Dr Pamela Moceri
email: moceri.p@chu-nice.fr

Nicolas Duchateau

Stéphane Gillon

Lolita Jaunay

Delphine Baudouy

Fabien Squara

Emile Ferrari

Maxime Sermesant

3D right ventricular shape and strain in congenital heart disease patients with right ventricular chronic volume loading

Keywords: Congenital heart disease, 3D echocardiography, Right ventricular function, Right ventricular strain, Curvature

Background: Right ventricular (RV) function assessment is crucial in congenital heart disease (CHD) patients, especially in atrial septal defect (ASD) and repaired Tetralogy of Fallot (TOF) patients with pulmonary regurgitation (PR). In this study, we aimed to analyse both 3D RV shape and deformation to better characterize RV function in ASD and TOF-PR. Methods: We prospectively included 110 patients (≥16 years old) into this case-control study: 27 ASD patients, 28 with TOF and 55 sex-and age-matched healthy controls. Endocardial tracking was performed on 3D transthoracic RV echocardiographic sequences and output RV meshes were post-processed to extract local curvature and deformation. Differences in shape and deformation patterns between subgroups were quantified both globally and locally.

Results: Curvature highlights differences in RV shape between controls and patients while ASD and TOF-PR patients are similar. Conversely, strain highlights differences between controls and TOF-PR patients while ASD and controls are similar (global area strain: -31.5±5.8%

[controls], -34.1±7.9% [ASD], -24.8±5.7% [TOF-PR], p<0.001, similar significance for longitudinal and circumferential strain). The regional and local analysis highlighted differences in particular in the RV free wall and the apical septum.

Conclusion:

Chronic RV volume loading results in similar RV shape remodeling in both ASD and TOF patients while strain analysis Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup

INTRODUCTION

Right ventricular (RV) function evaluation is of utmost importance in congenital heart diseases (CHD) [START_REF] Mertens | Imaging the right ventricle--current state of the art[END_REF] . RV chronic volume loading is frequently observed in CHD and leads to right ventricular (RV) remodelling in terms of shape and function [START_REF] Dragulescu | Differential effect of right ventricular dilatation on myocardial deformation in patients with atrial septal defects and patients after tetralogy of Fallot repair[END_REF] , which affects the patients' prognosis and in particular CHD patients [START_REF] Reddy | Molecular Mechanisms of Right Ventricular Failure[END_REF] .

RV response to pre-and after-load changes is a crucial issue in CHD.

Atrial septal defect (ASD) with left to right shunting is generally well tolerated for years, while repaired tetralogy of Fallot (TOF) patients with chronic pulmonary regurgitation are at risk for developing RV dilatation and ultimately failure [START_REF] Bouzas | Pulmonary regurgitation: not a benign lesion[END_REF][START_REF] Rashid | Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot[END_REF] .

The assessment of RV differences in shape and deformation is challenging given the peculiar RV geometry, which requires 3D imaging and dedicated analysis tools. The echocardiographic literature only focused on 2D regional and global observations on these populations.

Local 3D descriptors such as curvature and strain have been recently exploited in the context of specific diseases affecting the RV (pulmonary hypertension, patients with left ventricular assist devices), but not in the context of RV chronic volume loading. In addition, they have only been examined separately, which may be limited when both shape and function are altered.

In this study, we investigated the effects of RV volume chronic volume loading on 3D descriptors of the RV anatomy and mechanics, both in ASD and TOF patients compared to a control group. We hypothesized Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging that a finer analysis that integrates RV shape and deformation, in 3D and both globally and locally up to each point of the RV endocardial surface, could provide novel insights into the relationship between shape and function to better characterize these patients.

METHODS

Study design and patients

We performed a case control study on patients (adults and adolescents > 16 years old) with ASD and TOF with chronic pulmonary regurgitation Repaired TOF patients were included if they had no other defect.

Patients with significant residual pulmonary stenosis were excluded (maximum gradient across the pulmonary valve > 40mmHg). The presence of significant pulmonary regurgitation (at least moderate) was defined by a pulmonary regurgitation jet width on colour Doppler > 50% of the pulmonary annulus, a pulmonary regurgitation index < 0.77 (pulmonary regurgitation duration/diastolic duration ratio) and/or diastolic flow Doppler reversal [START_REF] Li | Doppler-echocardiographic assessment of pulmonary regurgitation in Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging[END_REF][START_REF] Renella | Two-dimensional and Doppler echocardiography reliably predict severe pulmonary regurgitation as quantified by cardiac magnetic resonance[END_REF][START_REF] Valente | Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the American Society of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology[END_REF] .

Demographics and clinical data (age, gender, diagnosis, baseline WHO class, type of repair, number of surgeries) were collected at inclusion.

2D-echocardiographic acquisitions and measurements

Echocardiographic examinations were performed using an EPIQ-7 ultrasound system and an X5-1 transducer (Philips Medical system, Andover, MA, USA). Doppler echocardiography was performed per the recommendations of the American Society of Echocardiography and the European Association for Cardiovascular Imaging [START_REF] Rudski | Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography[END_REF][START_REF] Douglas | Echocardiographic Imaging in Clinical Trials: American Society of Echocardiography Standards for Echocardiography Core Laboratories[END_REF][14]

3D transthoracic echocardiography

At least four 3D cine-loops were acquired from an apical 4-chamber view focused on the RV, using an IE-33 or EPIQ-7 ultrasound system and a matrix-array X5-1 transducer (Philips Medical system, Andover, MA). Fullvolume acquisition over two heartbeats (for loop storage) was performed using ECG-gating over four cardiac cycles, during a quiet breath-hold if possible. Frame rate was maximized to allow quantification from RVdedicated software and follow the current quantification guidelines (frame rate > 20 Hz) [START_REF] Rudski | Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography[END_REF] . Care was taken to include the entire RV within the images. Digital 3D datasets were stored and analysed using RV-dedicated commercial software (4D RV Function 2.0, TomTec Imaging Systems GmbH, DE). This software allowed semi-automatic delineation of the RV endocardium, which was then automatically tracked across the cardiac cycle, and resulted in a sequence of 3D triangulated meshes with point-topoint correspondences (i.e. each vertex is labelled similarly across the cycle and subjects). It also provided an estimation of the RV end-diastolic and end-systolic volumes, ejection fraction, and wall-specific peak strain.

Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging An example of adequate RV tracking is illustrated for a patient with a primum atrial septal defect in Figure 1.

3D deformation analysis

The commercial software also allows exporting the RV surface meshes tracked along the cardiac cycle for external post-processing. For each subject, we computed deformation locally (at each point of the RV endocardial surface), and regionally/globally (average over a given segment or the whole ventricle) using VTK (v7.10, Kitware, New York, US), similar to our previous work 15 . Our results focus on end-systolic strain values. Circumferential and longitudinal strain computations were based on the nominal strain ---the relative change of length from end-diastole, also referred to as engineering strain or Cauchy strain---along these directions, within a 5mm neighbourhood. Nonetheless, the computation of the circumferential and longitudinal directions may introduce additional variability due to the lack of consensus in their 3D definition, in particular for the RV. As a complement, we also provide area strain, computed as the relative change of area from end-diastole for each triangle of the RV surface mesh. This definition does not involve the circumferential and longitudinal directions and therefore does not suffer the above-mentioned limitation. Besides, under the hypothesis of an incompressible myocardium, it represents a relevant surrogate for radial deformation, which cannot be accessed otherwise as only endocardial surfaces are available.

Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging

3D shape analysis

We also estimated the curvature at each point of the RV, at enddiastole. We used the "mean curvature" definition, which stands for the average of principal curvatures, as used in previous studies [START_REF] Addetia | Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension[END_REF][START_REF] Addetia | 3D Morphological Changes in LV and RV During LVAD Ramp Studies[END_REF] .

Positive/negative curvature means that the surface locally bends towards/ away from the centre of the RV. This 3D curvature analysis provides a detailed quantitative evaluation of RV remodelling patterns over the whole endocardial surface, which is not accessible with conventional 2D measurements and global values such as volumes. Computations used the Computational Geometry Algorithms Library (CGAL 4.11, Inria, FR) [START_REF] Board | CGAL 4.11[END_REF] , which relies on smooth differential geometry calculations and approximates the local surface with a quadric, over a circular neighbourhood of 10mm (2 rings of nearest neighbours around the point of interest). This neighbourhood size was chosen a priori, small enough to prevent over smoothing of the data and reflect local changes, but not too small to be robust to local noisy surface variations.

Local/regional/global analysis

Spatial correspondences between the subjects' 3D deformation and curvature data were obtained by using the labels attached to the mesh vertices by the commercial software, which were consistent across the cycle and subjects. Temporal correspondences were achieved by normalizing these data according to the onset and end of the cardiac Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging cycle. These steps are compulsory to compare the local 3D deformation and curvature data across subjects.

In addition, the RV was labelled according to the regions defined in Haddad et al. [START_REF] Haddad | Right ventricular function in cardiovascular disease, part I: Anatomy, physiology, aging, and functional assessment of the right ventricle[END_REF]

Statistical analysis

Data were summarized as mean ± standard deviation for continuous variables with normal distribution; median [95% confidence interval] for other continuous variables and number of subjects (%) for categorical variables. Inter-group differences were assessed by the Student t-test for normally distributed variables, or the Mann-Whitney U-test otherwise, and categorical variables were compared using Fisher's exact test. Bonferroni correction was used for multiple comparisons (ANOVA). Correlation coefficients were calculated between the regional curvature and deformation values. These analyses were performed using MedCalc 19.1 (MedCalc Software, Mariakerke, BE).

Inter-group differences in the local curvature and deformation data were assessed by the Hotelling's T-Square test statistic [START_REF] Hotelling | The generalization of Student's ratio[END_REF] In all analyses, statistical significance was defined as a p-value < 0.05.

RESULTS

General characteristics of the population

Our study included 110 patients: 28 patients after TOF repair, 27 ASD patients and 55 controls. Controls and patients were matched for sex and age. General characteristics of the study groups are presented in Table 1.

Among TOF patients, 7 had initially a Blalock-Taussig shunt (25%) and all underwent a complete repair during childhood (the latest repair occurred at 15 years old in one patient). TOF repair included a transannular patch in 23 patients (82.1%). All TOF patients had significant pulmonary regurgitation, 3 of them had already had pulmonary valve replacement (but still suffered from significant pulmonary regurgitation).

Among ASD patients, all patients had significant defects with 2D echocardiographic evidence of RV chronic volume loading. Twenty-three had secundum ASD (85.2%), 3 had a sinus venosus defect (11.1%) and 1 had a primum ASD (3.7%). Seven suffered from embolic ischemic stroke Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging (25.9%) and 5 (18.5%) presented paroxysmal supra-ventricular tachycardia, but all patients were in sinus rhythm at the time of the study. Two-dimensional echocardiographic measurements are summarized in Table 2. All patients had a dilated right ventricle. RV diameter was not statistically different between ASD and TOF patients.

Compared to ASD patients, TOF patients had a more hypertrophic right ventricle (p<0.001) but reduced longitudinal contraction at the tricuspid annulus (reduced TAPSE (p<0.001) and tricuspid valve s' (p=0.006)).

3D strain analysis

Results from the analysis of 3D regional and global deformation are presented in Table 3. ASD and TOF patients have larger volumes than controls (p<0.001), while TOF patients also have a reduced RV EF (p<0.001).

Strain tends to be higher in ASD patients compared to controls, but these differences were not significant regarding RV area, longitudinal and circumferential strains, at the global RV level and at the regional level.

In contrast, many differences were observed between TOF patients and controls. RV area and circumferential strains were lower in TOF patients, especially in the RV free wall and in the trabecular / apical septum (Figures 2 and3). Longitudinal strain was also significantly decreased in TOF patients, at slightly different locations (Figure 3). The inlet septum and superior part of the free wall were preserved compared Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging to healthy controls. The ratio circumferential / longitudinal strain in TOF patients did not significantly differ from controls, which confirms that the extent of strain decrease was similar for longitudinal and circumferential strain.

TOF and ASD patients significantly differed regarding all variables, in almost all segments. Area strain mainly differed in the RV free wall, but the inlet and posterior septum looked preserved (Figure 2 and3).

Longitudinal and circumferential strain mostly differed in the RV free wall and the apical septum.

3D curvature analysis

Figure 4 summarizes curvature differences between ASD and TOF patients and controls. ASD patients and controls significantly differed in the extreme borders of the RV, the apex, and the septum. Differences were also marked between TOF and controls, mainly at the septal level, and the lateral and inferior walls. They were less visible between TOF and ASD patients, except in the operated RV outflow tract. No correlation was found between the regional curvature and strain values.

DISCUSSION

RV chronic volume loading results in different adaptations depending on the underlying congenital heart disease. Our analysis examined differences in the 3D patterns of RV shape and deformation, and therefore Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging provides finer insights into the differences in ASD and TOF patients compared to controls.

3D RV shape differences

Assessing RV shape differences locally and in 3D is challenging. Indeed, there is no standard to appreciate RV shape, especially using 3D echocardiography. RV shape has been previously described using curvature from 3D-echocardiography in healthy volunteers [START_REF] Addetia | Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography-Derived Curvature Indices[END_REF] , pulmonary arterial hypertension [START_REF] Addetia | Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension[END_REF] and LVAD patients [START_REF] Addetia | 3D Morphological Changes in LV and RV During LVAD Ramp Studies[END_REF] .

We had previously hypothesized that RV shape would be affected differently depending on the underlying pathology and thus, that a detailed assessment of RV shape would reveal differences between TOF and ASD patients. It was not the case. Despite coming from different sources (the right atrium or the pulmonary valve), the chronic volume loading affects the RV shape similarly in both subgroups. Even when quantifying an advanced descriptor such as curvature, locally and in 3D, no significant differences between ASD and TOF patients were observed.

However, patients with chronic volume loading were very different from controls and had lower curvature and more dilated shapes. In TOF patients, the infundibulum is significantly less curved than in ASD patients (Figure 4), which was expected given the history of ventricular septal defect and trans-annular patch in more than 80% of TOF patients during surgical correction. The detrimental role of the RV outflow tract akinesia has already been demonstered [START_REF] Davlouros | Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse rightto-left ventricular interaction[END_REF]

3D RV strain differences

RV deformation differed between ASD and TOF patients. This difference has already been suggested in children but only focusing on 2D analysis and longitudinal strain 2 . While ASD patients and controls had similar circumferential and longitudinal strain, TOF patients had markedly reduced area, longitudinal and circumferential strains. These observations agree with other echocardiographic data: 3D ejection fraction, TAPSE and tricuspid valve s' are all reduced in TOF patients under the influence of the reduced global RV deformation.

In contrast, chronic volume loading in ASD seems to slightly increase RV deformation, as previously reported [START_REF] Eyskens | Ultrasonic strain rate and strain imaging of the right ventricle in children before and after percutaneous closure of an atrial septal defect[END_REF][START_REF] Jategaonkar | Two-dimensional strain and strain rate imaging of the right ventricle in adult patients before and after percutaneous closure of atrial septal defects[END_REF] . Our study demonstrates that both longitudinal and circumferential strains are preserved in ASD (physiological response probably related to the increased wall shear stress [START_REF] Hayabuchi | A novel bilayer approach to ventricular septal deformation analysis by speckle tracking imaging in children with right ventricular overload[END_REF] ), contrary to what is observed for TOF patients. However, only little is known about RV remodelling after ASD closure. Some authors suggested that RV function after ASD closure (either surgical or interventional closure) declines compared to the pre-intervention assessment [START_REF] Jategaonkar | Two-dimensional strain and strain rate imaging of the right ventricle in adult patients before and after percutaneous closure of atrial septal defects[END_REF][START_REF] Ko | Segmental Analysis of Right Ventricular Longitudinal Deformation in Children before and after Percutaneous Closure of Atrial Septal Defect[END_REF] . Regional differences in patients with open ASD have also been described 28 using 2D echocardiography, with increased apical longitudinal strain that also correlates with volume load severity. However, in our study, no significant difference was observed between ASD and controls, only a trend toward both higher area, longitudinal and circumferential strain.

Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging

RV characteristics in TOF patients

ASD patients showed a better RV remodelling pattern than TOF patients. TOF patients had a more hypertrophic RV (significantly higher wall thickness) but reduced systolic function and strain despite very good clinical adaptation (no difference in NYHA class between TOF and ASD patients). The reduced RV strain in TOF patients might be explained by several factors: an abnormal development, the prior pre-op RV pressure overload and RV hypertrophy (observed in our cohort), a large ventriculotomy, the influence of myocardial damage related to prolonged cyanosis and surgery and the advanced age of our TOF cohort.

RV dyssynchrony may also affect the strain pattern across the cycle and therefore the end-systolic values, as reported on 2D echocardiographic data [START_REF] Hui | Mechanisms of right ventricular electromechanical dyssynchrony and mechanical inefficiency in children after repair of tetralogy of fallot[END_REF] . In our population, TOF patients had significantly longer QRS duration, which has been shown to impact RV function more than PR [START_REF] Lumens | Relative impact of right ventricular electromechanical dyssynchrony versus pulmonary regurgitation on right ventricular dysfunction and Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging[END_REF] .

Regarding the impact of surgery at the regional level, differences in RV strain between TOF patients and the other subgroups was not only observed within the infundibular area, but also and predominantly in the RV free wall, suggesting a global remodelling.

Differential regional effects of RV chronic volume loading have been observed in TOF. During the last decade, authors emphasized the importance of regional differences within the RV of TOF patients [START_REF] Bodhey | Functional analysis of the components of the right ventricle in the setting of tetralogy of Fallot[END_REF] , as also suggested by our study, with a variable adaptive response to isolated

Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging chronic volume loading as opposed to combined pressure/volume overload. The role of the apex has been previously underlined, with a loss of function in TOF patients [START_REF] Dragulescu | Differential effect of right ventricular dilatation on myocardial deformation in patients with atrial septal defects and patients after tetralogy of Fallot repair[END_REF] . In our study, the use of 3D echocardiography allows analysing more precisely differences in TOF patients (regionally and locally).

Limitations

Curvature assessment was performed on end-diastolic shapes, to avoid mixing the effect of systolic contraction on RV shape. However, analysing the RV shape throughout the whole cardiac cycle might provide complementary insights, especially in TOF patients, knowing the role of dyssynchrony in those [START_REF] Friedberg | Relation of right ventricular mechanics to exercise tolerance in children after tetralogy of Fallot repair[END_REF] .

Apart from the detailed area strain patterns, we also reported regional and global area strain values, meaning that area strain was averaged over a given region or the whole RV. We did not consider changes in the area of the RV regions or the whole RV for the sake of clarity, although this slightly different computation should lead to similar conclusions.

3D RV study was feasible in all of our patients, however this method is hardly applicable to patients with poor acoustic windows. Our study was monocentric and suffers from a lack of power given the relatively small cohort of patients. Current guidelines [START_REF] Simpson | Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography[END_REF]

  followed up at the Pasteur University Hospital, Nice, FR between September 2016 and January 2019. Stable patients (no hospitalization during the 2 years preceding the inclusion) were enrolled into a standardized echocardiographic protocol including 2D and 3D echocardiography. Our study protocol was approved by the local research Ethics committee. Personal patient and parental or guardian's consent were obtained together with the adolescent's assent in patients < 18 years old. Asymptomatic healthy volunteers (with no prior history of cardiovascular disease) were recruited from the community to serve as controls and were included if they had a normal transthoracic echocardiography, and if they were in sinus rhythm. They were matched 1/1 to the study population regarding age and sex. ASD patients were included if they had no other defect and an open and significant left-to-right shunt at the atrial level with hemodynamic Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging consequence defined by a basal RV diameter > 41mm 8 . ASD patients were excluded if they had pulmonary hypertension defined by mean pulmonary artery pressure ≥ 25mmHg and pulmonary vascular resistance > 3 Wood Units (assessed by right heart catheterization either during the initial assessment of a dilated right heart to eliminate pulmonary hypertension, or before the ASD closure procedure).

  , and regional/global values were obtained by averaging the local deformation and curvature values over these regions / the whole ventricle.These computations were carried out in Matlab (v.R2011a, MathWorks, Natick, US, USA).

  using Matlab (v.R2011a, MathWorks, Natick, US, USA), which returned a p-value at each point of the RV, low p-value indicating high differences. These values were Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging visualized on the average shape representative of each subgroup, obtained by standard computational anatomy tools (generalized Procrustes analysis), and displayed in a customized logarithmic colourscale to better visualize significantly different regions.

FIGURE TITLES AND LEGENDSFigure 1 :

 1 FIGURE TITLES AND LEGENDS

Figure 2 :

 2 Figure 2: Area strain represented over the average RV shape for each subgroup.Top two rows: RV septum; bottom two rows: RV free wall. Rows respectively represent the median area strain pattern, and the corresponding statistical differences between subgroups (controls vs. ASD and TOF patients, as well as ASD vs. TOF patients). The customized colourscale allows better visualizing the statistically significant differences: pvalues <0.05 are red -orange -yellow and green, whereas blue indicates no significant difference between the studied groups. This figure confirms at a finer level (local comparisons) the differences in area strain observed regionally in Table3, especially in TOF patients against controls and ASD patients.

Figure 3 :

 3 Figure 3: Circumferential and longitudinal strains represented over the average RV shape for each subgroup.

Figure 4 :

 4 Figure 4: RV curvature represented over the average RV shape for each subgroup. Display similar to Figure 2. Statistically significant differences are observed within the septum between RV chronic volume loading patients and controls, whereas almost no difference is visible between TOF and ASD patients, except within the right ventricular outflow tract.

  . A cardiologist, with

	Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging.
	Final version of this paper available at https://academic.oup.com/ehjcimaging
	advanced training in echocardiography, performed the cine-loop
	acquisitions and interpreted the 2D datasets. The measured parameters
	were averaged over three consecutive cycles, and consisted of: left
	ventricular ejection fraction, right atrial area, tricuspid annular peak
	systolic velocity (s'), tricuspid annular plane systolic excursion (TAPSE), RV
	basal diameter and RV wall thickness.

  regarding the decreased RV systolic Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging

  do not recommend routine assessment of 3D RV volumes and deformation given the paucity of normal data in congenital heart disease patients. Thus, future work should Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging aim at increasing the cohorts of both healthy controls and CHD patients

	from multicentre acquisitions, further analysed using the same
	methodology. Larger amount of cases in each subgroup would also allow
	examining the complex relationship between RV size or shape and
	deformation descriptors. Investigating the relationship between RV
	pressure and strain would require a different cohort of patients, as we
	carefully excluded patients with residual pulmonary stenosis.
	Finally, the current version of the commercial software only allowed
	us to analyse a single layer across the RV wall. Processing different layers
	may help investigate complementary shape and deformation
	characteristics across the wall.
	CONCLUSION
	With 3D assessment up to each point of the RV endocardial surface,
	our study demonstrates differences in RV function between ASD patients
	(preserved deformation) and TOF patients (reduced deformation), despite
	comparable shape remodelling. Left-to-right atrial shunt and pulmonary
	regurgitation are responsible for different types of RV remodelling,
	probably related to the underlying myocardial substrate in TOF patients.

Table 1 : Main characteristics of the study groups

 1 Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging TABLES Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging

			Controls	ASD	Tetralogy of	p-value
			n=55	n=27	Fallot
					n=28
	Age, years		33.0[28.0-36.0]	30.0[19.0-42.1]	31.0[24.4-34.0]	0.42
	Female sex, n (%)		10 (47.6%)	11 (73.3%)	9 (60%)	0.46
	Height, cm		166.3±7.6	167.2±11.2	166.2±11.8	0.71
	Weight, kg		69.3±14.1	70.5±17.1	66.2±18.4	0.81
	NYHA class, n(%)	I or II	-	22 (81.5%)	23 (82.1%)	0.96
		III	-	5 (18.5%)	5 (17.9%)	0.95
	Heart rate, bpm		68.3±12.4	76.1±13.4	79.3±15.2	0.73
	BNP, ng/mL		-	72.2[45.9-81.0]	85.0[49.3-96.8]	0.39
	QRS duration, ms		-	104.0[87.1-108.9] 140.0[121.3-167.2] 0.0006
	Frame rate, Hz		26.0[24.0-28.0]	23.0[21.6-26.0]	25.0[22.0-26.0]	0.53
	ASD, atrial septal defect; BNP, brain natriuretic peptide; NYHA, New York Heart Association; PAH,
	pulmonary arterial hypertension

Table 2 : Echocardiographic characteristics of the study groups

 2 septal defect; EF, ejection fraction; LV, left ventricular; RV, right ventricular; TAPSE, tricuspid annular plane systolic excursion; TV s', tricuspid annular peak systolic velocity. Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging

		ASD	Tetralogy of Fallot	p-value
		n=27	n=28
	RV diameter, mm	43.0[40.2-48.0]	45.0[42.7-49.3]	0.35
	RV wall thickness,	5.0[4.0-5.5]	8.0[6.7-8.3]	<0.001
	mm
	TAPSE, mm	28.0[24.1-30.9]	19.0[18.0-20.0]	<0.001
	TV s', cm/s	14.9±3.4	10.8±3.3	0.006
	LV EF, %	60.6±5.6	60.8±8.3	0.96
	ASD, atrial

ACKNOWLEDGMENTS

The authors would like to thank Shuman Jia and Come Le Breton (Inria) for their help with the CGAL software.

Funding sources: This study was partly funded by a grant from the University hospital of Nice, France (AO2I-2013). The authors also acknowledge the partial support from the European Union 7th Framework Program (VP2HF FP7-2013-611823).

Preprint version accepted to appear in European Heart Journal Cardiovascular Imaging. Final version of this paper available at https://academic.oup.com/ehjcimaging function but also the onset of ventricular arrythmias [START_REF] Bonello | Right atrial area and right ventricular outflow tract akinetic length predict sustained tachyarrhythmia in repaired tetralogy of Fallot[END_REF] . Due to limited magnetic resonance data, we could not relate infundibular curvature data to the extent of the akinetic RV outflow tract area.

Other studies tried to assess RV shape in TOF patients: Zhong et al. [START_REF] Zhong | Right ventricular regional wall curvedness and area strain in patients with repaired tetralogy of Fallot[END_REF] used cardiac magnetic resonance data but failed to demonstrate any difference at the RV outflow tract level between TOF patients and controls.

In contrast, a recent 3D magnetic resonance study pointed out curvature differences at the RV outflow tract level between TOF and control patients but no difference in this area between TOF patients with or without transannular patch [START_REF] Zaidi | Three-dimensional analysis of regional right ventricular shape and function in repaired tetralogy of Fallot using cardiovascular magnetic resonance[END_REF] . Our study goes further by jointly assessing RV shape and strain in TOF patients, and in 3D and locally, using 3D echocardiography. However, our cohort of patients was too limited to distinguish patterns depending on the type of repair, with more than 80% patients having history of trans-annular patch.

Previous authors implied that mechanical wall stress was inversely proportional to the local RV curvature 2 . The characterization of RV shape with local 3D curvature indirectly reflects the effects of chronic volume loading and allows better understanding of RV remodelling. While marked differences in strain data were observed in the trabecular septum, no significant difference in curvature was observed between TOF and ASD patients, indicating that RV shape may carry independent information. Therefore, for the assessment of TOF patients, RV shape and deformation could provide complementary insights into disease, and their potential for prognosis should be confirmed on larger cohort.


Abdelfettah Benchenna

Dominique Marchetti

Writing between the "red lines" Morocco's digital media landscape

Keywords: Censorship, digital press, field, journalism, Maghreb, media freedom, Morocco, political economy Censorship, digital press, field, journalism, Maghreb, media freedom, Morocco, political economy

This paper present an overview of the emergence of online news sites, which has radically altered news provision and media consumption patterns in Morocco. This sector has rapidly become a strategic site. Firstly, its precedence over print media and national television networks does not only stem from the high traffic figures of news websites. Along with certain social platforms, these websites are the only place for 24/7 news in a country which currently has just one such news channel and where, in spite of the "liberalization" of media, national networks provide very institutionalised news programs. Secondly, certain domestic Arabiclanguage news websites have become the main platform for the voicing of political dissent. Based on 31 interviews, the article briefly describes the historical development of the online press, since the "February 20th Movement" of 2011. This case study provides a good example of the new challenges surrounding the control of information: an issue long shaped by the limitation of news provision to duly authorised political and journalistic organizations and by limited "demand" resulting from widespread illiteracy. This paper describes how the Moroccan establishment react to the explosive growth of online news media by creating new mechanisms to control it.

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(irrespective of the medium: book, newspaper, etc.) stood at 2 minutes among people aged 15 and above. Paid print titles, which have experienced a sharp decline (250,296 papers in circulation in 2009 compared to 175,760 in 2014) (Source: OJD Morocco), are almost exclusively read by an urban demographic endowed with greater cultural and economic capital and mainly living in the Rabat-Salé-Kenitra and Casablanca-Settat areas.

These patterns in media consumption have been disrupted by the expansion of the Internet in a country where the penetration rate stood at 63.7% in 2017, according to the National Agency for the Regulation of Telecommunications (ANRT). Morocco has actively developed Internet usage, with 21 million Internet users in 2016 according to the International Telecommunication Union. Morocco was ranked third in the category "Arab countries", after Egypt (39 million) and Saudi Arabia (24 million). The "February 20th Movement" of 2011 and the uprisings (Hirak) which began in 2016 in the northern Rif region are a sign of the growing influence of online news, which is no longer limited to written articles but increasingly encompasses audio or visual formats. This development has led to a sharp increase in online traffic in a country where the majority of Internet usage occurs on cell phones: 66.5% of Moroccans rely on mobile devices for Internet access and 94% of overall Internet subscriptions are tied to cell phones plans. This expansion of the audience -a process already well under way with the development of domestic and foreign television networks, private radio stations (Sonay,

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2017), and Arabic-language newspapers in the years 2000 -is reflected in the high number of visitors attracted by online media in comparison with the printed press.

According to a 2015 study [START_REF] Lms-Csa | [END_REF], based on a sample of literate Moroccans aged 15 and above, 67% of respondents said they read the online press, while 17% favoured the printed press and 26% read both. In addition, the demographics of online news readers departs from that of print media readers.: it is at once more female (73% of women visit online news sites, while 8% of them read print titles) and younger (respectively 70% versus 8% of respondents aged 15 to 24). Interestingly, according to Alexa's "one month ranking",1 ten domestic general news sites were as of mid-October 2018 among the 50 most visited websites, including Hespress.com (created in 2007) and Chouftv.ma (2012), ranked after Google.com and YouTube.com but before Facebook. Other general news "pure play" outlets (Le360.ma, 13 th , Akhbarona.com, 14 th , Goud.ma, 21 st , Lesiteinfo.com, 23 rd , and Barlamane.com, 26 th ), all created after 2011, complete the group. Only four websites with ties to print titles -both weeklies (Alayam24.com, 58 th ; Telquel.ma, 90 th ) and dailies (Lematin.ma, 70 th ; Alyaoum24.com, 88 th ) -feature in the 150 most visited websites, before or after other popular Arabic-language pure play outlets (Aljarida24.ma, 49 th , Lakome2.com, 69 th , Febrayer.com, 102 nd , Alaoual.com, 138 th ). Lastly, several websites in the "general sports" category also garner heavy traffic Elbotola.com and Hesport, ranked 19 th and 38 th ), as well as a few regional outlets based in northern Morocco (Nadorcity.com, 45 th , Tanja7.com, 98 th , and Tanja24.com, 100 th ), in Marrakech (Kech24.com, 46 th ) or Fes (Fesnews.net, 97 th ). The scope of these media appears considerably broadened by Morocco's status as a country of emigration.

Because of this, international traffic, mainly tied to the diaspora, can carry a lot of weight: it makes up over 20% of traffic on many websites, including the most popular (Chouftv.ma, Hespress.com). France generally comes in 2 nd place, with overseas traffic making up a major share of visits on the more Francophone and Francophile websites (10.7% on Le360.ma,15% on Telquel.ma,16.4% on Desk.ma,20.9% on H24.ma and 35.9% on Medias24.com). For a website originally explicitly addressed to Moroccans expatriates such as Yabiladi -which has since evolved towards more generalist newsthe share of traffic coming from France exceeds that coming from Morocco (35.8% versus 21%).

As it broadened the scope of its audience, the online media sphere boosted an already thriving news sector in Morocco: by the end of 2017, the Ministry of Culture and Communication had identified 656 authorised news sites, versus 262 in 2015 (Ministry of Culture and Communication, 2018a). While these websites are often short-lived, the sector has rapidly become a strategic site for the production and dissemination of news for at least two reasons. First, its precedence over print media and national television networks does not only stem from the high traffic figures of news websites: along with

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certain social platforms, these websites are also the only place for 24/7 news in a country which currently has just one such news channel and where, in spite of the "liberalization" of media (Hidass, 2010;[START_REF] Issiali | Liberalization of the Moroccan Broadcasting Sector: Breakthroughs and Limitations[END_REF], national networks provide very institutionalised news programs. As a result, controlling the images circulated on digital media, especially online videos (which require since 2016 a filming permit issued by the Moroccan Film Centre), has become the authorities' main focus.

The second reason why these outlets have become a strategic site is that certain domestic Arabic-language news websites -with foreign-based media currently drawing in less visitors than their national counterparts (source : Alexa) -have become the main platform for the voicing of political dissent against the power structure.

Al Jazeera was ranked behind Hespress in terms of traffic according to a study carried out in 2010/11 also citing Alexa (Zaid and Ibahrine, 2011: 55), but the top foreign general news websites lagged far behind in mid-October 2018: among them were two London-based pan-Arab media, Arabi21.com (62 nd ) and Alaraby.co.uk (164 th ), Aljazeera.net (223 rd ), the Englishversion website of the transnational Russian TV network Russia Today Rt.com (275 th ). The top French-language website was nouvelobs.com (285 th ).

Along with social media, these websites have become a space of political confrontation for the more politically-inclined of readers, including websites in Arabic -a language long held to be "the language of silence", as Anouk Cohen put it (2011). Many of these

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media were created by former journalists critical of institutions and at odds with the mainstream newspapers ahead, during or in the wake of the "February 20th Movement" of 2011: such is the case for the Arabic-language websites Lakome.com (Aït-Mouss and Ksikes, 2018), Goud.ma and Febrayer.com. These websites, which have or have had connections with the social movement's core demands -with reporters often being called out as "militant" or "activist" in an effort to discredit them -have faced prosecution. In addition to these media often labelled as left-wing, this category comprises websites with various ties to the Islamist conservative party PJD -also polarising the "partisan field", in an ideological sense (Bennani-Chraibi, 2013: 1181-86), and which became the main ruling party in 2011 -and other websites furthered by senior members of the ruling elite ("the yellow press", as their detractors call them). This surge in various forms of critical news was a key component in a wider international context that led to the 2011 "uprisings" in several predominantly Arabicspeaking countries, driving dominant sections of the ruling elite to seek control over said outlets' influence on the political and journalistic spheres through various means: the creation of new online media; the prosecution of website managers 2 ; the legal and political reorganization of the journalistic sphere through the reshaping of the "journalists' code" in 2016 (Loi n°88-13 relative à la presse et à l'édition, 2016), which now 2 In 2013, Ali Anouzla, director of the Arabic version of the news website Lakome, was incarcerated by the King's Attorney General for "providing material assistance", "promoting" and "inciting terrorist acts" after the website posted a link to a propaganda video by Al-Qaeda in the Islamic Maghreb. The website (both French and Arabic versions) was shut down and resurfaced in 2014 under another name, Lakome 2, with very little financial resources. L'Économiste, launched e-formats of their print editions. This first tendency led to the proliferation of websites merely designed to "replicate all or part of a print edition's content in a PDF or Web format, with a day or a week's delay according to frequency" (Naji, 2011: 242). In addition to traditional print outlets, news portals launched by telecommunication operators have been another tendency furthering the emergence of news websites. This second tendency was promoted by two new entrants: Menara, launched by Maroc Télécom in 1995 (Menara, 2016), and Inwi (formerly Wanadoo) in 1999 (traffic on these sites has since plummeted). These portals first focused on aggregating editorial content found on print titles' websites. Content aggregation was also promoted by young IT engineers living abroad, often working outside the field of journalism and engaging with online tools (Scopsi, 2009;[START_REF] Souley | L'internet des diasporas noires aux États-Unis, en Grande-Bretagne et en France[END_REF]Guye, 2009). In 2006, a number of regional online media were launched, most of them based in northern Morocco (Nador, Oujda and Errachidia). These media were not traditional press outlets, but rather experiments launched by small groups of publishers developing a grassroots approach to journalism -one apparently more appealing than the regional sections of Casablanca or Rabat-based national newspapers (Naji, 2011: 244). This second phase also included, in 2007, the gradual transformation of several aggregators into pure play outlets, as was the case for Yabiladi or Hespress (the latter originally marketed itself as a "participatory platform"). Several advertising agencies specialising in online services, such as Adweb and Pub Online, were created that same year. A third phase, beginning in 2010/11, saw the emergence of several pure play outlets. Along with a few Arabic-language newspapers, these predominantly Arabic-language outlets became an alternate site for the voicing of political criticism against the power structure.

The new Constitution adopted in 2011 in the wake of the uprisings accelerated the boom in online news.

Loose professional and economic structuring

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In Morocco, massive traffic on news websites should not hide the fact that online media whose actual shareholders may be difficult to identify. Most website owners rely on personal -and often modest -funding during the initial funding stage. With the exception of a few outlets (including Le360.ma, HuffPost and Elbotola.com), initial investments in digital media seldom exceed 100,000 dirhams (less than 10,000 euros) according to the publishers we have interviewed. A lot of websites are "pure-play" businesses, and their founders do not necessarily apply the strategies of a "media outlet" -in the words of a website manager (Interview with the authors, March 22, 2016), such outlets apply the same management methods as those of a "grocery" (Hanout). The prevalence of an economic model based on free access also points to the fragility of the sector. Apart from ledesk.ma, a media outlet launched in 2015 which relies on paid subscriptions, all other outlets have opted for free access models and rely on advertising or invisible investments. The website's main founder (El Azzaz, 2018) claimed that ledesk.ma "raised more than 700,000 euros in funds but did not reach the initial target of 10,000 subscribers after one year in operation". A year and a half after its launch, the website introduced two different pay models: a paywall, and a freemium offer which includes digital advertising (Ledesk.ma, July 25, 2016).

However, online news sites hardly benefit from advertising revenues. According to a 2018 survey conducted by IPSOS for the Moroccan Group of Advertisers (GAM), Google and Facebook get the lion's share of these revenues with 62% of the overall budget allocated to digital media, while domestic websites only receive a 38% share. In

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2015, digital advertising allegedly reached 400-450 million dirhams (6.25% to 7% of advertisers' overall budget). For digital companies such as Telquel.ma or HuffPost Maroc, the development of branded content strategies, whose aim is to promote values that the brand wants to be associated with (Interviews with the owners, April 11 and 14, 2016), is not sufficient to ensure economic growth.

As is the case with print titles, advertising revenues for digital media vary depending on whether the title is published in French or in Arabic. Among the 656 digital titles authorised by the Ministry of Culture and Communication in 2017, Arabic remains the most frequently used language: 49.5% of websites are in Arabic only, 25.6% offer content in two languages (Arabic and French), 2.3% in three languages (Arabic, Amazigh and French), 18.5% are multilingual websites and 4.1% use French only. French-language media may have become a "niche" market (as advertising professionals would say), but in terms of advertising revenues it is the most profitable market because it is directed at an audience with greater economic and cultural capital (Authors removed, 2017: 255-256). There is a paradox here, summarised as follows by the manager of a bilingual online news outlet (published in French and Arabic): "French is the language of economics, but not the consumers' language" (Interview conducted on October 21, 2015). "You know, advertisers are terrible

Economic, political and career opportunities: a few owners' professional trajectories

This new sphere in the production and dissemination of information has developed because journalists and entrepreneurs in various lines of business saw digital media as another way of developing their political, journalistic and/or economic activities.

Among these entrants and investors, particularly noticeable are the trajectories of a few journalists who have always been strongly critical of the regime. But they also show the limitations imposed upon these new media whenever the basic interests of the ruling elites are at stake. These middle-aged journalists were the owners of print outlets which were pushed into bankruptcy; they quickly saw digital media as a new opportunity -a new place of expression that would be free of censorship [START_REF] Jamaï | Aboubakr Jamaï : Seuls les médias en ligne sont libres[END_REF]. Ali Anouzla and Aboubakr Jamaï, who launched the news website Lakome.com in Arabic in January 2011 and later added a French version, match this description. In 2004, Ali Anouzla and Taoufik Bouachrine co-founded a weekly newspaper named Al-Jarida al-Oukhra ("The Other Newspaper"), which was discontinued two years after its launch. It included editorials from political dissidents, becoming famous for its 2005 "Person of the year" poll -in which King Mohammed VI slumped to second place [START_REF] Tuquoi | Au Maroc, un sondage détrône le roi Mohammed VI[END_REF] a 2005 report on the daily life of princess Lalla Asma, the King's wife [START_REF] Tuquoi | Au Maroc, la princesse aux pieds nus attire sur la presse la colère du Palais[END_REF].

These two issues led to the demise of Al-Jarida al-Oukhra at a time when the newspaper had a weekly circulation of over 50,000 copies. Shortly before that, Ali Anouzla joined the founding team of the Arabic-language daily Al-Massae ("The Evening Paper"), which he left two years later, in 2008, to launch Al-Jarida al-Oula ("The First Newspaper"). This title also ceased to be published in 2010 because of financial difficulties arising from a lack of advertising revenues and a series of finesincluding a $120,000 fine following the publication of an editorial lambasting Libyan president Muammar Gaddafi. According to Ali Anouzla, the Lakome online news site was "a haven. My newspaper had been shut down […], we had been forced to bury the idea. I can remember the day -I mean, the day when the printing company told me 'Listen, we're not going to print your paper today'… It was a tough blow. We had no other choice -it was a day of mourning at the office" (Interview, October 20, 2015). For his associate Aboubakr Jamaï, digital media was also a "haven" after several Moroccan weekly, that Sahrawi prisoners in Tindouf, Algeria, were "refugees" according to the UN, and not "people who are being held captive by the Polisario Front" [START_REF] Lmrabet | Ali Lmrabet chez Ubu Roi du Maroc[END_REF]. Following legal proceedings, the online outlets of these four journalists -who are among the most critical of the regime -have either ceased to exist or been seriously threatened.

At the same time, online news outlets have logically attracted younger salaried journalists from print titles, who saw online media as an ideal opportunity to launch their own outlets and free themselves from various forms of censorship. Among these journalists is Maria Moukrim, who worked with Noureddine Miftah at the weekly Assahifa from 1999 to 2001, then for the weekly Al Ayam (Hespress, 2009) for ten years [START_REF] Tizpress | Licenciement sans dédommagement de Maria Mokrim, rédactrice en chef de l'hebdomadaire Alayam[END_REF], where she occupied the position of editor-in-chief; in 2012, following As for the rest of the entrants, the reasons for investing in the sphere of digital media

have not yet been clearly identified. We can assume that the presence of IT engineerssuch as the founders of the online news outlet Yabiladi.com (Mohamed Ezzouak), the sports website Elbotola.com (Oussama Benhammou and Akram Benmbarek), Hibapress (Mohamed Lakbir), Hespress (Amine Guennouni being one of its cofounders) and the actual owner of Telquel magazine (Khalid El Hariri) -is to a certain extent related to the operational specificities of digital media, in which technical and commercial dimensions are closely intertwined. It is worth noting that, from a purely economic point of view, the websites they have created seem to be the most viable type.

For entrants coming from the distribution sector -particularly free newspapers -such as the founder of the Géomédia group and owner of the H24info.ma "pure play" outlet, investing in digital outlets is part of a commercial strategy aimed at furthering their activities in the field via other media.

Lastly, the trajectories of a number of entrants seem to be linked to their connections with members of the Moroccan establishment -in a more or less direct and visible way. who contributed to its launch is Aziz Daki: a gallery owner and art critic at the time he invested in this holding company (which controls Le360.ma), Daki is very close to the King's private secretary Mounir Majidi, who was recruited as artistic director and spokesperson of the Mawazine Festival -Morocco's major musical event [START_REF] Michel | Maroc : la méthode d'un média proche du palais pour « dégonfler » les scoops gênants[END_REF]. Another example is Abdelmalek Alaoui, the son of one of King Hassan II's counsellors and founder of a company which owns HuffPost Maroc and also operates in the field of "strategy consulting, specialising in active competitive intelligence all across West Africa" (Guepard Group, 2019). These suspicions are heightened by the lack of certainty as to the actual financial backers of these online news outlets.

Control mechanisms and dependence on political actors

The reaction of the Moroccan establishment to the explosive growth of online news media was to create mechanisms designed to control it -a process that started in 2011.

As is the case with print titles, one method of establishing political control through legal mechanisms is to punish non-compliance with the "red lines", as they are called in Morocco (Hidass, 2016). In an "ethical code" posted on the news website Le360.ma, these red lines are defined as follows: "While being committed to the main universal values, the editorial board of Le360 complies with the core values of Moroccan society:

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tolerant Muslim faith, national unity in a remarkably diverse society, and monarchy as the nation's unifying institution" (Le360.ma, 2019). This kind of notice is extremely frequent in the latest regulations related to the media industry. For instance, Article 179 of the Criminal Law (2016) provides for steep fines and prison sentences for "libel, insult and offense directed at the King's person or Heir to the Throne, as well as any violation of the respect owed to the King" or "any violation of the royals' private life".

In the same way, Article 267-5 states that "anyone attacking the Muslim religion or the monarchy or making statements harming the Kingdom's territorial integrity" may incur fines and prison sentences. The 88-16 Regulation on media outlets and publishing companies provides for "suspension" (Article 104), "cancellation of the publication's serial number or removal of its journalistic content", as well as blocking "access" in the case of a digital media (Article 106)

As the two following journalists explain, these "red lines" may also influence an outlet's ability to attract advertisers -albeit in a more subtle fashion. "It's always the same questions: 'What is your take on the situation in [Western] Sahara? How are you going to report on the monarchy?' People were telling us: 'Okay, we're going to help you, but let's see how things shape up after the launch.'" (Interview conducted on October 20, 2015 with the creator of an online news outlet who detailed the difficulties encountered in raising funds for his company, including through the use of advertisers).

"The only explanation is that they disagree with our editorial content. The director of a major PR firm candidly told me that there are other journalists who 'defend the nation's

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interests'. He was very direct in the words he used: 'Those are the real guys, they defend His Majesty. You don't defend His Majesty, so we're not going to provide advertising for you'. His agency defends the interests of major clients, big corporations, etc." (Ali Amar, Le Monde Afrique, October 20, 2016) In order to control access, production conditions and contents, authorities also seek to impose general rules to this normless space by establishing legal regulations applying to the press industry in general -and digital titles in particular since 2016. For example, Article 11 of Decree 89-13, adopted in 2016 in relation to the practice of journalism, stipulates that "it is forbidden for any media outlet to employ journalists for more than three months if the journalist's press card for the ongoing year has not been delivered to or requested by the journalist". Article 35 of Decree 88-13 on media outlets and publishing companies states that every online news outlet shall apply for a "filming permit delivered by the Moroccan Film Centre […], valid for one year and renewable every year, in line with the regulations applying to audio-visual productions in the field of digital media". Lastly, Article 36 specifies that "comments and links posted by Internet users on the website are subject to the principle of freedom" and that "managing editor shall not publish material that would be considered as a crime under applicable regulations, and must remove any comment that is deemed offensive". These legal provisions can be used to support prosecutions against journalists for issues related to their work -especially when they do not comply with the "red lines" -but also, in a more frequent if not altogether new trend, for matters pertaining to their private lives. In that respect, the recent example of Hicham Mansouri, a project manager within the Moroccan Association of Investigative Journalism, is enlightening: in 2015, he was handed a three-month prison sentence for "public drunkenness" and "assaulting public officials", namely police officers. Taoufik Bouachrine, who runs the daily newspaper Akhbar El Yaoum and the AlYaoum24 website, has been attacked over his private life on two occasions. On February 23, 2018, he was arrested and jailed after being accused of "human trafficking", "abuse of position for sexual purpose" and "rape and attempted rape". The accusations were based on video footage discovered in the journalist's office on the day of his arrest -but the footage has not been made public.

Mr. Bouachrine strongly denies these attacks and claims to be the victim of a "political trial" (AFP, 2018).

Since 2016, another way for authorities to maintain their control has been the creation of new and highly selective support mechanisms for digital media. For instance, of the 69 companies with digital media outlets in operation in 2016, only 7 had benefited from government support. Among other methods of controlling journalistic activities, the interviewees have also singled out the ruling elites' control over the police force and intelligence services. "What kind of pressure did we face today? So, we've had the odd visit from the local intelligence services -actually, it's not that unusual, I think it's part of their job. Other than that, there have been a few hassles: we were trying to create a nice work environment, with some degree of comfort, and then the health and safety inspector came to visit us -twelve times. I thought he might be looking for a bribe, but no. On his tenth visit, he told me: 'Look, they asked me to pay you a visit, so I'm paying you a visit. I don't want any money, I don't want anything at all, but I have to write something'. So, he came to our offices, and it was… The first time, it was about the fire extinguisher, another time it was, 'You should have a notice somewhere detailing labour rights for staff members'. No one was working undeclared, every foreign employee had a contract, but he told me: 'I have to find something wrong here, because I need to have that as a precaution'. They need to know your weaknesses. For now, we don't have any, but soon…" (Interview with the manager of a "critical" online news website, April 13, 2016) Lastly, other ways of maintaining surveillance over these outlets include attempts at controlling the technologies they use -hacking or trying to hack their websites, slowing down or shutting down their Internet connection or SIM card.

(

  with the pan-Arab website Kooora.com, ranked 10 th , and two Moroccan sports sites, http://mc.manuscriptcentral.com/

  online media. As BouzianeZaid has argued (2016), the Internet (and especially the online press) catalyses a "change" -all the while serving as a new "instrument of repression". After briefly describing the historical development of the online press, this paper will present an overview of the contemporary workings of this nascent sphere and the issues at stake. This paper stems from an ongoing study initiated in 2015 with Driss Ksikes and largely based on interviews (n=31) conducted with him between 2015 and 2017. Interviews were also conducted with heads of the main online and print news titles as well as with journalists having worked in various media, past and present, central to the journalistic sphere since the 1980s and 1990s. They are only briefly mentioned here for reasons of space. The development of Moroccan online media: from content-reproduction and aggregation to the rise of "pure play" outlets The early days of the online press in Morocco in the late 1990s were marked by the emergence of two distinct movements, nonspecific to Morocco. The first of the two refers to the creation of websites designed for the sole purpose of showcasing print newspapers or magazines, or what Pierre-Jean Benghozi (2013) called a "pro forma digitality". Certain media outlets, such as Maroc Hebdo and the weekly newspaper http://mc.manuscriptcentral.com/

  Articles published in newspapers were taken up, often without requesting the consent of beneficiaries, and posted on websites such as bladi.net or Maghress.com. A typical case is the website Yabiladi, created in 2002 by Mohamed Ezzouak, a young French national of Moroccan descent (Author removed, 2014). This tendency is not specific to Morocco, as Hadj Bangali Cissé (2010: 137) and Thomas Guignard (2007) have shown: similar media projects have been launched by Senegalese expatriates (SénéWeb, Xalima, Homeview Sénégal, Ferloo.com, Nettali.net), by Beninese nationals in France (Opays.com), or by Ivorians in the United States (Abidjan.net). Aside from contentaggregation, and in the hope of consolidating their business, these outlets also provide http://mc.manuscriptcentral.com/generally positioning themselves as service providers in Web development and Web hosting, domain trading, or new media, Internet and multimedia training.

  which are not backed by print publications remain loosely structured in both professional and economic terms. Documentation released by the Ministry of Communication highlights this loose professional structuring. In 2016, in an effort to regulate and control the field, the Ministry set out a number of provisions regarding the registering of news websites as media outlets (Ministry of Culture and Communication, 2018b). At the end of 2017, the Ministry numbered 656 authorizations issued for the creation of "325 Arabic-language websites, 27 French-language websites, 168 bilingual (French-Arabic) websites, 15 trilingual (Arabic-French-Amazigh) websites, as well as other multilingual websites" (Ministry of Culture and Communication, 2018a). However, other documentation issued by the same source states that in 2016, only 69 news websites employed journalists with a press card (Ministry of Communication, 2016)one of the necessary conditions for a news website to be registered as an online media outlet. These new outlets only employed 265 journalists 3 (approximatively 10% of the total amount of authorised journalists), with 58% of newsrooms employing only one to three journalists. Of course, the better-endowed among them are tied to the most wellstructured companies: Le360.ma (n=18) hires roughly sixty employees (Interview with the director, October 21, 2015), and its founders are close to the ruling monarchy; Alyaoum24 (n=15) is connected to Akhbar Al Yaoum, an Arabic-language newspaper http://mc.manuscriptcentral.com/Taoufik Bouachrine, who has close ties to the PJD and regularly faces prosecution; Hespress (n=15), the most popular website in Morocco; and Medias24 (n=14), an exclusively French-language economic news site. In comparison, media outlets labelled as the most critical of the power structure work with limited staff, as shown byLakome2.com, Badil.info (one journalist), Alaoual.com and Febrayer.com (which produce news with three professionals), or Goud.ma (which works with a team of four).Finally, this loose professional structuring may be noticed in the lack of available data on digital media producers. Most of them have no journalistic training (46% in 2012 according to a survey by ISESCO) and have no social security or work contract. Often dismissed as "opinion journalism" or "rumours", online news media work with limited human resources, even if some of its leading figures have sought to acquire professional credit (sometimes an economic necessity): several major websites have hence tried to create a professional organization designed to represent them when dealing with political institutions(Médias24, 2014). This emerging sphere also lacks reliable financial structuring. General information about media owners in Morocco is often incomplete, as noted in the investigation published by Reporters Without Borders and Le Desk in 2017(Le Desk-RSF, 2017), but evidently online news outlets rarely benefit from substantial investment -except when they are part of integrated advertising agencies such as Géomédia or Media Holding, or corporate groups and institutions http://mc.manuscriptcentral.com/

  […], they have their own rationale, lobbying agenda, practices […], and most of them cannot read Arabic", he adds. Significantly, according to a 2018 Ipsos survey carried out with executives and digital marketing and communication managers in Morocco, 95% of advertisers use French on websites and social media, while 47% and 44% of them use http://mc.manuscriptcentral.com/websites and social media, respectively, with darija, the Moroccan Arabic dialect, exceeding the use of standard Arabic on social media (51%).

  experiences in print media. He founded the weekly newspaper Le Journal with Ali Amar in 1997, along with its Arabic edition Assahifa. Both were banned in 2000 after publishing a report on the involvement of Moroccan left-wing parties and the then Prime Minister in the 1972 coup attempt against King Hassan II. Le Journal hebdomadaire and Assahifa Al Ousbouiya were discontinued after a 2010 court order, http://mc.manuscriptcentral.com/failure to pay off the debt owed to the National Social Security Fund, tax authorities and several banks (Benslimane, 2015). Among these journalists who found a "haven" in digital media following their experiences with print titles, Ali Lmrabet embodies a different type of trajectory. Before founding the online magazine demainonline.com in 2011, Lmrabet had already created two weeklies in 2000 -one in French (Demain Magazine) and the other in Arabic (Doumane) -which ceased to be published in 2003 when he was given a four-year prison sentence for offending King Mohammed VI. He was sentenced a second time in 2005 and banned from working as a journalist after stating, in an interview with a

  Among these entrants is Edit Holding group, owner of the French-Arabic news portal Le360.ma -the news outlet with the most human and material resources. One person

  Naturally, such tight control over news outlets has been met with resistance in different ways. Within domestic borders, the ruling elites' actions in Morocco have been criticised by a number of print and digital titles (with the latter struggling to secure http://mc.manuscriptcentral.com/However, the frequent prosecutions, or threats of prosecution, especially when the defendant is accused of breaching the "red lines", are likely to encourage selfcensorship. Social media -Facebook in particular(El-Issawi, 2016: 26-27) -operate as a genuine alternate space where people can share comments and political information, for instance by uploading videos during a protest. Facebook has not been targeted, which explains the vast discrepancy between the fierce political criticism found on social media and the much more contained criticism expressed in national print and digital media. Foreign national media spaces (especially France and Spain), as well as transnational ones (especially Arabic-language media such as Al Jazeera online edition) continue to play this role, even though their correspondents too are subject to strict self-www.jadaliyya.com/Details/36378/The-Life-Span-of-Alternative-Media-in-a-Hybrid-Configuration-Cases-of-Lakome-and-Mamfakinch-in-Morocco (J and Lyubareva I (2013) La presse française en ligne en 2012 : modèles d'affaires et pratiques de financement. Culture études 3: 1-12.Bennani-Chraïbi M (2013) L'espace partisan marocain : un microcosme polarisé ?.Revue française de science politique 63 (6): 1163-1192. Benslimane M (2015) "Presse indépendante" et pouvoir. Le Journal (1997-2010) promoteur du trône au Maroc. Une psycho-socio-anthropologie historique du journalisme politique. PhD Thesis in political science, University of Grenoble-Alps, France. Caubet D and Miller C (2017) Quels enjeux sociopolitiques autour de la darija au Maroc ? In: Laroussi F and Sini C (eds) Langues et Mutations sociopolitiques au Maghreb Rennes: Presses universitaires de Rouen et du Havre. Cissé H B (2010) La presse écrite sénégalaise en ligne: enjeux, usages et appropriation des technologies de l'information et de la communication par les journalistes (1980-2008). PhD Thesis in Information and Communication Sciences, Université Paul Verlaine Metz, France. http://mc.manuscriptcentral.com/2011) La langue du silence dans le Maroc urbain contemporain. Revue de l'histoire des religions 228 (2): 245-263. El Azzaz Y (2018) Au Maroc, les sites d'information luttent pour leur survie. Le Monde, 4 March, 2018. El Issawi F (2016) Moroccan National Media: Between Change and Status Quo.

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  Al Ayam's owner, she launched Febrayer.com. In the same way, Hamid El Mahdaoui started his career at Al Ayam, joined Chouf TV and Lakome.com in 2013, and created Badil.info in 2014.

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  Report, LSE Middle East Centre Report, April. /www.guepardgroup.com/fondateur.html (accessed 20 May 2020) Gueye M (2009) Le site portail seneweb.com, lieu virtuel de convergence des sénégalais à travers le monde. In: Actes du symposium NetSuds 2009, Tic et mobilités, diasporas, migration. Bordeaux, October. Guignard T (2007) Le Sénégal, les Sénégalais et Internet : médias et identité. PhD Thesis in Information and Communication Sciences, Université Charles de Gaulle Lille, La jeune journaliste, Maria Mokrim, nommée rédactrice en chef de l'hebdomadaire le plus diffusé du Maroc. Hespress, 9 January, 2009 (in arabic). Available at: https://www.hespress.com/medias/10423.html (accessed 21 Octobre 2016) Hidass A (2016) Quand "l'exception" confirme la règle. L'encadrement juridique de la liberté de la presse écrite au Maroc. L'Année du Maghreb 15: 29-44. De los manuscritos medievales a internet: la presencia del árabe vernáculo en las fuentes escritas Zaragoza, University of Zaragoza, pp. 419-440. Ministry of Culture and Communication (2016) Liste nominative des journalistes détenteurs de carte de presse professionnelle. Report, Ministry of Communication of Morocco (in arabic). /www.mincom.gov.ma/donnees-a-propos-les-autorisations-de-creation-de-siteselectroniques/ (accessed 19 September 2019) Ministry of Culture and Communication (2018b) Liste des documents pour la demande de renouvellement. Numéro de la commission paritaire la presse écrite électronique Media et Société au Maroc. Diagnostic et feuille de route. Les sites web diasporiques : un nouveau genre médiatique ?.

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	(eds) Ministry of Culture and Communication (2018a) Données à propos les autorisations de
	Guepard http:/France. Hespress (2009) M Group (2019) C S Abdelmalek f o r R e Alaoui, v i e w CEO. M C S f o r R e v i e w M C S f o r R e v i e w création de sites électroniques March 20, 2018. M C S f o r http:/pour l'année 2018. Available at: R http://www.mincom.gov.ma/a/wp-Available at: Available at: content/uploads/sites/2/2018/09/5.pdf (accessed 3 January 2019) Mouhtadi N (2008) Pouvoir et communication au Maroc. Monarchie, médias et acteurs politiques (1956-1999). Paris: L'Harmattan Publications. e v i e w
	Naji J E (ed) (2011) Casablanca: Editions Maghrébines.
	Scopsi C (2009) Tic&société 3(1-2): 80-100.
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The statistics in this paragraph are based on data by Alexa (accessed October 18,

2018), displaying therefore only broad tendencies.

The data used is that provided in the document "Liste nominative des journalistes détenteurs d'une carte professionnelle" [List of Journalists with a Professional Press Card] released by the Ministry, which stated that it reflected the situation as of August 30, 2016.

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