insulin.

Causes of Ischemic heart disease. Risk factors include smoking, diabetes mellitus, and cholesterol levels. Genetic and hereditary factors may also cause this disease. Hypertension; Stress is also a risk factor; Treatment. Treatment of Ischemic heart disease includes medications like. Organic nitrates which help to relax the non-specific smooth. Background: Spinal cord stimulation has been used for the treatment of severe angina pectoris since the beginning of the 1980s. About 1500 patients have been implanted globally to date. The treatment has been shown to have a good symptom relieving effect, i.e. a reduction in the severity and frequency of anginal symptoms which is secondary to a decrease in myocardial ischemia.Methods: The main. Coronary artery disease (CAD), also known as ischemic heart disease, is a condition in which fatty plaque deposits narrow artery walls leading to the heart and reduce blood flow. When a clogged artery completely blocks blood flow, a heart attack occurs. Coronary artery disease is a result of coronary heart disease Introduction The contemporary management of patients with ischemic heart disease demands a sound understanding of the pathophysiologic precipitants of both angina pectoris and myocardial ischemia from which the principles of pharmacotherapy can be applied and tailored to the specific causes underlying these perturbations of myocardial oxygen supply and demand 1.1. Concepts. Patients with congenital heart disease (CxHD) are surviving into adulthood, as well as living longer and growing older [], due the major achievements in their diagnosis, medical management, surgical repair, and postoperative treatment in the last three to four decades.An increasing numbers of patients with CxHD are encountered in our everyday practice

(Pdf) Ischaemic Heart Disease - Surgical Treatment and

Ischemic heart disease (IHD) is one of the most important cardiac diseases and defined by an inadequate oxygen supply of the myocardial cells (Task Force Members et al., 2013). From: Encyclopedia of Cardiovascular Research and Medicine, 2018. Download as PDF. About this page II. Ischemic Heart Disease 5. Pharmacologic Options for Treatment of Ischemic Disease 6. Mechanical Approaches to Percutaneous Coronary Intervention 7. DES, thrombus extraction, embolization protection devices 8. Ischemic Heart Disease: Surgical Options-A Cardiology Perspective 9. Coronary Artery Bypass Surgery: A Surgical Perspective 10 Fortunately, ischemic heart disease can be treated successfully with lifestyle changes, medicines, and surgical procedures. Even better, you can reduce your risk of ischemic heart disease by following heart-healthy practices, such as eating a low-fat, low-sodium diet, being physically active, not smoking, and maintaining a healthy body weight.. Left untreated, ischemic heart disease may lead. Various drugs can be used to treat coronary artery disease, including: Cholesterol-modifying medications. These medications reduce (or modify) the primary material that deposits on the coronary arteries. As a result, cholesterol levels — especially low-density lipoprotein ( LDL, or the bad) cholesterol — decrease Introduction: The life expectancy increase is steadily leading to the fact that more and more severe patients begin to undergo surgical treatment of coronary artery disease. Off-pump coronary artery bypass grafting may be the operation of choice in treating this category of patients. Objective: To study the immediate results of surgical treatment of coronary artery disease using Off-pump.

Myocardial ischemia - Diagnosis and treatment - Mayo Clini

Up To 30% Off Marked Prices In The Swell UK Summer Sale - Save On Thousands Of Products. Pond Pumps, Liners, Electricals, Lighting, Treatments, Food, Test Kits And Much More Abstract Background and aim: To review the various concepts, surgical experiments, and actual procedures performed for the treatment of ischemic heart disease, which eventually led to the evolution of direct coronary artery bypass surgery. Methods: References were collected from original articles and through pubmed search. Results: Various concepts and procedures were introduced, all with the. Surgical Management of Ischemic Heart Disease- An Update - Free download as Powerpoint Presentation (.ppt / .pptx), PDF File (.pdf), Text File (.txt) or view presentation slides online Treatment goals for patients with ischaemic heart disease Prevention in Ischaemic Heart Disease (IHD) Dr. Jeroen Hendriks Preventive measures in risk factor control, recommended for patients with ischaemic heart disease, are reviewed, including pharmacotherapeutic and invasive or surgical therapies, professional lifestyle interventions.

Heart Attacks | Electrophysiology

tients with stable ischemic heart disease (IHD). Many patients are not suitable for percutaneous or surgical revascularization because of unfavourable anatomy, or the presence of co-morbidities Drug Treatment of Ischemic Heart Disease. Reversible: Secondary (Fixed or Stable Angina) Primary (Variant angina or Coronary Vasospasm) Unstable Angina: Intermediate stage. Myocardial Infarction: Permanent damage to part of the heart, usually ends with heart failure Surgery or procedure for Coronary heart disease Treatment You may need a procedure or heart surgery to more advanced ischemic heart disease treatment. • Coronary artery bypass grafting (CABG) to improve blood flow to the heart by using normal arteries from the chest wall and veins from the legs to bypass the blocked arteries,

Surgical Treatment for Ischemic Heart Failure (STICH

  1. This monograph, with a primary focus on ischemic heart disease (IHD), discusses the basic anatomy of the heart and coronary arteries; vascular biology; pathogenesis of atherosclerosis; and the screening, prevention, diagnosis, and treatment of IHD as well as the multiple risk factors associated with the development of IHD that contribute to.
  2. Ischemic artery heart disease is a disorder caused by decreased blood supply to the heart. Due to narrowed arteries, the heart muscle doesn't get enough blood and oxygen. It can provoke a myocardial infarction, angina and arrhythmia, which in some cases leads to death
  3. Treatment is aimed at restoring normal blood supply to the myocardium and improving the quality of patients' lives. Open hours: Mon - Sat, from 08:00 to 18:00. Call center: +998 (78) 148 30 30. REQUEST A CALL. Treatment of ischemic heart disease.
Cardiology: signs of heart disease, heart murmurs and

Through positive lifestyle changes, proper medication, and surgery if necessary, the arteries may be cleared, and many of the symptoms of ischemic heart disease may be reversible. Because risk of developing ischemic heart disease increases with age, it is difficult to pronounce anyone cured, but taking the steps towards treatment and prevention. The Cardiothoracic Surgical Trials Network (CTSN) is an international network that studies heart valve diseases, arrhythmias, heart failure, ischemic heart disease, and the complications of surgery. Since it was established, CTSN has developed a portfolio of trials spanning from early translation to the completion of six randomized clinical.

Ischemic heart disease (ischemic cardiomyopathy) is currently the leading cause of death in the elderly. we undertook a bibliographic review aiming at to seek for clinical evidence either regarding surgical treatment benefit or the percutaneous intervention for patients over the age of 75 presenting with ischemic heart disease After nearly 50 years CABG now has the most solid evidence supporting its role in revascularization for stable ischemic heart disease -- in its history Conventional surgery-based therapy for the treatment of ischemic heart diseases has been advanced with biopharmaceutical-based therapy, such as protein, gene and cell therapy. The conventional medical therapy focuses on the use of drug eluting stents, coronary-artery bypass-graft surgery and anti-thrombosis Ischemic Risk. Antiplatelet therapy is a mainstay in the management of patients with CAD. This includes not only patients who have undergone stent implantation, but also those with an acute coronary syndrome (ACS) who are medically treated, in whom the clustering of adverse thrombotic events has been described in the early period after interruption of oral antiplatelet agents. 10 - 12 The. Coronary artery bypass grafting (CABG) is a procedure to improve poor blood flow to the heart. It may be needed when the arteries supplying blood to heart tissue, called coronary arteries, are narrowed or blocked. This surgery may lower the risk of serious complications for people who have obstructive coronary artery disease, a type of ischemic.

Video: Guideline for Treating Stable Ischemic Heart Disease

Important differences exist between women and men in clinical presentation, recognition of symptoms, response to treatment, and outcomes in ischaemic heart disease (IHD). In this Review, Vaccarino. Given these limitations, a 50% or greater stenosis in a patient with ischemic heart disease is defined as a significant stenosis. FIGURE 7-12 Necessity for multiple projections. The severe stenosis (arrow) is not clearly visible in the lateral view (A), but is nicely demonstrated in the mid left anterior descending artery (LAD) in the cranial. Canine heart disease is a serious, life-threatening condition that affects a significant number of dogs. Any of a number of ischemic heart diseases may cause canine heart failure, an emergency medical condition for any animal. Canine heart disease may be either congenital or acquired over the course of a lifetime, and it is critical that pet owners be aware of the symptoms and surgical.

Ischemic Heart Disease Surger

43 Thoracic Aortic Disease Intervention and Surgery . 44 Surgical Revascularization for Ischemic Heart Disease 45 Myocardial Protection, Intraoperative Management, and Postoperative Critical Care 46 Surgical Therapy for Valvular Heart Disease 47 Surgical Treatment of Heart Failure, Transplantation, and Arrhythmia A) Ischemic Heart Disease (IHD): It is the imbalance between myocardial oxygen supply and demand, resulting in myocardial hypoxia and accumulation of waste metabolites. The components of IHD are: B) Stable Angina: Pattern of chronic, predictable, transient chest discomfort during exertion or emotional rest and relieves with rest ECCP for Ischemic heart disease treatment. The ECCP is a non- invasive treatment which a large group of doctors think of as an ideal treatment for the Ischemic disease. Though ischemic heart disease may lead to severe consequences like a heart attack. In ECCP treatment for ischemic heart disease, the patient lies on a padded table in which sets.

Hypoxic-Ischemic Encephalopathy (HIE) | HIE Help Center2016 ACC/AHA guideline focused update on duration of dualChest Pain Explained | Dubai Cardiology Clinic

Ischemic Heart Disease. Cardiovascular disease (CVD) is ranked as the leading cause of death world wide, responsible for 17.1 million deaths globally each year. This text reviews the epidemiology, development, risk factors, diagnosis and treatment of ischemic heart disease. Author(s): David C. Gaz Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are. Ischemic heart disease is also known as ischemic cardiomyopathy in medical lingo. It generally results from weakened heart muscles due to previous conditions such as heart attack or other coronary diseases. The left ventricle of an IC patient tends to enlarge and gets dilated If the Surgical Treatment of Ischemic Heart Failure (STICH) trial demonstrates that surgical therapy is superior to medical therapy, early aggressive evaluation of coronary artery disease as a potentially correctable cause of new-onset heart failure would be the preferred strategy Long-awaited study results may finally settle the question of when to use stents and bypass surgery in patients with stable heart disease, showing that drugs work equally as well in preventing.