Case report
Left ventricular assist device in a five-year-old child: A bridge to recovery in a case of viral myocarditis
Assistência ventricular esquerda numa criança de cinco anos – ponte para recuperação num caso de miocardite viral
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(A) Axial image showing a giant thrombosed right coronary aneurysm with maximum dimensions of 40.4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>54.5<span class="elsevierStyleHsp" style=""></span>mm, thus demonstrating that the true size of the aneurysms had been significantly underestimated on angiography. 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Brito, Marta Conde, Mário Oliveira, Gonçalo C. Ferreira" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Marta" "apellidos" => "Cabral" ] 1 => array:2 [ "nombre" => "Maria J." "apellidos" => "Brito" ] 2 => array:2 [ "nombre" => "Marta" "apellidos" => "Conde" ] 3 => array:2 [ "nombre" => "Mário" "apellidos" => "Oliveira" ] 4 => array:2 [ "nombre" => "Gonçalo C." "apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491200116X?idApp=UINPBA00004E" "url" => "/21742049/0000003100000078/v1_201308021407/S217420491200116X/v1_201308021407/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Left ventricular assist device in a five-year-old child: A bridge to recovery in a case of viral myocarditis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "521" "paginaFinal" => "524" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Margarida Silva, Nuno Carvalho, Graça Nogueira, Patrícia Costa, Rui Rodrigues, Miguel Abecasis, Manuela Nunes, Rui Anjos, José Neves" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Margarida" "apellidos" => "Silva" "email" => array:1 [ 0 => "margaridaoms@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Nuno" "apellidos" => "Carvalho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Graça" "apellidos" => "Nogueira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Patrícia" "apellidos" => "Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Rui" "apellidos" => "Rodrigues" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Miguel" "apellidos" => "Abecasis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Manuela" "apellidos" => "Nunes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 7 => array:3 [ "nombre" => "Rui" "apellidos" => "Anjos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "José" "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Serviços de Cardiologia Pediátrica, Hospital de Santa Cruz, Carnaxide, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cardiologia Pediátrica, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cirurgia Cardio-Torácica, Hospital de Santa Cruz, Carnaxide, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Anestesia, Hospital de Santa Cruz, Carnaxide, Portugal" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Assistência ventricular esquerda numa criança de cinco anos – ponte para recuperação num caso de miocardite viral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1069 "Ancho" => 1271 "Tamanyo" => 93999 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Gradual improvement in cardiac function and reduction in left ventricular dilatation after implantation of the ventricular assist device. The arrows indicate the days on which the device was implanted (left) and explanted (right). Admit: day admitted; D13 VAD, D18 VAD, D24 VAD: 13th, 18th, 24th day after implantation of the ventricular assist device; D2 post-VAD, D6 post-VAD, D13 post-VAD: 2nd, 6th, 13th day after explantation of the ventricular assist device. LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; LVEDD: left ventricular end-diastolic diameter in parasternal long-axis M-mode; TVI: left ventricular outflow tract time/velocity integral.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Viral myocarditis is rare in children; its real incidence in the general population is unknown. Histologically it is characterized by a mononuclear inflammatory cell infiltrate, interstitial edema and, in some cases, necrosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its clinical course is mostly benign, with cardiac function recovering spontaneously after a few months, but there can be extensive myocardial necrosis, the necrotic tissue subsequently being replaced by fibrous tissue. The most severe cases progress to dilated cardiomyopathy with heart failure refractory to medication; in such situations a ventricular assist device (VAD) can be used as a bridge to transplantation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the first case in Portugal of recovery with ventricular assistance after severe myocarditis.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a five-year-old boy, obese (weight 26<span class="elsevierStyleHsp" style=""></span>kg, height 117<span class="elsevierStyleHsp" style=""></span>cm, BMI >97th percentile), with a history of bronchial asthma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Three days before admission to the first hospital he presented vomiting, diarrhea, cough and fever. Initial examination revealed gallop rhythm, bilateral rales and hepatomegaly 3<span class="elsevierStyleHsp" style=""></span>cm below the right costal margin. The chest X-ray showed a cardiothoracic index of 65% and diffuse interstitial infiltrate. On echocardiography there was severe left ventricular (LV) dilatation, reduced global contractility, mild mitral regurgitation and pericardial effusion. LV end-diastolic diameter (LVEDD) in parasternal long-axis M-mode was 54<span class="elsevierStyleHsp" style=""></span>mm (z-score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.5) and LV fractional shortening (LVFS) was 22%. He was admitted and dopamine, milrinone and noradrenaline, furosemide, broad-spectrum antibiotic therapy and invasive mechanical ventilation were begun. During endotracheal intubation he suffered cardiopulmonary arrest and was resuscitated. Digoxin was begun on the third day of hospitalization and a course of levosimendan was begun on the seventh day. Despite this treatment, his condition worsened progressively, with generalized edema and 6-cm hepatomegaly and worsening ventricular function. Etiological study revealed positive serology for parvovirus B19 and Ebstein-Barr virus. His fever persisted despite triple antibiotic therapy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the 15th day of hospital stay he was transferred to our center for placement of a VAD as a bridge to heart transplantation due to failure of conventional therapy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Under inotropic therapy, echocardiography confirmed a highly dilated left ventricle (LVEDD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mm; z-score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7.5), dilatation of the inferior vena cava (8<span class="elsevierStyleHsp" style=""></span>mm) and moderate mitral regurgitation. LV end-systolic diameter (LVESD) was 49<span class="elsevierStyleHsp" style=""></span>mm (z-score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9) and LV ejection fraction (LVEF) was 30%. Right ventricular (RV) pressure and function were normal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A Berlin Heart Excor<span class="elsevierStyleSup">®</span> was implanted, with a 50-ml blood pump, and two 9/12-mm cannulas were introduced into the apical region of the left ventricle and the ascending aorta above the origin of the coronary arteries. The aortic cannula was positioned at an angle of 85° to the aorta. The procedure was performed under cardiopulmonary bypass (103<span class="elsevierStyleHsp" style=""></span>min); the operation lasted three hours and was uneventful. RV function was preserved and there were no signs of RV failure.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was extubated on the fifth day following implantation, without complications, and inotropic support was discontinued on the eighth day.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Rigorous anticoagulation control, which is essential for the correct function of the assist device, was maintained throughout the postoperative period. Intravenous heparin perfusion was begun six hours after implantation at an initial dose of 20<span class="elsevierStyleHsp" style=""></span>U/kg/h, which was then adjusted every six hours during the first week according to activated partial thromboplastin time and platelet count. Thromboelastography was performed and levels of antithrombin III, fibrinogen, d-dimers, platelets, leukocytes and C-reactive protein were assessed daily. Oral anticoagulation with warfarin was begun on the fifth postoperative day and heparin perfusion was discontinued once INR 3.0–3.5 was achieved. There were no thromboembolic or bleeding complications.</p><p id="par0050" class="elsevierStylePara elsevierViewall">With regard to the infection, high fever that was difficult to control persisted until the fifth postoperative day, with positive inflammatory markers. Broad-spectrum antibiotics were administered with a good response. Microbiological exams were all negative. On the 15th postoperative day the fever returned, with positive inflammatory markers. <span class="elsevierStyleItalic">Staphylococcus sanguis</span> was isolated from blood cultures and bronchial secretions and he was treated with antibiotics following antibiotic sensitivity testing, with a good response.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Myocardial biopsy performed at the time of implantation showed moderate subendocardial fibroelastosis but no inflammatory infiltrate or thrombi, but with one focus of myofibroblast proliferation and focal myocytolysis.The following parameters were assessed by serial transthoracic echocardiography: LVEF, LVFS, LVEDD, LVESD, LV outflow tract time/velocity integral, and degree of mitral regurgitation. Progressive improvement in LV contractility was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); the pump frequency of the VAD was reduced to 30<span class="elsevierStyleHsp" style=""></span>cycles/min and on the 19th day after implantation the patient was transferred to the ward. On the 27th day LV function was assessed with the Berlin Heart Excor<span class="elsevierStyleSup">®</span> stopped; an increase in cardiac output was seen, due to significantly increased heart rate, and carvedilol was begun. LV function was again assessed with the VAD stopped on the 34th day, with good results. Forty days after implantation, after another course of levosimendan, the Berlin Heart Excor<span class="elsevierStyleSup">®</span> was explanted electively. The postoperative period was uneventful. He was extubated and inotropic support was withdrawn within 24 hours, and he was transferred back to the ward on the fourth postoperative day. The last echocardiogram before discharge showed LVEF of 60% and LVEDD of 37 mm (z-score<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.03). The patient was discharged clinically asymptomatic on the 55th day of hospital stay and 15 days after withdrawal of the VAD, medicated with furosemide, spironolactone, aspirin, digoxin, carvedilol and captopril. Three months after discharge he was in NYHA class I, with normal LVEF and being weaned from medication.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Viral myocarditis is rare in children and its clinical course is mostly benign, but occasionally it can evolve to severe acute heart failure or to late dilated cardiomyopathy. In such cases, a VAD can act as a last-resort measure, as a bridge to transplantation or recovery. Several devices are available for adults and adolescents, but for children with body surface area of less than 1.20<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> there are only two extracorporeal pulsatile alternatives: the Berlin Heart Excor® (Berlin Heart AG, Berlin, Germany) and the Medos HIA device (Medos Medizintechnik AG, Stolberg, Germany),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> of which the more widely used is the Berlin Heart Excor®. This can be used in single- or biventricular mode; in the former, the pump has two chambers (air and blood) separated by a triple-layer polyurethane membrane, with the air chamber connected to the main apparatus by a tube that transmits the air pressure pulse to move the membrane.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The blood chamber is connected by two cannulas to the LV apex or the left atrium and the ascending aorta.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There have been various advances in recent years in adapting VADs for use in pediatric patients, particularly in size of cannulas, chambers and connectors, heparin coating of the blood pump inner surface, and anticoagulant therapy,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the technique can now be used at all ages from newborns to adults.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The throughput of the device can be varied by regulating the pump frequency.</p><p id="par0070" class="elsevierStylePara elsevierViewall">First used in 1990, the Berlin Heart Excor<span class="elsevierStyleSup">®</span> had been implanted in 500 pediatric patients by May 2009.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">VAD implantation should be carefully planned and every effort should be made to begin ventricular assistance on an urgent rather than emergent basis, before the onset of target-organ dysfunction or cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As myocarditis is generally self-limiting and cardiac function usually recovers, the use of ventricular assistance in children with severe ventricular dysfunction can be an effective and safe solution; the VAD can remain in place for relatively long periods and can even avoid the need for transplantation. Careful anticoagulation control is required to prevent thromboembolic complications, and clinical and laboratory signs of infection must be closely monitored. The timing for weaning from the device is of great importance; cardiac function must be systematically assessed with the device both on and off, and medical therapy must be optimized. If the device is removed too soon, there is a risk of LV failure necessitating a return to ventricular assistance, while prolonging assistance longer than absolutely necessary carries a high risk of infection and thromboembolic events.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the case presented, although the biopsy showed subendocardial fibrosis, cardiac function recovered. The presence of fibrosis on biopsy is not a mandatory indication for transplantation or a contraindication to the implantation of a ventricular assist device as a bridge to recovery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres251782" "titulo" => array:4 [ 0 => "Abstract" 1 => "Introduction" 2 => "Case report" 3 => "Discussion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec239380" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251783" "titulo" => array:4 [ 0 => "Resumo" 1 => "Introdução" 2 => "Caso Clínico" 3 => "Discussão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec239381" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack54271" "titulo" => "Acknowledgement" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-11-09" "fechaAceptado" => "2012-01-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec239380" "palabras" => array:4 [ 0 => "Assisted circulation" 1 => "Circulatory assist devices" 2 => "Heart failure" 3 => "Viral myocarditis" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec239381" "palabras" => array:4 [ 0 => "Assistência ventricular externa" 1 => "Berlin Heart Excor<span class="elsevierStyleSup">®</span>" 2 => "Insuficiência cardíaca" 3 => "Miocardite viral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Viral myocarditis can lead to heart failure that is refractory to medication. In these cases, a ventricular assist device is a good therapeutic option that can be used as a bridge to transplantation or recovery. We describe the first case in Portugal of recovery with ventricular assistance after severe myocarditis.</p> <span class="elsevierStyleSectionTitle">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A five-year-old boy with no previous cardiac disease presented with severe viral myocarditis, refractory to medical treatment, with positive serology for parvovirus B19 and Ebstein-Barr virus. A Berlin Heart Excor<span class="elsevierStyleSup">®</span> was implanted 15 days after diagnosis. A biopsy at the time of implantation showed subendocardial fibrosis. After 40 days of assistance ventricular function recovered and the device was explanted. The patient was discharged from hospital 15 days later.</p> <span class="elsevierStyleSectionTitle">Discussion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Survival of children with ventricular assistance has improved significantly because of earlier implantation and coagulation monitoring. The presence of subendocardial fibrosis in the context of myocarditis is not a mandatory indication for transplantation.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle">Introdução</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A miocardite viral pode cursar com insuficiência cardíaca refractária à medicação. Nestes casos, a assistência ventricular externa é uma alternativa que pode ser usada como ponte para transplante ou para recuperação. Descrevemos o primeiro caso em Portugal de recuperação da função ventricular após assistência ventricular por miocardite grave.</p> <span class="elsevierStyleSectionTitle">Caso Clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de uma criança de cinco anos, sexo masculino, sem doença cardíaca prévia, com miocardite viral grave, insuficiência cardíaca refractária à medicação e serologias positivas para Parvovírus B19 e vírus Ebstein-Barr. Foi implantado o Berlin Heart Excor<span class="elsevierStyleSup">®</span> 15 dias após o diagnóstico. A biopsia cardíaca, na altura da implantação, mostrava áreas de fibrose subendocárdica. Verificou-se recuperação da função miocárdica, tendo sido retirada a assistência ventricular após 40 dias da implantação. O doente teve alta 15 dias depois.</p> <span class="elsevierStyleSectionTitle">Discussão</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A sobrevida das crianças em assistência ventricular tem vindo a melhorar significativamente, devido ao planeamento atempado e à optimização da anti-coagulação. A presença de fibrose subendocárdica no contexto de miocardite não constitui uma indicação formal para transplante.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Silva, M. Assistência ventricular esquerda numa criança de cinco anos – ponte para recuperação num caso de miocardite viral. Rev Port Cardiol. 2012;<span class="elsevierStyleBold">31(7-8)</span>:521-524.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1069 "Ancho" => 1271 "Tamanyo" => 93999 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Gradual improvement in cardiac function and reduction in left ventricular dilatation after implantation of the ventricular assist device. The arrows indicate the days on which the device was implanted (left) and explanted (right). Admit: day admitted; D13 VAD, D18 VAD, D24 VAD: 13th, 18th, 24th day after implantation of the ventricular assist device; D2 post-VAD, D6 post-VAD, D13 post-VAD: 2nd, 6th, 13th day after explantation of the ventricular assist device. LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; LVEDD: left ventricular end-diastolic diameter in parasternal long-axis M-mode; TVI: left ventricular outflow tract time/velocity integral.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myocarditis in infants and children: a review for the paediatrician" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Dancea" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Paediatr Child Health" "fecha" => "2001" "volumen" => "6" "paginaInicial" => "543" "paginaFinal" => "545" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20084124" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Technology Insight: use of ventricular assist devices in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Hetzer" 1 => "B. Stiller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Nat Clin Prac Cardiovasc Med" "fecha" => "2006" "volumen" => "3" "paginaInicial" => "377" "paginaFinal" => "386" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Berlin Heart GmbH. Excor Pediatric – Medical Professionals. <a class="elsevierStyleInterRef" href="http://www.berlinheart.com/englisch/medpro/excor-pediatric/">http://www.berlinheart.com/englisch/medpro/excor-pediatric/</a>; 2010 [consulted on October 21]." ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in pediatric patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Hetzer" 1 => "B. Stiller" 2 => "E. Potapov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2006.03.065" "Revista" => array:7 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2006" "volumen" => "82" "numero" => "3" "paginaInicial" => "917" "paginaFinal" => "924" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16928509" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "500th patient receives Berlin Heart EXCOR pediatric ventricular assist device" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Berlin Heart GmbH." "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "PRNewswire" "fecha" => "2009" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Cardiac extracorporeal life support: state of the art in 2007" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1017/S1047951107001217" "Revista" => array:7 [ "tituloSerie" => "Cardiol Young" "fecha" => "2007" "volumen" => "17" "numero" => "Suppl. 2" "paginaInicial" => "104" "paginaFinal" => "115" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18039404" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack54271" "titulo" => "Acknowledgement" "texto" => "<p id="par0095" class="elsevierStylePara elsevierViewall">We thank Nuno Raposo of the Cardiothoracic Surgery Department of Hospital de Santa Cruz.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003100000078/v1_201308021407/S2174204912000943/v1_201308021407/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/21742049/0000003100000078/v1_201308021407/S2174204912000943/v1_201308021407/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204912000943?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2024 November | 6 | 3 | 9 |
| 2024 October | 39 | 36 | 75 |
| 2024 September | 52 | 20 | 72 |
| 2024 August | 46 | 36 | 82 |
| 2024 July | 33 | 33 | 66 |
| 2024 June | 29 | 20 | 49 |
| 2024 May | 48 | 19 | 67 |
| 2024 April | 30 | 28 | 58 |
| 2024 March | 36 | 16 | 52 |
| 2024 February | 26 | 24 | 50 |
| 2024 January | 29 | 27 | 56 |
| 2023 December | 34 | 28 | 62 |
| 2023 November | 31 | 28 | 59 |
| 2023 October | 22 | 16 | 38 |
| 2023 September | 29 | 21 | 50 |
| 2023 August | 25 | 19 | 44 |
| 2023 July | 25 | 10 | 35 |
| 2023 June | 28 | 19 | 47 |
| 2023 May | 40 | 25 | 65 |
| 2023 April | 20 | 8 | 28 |
| 2023 March | 22 | 19 | 41 |
| 2023 February | 18 | 16 | 34 |
| 2023 January | 25 | 20 | 45 |
| 2022 December | 39 | 16 | 55 |
| 2022 November | 41 | 25 | 66 |
| 2022 October | 25 | 18 | 43 |
| 2022 September | 21 | 22 | 43 |
| 2022 August | 28 | 23 | 51 |
| 2022 July | 29 | 32 | 61 |
| 2022 June | 32 | 21 | 53 |
| 2022 May | 19 | 33 | 52 |
| 2022 April | 30 | 19 | 49 |
| 2022 March | 18 | 36 | 54 |
| 2022 February | 26 | 40 | 66 |
| 2022 January | 29 | 16 | 45 |
| 2021 December | 18 | 26 | 44 |
| 2021 November | 26 | 33 | 59 |
| 2021 October | 40 | 28 | 68 |
| 2021 September | 26 | 26 | 52 |
| 2021 August | 31 | 29 | 60 |
| 2021 July | 21 | 28 | 49 |
| 2021 June | 25 | 15 | 40 |
| 2021 May | 33 | 42 | 75 |
| 2021 April | 59 | 37 | 96 |
| 2021 March | 71 | 23 | 94 |
| 2021 February | 98 | 12 | 110 |
| 2021 January | 41 | 11 | 52 |
| 2020 December | 47 | 8 | 55 |
| 2020 November | 24 | 17 | 41 |
| 2020 October | 31 | 7 | 38 |
| 2020 September | 58 | 6 | 64 |
| 2020 August | 29 | 8 | 37 |
| 2020 July | 49 | 9 | 58 |
| 2020 June | 40 | 10 | 50 |
| 2020 May | 34 | 5 | 39 |
| 2020 April | 35 | 16 | 51 |
| 2020 March | 63 | 10 | 73 |
| 2020 February | 60 | 30 | 90 |
| 2020 January | 43 | 10 | 53 |
| 2019 December | 46 | 4 | 50 |
| 2019 November | 31 | 3 | 34 |
| 2019 October | 43 | 5 | 48 |
| 2019 September | 18 | 3 | 21 |
| 2019 August | 28 | 5 | 33 |
| 2019 July | 41 | 9 | 50 |
| 2019 June | 35 | 4 | 39 |
| 2019 May | 59 | 14 | 73 |
| 2019 April | 45 | 15 | 60 |
| 2019 March | 152 | 7 | 159 |
| 2019 February | 83 | 8 | 91 |
| 2019 January | 53 | 9 | 62 |
| 2018 December | 50 | 8 | 58 |
| 2018 November | 182 | 8 | 190 |
| 2018 October | 420 | 17 | 437 |
| 2018 September | 85 | 12 | 97 |
| 2018 August | 66 | 6 | 72 |
| 2018 July | 58 | 5 | 63 |
| 2018 June | 79 | 4 | 83 |
| 2018 May | 85 | 7 | 92 |
| 2018 April | 76 | 3 | 79 |
| 2018 March | 83 | 6 | 89 |
| 2018 February | 65 | 3 | 68 |
| 2018 January | 88 | 9 | 97 |
| 2017 December | 132 | 14 | 146 |
| 2017 November | 32 | 7 | 39 |
| 2017 October | 44 | 13 | 57 |
| 2017 September | 34 | 8 | 42 |
| 2017 August | 39 | 14 | 53 |
| 2017 July | 27 | 13 | 40 |
| 2017 June | 32 | 9 | 41 |
| 2017 May | 28 | 4 | 32 |
| 2017 April | 17 | 3 | 20 |
| 2017 March | 23 | 31 | 54 |
| 2017 February | 36 | 4 | 40 |
| 2017 January | 28 | 2 | 30 |
| 2016 December | 42 | 11 | 53 |
| 2016 November | 14 | 1 | 15 |
| 2016 October | 11 | 6 | 17 |
| 2016 September | 27 | 2 | 29 |
| 2016 August | 6 | 1 | 7 |
| 2016 July | 12 | 4 | 16 |
| 2016 June | 8 | 1 | 9 |
| 2016 May | 15 | 3 | 18 |
| 2016 April | 20 | 4 | 24 |
| 2016 March | 16 | 9 | 25 |
| 2016 February | 24 | 9 | 33 |
| 2016 January | 34 | 9 | 43 |
| 2015 December | 11 | 9 | 20 |
| 2015 November | 20 | 9 | 29 |
| 2015 October | 17 | 6 | 23 |
| 2015 September | 19 | 2 | 21 |
| 2015 August | 19 | 5 | 24 |
| 2015 July | 14 | 2 | 16 |
| 2015 June | 12 | 3 | 15 |
| 2015 May | 12 | 2 | 14 |
| 2015 April | 12 | 4 | 16 |
| 2015 March | 7 | 4 | 11 |
| 2015 February | 7 | 0 | 7 |
| 2015 January | 15 | 6 | 21 |
| 2014 December | 26 | 6 | 32 |
| 2014 November | 12 | 0 | 12 |
| 2014 October | 22 | 3 | 25 |
| 2014 September | 20 | 1 | 21 |
| 2014 August | 22 | 5 | 27 |
| 2014 July | 18 | 4 | 22 |
| 2014 June | 17 | 5 | 22 |
| 2014 May | 19 | 0 | 19 |
| 2014 April | 18 | 4 | 22 |
| 2014 March | 34 | 13 | 47 |
| 2014 February | 23 | 6 | 29 |
| 2014 January | 35 | 13 | 48 |
| 2013 December | 29 | 5 | 34 |
| 2013 November | 33 | 19 | 52 |
| 2013 October | 28 | 7 | 35 |
| 2013 September | 30 | 10 | 40 |
| 2013 August | 36 | 14 | 50 |
| 2013 July | 46 | 19 | 65 |
| 2013 June | 37 | 6 | 43 |
| 2013 May | 34 | 11 | 45 |
| 2013 April | 41 | 16 | 57 |
| 2013 March | 35 | 12 | 47 |
| 2013 February | 42 | 20 | 62 |
| 2013 January | 37 | 8 | 45 |
| 2012 December | 26 | 11 | 37 |
| 2012 November | 18 | 10 | 28 |
| 2012 October | 10 | 5 | 15 |
| 2012 September | 13 | 10 | 23 |
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