Case report
Prosthetic aortic valve: A bone in the system
Prótese valvular aórtica: «um osso na engrenagem»
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=> "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Joana" "apellidos" => "Guardado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marina" "apellidos" => "Fernandes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Mário" "apellidos" => "Lourenço" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Inocência" "apellidos" => "Machado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Isabel" "apellidos" => "Quelhas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Olga" "apellidos" => "Azevedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "António" "apellidos" => "Lourenço" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cardiology Department, Alto Ave Hospital Center, Guimarães, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Prótese valvular aórtica: «um osso na engrenagem»" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1784 "Ancho" => 2500 "Tamanyo" => 459432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing multiple abscesses (asterisk) surrounding the single-disc mechanical prosthetic valve (cross). These abscesses had ruptured to the left ventricular outflow tract forming a pseudoaneurysm (white arrow) extending above the aortic valve plane. Severe periprosthetic regurgitation and mild to moderate mitral regurgitation were also noted (D). The images were obtained in mid-esophageal view at 0° (A); short-axis view (B); and long-axis view without (C) and with (D) color flow Doppler.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infective endocarditis (IE) is a relatively common disease with an estimated in-hospital mortality of 15–20%.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a> Currently, the most common agent of IE is <span class="elsevierStyleItalic">Staphylococcus aureus</span>, accounting for approximately one-third of cases,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> followed by <span class="elsevierStyleItalic">Streptococcus viridans</span>. This reflects a shift in the epidemiology of IE, mainly driven by medical progress and increased health care contact, and a consequent rise in the incidence of <span class="elsevierStyleItalic">Staphylococcus</span> bacteremia.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> It also reflects changes in the characteristics of patients with IE, with an increasing incidence of patients presenting with immunodeficiency and/or cardiac prosthetic devices.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> While multiple factors contribute to the pathophysiology of IE, the presence of bacteremia is an essential condition for the occurrence of an infection in cardiac structures.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> Prophylactic antibiotic therapy is therefore recommended for high-risk patients before some medical procedures.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Although not all procedures are considered in these recommendations, as discussed later, it should be kept in mind that, independently of its source, the occurrence of bacteremia is itself a risk factor for the occurrence of IE. In view of this consideration we report a case of a patient with prosthetic valve endocarditis following the removal of a foreign body from the esophagus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 73-year-old female patient presented to the emergency department complaining of asthenia, weight loss (>10% of initial body weight) and fever (38–38.5<span class="elsevierStyleHsp" style=""></span>°C) during the last four weeks. She had a history of a single-disc mechanical aortic valve implanted two years earlier due to severe aortic stenosis. She was taking warfarin and was doing well in the follow-up. After an initial diagnostic work-up, in which no infectious focus was identified, the patient underwent transthoracic and transesophageal echocardiograms. Both exams showed a normally functioning mechanical prosthesis, normal left ventricular systolic function, and no vegetations or images compatible with abscesses or other paravalvular complications (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">One month later, the patient presented again in the emergency department complaining of abdominal pain and persistent asthenia and fatigue. An abdominal computed tomography scan showed a large splenic mass and an exploratory laparotomy was performed. Intraoperatively, an extensive abscess was noted which extended to the diaphragm and ipsilateral pleural cavity. The spleen was removed and the material collected for microbiological analysis. Given this setting, and to exclude potential embolic sources, echocardiographic assessment was repeated. The transesophageal echocardiogram showed multiple abscesses (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A, asterisk) surrounding the single-disc mechanical aortic prosthesis (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A, cross). There appeared to be no communication between the abscesses and the cardiac cavities, thus excluding the possibility of a pseudoaneurysm (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B, white arrow) and there were no signs of prosthetic dysfunction. The patient began appropriate antibiotic therapy and was referred for surgery.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">While awaiting surgery a new-onset systolic-diastolic murmur was noted. The echocardiogram performed at that time revealed marked paravalvular involvement of the prosthetic valve with multiple larger abscesses (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and 3B, asterisks) surrounding the anterior, posterior and right portions of the prosthesis (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and 3B, cross) which communicated with the left ventricular outflow tract, forming a pseudoaneurysm that extended 3 cm above the aortic valve plane (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>C, white arrows). Severe periprosthetic regurgitation was also noted (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>D) and the patient underwent cardiac surgery. Meanwhile, microbiological study revealed the presence of <span class="elsevierStyleItalic">Streptococcus milleri</span> sensitive to the empirically started antimicrobial therapy. Interestingly, the patient had a history of ingestion of a bone fragment that had been removed from the esophagus by upper gastrointestinal endoscopy 2–3 weeks before the beginning of the constitutional symptoms. This event was the most probable portal of entry for the bacteremia. Unfortunately, the patient died in the perioperative period due to surgical complications.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Herein, we report a case of a fatal IE with extensive paravalvular complications in a patient with a mechanical prosthetic aortic valve, occurring some weeks after the removal of a foreign body lodged in the esophagus. While the origin of the bacteremia may be controversial in this case, <span class="elsevierStyleItalic">S. milleri</span> has been identified in the normal gastrointestinal mucosa<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> and has been previously described as an uncommon agent of IE.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> In a study comparing the clinical course of IE among <span class="elsevierStyleItalic">Streptococcus</span> species, Lefort et al. reported that the portal of entry was the gastrointestinal system in about 10% of cases caused by <span class="elsevierStyleItalic">S. milleri</span>.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> This information, together with the temporal association between the bone removal and the onset of symptoms, corroborates the idea that the ingestion and removal of the foreign body was the portal of entry for the agent identified in our patient. Additionally, <span class="elsevierStyleItalic">S. milleri</span> has been associated with a particular predisposition to pyogenic infections and abscess formation.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8,9</span></a> This characteristic may have contributed to the distinct clinical course of our patient's IE, which can be divided into two separate phases. After an initial locally indolent period without evidence of endocarditis or prosthesis dysfunction on the transesophageal echocardiogram, the patient experienced a rapidly evolving pyogenic phase of the disease in spite of appropriate treatment with broad-spectrum antibiotics. These complications ultimately led to systemic and paravalvular complications, with the formation of a pseudoaneurysm and several abscesses that were well documented on the transesophageal echocardiogram. The value of this exam in the diagnosis and management of IE is indisputable, with good sensitivity and specificity for the detection of vegetations and paravalvular complications. However, in the presence of mechanical prosthetic valves, as in the case of our patient, a negative transesophageal echocardiogram significantly decreases the likelihood of IE, but does not completely exclude the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> In such scenarios the clinical course assumes particular importance for a correct diagnosis.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> This may explain the absence of findings suggestive of IE on the patient's first transesophageal echocardiogram.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Finally, while in our patient the foreign body itself could have been responsible for the bacteremia, the question arises of the need for prophylactic antibiotic therapy in medical procedures. In recent years, recommendations for prophylactic antibiotic therapy have changed significantly.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> In fact, in the light of new evidence showing that IE is more likely to occur following bacteremia due to daily routine activities than following medical procedures, recommendations for prophylactic antibiotic therapy are now limited to high-risk patients undergoing dental procedures.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> While there is no compelling evidence supporting prophylaxis in patients undergoing gastrointestinal procedures, there are anecdotal reports supporting this practice based on clinical cases in which the gastrointestinal system was the portal of entry for the IE.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> Irrespective of the recommendations in the guidelines, it should be borne in mind that any condition predisposing to bacteremia is a foundation for the development of IE, particularly in high-risk patients. This recognition may lead to a more careful medical work-up after febrile illness in patients exposed to a potential source of bacteremia.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The present case highlights the variability in the clinical presentation of IE depending on the microbiological agent responsible for the disease, and reinforces the importance of bacteremia in its pathophysiology. Specifically, it illustrates the rapidly progressive course of IE caused by <span class="elsevierStyleItalic">S. milleri</span>, and shows striking images of paravalvular complications in a patient with a mechanical prosthetic aortic valve. This case also emphasizes that transesophageal echocardiography is less accurate in the diagnosis of IE in patients with mechanical prosthetic valves, in whom the clinical scenario may assume a preponderant role.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres847991" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec843009" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres847990" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec843008" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-20" "fechaAceptado" => "2014-08-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec843009" "palabras" => array:5 [ 0 => "Infective endocarditis" 1 => "Prosthetic aortic valve" 2 => "<span class="elsevierStyleItalic">Streptococcus milleri</span>" 3 => "Abscesses" 4 => "Pseudoaneurysm" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec843008" "palabras" => array:5 [ 0 => "Endocardite infecciosa" 1 => "Prótese valvular nórtica" 2 => "<span class="elsevierStyleItalic">Streptococcus milleri</span>" 3 => "Abcessos" 4 => "Pseudoaneurisma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report a case of a 73-year-old female patient admitted to the surgical department for a splenic abscess. She had a history of a mechanical aortic valve implanted two years earlier. During the diagnostic work-up, the patient underwent a transesophageal echocardiogram that revealed the presence of multiple paravalvular abscesses, establishing the diagnosis of prosthetic valve endocarditis. A few days later, the echocardiogram was repeated due to a new-onset systolic-diastolic murmur. A large pseudoaneurysm and significant periprosthetic regurgitation were now noted and the patient was referred for cardiac surgery. The microbiologic exam revealed the presence of <span class="elsevierStyleItalic">Streptococcus milleri</span>, usually found in the gastrointestinal flora and a known pathogenic agent of endocarditis. Interestingly, the patient had had a foreign body (bone fragment) removed from her esophagus a few weeks earlier, which was the probable portal of entry for this infective endocarditis.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores reportam o caso de uma doente de 73 anos de idade, do sexo feminino, admitida no Serviço de Cirurgia Geral por um abcesso esplénico. A doente tinha antecedentes de uma prótese mecânica em posição aórtica implantada dois anos antes. Durante o estudo diagnóstico foi realizado um ecocardiograma transesofágico que revelou a presença de múltiplos abcessos periprotésicos que permitiram estabelecer o diagnóstico de endocardite de prótese. Alguns dias depois a doente repetiu o exame por sopro sisto-diastólico de novo. Neste estudo destacava-se agora a presença de um volumoso pseudoaneurisma e uma regurgitação periprotésica significativa, pelo que a doente foi orientada para cirurgia cardíaca urgente. O estudo microbiológico revelou a presença de <span class="elsevierStyleItalic">Streptococcus milleri</span>, um constituinte normal da flora gastrointestinal e um agente patogénico já conhecido de endocardite infecciosa. Curiosamente, a doente tinha antecedentes de remoção de um corpo estranho alojado no esófago (um fragmento ósseo) algumas semanas antes, e que foi a provável porta de entrada para a endocardite infecciosa.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1131 "Ancho" => 1658 "Tamanyo" => 149413 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram in mid-esophageal long-axis view of the aortic prosthesis. No signs of prosthetic valve endocarditis were visualized at this point.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 861 "Ancho" => 2500 "Tamanyo" => 209310 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram in mid-esophageal short- (A) and long-axis (B) views of the aortic prosthesis, showing two abscesses (A, asterisk) surrounding the single-disc mechanical prosthetic valve (A, cross). There appears to be no rupture from these abscesses (B, white arrow) to the left ventricular outflow tract.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1784 "Ancho" => 2500 "Tamanyo" => 459432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing multiple abscesses (asterisk) surrounding the single-disc mechanical prosthetic valve (cross). These abscesses had ruptured to the left ventricular outflow tract forming a pseudoaneurysm (white arrow) extending above the aortic valve plane. Severe periprosthetic regurgitation and mild to moderate mitral regurgitation were also noted (D). The images were obtained in mid-esophageal view at 0° (A); short-axis view (B); and long-axis view without (C) and with (D) color flow Doppler.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changing profile of infective endocarditis: results of a 1-year survey in France" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Hoen" 1 => "F. Alla" 2 => "C. 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Casassus" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Intern Med" "fecha" => "2002" "volumen" => "162" "paginaInicial" => "2450" "paginaFinal" => "2456" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12437404" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0100" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (“Streptococcus milleri group”) are of different clinical importance and are not equally associated with abscess" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.E. Claridge 3rd" 1 => "S. Attorri" 2 => "D.M. Musher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/320163" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2001" "volumen" => "32" "paginaInicial" => "1511" "paginaFinal" => "1515" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11317256" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1699258X13001964" "estado" => "S300" "issn" => "1699258X" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0105" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "‘Streptococcus milleri’ aortic valve endocarditis and hepatic abscess" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Rashid RM1" 1 => "W. Salah" 2 => "J.P. Parada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1099/jmm.0.46781-0" "Revista" => array:7 [ "tituloSerie" => "J Med Microbiol" "fecha" => "2007" "volumen" => "56" "numero" => "Pt 2" "paginaInicial" => "280" "paginaFinal" => "282" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17244814" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0110" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical impact of transesophageal echocardiography in the diagnosis and management of infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.W. Lowry" 1 => "W.A. Zoghbi" 2 => "W.B. 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Cart-Regal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.acvd.2009.01.002" "Revista" => array:6 [ "tituloSerie" => "Arch Cardiovasc Dis" "fecha" => "2009" "volumen" => "102" "paginaInicial" => "233" "paginaFinal" => "245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19375677" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0120" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute aortic valve rupture from infective endocarditis after transrectal prostate biopsy: a call to revise the AHA guidelines for prevention of infective endocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Ansari" 1 => "G.S. Garcha" 2 => "H. Huang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4137/CCRep.S10503" "Revista" => array:6 [ "tituloSerie" => "Clin Med Insights Case Rep" "fecha" => "2013" "volumen" => "6" "paginaInicial" => "29" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23471201" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003400000002/v3_201706020139/S0870255115000098/v3_201706020139/en/main.assets" "Apartado" => array:4 [ "identificador" => "362" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003400000002/v3_201706020139/S0870255115000098/v3_201706020139/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255115000098?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2016 July | 14 | 3 | 17 |
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| 2016 April | 44 | 3 | 47 |
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| 2016 January | 55 | 17 | 72 |
| 2015 December | 65 | 15 | 80 |
| 2015 November | 53 | 18 | 71 |
| 2015 October | 43 | 21 | 64 |
| 2015 September | 53 | 13 | 66 |
| 2015 August | 61 | 16 | 77 |
| 2015 July | 50 | 13 | 63 |
| 2015 June | 40 | 11 | 51 |
| 2015 May | 40 | 15 | 55 |
| 2015 April | 52 | 17 | 69 |
| 2015 March | 82 | 50 | 132 |
| 2015 February | 69 | 46 | 115 |
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