Computed tomography-guided pericardiocentesis – A single-center experience | Revista Portuguesa de Cardiologia (English edition)

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(a) Characterization and assessment of effusion; (b) determination of best entry point and needle orientation; (c) control of needle progression and relation with surrounding structures; (d) pigtail positioning; (e) final result and control of evolution." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "David Neves, Guida Silva, Gustavo Morais, Nuno Ferreira, Mónica Carvalho, Vasco Gama Ribeiro, Nuno Bettencourt" "autores" => array:7 [ 0 => array:2 [ "nombre" => "David" "apellidos" => "Neves" ] 1 => array:2 [ "nombre" => "Guida" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Gustavo" "apellidos" => "Morais" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "Mónica" "apellidos" => "Carvalho" ] 5 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama Ribeiro" ] 6 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204916300356" "doi" => "10.1016/j.repce.2015.11.023" "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/S2174204916300356?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116300026?idApp=UINPBA00004E" "url" => "/08702551/0000003500000005/v3_201702080059/S0870255116300026/v3_201702080059/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204916300381" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.10.025" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "807" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Cardiol. 2016;35:291-304" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2885 "formatos" => array:3 [ "EPUB" => 190 "HTML" => 2131 "PDF" => 564 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review article" "titulo" => "A closer look at acute heart failure: Putting Portuguese and European data into perspective" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "291" "paginaFinal" => "304" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Um olhar sobre a insuficiência cardíaca aguda: dados portugueses e europeus em perspetiva" ] ] "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" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1732 "Ancho" => 1227 "Tamanyo" => 236986 ] ] "descripcion" => array:1 [ "en" => "Selection criteria for literature review. CHF: chronic heart failure." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cândida Fonseca, Inês Araújo, Filipa Marques, Daniel Brás, Paulo Bettencourt" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Cândida" "apellidos" => "Fonseca" ] 1 => array:2 [ "nombre" => "Inês" "apellidos" => "Araújo" ] 2 => array:2 [ "nombre" => "Filipa" "apellidos" => "Marques" ] 3 => array:2 [ "nombre" => "Daniel" "apellidos" => "Brás" ] 4 => array:2 [ "nombre" => "Paulo" "apellidos" => "Bettencourt" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116300051" "doi" => "10.1016/j.repc.2015.10.011" "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/S0870255116300051?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916300381?idApp=UINPBA00004E" "url" => "/21742049/0000003500000005/v3_201704120129/S2174204916300381/v3_201704120129/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S217420491630037X" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.11.025" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "806" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2016;35:277-83" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2729 "formatos" => array:3 [ "EPUB" => 147 "HTML" => 2135 "PDF" => 447 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Characterization of left atrial dysfunction in hypereosinophilic syndrome – Insights from the Motion analysis of the heart and great vessels by three-dimensional speckle tracking echocardiography in pathological cases (MAGYAR-Path) Study" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "277" "paginaFinal" => "283" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Caracterização da disfunção auricular esquerda na síndrome hipereosinofílica – visão da análise de movimentos do coração e dos grandes vasos por ecocardiografia tridimensional speckle tracking em casos patológicos – estudo MAGYAR-Path" ] ] "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" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1311 "Ancho" => 1500 "Tamanyo" => 231731 ] ] "descripcion" => array:1 [ "en" => "Images from three-dimensional full-volume dataset showing left atrium: apical 4-chamber (A) and 2-chamber views (B) and short-axis views at basal (C3), mid- (C5) and superior (C7) left atrial level are demonstrated together with left atrial volumetric data and a three-dimensional cast of the left atrium. Time-segmental strain curves of all 16 left atrial segments and global left atrial volume changes throughout the cardiac cycle are also presented. White arrow: peak strain. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; Vmax, Vmin and VpreA: maximum and minimum left atrial volumes and left atrial volume before atrial contraction, respectively." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Attila Nemes, Imelda Marton, Péter Domsik, Anita Kalapos, Éva Pósfai, Szabolcs Modok, Zita Borbényi, Tamás Forster" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Attila" "apellidos" => "Nemes" ] 1 => array:2 [ "nombre" => "Imelda" "apellidos" => "Marton" ] 2 => array:2 [ "nombre" => "Péter" "apellidos" => "Domsik" ] 3 => array:2 [ "nombre" => "Anita" "apellidos" => "Kalapos" ] 4 => array:2 [ "nombre" => "Éva" "apellidos" => "Pósfai" ] 5 => array:2 [ "nombre" => "Szabolcs" "apellidos" => "Modok" ] 6 => array:2 [ "nombre" => "Zita" "apellidos" => "Borbényi" ] 7 => array:2 [ "nombre" => "Tamás" "apellidos" => "Forster" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => 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=> array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Gustavo" "apellidos" => "Morais" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Nuno" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Mónica" "apellidos" => "Carvalho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Vasco" "apellidos" => "Gama Ribeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital do Espírito Santo, Évora, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pericardiocentese guiada por tomografia computorizada – experiência num centro" ] ] "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" => 611 "Ancho" => 2085 "Tamanyo" => 226323 ] ] "descripcion" => array:1 [ "en" => "Example of a case in which intrapericardial contrast was used. (a) Coronal view; (b) sagittal view; (c) axial view." ] ] ] "textoCompleto" => "IntroductionThere are many clinical scenarios in which pericardial effusion may develop.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> It can be caused by bleeding into the pericardial space or other fluid accumulation. Etiology may be inflammatory/infectious, traumatic, post-operative,<a class="elsevierStyleCrossRef" href="#bib0130">2</a> or related to cancer or other chronic conditions such as uremia.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> Its main adverse consequence is its potential impact on cardiac hemodynamics, which will depend mainly on the volume and rate of development of the effusion.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> Clinical presentation of a significant pericardial effusion usually includes lightheadedness, chest discomfort, dyspnea, anxiety, tachycardia and hypotension.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> Echocardiography is the imaging modality of choice for diagnosis and for estimating hemodynamic impairment, through assessment of right heart chamber dynamics. Other diagnostic tools may be required for etiologic investigation or anatomical definition, such as computed tomography (CT) and cardiovascular magnetic resonance.<a class="elsevierStyleCrossRefs" href="#bib0150">6,7</a> Pericardiocentesis is usually indicated when hemodynamic impact is significant or when needed for etiologic diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0160">8–10</a>As it is an invasive procedure, there is always a significant risk of complications, which may be reduced with enhanced control in needle positioning, in order to avoid unintended puncture of structures. Electrocardiogram-guided<a class="elsevierStyleCrossRef" href="#bib0175">11</a> and fluoroscopy-guided<a class="elsevierStyleCrossRef" href="#bib0180">12</a> techniques have been described. Guidance in recent years has been mainly through echocardiography<a class="elsevierStyleCrossRefs" href="#bib0185">13–16</a> (offline or real-time) because of its improved safety over a blind approach. CT-guided pericardiocentesis (CTP) is also an option in centers with access to and expertise in this technique,<a class="elsevierStyleCrossRefs" href="#bib0205">17,18</a> with the advantage of detailed three-dimensional imaging, which enables fine needle positioning.This work reports on our experience with CTP.MethodsAll procedures were performed by experienced cardiologists or cardiac surgeons, using a Seldinger technique according to previously described protocols.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> CT guidance was obtained using a 64-slice scanner (Siemens SOMATOM Sensation, Erlangen, Germany) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Patients provided informed consent. During the procedure they were asked to breathe steadily and abstain from moving or breathing deeply. Local anesthesia with subcutaneous lidocaine was performed in every patient and light sedation (diazepam 5 mg orally) was administered when needed.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Images of the whole thorax were acquired before the procedure and were analyzed with dedicated software (Siemens Syngo Viewer®). Parameters used by protocol were: tube voltage 100 kV, tube current 110 mAs, reconstruction with 0.75 mm sections, overlap 0.5 mm. Typical window width/level used during the procedure was 700/80. The best entry point and needle orientation were determined (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). We used an 18 gauge needle from the PeriVac™ kit (Boston Scientific®). After superficial needle insertion, new images of the area of interest were acquired. Needle orientation was corrected as needed and the needle was advanced under aspiration. New images were acquired as needed. When the pericardial space was reached, a drain (8.3F pigtail catheter from the kit) was inserted through a guidewire (J-tipped 0.035″×80 cm) and final images were acquired. When in doubt (due to limited pericardial width at the puncture site) a small amount of contrast (by protocol 5 ml diluted in 10 ml of saline) was injected to confirm an intra-pericardial needle position before dilation and drain insertion (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Data were stored in a dedicated computer database. Statistical analysis was performed using IBM SPSS Statistics 21 (2012). Values are presented as mean ± standard deviation or median (interquartile range) as appropriate. Normality of the sample distribution was tested using the Shapiro-Wilk test.ResultsBetween August 2008 and February 2014, 49 patients were referred for CTP, which was performed in 46 patients. In three patients the effusion was considered unsuitable for pericardiocentesis (shallow or posterior location). Patient characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>A total of 51 procedures were reported. Five patients underwent repeat procedures due to recurrence of significant effusion (three post-surgical, two of unknown etiology). The purpose of the procedure was mainly diagnostic in only two cases. The most common etiologies of pericardial effusion were post-surgical (48%, 22 cases) and neoplasm-related (17%, eight cases).International normalized ratio (INR) was measured in 33 procedures, including in all patients under oral anticoagulation; there were five patients with INR >2, with a maximum of 6.88.Procedural data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The procedure had a median duration of 65 (50-80) min and median total effective radiation exposure was 3.3 (2.38–5.17) mSv.The volume of drained fluid was variable, with a mean of 781±452.4 ml. Drainage was considered completely successful in 46 (90%) of cases. It was considered only partially successful in two cases (4%), both due to persistent fluid accumulation in a posterior location; one of them underwent successful surgical drainage, the other needed no further intervention. CTP was considered unsuccessful in three cases (6%), probably due to highly septated/organized effusions; one had been attempted for diagnostic purposes, the other two underwent successful surgical drainage.There were no significant immediate adverse events related to the procedure, even in patients with INR >2. There was, however, one late complication, with development of pyopericardium.The results are integrated with previously published data in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe main finding of our study is that CT is an effective and safe technique to guide pericardiocentesis, which is an invasive and potentially dangerous procedure reserved for specific clinical scenarios.In an era of multimodality imaging in cardiology, blind (or even ECG-guided or fluoroscopy-guided) pericardiocentesis is becoming obsolete, and is not recommendable, except in life-saving situations. Other imaging techniques may have some advantages for needle guidance. Echocardiography, above all, is a valuable and practical option, and is probably best when using a probe-mounted needle.<a class="elsevierStyleCrossRef" href="#bib0215">19</a> It provides continuous real-time imaging, and is widely available and probably logistically simpler and less time-consuming than CT. It has, however, the disadvantage of not infrequent poor acoustic windows and less reliable needle tip visualization and orientation. CT allows the physician to better evaluate needle direction, tip positioning and relation with surrounding structures. The main limitation of CT is probably its availability, which is not as ubiquitous as echocardiography but is increasing.CTP has previously been described as safe and effective. This series illustrates our good experience with this technique. It encompasses a reasonable-sized sample of 46 patients, almost half of them post-surgical, with a high procedural success rate (90% complete drainage, 4% incomplete and 6% unsuccessful), and no major immediate complications recorded. There was one case of pyopericardium, which developed several days after the procedure, performed for a significant effusion in the likely context of Dressler syndrome. No immediate complications were observed and the patient was transferred back to the referring hospital. He was readmitted seven days after the procedure due to recurrence of the effusion and pyopericardium was confirmed after surgical drainage. The patient eventually died 52 days after the index procedure. This was assumed to be a late complication of pericardiocentesis. Infectious complications secondary to pericardiocentesis appear to be rare but have been described before with other imaging techniques<a class="elsevierStyleCrossRefs" href="#bib0190">14,20</a> and are probably related to the drainage technique, rather than the imaging modality.These findings of high success and low complication rates are in line with the literature. Duvernoy et al.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> reported the first series of 10 patients in 1996, all with successful drainage and no major complications. Bruning et al.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> described a series of 11 patients with effusions not drainable under sonographic surveillance, all successful, and one complication (an epicardial laceration requiring surgery). Klein et al.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> published a single-center experience of 319 procedures with a success rate of 98.4% and a major complication rate of 0.3%. In 2008 Palmer et al.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> presented a series of 39 procedures in post-surgical patients, all of them successful, without significant complications, and CTP was shown to have the additional benefit of reducing costs compared to surgical drainage. Eichler et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> published a series of 20 patients (85% post-surgical); all of them were successful and no major complications were reported. Ceviz et al.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> recently published a series of 30 patients, successful in 29, with one major complication (hemopericardium due to epicardial injury).Complications are more likely to occur with increasing numbers of procedures, and are never completely avoidable in invasive procedures. Pericardiocentesis is an invasive procedure frequently performed in frail patients, and is thus associated with a non-negligible risk of complications. The decision to perform it is therefore classically conservative, given the potential benefit/risk ratio. CT guidance is proving to be an important tool in improving that ratio due to its ability to guide the procedure and increase safety. Holistic, informed, and whenever possible evidence-based clinical judgment is essential for every decision in medicine. Increasing the safety of an invasive procedure does not mean it should be performed in more patients who have smaller effusions. But it certainly means it can be performed in an urgent setting, before there is frank hemodynamic instability, which is preferable to an emergent setting, with the patient in cardiac tamponade.In line with the published literature, this work provides evidence for the feasibility, advantages and disadvantages of CTP, when using a standardized protocol, performed by experienced physicians and in specific clinical settings.LimitationsThis is a retrospective descriptive analysis of the experience of a single center with clinical expertise in cardiac MDCT. Additionally, this is a tertiary center with a locally available catheterization laboratory and cardiac surgery facilities. Therefore, our data reflect a specific hospital population that may preclude generalization of the findings.ConclusionsIn our experience CTP is an effective and safe option in patients with clinical indications for pericardial fluid drainage.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres827476" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec823739" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres827475" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec823740" "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" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-08-18" "fechaAceptado" => "2015-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec823739" "palabras" => array:3 [ 0 => "Pericardiocentesis" 1 => "Computed tomography" 2 => "Pericardial effusion" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec823740" "palabras" => array:3 [ 0 => "Pericardiocentese" 1 => "Tomografia computorizada" 2 => "Derrame pericárdico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and ObjectivesPericardial effusion is a common complication in clinical situations such as cardiothoracic surgery and cancer, in which pericardiocentesis may be essential. Pericardiocentesis can be guided by different imaging techniques, most commonly echocardiography. Computed tomography (CT) has significant advantages but there is still little evidence supporting its use in this context. In this work we describe our experience with CT-guided pericardiocentesis (CTP) in a single center. MethodsPatients referred for CTP between August 2008 and February 2014 were retrospectively analyzed. We assessed demographics, etiology of the effusion, international normalized ratio during the procedure, radiation doses, success rate and complications. Results were compared with those in the literature. ResultsDuring this period, 51 procedures were performed, in 46 patients. Five patients underwent a repeat procedure due to recurrence of effusion. The most common etiologies were post-surgical (48%, 22 patients) and neoplasm-related (17%, eight patients).Drainage was considered completely successful in 46 cases (90%), partially successful in two (4%) and unsuccessful in three (6%).The median duration of the procedure was 65 min (interquartile range 50–80) and median effective radiation exposure was 3.3 mSv (interquartile range 2.4–5.2 mSv). There were no significant adverse events related to the procedure. ConclusionsBy providing high-definition three-dimensional images, CTP enables accurate positioning of pericardiocentesis material. It was shown to be an accurate, effective and safe method, in agreement with previous findings. CTP should be considered a good option in centers with CT facilities." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosO derrame pericárdico é uma complicação temível em várias situações clínicas, em que a pericardiocentese pode ter um papel fundamental. Esta pode ser guiada por vários métodos de imagem, sobretudo ecocardiografia. A tomografia computorizada (TC) tem várias vantagens, mas o seu uso tem ainda fraca evidência clínica. Neste trabalho é reportada a experiência de um centro em pericardiocentese guiada por TC (P-TC). MétodosForam analisados retrospetivamente pacientes (pts) referenciados para P-TC durante o período de agosto de 2008 a fevereiro de 2014. Foi avaliada a demografia, etiologia do derrame, INR, radiação, sucesso e complicações, sendo os resultados comparados aos publicados na literatura. ResultadosDurante este período, foram realizados 51 procedimentos em 46 doentes. Cinco doentes repetiram o procedimento devido a recorrência do derrame. A idade média foi de 63±13,8 anos. As etiologias mais frequentes foram pós-cirúrgica (48%, 22 pts) e neoplasia (17%, oito pts).A drenagem foi considerada completa em 90% (46) dos casos, parcial em 4% (dois) e ineficaz em 6% (três).O procedimento teve uma duração mediana de 65 minutos (Q1-Q3 50-80 minutos) e a exposição de radiação foi de 3,3 mSv (Q1-Q3 2,4-5,2 mSv). Não foram detetadas complicações imediatas relevantes. ConclusõesAo providenciar imagens de alta definição em três dimensões, a P-TC permite o posicionamento preciso do material de pericardiocentese, tendo demonstrado nesta série ser um método eficaz e seguro, indo ao encontro da informação previamente publicada. A P-TC deve, por isso, ser considerada uma boa opção em centros com disponibilidade de TC." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "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" => 674 "Ancho" => 2085 "Tamanyo" => 279450 ] ] "descripcion" => array:1 [ "en" => "Use of computed tomography in pericardiocentesis. (a) Characterization and assessment of effusion; (b) determination of best entry point and needle orientation; (c) control of needle progression and relation with surrounding structures; (d) pigtail positioning; (e) final result and control of evolution." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 611 "Ancho" => 2085 "Tamanyo" => 226323 ] ] "descripcion" => array:1 [ "en" => "Example of a case in which intrapericardial contrast was used. (a) Coronal view; (b) sagittal view; (c) axial view." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ASD: atrial septal defect; BMI: body mass index; CABG: coronary artery bypass grafting; EPS: electrophysiological study; INR: international normalized ratio; MI: myocardial infarction; VSD: ventricular septal defect." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63±13.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Gender</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (54.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 (45.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27±4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Etiology of effusion</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Post-surgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (48%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valvular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CABG \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valvular + CABG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ASD \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VSD \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other surgery \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neoplasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lung \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ovary \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuroendocrine \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breast \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stomach \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Autoimmune \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Free wall rupture after MI \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute pericarditis \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyperuricemia \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complication of EPS \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (15%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Referring service</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiology \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiothoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internal medicine \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pneumology \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiac care unit \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></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">INR</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of cases measured \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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median (range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.44 (1.09–6.88) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392123.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "IQR: interquartile range." "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Purpose of procedure</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Therapeutic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 (96%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Success \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48 (94%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (90%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incomplete \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insuccess \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Effective radiation (mSv) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.3 (IQR 2.4-5.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drained volume (ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">781±452.4 (10–2000) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Fluid type</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clear yellow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serosanguineous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sanguineous \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Data not available/unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Contrast use (no. of procedures) \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat procedures (no. of procedures) \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time between procedures (median in days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 (7–111) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392124.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Procedural data." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "N/A: not available." "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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Authors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Year of publication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">No. of procedures \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Success \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Minor \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">Major \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duvernoy et al.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1996 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bruning et al.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klein et al.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">319 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">314 (98.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (6.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palmer et al.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eichler et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceviz et al.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (97%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (94%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">480 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">471 (98%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (0.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1392125.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Published series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical clues to the causes of large pericardial effusions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Sagristà-Sauleda" 1 => "J. Mercé" 2 => "G. Permanyer-Miralda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "2000" "volumen" => "109" "paginaInicial" => "95" "paginaFinal" => "101" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10967149" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postoperative cardiac tamponade in the modern surgical era" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.T. Kuvin" 1 => "N.A. Harati" 2 => "N.G. Pandian" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2002" "volumen" => "74" "paginaInicial" => "1148" "paginaFinal" => "1153" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12400760" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of pericardial effusion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Imazio" 1 => "Y. Adler" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehs372" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2013" "volumen" => "34" "paginaInicial" => "1186" "paginaFinal" => "1197" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23125278" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0140" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and management of pericardial effusion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Sagristà-Sauleda" 1 => "A.S. Mercé" 2 => "J. 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Computed tomography-guided pericardiocentesis – A single-center experience

Pericardiocentese guiada por tomografia computorizada – experiência num centro

David Nevesa,b,

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dcneves25@hotmail.com

Corresponding author.

, Margarida Silvab, Gustavo Moraisb, Nuno Ferreirab, Mónica Carvalhob, Vasco Gama Ribeirob, Nuno Bettencourtb

a Serviço de Cardiologia, Hospital do Espírito Santo, Évora, Portugal

b Serviço de Cardiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">There are many clinical scenarios in which pericardial effusion may develop&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> It can be caused by bleeding into the pericardial space or other fluid accumulation&#46; Etiology may be inflammatory&#47;infectious&#44; traumatic&#44; post-operative&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> or related to cancer or other chronic conditions such as uremia&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> Its main adverse consequence is its potential impact on cardiac hemodynamics&#44; which will depend mainly on the volume and rate of development of the effusion&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> Clinical presentation of a significant pericardial effusion usually includes lightheadedness&#44; chest discomfort&#44; dyspnea&#44; anxiety&#44; tachycardia and hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> Echocardiography is the imaging modality of choice for diagnosis and for estimating hemodynamic impairment&#44; through assessment of right heart chamber dynamics&#46; Other diagnostic tools may be required for etiologic investigation or anatomical definition&#44; such as computed tomography &#40;CT&#41; and cardiovascular magnetic resonance&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">6&#44;7</span></a> Pericardiocentesis is usually indicated when hemodynamic impact is significant or when needed for etiologic diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As it is an invasive procedure&#44; there is always a significant risk of complications&#44; which may be reduced with enhanced control in needle positioning&#44; in order to avoid unintended puncture of structures&#46; Electrocardiogram-guided<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> and fluoroscopy-guided<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> techniques have been described&#46; Guidance in recent years has been mainly through echocardiography<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#8211;16</span></a> &#40;offline or real-time&#41; because of its improved safety over a blind approach&#46; CT-guided pericardiocentesis &#40;CTP&#41; is also an option in centers with access to and expertise in this technique&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#44;18</span></a> with the advantage of detailed three-dimensional imaging&#44; which enables fine needle positioning&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This work reports on our experience with CTP&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">All procedures were performed by experienced cardiologists or cardiac surgeons&#44; using a Seldinger technique according to previously described protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> CT guidance was obtained using a 64-slice scanner &#40;Siemens SOMATOM Sensation&#44; Erlangen&#44; Germany&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Patients provided informed consent&#46; During the procedure they were asked to breathe steadily and abstain from moving or breathing deeply&#46; Local anesthesia with subcutaneous lidocaine was performed in every patient and light sedation &#40;diazepam 5 mg orally&#41; was administered when needed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Images of the whole thorax were acquired before the procedure and were analyzed with dedicated software &#40;Siemens Syngo Viewer<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Parameters used by protocol were&#58; tube voltage 100 kV&#44; tube current 110 mAs&#44; reconstruction with 0&#46;75 mm sections&#44; overlap 0&#46;5 mm&#46; Typical window width&#47;level used during the procedure was 700&#47;80&#46; The best entry point and needle orientation were determined &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; We used an 18 gauge needle from the PeriVac&#8482; kit &#40;Boston Scientific<span class="elsevierStyleSup">&#174;</span>&#41;&#46; After superficial needle insertion&#44; new images of the area of interest were acquired&#46; Needle orientation was corrected as needed and the needle was advanced under aspiration&#46; New images were acquired as needed&#46; When the pericardial space was reached&#44; a drain &#40;8&#46;3F pigtail catheter from the kit&#41; was inserted through a guidewire &#40;J-tipped 0&#46;035&#8243;&#215;80 cm&#41; and final images were acquired&#46; When in doubt &#40;due to limited pericardial width at the puncture site&#41; a small amount of contrast &#40;by protocol 5 ml diluted in 10 ml of saline&#41; was injected to confirm an intra-pericardial needle position before dilation and drain insertion &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Data were stored in a dedicated computer database&#46; Statistical analysis was performed using IBM SPSS Statistics 21 &#40;2012&#41;&#46; Values are presented as mean &#177; standard deviation or median &#40;interquartile range&#41; as appropriate&#46; Normality of the sample distribution was tested using the Shapiro-Wilk test&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Between August 2008 and February 2014&#44; 49 patients were referred for CTP&#44; which was performed in 46 patients&#46; In three patients the effusion was considered unsuitable for pericardiocentesis &#40;shallow or posterior location&#41;&#46; Patient characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 51 procedures were reported&#46; Five patients underwent repeat procedures due to recurrence of significant effusion &#40;three post-surgical&#44; two of unknown etiology&#41;&#46; The purpose of the procedure was mainly diagnostic in only two cases&#46; The most common etiologies of pericardial effusion were post-surgical &#40;48&#37;&#44; 22 cases&#41; and neoplasm-related &#40;17&#37;&#44; eight cases&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">International normalized ratio &#40;INR&#41; was measured in 33 procedures&#44; including in all patients under oral anticoagulation&#59; there were five patients with INR &#62;2&#44; with a maximum of 6&#46;88&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Procedural data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The procedure had a median duration of 65 &#40;50-80&#41; min and median total effective radiation exposure was 3&#46;3 &#40;2&#46;38&#8211;5&#46;17&#41; mSv&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The volume of drained fluid was variable&#44; with a mean of 781&#177;452&#46;4 ml&#46; Drainage was considered completely successful in 46 &#40;90&#37;&#41; of cases&#46; It was considered only partially successful in two cases &#40;4&#37;&#41;&#44; both due to persistent fluid accumulation in a posterior location&#59; one of them underwent successful surgical drainage&#44; the other needed no further intervention&#46; CTP was considered unsuccessful in three cases &#40;6&#37;&#41;&#44; probably due to highly septated&#47;organized effusions&#59; one had been attempted for diagnostic purposes&#44; the other two underwent successful surgical drainage&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There were no significant immediate adverse events related to the procedure&#44; even in patients with INR &#62;2&#46; There was&#44; however&#44; one late complication&#44; with development of pyopericardium&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The results are integrated with previously published data in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The main finding of our study is that CT is an effective and safe technique to guide pericardiocentesis&#44; which is an invasive and potentially dangerous procedure reserved for specific clinical scenarios&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In an era of multimodality imaging in cardiology&#44; blind &#40;or even ECG-guided or fluoroscopy-guided&#41; pericardiocentesis is becoming obsolete&#44; and is not recommendable&#44; except in life-saving situations&#46; Other imaging techniques may have some advantages for needle guidance&#46; Echocardiography&#44; above all&#44; is a valuable and practical option&#44; and is probably best when using a probe-mounted needle&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> It provides continuous real-time imaging&#44; and is widely available and probably logistically simpler and less time-consuming than CT&#46; It has&#44; however&#44; the disadvantage of not infrequent poor acoustic windows and less reliable needle tip visualization and orientation&#46; CT allows the physician to better evaluate needle direction&#44; tip positioning and relation with surrounding structures&#46; The main limitation of CT is probably its availability&#44; which is not as ubiquitous as echocardiography but is increasing&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">CTP has previously been described as safe and effective&#46; This series illustrates our good experience with this technique&#46; It encompasses a reasonable-sized sample of 46 patients&#44; almost half of them post-surgical&#44; with a high procedural success rate &#40;90&#37; complete drainage&#44; 4&#37; incomplete and 6&#37; unsuccessful&#41;&#44; and no major immediate complications recorded&#46; There was one case of pyopericardium&#44; which developed several days after the procedure&#44; performed for a significant effusion in the likely context of Dressler syndrome&#46; No immediate complications were observed and the patient was transferred back to the referring hospital&#46; He was readmitted seven days after the procedure due to recurrence of the effusion and pyopericardium was confirmed after surgical drainage&#46; The patient eventually died 52 days after the index procedure&#46; This was assumed to be a late complication of pericardiocentesis&#46; Infectious complications secondary to pericardiocentesis appear to be rare but have been described before with other imaging techniques<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14&#44;20</span></a> and are probably related to the drainage technique&#44; rather than the imaging modality&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">These findings of high success and low complication rates are in line with the literature&#46; Duvernoy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> reported the first series of 10 patients in 1996&#44; all with successful drainage and no major complications&#46; Bruning et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> described a series of 11 patients with effusions not drainable under sonographic surveillance&#44; all successful&#44; and one complication &#40;an epicardial laceration requiring surgery&#41;&#46; Klein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> published a single-center experience of 319 procedures with a success rate of 98&#46;4&#37; and a major complication rate of 0&#46;3&#37;&#46; In 2008 Palmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> presented a series of 39 procedures in post-surgical patients&#44; all of them successful&#44; without significant complications&#44; and CTP was shown to have the additional benefit of reducing costs compared to surgical drainage&#46; Eichler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> published a series of 20 patients &#40;85&#37; post-surgical&#41;&#59; all of them were successful and no major complications were reported&#46; Ceviz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> recently published a series of 30 patients&#44; successful in 29&#44; with one major complication &#40;hemopericardium due to epicardial injury&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Complications are more likely to occur with increasing numbers of procedures&#44; and are never completely avoidable in invasive procedures&#46; Pericardiocentesis is an invasive procedure frequently performed in frail patients&#44; and is thus associated with a non-negligible risk of complications&#46; The decision to perform it is therefore classically conservative&#44; given the potential benefit&#47;risk ratio&#46; CT guidance is proving to be an important tool in improving that ratio due to its ability to guide the procedure and increase safety&#46; Holistic&#44; informed&#44; and whenever possible evidence-based clinical judgment is essential for every decision in medicine&#46; Increasing the safety of an invasive procedure does not mean it should be performed in more patients who have smaller effusions&#46; But it certainly means it can be performed in an urgent setting&#44; before there is frank hemodynamic instability&#44; which is preferable to an emergent setting&#44; with the patient in cardiac tamponade&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In line with the published literature&#44; this work provides evidence for the feasibility&#44; advantages and disadvantages of CTP&#44; when using a standardized protocol&#44; performed by experienced physicians and in specific clinical settings&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limitations</span><p id="par0105" class="elsevierStylePara elsevierViewall">This is a retrospective descriptive analysis of the experience of a single center with clinical expertise in cardiac MDCT&#46; Additionally&#44; this is a tertiary center with a locally available catheterization laboratory and cardiac surgery facilities&#46; Therefore&#44; our data reflect a specific hospital population that may preclude generalization of the findings&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">In our experience CTP is an effective and safe option in patients with clinical indications for pericardial fluid drainage&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pericardial effusion is a common complication in clinical situations such as cardiothoracic surgery and cancer&#44; in which pericardiocentesis may be essential&#46; Pericardiocentesis can be guided by different imaging techniques&#44; most commonly echocardiography&#46; Computed tomography &#40;CT&#41; has significant advantages but there is still little evidence supporting its use in this context&#46; In this work we describe our experience with CT-guided pericardiocentesis &#40;CTP&#41; in a single center&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients referred for CTP between August 2008 and February 2014 were retrospectively analyzed&#46; We assessed demographics&#44; etiology of the effusion&#44; international normalized ratio during the procedure&#44; radiation doses&#44; success rate and complications&#46; Results were compared with those in the literature&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During this period&#44; 51 procedures were performed&#44; in 46 patients&#46; Five patients underwent a repeat procedure due to recurrence of effusion&#46; The most common etiologies were post-surgical &#40;48&#37;&#44; 22 patients&#41; and neoplasm-related &#40;17&#37;&#44; eight patients&#41;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Drainage was considered completely successful in 46 cases &#40;90&#37;&#41;&#44; partially successful in two &#40;4&#37;&#41; and unsuccessful in three &#40;6&#37;&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The median duration of the procedure was 65 min &#40;interquartile range 50&#8211;80&#41; and median effective radiation exposure was 3&#46;3 mSv &#40;interquartile range 2&#46;4&#8211;5&#46;2 mSv&#41;&#46; There were no significant adverse events related to the procedure&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">By providing high-definition three-dimensional images&#44; CTP enables accurate positioning of pericardiocentesis material&#46; It was shown to be an accurate&#44; effective and safe method&#44; in agreement with previous findings&#46; CTP should be considered a good option in centers with CT facilities&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O derrame peric&#225;rdico &#233; uma complica&#231;&#227;o tem&#237;vel em v&#225;rias situa&#231;&#245;es cl&#237;nicas&#44; em que a pericardiocentese pode ter um papel fundamental&#46; Esta pode ser guiada por v&#225;rios m&#233;todos de imagem&#44; sobretudo ecocardiografia&#46; A tomografia computorizada &#40;TC&#41; tem v&#225;rias vantagens&#44; mas o seu uso tem ainda fraca evid&#234;ncia cl&#237;nica&#46; Neste trabalho &#233; reportada a experi&#234;ncia de um centro em pericardiocentese guiada por TC &#40;P-TC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foram analisados retrospetivamente pacientes &#40;pts&#41; referenciados para P-TC durante o per&#237;odo de agosto de 2008 a fevereiro de 2014&#46; Foi avaliada a demografia&#44; etiologia do derrame&#44; INR&#44; radia&#231;&#227;o&#44; sucesso e complica&#231;&#245;es&#44; sendo os resultados comparados aos publicados na literatura&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Durante este per&#237;odo&#44; foram realizados 51 procedimentos em 46 doentes&#46; Cinco doentes repetiram o procedimento devido a recorr&#234;ncia do derrame&#46; A idade m&#233;dia foi de 63&#177;13&#44;8 anos&#46; As etiologias mais frequentes foram p&#243;s-cir&#250;rgica &#40;48&#37;&#44; 22 pts&#41; e neoplasia &#40;17&#37;&#44; oito pts&#41;&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">A drenagem foi considerada completa em 90&#37; &#40;46&#41; dos casos&#44; parcial em 4&#37; &#40;dois&#41; e ineficaz em 6&#37; &#40;tr&#234;s&#41;&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">O procedimento teve uma dura&#231;&#227;o mediana de 65 minutos &#40;Q1-Q3 50-80 minutos&#41; e a exposi&#231;&#227;o de radia&#231;&#227;o foi de 3&#44;3 mSv &#40;Q1-Q3 2&#44;4-5&#44;2 mSv&#41;&#46; N&#227;o foram detetadas complica&#231;&#245;es imediatas relevantes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ao providenciar imagens de alta defini&#231;&#227;o em tr&#234;s dimens&#245;es&#44; a P-TC permite o posicionamento preciso do material de pericardiocentese&#44; tendo demonstrado nesta s&#233;rie ser um m&#233;todo eficaz e seguro&#44; indo ao encontro da informa&#231;&#227;o previamente publicada&#46; A P-TC deve&#44; por isso&#44; ser considerada uma boa op&#231;&#227;o em centros com disponibilidade de TC&#46;</p></span>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Use of computed tomography in pericardiocentesis&#46; &#40;a&#41; Characterization and assessment of effusion&#59; &#40;b&#41; determination of best entry point and needle orientation&#59; &#40;c&#41; control of needle progression and relation with surrounding structures&#59; &#40;d&#41; pigtail positioning&#59; &#40;e&#41; final result and control of evolution&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Example of a case in which intrapericardial contrast was used&#46; &#40;a&#41; Coronal view&#59; &#40;b&#41; sagittal view&#59; &#40;c&#41; axial view&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ASD&#58; atrial septal defect&#59; BMI&#58; body mass index&#59; CABG&#58; coronary artery bypass grafting&#59; EPS&#58; electrophysiological study&#59; INR&#58; international normalized ratio&#59; MI&#58; myocardial infarction&#59; VSD&#58; ventricular septal defect&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Age &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#177;13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Male</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;54&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Female</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#40;45&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">BMI &#40;kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">2</span></span><span class="elsevierStyleBold">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#177;4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Etiology of effusion</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Post-surgical</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Valvular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>CABG&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Valvular &#43; CABG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>ASD&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>VSD&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Other surgery&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neoplasm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Lung&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ovary&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Neuroendocrine&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Breast&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Stomach&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Heart failure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Autoimmune</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Other</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Free wall rupture after MI&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Acute pericarditis&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hyperuricemia&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Complication of EPS&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Unknown</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Referring service</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiology</span>&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiothoracic surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Internal medicine</span>&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pneumology</span>&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Cardiac care unit</span>&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></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">INR</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Number of cases measured</span>&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Median &#40;range&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;44 &#40;1&#46;09&#8211;6&#46;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Purpose of procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diagnostic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Therapeutic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49 &#40;96&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Success</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48 &#40;94&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46 &#40;90&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Incomplete&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;4&#37;&#41;&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Insuccess</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Effective radiation &#40;mSv&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;3 &#40;IQR 2&#46;4-5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Drained volume &#40;ml&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">781&#177;452&#46;4 &#40;10&#8211;2000&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Fluid type</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clear yellow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Serosanguineous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sanguineous&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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Data not available&#47;unknown&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Contrast use &#40;no&#46; of procedures&#41;</span>&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
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                  \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Time between procedures &#40;median in days&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35 &#40;7&#8211;111&#41;&nbsp;\t\t\t\t\t\t\n
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                  <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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Authors&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">Year of publication&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">No&#46; of procedures&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">Success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&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">Minor&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">Major&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-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duvernoy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</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">1996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bruning et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</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">2002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</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">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">314 &#40;98&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;6&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</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">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eichler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</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">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ceviz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</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">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;97&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Current study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;94&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#37;&#41;&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">480&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">471 &#40;98&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;0&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Published series&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Clinical clues to the causes of large pericardial effusions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Sagrist&#224;-Sauleda"
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                            2 => "G&#46; Permanyer-Miralda"
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                        "tituloSerie" => "Am J Med"
                        "fecha" => "2000"
                        "volumen" => "109"
                        "paginaInicial" => "95"
                        "paginaFinal" => "101"
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              "identificador" => "bib0130"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Postoperative cardiac tamponade in the modern surgical era"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46;T&#46; Kuvin"
                            1 => "N&#46;A&#46; Harati"
                            2 => "N&#46;G&#46; Pandian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2002"
                        "volumen" => "74"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12400760"
                            "web" => "Medline"
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              "identificador" => "bib0135"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of pericardial effusion"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Imazio"
                            1 => "Y&#46; Adler"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehs372"
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                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2013"
                        "volumen" => "34"
                        "paginaInicial" => "1186"
                        "paginaFinal" => "1197"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23125278"
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis and management of pericardial effusion"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Sagrist&#224;-Sauleda"
                            1 => "A&#46;S&#46; Merc&#233;"
                            2 => "J&#46; Soler-Soler"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4330/wjc.v3.i5.135"
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                        "tituloSerie" => "World J Cardiol"
                        "fecha" => "2011"
                        "volumen" => "3"
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                        "paginaFinal" => "143"
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                      "titulo" => "Pericardial disease&#58; diagnosis and management"
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                            2 => "R&#46;A&#46; Nishimura"
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                      "doi" => "10.1148/rg.276065002"
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                        "tituloSerie" => "Radiographics"
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                        "volumen" => "27"
                        "paginaInicial" => "1595"
                        "paginaFinal" => "1610"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.11.023

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Year/Month	Html	Pdf	Total

2024 November	7	6	13
2024 October	31	28	59
2024 September	45	20	65
2024 August	32	27	59
2024 July	35	36	71
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2021 March	53	21	74
2021 February	62	23	85
2021 January	35	20	55
2020 December	35	11	46
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2020 August	27	8	35
2020 July	45	17	62
2020 June	46	4	50
2020 May	45	12	57
2020 April	55	20	75
2020 March	39	7	46
2020 February	167	32	199
2020 January	28	6	34
2019 December	43	8	51
2019 November	38	12	50
2019 October	33	6	39
2019 September	36	5	41
2019 August	31	4	35
2019 July	35	8	43
2019 June	30	12	42
2019 May	56	10	66
2019 April	35	14	49
2019 March	176	18	194
2019 February	118	12	130
2019 January	84	10	94
2018 December	127	11	138
2018 November	193	14	207
2018 October	559	17	576
2018 September	116	18	134
2018 August	66	5	71
2018 July	56	2	58
2018 June	70	5	75
2018 May	88	4	92
2018 April	110	7	117
2018 March	45	9	54
2018 February	24	11	35
2018 January	23	16	39
2017 December	37	15	52
2017 November	27	16	43
2017 October	22	10	32
2017 September	26	16	42
2017 August	27	12	39
2017 July	16	9	25
2017 June	31	10	41
2017 May	31	9	40
2017 April	26	5	31
2017 March	26	30	56
2017 February	35	11	46
2017 January	27	1	28
2016 December	29	8	37
2016 November	28	5	33
2016 October	43	11	54
2016 September	34	5	39
2016 August	9	3	12
2016 July	31	10	41
2016 June	14	19	33
2016 May	7	7	14

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