Percutaneous treatment of mitral valve regurgitation: Initial experience with the MitraClip device | Revista Portuguesa de Cardiologia (English edition)

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Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Terapêutica percutânea da insuficiência mitral: experiência inicial com o dispositivo MitraClip" ] ] "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" => 1260 "Ancho" => 1800 "Tamanyo" => 221825 ] ] "descripcion" => array:1 [ "en" => "(A) Positioning of the MitraClip in the center of the regurgitant jet; (B) view of the MitraClip from the atrial side; (C) clip inserted and released. Adapted by permission from Abbott Vascular." ] ] ] "textoCompleto" => "IntroductionMitral regurgitation (MR), of varying severity, is the most common valvular disorder, with a prevalence of 1.7%, increasing to 10% in those aged over 75.<a class="elsevierStyleCrossRef" href="#bib0115">1</a> However, around half of patients with severe MR are not referred for surgery, mainly due to advanced age, comorbidities or severe left ventricular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0120">2</a> Of those who do undergo surgery, only 34–53%<a class="elsevierStyleCrossRef" href="#bib0125">3</a> are treated by valvuloplasty rather than valve replacement.There are two types of MR: anatomical, in which one of the elements of the valve apparatus (annulus, leaflets or chordae) is dysfunctional; and functional, in which there is a geometric and/or functional alteration in the left ventricle that changes the normal relationship between these elements.Sooner or later, severe MI leads to left ventricular dysfunction and hence congestive heart failure. Although medical therapy can relieve symptoms, it does not alter progression of the disease, which is responsible for annual mortality of ≥5% in symptomatic individuals.<a class="elsevierStyleCrossRefs" href="#bib0130">4,5</a> Another reason for the large number of patients with severe MR who are not referred for surgery is that its benefit in functional MR is unproven. Although functional MR is 5–10 times more prevalent than anatomical MR or aortic stenosis,<a class="elsevierStyleCrossRef" href="#bib0140">6</a> surgical treatment has only a class IIb recommendation in the European and American guidelines for chronic secondary MR unless coronary artery bypass grafting is also indicated.<a class="elsevierStyleCrossRef" href="#bib0145">7</a> Percutaneous procedures thus do not in fact compete with surgery for the treatment of functional MR.Treatment of MR was until recently exclusively surgical, but in recent years a number of percutaneous approaches have been developed, of which the most widely used with consistent results involves implantation of a clip device, the MitraClip (Abbott Laboratories, Abbott Park, IL, USA).There have been various approaches for the treatment of MR:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Annulus: this D-shaped orifice, which is in fact the left atrioventricular junction,<a class="elsevierStyleCrossRef" href="#bib0115">1</a> is nonplanar, with elevated septal and lateral segments. The goal of surgical annuloplasty is to decrease the septal-to-lateral diameter by at least 8 mm.<a class="elsevierStyleCrossRef" href="#bib0150">8</a></li><li class="elsevierStyleListItem" id="lsti0010">•Leaflets: the anterior leaflet is in fibrous continuity with the coronary and non-coronary leaflets of the aortic valve, and has a wider surface with a shorter base, guarding only one-third of the left atrioventricular junction, than the posterior leaflet. The surface area of both leaflets taken together is 2.5 times the area of the valvular orifice. In systole, the leaflets coapt over a height of, on average, 8 mm, giving a “coaptation reserve” in case of annular dilation.<a class="elsevierStyleCrossRef" href="#bib0115">1</a></li><li class="elsevierStyleListItem" id="lsti0015">•Chordae tendineae: these connect the valve leaflets to the ventricular free wall via the papillary muscles or directly to the wall (basal cords).</li><li class="elsevierStyleListItem" id="lsti0020">•Ventricular geometry: changes in left ventricular geometry, whether due to ischemia or other processes, can severely disrupt the dynamics of mitral coaptation.<a class="elsevierStyleCrossRef" href="#bib0155">9</a> Dyskinesia can alter the orientation of the basal cords, leading to tethering of the posterior leaflet, and ventricular dilatation can cause the papillary muscles to move apically, leading to leaflet tenting and loss of coaptation.</li></ul>The Alfieri stitch is a surgical treatment for severe MR due to incomplete leaflet coaptation that consists of suturing together the free edges of the middle segments of the anterior and posterior leaflets (A2 and P2 scallops), together with annuloplasty,<a class="elsevierStyleCrossRef" href="#bib0160">10</a> and configuring the valve with a double orifice. However, the group who developed this procedure discovered that omitting the annuloplasty often produced a good hemodynamic result, which was the rationale for a percutaneous approach with the MitraClip.<a class="elsevierStyleCrossRef" href="#bib0165">11</a>MethodsOf a total of 20 patients referred for this procedure over a two-year period, six were initially selected for the treatment after transthoracic and transesophageal echocardiographic assessment. Clinical criteria were functional MR grade 4+, New York Heart Association (NYHA) class III or IV and previous admissions for heart failure, and they also had to have exhausted all other treatment options, surgical or otherwise, including cardiac resynchronization therapy. Most of those referred were being followed in heart failure clinics. Patients who fulfilled the clinical criteria also had to meet the anatomical criteria (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) for implantation of the MitraClip device. As the technique has become more widespread, the initially proposed anatomical criteria have been somewhat modified, but they should be closely followed by centers beginning to use the procedure. The criteria are: central MR jet; coaptation length >2 mm and coaptation depth <11 mm; in the event of a flail leaflet, flail gap and flail width should be no more than 10 and 15 mm, respectively.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>These criteria inevitably exclude patients with severe left ventricular dilatation, since dilatation of the annulus separates the leaflets to such an extent that it is extremely difficult to implant the clip. All echocardiographic records were reviewed by a proctor, who decided on the feasibility of the procedure.In demographic terms (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) this initial experience involved relatively young patients (mean age 58.5±13.1 years), with a mean ejection fraction (EF) of 29±10.36% and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 20.06±16.86. Four patients had been assessed for heart transplantation, one of whom had been rejected due to fixed pulmonary vascular resistance. Three patients would have been excluded from the Endovascular Valve Edge-to-Edge Repair Study (EVEREST II) trial<a class="elsevierStyleCrossRef" href="#bib0170">12</a> due to EF <25% and/or left ventricular end-systolic dimension of >55 mm (mean 55.0±7.19 mm).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The selected patients underwent transthoracic echocardiography before the procedure, at discharge, and at one, six and 12 months, as well as clinical assessment, pro-brain-type natriuretic peptide (proBNP) measurement, and six-minute walk test the day before implantation and at one, six and 12 months post-implantation. All patients gave their written informed consent.Procedural success was defined as grade 2+ or less MR in the absence of complications.<a class="elsevierStyleCrossRef" href="#bib0170">12</a>The MitraClip resembles a clothes-peg, and is made of cobalt chromium, 4 mm wide, with two articulated arms that open from 0° (closed position) to 240° (open position), and uses a delivery system (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>) that enables the arms to be opened and closed and the device to be maneuvered in three dimensions (rotated and moved in anterior, posterior, lateral and medial directions).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The procedure is performed under general anesthesia. Via a femoral approach, a 24F delivery system is introduced into the left atrium following transseptal puncture, under fluoroscopic and transesophageal echocardiographic guidance. Three-dimensional echocardiography is essential, since it allows simultaneous visualization in two orthogonal planes (x-plane mode) and thus helps to fine-tune the delivery and placement of the device and fixation of the leaflets. The clip is moved to the base of the regurgitant flow and grasps the mid segments of both leaflets, bringing them together, and is only released when the jet is deemed to be sufficiently reduced (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). If the leaflets cannot be correctly fixed, the arms can be opened to release the leaflets, and the clip withdrawn to the left atrium to be repositioned. Between one and four clips are usually implanted. Following implantation, a fibrous bridge forms between the two leaflets, providing additional strength and reducing the risk of septal-lateral distension.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The procedures were performed in the catheterization laboratory of the cardiology department of Hospital de Santa Marta, Lisbon, under general anesthesia and two- and three-dimensional transesophageal echocardiographic guidance (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). Three proctors (an interventional cardiologist, an echocardiographic cardiologist and a device technician) were present for the first two cases and one, a device technician, was present for the others. Following transseptal puncture and administration of intravenous heparin to achieve an activated clotting time >250 s, the 22F MitraClip delivery system was positioned in the left atrium via a 24F sheath in the right femoral vein. One MitraClip was placed at the base of the regurgitant jet, dividing it into two; if these jets were small, the clip was implanted, otherwise two clips were used (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>), implanting the first in a mid position and the second more laterally (<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>), which was only released after confirmation that there was no significant transmitral gradient. If the leaflets were particularly difficult to grasp, a brief period of apnea was induced by disconnecting the patient from the ventilator for a few seconds and/or intense bradycardia was induced by administering a short half-life beta-blocker (esmolol).<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>In accordance with our protocol, patients were extubated in the catheterization laboratory and transferred already conscious to the intensive care unit (ICU) for 24 hours, after which they were transferred to the ward.Since five patients were under oral anticoagulation with acenocoumarol or warfarin, clopidogrel was prescribed for a month following the procedure only in the remaining patient, who was taking aspirin.Results of the statistical analysis of quantitative variables in these six cases were expressed as means ± standard deviation.ResultsProcedural success in these six patients was 100%, with no adverse events during the intervention or during hospital stay (mean 6.2±1.48 days).Although the intervention is relatively lengthy (115.8±23.7 min), fluoroscopy time is relatively short (49.2±19.38 min), because the procedure is mainly guided by transesophageal echocardiography (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Echocardiographic assessment (<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>) revealed improvement in left ventricular end-diastolic (229.5±118.53 vs. 182.5±88.24 ml) and end-systolic (158.2±100.28 vs. 127.2±57.71 ml) volume, EF (31.3±8.2 vs. 37.3±6.11%) and pulmonary artery systolic pressure (44.5±16.75 vs. 41.0±9.97 mmHg).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>At one-month follow-up (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>), functional status had improved in five of the six patients, with an improvement of one (two patients) or two (three patients) NYHA classes. There were a total of three readmissions (two in one patient) and two deaths, in two of the four patients who had been initially considered for heart transplantation. Of these, one had been rejected due to fixed pulmonary vascular resistance and the other was in terminal heart failure before the MitraClip procedure. This patient was readmitted a month later for congestive heart failure and died 84 days after admission without a donor having been found; he was the only patient in whom proBNP had risen significantly at one-month follow-up, all the others showing a fall in this parameter (557.8±376.73 vs. 494.2±249.5 ng/l). The patient who had been denied transplantation was briefly admitted twice within six months of MitraClip implantation (before the procedure she had been admitted virtually every month) and suffered outpatient sudden death after nine months.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>The one-month six-minute walk test showed an improvement in all patients (329.8±98.42 vs. 385.33±109.95 m). The four patients still alive at the end of follow-up (290±140 days) maintained an improvement of one or two NYHA functional classes (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).DiscussionThe six cases described constitute our initial experience with the MitraClip. This small number, together with a still short follow-up and the fact that the echocardiographic studies were not evaluated by an independent laboratory, are the main limitations of this study and prevent any generalizations. Nevertheless, the most striking finding is the safety of the intervention.We began using this procedure after a two-year period of patient selection, which included detailed study of the mitral anatomy by transthoracic and transesophageal echocardiography. There are currently eight patients on the waiting list, all with severe MR and symptoms of heart failure. Accumulated experience worldwide suggests that when a center first begins to use the device only one in three patients referred for MitraClip implantation is considered suitable.The device received CE Mark approval in 2008 and US Food and Drug Administration approval in 2013, the latter on the basis of the EVEREST II trial, in which 279 patients with MR grade 3+ or 4+ were randomized in a 2:1 ratio to MitraClip or surgery (repair or replacement). The primary composite endpoint for efficacy was freedom from death, from surgery for mitral valve dysfunction, and from grade 3+ or 4+ MR at 12 months, and the primary safety endpoint was a composite of major adverse events within 30 days. The rates of the primary end point for efficacy were 55% in the MitraClip group and 73% in the surgery group (p=0.007), with 6% mortality in each group, 20% vs. 2% surgery for mitral valve dysfunction, and 21% vs. 20% grade 3+ or 4+ MR. The rates for the safety endpoint were 15% vs. 48% (p<0.001). At 12 months, both groups had improved left ventricular size, NYHA functional class, and quality-of-life measures.Of the patients treated with the MitraClip, 41 (23%) had grade 3+ or 4+ MR before hospital discharge and were referred for surgery. Of these 41 patients, 28 underwent subsequent mitral valve surgery. In the surgery group, mitral valve replacement was performed in 14% and repair in 86%.Transfusion of ≥2 units of blood (which has an important effect on late outcomes<a class="elsevierStyleCrossRef" href="#bib0175">13</a>) comprised the largest single component of major adverse events at 30 days. Even after the exclusion of transfusion events, the rate of adverse events was lower in the MitraClip group.In two subgroups in the MitraClip arm, those with functional MR and patients aged ≥70 years, efficacy was not inferior to surgery. Four-year results in the EVEREST II trial show 83% survival in the MitraClip group and 82% in the surgical group, and no significant difference in the number of patients with MR grade 3+ or 4+.<a class="elsevierStyleCrossRef" href="#bib0180">14</a> The efficacy and safety of the device compared with medical therapy in high-risk patients has been confirmed by the European ACCESS-EU registry<a class="elsevierStyleCrossRef" href="#bib0185">15</a> and the German TRAnscatheter Mitral valve Interventions (TRAMI) registry.<a class="elsevierStyleCrossRef" href="#bib0190">16</a> Also comparing the MitraClip with standard of care are the randomized trials Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for Extremely High Surgical Risk Patients (COAPT) in the USA and A Randomized Study of the MitraClip Device in Heart Failure Patients with Clinically Significant Functional Mitral Regurgitation (RESHAPE-HF) in Europe.The most striking demographic feature in our series was the relatively young age of the patients (only one octogenarian; mean age 58.5±13.1 years), which was the main reason for the low logistic EuroSCORE of 20.06±16.86. Given the weight attributed to age in this risk score, the real risk of these patients may have been underestimated, as indicated by the two non-procedure-related deaths in the 12 months after implantation. The purpose of selecting such young patients was to use the device in those with the longest expected survival, who would thus obtain the maximum possible benefit from the procedure. The idea of choosing patients who were under consideration for heart transplantation was to postpone for as long as possible – ideally for years – the need to go on the waiting list for a donor. However, the results suggest that in some of these patients, the natural history of the disease has progressed too far for them to derive any benefit. Patient selection remains the most important factor, since the purpose of the MitraClip is to improve symptoms, but current evidence indicates that a quarter of patients experience little or no symptomatic relief.Other series of patients mainly with functional MR,<a class="elsevierStyleCrossRef" href="#bib0195">17</a> including the largest European registry and the one that is perhaps closest to our experience, ACCESS-EU,<a class="elsevierStyleCrossRef" href="#bib0185">15</a> show that 72–83% of patients who survive to one-year follow-up have grade ≤2+ MR and 79–83% are in NYHA class I or II. Hospital stay in ACCESS-EU was slightly longer than in our series (7.7±8.2 days, including 2.5±6.5 days in the ICU), and as in our series there was consistent improvement in echocardiographic parameters and in the six-minute walk test; in the latter the mean gain was around 60 m, also similar to our experience (55 m). Hospital stay in European series tends to be longer than in US registries, in which the average is three days.Historically, US and European approaches have differed. EVEREST I<a class="elsevierStyleCrossRef" href="#bib0200">18</a> and II were American trials, and they gave initial credibility to the MitraClip device; their patients also had to be candidates for surgery. In Europe, by contrast, the focus has been more on patients who would be ineligible for such trials: those with severe functional MR and heart failure, not considered suitable for surgery and often non-responders to cardiac resynchronization therapy, most of whom are being followed in heart failure clinics and some under consideration for or denied transplantation, as were four of our patients. In Europe MitraClip implantation is perceived as a procedure that does not compete with surgery for patients who have no non-pharmacological alternative. Thus, unlike in EVEREST II, in which 73% of the trial population had degenerative MR, in our series all six patients had functional MR. As a result, unlike transcatheter aortic valve replacement, there is little possibility of a turf war between interventional cardiology and cardiac surgery.There are two patient groups for whom MitraClip therapy is particularly attractive: those with severe annular calcification, since this can act as a prosthetic ring to provide additional support and thus prevent progressive annular dilatation; and those with severe functional MR and heart failure refractory to pharmacological and resynchronization therapy (non-responders).<a class="elsevierStyleCrossRef" href="#bib0205">19</a>Despite the successful and increasing use of the procedure, the MitraClip does have some potential limitations.<a class="elsevierStyleCrossRef" href="#bib0210">20</a> It is not a complete substitute for the Alfieri stitch, since it does not treat the annulus, which may explain the recurrence of significant MR in the medium to long term; it can be difficult to quantify MR, particularly residual regurgitation after implantation of the clip during a procedure under general anesthesia (although this problem is also found with surgery); MR could be replaced by mitral stenosis, although no cases have been reported to date<a class="elsevierStyleCrossRef" href="#bib0215">21</a>; and there are no data on its long-term durability and efficacy.Meanwhile, as the procedure has become more widespread, the initial anatomical criteria have been widened, with cases reported of treatment of eccentric MR, and variations on the original technique have been developed, such as the zipping technique, in which four or five clips are implanted.There are a growing number of percutaneous MR therapies besides the MitraClip, some of them already being implemented. These can be divided into two main types, according to whether they involve the annulus or other elements of the mitral valve apparatus.In most surgical approaches to MR, the two main components of the valve, the leaflets and the annulus, are treated. It is thus understandable that there has also been extensive research into percutaneous interventions on the annulus, which in fact precedes the development of the MitraClip.There are two forms of percutaneous annuloplasty, indirect and direct. The CARILLON Mitral Contour System (Cardiac Dimensions) is an indirect annuloplasty device consisting of two nitinol anchors connected by a central nitinol element, positioned in the coronary sinus. It is delivered via a 9F catheter through the internal jugular vein, and tension on the device is adjusted manually by moving it 4–5 cm before final release. The procedure is monitored by transesophageal echocardiography, to assess MR grade, and left coronary angiography, to exclude coronary compression. It is the only percutaneous annuloplasty device currently approved in the European Union.Unlike indirect annuloplasty devices, which are positioned in the coronary sinus, direct approaches treat the annulus itself, as in surgical repair. Access is more complex with direct devices. With the Mitralign Bident system, the device is introduced retrogradely via the femoral artery and positioned in the left ventricle under the posterior leaflet. Two pledget pairs are implanted in the annulus and plicated with a Mitralign lock; the resulting tension brings the leaflets closer together, reducing the annular circumference. Another direct annuloplasty device is the Valtech Cardioband, in which access is transseptal; this has been used exclusively to treat functional MR.Since patients treated by the MitraClip may suffer recurrence of their original grade of MR in the medium to long term, the idea of associating annuloplasty is an attractive one, since it more closely reproduces surgical repair, and appears to be the most promising approach<a class="elsevierStyleCrossRef" href="#bib0220">22</a> while we await the development of a prosthetic mitral valve that can be implanted percutaneously in the native valve.ConclusionsOur initial experience with the MitraClip device confirmed the safety of the procedure in a group of patients with heart failure and grade 4+ functional MR who were not considered suitable for surgery, three of whom would have been excluded from the EVEREST II trial and four of whom had been considered for heart transplantation.The short follow-up does not allow a proper analysis of the device's efficacy, but the absence of reintervention (surgical or otherwise), improvements in functional class, left ventricular volumes and six-minute walk test, and consistent falls in proBNP levels, all suggest that it is at least reasonable. However, MitraClip implantation does not appear to alter the natural history of the disease in patients under consideration for heart transplantation.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this investigation.Confidentiality of dataThe authors declare that no patient data appears in this article.Right to privacy and informed consentThe authors declare that no patient data appears in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres552143" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec569507" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres552142" "titulo" => "Resumo" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec569506" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-09-23" "fechaAceptado" => "2015-04-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec569507" "palabras" => array:5 [ 0 => "MitraClip" 1 => "Mitral regurgitation" 2 => "Percutaneous mitral valve repair" 3 => "Functional mitral regurgitation" 4 => "Transcatheter mitral repair" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec569506" "palabras" => array:4 [ 0 => "MitraClip" 1 => "Insuficiência mitral" 2 => "Reparação percutânea da válvula mitral" 3 => "Insuficiência mitral funcional" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionMitral regurgitation (MR) is the most common valvular disease and has recently been the target of a number of percutaneous approaches. The MitraClip is virtually the only device for which there is considerable experience, with more than 20000 procedures performed worldwide. ObjectiveTo describe our initial experience of the percutaneous treatment of MR with the MitraClip device. MethodsWe describe the first six MitraClip cases performed in this institution (mean age 58.5±13.1 years), with functional MR grade 4+ and New York Heart Association (NYHA) heart failure class III or IV (n=3), with a mean follow-up of 290±145 days. ResultsProcedural success (MR ≤2+) was 100%. Total procedure time was 115.8±23.7 min, with no in-hospital adverse events and discharge between the fourth and eighth day, and consistent improvement in the six-minute walk test (329.8±98.42 vs. 385.33±106.95 m) and in NYHA class (three patients improved by two NYHA classes). During follow-up there were two deaths, in two of the four patients who had been initially considered for heart transplantation. ConclusionIn patients with functional MR the MitraClip procedure is safe, with both a high implantation and immediate in-hospital success rate. A longer follow-up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease, namely those denied transplantation or on the heart transplant waiting list." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "IntroduçãoA insuficiência valvular mitral (IM) é a valvulopatia mais comum e começa agora a ser alvo de abordagens percutâneas. O dispositivo MitraClip é virtualmente o único dispositivo com uma experiência considerável, ultrapassando atualmente as 20000 implantações. ObjetivoDescrever a experiência inicial da terapêutica percutânea da IM com o dispositivo MitraClip. MétodosDescrevem-se os primeiros seis casos de MitraClip realizados nesta instituição (idade 58,5±13,1 anos), com IM 4+ de etiologia funcional e insuficiência cardíaca classe III ou IV (n=3) da New York Heart Association (NYHA), sem indicação cirúrgica ou recusados para cirurgia, com um follow-up médio 290±145 dias avaliado clinicamente pela sobrevivência, classe funcional, teste da marcha dos seis minutos, estudo ecocardiográfico e determinação do proBNP. ResultadosO sucesso do procedimento (IM ≤2+) foi de 100%, com um tempo de procedimento de 115,8±23,7mins, sem intercorrências intra-hospitalares, alta entre o 4.° e 8.° dia e uma melhoria consistente no teste da marcha dos seis minutos (329,8±98,42 versus 385,3±106,95m) e da classe funcional (três dos pacientes com melhoria de duas classes funcionais NYHA). Na totalidade do follow-up (290±145 dias) constatam-se dois óbitos, em dois dos quatro pacientes que tinham sido considerados para transplantação cardíaca. ConclusõesO procedimento de implantação do dispositivo MitraClip é seguro, com uma alta taxa de sucesso imediato nos pacientes com IM funcional. A médio prazo o benefício clínico parece esbater-se ou anular-se nos pacientes com insuficiência cardíaca mais terminal, nomeadamente nos pacientes a aguardar ou recusados para transplante." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Cacela D, Fiarresga A, Branco L, et al. Terapêutica percutânea da insuficiência mitral: experiência inicial com o dispositivo MitraClip. Rev Port Cardiol. 2015;34:515–524." ] ] "multimedia" => array:12 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 757 "Ancho" => 3236 "Tamanyo" => 255707 ] ] "descripcion" => array:1 [ "en" => "Anatomical criteria for MitraClip implantation (besides mitral area of ≥4.0 cm2): flail gap <10 mm; flail width <15 mm; coaptation depth <11 mm; coaptation length >2 mm. Adapted by permission from the Transesophageal Echo Acquisition Guide (Abbott Vascular)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 914 "Ancho" => 1501 "Tamanyo" => 108306 ] ] "descripcion" => array:1 [ "en" => "The MitraClip device." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1042 "Ancho" => 1673 "Tamanyo" => 153018 ] ] "descripcion" => array:1 [ "en" => "Components of the MitraClip delivery system." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1260 "Ancho" => 1800 "Tamanyo" => 221825 ] ] "descripcion" => array:1 [ "en" => "(A) Positioning of the MitraClip in the center of the regurgitant jet; (B) view of the MitraClip from the atrial side; (C) clip inserted and released. Adapted by permission from Abbott Vascular." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 731 "Ancho" => 975 "Tamanyo" => 81570 ] ] "descripcion" => array:1 [ "en" => "Three-dimensional echocardiographic image of the A2 and P2 scallops held by the MitraClip." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 821 "Ancho" => 975 "Tamanyo" => 72920 ] ] "descripcion" => array:1 [ "en" => "Angiographic image of the release of a second MitraClip." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1276 "Ancho" => 1950 "Tamanyo" => 283488 ] ] "descripcion" => array:1 [ "en" => "Implantation of a second MitraClip. If it is expected that a second clip will be required, the first should be placed in a mid position and the second more laterally. (A and B) Confirmation in different views of the position of the MitraClip; (C) the two mitral valve leaflets are grasped by the MitraClip; (D) after release, with residual regurgitation jets." ] ] 7 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "EF: ejection fraction; ES II: EuroSCORE II; EVER II: EVEREST II criteria; F: female; Func: functional MR; log ES: logistic EuroSCORE; LVESD: left ventricular end-diastolic diameter in mm; M: male; MR: mitral regurgitation grade; N: no; NYHA: New York Heart Association class; Org: organic or degenerative MR; Y: yes." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EVER II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">log ES \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ES II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Func \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Org \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ischemic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myocarditis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dilated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dilated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dilated \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Y \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ischemic \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891404.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical characteristics of the study population." ] ] 8 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Device time: time between entry of the steerable guide catheter into the left atrium via the interatrial septum and withdrawal of the MitraClip delivery catheter into the steerable guide catheter; Procedure time: time between transseptal puncture and removal of the steerable guide catheter." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean ± SD \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fluoroscopy time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49.2±19.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procedure time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">155 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">135 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115.8±23.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Device time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">130 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.7±20.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Radiation dose (mGy) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">915 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2680 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1487 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">209 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4456 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2026 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1962.2±1362.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No. of clips implanted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3±0.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hospital stay after procedure (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.0±1.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891408.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Procedural data and hospital stay." ] ] 9 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "b, 1, 6, 12: baseline, 1 month, 6 months, 12 months, respectively; d: died; LVEDV: left ventricular end-diastolic volume in ml; LVESV: left ventricular end-systolic volume in ml; MR: mitral regurgitation grade; Pt: patient." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pt \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MRb \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR12 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDVb \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV12 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESVb \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV12 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">443 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">390 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">403 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">337 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">360 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">315 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">312 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">228 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">110 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">151 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">139 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">107 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">142 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">136 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">317 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">262 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">204 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">231 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891407.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Last echocardiographic assessment before death." ] ] ] "descripcion" => array:1 [ "en" => "Echocardiographic evolution of mitral regurgitation and ventricular volumes." ] ] 10 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "b, 1, 6, 12: baseline, 1 month, 6 months, 12 months, respectively; d: died; EF: ejection fraction (%); PASP: pulmonary artery systolic pressure (mmHg)." "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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EFb \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF12 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASPb \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP6 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP12 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">d \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab891406.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Echocardiographic evolution of ejection fraction and pulmonary artery systolic pressure." ] ] 11 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "b, 1, 6, 12: baseline, 1 month, 6 months, 12 months, respectively; d: died; NYHA: New York Heart Association class; proBNP: pro-brain-type natriuretic peptide (ng/l); WT: six-minute walk test (m)." 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Percutaneous treatment of mitral valve regurgitation: Initial experience with the MitraClip device

Terapêutica percutânea da insuficiência mitral: experiência inicial com o dispositivo MitraClip

Duarte Cacela

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dcacela@hotmail.com

Corresponding author.

, António Fiarresga, Luísa Branco, Ana Galrinho, Pedro Rio, Mafalda Selas, Rui Ferreira

Serviço de Cardiologia, Hospital S. Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal

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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Positioning of the MitraClip in the center of the regurgitant jet&#59; &#40;B&#41; view of the MitraClip from the atrial side&#59; &#40;C&#41; clip inserted and released&#46; Adapted by permission from Abbott Vascular&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mitral regurgitation &#40;MR&#41;&#44; of varying severity&#44; is the most common valvular disorder&#44; with a prevalence of 1&#46;7&#37;&#44; increasing to 10&#37; in those aged over 75&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> However&#44; around half of patients with severe MR are not referred for surgery&#44; mainly due to advanced age&#44; comorbidities or severe left ventricular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> Of those who do undergo surgery&#44; only 34&#8211;53&#37;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> are treated by valvuloplasty rather than valve replacement&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are two types of MR&#58; anatomical&#44; in which one of the elements of the valve apparatus &#40;annulus&#44; leaflets or chordae&#41; is dysfunctional&#59; and functional&#44; in which there is a geometric and&#47;or functional alteration in the left ventricle that changes the normal relationship between these elements&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Sooner or later&#44; severe MI leads to left ventricular dysfunction and hence congestive heart failure&#46; Although medical therapy can relieve symptoms&#44; it does not alter progression of the disease&#44; which is responsible for annual mortality of &#8805;5&#37; in symptomatic individuals&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;5</span></a> Another reason for the large number of patients with severe MR who are not referred for surgery is that its benefit in functional MR is unproven&#46; Although functional MR is 5&#8211;10 times more prevalent than anatomical MR or aortic stenosis&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> surgical treatment has only a class IIb recommendation in the European and American guidelines for chronic secondary MR unless coronary artery bypass grafting is also indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> Percutaneous procedures thus do not in fact compete with surgery for the treatment of functional MR&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment of MR was until recently exclusively surgical&#44; but in recent years a number of percutaneous approaches have been developed&#44; of which the most widely used with consistent results involves implantation of a clip device&#44; the MitraClip &#40;Abbott Laboratories&#44; Abbott Park&#44; IL&#44; USA&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">There have been various approaches for the treatment of MR&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Annulus&#58; this D-shaped orifice&#44; which is in fact the left atrioventricular junction&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> is nonplanar&#44; with elevated septal and lateral segments&#46; The goal of surgical annuloplasty is to decrease the septal-to-lateral diameter by at least 8 mm&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Leaflets&#58; the anterior leaflet is in fibrous continuity with the coronary and non-coronary leaflets of the aortic valve&#44; and has a wider surface with a shorter base&#44; guarding only one-third of the left atrioventricular junction&#44; than the posterior leaflet&#46; The surface area of both leaflets taken together is 2&#46;5 times the area of the valvular orifice&#46; In systole&#44; the leaflets coapt over a height of&#44; on average&#44; 8 mm&#44; giving a &#8220;coaptation reserve&#8221; in case of annular dilation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Chordae tendineae&#58; these connect the valve leaflets to the ventricular free wall via the papillary muscles or directly to the wall &#40;basal cords&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Ventricular geometry&#58; changes in left ventricular geometry&#44; whether due to ischemia or other processes&#44; can severely disrupt the dynamics of mitral coaptation&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a> Dyskinesia can alter the orientation of the basal cords&#44; leading to tethering of the posterior leaflet&#44; and ventricular dilatation can cause the papillary muscles to move apically&#44; leading to leaflet tenting and loss of coaptation&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">The Alfieri stitch is a surgical treatment for severe MR due to incomplete leaflet coaptation that consists of suturing together the free edges of the middle segments of the anterior and posterior leaflets &#40;A2 and P2 scallops&#41;&#44; together with annuloplasty&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> and configuring the valve with a double orifice&#46; However&#44; the group who developed this procedure discovered that omitting the annuloplasty often produced a good hemodynamic result&#44; which was the rationale for a percutaneous approach with the MitraClip&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">Of a total of 20 patients referred for this procedure over a two-year period&#44; six were initially selected for the treatment after transthoracic and transesophageal echocardiographic assessment&#46; Clinical criteria were functional MR grade 4&#43;&#44; New York Heart Association &#40;NYHA&#41; class III or IV and previous admissions for heart failure&#44; and they also had to have exhausted all other treatment options&#44; surgical or otherwise&#44; including cardiac resynchronization therapy&#46; Most of those referred were being followed in heart failure clinics&#46; Patients who fulfilled the clinical criteria also had to meet the anatomical criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41; for implantation of the MitraClip device&#46; As the technique has become more widespread&#44; the initially proposed anatomical criteria have been somewhat modified&#44; but they should be closely followed by centers beginning to use the procedure&#46; The criteria are&#58; central MR jet&#59; coaptation length &#62;2 mm and coaptation depth &#60;11 mm&#59; in the event of a flail leaflet&#44; flail gap and flail width should be no more than 10 and 15 mm&#44; respectively&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">These criteria inevitably exclude patients with severe left ventricular dilatation&#44; since dilatation of the annulus separates the leaflets to such an extent that it is extremely difficult to implant the clip&#46; All echocardiographic records were reviewed by a proctor&#44; who decided on the feasibility of the procedure&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In demographic terms &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; this initial experience involved relatively young patients &#40;mean age 58&#46;5&#177;13&#46;1 years&#41;&#44; with a mean ejection fraction &#40;EF&#41; of 29&#177;10&#46;36&#37; and logistic European System for Cardiac Operative Risk Evaluation &#40;EuroSCORE&#41; of 20&#46;06&#177;16&#46;86&#46; Four patients had been assessed for heart transplantation&#44; one of whom had been rejected due to fixed pulmonary vascular resistance&#46; Three patients would have been excluded from the Endovascular Valve Edge-to-Edge Repair Study &#40;EVEREST II&#41; trial<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a> due to EF &#60;25&#37; and&#47;or left ventricular end-systolic dimension of &#62;55 mm &#40;mean 55&#46;0&#177;7&#46;19 mm&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The selected patients underwent transthoracic echocardiography before the procedure&#44; at discharge&#44; and at one&#44; six and 12 months&#44; as well as clinical assessment&#44; pro-brain-type natriuretic peptide &#40;proBNP&#41; measurement&#44; and six-minute walk test the day before implantation and at one&#44; six and 12 months post-implantation&#46; All patients gave their written informed consent&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Procedural success was defined as grade 2&#43; or less MR in the absence of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The MitraClip resembles a clothes-peg&#44; and is made of cobalt chromium&#44; 4 mm wide&#44; with two articulated arms that open from 0&#176; &#40;closed position&#41; to 240&#176; &#40;open position&#41;&#44; and uses a delivery system &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>&#41; that enables the arms to be opened and closed and the device to be maneuvered in three dimensions &#40;rotated and moved in anterior&#44; posterior&#44; lateral and medial directions&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The procedure is performed under general anesthesia&#46; Via a femoral approach&#44; a 24F delivery system is introduced into the left atrium following transseptal puncture&#44; under fluoroscopic and transesophageal echocardiographic guidance&#46; Three-dimensional echocardiography is essential&#44; since it allows simultaneous visualization in two orthogonal planes &#40;x-plane mode&#41; and thus helps to fine-tune the delivery and placement of the device and fixation of the leaflets&#46; The clip is moved to the base of the regurgitant flow and grasps the mid segments of both leaflets&#44; bringing them together&#44; and is only released when the jet is deemed to be sufficiently reduced &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; If the leaflets cannot be correctly fixed&#44; the arms can be opened to release the leaflets&#44; and the clip withdrawn to the left atrium to be repositioned&#46; Between one and four clips are usually implanted&#46; Following implantation&#44; a fibrous bridge forms between the two leaflets&#44; providing additional strength and reducing the risk of septal-lateral distension&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The procedures were performed in the catheterization laboratory of the cardiology department of Hospital de Santa Marta&#44; Lisbon&#44; under general anesthesia and two- and three-dimensional transesophageal echocardiographic guidance &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Three proctors &#40;an interventional cardiologist&#44; an echocardiographic cardiologist and a device technician&#41; were present for the first two cases and one&#44; a device technician&#44; was present for the others&#46; Following transseptal puncture and administration of intravenous heparin to achieve an activated clotting time &#62;250 s&#44; the 22F MitraClip delivery system was positioned in the left atrium via a 24F sheath in the right femoral vein&#46; One MitraClip was placed at the base of the regurgitant jet&#44; dividing it into two&#59; if these jets were small&#44; the clip was implanted&#44; otherwise two clips were used &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>&#41;&#44; implanting the first in a mid position and the second more laterally &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>&#41;&#44; which was only released after confirmation that there was no significant transmitral gradient&#46; If the leaflets were particularly difficult to grasp&#44; a brief period of apnea was induced by disconnecting the patient from the ventilator for a few seconds and&#47;or intense bradycardia was induced by administering a short half-life beta-blocker &#40;esmolol&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In accordance with our protocol&#44; patients were extubated in the catheterization laboratory and transferred already conscious to the intensive care unit &#40;ICU&#41; for 24 hours&#44; after which they were transferred to the ward&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Since five patients were under oral anticoagulation with acenocoumarol or warfarin&#44; clopidogrel was prescribed for a month following the procedure only in the remaining patient&#44; who was taking aspirin&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Results of the statistical analysis of quantitative variables in these six cases were expressed as means &#177; standard deviation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0110" class="elsevierStylePara elsevierViewall">Procedural success in these six patients was 100&#37;&#44; with no adverse events during the intervention or during hospital stay &#40;mean 6&#46;2&#177;1&#46;48 days&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Although the intervention is relatively lengthy &#40;115&#46;8&#177;23&#46;7 min&#41;&#44; fluoroscopy time is relatively short &#40;49&#46;2&#177;19&#46;38 min&#41;&#44; because the procedure is mainly guided by transesophageal echocardiography &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Echocardiographic assessment &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#41; revealed improvement in left ventricular end-diastolic &#40;229&#46;5&#177;118&#46;53 vs&#46; 182&#46;5&#177;88&#46;24 ml&#41; and end-systolic &#40;158&#46;2&#177;100&#46;28 vs&#46; 127&#46;2&#177;57&#46;71 ml&#41; volume&#44; EF &#40;31&#46;3&#177;8&#46;2 vs&#46; 37&#46;3&#177;6&#46;11&#37;&#41; and pulmonary artery systolic pressure &#40;44&#46;5&#177;16&#46;75 vs&#46; 41&#46;0&#177;9&#46;97 mmHg&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">At one-month follow-up &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44; functional status had improved in five of the six patients&#44; with an improvement of one &#40;two patients&#41; or two &#40;three patients&#41; NYHA classes&#46; There were a total of three readmissions &#40;two in one patient&#41; and two deaths&#44; in two of the four patients who had been initially considered for heart transplantation&#46; Of these&#44; one had been rejected due to fixed pulmonary vascular resistance and the other was in terminal heart failure before the MitraClip procedure&#46; This patient was readmitted a month later for congestive heart failure and died 84 days after admission without a donor having been found&#59; he was the only patient in whom proBNP had risen significantly at one-month follow-up&#44; all the others showing a fall in this parameter &#40;557&#46;8&#177;376&#46;73 vs&#46; 494&#46;2&#177;249&#46;5 ng&#47;l&#41;&#46; The patient who had been denied transplantation was briefly admitted twice within six months of MitraClip implantation &#40;before the procedure she had been admitted virtually every month&#41; and suffered outpatient sudden death after nine months&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The one-month six-minute walk test showed an improvement in all patients &#40;329&#46;8&#177;98&#46;42 vs&#46; 385&#46;33&#177;109&#46;95 m&#41;&#46; The four patients still alive at the end of follow-up &#40;290&#177;140 days&#41; maintained an improvement of one or two NYHA functional classes &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">The six cases described constitute our initial experience with the MitraClip&#46; This small number&#44; together with a still short follow-up and the fact that the echocardiographic studies were not evaluated by an independent laboratory&#44; are the main limitations of this study and prevent any generalizations&#46; Nevertheless&#44; the most striking finding is the safety of the intervention&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We began using this procedure after a two-year period of patient selection&#44; which included detailed study of the mitral anatomy by transthoracic and transesophageal echocardiography&#46; There are currently eight patients on the waiting list&#44; all with severe MR and symptoms of heart failure&#46; Accumulated experience worldwide suggests that when a center first begins to use the device only one in three patients referred for MitraClip implantation is considered suitable&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The device received CE Mark approval in 2008 and US Food and Drug Administration approval in 2013&#44; the latter on the basis of the EVEREST II trial&#44; in which 279 patients with MR grade 3&#43; or 4&#43; were randomized in a 2&#58;1 ratio to MitraClip or surgery &#40;repair or replacement&#41;&#46; The primary composite endpoint for efficacy was freedom from death&#44; from surgery for mitral valve dysfunction&#44; and from grade 3&#43; or 4&#43; MR at 12 months&#44; and the primary safety endpoint was a composite of major adverse events within 30 days&#46; The rates of the primary end point for efficacy were 55&#37; in the MitraClip group and 73&#37; in the surgery group &#40;p&#61;0&#46;007&#41;&#44; with 6&#37; mortality in each group&#44; 20&#37; vs&#46; 2&#37; surgery for mitral valve dysfunction&#44; and 21&#37; vs&#46; 20&#37; grade 3&#43; or 4&#43; MR&#46; The rates for the safety endpoint were 15&#37; vs&#46; 48&#37; &#40;p&#60;0&#46;001&#41;&#46; At 12 months&#44; both groups had improved left ventricular size&#44; NYHA functional class&#44; and quality-of-life measures&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Of the patients treated with the MitraClip&#44; 41 &#40;23&#37;&#41; had grade 3&#43; or 4&#43; MR before hospital discharge and were referred for surgery&#46; Of these 41 patients&#44; 28 underwent subsequent mitral valve surgery&#46; In the surgery group&#44; mitral valve replacement was performed in 14&#37; and repair in 86&#37;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Transfusion of &#8805;2 units of blood &#40;which has an important effect on late outcomes<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a>&#41; comprised the largest single component of major adverse events at 30 days&#46; Even after the exclusion of transfusion events&#44; the rate of adverse events was lower in the MitraClip group&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In two subgroups in the MitraClip arm&#44; those with functional MR and patients aged &#8805;70 years&#44; efficacy was not inferior to surgery&#46; Four-year results in the EVEREST II trial show 83&#37; survival in the MitraClip group and 82&#37; in the surgical group&#44; and no significant difference in the number of patients with MR grade 3&#43; or 4&#43;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">14</span></a> The efficacy and safety of the device compared with medical therapy in high-risk patients has been confirmed by the European ACCESS-EU registry<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> and the German TRAnscatheter Mitral valve Interventions &#40;TRAMI&#41; registry&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">16</span></a> Also comparing the MitraClip with standard of care are the randomized trials Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for Extremely High Surgical Risk Patients &#40;COAPT&#41; in the USA and A Randomized Study of the MitraClip Device in Heart Failure Patients with Clinically Significant Functional Mitral Regurgitation &#40;RESHAPE-HF&#41; in Europe&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The most striking demographic feature in our series was the relatively young age of the patients &#40;only one octogenarian&#59; mean age 58&#46;5&#177;13&#46;1 years&#41;&#44; which was the main reason for the low logistic EuroSCORE of 20&#46;06&#177;16&#46;86&#46; Given the weight attributed to age in this risk score&#44; the real risk of these patients may have been underestimated&#44; as indicated by the two non-procedure-related deaths in the 12 months after implantation&#46; The purpose of selecting such young patients was to use the device in those with the longest expected survival&#44; who would thus obtain the maximum possible benefit from the procedure&#46; The idea of choosing patients who were under consideration for heart transplantation was to postpone for as long as possible &#8211; ideally for years &#8211; the need to go on the waiting list for a donor&#46; However&#44; the results suggest that in some of these patients&#44; the natural history of the disease has progressed too far for them to derive any benefit&#46; Patient selection remains the most important factor&#44; since the purpose of the MitraClip is to improve symptoms&#44; but current evidence indicates that a quarter of patients experience little or no symptomatic relief&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Other series of patients mainly with functional MR&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">17</span></a> including the largest European registry and the one that is perhaps closest to our experience&#44; ACCESS-EU&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">15</span></a> show that 72&#8211;83&#37; of patients who survive to one-year follow-up have grade &#8804;2&#43; MR and 79&#8211;83&#37; are in NYHA class I or II&#46; Hospital stay in ACCESS-EU was slightly longer than in our series &#40;7&#46;7&#177;8&#46;2 days&#44; including 2&#46;5&#177;6&#46;5 days in the ICU&#41;&#44; and as in our series there was consistent improvement in echocardiographic parameters and in the six-minute walk test&#59; in the latter the mean gain was around 60 m&#44; also similar to our experience &#40;55 m&#41;&#46; Hospital stay in European series tends to be longer than in US registries&#44; in which the average is three days&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Historically&#44; US and European approaches have differed&#46; EVEREST I<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a> and II were American trials&#44; and they gave initial credibility to the MitraClip device&#59; their patients also had to be candidates for surgery&#46; In Europe&#44; by contrast&#44; the focus has been more on patients who would be ineligible for such trials&#58; those with severe functional MR and heart failure&#44; not considered suitable for surgery and often non-responders to cardiac resynchronization therapy&#44; most of whom are being followed in heart failure clinics and some under consideration for or denied transplantation&#44; as were four of our patients&#46; In Europe MitraClip implantation is perceived as a procedure that does not compete with surgery for patients who have no non-pharmacological alternative&#46; Thus&#44; unlike in EVEREST II&#44; in which 73&#37; of the trial population had degenerative MR&#44; in our series all six patients had functional MR&#46; As a result&#44; unlike transcatheter aortic valve replacement&#44; there is little possibility of a turf war between interventional cardiology and cardiac surgery&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">There are two patient groups for whom MitraClip therapy is particularly attractive&#58; those with severe annular calcification&#44; since this can act as a prosthetic ring to provide additional support and thus prevent progressive annular dilatation&#59; and those with severe functional MR and heart failure refractory to pharmacological and resynchronization therapy &#40;non-responders&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">19</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Despite the successful and increasing use of the procedure&#44; the MitraClip does have some potential limitations&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> It is not a complete substitute for the Alfieri stitch&#44; since it does not treat the annulus&#44; which may explain the recurrence of significant MR in the medium to long term&#59; it can be difficult to quantify MR&#44; particularly residual regurgitation after implantation of the clip during a procedure under general anesthesia &#40;although this problem is also found with surgery&#41;&#59; MR could be replaced by mitral stenosis&#44; although no cases have been reported to date<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a>&#59; and there are no data on its long-term durability and efficacy&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Meanwhile&#44; as the procedure has become more widespread&#44; the initial anatomical criteria have been widened&#44; with cases reported of treatment of eccentric MR&#44; and variations on the original technique have been developed&#44; such as the zipping technique&#44; in which four or five clips are implanted&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">There are a growing number of percutaneous MR therapies besides the MitraClip&#44; some of them already being implemented&#46; These can be divided into two main types&#44; according to whether they involve the annulus or other elements of the mitral valve apparatus&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In most surgical approaches to MR&#44; the two main components of the valve&#44; the leaflets and the annulus&#44; are treated&#46; It is thus understandable that there has also been extensive research into percutaneous interventions on the annulus&#44; which in fact precedes the development of the MitraClip&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">There are two forms of percutaneous annuloplasty&#44; indirect and direct&#46; The CARILLON Mitral Contour System &#40;Cardiac Dimensions&#41; is an indirect annuloplasty device consisting of two nitinol anchors connected by a central nitinol element&#44; positioned in the coronary sinus&#46; It is delivered via a 9F catheter through the internal jugular vein&#44; and tension on the device is adjusted manually by moving it 4&#8211;5 cm before final release&#46; The procedure is monitored by transesophageal echocardiography&#44; to assess MR grade&#44; and left coronary angiography&#44; to exclude coronary compression&#46; It is the only percutaneous annuloplasty device currently approved in the European Union&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Unlike indirect annuloplasty devices&#44; which are positioned in the coronary sinus&#44; direct approaches treat the annulus itself&#44; as in surgical repair&#46; Access is more complex with direct devices&#46; With the Mitralign Bident system&#44; the device is introduced retrogradely via the femoral artery and positioned in the left ventricle under the posterior leaflet&#46; Two pledget pairs are implanted in the annulus and plicated with a Mitralign lock&#59; the resulting tension brings the leaflets closer together&#44; reducing the annular circumference&#46; Another direct annuloplasty device is the Valtech Cardioband&#44; in which access is transseptal&#59; this has been used exclusively to treat functional MR&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Since patients treated by the MitraClip may suffer recurrence of their original grade of MR in the medium to long term&#44; the idea of associating annuloplasty is an attractive one&#44; since it more closely reproduces surgical repair&#44; and appears to be the most promising approach<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> while we await the development of a prosthetic mitral valve that can be implanted percutaneously in the native valve&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">Our initial experience with the MitraClip device confirmed the safety of the procedure in a group of patients with heart failure and grade 4&#43; functional MR who were not considered suitable for surgery&#44; three of whom would have been excluded from the EVEREST II trial and four of whom had been considered for heart transplantation&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The short follow-up does not allow a proper analysis of the device&#39;s efficacy&#44; but the absence of reintervention &#40;surgical or otherwise&#41;&#44; improvements in functional class&#44; left ventricular volumes and six-minute walk test&#44; and consistent falls in proBNP levels&#44; all suggest that it is at least reasonable&#46; However&#44; MitraClip implantation does not appear to alter the natural history of the disease in patients under consideration for heart transplantation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2014-09-23"
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            0 => "MitraClip"
            1 => "Mitral regurgitation"
            2 => "Percutaneous mitral valve repair"
            3 => "Functional mitral regurgitation"
            4 => "Transcatheter mitral repair"
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            0 => "MitraClip"
            1 => "Insufici&#234;ncia mitral"
            2 => "Repara&#231;&#227;o percut&#226;nea da v&#225;lvula mitral"
            3 => "Insufici&#234;ncia mitral funcional"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mitral regurgitation &#40;MR&#41; is the most common valvular disease and has recently been the target of a number of percutaneous approaches&#46; The MitraClip is virtually the only device for which there is considerable experience&#44; with more than 20<span class="elsevierStyleHsp" style=""></span>000 procedures performed worldwide&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe our initial experience of the percutaneous treatment of MR with the MitraClip device&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We describe the first six MitraClip cases performed in this institution &#40;mean age 58&#46;5&#177;13&#46;1 years&#41;&#44; with functional MR grade 4&#43; and New York Heart Association &#40;NYHA&#41; heart failure class III or IV &#40;n&#61;3&#41;&#44; with a mean follow-up of 290&#177;145 days&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Procedural success &#40;MR &#8804;2&#43;&#41; was 100&#37;&#46; Total procedure time was 115&#46;8&#177;23&#46;7 min&#44; with no in-hospital adverse events and discharge between the fourth and eighth day&#44; and consistent improvement in the six-minute walk test &#40;329&#46;8&#177;98&#46;42 vs&#46; 385&#46;33&#177;106&#46;95 m&#41; and in NYHA class &#40;three patients improved by two NYHA classes&#41;&#46; During follow-up there were two deaths&#44; in two of the four patients who had been initially considered for heart transplantation&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In patients with functional MR the MitraClip procedure is safe&#44; with both a high implantation and immediate in-hospital success rate&#46; A longer follow-up suggests that the clinical benefit decreases or disappears completely in patients with more advanced heart disease&#44; namely those denied transplantation or on the heart transplant waiting list&#46;</p></span>"
        "secciones" => array:5 [
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            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A insufici&#234;ncia valvular mitral &#40;IM&#41; &#233; a valvulopatia mais comum e come&#231;a agora a ser alvo de abordagens percut&#226;neas&#46; O dispositivo MitraClip &#233; virtualmente o &#250;nico dispositivo com uma experi&#234;ncia consider&#225;vel&#44; ultrapassando atualmente as 20<span class="elsevierStyleHsp" style=""></span>000 implanta&#231;&#245;es&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Descrever a experi&#234;ncia inicial da terap&#234;utica percut&#226;nea da IM com o dispositivo MitraClip&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Descrevem-se os primeiros seis casos de MitraClip realizados nesta institui&#231;&#227;o &#40;idade 58&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#44;1 anos&#41;&#44; com IM 4&#43; de etiologia funcional e insufici&#234;ncia card&#237;aca classe <span class="elsevierStyleSmallCaps">III</span> ou <span class="elsevierStyleSmallCaps">IV</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41; da <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41;&#44; sem indica&#231;&#227;o cir&#250;rgica ou recusados para cirurgia&#44; com um <span class="elsevierStyleItalic">follow-up</span> m&#233;dio 290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>145 dias avaliado clinicamente pela sobreviv&#234;ncia&#44; classe funcional&#44; teste da marcha dos seis minutos&#44; estudo ecocardiogr&#225;fico e determina&#231;&#227;o do proBNP&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">O sucesso do procedimento &#40;IM &#8804;2<span class="elsevierStyleHsp" style=""></span>&#43;&#41; foi de 100&#37;&#44; com um tempo de procedimento de 115&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;7<span class="elsevierStyleHsp" style=""></span>mins&#44; sem intercorr&#234;ncias intra-hospitalares&#44; alta entre o 4&#46;&#176; e 8&#46;&#176; dia e uma melhoria consistente no teste da marcha dos seis minutos &#40;329&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>98&#44;42 <span class="elsevierStyleItalic">versus</span> 385&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>106&#44;95<span class="elsevierStyleHsp" style=""></span>m&#41; e da classe funcional &#40;tr&#234;s dos pacientes com melhoria de duas classes funcionais NYHA&#41;&#46; Na totalidade do <span class="elsevierStyleItalic">follow-up</span> &#40;290<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>145 dias&#41; constatam-se dois &#243;bitos&#44; em dois dos quatro pacientes que tinham sido considerados para transplanta&#231;&#227;o card&#237;aca&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O procedimento de implanta&#231;&#227;o do dispositivo MitraClip &#233; seguro&#44; com uma alta taxa de sucesso imediato nos pacientes com IM funcional&#46; A m&#233;dio prazo o benef&#237;cio cl&#237;nico parece esbater-se ou anular-se nos pacientes com insufici&#234;ncia card&#237;aca mais terminal&#44; nomeadamente nos pacientes a aguardar ou recusados para transplante&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Cacela D&#44; Fiarresga A&#44; Branco L&#44; et al&#46; Terap&#234;utica percut&#226;nea da insufici&#234;ncia mitral&#58; experi&#234;ncia inicial com o dispositivo MitraClip&#46; Rev Port Cardiol&#46; 2015&#59;34&#58;515&#8211;524&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Anatomical criteria for MitraClip implantation &#40;besides mitral area of &#8805;4&#46;0 cm<span class="elsevierStyleSup">2</span>&#41;&#58; flail gap &#60;10 mm&#59; flail width &#60;15 mm&#59; coaptation depth &#60;11 mm&#59; coaptation length &#62;2 mm&#46; Adapted by permission from the Transesophageal Echo Acquisition Guide &#40;Abbott Vascular&#41;&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The MitraClip device&#46;</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" => 1042
            "Ancho" => 1673
            "Tamanyo" => 153018
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Components of the MitraClip delivery system&#46;</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" => 1260
            "Ancho" => 1800
            "Tamanyo" => 221825
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Positioning of the MitraClip in the center of the regurgitant jet&#59; &#40;B&#41; view of the MitraClip from the atrial side&#59; &#40;C&#41; clip inserted and released&#46; Adapted by permission from Abbott Vascular&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 731
            "Ancho" => 975
            "Tamanyo" => 81570
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional echocardiographic image of the A2 and P2 scallops held by the MitraClip&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 821
            "Ancho" => 975
            "Tamanyo" => 72920
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Angiographic image of the release of a second MitraClip&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1276
            "Ancho" => 1950
            "Tamanyo" => 283488
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Implantation of a second MitraClip&#46; If it is expected that a second clip will be required&#44; the first should be placed in a mid position and the second more laterally&#46; &#40;A and B&#41; Confirmation in different views of the position of the MitraClip&#59; &#40;C&#41; the two mitral valve leaflets are grasped by the MitraClip&#59; &#40;D&#41; after release&#44; with residual regurgitation jets&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">EF&#58; ejection fraction&#59; ES II&#58; EuroSCORE II&#59; EVER II&#58; EVEREST II criteria&#59; F&#58; female&#59; Func&#58; functional MR&#59; log ES&#58; logistic EuroSCORE&#59; LVESD&#58; left ventricular end-diastolic diameter in mm&#59; M&#58; male&#59; MR&#58; mitral regurgitation grade&#59; N&#58; no&#59; NYHA&#58; New York Heart Association class&#59; Org&#58; organic or degenerative MR&#59; Y&#58; yes&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EVER II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">log ES&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ES II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Func&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Org&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ischemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myocarditis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dilated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ischemic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab891404.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of the study population&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Device time&#58; time between entry of the steerable guide catheter into the left atrium via the interatrial septum and withdrawal of the MitraClip delivery catheter into the steerable guide catheter&#59; Procedure time&#58; time between transseptal puncture and removal of the steerable guide catheter&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fluoroscopy time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#46;2&#177;19&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Procedure time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">155&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115&#46;8&#177;23&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Device time &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;7&#177;20&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Radiation dose &#40;mGy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">915&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2680&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1487&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2026&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1962&#46;2&#177;1362&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">No&#46; of clips implanted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&#177;0&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospital stay after procedure &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;0&#177;1&#46;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab891408.png"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Procedural data and hospital stay&#46;</p>"
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      ]
      9 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">b&#44; 1&#44; 6&#44; 12&#58; baseline&#44; 1 month&#44; 6 months&#44; 12 months&#44; respectively&#59; d&#58; died&#59; LVEDV&#58; left ventricular end-diastolic volume in ml&#59; LVESV&#58; left ventricular end-systolic volume in ml&#59; MR&#58; mitral regurgitation grade&#59; Pt&#58; patient&#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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pt&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MRb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MR12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDVb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVEDV12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESVb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LVESV12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">443&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">390&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">403&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">337&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">315&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">312&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">228&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">134&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">107&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">142&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">317&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">204&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab891407.png"
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Last echocardiographic assessment before death&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic evolution of mitral regurgitation and ventricular volumes&#46;</p>"
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      10 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">b&#44; 1&#44; 6&#44; 12&#58; baseline&#44; 1 month&#44; 6 months&#44; 12 months&#44; respectively&#59; d&#58; died&#59; EF&#58; ejection fraction &#40;&#37;&#41;&#59; PASP&#58; pulmonary artery systolic pressure &#40;mmHg&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EFb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EF12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASPb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PASP12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic evolution of ejection fraction and pulmonary artery systolic pressure&#46;</p>"
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          "leyenda" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">b&#44; 1&#44; 6&#44; 12&#58; baseline&#44; 1 month&#44; 6 months&#44; 12 months&#44; respectively&#59; d&#58; died&#59; NYHA&#58; New York Heart Association class&#59; proBNP&#58; pro-brain-type natriuretic peptide &#40;ng&#47;l&#41;&#59; WT&#58; six-minute walk test &#40;m&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "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"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pt&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">proBNPb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">proBNP1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">proBN6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">proBNP12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WTb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WT1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WT6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">WT12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHAb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NYHA12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">724&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">632&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">477&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">506&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">390&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">487&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">472&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">240&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">171&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">623&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">450&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">417&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">488&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1226&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1080&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">884&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">325&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">340&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">276&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">275&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">198&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">477&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">227&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">259&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.07.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	10	3	13
2024 October	66	35	101
2024 September	89	30	119
2024 August	100	40	140
2024 July	57	39	96
2024 June	56	36	92
2024 May	58	29	87
2024 April	56	36	92
2024 March	63	36	99
2024 February	59	54	113
2024 January	69	48	117
2023 December	47	35	82
2023 November	78	30	108
2023 October	72	27	99
2023 September	61	26	87
2023 August	76	47	123
2023 July	86	16	102
2023 June	68	23	91
2023 May	83	43	126
2023 April	61	19	80
2023 March	100	38	138
2023 February	58	33	91
2023 January	60	14	74
2022 December	75	20	95
2022 November	72	26	98
2022 October	63	24	87
2022 September	55	26	81
2022 August	67	42	109
2022 July	76	39	115
2022 June	53	25	78
2022 May	84	33	117
2022 April	92	42	134
2022 March	64	34	98
2022 February	77	44	121
2022 January	126	18	144
2021 December	53	27	80
2021 November	77	44	121
2021 October	74	46	120
2021 September	49	36	85
2021 August	45	27	72
2021 July	52	32	84
2021 June	60	24	84
2021 May	69	42	111
2021 April	88	74	162
2021 March	102	16	118
2021 February	64	20	84
2021 January	36	23	59
2020 December	46	11	57
2020 November	52	24	76
2020 October	43	17	60
2020 September	61	13	74
2020 August	49	7	56
2020 July	95	9	104
2020 June	72	8	80
2020 May	67	12	79
2020 April	101	13	114
2020 March	83	17	100
2020 February	143	24	167
2020 January	66	14	80
2019 December	75	7	82
2019 November	73	8	81
2019 October	34	6	40
2019 September	135	8	143
2019 August	51	6	57
2019 July	54	14	68
2019 June	58	13	71
2019 May	56	12	68
2019 April	66	19	85
2019 March	65	11	76
2019 February	67	11	78
2019 January	38	6	44
2018 December	101	12	113
2018 November	131	20	151
2018 October	344	19	363
2018 September	145	15	160
2018 August	169	9	178
2018 July	66	3	69
2018 June	83	7	90
2018 May	60	7	67
2018 April	98	1	99
2018 March	69	8	77
2018 February	82	8	90
2018 January	90	8	98
2017 December	61	9	70
2017 November	131	9	140
2017 October	74	17	91
2017 September	134	7	141
2017 August	140	18	158
2017 July	95	7	102
2017 June	141	10	151
2017 May	143	6	149
2017 April	76	23	99
2017 March	134	41	175
2017 February	162	5	167
2017 January	100	0	100
2016 December	58	6	64
2016 November	89	8	97
2016 October	96	2	98
2016 September	143	1	144
2016 August	60	3	63
2016 July	62	3	65
2016 June	54	2	56
2016 May	30	2	32
2016 April	40	2	42
2016 March	55	17	72
2016 February	81	22	103
2016 January	65	26	91
2015 December	68	19	87
2015 November	52	16	68
2015 October	64	19	83
2015 September	67	7	74

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