Case report
Severe left ventricular outflow tract obstruction as a complication of mitral valve repair: Case report
Obstrução severa do tracto de saída do ventrículo esquerdo como complicação de valvuloplastia mitral: a propósito de um caso clínico
Bruno Rodrigues
, Luís Ferreira Santos, Emanuel Correia, Rita Faria, Davide Moreira, Pedro Gama, Costa Cabral, João Pipa, Oliveira Santos
Corresponding author
Serviço de Cardiologia, Hospital São Teotónio, Viseu, Portugal
Read
20687
Timeswas read the article
3364
Total PDF
17323
Total HTML
Share statistics
array:24 [ "pii" => "S2174204911000043" "issn" => "21742049" "doi" => "10.1016/j.repce.2011.10.002" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "1" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2010" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2011;30:837-43" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 14038 "formatos" => array:3 [ "EPUB" => 226 "HTML" => 12349 "PDF" => 1463 ] ] "itemSiguiente" => array:19 [ "pii" => "S2174204911000237" "issn" => "21742049" "doi" => "10.1016/j.repce.2011.11.003" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "6" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2011;30:845-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4207 "formatos" => array:3 [ "EPUB" => 156 "HTML" => 3184 "PDF" => 867 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Hyponatremia – an unusual trigger of Takotsubo cardiomyopathy" "tienePdf" => "en" "tieneTextoCompleto" => 0 "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "845" "paginaFinal" => "848" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hiponatremia – um estímulo desencadeador da cardiomiopatia de Takotsubo" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mário Santos, Vasco Dias, Ana Meireles, Catarina Gomes, André Luz, Duarte Mendes, Luísa Caiado, Henrique Carvalho, Sofia Cabral, Severo Torres" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Mário" "apellidos" => "Santos" ] 1 => array:2 [ "nombre" => "Vasco" "apellidos" => "Dias" ] 2 => array:2 [ "nombre" => "Ana" "apellidos" => "Meireles" ] 3 => array:2 [ "nombre" => "Catarina" "apellidos" => "Gomes" ] 4 => array:2 [ "nombre" => "André" "apellidos" => "Luz" ] 5 => array:2 [ "nombre" => "Duarte" "apellidos" => "Mendes" ] 6 => array:2 [ "nombre" => "Luísa" "apellidos" => "Caiado" ] 7 => array:2 [ "nombre" => "Henrique" "apellidos" => "Carvalho" ] 8 => array:2 [ "nombre" => "Sofia" "apellidos" => "Cabral" ] 9 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204911000237?idApp=UINPBA00004E" "url" => "/21742049/0000003000000011/v1_201305151656/S2174204911000237/v1_201305151656/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204911000225" "issn" => "21742049" "doi" => "10.1016/j.repce.2011.11.002" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "aid" => "5" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2011;30:829-35" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4390 "formatos" => array:3 [ "EPUB" => 176 "HTML" => 3267 "PDF" => 947 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "From hypertrophic cardiomyopathy centers to inherited cardiovascular disease centers in Europe. A small or a major step? A position paper from the Nucleus of the Working Group on Myocardial and Pericardial Diseases of the Portuguese Society of Cardiology" "tienePdf" => "en" "tieneTextoCompleto" => 0 "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "829" "paginaFinal" => "835" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Dos centros de miocardiopatia hipertrófica até às unidades de doenças cardíacas hereditárias na Europa: um pequeno grande passo?" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuno Cardim, António Freitas, Dulce Brito" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cardim" ] 1 => array:2 [ "nombre" => "António" "apellidos" => "Freitas" ] 2 => array:2 [ "nombre" => "Dulce" "apellidos" => "Brito" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204911000225?idApp=UINPBA00004E" "url" => "/21742049/0000003000000011/v1_201305151656/S2174204911000225/v1_201305151656/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Severe left ventricular outflow tract obstruction as a complication of mitral valve repair: Case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "837" "paginaFinal" => "843" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Bruno Rodrigues, Luís Ferreira Santos, Emanuel Correia, Rita Faria, Davide Moreira, Pedro Gama, Costa Cabral, João Pipa, Oliveira Santos" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Bruno" "apellidos" => "Rodrigues" "email" => array:1 [ 0 => "onurb80@sapo.pt" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Luís Ferreira" "apellidos" => "Santos" ] 2 => array:2 [ "nombre" => "Emanuel" "apellidos" => "Correia" ] 3 => array:2 [ "nombre" => "Rita" "apellidos" => "Faria" ] 4 => array:2 [ "nombre" => "Davide" "apellidos" => "Moreira" ] 5 => array:2 [ "nombre" => "Pedro" "apellidos" => "Gama" ] 6 => array:2 [ "nombre" => "Costa" "apellidos" => "Cabral" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "Pipa" ] 8 => array:2 [ "nombre" => "Oliveira" "apellidos" => "Santos" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Serviço de Cardiologia, Hospital São Teotónio, Viseu, Portugal" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Obstrução severa do tracto de saída do ventrículo esquerdo como complicação de valvuloplastia mitral: a propósito de um caso clínico" ] ] "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" => 1372 "Ancho" => 2251 "Tamanyo" => 261211 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram, with Doppler study of the left ventricular outflow tract.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systolic anterior motion (SAM) is due to partial obstruction of the left ventricular outflow tract (LVOT) by the mitral valve (MV) anterior leaflet.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has been reported in patients with hypertrophic cardiomyopathy, following myocardial infarction, and as a postoperative complication of MV repair.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 71-year-old female patient, Caucasian, admitted to our department for decompensated heart failure (NYHA class III/IV). Her personal history included hypertension, dyslipidemia, chronic atrial fibrillation, severe mitral regurgitation (posterior leaflet prolapse) and moderate to severe tricuspid regurgitation, with pulmonary hypertension. She had undergone cardiothoracic surgery 15 days before, with mitral valve repair (quadrangular resection of the posterior leaflet with implantation of a Carpentier ring) and tricuspid annuloplasty. Postoperative transesophageal echocardiography (TEE) showed good mitral valve competence and no regurgitation, and no other significant alterations.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was medicated with furosemide (40+20<span class="elsevierStyleHsp" style=""></span>mg), enalapril 5<span class="elsevierStyleHsp" style=""></span>mg once a day, carvedilol 6.25<span class="elsevierStyleHsp" style=""></span>mg twice a day, amiodarone 200<span class="elsevierStyleHsp" style=""></span>mg once a day, spironolactone 25<span class="elsevierStyleHsp" style=""></span>mg once a day, potassium chloride (Retard) once a day, warfarin (for INR 2–3), omeprazole 20<span class="elsevierStyleHsp" style=""></span>mg once a day and sertraline 50<span class="elsevierStyleHsp" style=""></span>mg once a day.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On admission to the emergency department, the patient complained of precordial discomfort and worsening dyspnea on minimal exertion, as well as paroxysmal nocturnal orthopnea and dyspnea. Physical examination showed blood pressure of 86/64<span class="elsevierStyleHsp" style=""></span>mmHg and mean heart rate (HR) of 150<span class="elsevierStyleHsp" style=""></span>bpm; cardiac auscultation revealed arrhythmia and a grade III/VI systolic murmur over the aorta. Pulmonary auscultation revealed absence of breath sounds in the left lung base. There was no lower limb edema.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests showed normocytic and normochromic anemia (Hb 10.9<span class="elsevierStyleHsp" style=""></span>g/dl) and worsening baseline renal function (urea 146<span class="elsevierStyleHsp" style=""></span>mg/dl; creatinine 1.9<span class="elsevierStyleHsp" style=""></span>mg/dl; creatinine clearance [by the MDRD formula] 27.69<span class="elsevierStyleHsp" style=""></span>ml/min). The ECG revealed atrial fibrillation with mean ventricular response of 150<span class="elsevierStyleHsp" style=""></span>bpm and poor R-wave progression in V1–V2. The chest X-ray showed cardiomegaly and moderate left pleural effusion.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted for decompensated heart failure. Transthoracic echocardiography (TTE) performed on the first day of hospitalization (with HR 120–150<span class="elsevierStyleHsp" style=""></span>bpm) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) revealed aortic valve fibrosis with no restriction of opening, together with mild regurgitation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The MV presented fibrocalcification, with increased echogenicity of the annulus; the anterior leaflet and subvalvular apparatus were obstructing the LVOT, resulting in an intraventricular gradient of 110<span class="elsevierStyleHsp" style=""></span>mmHg and moderate paroxysmal regurgitation (probably related to the intermittent nature of the LVOT obstruction). The left atrium was severely dilated (6.1<span class="elsevierStyleHsp" style=""></span>cm), and the left ventricle was hypertrophied (diastolic diameter 4.3<span class="elsevierStyleHsp" style=""></span>cm) but with good global systolic function. The right chambers were of normal size, with pulmonary artery pressure estimated at 40<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0040" class="elsevierStylePara elsevierViewall">For a more accurate assessment of MV function, TEE was performed (with HR 120–150<span class="elsevierStyleHsp" style=""></span>bpm) (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>), which showed the MV with a Carpentier ring and leaflet degeneration and redundancy, good opening in diastole but with SAM leading to LVOT obstruction by the anterior leaflet, and severe regurgitation (vena contracta 8<span class="elsevierStyleHsp" style=""></span>mm). The aortic valve was tricuspid, with good opening and mild regurgitation. The left atrial appendage was free of thrombi.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Since the patient's clinical condition was extremely unstable during hospital stay, systolic blood pressure remaining below 90<span class="elsevierStyleHsp" style=""></span>mmHg and with clear signs of heart failure in NYHA class IV, the patient was transferred to a surgical center 14 days after admission to be evaluated for surgical reintervention.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Six weeks after her initial admission to our department, the patient was seen at the outpatient clinic; she was hemodynamically stable, in good general health and with no signs of heart failure. The report from the surgical center, where she had remained for three weeks, revealed that surgical reintervention had not been necessary. TTE at discharge showed significant improvement in echocardiographic parameters (mild mitral regurgitation and no LVOT obstruction by the mitral anterior leaflet). Repeat TTE a week after reassessment, with optimized HR, revealed good MV function (mild regurgitation), with no LVOT obstruction (<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pathophysiology of SAM</span><p id="par0055" class="elsevierStylePara elsevierViewall">The literature indicates that SAM, which has been reported after mitral valve repair in various studies,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> is caused by the velocity of the blood flow drawing the ventricular surface of the MV anterior leaflet into the LVOT. The position and any abnormalities of the two leaflets contribute to the phenomenon.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Firstly, the distance between the MV coaptation point and the septum is shortened due to elongation of the posterior or anterior leaflets during surgical repair, increasing the area of the anterior leaflet exposed to LVOT flow.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Secondly, during surgical repair of the papillary muscles, the MV may be displaced anteriorly around the LVOT, thus directly exposing the anterior leaflet to the outflow stream.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> Fluid overload in the pre- and postoperative period causes the septum to bulge leftwards and restrict the LVOT, while postoperative hypovolemia reduces left ventricular diastolic dimensions, thus decreasing LVOT diameter. All these pathophysiological conditions contribute to the development of SAM following mitral valve repair.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">However, there is some debate as to how and why the MV anterior leaflet is pushed towards the LVOT once the above-mentioned conditions are present.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–12</span></a> One theory is that it is due to a Venturi effect, the result of a fall in pressure distally to an obstruction. Pressure can be restored if there is dilatation distally to the stenosis with an angle of no more than 15°.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The abrupt drop in pressure before the obstruction leads to the MV being sucked towards the LVOT. However, studies have measured the angle of MV leaflets at the point of coaptation and reported a mean of 21°, which goes against the above theory.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Another mechanism proposed to explain this phenomenon is flow drag, which has been likened to an open door in a corridor subjected to strong gusts of wind. The stronger air flow in the middle of the corridor pushes the door in the direction of the air flow, exerting pressure on an increasing area of the door until it finally slams shut.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Applying this analogy to the MV, it is possible that the flow drag of blood passing the anterior leaflet pulls it towards the LVOT and causes obstruction.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Other studies have proposed a combined mechanism, in which a Venturi effect lifts the leaflet towards the septum, while flow drag pulls the leaflet through it, closing the LVOT.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis of SAM</span><p id="par0085" class="elsevierStylePara elsevierViewall">Echocardiography, whether transesophageal or transthoracic, is essential to a diagnosis of SAM, as it reveals any residual parts of the MV that extend beyond the point of coaptation after valve repair and protrude into the middle of the LVOT, as well as showing a reduction in ventricular dimensions and/or septal bulging.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In certain types of valve repair, the point of coaptation will be next to the septum. Patients with documented SAM can present with dyspnea, angina, palpitations, heart failure, syncope or arrhythmias, or a combination of symptoms.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Management and treatment of SAM: is surgical reintervention necessary?</span><p id="par0090" class="elsevierStylePara elsevierViewall">There is uncertainty regarding the natural history and management of patients with SAM after MV repair. The degree of SAM extends along a spectrum from minor repercussions in the MV to its most severe form with LVOT obstruction.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Despite numerous descriptions of preventative techniques, it continues to occur.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18–21</span></a> Management of SAM by surgical means remains controversial, some groups advocating non-surgical treatment<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a> and others direct surgical correction.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24–26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Both hypervolemia and hypovolemia can trigger SAM. Thus, a patient who has undergone MV repair may initially have normal TEE. Most patients undergoing cardiac surgery have hypovolemia, which plays a central role in the development of hyperdynamic SAM since the Venturi effect is more marked, resulting in decreased systolic volume and blood pressure.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However, SAM can also occur in hypervolemic states. Increased right ventricular volume, which raises pulmonary pressure, causes the interventricular septum to bulge leftwards, narrowing the LVOT. In this situation, intravenous nitrates should be considered for immediate reduction of pulmonary pressure.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Management of patients with SAM in the immediate postoperative period consists of keeping the left ventricle expanded to allow reasonable LVOT opening, for which crystalloid and colloid solutions are essential.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Heart rate should be stabilized to maximize diastolic time. Tachyarrhythmias reduce ventricular filling time and affect end-diastolic volume and so beta-blockers are the first-choice drug in this context.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,16</span></a> Continuous infusion is recommended rather than a bolus, since the former is easier to titrate to reduce HR with the least effect on blood pressure.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Positive inotropes such as epinephrine, which increase HR and contractility, should be used with caution in these patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> since they have an adverse effect on left ventricular diastolic time, resulting in a hyperdynamic state and LVOT narrowing, thus increasing the severity of SAM. The overall aim of medical treatment is to maintain optimal left ventricular volume, which means that therapies that reduce peripheral vascular resistance should be avoided.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Since SAM can be transient or persistent, treatment should be based on the severity of symptoms. If these are disabling or progressively worsen, surgical reintervention is recommended,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the type of correction depending on the original surgery.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Brown et al. carried out a major retrospective study of all patients between January 1993 and December 2002 in the Division of Cardiovascular Surgery of the Mayo Clinic in whom SAM occurred during the intraoperative period, and who were subsequently followed up.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> MV repair was performed in 2076 patients, in 174 (8.4%) of whom SAM was detected by intraoperative echocardiography. These patients were initially treated with a combination of beta-blockade, vasoconstriction with phenylephrine and/or intravascular volume expansion; four underwent surgical repair because of persistent SAM and three underwent late surgical reintervention because of mitral regurgitation from other causes. The median follow-up of the remaining 167 patients was 5.4 years. There were two other late reoperations, but neither was due to SAM or LVOT obstruction. Around 90% of patients were in NYHA class I, 7% in class II and 3% in class III or IV. Echocardiograms were available for review in 93 patients, of whom 13 had SAM and four had SAM with LVOT obstruction.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The above study's conclusions emphasized the fact that most cases of SAM were resolved with conservative treatment (beta-blockade, vasoconstriction and administration of fluids). Persistent SAM with LVOT obstruction was documented in 2.3% of patients but did not require late reintervention. The outcomes in this series (no mortality and 90% of patients in NYHA class I at late follow-up) support a strategy of non-surgical treatment of SAM, with or without LVOT obstruction.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">The review of the literature carried out in order to answer the questions raised by our case led to the conclusion that late surgical reintervention is rarely required to treat SAM with LVOT obstruction following mitral valve repair, since it improves with optimized therapy and ventricular remodeling in the long term. Nevertheless, patients with SAM after MV repair need regular follow-up, beta-blockade and avoidance of afterload-reducing medications. Lifelong beta-blocker therapy is not generally required; if LVOT obstruction resolves, the dose can be titrated based on three-monthly echocardiographic study, and if no LVOT obstruction is detected, the patient can be reassessed at longer intervals.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">SAM is an important cause of mitral regurgitation early after MV repair, but optimized medical therapy can preclude the need for surgical reintervention.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The phenomenon occurs with a variety of surgical techniques, and no ring or band, rigid or flexible, appears to have a direct influence on the outcome.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">To summarize, studies support a non-surgical approach to SAM, with or without LVOT obstruction.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres175978" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec164344" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres175977" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec164343" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Pathophysiology of SAM" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis of SAM" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Management and treatment of SAM: is surgical reintervention necessary?" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-02-17" "fechaAceptado" => "2011-04-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164344" "palabras" => array:3 [ 0 => "Systolic anterior motion" 1 => "Mitral valve repair" 2 => "Pathophysiology" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164343" "palabras" => array:3 [ 0 => "Movimento anterior sistólico" 1 => "Valvuloplastia mitral" 2 => "Fisiopatologia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systolic anterior motion (SAM) is a postoperative complication of mitral valve repair, with an incidence of 5–10%. Early recognition of the signs and symptoms of SAM is essential for the management of these patients. This article focuses on the pathophysiology and dynamics of SAM and the treatment strategies described in the literature. The authors present a case study and echocardiographic images illustrating the clinical relevance of the mechanism involved, in order to clarify whether surgical reintervention is necessary.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O movimento anterior sistólico (SAM) é uma complicação pós cirúrgica da valvuloplastia mitral, sendo a sua incidência de 5-10%. O reconhecimento precoce dos sinais e sintomas de SAM é imperativo no delinear de estratégia terapêutica nesses pacientes. Este artigo foca os principais mecanismos fisiopatológicos do SAM dinâmico e modalidades de tratamento descritas na literatura. Os autores descrevem um caso clínico e as imagens ecocardiográficas captadas ilustrando a relevância clínica do mecanismo envolvido, na tentativa de esclarecer uma questão suscitada: reintervenção cirúrgica necessária?</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Rodrigues, B. Obstrução severa do tracto de saída do ventrículo esquerdo como complicação de valvuloplastia mitral: a propósito de um caso clínico. Rev Port Cardiol. 2011;<span class="elsevierStyleBold">30(11)</span>:837–843.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1576 "Ancho" => 2251 "Tamanyo" => 314399 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Peak gradient in the left ventricular outflow tract caused by systolic anterior motion.</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" => 1569 "Ancho" => 2251 "Tamanyo" => 179250 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram showing systolic anterior motion of the mitral valve anterior leaflet.</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" => 1372 "Ancho" => 2251 "Tamanyo" => 261211 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiogram, with Doppler study of the left ventricular outflow tract.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1539 "Ancho" => 2251 "Tamanyo" => 149998 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram in parasternal view, showing left ventricular outflow tract in systole after optimization of therapy, with no systolic anterior motion.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1570 "Ancho" => 2251 "Tamanyo" => 327408 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram with continuous wave Doppler study of the left ventricular outflow tract, showing normalization of the left ventricular-aortic gradient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular outflow tract obstruction after mitral valve replacement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.D. Canniere" 1 => "J.L. Jansens" 2 => "P. Unger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1997" "volumen" => "64" "paginaInicial" => "1805" "paginaFinal" => "1806" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9436577" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of left ventricular outflow tract area on systolic outflow velocity in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.X. Qin" 1 => "T. Shiota" 2 => "H.M. Lever" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2002" "volumen" => "39" "paginaInicial" => "308" "paginaFinal" => "314" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11788224" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dynamic left ventricular outflow tract obstruction in the setting of acute anterior myocardial infarction—a serious and potentially fatal complication?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Hrovatin" 1 => "R. Piazza" 2 => "D. Pavan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2002" "volumen" => "19" "paginaInicial" => "449" "paginaFinal" => "455" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12356339" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SAM-systolic anterior motion of the anterior mitral valve leaflet post-surgical mitral valve repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "L.M. Charls" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hrtlng.2003.07.004" "Revista" => array:6 [ "tituloSerie" => "Heart Lung" "fecha" => "2003" "volumen" => "32" "paginaInicial" => "402" "paginaFinal" => "406" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14652532" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Importance of leaflet elongation in causing systolic anterior motion of the mitral valve" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. He" 1 => "J. Hopmeyer" 2 => "X.P. Lefebvre" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Heart Valve Dis" "fecha" => "1997" "volumen" => "6" "paginaInicial" => "149" "paginaFinal" => "159" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9130123" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanism of mitral regurgitation in hypertrophic cardiomyopathy. Mismatch of posterior to anterior leaflet length and mobility" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Schwammenthal" 1 => "S. Makatami" 2 => "S. He" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1998" "volumen" => "98" "paginaInicial" => "856" "paginaFinal" => "865" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9738640" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Septal myectomy for left ventricular outflow tract obstruction after mitral valve repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Perier" 1 => "T. Hagen" 2 => "J. Stumpf" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1994" "volumen" => "57" "paginaInicial" => "1328" "paginaFinal" => "1330" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8179412" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resting echocardiographic features of latent left ventricular outflow obstruction in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Nakatani" 1 => "T. Marwick" 2 => "H. Lever" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "1996" "volumen" => "78" "paginaInicial" => "662" "paginaFinal" => "667" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8831401" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systolic anterior motion begins at low left ventricular outflow tract velocity in obstructive hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.V. Sherrid" 1 => "D.Z. Gunsburg" 2 => "S. Moldenhauer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2000" "volumen" => "36" "paginaInicial" => "1344" "paginaFinal" => "1354" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11028493" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New insights into the reduction of mitral valve systolic anterior motion after ventricular septal myectomy in hypertrophic obstructive cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Nakatani" 1 => "E. Schwammenthal" 2 => "H.M. Lever" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "1996" "volumen" => "131" "paginaInicial" => "294" "paginaFinal" => "300" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8579024" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dynamic left ventricular outflow obstruction in hypertrophic cardiomyopathy revisited" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.V. Sherrid" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cardiol Rev" "fecha" => "1998" "volumen" => "6" "paginaInicial" => "135" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10348935" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A three-dimensional computational investigation of intraventricular fluid dynamics. Examination into the initiation of systolic anterior motion of the mitral valve leaflets" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.P. Yoganathan" 1 => "J.D. Lemmon" 2 => "Y.H. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Biomech Eng" "fecha" => "1995" "volumen" => "116" "paginaInicial" => "307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7799632" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An echocardiographic study of the fluid mechanics of obstruction in hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.V. Sherrid" 1 => "C.K. Chu" 2 => "E. Delia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1993" "volumen" => "22" "paginaInicial" => "816" "paginaFinal" => "825" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8354817" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fixed left ventricular outflow tract obstruction in presumed hypertrophic obstructive cardiomyopathy: implications for therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.J. Bruce" 1 => "R.A. Nishimura" 2 => "A.J. Tajik" 3 => "H.V. Schaff" 4 => "G.K. Danielson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1999" "volumen" => "68" "paginaInicial" => "100" "paginaFinal" => "104" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10421123" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A physician's guide to the treatment of hypertrophic cardiomyopathy. Treatment of patients with hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.R. Ommen" 1 => "R.A. Nishimura" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Heart Views" "fecha" => "2000" "volumen" => "1" "paginaInicial" => "394" "paginaFinal" => "401" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular regional systolic motion in patients with right ventricular pressure overload" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Kurotobi" 1 => "H. Naito" 2 => "T. Sano" 3 => "J. Arisawa" 4 => "T. Matsushita" 5 => "M. Takeuchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "1998" "volumen" => "67" "paginaInicial" => "55" "paginaFinal" => "63" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9880201" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systolic anterior motion after mitral valve repair: is surgical intervention necessary?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:8 [ 0 => "M.L. Brown" 1 => "D.A. Martin" 2 => "R.L. Click" 3 => "R.G. Morford" 4 => "J.A. Dearani" 5 => "T.M. Sundt" 6 => "T.A. Orszulak" 7 => "H.V. Schaff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2006.09.024" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2007" "volumen" => "133" "paginaInicial" => "136" "paginaFinal" => "143" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17198799" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The sliding leaflet technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Carpentier" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Le Club Mitrale Newslett" "fecha" => "1988" "volumen" => "I" "paginaInicial" => "5" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systolic anterior motion of the mitral valve after mitral valve repair: a method of prevention" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Sternik" 1 => "K. Zehr" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Tex Heart Inst J" "fecha" => "2005" "volumen" => "32" "paginaInicial" => "47" "paginaFinal" => "49" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15902821" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of systolic anterior motion after repair of the severely myxomatous mitral valve with an anterior leaflet valvuloplasty" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Quigley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2005.01.066" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2005" "volumen" => "80" "paginaInicial" => "179" "paginaFinal" => "182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15975363" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early results of posterior leaflet folding plasty for mitral valve reconstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E.A. Grossi" 1 => "A.C. Galloway" 2 => "K. Kallenbach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1998" "volumen" => "65" "paginaInicial" => "1057" "paginaFinal" => "1059" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9564927" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V.A. Jebara" 1 => "S. Mihaileanu" 2 => "C. Acar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Circulation" "fecha" => "1993" "volumen" => "88" "numero" => "5 Pt 2" "paginaInicial" => "II30" "paginaFinal" => "II34" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8222170" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E.A. Grossi" 1 => "A.C. Galloway" 2 => "M.A. Parish" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "1992" "volumen" => "103" "paginaInicial" => "466" "paginaFinal" => "470" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1545545" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The ‘Pomeroy procedure’: a new method to correct post-mitral valve repair systolic anterior motion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.A. Raney" 1 => "P.M. Shah" 2 => "C.I. Joyo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Heart Valve Dis" "fecha" => "2001" "volumen" => "10" "paginaInicial" => "307" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11380092" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of the Alfieri edge-to-edge technique to eliminate left ventricular outflow tract obstruction caused by mitral systolic anterior motion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Gillinov" 1 => "N.G. Smedira" 2 => "T. Shiota" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2004" "volumen" => "78" "paginaInicial" => "92" "paginaFinal" => "93" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Edge-to-edge technique to treat post-mitral-valve repair systolic anterior motion and left ventricular outflow tract obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Mascagni" 1 => "N. Al Attar" 2 => "M. Lamarra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2004.08.008" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2005" "volumen" => "79" "paginaInicial" => "471" "paginaFinal" => "474" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15680816" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The mechanism of benefit of negative inotropes in obstructive hypertrophic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.V. Sherrid" 1 => "G. Pearle" 2 => "D. Gunsburg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "1998" "volumen" => "97" "paginaInicial" => "41" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9443430" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obstructive hypertrophic cardiomyopathy, echocardiography, pathophysiology, and the continuing evolution of surgery for obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.V. Sherrid" 1 => "F.A. Chaudhry" 2 => "D.G. Swistel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2003" "volumen" => "75" "paginaInicial" => "620" "paginaFinal" => "632" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12607696" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003000000011/v1_201305151656/S2174204911000043/v1_201305151656/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003000000011/v1_201305151656/S2174204911000043/v1_201305151656/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204911000043?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 278 | 69 | 347 |
| 2024 September | 90 | 39 | 129 |
| 2024 August | 153 | 71 | 224 |
| 2024 July | 96 | 58 | 154 |
| 2024 June | 82 | 34 | 116 |
| 2024 May | 66 | 26 | 92 |
| 2024 April | 112 | 51 | 163 |
| 2024 March | 98 | 28 | 126 |
| 2024 February | 99 | 34 | 133 |
| 2024 January | 104 | 38 | 142 |
| 2023 December | 97 | 36 | 133 |
| 2023 November | 135 | 60 | 195 |
| 2023 October | 168 | 45 | 213 |
| 2023 September | 129 | 32 | 161 |
| 2023 August | 85 | 34 | 119 |
| 2023 July | 79 | 28 | 107 |
| 2023 June | 79 | 22 | 101 |
| 2023 May | 100 | 37 | 137 |
| 2023 April | 57 | 9 | 66 |
| 2023 March | 61 | 19 | 80 |
| 2023 February | 67 | 26 | 93 |
| 2023 January | 68 | 13 | 81 |
| 2022 December | 58 | 23 | 81 |
| 2022 November | 102 | 33 | 135 |
| 2022 October | 56 | 22 | 78 |
| 2022 September | 56 | 52 | 108 |
| 2022 August | 60 | 47 | 107 |
| 2022 July | 66 | 35 | 101 |
| 2022 June | 62 | 24 | 86 |
| 2022 May | 51 | 30 | 81 |
| 2022 April | 63 | 35 | 98 |
| 2022 March | 44 | 38 | 82 |
| 2022 February | 60 | 24 | 84 |
| 2022 January | 77 | 22 | 99 |
| 2021 December | 46 | 41 | 87 |
| 2021 November | 65 | 38 | 103 |
| 2021 October | 80 | 55 | 135 |
| 2021 September | 72 | 43 | 115 |
| 2021 August | 102 | 71 | 173 |
| 2021 July | 38 | 36 | 74 |
| 2021 June | 51 | 20 | 71 |
| 2021 May | 68 | 39 | 107 |
| 2021 April | 109 | 40 | 149 |
| 2021 March | 93 | 26 | 119 |
| 2021 February | 112 | 26 | 138 |
| 2021 January | 72 | 28 | 100 |
| 2020 December | 73 | 30 | 103 |
| 2020 November | 87 | 26 | 113 |
| 2020 October | 85 | 24 | 109 |
| 2020 September | 112 | 20 | 132 |
| 2020 August | 68 | 27 | 95 |
| 2020 July | 118 | 15 | 133 |
| 2020 June | 93 | 19 | 112 |
| 2020 May | 113 | 15 | 128 |
| 2020 April | 94 | 27 | 121 |
| 2020 March | 130 | 32 | 162 |
| 2020 February | 209 | 29 | 238 |
| 2020 January | 81 | 16 | 97 |
| 2019 December | 83 | 12 | 95 |
| 2019 November | 51 | 9 | 60 |
| 2019 October | 81 | 17 | 98 |
| 2019 September | 150 | 26 | 176 |
| 2019 August | 87 | 11 | 98 |
| 2019 July | 161 | 20 | 181 |
| 2019 June | 127 | 29 | 156 |
| 2019 May | 80 | 28 | 108 |
| 2019 April | 82 | 30 | 112 |
| 2019 March | 110 | 16 | 126 |
| 2019 February | 133 | 26 | 159 |
| 2019 January | 120 | 22 | 142 |
| 2018 December | 146 | 22 | 168 |
| 2018 November | 123 | 20 | 143 |
| 2018 October | 259 | 32 | 291 |
| 2018 September | 62 | 11 | 73 |
| 2018 August | 87 | 24 | 111 |
| 2018 July | 52 | 7 | 59 |
| 2018 June | 55 | 6 | 61 |
| 2018 May | 58 | 13 | 71 |
| 2018 April | 125 | 10 | 135 |
| 2018 March | 104 | 19 | 123 |
| 2018 February | 64 | 19 | 83 |
| 2018 January | 47 | 23 | 70 |
| 2017 December | 58 | 16 | 74 |
| 2017 November | 55 | 16 | 71 |
| 2017 October | 78 | 16 | 94 |
| 2017 September | 93 | 14 | 107 |
| 2017 August | 74 | 20 | 94 |
| 2017 July | 58 | 13 | 71 |
| 2017 June | 75 | 17 | 92 |
| 2017 May | 144 | 13 | 157 |
| 2017 April | 84 | 10 | 94 |
| 2017 March | 88 | 8 | 96 |
| 2017 February | 136 | 8 | 144 |
| 2017 January | 102 | 8 | 110 |
| 2016 December | 101 | 33 | 134 |
| 2016 November | 189 | 12 | 201 |
| 2016 October | 163 | 28 | 191 |
| 2016 September | 108 | 10 | 118 |
| 2016 August | 42 | 4 | 46 |
| 2016 July | 43 | 11 | 54 |
| 2016 June | 29 | 4 | 33 |
| 2016 May | 44 | 5 | 49 |
| 2016 April | 159 | 2 | 161 |
| 2016 March | 268 | 25 | 293 |
| 2016 February | 272 | 34 | 306 |
| 2016 January | 235 | 26 | 261 |
| 2015 December | 211 | 23 | 234 |
| 2015 November | 270 | 18 | 288 |
| 2015 October | 238 | 19 | 257 |
| 2015 September | 215 | 14 | 229 |
| 2015 August | 224 | 13 | 237 |
| 2015 July | 308 | 13 | 321 |
| 2015 June | 199 | 8 | 207 |
| 2015 May | 211 | 7 | 218 |
| 2015 April | 225 | 19 | 244 |
| 2015 March | 224 | 9 | 233 |
| 2015 February | 188 | 11 | 199 |
| 2015 January | 134 | 9 | 143 |
| 2014 December | 169 | 15 | 184 |
| 2014 November | 197 | 13 | 210 |
| 2014 October | 244 | 8 | 252 |
| 2014 September | 222 | 19 | 241 |
| 2014 August | 194 | 6 | 200 |
| 2014 July | 201 | 14 | 215 |
| 2014 June | 159 | 8 | 167 |
| 2014 May | 170 | 14 | 184 |
| 2014 April | 191 | 12 | 203 |
| 2014 March | 204 | 23 | 227 |
| 2014 February | 200 | 11 | 211 |
| 2014 January | 221 | 24 | 245 |
| 2013 December | 184 | 14 | 198 |
| 2013 November | 157 | 19 | 176 |
| 2013 October | 170 | 18 | 188 |
| 2013 September | 169 | 17 | 186 |
| 2013 August | 139 | 25 | 164 |
| 2013 July | 191 | 23 | 214 |
| 2013 June | 113 | 16 | 129 |
| 2013 May | 117 | 18 | 135 |
| 2013 April | 110 | 25 | 135 |
| 2013 March | 118 | 20 | 138 |
| 2013 February | 93 | 21 | 114 |
| 2013 January | 115 | 20 | 135 |
| 2012 December | 86 | 16 | 102 |
| 2012 November | 74 | 24 | 98 |
| 2012 October | 61 | 11 | 72 |
| 2012 September | 33 | 5 | 38 |
Show all
