Case report
Atrioventricular septal defect in an adult patient: There are ‘clefts’ and clefts
Defeito do septo auriculoventricular num doente adulto. Há «fendas» e fendas
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Há «fendas» e fendas" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "181.e1" "paginaFinal" => "181.e4" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Atrioventricular septal defect in an adult patient: There are ‘clefts’ and clefts" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1985 "Ancho" => 2917 "Tamanyo" => 577136 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A,B – 2<span class="elsevierStyleHsp" style=""></span>D janela transgástrica. Em diástole (A), observa‐se o aspeto trifoliado do componente esquerdo da válvula AV e a «fenda» (*). Em sístole (B), evidencia‐se a regurgitação mitral com ponto de partida na «fenda».</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fig. 1<span class="elsevierStyleHsp" style=""></span>C,D – 3<span class="elsevierStyleHsp" style=""></span>D <span class="elsevierStyleItalic">zoom</span> em tempo real <span class="elsevierStyleItalic">cropped images</span>. Em diástole, por vista auricular (C) e ventricular (D), a morfologia dos três folhetos da válvula AV esquerda aparece bem detalhada e a orientação septal (ventrículo direito) da «fenda» bem definida. A presença de cordas anormais ligando os bordos da «fenda» ao septo interventricular é bem observada por vista ventricular (seta).</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aprecie‐se o formato elíptico do anel e a reduzida dimensão do folheto mural, outras particularidades de uma válvula esquerda AV. 1 – folheto ântero‐superior, 2 – folheto póstero‐inferior, 3 – folheto mural. AOV – válvula aórtica; LVOT – trato de saída do ventrículo esquerdo, TV – válvula tricúspide.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuno Moreno, Jorge Almeida, Mário Jorge Amorim" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nuno" "apellidos" => "Moreno" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "Almeida" ] 2 => array:2 [ "nombre" => "Mário Jorge" "apellidos" => "Amorim" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916000428" "doi" => "10.1016/j.repce.2015.11.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000428?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511500342X?idApp=UINPBA00004E" "url" => "/08702551/0000003500000003/v1_201603080050/S087025511500342X/v1_201603080050/pt/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204916000556" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.06.010" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "774" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:183.e1-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3256 "formatos" => array:3 [ "EPUB" => 193 "HTML" => 2633 "PDF" => 430 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Giant high-pressure pulmonary artery aneurysm in an elderly patient with chronic obstructive pulmonary disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "183.e1" "paginaFinal" => "183.e6" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma gigante da artéria pulmonar de altas pressões em idoso com doença obstrutiva pulmonar crónica" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 649 "Ancho" => 1500 "Tamanyo" => 117503 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography scan, February 2011, revealing pronounced dilatation of the pulmonary trunk, with a maximum diameter of 72 mm, and enlargement of the main pulmonary arteries, 40 mm in diameter on the right and 33 mm in diameter on the left.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sandra A. 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(B) lateral chest radiograph showing posterior orientation of the pacing lead.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raluca Şoşdean, Bogdan Enache, Răzvan Ioan Macarie, Sorin Pescariu" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Raluca" "apellidos" => "Şoşdean" ] 1 => array:2 [ "nombre" => "Bogdan" "apellidos" => "Enache" ] 2 => array:2 [ "nombre" => "Răzvan Ioan" "apellidos" => "Macarie" ] 3 => array:2 [ "nombre" => "Sorin" "apellidos" => "Pescariu" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116000160" "doi" => "10.1016/j.repc.2015.11.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000160?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000544?idApp=UINPBA00004E" "url" => "/21742049/0000003500000003/v1_201603180035/S2174204916000544/v1_201603180035/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Atrioventricular septal defect in an adult patient: There are ‘clefts’ and clefts" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "181.e1" "paginaFinal" => "181.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nuno Moreno, Jorge Almeida, Mário Jorge Amorim" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Nuno" "apellidos" => "Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Jorge" "apellidos" => "Almeida" "email" => array:1 [ 0 => "jalmeida@hsjoao.min-saude.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Mário Jorge" "apellidos" => "Amorim" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cardiologia, Hospital Tâmega e Sousa, Penafiel, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirurgia Cardiotorácica, Centro Hospitalar São João, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Defeito do septo auriculoventricular num doente adulto. Há «fendas» e fendas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2030 "Ancho" => 2917 "Tamanyo" => 477042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) Two-dimensional transesophageal echocardiography, transgastric view, showing mitral valve anterior leaflet cleft (*) in diastole (A) and in systole (B); (C and D) real-time three-dimensional zoom, cropped images: in diastole, anterior leaflet cleft in atrial view (C) and ventricular view (D). Note the typical orientation of the cleft towards the left ventricular outflow tract.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atrioventricular septal defect (AVSD) covers a range of congenital cardiac malformations that have in common a single atrioventricular (AV) junction. This results in significant morphological alterations, partial AVSD being characterized by a common AV junction but two separate AV valves due to the fusion of the superior and inferior leaflets (bridging leaflets), which gives the left AV valve a trifoliate configuration. This is different from mitral valve clefts not associated with endocardial cushion defects.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 52-year-old man was referred for valve surgery due to severe mitral regurgitation secondary to a mitral cleft and moderate aortic regurgitation through a bicuspid aortic valve. Two-dimensional transesophageal echocardiography (2D TEE) showed a single AV junction with a trifoliate left valve: one mural, one anterosuperior and one posteroinferior, with a ‘cleft’ oriented towards the interventricular septum in the zone of apposition (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B). The papillary muscles were displaced laterally, next to the mural leaflet commissures with bridging leaflets. Three-dimensional (3D) TEE provided detailed anatomical information (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C and D). No evidence of interatrial or interventricular communication, usually characteristic of AVSD, was observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Both valves were reconstructed. The mitral valve was repaired by direct suturing of the ‘cleft’ using separate 6-0 polypropylene sutures, enlarging the posterior leaflet with an autologous pericardial patch, and annuloplasty using a 28 mm semi-rigid Physio ring (Carpentier-Edwards, Edwards Lifesciences). Aortic regurgitation was corrected by plicating the noncoronary leaflet and reducing the annulus by annuloplasty of the aortoventricular junction. Postoperative TEE showed minimal regurgitation and a mean left atrial/left ventricular gradient of 5 mmHg.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Unlike the normal heart that has separate left and right AV junctions, the distinguishing feature of AVSD is a common AV junction – there is no AV septum and the AV annuli are in the same anatomical plane,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and there is no morphologically normal AV valve. In total AVSD there is a single common AV valve consisting of five leaflets, while in partial AVSD the valve is usually trifoliate, arising from the fusion of the superior and inferior leaflets and consisting of the anterosuperior, posteroinferior and mural leaflets, with three commissures designated anterolateral, posterolateral and septal according to their respective positions. This fusion results in a ‘cleft’ that causes varying degrees of valvular regurgitation, although valve stenosis is rare. Chordal abnormalities are also frequently observed, linking the edges of the ‘cleft’ to the interventricular septum.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This morphology is completely different from the clefts observed in structurally normal mitral valves, which are more common in the anterior leaflet and the solution of continuity not only does not divide the leaflet into two separate parts but is oriented towards the left ventricular outflow tract (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The distinction is important since it implies different surgical approaches. In AVSD ‘clefts’, simply closing the edges by direct suturing or with a patch does not transform the left AV valve into an anatomically normal valve.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Annular dilatation and a degree of central restriction usually cause residual regurgitation. Resolving this and avoiding valve stenosis generally require the use of corrective techniques other than the usual commissuroplasty or direct closure of the ‘cleft’ and placement of a prosthetic ring. Increasing anterior leaflet mobility through excision of the chordae of the accessory commissure, together with total closure with or without the use of an autologous pericardial patch, and enlarging the posterior leaflet with an autologous pericardial patch normally lead to a good final functional result.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In order to avoid damage to conduction tissue, it should be borne in mind that in AVSD the AV node is posteroinferiorly displaced from the tip of the triangle of Koch.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In the case presented, although most features of the AVSD were identified by 2D TEE, 3D TEE was essential for detailed characterization of the AV valve, which was important for planning the surgical approach to valve reconstruction and highlights the importance of 3D study to guide surgical repair.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres617687" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec631900" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres617688" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec631899" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-03-16" "fechaAceptado" => "2015-11-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec631900" "palabras" => array:3 [ 0 => "Mitral cleft" 1 => "Three-dimensional transoesophageal echocardiography" 2 => "Atrioventricular septal defect" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec631899" "palabras" => array:3 [ 0 => "Fenda mitral" 1 => "Ecocardiografia tridimensional" 2 => "Defeito do septo auriculoventricular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In this report, we present the case of an adult male with severe mitral regurgitation due to an atrioventricular septal defect. Anatomical assessment by two- and three-dimensional transesophageal echocardiography was essential for detailed morphological characterization and surgical planning. The different features of a ‘cleft’ in an atrioventricular septal defect compared to an anterior leaflet cleft in an otherwise normal mitral valve are here discussed.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam o caso de um doente adulto com regurgitação mitral severa no contexto de um defeito do septo auriculoventricular. A avaliação conjunta por ETE 2 D e 3 D foi fundamental para a caracterização anátomo-funcional da válvula e orientação do procedimento cirúrgico. As particularidades anatómicas de uma «fenda» em contexto de defeito do septo auriculoventricular e de uma fenda numa válvula mitral são aqui discutidas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moreno N, Almeida J, Amorim MJ. Defeito do septo auriculoventricular num doente adulto. Há «fendas» e fendas. Rev Port Cardiol. 2016;35:181.e1–181.e4.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1985 "Ancho" => 2917 "Tamanyo" => 474559 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A and B) Two-dimensional transesophageal echocardiography, transgastric view, showing trifoliate configuration of the left AV valve and the ‘cleft’ (*) in diastole (A); mitral regurgitation from the ‘cleft’ in systole (B); (C and D) real-time three-dimensional zoom, cropped images: in diastole, atrial view (C) and ventricular view (D), the morphology of the three leaflets of the left AV valve can be seen in detail, as well as the septal orientation (towards the right ventricle) of the ‘cleft’. Abnormal chordal attachments linking the edges of the ‘cleft’ to the interventricular septum can be clearly seen in ventricular view (arrow). Other features of a left atrioventricular valve can be seen – elliptical annulus and small mural leaflet. 1: anterosuperior leaflet; 2: posteroinferior leaflet; 3: mural leaflet; AOV: aortic valve; LVOT: left ventricular outflow tract; TV: tricuspid valve.</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" => 2030 "Ancho" => 2917 "Tamanyo" => 477042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) Two-dimensional transesophageal echocardiography, transgastric view, showing mitral valve anterior leaflet cleft (*) in diastole (A) and in systole (B); (C and D) real-time three-dimensional zoom, cropped images: in diastole, anterior leaflet cleft in atrial view (C) and ventricular view (D). Note the typical orientation of the cleft towards the left ventricular outflow tract.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolated cleft of the mitral valve: clinical spectrum and course" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Zhu" 1 => "R. Bryant" 2 => "J. Heinle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Tex Heart Inst J" "fecha" => "2009" "volumen" => "36" "paginaInicial" => "553" "paginaFinal" => "556" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20069080" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrioventricular septal defect: from fetus to adult" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. Craig" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2006.093344" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2006" "volumen" => "92" "paginaInicial" => "1879" "paginaFinal" => "1885" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17105897" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Of clefts, commissures, and things" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.H. Anderson" 1 => "J.R. Zuberbuhler" 2 => "P.A. Penkoske" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "1985" "volumen" => "90" "paginaInicial" => "605" "paginaFinal" => "610" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4046626" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical anatomy of atrioventricular septal defect" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I. Adachi" 1 => "H. Uemura" 2 => "K.P. McCarthy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Asian Cardiovasc Thorac Ann" "fecha" => "2008" "volumen" => "16" "paginaInicial" => "497" "paginaFinal" => "502" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18984764" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Real-time three-dimensional transesophageal echocardiography in the intraoperative assessment of mitral valve disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Grewal" 1 => "S. Mankad" 2 => "W.K. Freeman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.echo.2008.11.008" "Revista" => array:6 [ "tituloSerie" => "J Am Soc Echocardiogr" "fecha" => "2009" "volumen" => "22" "paginaInicial" => "34" "paginaFinal" => "41" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19131000" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003500000003/v1_201603180035/S2174204916000428/v1_201603180035/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003500000003/v1_201603180035/S2174204916000428/v1_201603180035/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000428?idApp=UINPBA00004E" ]
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