Case report
Aborted sudden cardiac death as first presentation of Wolff–Parkinson–White syndrome
Morte súbita cardíaca abortada como primeira manifestação da síndrome de Wolff–Parkinson–White
Guida Silva
, Gustavo Pires de Morais, João Primo, Olga Sousa, Eulália Pereira, Marta Ponte, Lino Simões, Vasco Gama
Corresponding author
Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho-EPE, Vila Nova de Gaia, Portugal
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Shortened PR interval, delta wave, widened QRS complex and secondary repolarization abnormalities are seen. This ECG is indicative of WPW syndrome, and a left lateral AP is suggested (positive delta wave in V1 and inferior leads and negative delta wave in aVL and DI).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0070" class="elsevierStylePara elsevierViewall">WPW syndrome is a disorder characterized by the presence of one or more accessory pathways that predispose patients to frequent episodes of arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The 2003 ESC/ACC/AHA guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> recommend routine electrophysiological study (EPS) with liberal indications for catheter ablation in symptomatic patients. However, management of asymptomatic subjects with incidentally found pre-excitation patterns remains controversial. Prognosis is usually good, but there is a lifetime risk of malignant arrhythmias and sudden cardiac death (SCD), and the latter can be the first presentation of the disease. Although risk factors for fatal arrhythmic events are not well established, EPS can be a useful tool in risk stratification.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A short accessory pathway anterograde effective refractory period (AP-AERP), inducibility of sustained tachyarrhythmias (atrioventricular reciprocating tachycardia [AVRT] and/or atrial fibrillation [AF]) and the presence of multiple accessory pathways are the strongest predictors of life-threatening arrhythmias and SCD.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0075" class="elsevierStylePara elsevierViewall">A 17-year-old male with no history of cardiovascular disease or familial SCD presented to the emergency department (ED) with palpitations. No medication or drug abuse was reported. Symptoms had started three hours earlier at rest. The physical examination revealed normal blood pressure (130/70<span class="elsevierStyleHsp" style=""></span>mmHg) and an irregular pulse approaching 200<span class="elsevierStyleHsp" style=""></span>bpm. The rest of the physical evaluation was unremarkable, with no cardiac murmurs or signs of pulmonary edema. An electrocardiogram (ECG) showed a wide-complex irregular tachycardia with rapid ventricular rate (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), suggesting pre-excited AF. Continuous heart monitoring was initiated and two venous lines were inserted.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A few minutes after admission to the ED, the rhythm degenerated into ventricular fibrillation (VF) (checked on the monitor) and the patient collapsed without pulse. Cardiopulmonary resuscitation was promptly started. Recovery of regular pulse and rhythm was confirmed after defibrillation with two electrical shocks (2× 150<span class="elsevierStyleHsp" style=""></span>J, biphasic). The ECG then obtained revealed sinus rhythm with ventricular pre-excitation (shortened PR interval, widened QRS complex with delta wave and secondary ventricular repolarization abnormalities) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The patient was admitted to the coronary care unit (CCU). No rhythm abnormalities were recorded during CCU monitoring. Serum potassium and magnesium levels were normal and transthoracic echocardiography excluded structural heart disease.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">EPS was scheduled and performed within 12<span class="elsevierStyleHsp" style=""></span>hours of admission. Two catheters were positioned via the right femoral vein: a deflectable decapolar catheter in the coronary sinus, and a nondeflectable quadripolar catheter in the right ventricle for His activity tracing and ventricular stimulation. Atrial stimulation was performed using the decapolar catheter. A short AP-AERP was recorded (210<span class="elsevierStyleHsp" style=""></span>ms) using programmed atrial stimulation, indicating a high-risk AP.</p><p id="par0090" class="elsevierStylePara elsevierViewall">A 4-mm ablation catheter (RF Mariner™, Medtronic Inc., Minneapolis, USA) was advanced retrogradely via the right femoral artery and placed in the mitral ring.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Radiofrequency energy (50<span class="elsevierStyleHsp" style=""></span>W/70<span class="elsevierStyleHsp" style=""></span>°C) was applied for 60<span class="elsevierStyleHsp" style=""></span>s to the atrial side of the left lateral mitral ring. Conduction over the AP was successfully interrupted within 3<span class="elsevierStyleHsp" style=""></span>s of energy delivery (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). During the procedure, AF without pre-excitation was triggered, and sinus rhythm was spontaneously recovered. Total procedure time was 90<span class="elsevierStyleHsp" style=""></span>min, and total fluoroscopy time was 17<span class="elsevierStyleHsp" style=""></span>min. The ECG tracing after catheter ablation showed PR and QRS intervals within normal limits (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). No procedural complications ensued and the patient was discharged three days after admission. Six months after catheter ablation the patient was asymptomatic with a normal ECG tracing. No tachyarrhythmias were documented during this period.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">WPW is a cardiac conduction disorder characterized by the presence of one or multiple APs that predispose patients to frequent episodes of arrhythmia. A Wolff–Parkinson–White pattern is present in 0.1–0.2% of the general population,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> most of whom will never be aware of the issue unless it is discovered incidentally. Symptomatic patients generally experience a good outcome, with either no recurrent arrhythmias or only benign recurrences. Risk of SCD is low, with annual estimates of 0.1% for asymptomatic<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and 0.15–0.39% for symptomatic patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The ECG features of WPW include a PR interval of <0.12<span class="elsevierStyleHsp" style=""></span>s, slurring and slow rise of the initial QRS complex (delta wave), a widened QRS complex with a total duration greater than 0.12<span class="elsevierStyleHsp" style=""></span>s, and secondary repolarization abnormalities that are generally directed in an opposite direction to the major delta and QRS vectors. Diagnosis of WPW syndrome requires typical ECG findings with a documented dysrhythmia. The most frequently encountered dysrhythmia in patients with WPW is atrioventricular reciprocating tachycardia (AVRT), which occurs in 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> AF is not uncommon, occurring in 15–30% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This is a potentially life-threatening arrhythmia in patients with WPW syndrome and may lead to SCD. If an AP has a short anterograde refractory period, rapid repetitive conduction to the ventricles during AF can result in rapid ventricular response with subsequent degeneration to VF.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Predicting clinical outcome is one of the major issues in asymptomatic WPW subjects. Risk assessment is not well defined and remains a considerable clinical challenge.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Risk factors for potentially life-threatening arrhythmic events in WPW<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> include: (1) short AP-AERP (<250<span class="elsevierStyleHsp" style=""></span>ms) allowing a rapid ventricular response in AF; (2) inducibility of tachyarrhythmia during EPS (AVRT and/or AF); (3) short pre-excited RR interval during AF (<250<span class="elsevierStyleHsp" style=""></span>ms); (4) multiple APs; (5) male gender; (6) age; and (7) syncope.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Invasive EPS most accurately assesses the electrophysiological properties of the AP and its role in the patient's clinical arrhythmia, although no single factor has high sensitivity, specificity and positive predictive value.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Pappone et al.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5,10</span></a> reported that a particular subgroup of asymptomatic patients may be at risk for a malignant arrhythmic event and demonstrated the value of EPS in stratifying asymptomatic patients into high- and low-risk groups.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Noninvasive markers of lower risk such as intermittent loss of pre-excitation, loss of AP conduction on exercise stress testing, and sudden loss of AP conduction after treatment with the antiarrhythmic drugs procainamide or flecainide are limited by insufficient sensitivity and specificity, and currently play little role in patient management.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In our case of a previously healthy 17-year-old patient there were no past ECG records and thus the existence of an AP was not known. A malignant arrhythmia with degeneration to VF was the first presentation and could have resulted in SCD. The first-line therapeutic option was EPS before hospital discharge, resulting in successful ablation of the high-risk AP. However, had the WPW pattern been incidentally found before symptoms, how should we have proceeded?</p><p id="par0135" class="elsevierStylePara elsevierViewall">The 2003 ESC/ACC/AHA guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> are restrictive regarding the management of an asymptomatic WPW pattern, and recommend routine invasive EPS and catheter ablation only in symptomatic patients. This may be questionable: catheter ablation is now routinely and safely performed by skilled operators, and asymptomatic patients are more commonly referred for invasive risk stratification and prophylactic AP ablation. Pappone et al.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10</span></a> reported that prophylactic AP catheter ablation performed at the time of initial EPS improved the long-term outcome of patients at high risk for malignant arrhythmias, and the risk significantly and persistently decreased over time after ablation. Furthermore, the efficacy of catheter AP ablation approaches 100%, and overall procedure-related mortality is less than 0.2%.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,12</span></a> Accordingly, radiofrequency catheter ablation (RFA) is now widely accepted as a therapy for WPW and is frequently considered the first-line therapy. However, different AP locations still represent challenges for ablation. Parahisian and midseptal APs, which account for only a minority of cases, pose a significant challenge to RFA due to their proximity to the His bundle and AV node, increasing the risk of AV block. A possibly safer approach for elimination of these challenging APs is cryoablation, which creates homogeneous and smaller lesions and is less thrombogenic than RFA, reducing the risk of inadvertent AV block.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The potential risk of AV block due to RFA of parahisian and midseptal APs must always be discussed with the patient, particularly in the younger, and balanced against the benefits of ablation. In conclusion, the benefits of prophylactic catheter ablation (RFA or cryoablation) can outweigh the procedural risks when performed by a skilled operator, and the issue of the management of asymptomatic WPW patients could be readdressed.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our case illustrates how a WPW pattern may not be as benign as thought. Sudden cardiac death is a dramatic occurrence, particularly in young healthy subjects, and is a real-life event and not merely an item on the reference list of a report on the natural history of the disease. If our patient had had a previous ECG tracing showing a WPW pattern, and if the guidelines had been followed, his fate would have been SCD in the absence of prompt medical assistance. This scenario must be always taken into consideration in each patient with an incidental WPW pattern.</p><p id="par0145" class="elsevierStylePara elsevierViewall">WPW-associated deaths are preventable given the availability of a permanent treatment that is safe and effective, and the benefits of catheter ablation are likely to outweigh the procedural risks when performed by a skilled operator.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The latest guidelines<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> were published over nine years ago. The authors consider that it is currently unacceptable that even one asymptomatic patient with WPW pattern should die or experience a life-threatening arrhythmic event due to a high-risk accessory pathway.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres251721" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec239318" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres251722" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec239319" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-25" "fechaAceptado" => "2012-08-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec239318" "palabras" => array:3 [ 0 => "Wolff–Parkinson–White" 1 => "Sudden cardiac death" 2 => "Catheter ablation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec239319" "palabras" => array:3 [ 0 => "Wolff–Parkinson–White" 1 => "Morte súbita cardíaca" 2 => "Ablação por catéter" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sudden cardiac death (SCD) can be the first clinical manifestation of Wolff–Parkinson–White (WPW) syndrome.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Catheter ablation of accessory pathways is now a safe and effective procedure, and is widely recommended in patients with WPW syndrome. However, management of the asymptomatic WPW patient remains controversial. Recent studies have readdressed the issue of risk stratification and prophylactic catheter ablation.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We describe a case of malignant arrhythmia and aborted SCD as first presentation of WPW syndrome in a previously asymptomatic 17-year-old patient.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A morte súbita cardíaca (MSC) pode ser a primeira manifestação da síndrome de Wolff–Parkinson–White (WPW).</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A ablação por cateter da via acessória é atualmente um tratamento seguro e eficaz, estando liberalmente recomendado em doentes sintomáticos. Já na presença de padrão electrocardiográfico de WPW, a orientação terapêutica é alvo de controvérsia. Alguns estudos vieram reativar a discussão relativamente à estratificação de risco e benefício da ablação profilática.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descrevemos o caso clínico de um jovem de 17 anos previamente assintomático, com arritmia maligna e morte súbita cardíaca abortada como primeira manifestação da doença.</p>" ] ] "nomenclatura" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleSectionTitle">Abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:13 [ 0 => array:2 [ "termino" => "AF" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial fibrillation</p>" ] 1 => array:2 [ "termino" => "AP" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">accessory pathway</p>" ] 2 => array:2 [ "termino" => "AP-AERP" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">accessory pathway antegrade effective refractory period</p>" ] 3 => array:2 [ "termino" => "AV" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">atrioventricular</p>" ] 4 => array:2 [ "termino" => "AVRT" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">atrioventricular reciprocating tachycardia</p>" ] 5 => array:2 [ "termino" => "CCU" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">coronary care unit</p>" ] 6 => array:2 [ "termino" => "ECG" "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">electrocardiogram</p>" ] 7 => array:2 [ "termino" => "ED" "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">emergency department</p>" ] 8 => array:2 [ "termino" => "EPS" "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">electrophysiological study</p>" ] 9 => array:2 [ "termino" => "RFA" "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">radiofrequency ablation</p>" ] 10 => array:2 [ "termino" => "SCD" "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">sudden cardiac death</p>" ] 11 => array:2 [ "termino" => "VF" "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">ventricular fibrillation</p>" ] 12 => array:2 [ "termino" => "WPW" "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Wolff–Parkinson–White</p>" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1611 "Ancho" => 2923 "Tamanyo" => 1505475 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presenting 12-lead ECG. A wide-complex irregular tachycardia is shown consistent with pre-excited AF. The ventricular response is very rapid, and the shortest pre-excited RR interval is nearly 200<span class="elsevierStyleHsp" style=""></span>ms.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1667 "Ancho" => 2923 "Tamanyo" => 1409949 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Twelve-lead ECG after conversion to sinus rhythm. Shortened PR interval, delta wave, widened QRS complex and secondary repolarization abnormalities are seen. This ECG is indicative of WPW syndrome, and a left lateral AP is suggested (positive delta wave in V1 and inferior leads and negative delta wave in aVL and DI).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1527 "Ancho" => 3333 "Tamanyo" => 451683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Accessory pathway ablation. Surface leads I, II, III, aVF, aVL, aVF and V1–V6 are shown, with intracardiac recordings from catheters in the right ventricle (HRVp and HRVd), distal (CS1) and proximal (CS5) coronary sinus, and proximal (RFp) and distal (RFd) ablation catheter. Atrial (A) and ventricular (V) electrical signals are shown. (A) Electrocardiographic and intracardiac signals immediately before catheter ablation, recorded at 200<span class="elsevierStyleHsp" style=""></span>mm/s. (B) Catheter accessory pathway ablation, recorded at 50<span class="elsevierStyleHsp" style=""></span>mm/s. Conduction over the AP disappeared within 3<span class="elsevierStyleHsp" style=""></span>s of radiofrequency energy application. The asterisk represents the beginning of radiofrequency energy application.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1507 "Ancho" => 2917 "Tamanyo" => 1340510 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Twelve-lead ECG after catheter ablation. PR and QRS intervals are within normal limits.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrial fibrillation in the Wolff–Parkinson–White syndrome: ECG recognition and treatment in the ED" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.T. Fengler" 1 => "W.J. Brady" 2 => "C.U. 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| 2023 June | 84 | 30 | 114 |
| 2023 May | 95 | 60 | 155 |
| 2023 April | 48 | 9 | 57 |
| 2023 March | 82 | 26 | 108 |
| 2023 February | 75 | 23 | 98 |
| 2023 January | 73 | 19 | 92 |
| 2022 December | 97 | 25 | 122 |
| 2022 November | 91 | 25 | 116 |
| 2022 October | 77 | 16 | 93 |
| 2022 September | 55 | 35 | 90 |
| 2022 August | 81 | 27 | 108 |
| 2022 July | 67 | 39 | 106 |
| 2022 June | 60 | 30 | 90 |
| 2022 May | 52 | 33 | 85 |
| 2022 April | 106 | 34 | 140 |
| 2022 March | 119 | 33 | 152 |
| 2022 February | 129 | 19 | 148 |
| 2022 January | 82 | 27 | 109 |
| 2021 December | 47 | 36 | 83 |
| 2021 November | 56 | 41 | 97 |
| 2021 October | 72 | 39 | 111 |
| 2021 September | 62 | 24 | 86 |
| 2021 August | 100 | 46 | 146 |
| 2021 July | 78 | 40 | 118 |
| 2021 June | 63 | 40 | 103 |
| 2021 May | 106 | 51 | 157 |
| 2021 April | 180 | 43 | 223 |
| 2021 March | 158 | 27 | 185 |
| 2021 February | 141 | 16 | 157 |
| 2021 January | 115 | 11 | 126 |
| 2020 December | 100 | 4 | 104 |
| 2020 November | 73 | 26 | 99 |
| 2020 October | 127 | 20 | 147 |
| 2020 September | 73 | 26 | 99 |
| 2020 August | 82 | 13 | 95 |
| 2020 July | 103 | 15 | 118 |
| 2020 June | 99 | 5 | 104 |
| 2020 May | 113 | 13 | 126 |
| 2020 April | 90 | 13 | 103 |
| 2020 March | 137 | 8 | 145 |
| 2020 February | 263 | 29 | 292 |
| 2020 January | 148 | 10 | 158 |
| 2019 December | 111 | 5 | 116 |
| 2019 November | 92 | 7 | 99 |
| 2019 October | 229 | 16 | 245 |
| 2019 September | 266 | 17 | 283 |
| 2019 August | 124 | 10 | 134 |
| 2019 July | 85 | 10 | 95 |
| 2019 June | 87 | 3 | 90 |
| 2019 May | 79 | 11 | 90 |
| 2019 April | 95 | 20 | 115 |
| 2019 March | 160 | 14 | 174 |
| 2019 February | 137 | 12 | 149 |
| 2019 January | 141 | 9 | 150 |
| 2018 December | 159 | 14 | 173 |
| 2018 November | 123 | 4 | 127 |
| 2018 October | 177 | 22 | 199 |
| 2018 September | 85 | 14 | 99 |
| 2018 August | 53 | 10 | 63 |
| 2018 July | 66 | 4 | 70 |
| 2018 June | 66 | 8 | 74 |
| 2018 May | 74 | 8 | 82 |
| 2018 April | 143 | 4 | 147 |
| 2018 March | 93 | 8 | 101 |
| 2018 February | 50 | 3 | 53 |
| 2018 January | 57 | 4 | 61 |
| 2017 December | 76 | 5 | 81 |
| 2017 November | 84 | 6 | 90 |
| 2017 October | 57 | 6 | 63 |
| 2017 September | 80 | 7 | 87 |
| 2017 August | 74 | 9 | 83 |
| 2017 July | 44 | 7 | 51 |
| 2017 June | 53 | 20 | 73 |
| 2017 May | 58 | 5 | 63 |
| 2017 April | 108 | 3 | 111 |
| 2017 March | 128 | 31 | 159 |
| 2017 February | 181 | 11 | 192 |
| 2017 January | 80 | 1 | 81 |
| 2016 December | 96 | 10 | 106 |
| 2016 November | 78 | 8 | 86 |
| 2016 October | 127 | 13 | 140 |
| 2016 September | 315 | 10 | 325 |
| 2016 August | 25 | 1 | 26 |
| 2016 July | 36 | 2 | 38 |
| 2016 June | 28 | 7 | 35 |
| 2016 May | 35 | 3 | 38 |
| 2016 April | 42 | 4 | 46 |
| 2016 March | 62 | 22 | 84 |
| 2016 February | 82 | 26 | 108 |
| 2016 January | 53 | 16 | 69 |
| 2015 December | 61 | 15 | 76 |
| 2015 November | 57 | 13 | 70 |
| 2015 October | 72 | 16 | 88 |
| 2015 September | 71 | 14 | 85 |
| 2015 August | 62 | 15 | 77 |
| 2015 July | 84 | 9 | 93 |
| 2015 June | 36 | 6 | 42 |
| 2015 May | 36 | 9 | 45 |
| 2015 April | 41 | 10 | 51 |
| 2015 March | 29 | 6 | 35 |
| 2015 February | 58 | 3 | 61 |
| 2015 January | 46 | 7 | 53 |
| 2014 December | 50 | 7 | 57 |
| 2014 November | 46 | 6 | 52 |
| 2014 October | 37 | 4 | 41 |
| 2014 September | 48 | 7 | 55 |
| 2014 August | 60 | 4 | 64 |
| 2014 July | 47 | 12 | 59 |
| 2014 June | 42 | 1 | 43 |
| 2014 May | 46 | 9 | 55 |
| 2014 April | 59 | 3 | 62 |
| 2014 March | 95 | 11 | 106 |
| 2014 February | 87 | 4 | 91 |
| 2014 January | 84 | 9 | 93 |
| 2013 December | 63 | 8 | 71 |
| 2013 November | 78 | 10 | 88 |
| 2013 October | 72 | 11 | 83 |
| 2013 September | 72 | 11 | 83 |
| 2013 August | 79 | 12 | 91 |
| 2013 July | 51 | 8 | 59 |
| 2013 June | 16 | 3 | 19 |
Show all
