Case report
High left ventricular outflow tract gradient: Aortic stenosis, obstructive hypertrophic cardiomyopathy or both?
Gradiente elevado no trato de saída do ventrículo esquerdo: estenose aórtica, miocardiopatia hipertrófica obstrutiva ou ambas?
Inês Almeida
, Francisca Caetano, Joana Trigo, Paula Mota, António Leitão Marques
Corresponding author
Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Geral, Coimbra, Portugal
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HLHS: hypoplastic left heart syndrome.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sérgio Laranjo, Glória Costa, Isabel Freitas, José Diogo Ferreira Martins, Luís Bakero, Conceição Trigo, Isabel Fragata, José Fragata, Fátima F. Pinto" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Sérgio" "apellidos" => "Laranjo" ] 1 => array:2 [ "nombre" => "Glória" "apellidos" => "Costa" ] 2 => array:2 [ "nombre" => "Isabel" "apellidos" => "Freitas" ] 3 => array:2 [ "nombre" => "José Diogo" "apellidos" => "Ferreira Martins" ] 4 => array:2 [ "nombre" => "Luís" "apellidos" => "Bakero" ] 5 => array:2 [ "nombre" => "Conceição" "apellidos" => "Trigo" ] 6 => array:2 [ "nombre" => "Isabel" "apellidos" => "Fragata" ] 7 => array:2 [ "nombre" => "José" "apellidos" => "Fragata" ] 8 => array:2 [ "nombre" => "Fátima" "apellidos" => "F. 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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "357.e1" "paginaFinal" => "357.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Inês Almeida, Francisca Caetano, Joana Trigo, Paula Mota, António Leitão Marques" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Inês" "apellidos" => "Almeida" "email" => array:1 [ 0 => "inesalm@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Francisca" "apellidos" => "Caetano" ] 2 => array:2 [ "nombre" => "Joana" "apellidos" => "Trigo" ] 3 => array:2 [ "nombre" => "Paula" "apellidos" => "Mota" ] 4 => array:2 [ "nombre" => "António Leitão" "apellidos" => "Marques" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra – Hospital Geral, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Gradiente elevado no trato de saída do ventrículo esquerdo: estenose aórtica, miocardiopatia hipertrófica obstrutiva ou ambas?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 917 "Ancho" => 3257 "Tamanyo" => 274226 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography: (left) malformed aortic valve with area calculated by planimetry of 0.6 cm<span class="elsevierStyleSup">2</span>; (center) left ventricular outflow tract without visible obstruction; (right) color Doppler differentiating laminar flow in the left ventricular outflow tract and turbulent flow through the aortic valve, confirming obstruction at the level of the valve.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Aortic stenosis (AS) and hypertrophic cardiomyopathy (HCM) are two conditions that can cause hemodynamic gradients in the left ventricular outflow tract (LVOT).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> In both cases the presence of significant obstruction has clinical, therapeutic and prognostic implications.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The presence of both of these conditions in the same patient has been documented, although it is uncommon. This association poses particular diagnostic and therapeutic challenges.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Meticulous echocardiographic assessment is required for correct identification of the cause of the obstruction,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> although this can be complicated, and the result can lead to different therapeutic options.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This case report aims to discuss the complexity of such cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 68-year-old woman, with a history of hypertension, dyslipidemia, obesity and breast cancer (treated by left mastectomy and adjuvant chemotherapy and radiotherapy in 1998), was referred for cardiology consultation in April 2011 to investigate chest pain; she had no other cardiovascular symptoms. On physical examination, auscultation revealed a grade III/VI systolic murmur audible at the right second intercostal space, crescendo-decrescendo and radiating to the carotids; the murmur became less intense with the Valsalva maneuver and on standing up, and increased with squatting.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A previous electrocardiogram had shown sinus rhythm with voltage criteria for left ventricular hypertrophy without overload (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), while transthoracic echocardiography (TTE) (described as “technically very difficult”) had revealed concentric hypertrophy of the left ventricle (LV) with no wall motion abnormalities and with preserved global systolic function and a calcified aortic valve (AV) with moderate stenosis (mean left ventricle/aorta [LV/Ao] gradient of 21 mmHg).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Given the patient's low pretest probability of coronary artery disease, coronary computed tomography angiography was performed, which identified mild coronary calcification (calcium score 54 Agatston units) with no endoluminal obstruction, and also revealed thickening (22 mm) of the interventricular septum (IVS). Suspicion of HCM prompted investigation by magnetic resonance imaging (MRI), which confirmed the diagnosis of asymmetric HCM with hypertrophy of the basal and mid IVS (22 mm), all other walls being of normal thickness; non-dilated LV with ejection fraction of 69% and LV mass index of 78 g/m<span class="elsevierStyleSup">2</span>; moderately dilated left atrium (area 33 cm<span class="elsevierStyleSup">2</span>); and no late gadolinium enhancement (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The patient presented no risk factors for sudden cardiac death and genetic study for Fabry disease was negative; screening for classic mutations in sarcomere protein genes is in progress.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At 18-month follow-up she presented worsening functional capacity with dyspnea on moderate exertion (New York Heart Association class II). TTE was repeated and showed marked LV hypertrophy of the basal IVS and good global systolic function; an apparently tricuspid AV, calcified, with reduced opening, that could not be assessed by planimetry; and a calcified mitral valve with systolic anterior motion (SAM). Doppler study revealed accelerated flow beginning in the LVOT, with peak velocity at mid-systole and peak and mean LV/Ao gradient of 49 mmHg and 32 mmHg, respectively, supporting the hypothesis of a fixed obstruction (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). No late-systolic velocity peak was observed, with or without the Valsalva maneuver.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In view of the limitations of TTE, transesophageal echocardiography (TEE) was performed, which revealed a malformed AV with marked calcification and fusion of the noncoronary and left coronary leaflets, with an area estimated by planimetry of 0.6 cm<span class="elsevierStyleSup">2</span> (0.27 cm<span class="elsevierStyleSup">2</span>/m<span class="elsevierStyleSup">2</span>) (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). Color Doppler study clearly differentiated laminar flow in the LVOT and turbulent flow through the AV throughout systole, confirming the suspicion of obstruction of the valve only (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Invasive hemodynamic study showed a peak-to-peak LV/Ao gradient of 52 mmHg and no intraventricular gradient, and excluded significant coronary artery disease.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A 22-mm Medtronic Hall mechanical valve was implanted surgically in aortic position. At six-month follow-up the patient presented improved functional capacity and TTE revealed a normally functioning aortic valve.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">This case report highlights the difficulties of investigating a patient with both HCM and AS, particularly in assessing the severity of each condition and determining which is functionally more important. Identifying the cause of the high LVOT gradient as AS led to the patient being referred for valve replacement surgery, which resolved the obstruction and improved symptoms.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Assessment of such patients is based on a thorough echocardiographic assessment of the LVOT region.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,5</span></a> Color and pulse wave Doppler study are essential to locate the level at which flow acceleration occurs,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> but TTE does not always provide definitive information.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Continuous-wave Doppler can quantify the obstruction, and the shape of the velocity waveform is particularly useful in differentiating fixed and dynamic obstruction.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9,10</span></a> Obstructive HCM is characterized by an LVOT or, less commonly, a midventricular gradient<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> that changes with variations in preload, afterload and contractility.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Since it is predominantly dynamic, the gradient develops at end-systole and the waveform is dagger-shaped. By contrast, AS results in a fixed obstruction to LV outflow throughout systole with peak velocity at mid-systole, giving a bell-shaped waveform.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,9,10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In the case presented, continuous-wave Doppler study indicated the presence of a fixed obstruction; however, the existence of SAM and marked septal hypertrophy raised the suspicion of a dynamic subaortic obstruction. When assessing these patients, particular care should be taken in interpreting the Doppler waveform, since the two patterns may overlap and the presence of a second gradient may be overlooked.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> If the level of suspicion is high, and TTE study is inconclusive, TEE should be used.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">TEE also plays an important role in screening for other conditions that can cause a fixed LVOT obstruction, such as HCM itself (due to fibrous tissue formation caused by contact between the mitral valve and the IVS), accessory mitral tissue, subaortic ridge, and tunnel subaortic stenosis.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> In the present case, TEE was crucial in identifying flow acceleration at the valve and in excluding other conditions.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The use of cardiac MRI to measure LVOT velocities has been described, but Doppler TTE has been more thoroughly validated.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> In some cases an accurate hemodynamic study can only be obtained by invasive means.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Assessment of the severity of AS in patients with suspected obstructive HCM poses particular challenges and there is little information available on the subject.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,9,14</span></a> Use of the modified Bernoulli equation (ΔP=4v<span class="elsevierStyleSup">2</span>) is based on certain assumptions that mean it cannot be used in patients with serial stenoses.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> When flow velocity exceeds 1.0 m/s, the peak gradient can be estimated using the formula 4(v<span class="elsevierStyleSup">2</span>max−v<span class="elsevierStyleSup">2</span> proximal), but calculating the mean gradient is more complex and is not easy to apply in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Accurate measurement of gradients may only be possible by means of an invasive hemodynamic study.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The continuity equation for measuring valve area cannot be used in the presence of LVOT obstruction.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> Planimetry is the recommended method, ideally by TEE.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> In our patient, the presence of valve malformation with marked calcification and an anatomical area of 0.6 cm<span class="elsevierStyleSup">2</span> led to a diagnosis of severe AS.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Diagnosis of HCM in a patient with significant AS is also not straightforward. It is based on the presence of LV hypertrophy, frequently asymmetric and involving the IVS, in the absence of other causes.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8,11,13,15</span></a> AS is usually associated with a uniform or symmetric (i.e. concentric) distribution of LV hypertrophy,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> although an asymmetric septal distribution is reported in around 10% of cases.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,16,17</span></a> This makes diagnosis more difficult: is the hypertrophy an adaptive response to AS or is it due to concomitant HCM? In the case described here, the presence of marked septal hypertrophy and SAM favored a diagnosis of concomitant HCM. Genetic study and assessment of the evolution of ventricular hypertrophy following valve surgery may support the diagnosis. Some authors have suggested other characteristics that corroborate a diagnosis of HCM, including mitral valve abnormalities (such as lengthening of the anterior leaflet), hypertrophied or bifid papillary muscles or anteroapical displacement, and family history.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4,8,14</span></a> MRI can have an important role in assessing some of these characteristics.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">This paper highlights the complexity of assessing patients with HCM and severe symptomatic AS with high LVOT gradients. Echocardiographic study is a challenge, but thorough assessment is important due to its direct effect on choice of therapeutic strategy and thus on prognosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres521197" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec541757" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres521196" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec541758" "titulo" => "<span class="elsevierStyleBold">Palavras-chave</span>" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-31" "fechaAceptado" => "2014-10-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec541757" "palabras" => array:5 [ 0 => "Aortic valve stenosis" 1 => "Hypertrophic cardiomyopathy" 2 => "Left ventricular outflow tract obstruction" 3 => "Echocardiography" 4 => "Doppler echocardiography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "<span class="elsevierStyleBold">Palavras-chave</span>" "identificador" => "xpalclavsec541758" "palabras" => array:5 [ 0 => "Estenose aórtica" 1 => "Cardiomiopatia hipertrófica" 2 => "Obstrução do trato de saída do ventrículo esquerdo" 3 => "Ecocardiografia" 4 => "Ecocardiografia <span class="elsevierStyleItalic">Doppler</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors report the case of a patient diagnosed with both hypertrophic cardiomyopathy and aortic stenosis. Due to clinical deterioration, additional investigation was performed, and a high left ventricular outflow tract gradient was identified. Correct identification of the condition causing the symptoms was challenging, and involved several imaging techniques, the contribution of transesophageal echocardiography being crucial. The final diagnosis of severe aortic stenosis led to successful valve replacement surgery. The presence of these two conditions in the same patient has been documented, although it is uncommon. This association poses particular diagnostic and therapeutic challenges, which are discussed in this paper.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam o caso de uma doente com os diagnósticos de miocardiopatia hipertrófica e estenose aórtica, na qual foi identificada a presença de um gradiente elevado ao nível do trato de saída do ventrículo esquerdo. O reconhecimento da patologia responsável pela sintomatologia foi desafiante, com envolvimento de várias técnicas de imagem, tendo sido fundamental a contribuição do ecocardiograma transesofágico. O diagnóstico final de estenose aórtica severa conduziu à referenciação para cirurgia de substituição valvular, com sucesso. A presença destas duas patologias em simultâneo num mesmo doente é conhecida, embora incomum. A sua combinação cria importantes desafios diagnósticos e terapêuticos, os quais serão objeto de discussão neste artigo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Almeida I, Caetano F, Trigo J, et al. Gradiente elevado no trato de saída do ventrículo esquerdo: estenose aórtica, miocardiopatia hipertrófica obstrutiva ou ambas? Rev Port Cardiol. 2015;34:357.</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" => 729 "Ancho" => 2507 "Tamanyo" => 385409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram showing sinus rhythm, heart rate 75 bpm, voltage criteria for left ventricular hypertrophy, without overload.</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" => 1320 "Ancho" => 1658 "Tamanyo" => 173453 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging showing marked hypertrophy of the basal and mid interventricular septum (22 mm) and moderately dilated left atrium (area 33 cm<span class="elsevierStyleSup">2</span>).</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" => 1090 "Ancho" => 2340 "Tamanyo" => 235298 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography: (left) color Doppler showing turbulent flow beginning in the left ventricular outflow tract; (right) continuous-wave Doppler showing rounded waveform with mid-systolic peak (bell-shaped) and peak and mean left ventricular/aortic gradient of 49 mmHg and 32 mmHg, respectively.</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" => 917 "Ancho" => 3257 "Tamanyo" => 274226 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography: (left) malformed aortic valve with area calculated by planimetry of 0.6 cm<span class="elsevierStyleSup">2</span>; (center) left ventricular outflow tract without visible obstruction; (right) color Doppler differentiating laminar flow in the left ventricular outflow tract and turbulent flow through the aortic valve, confirming obstruction at the level of the valve.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of left ventricular outflow gradient: hypertrophic cardiomyopathy versus aortic valvular stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 3 | 18 |
| 2024 October | 87 | 51 | 138 |
| 2024 September | 100 | 38 | 138 |
| 2024 August | 95 | 50 | 145 |
| 2024 July | 85 | 53 | 138 |
| 2024 June | 64 | 44 | 108 |
| 2024 May | 93 | 42 | 135 |
| 2024 April | 69 | 29 | 98 |
| 2024 March | 83 | 26 | 109 |
| 2024 February | 86 | 29 | 115 |
| 2024 January | 88 | 36 | 124 |
| 2023 December | 74 | 27 | 101 |
| 2023 November | 91 | 36 | 127 |
| 2023 October | 93 | 33 | 126 |
| 2023 September | 87 | 32 | 119 |
| 2023 August | 77 | 21 | 98 |
| 2023 July | 86 | 22 | 108 |
| 2023 June | 79 | 12 | 91 |
| 2023 May | 103 | 42 | 145 |
| 2023 April | 53 | 9 | 62 |
| 2023 March | 78 | 29 | 107 |
| 2023 February | 70 | 37 | 107 |
| 2023 January | 68 | 35 | 103 |
| 2022 December | 113 | 19 | 132 |
| 2022 November | 93 | 33 | 126 |
| 2022 October | 67 | 22 | 89 |
| 2022 September | 86 | 42 | 128 |
| 2022 August | 99 | 40 | 139 |
| 2022 July | 103 | 33 | 136 |
| 2022 June | 96 | 23 | 119 |
| 2022 May | 81 | 44 | 125 |
| 2022 April | 105 | 27 | 132 |
| 2022 March | 103 | 36 | 139 |
| 2022 February | 119 | 24 | 143 |
| 2022 January | 133 | 20 | 153 |
| 2021 December | 107 | 33 | 140 |
| 2021 November | 124 | 33 | 157 |
| 2021 October | 156 | 41 | 197 |
| 2021 September | 113 | 35 | 148 |
| 2021 August | 108 | 26 | 134 |
| 2021 July | 111 | 32 | 143 |
| 2021 June | 104 | 20 | 124 |
| 2021 May | 153 | 40 | 193 |
| 2021 April | 279 | 113 | 392 |
| 2021 March | 272 | 26 | 298 |
| 2021 February | 171 | 27 | 198 |
| 2021 January | 195 | 38 | 233 |
| 2020 December | 149 | 9 | 158 |
| 2020 November | 158 | 16 | 174 |
| 2020 October | 124 | 20 | 144 |
| 2020 September | 136 | 11 | 147 |
| 2020 August | 115 | 18 | 133 |
| 2020 July | 167 | 12 | 179 |
| 2020 June | 162 | 10 | 172 |
| 2020 May | 164 | 19 | 183 |
| 2020 April | 168 | 39 | 207 |
| 2020 March | 221 | 20 | 241 |
| 2020 February | 274 | 34 | 308 |
| 2020 January | 120 | 12 | 132 |
| 2019 December | 118 | 12 | 130 |
| 2019 November | 164 | 16 | 180 |
| 2019 October | 143 | 16 | 159 |
| 2019 September | 175 | 5 | 180 |
| 2019 August | 118 | 9 | 127 |
| 2019 July | 124 | 23 | 147 |
| 2019 June | 107 | 6 | 113 |
| 2019 May | 140 | 13 | 153 |
| 2019 April | 115 | 19 | 134 |
| 2019 March | 148 | 23 | 171 |
| 2019 February | 117 | 12 | 129 |
| 2019 January | 106 | 16 | 122 |
| 2018 December | 111 | 23 | 134 |
| 2018 November | 166 | 14 | 180 |
| 2018 October | 291 | 19 | 310 |
| 2018 September | 125 | 17 | 142 |
| 2018 August | 158 | 15 | 173 |
| 2018 July | 96 | 16 | 112 |
| 2018 June | 124 | 9 | 133 |
| 2018 May | 104 | 17 | 121 |
| 2018 April | 91 | 6 | 97 |
| 2018 March | 77 | 10 | 87 |
| 2018 February | 50 | 6 | 56 |
| 2018 January | 44 | 10 | 54 |
| 2017 December | 89 | 10 | 99 |
| 2017 November | 80 | 16 | 96 |
| 2017 October | 59 | 13 | 72 |
| 2017 September | 54 | 17 | 71 |
| 2017 August | 52 | 19 | 71 |
| 2017 July | 63 | 21 | 84 |
| 2017 June | 85 | 9 | 94 |
| 2017 May | 115 | 10 | 125 |
| 2017 April | 77 | 4 | 81 |
| 2017 March | 105 | 23 | 128 |
| 2017 February | 83 | 5 | 88 |
| 2017 January | 83 | 13 | 96 |
| 2016 December | 58 | 21 | 79 |
| 2016 November | 78 | 17 | 95 |
| 2016 October | 175 | 17 | 192 |
| 2016 September | 154 | 8 | 162 |
| 2016 August | 39 | 3 | 42 |
| 2016 July | 37 | 7 | 44 |
| 2016 June | 38 | 10 | 48 |
| 2016 May | 19 | 5 | 24 |
| 2016 April | 104 | 2 | 106 |
| 2016 March | 142 | 19 | 161 |
| 2016 February | 159 | 31 | 190 |
| 2016 January | 156 | 23 | 179 |
| 2015 December | 116 | 19 | 135 |
| 2015 November | 130 | 23 | 153 |
| 2015 October | 125 | 24 | 149 |
| 2015 September | 79 | 14 | 93 |
| 2015 August | 81 | 24 | 105 |
| 2015 July | 82 | 36 | 118 |
| 2015 June | 127 | 50 | 177 |
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