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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Eisenmenger syndrome &#40;ES&#41; is defined as significant pulmonary arterial hypertension &#40;PAH&#41; in conjunction with congenital heart disease &#40;CHD&#41; and shunt reversal&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and comprises about 1&#37; of all CHD&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although caused by a defect in the heart&#44; ES is a multiorgan disorder associated with numerous life-threatening complications&#44; including hemoptysis&#44; cerebrovascular accidents&#44; brain abscesses&#44; arrhythmias and syncope&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The majority of patients who develop ES survive to adulthood&#44; but markedly diminished exercise tolerance with reduced life expectancy is the rule&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although their survival is better than in idiopathic pulmonary arterial hypertension &#40;IPAH&#41;&#44; ES patients share many histopathological similarities with IPAH&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">These similarities made the use of pulmonary vasodilators in this subset of patients an attractive option&#46; In the BREATHE-5 study&#44; the first placebo-controlled trial in patients with ES&#44; the endothelin-receptor antagonist &#40;ETRA&#41; bosentan was well tolerated and improved exercise capacity and hemodynamics without compromising peripheral oxygen saturation&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and these results were further supported by the open-label extension of this pivotal trial&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; BREATHE-5 only included ES patients with simple CHD &#40;atrial septal defect&#44; ventricular septal defect or both&#41;&#44; excluding patients with complex CHD&#44; patent ductus arteriosus or segmental pulmonary hypertension as in pulmonary atresia&#46; Evidence for the use of bosentan in this patient subset is only available in the form of series with small samples or short follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Moreover&#44; due to the progressive nature of the disease&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> some patients may still have a negative evolution even though treated with advanced therapies&#44; highlighting the need for combination therapy&#46; In the only randomized controlled trial on combination therapy in ES&#44; the addition of sildenafil to ongoing bosentan failed to improve walking distance or pulmonary vascular resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aims of our study were &#40;i&#41; to assess the safety of bosentan and its short-term effects on systemic oxygen saturation and exercise capacity in patients with complex CHD and PAH&#44; and &#40;ii&#41; to perform a long-term follow-up to assess efficacy and safety of bosentan treatment and the need for combination therapy in this group of complex CHD patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">We prospectively collected data on a dedicated database of all patients with PAH due to complex CHD&#44; who were being followed or were referred to our tertiary center between August 2003 and July 2009&#46; All patients had complex CHD&#44; with Eisenmenger physiology &#40;non-restrictive intra- or extracardiac communication with a right-to-left shunt at rest and high pulmonary vascular resistance&#41; or with severe PAH&#46; Right heart catheterization was performed in all patients to confirm the diagnosis before treatment initiation&#46; Patients with isolated atrial or ventricular septal defects were excluded from the analysis&#46; Functional class was II&#8211;IV in all participants&#44; assessed by the World Health Organization &#40;WHO&#41; classification&#46; All pulmonary vasodilator prescriptions were authorized by the pharmacy and this investigation conformed to the principles outlined in the Declaration of Helsinki&#46; The local ethics committee approved the research protocol and informed consent was obtained from all subjects&#46; Data up to May 2011 were analyzed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medication</span><p id="par0025" class="elsevierStylePara elsevierViewall">Bosentan treatment was initiated at a dose of 62&#46;5 mg bid&#46; After one month&#44; if no adverse effects occurred&#44; the dosage was doubled to 125 mg bid and maintained thereafter&#46; Baseline and monthly hemoglobin and liver function tests were obtained&#46; Treatment with prostanoids&#44; phosphodiesterase V inhibitors and other endothelin receptor antagonists was not allowed before the introduction of bosentan&#46; Based on patients&#8217; overall clinical assessment&#44; the team of attending physicians &#40;including a cardiologist with specialization in adult congenital heart disease &#91;GC&#93; and a pediatric cardiologist &#91;AMS&#93;&#41; was authorized to add sildenafil to the ongoing therapy in a starting dosage of 20 mg tid up to 50 mg tid&#46; All patients had a baseline iron status assessment and bosentan therapy was initiated only after correction of anemia and&#47;or iron deficiency&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Follow-up and final assessment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical follow-up was performed by a monthly clinical visit to our hospital in the first six months of treatment and in three-month periods thereafter&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Six-minute walking test</span><p id="par0035" class="elsevierStylePara elsevierViewall">Submaximal exercise capacity was assessed by the six-minute walking test &#40;6MWT&#41;&#46; This test was conducted by three experienced operators in a 30-m indoor marked corridor&#44; according to the guidelines of the American Thoracic Society&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Heart rate&#44; pulse oximetry and Borg dyspnea score were recorded at baseline and six minutes in all tests&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as means &#177; standard deviation and categorical variables by percentages&#46; Pairwise comparison between baseline and follow-up continuous variables was performed using the paired Student&#39;s t test&#46; Due to the small sample size&#44; all variables were tested for normality using the Kolmogorov-Smirnov test&#46; Categorical variables at baseline and follow-up were compared using Fisher&#39;s test&#46; All p-values were two-sided and a p-value less than 0&#46;05 was considered to indicate statistical significance&#46; Analyses and calculations were performed using SPSS version 13&#46;0 &#40;Chicago&#44; USA&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baseline demographics and characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; baseline characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Fourteen patients were enrolled in the treatment protocol&#46; Mean age was 37&#46;1&#177;11&#46;7 years and half of the patients were female&#46; The most common diagnosis was pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries &#40;35&#46;7&#37;&#41; &#40;one patient had a palliative Blalock-Taussig shunt&#41;&#44; followed by truncus arteriosus with ventricular septal defect &#40;28&#46;6&#37;&#41;&#44; patent ductus arteriosus with ventricular septal defect &#40;21&#46;4&#37;&#41; and transposition of the great arteries &#40;14&#46;3&#37;&#41; &#40;one patient underwent a Mustard procedure&#41;&#46; More than half of the patients were taking diuretics &#40;57&#46;1&#37;&#41; and six had an oxygen prescription&#59; no patient was taking warfarin&#46; At baseline&#44; all patients were normotensive &#40;mean 114&#177;17&#47;71&#177;24 mmHg&#41;&#44; with heart rates in the high normal range &#40;mean 88&#177;12 bpm&#41;&#46; Baseline hemoglobin was elevated &#40;17&#46;9&#177;2&#46;1 g&#47;dl&#41;&#59; all patients had normal liver function tests&#46; Hemodynamic findings were remarkable for a very high mean pulmonary artery systolic pressure &#40;79&#46;6&#177;31&#46;3 mmHg&#41;&#46; Regarding functional capacity&#44; more than 90&#37; of patients were in WHO class III or IV&#46; Only one patient was in WHO class II before starting bosentan&#46; No phlebotomies were conducted in the cohort&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exposure to bosentan and need for combination therapy</span><p id="par0050" class="elsevierStylePara elsevierViewall">Median exposure to bosentan was 43 &#40;interquartile range 30-67&#41; months&#46; One patient discontinued bosentan after 16 months of usage due to low treatment adherence secondary to lower limb edema and was started on sildenafil&#46; During long-term follow-up&#44; four patients were started on sildenafil and one on triple combination therapy with intravenous iloprost due to progressive heart failure&#46; Sildenafil was added after a median bosentan treatment duration of 38 months&#46; Patients who needed combination therapy had a lower six-month 6MWT response after bosentan initiation &#40;&#43;22 m&#41; compared to patients who did not need therapeutic escalation during long-term follow-up &#40;&#43;85 m&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> summarizes the data for each patient&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exercise capacity and World Health Organization functional class</span><p id="par0055" class="elsevierStylePara elsevierViewall">After six months of bosentan treatment&#44; 6MWD increased in 12 and decreased two patients&#46; The mean increase in 6MWD was 56&#46;5 m&#44; from 371&#46;9&#177;90&#46;3 to 428&#46;4&#177;98&#46;3 m &#40;p&#61;0&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Changes in functional class were significant&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46; After a median follow-up of four years&#44; mean 6MWD for patients on bosentan monotherapy &#40;n&#61;8&#41; was 440&#46;1&#177;103&#46;8 m&#44; whereas for patients on bosentan-sildenafil combination therapy &#40;n&#61;4&#41; it was 428&#46;8&#177;96&#46;9 m &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Regarding functional class&#44; after a mean six months of treatment with bosentan&#44; nine patients were in class I or II and five patients remained in class III &#40;p&#61;0&#46;005&#41;&#46; No patient experienced worsening in functional class&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Results in patients with segmental pulmonary hypertension due to pulmonary atresia &#40;n&#61;5&#41; were similar to those of the overall population&#46; After six months&#44; mean 6MWD improved from 352&#46;6&#177;93&#46;2 m to 454&#46;0&#177;72&#46;7 m &#40;p&#61;0&#46;043&#41;&#46; The improvement in functional capacity was maintained at four years &#40;451&#46;8&#177;54&#46;7 m&#44; p&#61;0&#46;043 vs&#46; baseline and p&#61;0&#46;933 vs&#46; six months&#41;&#46; No differences were found regarding oxygen saturation pre- and post-exercise&#59; no patient required therapeutic escalation&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Safety&#44; morbidity and mortality</span><p id="par0065" class="elsevierStylePara elsevierViewall">One patient required discontinuation of bosentan due to lower limb edema&#46; No significant rise in liver transaminases was seen during follow-up and none of the patients had levels exceeding three times the upper limit of the reference range&#46; No signs of decreased oxygen saturation were seen&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Two patients &#40;14&#46;3&#37;&#41;&#44; both with truncus arteriosus&#44; died during follow-up after 48 months of vasodilator therapy&#46; One patient &#40;age 45&#41; on bosentan monotherapy died due to a complicated cerebral abscess&#46; The second patient &#40;age 48&#41;&#44; on triple combination therapy&#44; died of decompensated heart failure&#46; Survival rates in patients with complex CHD at one&#44; two and four years were 100&#37;&#44; 100&#37; and 85&#46;7&#37;&#44; respectively&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">In patients with PAH and complex CHD&#44; bosentan was a safe&#44; well tolerated and effective therapy&#46; The effects on 6MWT were evident after six months and were sustained in long-term follow-up&#46; The safety and drug tolerance were similar to those reported in the IPAH and BREATHE-5 studies&#44; with no serious side effects occurring during this long follow-up period&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with PAH and complex CHD have a better long-term prognosis than those with IPAH&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> mainly due to preservation of biventricular function until the later stages of disease&#46; Some authors suggest that the right ventricle is &#8216;primed&#8217; for a lifetime of functioning at systemic level pressure&#44; with persistence of a protective fetal morphology&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Unfortunately&#44; and in contrast to previous claims that the hemodynamics of patients with ES was stable over time&#44; the BREATHE-5 study demonstrated that even in a limited 16-week follow-up&#44; indicators of progressive vascular disease&#44; such as pulmonary vascular resistance index&#44; worsened in the placebo group&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The available evidence regarding the use of disease-targeting therapies has recently been reviewed elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The pivotal role of endothelin-1 in the development of pulmonary vasculopathy made the use of ETRA attractive and several studies&#44; including one randomized controlled trial&#44; established the benefit of ETRA in ES patients with simple defects&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a> The evidence for sildenafil or prostacyclins is based on smaller studies&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; BREATHE-5 excluded patients with complex CHD and a recent single-center&#44; randomized placebo-controlled study with 21 patients had only one patient with complex disease&#46; Although it was thought that the location of the shunt &#40;pre-tricuspid versus post-tricuspid&#41; would influence treatment outcomes&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> a subgroup analysis of the BREATHE-5 study and two recent reports do not support this hypothesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17</span></a> Moreover&#44; a comparison of patients with persistent PAH after shunt closure and ES patients found no differences in four-year survival&#46;<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">After the use of bosentan&#44; we noted a significant improvement in exercise capacity and in WHO functional class&#44; with no decrease in Borg dyspnea score&#44; indicating that these patients increased their exercise capacity with a similar level of perceived dyspnea&#46; Moreover&#44; mean six-month improvement in 6MWD was 56 m&#44; similar to other reports&#44; including patients with non-complex disease<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and with IPAH&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Our results reproduce&#44; in a larger population&#44; the findings of Diaz-Caraballo et al&#46;&#44; the only study to date focusing solely on complex congenital heart disease&#46; In that study&#44; mean 6MWD improved significantly at six months &#40;from 266&#177;161 to 343&#177;121 m&#44; p&#61;0&#46;045&#41;&#44; the change being maintained at two years&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> We extend these findings to a four-year follow-up&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We also included pulmonary atresia patients&#44; a distinct subgroup&#44; as they present with segmental pulmonary hypertension and no shunt reversal&#46; Little evidence is available regarding the role of pulmonary vasodilators in these patients&#46; A recent report by Schuuring et al&#46; on seven patients demonstrates a 62-m improvement in 6MWD after one year of bosentan treatment&#46;<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a> Our results are similar&#44; with a significant improvement in walking distance at six months&#44; sustained in the long term&#46; Interestingly&#44; none of the patients needed combination therapy&#46; The mechanism whereby bosentan acts on this subset of patients is not known&#44; but may be related to its action on the endothelin pathway&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although not evidence-based but in line with recommendations for IPAH&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> combination therapy with sildenafil was initiated in four patients due to disease progression&#44; reflecting the high-risk group that was studied and the progressive nature of the disease during long-term follow-up&#46; It is noteworthy that the four patients who underwent therapeutic escalation remained clinically stable for almost four years before the initiation of sildenafil&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Patients with PAH and complex CHD are at high risk of death<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> but there is a paucity of data regarding survival in such patients under vasodilator therapy&#46; In our cohort&#44; total mortality was 14&#37; at four years&#44; which is higher than in the series by Dimopoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> &#40;around 3&#37; at two years&#41;&#44; lower than that reported by Vis et al&#46;<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a> &#40;20&#37; at four years&#41;&#44; but similar to the recently published results by Monfredi et al&#46;<a class="elsevierStyleCrossRef" href="#bib20"><span class="elsevierStyleSup">20</span></a> Differences in study design&#44; follow-up duration and population selection may be responsible for these disparities&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The safety of bosentan in this high-risk population was remarkable&#46; No patient experienced a rise in liver enzymes exceeding three times the upper limit of normal or systemic hypotension&#46; Only one patient discontinued bosentan due to lower limb edema&#46; Moreover&#44; and in line with previous reports&#44; no changes were noted in systemic oxygenation&#46; This may be due to the limited influence of bosentan on the net right-to-left shunt because its effects on both pulmonary and systemic vascular resistance are similar&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This was a non-randomized&#44; single-center study&#44; with a limited number of patients reflecting the rarity of this condition&#46; It represents a cohort of patients being followed in a specialized pulmonary hypertension clinic&#46; Our small sample precludes further comparisons between different types of congenital defects&#46; Although only patients with right heart catheterization-confirmed pulmonary hypertension were included in this study&#44; the heterogeneity of the congenital lesions causing it may have influenced clinical evolution&#44; themselves affecting the outcome&#46; An example is truncal valve regurgitation in truncus arteriosus patients&#59; both patients who died had severe regurgitation that may have contributed to their dismal prognosis&#46; Several factors can influence exercise capacity in ES patients&#44; including iron status&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> associated cardiac lesions or pulmonary comorbidities&#59; however&#44; our results regarding exercise capacity and functional status were consistent with other studies in patients without complex congenital disease&#44; suggesting that bosentan has a true therapeutic effect&#59; all patients had regular iron status assessments and correction as needed&#46; We did not perform hemodynamic re-evaluation of patients after pulmonary vasodilator therapy&#59; all clinical decisions regarding therapeutic escalation were made in the light of clinical&#44; laboratorial&#44; echocardiographic and functional data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Bosentan was safe and was associated with improved exercise capacity in patients with complex congenital heart disease and PAH&#46; The improvement in exercise capacity was maintained up to four years and the longer-term safety profile was similar to that reported in simple congenital heart disease patients&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">Gra&#231;a Castro and Ant&#243;nio Marinho da Silva are consultants for Actelion Portugal&#46; Rui Baptista has received funding for research from Actelion Portugal&#46; Pedro Monteiro and Lu&#237;s Augusto Provid&#234;ncia have no relationships relevant to the contents of this paper to disclose&#46;</p></span></span>"
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    "fechaAceptado" => "2012-02-13"
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            1 => "Congenital heart disease"
            2 => "Pulmonary hypertension"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bosentan is recommended for symptomatic patients with Eisenmenger syndrome due to simple congenital lesions such as atrial and ventricular septal defects &#40;VSD&#41;&#46; However&#44; its long-term efficacy and safety in patients with pulmonary arterial hypertension &#40;PAH&#41; associated with complex congenital heart disease &#40;CHD&#41; is unknown&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We examined the short- and long-term effects and safety profile of bosentan in patients with PAH and complex CHD&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We followed 14 patients with PAH and complex CHD for a mean of four years&#46; Demographic parameters&#44; exercise capacity assessed by the six-minute walking test &#40;6MWT&#41; and oxygen saturation were assessed at baseline&#44; six months and at follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mean age was 37&#46;1&#177;11&#46;7 years&#59; 90&#37; were in WHO class III or IV&#46; The most common diagnosis was pulmonary atresia with VSD &#40;35&#46;7&#37;&#41;&#44; followed by truncus arteriosus &#40;28&#46;6&#37;&#41;&#44; patent ductus arteriosus &#40;21&#46;4&#37;&#41; and transposition of the great arteries &#40;14&#46;3&#37;&#41;&#46; After six months of treatment&#44; six-minute walking distance &#40;6MWD&#41; increased from 371&#46;9 to 428&#46;4 m &#40;p&#61;0&#46;005&#41; and functional class was improved &#40;p&#61;0&#46;005&#41;&#46; After four years&#44; one patient discontinued bosentan due to side effects and four patients were started on sildenafil&#44; after a mean 38 months of bosentan treatment&#46; Mean 6MWD for patients on bosentan monotherapy &#40;n&#61;8&#41; was 440&#46;1&#177;103&#46;8 m&#44; whereas for patients on bosentan-sildenafil combination therapy &#40;n&#61;4&#41; it was 428&#46;8&#177;96&#46;9 m&#44; after four years of therapy&#46; Two patients died during follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Bosentan was safe and was associated with improved exercise capacity in patients with PAH and complex CHD&#46; This improvement was sustained for up to four years and the safety profile was similar to simple CHD patients&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O bosentano &#233; recomendado em doentes com hipertens&#227;o arterial pulmonar &#40;HAP&#41; associada a les&#245;es cong&#233;nitas simples&#44; como comunica&#231;&#245;es interventriculares &#40;CIV&#41;&#46; Contudo&#44; a sua efic&#225;cia e seguran&#231;a a longo prazo em doentes com HAP associada a cardiopatias cong&#233;nitas complexas &#40;HAP-CCC&#41; &#233; desconhecida&#46;</p> <span class="elsevierStyleSectionTitle">Objectivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Avali&#225;mos a efic&#225;cia e seguran&#231;a a curto e longo-prazo do bosentano na HAP-CCC&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudaram-se 14 doentes com HAP-CCC&#44; relativamente a par&#226;metros demogr&#225;ficos&#44; capacidade funcional avaliada pelo teste de marcha de seis minutos &#40;TM6M&#41; e satura&#231;&#227;o de oxig&#233;nio&#44; antes de iniciar terap&#234;utica&#44; aos seis meses e durante o per&#237;odo de seguimento cl&#237;nico a longo-prazo &#40;quatro anos&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Noventa por cento dos doentes encontravam-se em classe OMS III ou IV&#44; com idade m&#233;dia de 37&#44;1 &#177; 11&#44;7 anos&#46; O diagn&#243;stico mais frequente foi a atr&#233;sia pulmonar com CIV &#40;35&#44;7&#37;&#41;&#44; seguida de <span class="elsevierStyleItalic">truncus arteriosus</span> &#40;28&#44;6&#37;&#41;&#44; canal arterial patente &#40;21&#44;4&#37;&#41; e transposi&#231;&#227;o de grandes vasos &#40;14&#44;3&#37;&#41;&#46; Ap&#243;s seis meses de tratamento&#44; o TM6M aumentou de 371&#44;9 para 428&#44;4 metros &#40;p &#61; 0&#44;005&#41; e a classe funcional melhorou &#40;p &#61; 0&#44;005&#41;&#46; Ap&#243;s quatro anos&#44; um doente suspendeu bosentano devido a efeitos secund&#225;rios e quatro doentes iniciaram sildenafil&#44; ap&#243;s uma dura&#231;&#227;o m&#233;dia de monoterapia de 38 meses&#46; Ap&#243;s quatro anos de terap&#234;utica&#44; nos doentes em monoterapia com bosentano &#40;n &#61; 8&#41; o TM6M foi de 440&#44;1 &#177; 103&#44;8 metros&#44; enquanto que nos doentes com bosentano-sildenafil &#40;n &#61; 4&#41; foi de 428&#44;8 &#177; 96&#44;9 metros&#46; Dois doentes faleceram durante o per&#237;odo de seguimento cl&#237;nico&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O bosentano foi seguro e esteve associado a melhoria na capacidade funcional em doentes com HAP-CCC at&#233; aos quatro anos de seguimento cl&#237;nico&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">n&#61;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;1&#177;11&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Female gender&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Diagnosis</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Truncus arteriosus&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;14&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;35&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patent ductus arteriosus&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;21&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Medications</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Warfarin&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Digoxin&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;21&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Diuretics&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;57&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Mean daily furosemide dosage &#40;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Beta-blockers&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Oxygen&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;42&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Laboratory variables</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hemoglobin&#44; g&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;9&#177;2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mean corpuscular volume&#44; fl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;0&#177;5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Creatinine&#44; mg g&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&#177;0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Alanine aminotransferase&#44; U&#47;l</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;4&#177;4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mean pulmonary artery pressure&#44; mmHg</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;6&#177;31&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Baselinen&#61;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">6 monthsn&#61;14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mean difference &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">88&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#177;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;&#8722;5-9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;765&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">114&#177;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">119&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;&#8722;3-13&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;170&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diastolic blood pressure&#44; mmHg</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">71&#177;24&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">59&#177;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  """
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab272094.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Long-term effect of bosentan monotherapy on exercise capacity&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">DOB&#58; date of birth&#59; F&#58; female&#59; M&#58; male&#59; PDA&#58; patent ductus arteriosus&#59; RHF&#58; right heart failure&#59; 6M&#58; six-month&#59; 6MWD&#58; six-minute walking distance&#44; in m&#59; TA&#58; truncus arteriosus&#59; TGA&#58; transposition of the great arteries&#59; VSD&#58; ventricular septal defect&#59; WHO&#58; World Health Organization functional class&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DOB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Vital status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO initial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT initial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bosentan start date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sildenafil start date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT prior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWD6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Date of death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Cause of death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 Jan 63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PDA and VSD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">258&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jun 04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">218&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">370&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 Jun 70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TGA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">517&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jan 07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">550&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Feb 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">450&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">540&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 Aug 93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PDA and VSD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">441&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">490&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Feb 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">410&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">468&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 Jul 61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deceased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">324&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">370&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apr 08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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Original article
Long-term effect of bosentan in pulmonary hypertension associated with complex congenital heart disease
Efeito a longo-prazo do bosentano na hipertensão pulmonar associada a cardiopatias congénitas complexas
Rui Baptistaa,b,
Corresponding author
ruibaptista@gmail.com

Corresponding author.
, Graça Castroa, António Marinho da Silvaa, Pedro Monteiroa,b, Luís Augusto Providênciaa,b
a Unidade de Hipertensão Pulmonar, Serviço de Cardiologia, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
b Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
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but markedly diminished exercise tolerance with reduced life expectancy is the rule&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although their survival is better than in idiopathic pulmonary arterial hypertension &#40;IPAH&#41;&#44; ES patients share many histopathological similarities with IPAH&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">These similarities made the use of pulmonary vasodilators in this subset of patients an attractive option&#46; In the BREATHE-5 study&#44; the first placebo-controlled trial in patients with ES&#44; the endothelin-receptor antagonist &#40;ETRA&#41; bosentan was well tolerated and improved exercise capacity and hemodynamics without compromising peripheral oxygen saturation&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and these results were further supported by the open-label extension of this pivotal trial&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; BREATHE-5 only included ES patients with simple CHD &#40;atrial septal defect&#44; ventricular septal defect or both&#41;&#44; excluding patients with complex CHD&#44; patent ductus arteriosus or segmental pulmonary hypertension as in pulmonary atresia&#46; Evidence for the use of bosentan in this patient subset is only available in the form of series with small samples or short follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> Moreover&#44; due to the progressive nature of the disease&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> some patients may still have a negative evolution even though treated with advanced therapies&#44; highlighting the need for combination therapy&#46; In the only randomized controlled trial on combination therapy in ES&#44; the addition of sildenafil to ongoing bosentan failed to improve walking distance or pulmonary vascular resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aims of our study were &#40;i&#41; to assess the safety of bosentan and its short-term effects on systemic oxygen saturation and exercise capacity in patients with complex CHD and PAH&#44; and &#40;ii&#41; to perform a long-term follow-up to assess efficacy and safety of bosentan treatment and the need for combination therapy in this group of complex CHD patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">We prospectively collected data on a dedicated database of all patients with PAH due to complex CHD&#44; who were being followed or were referred to our tertiary center between August 2003 and July 2009&#46; All patients had complex CHD&#44; with Eisenmenger physiology &#40;non-restrictive intra- or extracardiac communication with a right-to-left shunt at rest and high pulmonary vascular resistance&#41; or with severe PAH&#46; Right heart catheterization was performed in all patients to confirm the diagnosis before treatment initiation&#46; Patients with isolated atrial or ventricular septal defects were excluded from the analysis&#46; Functional class was II&#8211;IV in all participants&#44; assessed by the World Health Organization &#40;WHO&#41; classification&#46; All pulmonary vasodilator prescriptions were authorized by the pharmacy and this investigation conformed to the principles outlined in the Declaration of Helsinki&#46; The local ethics committee approved the research protocol and informed consent was obtained from all subjects&#46; Data up to May 2011 were analyzed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medication</span><p id="par0025" class="elsevierStylePara elsevierViewall">Bosentan treatment was initiated at a dose of 62&#46;5 mg bid&#46; After one month&#44; if no adverse effects occurred&#44; the dosage was doubled to 125 mg bid and maintained thereafter&#46; Baseline and monthly hemoglobin and liver function tests were obtained&#46; Treatment with prostanoids&#44; phosphodiesterase V inhibitors and other endothelin receptor antagonists was not allowed before the introduction of bosentan&#46; Based on patients&#8217; overall clinical assessment&#44; the team of attending physicians &#40;including a cardiologist with specialization in adult congenital heart disease &#91;GC&#93; and a pediatric cardiologist &#91;AMS&#93;&#41; was authorized to add sildenafil to the ongoing therapy in a starting dosage of 20 mg tid up to 50 mg tid&#46; All patients had a baseline iron status assessment and bosentan therapy was initiated only after correction of anemia and&#47;or iron deficiency&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Follow-up and final assessment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical follow-up was performed by a monthly clinical visit to our hospital in the first six months of treatment and in three-month periods thereafter&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Six-minute walking test</span><p id="par0035" class="elsevierStylePara elsevierViewall">Submaximal exercise capacity was assessed by the six-minute walking test &#40;6MWT&#41;&#46; This test was conducted by three experienced operators in a 30-m indoor marked corridor&#44; according to the guidelines of the American Thoracic Society&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Heart rate&#44; pulse oximetry and Borg dyspnea score were recorded at baseline and six minutes in all tests&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as means &#177; standard deviation and categorical variables by percentages&#46; Pairwise comparison between baseline and follow-up continuous variables was performed using the paired Student&#39;s t test&#46; Due to the small sample size&#44; all variables were tested for normality using the Kolmogorov-Smirnov test&#46; Categorical variables at baseline and follow-up were compared using Fisher&#39;s test&#46; All p-values were two-sided and a p-value less than 0&#46;05 was considered to indicate statistical significance&#46; Analyses and calculations were performed using SPSS version 13&#46;0 &#40;Chicago&#44; USA&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baseline demographics and characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients&#8217; baseline characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Fourteen patients were enrolled in the treatment protocol&#46; Mean age was 37&#46;1&#177;11&#46;7 years and half of the patients were female&#46; The most common diagnosis was pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries &#40;35&#46;7&#37;&#41; &#40;one patient had a palliative Blalock-Taussig shunt&#41;&#44; followed by truncus arteriosus with ventricular septal defect &#40;28&#46;6&#37;&#41;&#44; patent ductus arteriosus with ventricular septal defect &#40;21&#46;4&#37;&#41; and transposition of the great arteries &#40;14&#46;3&#37;&#41; &#40;one patient underwent a Mustard procedure&#41;&#46; More than half of the patients were taking diuretics &#40;57&#46;1&#37;&#41; and six had an oxygen prescription&#59; no patient was taking warfarin&#46; At baseline&#44; all patients were normotensive &#40;mean 114&#177;17&#47;71&#177;24 mmHg&#41;&#44; with heart rates in the high normal range &#40;mean 88&#177;12 bpm&#41;&#46; Baseline hemoglobin was elevated &#40;17&#46;9&#177;2&#46;1 g&#47;dl&#41;&#59; all patients had normal liver function tests&#46; Hemodynamic findings were remarkable for a very high mean pulmonary artery systolic pressure &#40;79&#46;6&#177;31&#46;3 mmHg&#41;&#46; Regarding functional capacity&#44; more than 90&#37; of patients were in WHO class III or IV&#46; Only one patient was in WHO class II before starting bosentan&#46; No phlebotomies were conducted in the cohort&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exposure to bosentan and need for combination therapy</span><p id="par0050" class="elsevierStylePara elsevierViewall">Median exposure to bosentan was 43 &#40;interquartile range 30-67&#41; months&#46; One patient discontinued bosentan after 16 months of usage due to low treatment adherence secondary to lower limb edema and was started on sildenafil&#46; During long-term follow-up&#44; four patients were started on sildenafil and one on triple combination therapy with intravenous iloprost due to progressive heart failure&#46; Sildenafil was added after a median bosentan treatment duration of 38 months&#46; Patients who needed combination therapy had a lower six-month 6MWT response after bosentan initiation &#40;&#43;22 m&#41; compared to patients who did not need therapeutic escalation during long-term follow-up &#40;&#43;85 m&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> summarizes the data for each patient&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exercise capacity and World Health Organization functional class</span><p id="par0055" class="elsevierStylePara elsevierViewall">After six months of bosentan treatment&#44; 6MWD increased in 12 and decreased two patients&#46; The mean increase in 6MWD was 56&#46;5 m&#44; from 371&#46;9&#177;90&#46;3 to 428&#46;4&#177;98&#46;3 m &#40;p&#61;0&#46;005&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Changes in functional class were significant&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46; After a median follow-up of four years&#44; mean 6MWD for patients on bosentan monotherapy &#40;n&#61;8&#41; was 440&#46;1&#177;103&#46;8 m&#44; whereas for patients on bosentan-sildenafil combination therapy &#40;n&#61;4&#41; it was 428&#46;8&#177;96&#46;9 m &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Regarding functional class&#44; after a mean six months of treatment with bosentan&#44; nine patients were in class I or II and five patients remained in class III &#40;p&#61;0&#46;005&#41;&#46; No patient experienced worsening in functional class&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Results in patients with segmental pulmonary hypertension due to pulmonary atresia &#40;n&#61;5&#41; were similar to those of the overall population&#46; After six months&#44; mean 6MWD improved from 352&#46;6&#177;93&#46;2 m to 454&#46;0&#177;72&#46;7 m &#40;p&#61;0&#46;043&#41;&#46; The improvement in functional capacity was maintained at four years &#40;451&#46;8&#177;54&#46;7 m&#44; p&#61;0&#46;043 vs&#46; baseline and p&#61;0&#46;933 vs&#46; six months&#41;&#46; No differences were found regarding oxygen saturation pre- and post-exercise&#59; no patient required therapeutic escalation&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Safety&#44; morbidity and mortality</span><p id="par0065" class="elsevierStylePara elsevierViewall">One patient required discontinuation of bosentan due to lower limb edema&#46; No significant rise in liver transaminases was seen during follow-up and none of the patients had levels exceeding three times the upper limit of the reference range&#46; No signs of decreased oxygen saturation were seen&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Two patients &#40;14&#46;3&#37;&#41;&#44; both with truncus arteriosus&#44; died during follow-up after 48 months of vasodilator therapy&#46; One patient &#40;age 45&#41; on bosentan monotherapy died due to a complicated cerebral abscess&#46; The second patient &#40;age 48&#41;&#44; on triple combination therapy&#44; died of decompensated heart failure&#46; Survival rates in patients with complex CHD at one&#44; two and four years were 100&#37;&#44; 100&#37; and 85&#46;7&#37;&#44; respectively&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">In patients with PAH and complex CHD&#44; bosentan was a safe&#44; well tolerated and effective therapy&#46; The effects on 6MWT were evident after six months and were sustained in long-term follow-up&#46; The safety and drug tolerance were similar to those reported in the IPAH and BREATHE-5 studies&#44; with no serious side effects occurring during this long follow-up period&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with PAH and complex CHD have a better long-term prognosis than those with IPAH&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> mainly due to preservation of biventricular function until the later stages of disease&#46; Some authors suggest that the right ventricle is &#8216;primed&#8217; for a lifetime of functioning at systemic level pressure&#44; with persistence of a protective fetal morphology&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Unfortunately&#44; and in contrast to previous claims that the hemodynamics of patients with ES was stable over time&#44; the BREATHE-5 study demonstrated that even in a limited 16-week follow-up&#44; indicators of progressive vascular disease&#44; such as pulmonary vascular resistance index&#44; worsened in the placebo group&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The available evidence regarding the use of disease-targeting therapies has recently been reviewed elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The pivotal role of endothelin-1 in the development of pulmonary vasculopathy made the use of ETRA attractive and several studies&#44; including one randomized controlled trial&#44; established the benefit of ETRA in ES patients with simple defects&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a> The evidence for sildenafil or prostacyclins is based on smaller studies&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; BREATHE-5 excluded patients with complex CHD and a recent single-center&#44; randomized placebo-controlled study with 21 patients had only one patient with complex disease&#46; Although it was thought that the location of the shunt &#40;pre-tricuspid versus post-tricuspid&#41; would influence treatment outcomes&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> a subgroup analysis of the BREATHE-5 study and two recent reports do not support this hypothesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17</span></a> Moreover&#44; a comparison of patients with persistent PAH after shunt closure and ES patients found no differences in four-year survival&#46;<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">After the use of bosentan&#44; we noted a significant improvement in exercise capacity and in WHO functional class&#44; with no decrease in Borg dyspnea score&#44; indicating that these patients increased their exercise capacity with a similar level of perceived dyspnea&#46; Moreover&#44; mean six-month improvement in 6MWD was 56 m&#44; similar to other reports&#44; including patients with non-complex disease<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and with IPAH&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Our results reproduce&#44; in a larger population&#44; the findings of Diaz-Caraballo et al&#46;&#44; the only study to date focusing solely on complex congenital heart disease&#46; In that study&#44; mean 6MWD improved significantly at six months &#40;from 266&#177;161 to 343&#177;121 m&#44; p&#61;0&#46;045&#41;&#44; the change being maintained at two years&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> We extend these findings to a four-year follow-up&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We also included pulmonary atresia patients&#44; a distinct subgroup&#44; as they present with segmental pulmonary hypertension and no shunt reversal&#46; Little evidence is available regarding the role of pulmonary vasodilators in these patients&#46; A recent report by Schuuring et al&#46; on seven patients demonstrates a 62-m improvement in 6MWD after one year of bosentan treatment&#46;<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a> Our results are similar&#44; with a significant improvement in walking distance at six months&#44; sustained in the long term&#46; Interestingly&#44; none of the patients needed combination therapy&#46; The mechanism whereby bosentan acts on this subset of patients is not known&#44; but may be related to its action on the endothelin pathway&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although not evidence-based but in line with recommendations for IPAH&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> combination therapy with sildenafil was initiated in four patients due to disease progression&#44; reflecting the high-risk group that was studied and the progressive nature of the disease during long-term follow-up&#46; It is noteworthy that the four patients who underwent therapeutic escalation remained clinically stable for almost four years before the initiation of sildenafil&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Patients with PAH and complex CHD are at high risk of death<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a> but there is a paucity of data regarding survival in such patients under vasodilator therapy&#46; In our cohort&#44; total mortality was 14&#37; at four years&#44; which is higher than in the series by Dimopoulos et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> &#40;around 3&#37; at two years&#41;&#44; lower than that reported by Vis et al&#46;<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a> &#40;20&#37; at four years&#41;&#44; but similar to the recently published results by Monfredi et al&#46;<a class="elsevierStyleCrossRef" href="#bib20"><span class="elsevierStyleSup">20</span></a> Differences in study design&#44; follow-up duration and population selection may be responsible for these disparities&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The safety of bosentan in this high-risk population was remarkable&#46; No patient experienced a rise in liver enzymes exceeding three times the upper limit of normal or systemic hypotension&#46; Only one patient discontinued bosentan due to lower limb edema&#46; Moreover&#44; and in line with previous reports&#44; no changes were noted in systemic oxygenation&#46; This may be due to the limited influence of bosentan on the net right-to-left shunt because its effects on both pulmonary and systemic vascular resistance are similar&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This was a non-randomized&#44; single-center study&#44; with a limited number of patients reflecting the rarity of this condition&#46; It represents a cohort of patients being followed in a specialized pulmonary hypertension clinic&#46; Our small sample precludes further comparisons between different types of congenital defects&#46; Although only patients with right heart catheterization-confirmed pulmonary hypertension were included in this study&#44; the heterogeneity of the congenital lesions causing it may have influenced clinical evolution&#44; themselves affecting the outcome&#46; An example is truncal valve regurgitation in truncus arteriosus patients&#59; both patients who died had severe regurgitation that may have contributed to their dismal prognosis&#46; Several factors can influence exercise capacity in ES patients&#44; including iron status&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> associated cardiac lesions or pulmonary comorbidities&#59; however&#44; our results regarding exercise capacity and functional status were consistent with other studies in patients without complex congenital disease&#44; suggesting that bosentan has a true therapeutic effect&#59; all patients had regular iron status assessments and correction as needed&#46; We did not perform hemodynamic re-evaluation of patients after pulmonary vasodilator therapy&#59; all clinical decisions regarding therapeutic escalation were made in the light of clinical&#44; laboratorial&#44; echocardiographic and functional data&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Bosentan was safe and was associated with improved exercise capacity in patients with complex congenital heart disease and PAH&#46; The improvement in exercise capacity was maintained up to four years and the longer-term safety profile was similar to that reported in simple congenital heart disease patients&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">Gra&#231;a Castro and Ant&#243;nio Marinho da Silva are consultants for Actelion Portugal&#46; Rui Baptista has received funding for research from Actelion Portugal&#46; Pedro Monteiro and Lu&#237;s Augusto Provid&#234;ncia have no relationships relevant to the contents of this paper to disclose&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bosentan is recommended for symptomatic patients with Eisenmenger syndrome due to simple congenital lesions such as atrial and ventricular septal defects &#40;VSD&#41;&#46; However&#44; its long-term efficacy and safety in patients with pulmonary arterial hypertension &#40;PAH&#41; associated with complex congenital heart disease &#40;CHD&#41; is unknown&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We examined the short- and long-term effects and safety profile of bosentan in patients with PAH and complex CHD&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We followed 14 patients with PAH and complex CHD for a mean of four years&#46; Demographic parameters&#44; exercise capacity assessed by the six-minute walking test &#40;6MWT&#41; and oxygen saturation were assessed at baseline&#44; six months and at follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mean age was 37&#46;1&#177;11&#46;7 years&#59; 90&#37; were in WHO class III or IV&#46; The most common diagnosis was pulmonary atresia with VSD &#40;35&#46;7&#37;&#41;&#44; followed by truncus arteriosus &#40;28&#46;6&#37;&#41;&#44; patent ductus arteriosus &#40;21&#46;4&#37;&#41; and transposition of the great arteries &#40;14&#46;3&#37;&#41;&#46; After six months of treatment&#44; six-minute walking distance &#40;6MWD&#41; increased from 371&#46;9 to 428&#46;4 m &#40;p&#61;0&#46;005&#41; and functional class was improved &#40;p&#61;0&#46;005&#41;&#46; After four years&#44; one patient discontinued bosentan due to side effects and four patients were started on sildenafil&#44; after a mean 38 months of bosentan treatment&#46; Mean 6MWD for patients on bosentan monotherapy &#40;n&#61;8&#41; was 440&#46;1&#177;103&#46;8 m&#44; whereas for patients on bosentan-sildenafil combination therapy &#40;n&#61;4&#41; it was 428&#46;8&#177;96&#46;9 m&#44; after four years of therapy&#46; Two patients died during follow-up&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Bosentan was safe and was associated with improved exercise capacity in patients with PAH and complex CHD&#46; This improvement was sustained for up to four years and the safety profile was similar to simple CHD patients&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">O bosentano &#233; recomendado em doentes com hipertens&#227;o arterial pulmonar &#40;HAP&#41; associada a les&#245;es cong&#233;nitas simples&#44; como comunica&#231;&#245;es interventriculares &#40;CIV&#41;&#46; Contudo&#44; a sua efic&#225;cia e seguran&#231;a a longo prazo em doentes com HAP associada a cardiopatias cong&#233;nitas complexas &#40;HAP-CCC&#41; &#233; desconhecida&#46;</p> <span class="elsevierStyleSectionTitle">Objectivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Avali&#225;mos a efic&#225;cia e seguran&#231;a a curto e longo-prazo do bosentano na HAP-CCC&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudaram-se 14 doentes com HAP-CCC&#44; relativamente a par&#226;metros demogr&#225;ficos&#44; capacidade funcional avaliada pelo teste de marcha de seis minutos &#40;TM6M&#41; e satura&#231;&#227;o de oxig&#233;nio&#44; antes de iniciar terap&#234;utica&#44; aos seis meses e durante o per&#237;odo de seguimento cl&#237;nico a longo-prazo &#40;quatro anos&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Noventa por cento dos doentes encontravam-se em classe OMS III ou IV&#44; com idade m&#233;dia de 37&#44;1 &#177; 11&#44;7 anos&#46; O diagn&#243;stico mais frequente foi a atr&#233;sia pulmonar com CIV &#40;35&#44;7&#37;&#41;&#44; seguida de <span class="elsevierStyleItalic">truncus arteriosus</span> &#40;28&#44;6&#37;&#41;&#44; canal arterial patente &#40;21&#44;4&#37;&#41; e transposi&#231;&#227;o de grandes vasos &#40;14&#44;3&#37;&#41;&#46; Ap&#243;s seis meses de tratamento&#44; o TM6M aumentou de 371&#44;9 para 428&#44;4 metros &#40;p &#61; 0&#44;005&#41; e a classe funcional melhorou &#40;p &#61; 0&#44;005&#41;&#46; Ap&#243;s quatro anos&#44; um doente suspendeu bosentano devido a efeitos secund&#225;rios e quatro doentes iniciaram sildenafil&#44; ap&#243;s uma dura&#231;&#227;o m&#233;dia de monoterapia de 38 meses&#46; Ap&#243;s quatro anos de terap&#234;utica&#44; nos doentes em monoterapia com bosentano &#40;n &#61; 8&#41; o TM6M foi de 440&#44;1 &#177; 103&#44;8 metros&#44; enquanto que nos doentes com bosentano-sildenafil &#40;n &#61; 4&#41; foi de 428&#44;8 &#177; 96&#44;9 metros&#46; Dois doentes faleceram durante o per&#237;odo de seguimento cl&#237;nico&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O bosentano foi seguro e esteve associado a melhoria na capacidade funcional em doentes com HAP-CCC at&#233; aos quatro anos de seguimento cl&#237;nico&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Effect of six months of bosentan therapy on WHO functional class&#46;</p>"
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                  \t\t\t\t">17&#46;9&#177;2&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;271&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Borg dyspnea score after exercise</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&#177;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5&#177;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8 &#40;&#8722;0&#46;2-1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab272095.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics at baseline and six months after bosentan therapy&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">6MWD&#58; six-minute walking distance&#44; in m&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow-up timePatients on bosentan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Baselinen&#61;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Six monthsn&#61;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three yearsn&#61;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Four yearsn&#61;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p&#40;trend&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6MWD&#44; m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">371&#46;9&#177;90&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">428&#46;4&#177;98&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">439&#46;5&#177;97&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">440&#46;1&#177;103&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab272094.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Long-term effect of bosentan monotherapy on exercise capacity&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">DOB&#58; date of birth&#59; F&#58; female&#59; M&#58; male&#59; PDA&#58; patent ductus arteriosus&#59; RHF&#58; right heart failure&#59; 6M&#58; six-month&#59; 6MWD&#58; six-minute walking distance&#44; in m&#59; TA&#58; truncus arteriosus&#59; TGA&#58; transposition of the great arteries&#59; VSD&#58; ventricular septal defect&#59; WHO&#58; World Health Organization functional class&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">DOB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Vital status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO initial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT initial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Bosentan start date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sildenafil start date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWT prior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6MWD6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">WHO6M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Date of death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Cause of death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 Jan 63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PDA and VSD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">258&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jun 04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">218&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">370&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 Jun 70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TGA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">517&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Jan 07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">550&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Feb 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">450&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">540&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 Aug 93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PDA and VSD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">441&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">490&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Feb 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">410&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">468&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 Jul 61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deceased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">324&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">370&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apr 08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aug 09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "imagenFichero" => array:1 [
                0 => "xTab272093.png"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Individual data for patients that required therapeutic escalation&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "P&#46; Wood"
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                    0 => array:1 [
                      "Revista" => array:6 [
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            1 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                          "etal" => true
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                            0 => "M&#46;G&#46; Duffels"
                            1 => "P&#46;M&#46; Engelfriet"
                            2 => "R&#46;M&#46; Berger"
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                      "Revista" => array:6 [
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            2 => array:3 [
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                          "etal" => true
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                            0 => "H&#46; Baumgartner"
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                    0 => array:1 [
                      "Revista" => array:6 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "doi" => "10.1093/eurheartj/ehp297"
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                    0 => array:2 [
                      "titulo" => "Bosentan therapy in patients with Eisenmenger syndrome&#58; a multicenter&#44; double-blind&#44; randomized&#44; placebo-controlled study"
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                        0 => array:2 [
                          "etal" => true
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                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.106.630715"
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                      "doi" => "10.1016/j.ijcard.2007.04.078"
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                      "titulo" => "Long-term bosentan treatment of complex congenital heart disease and Eisenmenger&#39;s syndrome"
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                          "etal" => true
                          "autores" => array:3 [
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                        "tituloSerie" => "Rev Esp Cardiol"
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                      "doi" => "10.1002/clc.20917"
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                      "titulo" => "Combination therapy with bosentan and sildenafil in Eisenmenger syndrome&#58; a randomized&#44; placebo-controlled&#44; double-blinded trial"
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                        0 => array:2 [
                          "etal" => true
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Revista Portuguesa de Cardiologia (English edition)
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