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Ebstein's anomaly in children: A single-center study in Angola
Anomalia de Ebstein em crianças: estudo unicêntrico em Angola
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Cumulative event-free survival was defined as freedom from death.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hamdi Pusuroglu, Huseyin Altug Cakmak, Ozgur Akgul, Mehmet Erturk, Ozgur Surgit, Emre Akkaya, Umit Bulut, Aydin Yildirim" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Hamdi" "apellidos" => "Pusuroglu" ] 1 => array:2 [ "nombre" => "Huseyin Altug" "apellidos" => "Cakmak" ] 2 => array:2 [ "nombre" => "Ozgur" "apellidos" => "Akgul" ] 3 => array:2 [ "nombre" => "Mehmet" "apellidos" => "Erturk" ] 4 => array:2 [ "nombre" => "Ozgur" "apellidos" => "Surgit" ] 5 => array:2 [ "nombre" => "Emre" "apellidos" => "Akkaya" ] 6 => array:2 [ "nombre" => "Umit" "apellidos" => "Bulut" ] 7 => array:2 [ "nombre" => "Aydin" "apellidos" => "Yildirim" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915002184?idApp=UINPBA00004E" "url" => 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"nombre" => "Humberto" "apellidos" => "Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Manuel Pedro" "apellidos" => "Magalhães" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Maria Ana Sampaio" "apellidos" => "Nunes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Gilberto" "apellidos" => "Leon" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Manuel" "apellidos" => "Ferreira" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "António Pedro" "apellidos" => "Filipe Júnior" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Cardio-Thoracic Center, Clinica Girassol, Luanda, Angola" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiology Department, Hospital Militar Principal/Instituto Superior, Luanda, Angola" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Cruz Vermelha, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Anomalia de Ebstein em crianças: estudo unicêntrico em Angola" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1280 "Ancho" => 2501 "Tamanyo" => 161533 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Chest X-rays showing an impressive reduction in cardiothoracic index after cone reconstruction.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ebstein's anomaly (EA) is a rare complex congenital heart defect (CHD) of the tricuspid valve (TV) first described by Wilhelm Ebstein in 1866.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> It occurs in about 1 per 200<span class="elsevierStyleHsp" style=""></span>000 live births and accounts for less than 1% of all CHDs.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2–8</span></a> The anatomical basis of EA consists in displacement by more than 8 mm/m<span class="elsevierStyleSup">2</span> body surface area of the septal and posterior leaflets of the TV in relation to the position of the mitral valve anterior leaflet.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,6</span></a> The genetic etiology is unknown.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> The usual clinical presentation is cyanosis, heart failure, arrhythmia and sudden death.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,8</span></a> The severity and onset of symptoms depend on the degree of displacement of the TV leaflets.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> Transthoracic echocardiography is the gold standard for diagnosis of this entity.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,6</span></a> EA may coexist with other CHDs, genetic syndromes, or Wolff-Parkinson-White (WPW) syndrome.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2–4,9</span></a> Surgical management of EA depends on the patient's age, the clinical presentation and association with other CHDs, and therefore the surgical approach should be individualized.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,10</span></a> Ebstein's anomaly is classified among the category of CHDs that requires early and specific health care.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">7,8</span></a> In this context, the present study aimed to describe the experience of a tertiary center in a developing country in managing this complex disease in patients less than 18 years old.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">Based on the records of the Cardiothoracic Center of Clínica Girassol, previously described,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> a retrospective study was performed that included all patients with CHDs over a period of 37 months (March 29, 2011 to April 29, 2014). Data on clinical presentation, chest X-ray, electrocardiography, echocardiographic studies and surgical reports were analyzed. Transthoracic echocardiography and Doppler studies was performed by pediatric cardiologists using a GE Vivid 7 system (GE Healthcare, Milwaukee, WI, USA) with multiple frequency probes (3S-RS, 4C-RS and RS-6S) in accordance with the recommendations of the American College of Cardiology/American Heart Association.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Only the first echocardiogram was validated. A diagnosis of EA was made when a displacement of the septal and posterior leaflets of the TV was observed of more than 8 mm/m<span class="elsevierStyleSup">2</span> body surface area in relation to the position of the mitral valve anterior leaflet.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,6</span></a> The surgical indications were the conventional ones: NYHA functional class III or IV; NYHA class I or II with cardiothoracic index (CTI) of 0.65 or greater; progressive right ventricular (RV) dilation; significant cyanosis and polycythemia.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9–11</span></a> In patients with favorable anatomy cone reconstruction (CR) of the TV was performed as described by Da Silva et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Atrial septal defect or patent foramen ovale, if present, was closed at the time of repair. Cavopulmonary shunt was reserved for patients less than six months old and for those with significant RV dysfunction. The modified Blalock-Taussig (MBT) shunt was reserved for patients with pulmonary artery hypoplasia (PAH). Follow-up was in the first half of June 2014, when all patients underwent clinical, radiological and echocardiography assessment.</p><p id="par0075" class="elsevierStylePara elsevierViewall">A descriptive statistical analysis was performed (absolute and relative frequencies, mean and standard deviation).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">During the study period, 1362 patients under the age of 19 years with a diagnosis of CHD were analyzed, eight (0.6%) of them with Ebstein's anomaly. Demographic data, clinical presentations, and NYHA functional class of the study population are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Mean age was 69±59 months, ranging from 4 to 168 months. Female gender was predominant, with a female:male ratio of 3:1. Regarding clinical presentation, five patients (62.5%) had signs and symptoms of heart failure, three of them in NYHA functional class IV and two in class III, and four also had cyanosis. Two patients (25%) were referred for a heart murmur and one for cyanosis; these were in NYHA functional class I. Data on X-ray, echocardiography, indications for surgery, type of surgical techniques and complications are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Mean CTI was 0.72, ranging from 0.56 to 0.95. Seven patients (87.5%) had severe tricuspid regurgitation (TR) and five (62.5%) had other CHDs associated with EA. Atrial septal defect (ASD) was the most frequent CHD (n=3; 37.5%). In two cases (25%) EA was associated with PAH. In one of these cases an extremely rare association was found (ostium primum ASD, pulmonary atresia and patent ductus arteriosus [PDA]). No patients with a genetic syndrome or WPW syndrome were found. All patients underwent surgical intervention. The indications for surgery were: heart failure, one patient; heart failure and cyanosis, four patients; cyanosis, one patient; and cardiothoracic index >0.65, in two asymptomatic patients. In five patients CR of the tricuspid valve was performed with 100% immediate success. In these patients, the mean bypass time was 82.8±42.2 minutes (46–148 minutes) with mean aortic cross-clamp time of 56.4±32.3 minutes (27–106 minutes). De Vega annuloplasty was performed concomitantly in two (25%) patients. At the time of CR, ASD closure was performed in two patients. Two patients (25%) had post-operative complications: one wound infection and the other complete atrioventricular block, and a DDD permanent pacemaker was implanted. Mean hospital stay was 10.6±2.7 days. At discharge, in this group two patients had no TR and three had mild TR. The survival rate was 100%. The remaining three patients, in two with PAH an MBT shunt was performed, and in one patient with unfavorable anatomy and severe EA a Glenn operation was performed along with CR of the TV. The patient with the rare association of ostium primum ASD, pulmonary valve atresia and PDA, who was treated by an MBT shunt, died five hours after surgery. The mean follow-up was 1.22±0.6 years. In this period, another patient who underwent an MBT shunt died (12.5%). At the end of the study four patients (80%) were in NYHA functional class I (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). CTI decreased in all patients, by a mean of 0.72–0.64 (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The third patient showed the greatest improvement (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Three patients (60%) had mild and two (40%) had moderate TR on the last echocardiogram. The patient with a permanent pacemaker was readmitted five months after surgery for pericardial effusion and minimal right pleural effusion and was discharged in NYHA class II seven days after readmission. The patient who underwent a Glenn procedure along with CR of the TV at the end of the follow-up period was in NYHA class I.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study revealed that 0.6% of patients with CHDs referred to our center had EA, a similar finding to those reported by other authors.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2–8</span></a> However, it contrasts with the high frequency of EA (2%) described in a study carried in the Sudanese population.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> In the present study, females had an almost three-fold higher probability of having EA. This result contrasts with those of Anderson<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> and Da Silva,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> who report a slight predominance of males, and with other studies that described no predominance of either gender.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2–6,8,13,14</span></a> In developed countries, the diagnosis of CHD is made in the fetal or neonatal period, enabling an early approach and improving the prognosis of these patients.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,3,8,14</span></a> In Africa,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> particularly in Angola, CHDs still tend to be diagnosed later,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> as shown by the mean age (29±36 years) found in the present series. Access to health care services are still a serious problem in our continent, from the prenatal period to old age, which is why we have a small sample without neonates with severe forms of EA and older patients with good functional status. In the present study more than half of the patients were in NYHA functional class III or IV. This result is similar to that reported in a study conducted in Sudan, in which the authors found that half of the patients were symptomatic.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> The mean CTI found in this series was higher than that reported by Arizmendi et al. and Ali and Nimeri, 0.65 and 0.64, respectively.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3,13</span></a> It should be noted that CTI >0.65 is consistently associated with a worse prognosis,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> and the mean CTI in this study was greater than this cut-off value, suggesting that our patients were at high risk.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography is the most important diagnostic test for EA, to determine TV morphology and physiology and to assess the cardiac chambers and the presence of other CHD.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4,6,14</span></a> Severe tricuspid regurgitation in our patients was almost twice as frequent as that reported by Ali and Nimeri (33%).<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> Dilation of the right cardiac chambers and therefore of the tricuspid annulus is the most likely cause of the severity of tricuspid regurgitation found in the population studied.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6,9,17</span></a> EA is frequently associated with other CHDs, in more than 50% of cases, most often ASD.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,3,6,10,14,15</span></a> Although in smaller proportions, the results of this study reflect this frequency. On the other hand, Arizmendi et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> reported pulmonary valve stenosis as the most frequent CHD (39%). Although associations between EA and certain genetic syndromes have been described, mainly trisomy 21 and WPW syndrome,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,14</span></a> these syndromes were not found in the present series. Finally, it is noteworthy that one patient in our series had an extremely rare association (ostium primum ASD, pulmonary atresia and PDA).<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The conventional surgical indications for the correction of EA are NYHA functional class III or IV; NYHA functional class I or II with CTI of 0.65 or greater; progressive RV dilatation; cyanosis (oxygen saturation <90%) and polycythemia.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9–11</span></a> In the present series the indications for surgery were heart failure and/or cyanosis in six patients and CTI >0.65 in two asymptomatic patients. The complexity of the anatomical and functional changes in EA and the possibility of association with other CHDs mean that the surgical approach should be individualized. Cavopulmonary shunt is reserved for patients with severe RV dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,15</span></a> The MBT shunt is generally reserved for patients with PAH.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Various techniques for tricuspid valve reconstruction have been developed in the last 35 years, with different results.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">20,21</span></a> The most recent technique is CR, developed by da Silva et al.,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> which we use in our center. Although the number of patients is small, the present series showed an immediate success rate of 100% for CR, with clinical and echocardiographic improvement in short-term follow-up, in agreement with the good results for this technique reported by other authors.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9,15</span></a> Da Silva et al. reported that CR was associated with low in-hospital mortality and was an effective and long-lasting repair of tricuspid regurgitation, restoring the functional area of the right ventricle and bringing clinical improvement in most patients in the long term.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Anderson et al., describing the Mayo Clinic experience with CR, reported difficulties in reconstructing the sepal portion of the TV. Several techniques have been described to avoid this complication.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Finally, in relation to ASD closure, partial closure of the foramen ovale enables preservation of right-to-left flow.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The low in-hospital mortality and long-term clinical improvement reported by da Silva et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> are supported by the Mayo Clinic experience, in which CR in 84 patients with EA aged under 21 years showed a success rate of 98%.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> In our present series also, there was an immediate success rate of 100%, with short-term clinical and echocardiographic improvement. However, the technique could not be applied in two patients for the reasons described above.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">The prevalence of EA found in this series was similar to other centers. Our patients had access to medical care at a critical stage of the disease. CR was performed in the majority of patients with excellent immediate and short-term results.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres817819" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec814932" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres817818" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e Objectivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec814933" "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" => "2015-02-06" "fechaAceptado" => "2015-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec814932" "palabras" => array:5 [ 0 => "Congenital heart disease" 1 => "Congenital heart surgery" 2 => "Valve lesion" 3 => "Tricuspid valve" 4 => "Cone reconstruction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec814933" "palabras" => array:5 [ 0 => "Cardiopatia congénita" 1 => "Cirurgia cardíaca congénita" 2 => "Lesão valvular" 3 => "Válvula tricúspide" 4 => "Reconstrução em cone" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ebstein's anomaly is a rare complex congenital heart defect of the tricuspid valve. We aimed to describe the frequency, clinical profile, and early and short-term post-operative results in patients under the age of 18 years operated for this anomaly in a tertiary center in Angola.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective cross-sectional study was conducted over a period of 37 months. We analyzed all patients diagnosed with congenital heart defects.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 1362 patients studied, eight (0.6%) had Ebstein's anomaly; six patients (75%) were female. Mean age was 69±59 months. Five patients were in NYHA functional class III or IV. Mean cardiothoracic index was 0.72. Seven patients (87.5%) had severe tricuspid regurgitation and five (62.5%) had another associated congenital heart defect. All patients were operated: two had complications and one (12.5%) died in the early post-operative period. The mean follow-up time was 1.22±0.6 years, and mortality during follow-up was 12.5% (n=1). At the end of the study, of the five patients in whom cone reconstruction was performed, four (80%) were in functional class I. Mean cardiothoracic index decreased to 0.64. Three patients had mild and two had moderate tricuspid regurgitation. The patient who underwent cone reconstruction and a Glenn procedure was in functional class I.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The frequency of Ebstein's anomaly was similar to that in other centers. Cone reconstruction was viable in the majority of patients, with good early and short-term results.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução e Objectivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A anomalia de Ebstein é uma cardiopatia congénita complexa e rara da válvula tricúspide. Descrever a frequência, o perfil clínico e os resultados pós operatórios imediatos desta anomalia em crianças e adolescentes.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudo transversal retrospetivo no único centro com tratamento integrado em cardiopatias congénitas em recém nascidos, crianças e adolescentes (<18 anos de idade) em Angola, num período de 37 meses. Foram analisados todos os doentes com diagnóstico de cardiopatia congénita. O diagnóstico foi feito com base no exame clínico e dados da ecocardiografia transtorácica e Doppler. Os ecocardiogramas foram realizados pelos Cardiologistas Pediátricos numa máquina Vivid 7 G.E.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foram analisados 1362 ecocardiogramas sequenciais. Oito doentes (0,6%) tinham anomalia de Ebstein, destes 6 (75%) eram do género feminino. As idades variaram entre 4 a 168 meses, a média foi de 69 ± 59 meses. Cinco estavam em classe funcional III ou IV da NYHA. A média do índice cardiotorácico foi de 0,72. Sete doentes (87,5%) tinham regurgitação tricúspide grave e 5 (62,5%) tinham outra cardiopatia congénita associada. Todos os doentes foram submetidos a intervenção cirúrgica. Dois tiveram complicações no pós-operatório imediato. A mortalidade pós operatória foi de 12,5% (n=1).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A frequência da Anomalia de Ebstein encontrada foi semelhante a de outros Centros. A técnica de Cone foi viável na maior parte dos pacientes. A mortalidade pós operatória imediata foi baixa.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e Objectivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:12 [ 0 => array:2 [ "termino" => "ASD" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial septal defect</p>" ] 1 => array:2 [ "termino" => "CHD" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">congenital heart defect</p>" ] 2 => array:2 [ "termino" => "CR" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">cone reconstruction</p>" ] 3 => array:2 [ "termino" => "CTI" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">cardiothoracic index</p>" ] 4 => array:2 [ "termino" => "EA" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">Ebstein's anomaly</p>" ] 5 => array:2 [ "termino" => "MBT" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">modified Blalock-Taussig</p>" ] 6 => array:2 [ "termino" => "NYHA" "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">New York Heart Association</p>" ] 7 => array:2 [ "termino" => "PAH" "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">pulmonary artery hypoplasia</p>" ] 8 => array:2 [ "termino" => "PDA" "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">patent ductus arteriosus</p>" ] 9 => array:2 [ "termino" => "RV" "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">right ventricular</p>" ] 10 => array:2 [ "termino" => "TV" "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">tricuspid valve</p>" ] 11 => array:2 [ "termino" => "WPW" "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Wolff-Parkinson-White</p>" ] ] ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 1622 "Tamanyo" => 93121 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Evolution of functional class in the five patients undergoing cone reconstruction. NYHA: New York Heart Association.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 812 "Ancho" => 1704 "Tamanyo" => 116779 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Evolution of cardiothoracic index in the five patients undergoing cone reconstruction.</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" => 1280 "Ancho" => 2501 "Tamanyo" => 161533 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Chest X-rays showing an impressive reduction in cardiothoracic index after cone reconstruction.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CHF: congestive heart failure; F: female; M: male; NYHA: New York Heart Association.</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 no. \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">Year \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 (months) \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">Symptoms \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 class \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">2012 \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">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \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">2012 \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">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and cyanosis \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></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">2013 \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cyanosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \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">2013 \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">168 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \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">2013 \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">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF \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></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">2013 \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">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and cyanosis \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></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \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">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and cyanosis \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></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \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">108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and cyanosis \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></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1374656.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Distribution of demographic data, year of diagnosis, clinical presentation and NYHA functional class.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">ASD: atrial septal defect; AVB: atrioventricular block; CHD: congenital heart defect; CHF: congestive heart failure; CR: cone reconstruction; CTI: cardiothoracic index; MBT: modified Blalock-Taussig; PA: pulmonary atresia; OPASD: ostium primum atrial septal defect; OSASD: ostium secundum atrial septal defect; PAH: pulmonary artery hypoplasia; PDA: persistent ductus arteriosus; RA: right atrium; RV: right ventricle; TR: tricuspid regurgitation.</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 no. \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">CTI \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">TR \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">Other CHD \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">Surgical indication \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">Surgery \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">Early post-operative \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">0.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OSASD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CTI >0.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR and ASD closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No complications \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">0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PA, PDA, OPASD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF, cyanosis, NYHA IV and CTI >0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MBT shunt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died five hours after surgery \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">0.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PAH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cyanosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MBT shunt \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No complications \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">0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CTI >0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No complications \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">0.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and CTI >0.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wound infection \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">0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF, cyanosis and CTI >0.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No complications \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">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OPASD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF, cyanosis and CTI >0.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR and ASD closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete AVB \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">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PAH, OPASD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF and cyanosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CR, ASD closure and Glenn operation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No complications \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1374655.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Cardiothoracic index, echocardiographic findings, surgical indications, surgery performed and early post-operative evaluation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 4 | 10 |
| 2024 October | 49 | 23 | 72 |
| 2024 September | 67 | 30 | 97 |
| 2024 August | 55 | 30 | 85 |
| 2024 July | 52 | 34 | 86 |
| 2024 June | 40 | 25 | 65 |
| 2024 May | 37 | 19 | 56 |
| 2024 April | 30 | 23 | 53 |
| 2024 March | 53 | 25 | 78 |
| 2024 February | 37 | 48 | 85 |
| 2024 January | 31 | 40 | 71 |
| 2023 December | 23 | 27 | 50 |
| 2023 November | 29 | 16 | 45 |
| 2023 October | 35 | 13 | 48 |
| 2023 September | 25 | 22 | 47 |
| 2023 August | 29 | 25 | 54 |
| 2023 July | 36 | 18 | 54 |
| 2023 June | 39 | 11 | 50 |
| 2023 May | 35 | 24 | 59 |
| 2023 April | 18 | 7 | 25 |
| 2023 March | 27 | 20 | 47 |
| 2023 February | 23 | 24 | 47 |
| 2023 January | 20 | 9 | 29 |
| 2022 December | 23 | 18 | 41 |
| 2022 November | 35 | 27 | 62 |
| 2022 October | 41 | 11 | 52 |
| 2022 September | 30 | 32 | 62 |
| 2022 August | 26 | 34 | 60 |
| 2022 July | 37 | 29 | 66 |
| 2022 June | 25 | 19 | 44 |
| 2022 May | 29 | 45 | 74 |
| 2022 April | 26 | 34 | 60 |
| 2022 March | 20 | 30 | 50 |
| 2022 February | 21 | 24 | 45 |
| 2022 January | 31 | 33 | 64 |
| 2021 December | 16 | 36 | 52 |
| 2021 November | 39 | 46 | 85 |
| 2021 October | 44 | 51 | 95 |
| 2021 September | 30 | 29 | 59 |
| 2021 August | 34 | 32 | 66 |
| 2021 July | 27 | 26 | 53 |
| 2021 June | 33 | 19 | 52 |
| 2021 May | 35 | 40 | 75 |
| 2021 April | 92 | 57 | 149 |
| 2021 March | 72 | 11 | 83 |
| 2021 February | 53 | 21 | 74 |
| 2021 January | 35 | 14 | 49 |
| 2020 December | 35 | 11 | 46 |
| 2020 November | 31 | 20 | 51 |
| 2020 October | 29 | 14 | 43 |
| 2020 September | 56 | 16 | 72 |
| 2020 August | 22 | 13 | 35 |
| 2020 July | 51 | 8 | 59 |
| 2020 June | 38 | 16 | 54 |
| 2020 May | 52 | 6 | 58 |
| 2020 April | 61 | 21 | 82 |
| 2020 March | 77 | 8 | 85 |
| 2020 February | 106 | 25 | 131 |
| 2020 January | 39 | 13 | 52 |
| 2019 December | 49 | 5 | 54 |
| 2019 November | 54 | 10 | 64 |
| 2019 October | 29 | 7 | 36 |
| 2019 September | 66 | 7 | 73 |
| 2019 August | 55 | 5 | 60 |
| 2019 July | 42 | 7 | 49 |
| 2019 June | 36 | 13 | 49 |
| 2019 May | 50 | 9 | 59 |
| 2019 April | 42 | 19 | 61 |
| 2019 March | 53 | 11 | 64 |
| 2019 February | 60 | 11 | 71 |
| 2019 January | 52 | 6 | 58 |
| 2018 December | 78 | 9 | 87 |
| 2018 November | 209 | 14 | 223 |
| 2018 October | 426 | 24 | 450 |
| 2018 September | 112 | 17 | 129 |
| 2018 August | 77 | 12 | 89 |
| 2018 July | 46 | 7 | 53 |
| 2018 June | 67 | 12 | 79 |
| 2018 May | 74 | 7 | 81 |
| 2018 April | 198 | 10 | 208 |
| 2018 March | 106 | 5 | 111 |
| 2018 February | 151 | 3 | 154 |
| 2018 January | 67 | 6 | 73 |
| 2017 December | 158 | 8 | 166 |
| 2017 November | 76 | 14 | 90 |
| 2017 October | 24 | 10 | 34 |
| 2017 September | 28 | 11 | 39 |
| 2017 August | 24 | 13 | 37 |
| 2017 July | 27 | 8 | 35 |
| 2017 June | 25 | 8 | 33 |
| 2017 May | 27 | 5 | 32 |
| 2017 April | 29 | 4 | 33 |
| 2017 March | 32 | 37 | 69 |
| 2017 February | 29 | 2 | 31 |
| 2017 January | 34 | 5 | 39 |
| 2016 December | 26 | 9 | 35 |
| 2016 November | 23 | 5 | 28 |
| 2016 October | 23 | 14 | 37 |
| 2016 September | 8 | 2 | 10 |
| 2016 August | 9 | 3 | 12 |
| 2016 July | 7 | 6 | 13 |
| 2016 June | 4 | 1 | 5 |
| 2016 May | 8 | 3 | 11 |
| 2016 April | 9 | 10 | 19 |
| 2016 March | 12 | 13 | 25 |
| 2016 February | 16 | 14 | 30 |
| 2016 January | 23 | 11 | 34 |
| 2015 December | 8 | 8 | 16 |
| 2015 November | 32 | 10 | 42 |
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