Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation – Acute phase results from a prospective observational study | Revista Portuguesa de Cardiologia (English edition)

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Bi-V: biventricular pacing; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Marques, Miguel Nobre Menezes, Gustavo Lima da Silva, Ana Bernardes, Andreia Magalhães, Nuno Cortez-Dias, Luís Carpinteiro, João de Sousa, Fausto J. Pinto" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Marques" ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" ] 2 => array:2 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Bernardes" ] 4 => array:2 [ "nombre" => "Andreia" "apellidos" => "Magalhães" ] 5 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cortez-Dias" ] 6 => array:2 [ "nombre" => "Luís" "apellidos" => "Carpinteiro" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "de Sousa" ] 8 => array:2 [ "nombre" => "Fausto J." 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results from a prospective observational study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "331" "paginaFinal" => "338" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pedro Marques, Miguel Nobre Menezes, Gustavo Lima da Silva, Ana Bernardes, Andreia Magalhães, Nuno Cortez-Dias, Luís Carpinteiro, João de Sousa, Fausto J. Pinto" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Pedro" "apellidos" => "Marques" "email" => array:1 [ 0 => "pedroncmarques@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" ] 2 => array:2 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Bernardes" ] 4 => array:2 [ "nombre" => "Andreia" "apellidos" => "Magalhães" ] 5 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cortez-Dias" ] 6 => array:2 [ "nombre" => "Luís" "apellidos" => "Carpinteiro" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "de Sousa" ] 8 => array:2 [ "nombre" => "Fausto J." "apellidos" => "Pinto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, University Hospital Santa Maria, Centro Hospitalar de Lisboa Norte, CCUL, University of Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pacing triple-site para ressincronização cardíaca na fibrilhação auricular permanente – resultados da fase aguda de um estudo prospetivo observacional" ] ] "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" => 2173 "Ancho" => 1656 "Tamanyo" => 151516 ] ] "descripcion" => array:1 [ "en" => "Differences in cardiac output between Tri-V and Bi-V pacing (A), between Bi-V pacing and RVOT septal pacing, and between RVOT septal pacing and RV apical pacing (B). Bi-V: biventricular pacing; LV: left ventricular; RV: right ventricular; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." ] ] ] "textoCompleto" => "IntroductionCardiac resynchronization therapy (CRT) is an established therapy for patients with drug-refractory heart failure and electrical evidence of dyssynchrony. Several large clinical trials have demonstrated that biventricular (Bi-V) pacing significantly reduces all-cause mortality and heart failure-related hospitalizations and symptoms, and improves quality of life, exercise tolerance and left ventricular (LV) systolic performance.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> However, even when appropriately selected, 20-30% of patients do not respond to CRT. This may be due to incomplete resynchronization, as intraventricular and interventricular dyssynchrony can persist in 25-30% of patients despite CRT.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> For such non-responders, multi-site and multi-point pacing are emerging as new methods of CRT. The few previously published studies regarding these novel pacing modalities have shown improved LV hemodynamics and synchrony.<a class="elsevierStyleCrossRefs" href="#bib0015">3–6</a> However, doubts remain concerning their indications and short-term and long-term efficacy and safety, and thus the optimal method of resynchronization remains unknown.In the subgroup of patients with atrial fibrillation (AF), no fewer than 23% of all those with implanted CRT devices,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> studies are still scarce, and these patients are particularly challenging. However, currently available evidence suggests CRT may be of benefit. A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0040">8</a> of prospective cohort studies comparing response to CRT in patients with sinus rhythm vs. AF showed not only that CRT was beneficial in both groups, but also that the AF group performed better in terms of reverse remodeling (assessed as improvement in ejection fraction [EF]), albeit with worse functional outcomes. Because achieving high levels of pacing is harder in patients with AF, there is evidence that atrioventricular (AV) junction ablation may further enhance CRT response and improve not only remodeling response but also functional outcomes.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Interestingly, there is evidence that even AF patients without severely depressed EF, prolonged QRS or severe heart failure (i.e. in New York Heart Association [NYHA] class ≤II) may benefit from CRT. A randomized trial<a class="elsevierStyleCrossRef" href="#bib0050">10</a> assessing patients who underwent AV junction ablation due to severely symptomatic permanent AF showed that CRT was more beneficial than conventional right ventricular (RV) apical pacing both in patients who met the current recommendations for CRT implantation regarding EF, QRS duration and functional class and in those who did not. Finally, only one trial of multi-site pacing has been undertaken in the subgroup of AF patients,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> with good results.Thus, to date, the optimal method of cardiac resynchronization remains to be established, especially in patients with AF. We are currently undertaking an observational prospective trial to assess this issue. In this paper we present our results from the acute post-implantation phase, with particular focus on hemodynamic performance.In this study cardiac resynchronization with multi-site pacing was achieved by means of two right ventricular (RV) leads. Most studies on multi-site pacing used two LV leads and one RV lead.<a class="elsevierStyleCrossRefs" href="#bib0060">12-14</a> Only two trials using two RV leads have been published thus far.<a class="elsevierStyleCrossRefs" href="#bib0025">5,13</a> Given that the former approach has shown to have greater procedure duration, radiation exposure and LV pacing threshold<a class="elsevierStyleCrossRefs" href="#bib0060">12,15</a> and that multi-site pacing using two RV leads has never been assessed in patients with AF, we chose to use the latter approach.Since the benefit of right ventricular outflow tract (RVOT) septal pacing is still regarded as controversial,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> we also assessed the performance of RVOT septal pacing vs. RV apical pacing as a secondary objective, in order to shed further light on this question.ObjectiveThe primary aim of this study was to assess the effects of triple-site ventricular (Tri-V) pacing vs. Bi-V pacing on hemodynamic performance and QRS duration. The secondary aim was to assess the effects of RVOT septal pacing vs. RV apical pacing on hemodynamic performance and QRS duration.MethodsPatient selectionPatients meeting all the following criteria were included: (1) permanent AF; (2) EF <40%; (3) heart failure NYHA ≥II despite appropriate medical treatment and baseline QRS >120 ms or need for anti-bradycardia pacing with an anticipated percentage of ventricular pacing >40%; (4) cognitive capacity to understand the study and hence give informed consent.Implantation and connection methodWhen a CRT defibrillator device was implanted, the defibrillator lead was positioned in the RV apex, and for CRT pacemaker implantation, one conventional RV lead was implanted in the RV apex. In both cases, a second RV lead was implanted in the RVOT septal wall meeting fluoroscopic criteria<a class="elsevierStyleCrossRef" href="#bib0070">14</a> combined with electrocardiographic (ECG) criteria for correct placement,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> ensuring avoidance of the RVOT anterior or free wall. Finally, a coronary sinus lead for LV pacing was implanted as usual for CRT pacing (i.e. in a posterolateral mid-basal position). The RV apical lead was connected to the RV channel. If the LV lead was bipolar, with a pacing threshold below 2.5 V and no diaphragmatic stimulation, the LV lead was connected to the atrial channel and the RVOT lead connected to the LV channel. If the LV lead was quadripolar, if the pacing threshold was over 2.5 V, if specific LV vector programming was necessary, or if there was any type of diaphragmatic stimulation, then the LV lead was connected to the LV channel and the RVOT lead was connected to the atrial channel on the generator. Any device and lead brand could be used. Programming was set to DDDR with the lowest possible AV interval (25-40 ms depending on device brand) and a VV interval of 0 ms.Hemodynamic assessmentUp to one month after implantation, all patients underwent minimally invasive hemodynamic assessment with placement of a radial arterial line using the FloTrac III™ Vigileo™ monitoring system (Edwards Lifesciences, Irvine, CA, USA), which calculates cardiac output based on the arterial pressure waveform. This system is widely used in peri- and intraoperative settings as well as in intensive care units, and is useful in detecting sudden changes in cardiac output and volume status provided the cardiac rhythm is regular.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Cardiac output and systolic volume were assessed at 70 beats per minute in the following configurations: RV apical, RV RVOT, LV, Bi-V pacing using the RV apical (RVA) and LV leads (Bi-V RVA-LV), Bi-V pacing using the RVOT and LV leads (Bi-V RVOT-LV), and Tri-V. The assessment was performed under ≥99% pacing. In order to achieve these levels, AV node suppression was achieved previously by means of pharmacotherapy or by AV node ablation in drug-refractory cases. Each configuration was assessed for 15 min to achieve stable measurements. During transitions, to avoid a potential carry-over effect, the first 5 min of measurements were disregarded, and only measurements from the following 15 min were considered. The operator performing the hemodynamic assessment was blinded to the pacing mode used.Electrocardiographic assessmentSimultaneously with the hemodynamic assessment, all patients underwent standard 12-lead ECG assessment in each of the following configurations: RV apical, RV RVOT, LV, Bi-V RVA-LV, Bi-V RVOT-LV and Tri-V. QRS duration was measured in each of these configurations by two blinded operators.Echocardiographic assessmentThe echocardiographic study was performed with a Vivid 7 device (General Electric®) in each of the following configurations: Tri-V, Bi-V RVA-LV and Bi-V RVOT-LV. The study was undertaken simultaneously with the hemodynamic assessment.EF was estimated by the Simpson biplane method determined from the cine loops acquired in two-dimensional mode, end-diastolic and late systolic volumes being measured in three consecutive cardiac cycles. Post-processing analysis was performed by two operators using EchoPAC© software (General Electric).Statistical analysisMean cardiac output, QRS and EF were calculated in each group. Differences were assessed by a paired samples t test.In order to assess differences in procedure duration, fluoroscopy duration and radiation dosage, the additional amounts of these parameters required for implantation of the second RV lead were quantified, and the differences between Bi-V and Tri-V were assessed by the t test.Ethical considerationsThis paper conforms with the Helsinki Declaration on the Ethical Principles for Medical Research Involving Human Subjects and was approved by our local ethics committee. Written informed consent was obtained from all patients.ResultsPopulationA total of 40 patients were included. Baseline pre-implantation characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Most patients were severely symptomatic, with markedly depressed EF and a significantly prolonged QRS. AV node ablation was necessary in six patients prior to hemodynamic assessment.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Hemodynamic resultsThe hemodynamic results are depicted in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Figures 1A and B</a>. Cardiac output was significantly higher during Tri-V compared to Bi-V pacing. There was no statistically significant difference between the two Bi-V pacing configurations, nor between Bi-V pacing and RVOT septal pacing. The latter produced a significantly higher cardiac output than RV apical pacing. These differences remain across ischemic and non-ischemic cardiomyopathy groups.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Electrocardiographic resultsMean QRS duration in each pacing configuration is depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Figures 2A, B and C</a>. Tri-V pacing produced a significantly shorter QRS than pre-implantation QRS and both Bi-V pacing configurations. Bi-V pacing also significantly shortened QRS duration compared with pre-implantation QRS. There was no statistically significant difference between the two Bi-V pacing configurations. RVOT septal pacing produced a significantly shorter QRS than pre-implantation QRS and RV apical pacing QRS, but a significantly longer QRS than Bi-V pacing. These differences remain across ischemic and non-ischemic cardiomyopathy groups.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Echocardiographic resultsEF results are depicted in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Figures 3A and B</a>. All modes of CRT produced a statistically significant improvement in EF. Tri-V produced the greatest improvement, with a significant difference compared to Bi-V. These differences remain across ischemic and non-ischemic cardiomyopathy groups.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Mean fluoroscopy and procedure timeAlthough implantation of the Tri-V system resulted in longer procedure and fluoroscopy times, the difference was not significant compared to conventional Bi-V implantation (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>DiscussionIn this study, Tri-V pacing produced a superior hemodynamic performance compared to conventional Bi-V pacing, as demonstrated by increased cardiac output and EF. This is likely an immediate consequence of improved resynchronization, given that QRS duration was significantly shorter in Tri-V pacing vs. conventional Bi-V pacing, and that this was an acute phase study, in which reverse remodeling could not yet have occurred. The reduction in QRS duration obtained by Tri-V pacing is especially remarkable, QRS having been shortened almost to normal length. Our fluoroscopy and procedure times were scarcely prolonged by this technique, and as such were not a significant limitation.There have been few studies on multi-site pacing, and the methodology has been very heterogeneous regarding not only pacing and implant techniques, but also the method used for assessing hemodynamic response. Most used two LV leads and one RV lead. In one non-randomized trial one of the LV leads was connected to the atrial channel (all patients had permanent AF), and the other two leads were connected as usual. Triple-site pacing yielded higher EF and reduced end-systolic volume, without clinical improvement, at three months.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Of course, by connecting an LV lead to an atrial channel, the use of vectors is limited. Two other randomized trials used a similar approach but connected both LV leads with a Y-connector. They demonstrated an additional clinical benefit, but greater procedure length, radiation exposure and LV pacing threshold.<a class="elsevierStyleCrossRefs" href="#bib0060">12,15</a> Regarding safety, none of these trials have shown significant differences between Tri-V or Bi-V pacing, and Ogano et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> recently demonstrated that dual LV pacing might even have a protective effect against ventricular arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Only three trials using two RV leads and one LV lead alone have been published.<a class="elsevierStyleCrossRefs" href="#bib0025">5,13,19</a> However, in two of these, the connection technique was different, as both RV leads were connected to the atrial channel by means of a Y-connector. Systolic function was assessed invasively by determining peak LV dP/dt (using a micromanometer-tipped pigtail angiographic catheter) and also cardiac output with a Swan-Ganz catheter. Dyssynchrony was assessed with tissue Doppler echocardiographic imaging. QRS duration was also assessed in each pacing configuration. Triple-site pacing was superior regarding all four parameters compared to conventional BiV pacing. There were also no safety issues regarding this method. Finally, one trial used both types of triple-site pacing (i.e. one group received two RV leads, and another two LV leads), with better clinical and hemodynamic results in triple-site pacing compared to conventional Bi-V pacing.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> A very recent randomized trial compared Tri-V pacing with conventional Bi-V pacing in terms of clinical and echocardiographic data at 12-month follow-up. There were no differences in adverse events or clinical benefit, however Tri-V did produce higher EF at 12 months.<a class="elsevierStyleCrossRefs" href="#bib0025">5,13,19</a>Despite the heterogeneity of the studies, and the unique methodology of our study, all of these trials using triple-site pacing have demonstrated superior hemodynamic performance and increased resynchronization compared to conventional Bi-V pacing. The benefit was also present in AF patients.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Thus, our results are consistent with previous studies.It is worth noting that no previous trial has ever assessed the use of triple-site pacing with two RV leads in patients with permanent AF. Given that these patients represent an understudied and particularly challenging group, our study adds pioneering scientific data on this modality of cardiac resynchronization therapy in this subgroup.Regarding the results of single-site pacing, our study produced interesting results. RVOT septal pacing was clearly superior to RV apical pacing, with improved cardiac output and much shorter QRS duration. RVOT septal pacing alone even decreased baseline QRS length in our patients. Studies comparing these two pacing modalities have produced conflicting results.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> However, the discrepancies are largely due to the significant heterogeneity in lead placement technique: few studies have been careful enough to ensure proper lead placement in both the RVOT and the septal wall. This was a critical concern in our study. Several trials in which the RV lead was placed under careful fluoroscopic and/or electrocardiographic guidance yielded superior results for RVOT septal pacing.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Our study adds further weight to this evidence.Finally, the absence of a statistical difference between cardiac output with Bi-V pacing and RVOT septal pacing was an unexpected finding, especially considering that the QRS was significantly shorter with Bi-V pacing. The clinical significance of this finding is unclear, given that we were not comparing the clinical performance of these two pacing modalities. Studies comparing single-site RV pacing vs. Bi-V pacing used echocardiographic and clinical endpoints obtained some time after implantation, and not immediate hemodynamic data.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In addition, the majority of these studies compare RV apical pacing rather than RVOT septal pacing. Thus, no study can be directly compared to ours, and while most studies favor Bi-V pacing, the above-mentioned limitations regarding RV pacing site may be of greater importance than previously thought. Therefore, whatever the interpretation of our particular results, they highlight the importance and potential of RVOT septal pacing. Indeed, in patients in whom the CRT indication is based on need for pacing rather than primarily on heart failure, could RVOT septal pacing be a sustainable alternative to Bi-V pacing? Our trial was neither designed nor statistically powered to answer such a question, but adds further evidence to the issue.LimitationsOur study has several limitations. Use of the FloTrac III™ Vigileo™ monitoring system is time-consuming and while it has been well validated in a variety of clinical scenarios,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> this is the first time that it has been tested in this setting. Also, ischemic cardiomyopathy was found in only 25% of all patients. Despite the fact that statistical results were similar across this subgroup of patients, the absolute number of patients is small, and as such this heterogeneity may have influenced our results. Finally, although the echocardiographic results were statistically significant, the resulting differences are small and within the inter- and intraobserver variability of the technique. Thus, these particular results should be interpreted with caution. The observed differences in cardiac output were also small, and therefore we cannot yet be absolutely sure of their clinical significance.Future directionsThe fact that multiple techniques, including ours, yielded benefit suggests that multi-site pacing should be further developed. The optimal method, whether with two RV leads, two LV leads, a single lead with multi-point pacing capabilities or a combination of these remains to be determined. We believe that if three ventricular leads are to be used, two RV leads are much faster and probably more stable. The development of CRT generators designed specifically for multi-site pacing may also be important. So far only one manufacturer has produced such a device, which will be tested in non-responders in a randomized trial.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> It is worth pointing out, however, that in our population we deliberately did not select a subset of non-responders, and still achieved superior results with this new pacing modality. This raises the possibility of organizing a large trial of multi-site pacing as a first-line treatment in candidates for cardiac resynchronization therapy.ConclusionTriple-site pacing produced a superior hemodynamic performance with shorter QRS duration, which is likely the consequence of improved resynchronization. RVOT septal pacing was clearly superior to RV apical pacing, with shorter QRS and greater cardiac output.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.FundingNo specific funding grants were used regarding this study.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres824744" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821201" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824743" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821200" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient selection" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Implantation and connection method" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Hemodynamic assessment" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Electrocardiographic assessment" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Echocardiographic assessment" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical analysis" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Ethical considerations" ] ] ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Population" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Hemodynamic results" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Electrocardiographic results" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Echocardiographic results" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Mean fluoroscopy and procedure time" ] ] ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Limitations" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Future directions" ] 11 => array:2 [ "identificador" => "sec0100" "titulo" => "Conclusion" ] 12 => array:3 [ "identificador" => "sec0105" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0120" "titulo" => "Right to privacy and informed consent" ] ] ] 13 => array:2 [ "identificador" => "sec0125" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0130" "titulo" => "Conflicts of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-28" "fechaAceptado" => "2015-12-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821201" "palabras" => array:8 [ 0 => "Cardiac resynchronization therapy" 1 => "Multi-site pacing" 2 => "Triple-site pacing" 3 => "Heart failure" 4 => "Atrial fibrillation" 5 => "Cardiac output" 6 => "QRS duration" 7 => "Ejection fraction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec821200" "palabras" => array:8 [ 0 => "Terapêutica de ressincronização cardíaca" 1 => "Pacing multi-site" 2 => "Pacing triple-site" 3 => "Insuficiência cardíaca" 4 => "Fibrilhação auricular" 5 => "Débito cardiaco" 6 => "Duração QRS" 7 => "Fração de ejeção" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and AimMulti-site pacing is emerging as a new method for improving response to cardiac resynchronization therapy (CRT), but has been little studied, especially in patients with atrial fibrillation. We aimed to assess the effects of triple-site (Tri-V) vs. biventricular (Bi-V) pacing on hemodynamics and QRS duration. MethodsThis was a prospective observational study of patients with permanent atrial fibrillation and ejection fraction <40% undergoing CRT implantation (n=40). One right ventricular (RV) lead was implanted in the apex and another in the right ventricular outflow tract (RVOT) septal wall. A left ventricular (LV) lead was implanted in a conventional venous epicardial position. Cardiac output (using the FloTrac™ Vigileo™ system), mean QRS and ejection fraction were calculated. ResultsMean cardiac output was 4.81±0.97 l/min with Tri-V, 4.68±0.94 l/min with RVOT septal and LV pacing, and 4.68±0.94 l/min with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV). Mean pre-implantation QRS was 170±25 ms, 123±18 ms with Tri-V, 141±25 ms with RVOT septal pacing and LV pacing and 145±19 with RV apical and LV pacing (p<0.001 for Tri-V vs. both BiV and pre-implantation). Mean ejection fraction was significantly higher with Tri-V (30±11%) vs. Bi-V pacing (28±12% with RVOT septal and LV pacing and 28±11 with RV apical and LV pacing) and pre-implantation (25±8%). ConclusionTri-V pacing produced higher cardiac output and shorter QRS duration than Bi-V pacing. This may have a significant impact on the future of CRT." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivoO pacing multi-site está a emergir como um novo método de ressincronização cardíaca. Todavia, foi pouco estudado, sobretudo em fibrilhação auricular. Este estudo visa aferir o efeito hemodinâmico e na duração do QRS de pacing Tri-V versus Bi-V. MétodosEstudo prospetivo observacional de doentes com fibrilhação auricular permanente e fração de ejeção < 40% submetidos a implantação de CRT (n=40). Implantou-se um eletrocateter direito no ápex, outro na parede septal do trato de saída direito e outro em posição venosa epicárdica esquerda convencional. Calcularam-se o débito cardíaco (usando o sistema Vigileo Flotrac®), o QRS médio e a fração de ejeção. ResultadosO débito cardíaco médio foi 4,81 ± 0,97 L/min em Tri-V, 4,68 ± 0,94 L/min com pacing septal e esquerdo e 4,68 ± 0,94 L/min com pacing apical e esquerdo (p < 0,001 para Tri-V versus ambos BiV). O QRS pré-implantação médio foi 170 ± 25 ms, 123 ± 18 ms em Tri-V, 141 ± 25 ms em pacing septal e esquerdo e145 ± 19 em pacing apical e esquerdo (p < 0,001 para Tri-V versus ambos BiV e pré-implantação). A fração de ejeção média foi estatisticamente superior em Tri-V (30 ± 11%) versus Bi-V (28 ± 12% em pacing septal e esquerdo e 28 ± 11em pacing apical e esquerdo), e versus pré-implantação (25 ± 8%). ConclusãoO pacing em Tri-V produziu um débito cardíaco superior e QRS mais estreito do que em Bi-V. Estes resultados poderão modificar o futuro da terapêutica de ressincronização." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:11 [ 0 => array:2 [ "termino" => "AF" "descripcion" => "atrial fibrillation" ] 1 => array:2 [ "termino" => "AV" "descripcion" => "atrioventricular" ] 2 => array:2 [ "termino" => "Bi-V" "descripcion" => "biventricular pacing" ] 3 => array:2 [ "termino" => "CRT" "descripcion" => "cardiac resynchronization therapy" ] 4 => array:2 [ "termino" => "ECG" "descripcion" => "electrocardiographic" ] 5 => array:2 [ "termino" => "EF" "descripcion" => "ejection fraction" ] 6 => array:2 [ "termino" => "LV" "descripcion" => "left ventricular" ] 7 => array:2 [ "termino" => "NYHA" "descripcion" => "New York Heart Association" ] 8 => array:2 [ "termino" => "RV" "descripcion" => "right ventricular" ] 9 => array:2 [ "termino" => "RVOT" "descripcion" => "right ventricular outflow tract" ] 10 => array:2 [ "termino" => "Tri-V" "descripcion" => "triple-site ventricular pacing" ] ] ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2173 "Ancho" => 1656 "Tamanyo" => 151516 ] ] "descripcion" => array:1 [ "en" => "Differences in cardiac output between Tri-V and Bi-V pacing (A), between Bi-V pacing and RVOT septal pacing, and between RVOT septal pacing and RV apical pacing (B). Bi-V: biventricular pacing; LV: left ventricular; RV: right ventricular; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2633 "Ancho" => 1651 "Tamanyo" => 217049 ] ] "descripcion" => array:1 [ "en" => "Differences in mean QRS between pre-implantation and pacing (A), between Tri-V and Bi-V pacing (B), between Bi-V and RVOT septal pacing, and between the latter and RV apical pacing (C). Bi-V: biventricular pacing; LV: left ventricular; RV: right ventricular; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2040 "Ancho" => 1642 "Tamanyo" => 136855 ] ] "descripcion" => array:1 [ "en" => "Differences in mean ejection fraction between pre-implantation and cardiac resynchronization therapy (A) and between Tri-V and Bi-V pacing (B). Bi-V: biventricular pacing; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." ] ] 3 => 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" => "ACE: angiotensin-converting enzyme; CRT-D: cardiac resynchronization therapy defibrillator; CRT-P: cardiac resynchronization therapy pacemaker; EF: ejection fraction; NYHA: New York Heart Association; SD: standard deviation." "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">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73±11 \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">Male, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (97.5) \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">Ischemic cardiomyopathy, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (25) \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">NYHA I, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.5) \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">NYHA II, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (34) \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">NYHA III, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (58.5) \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">NYHA IV, n (%) \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">ACE inhibitor, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (85) \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">Aldosterone receptor blocker, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7.5) \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">Mineralocorticoid receptor antagonist, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (57.5) \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">Beta-blocker, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (85) \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">Diuretic, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (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">Digoxin, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (27.5) \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">Amiodarone, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (17.5) \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">Antithrombotics, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (15) \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">Vitamin K antagonist, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (60) \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">New oral anticoagulant, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (27.5) \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">Pre-implantation QRS, ms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">170±25 \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">Pre-implantation EF, % (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27±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">CRT-D, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (65) \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">CRT-P, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (35) \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">AV node ablation, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (17.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386577.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient population details." ] ] 4 => 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" => "Bi-V: biventricular pacing; LV: left ventricular; RV: right ventricular; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration \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">Cardiac output, l/min (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tri-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.81±0.97 \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">Bi-V with RVOT septal pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.68±0.94 \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">Bi-V with RV apical pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.66±0.91 \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">RVOT septal pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.56±0.93 \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">RV apical pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.44±0.84 \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">LV pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.47±0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386576.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cardiac output in different pacing configurations." ] ] 5 => 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" => "Bi-V: biventricular pacing; LV: left ventricular; RV: right ventricular; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean QRS, ms (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tri-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123±18 \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">Bi-V with RVOT septal pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">141±25 \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">Bi-V with RV apical pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145±19 \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">RVOT septal pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">158±20 \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">RV apical pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">187±18 \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">LV pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201±22 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386575.png" ] ] ] ] "descripcion" => array:1 [ "en" => "QRS duration in each pacing configuration." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Bi-V: biventricular pacing; RV: right ventricle; RVOT: right ventricular outflow tract; Tri-V: triple-site pacing." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration \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">Ejection fraction, % (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre-implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25±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">Tri-V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30±11 \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">Bi-V with RVOT septal pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28±12 \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">Bi-V with RV apical pacing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28±11 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386578.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Echocardiographic ejection fraction in each pacing configuration." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Bi-V: biventricular pacing; Tri-V: triple-site pacing." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" 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">Tri-V \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">Bi-V \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">p \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">Procedure time, min (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81±34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75±31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Fluoroscopy time, min (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15±11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \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">Radiation dose, μGy/cm2 (mean ± SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61±0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.58±0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1386579.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Procedure and fluoroscopy times and radiation dose in Tri-V pacing vs. conventional Bi-V pacing." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac resynchronization in chronic heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W.T. Abraham" 1 => "W.G. Fisher" 2 => "A.L. Smith" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa013168" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2002" "volumen" => "346" "paginaInicial" => "1845" "paginaFinal" => "1853" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12063368" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical versus echocardiographic parameters to assess response to cardiac resynchronization therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.B. Bleeker" 1 => "J.J. Bax" 2 => "J.W.-H. Fung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2005.08.030" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2006" "volumen" => "97" "paginaInicial" => "260" "paginaFinal" => "263" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16442375" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Implantation feasibility, procedure-related adverse events and lead performance during 1-year follow-up in patients undergoing triple-site cardiac resynchronization therapy: a substudy of TRUST CRT randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Lenarczyk" 1 => "O. Kowalski" 2 => "B. Sredniawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8167.2012.02375.x" "Revista" => array:6 [ "tituloSerie" => "J Cardiovasc Electrophysiol" "fecha" => "2012" "volumen" => "23" "paginaInicial" => "1228" "paginaFinal" => "1236" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22651239" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multipoint left ventricular pacing in a single coronary sinus branch improves mid-term echocardiographic and clinical response to cardiac resynchronization therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Pappone" 1 => "Z. Calović" 2 => "G. Vicedomini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "J Cardiovasc Electrophysiol" "fecha" => "2014" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of triangle ventricular pacing on haemodynamics and dyssynchrony in patients with advanced heart failure: a comparison study with conventional bi-ventricular pacing therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Yoshida" 1 => "Y. Seo" 2 => "H. Yamasaki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehm441" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2007" "volumen" => "28" "paginaInicial" => "2610" "paginaFinal" => "2619" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17947217" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benefits of endocardial and multisite pacing are dependent on the type of left ventricular electric activation pattern and presence of ischemic heart disease: insights from electroanatomic mapping" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.R. Ginks" 1 => "A.K. Shetty" 2 => "P.D. Lambiase" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCEP.111.967505" "Revista" => array:6 [ "tituloSerie" => "Circ Arrhythm Electrophysiol" "fecha" => "2012" "volumen" => "5" "paginaInicial" => "889" "paginaFinal" => "897" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22832673" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The European cardiac resynchronization therapy survey" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Dickstein" 1 => "N. Bogale" 2 => "S. Priori" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehp359" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2009" "volumen" => "30" "paginaInicial" => "2450" "paginaFinal" => "2460" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19723694" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac resynchronization in patients with atrial fibrillation: a meta-analysis of prospective cohort studies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.A. Upadhyay" 1 => "N.K. Choudhry" 2 => "A. Auricchio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2008.06.043" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2008" "volumen" => "52" "paginaInicial" => "1239" "paginaFinal" => "1246" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18926327" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.B. Wilton" 1 => "A.A. Leung" 2 => "W.A. Ghali" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hrthm.2011.02.014" "Revista" => array:6 [ "tituloSerie" => "Heart Rhythm" "fecha" => "2011" "volumen" => "8" "paginaInicial" => "1088" "paginaFinal" => "1094" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21338711" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Brignole" 1 => "G. Botto" 2 => "L. Mont" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehr162" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "2420" "paginaFinal" => "2429" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21606084" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized comparison of triple-site versus dual-site ventricular stimulation in patients with congestive heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Leclercq" 1 => "F. Gadler" 2 => "W. Kranig" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2007.11.074" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2008" "volumen" => "51" "paginaInicial" => "1455" "paginaFinal" => "1462" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18402900" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Triple-site versus standard cardiac resynchronization therapy study (TRUST CRT): clinical rationale, design, and implementation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Lenarczyk" 1 => "O. Kowalski" 2 => "B. Sredniawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8167.2008.01394.x" "Revista" => array:6 [ "tituloSerie" => "J Cardiovasc Electrophysiol" "fecha" => "2009" "volumen" => "20" "paginaInicial" => "658" "paginaFinal" => "662" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19635069" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and procedural characteristics of acute hemodynamic responders undergoing triple-site ventricular pacing for advanced heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H. Yamasaki" 1 => "Y. Seo" 2 => "H. Tada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2011.06.048" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2011" "volumen" => "108" "paginaInicial" => "1297" "paginaFinal" => "1304" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21855835" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pacing the right ventricular outflow tract septum: time to embrace the future" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J. Hillock" 1 => "H.G. Mond" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/europace/eur251" "Revista" => array:6 [ "tituloSerie" => "Europace" "fecha" => "2011" "volumen" => "14" "paginaInicial" => "28" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21846639" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Triple-site biventricular pacing in patients undergoing cardiac resynchronization therapy: a feasibility study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Lenarczyk" 1 => "O. Kowalski" 2 => "T. 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Hillock" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8159.2006.00499.x" "Revista" => array:6 [ "tituloSerie" => "Pacing Clin Electrophysiol" "fecha" => "2006" "volumen" => "29" "paginaInicial" => "1063" "paginaFinal" => "1068" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17038137" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous arterial pressure waveform-based cardiac output using the FloTrac/Vigileo: a review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Mayer" 1 => "J. Boldt" 2 => "R. Poland" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2009.03.003" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2009" "volumen" => "23" "paginaInicial" => "401" "paginaFinal" => "406" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19464625" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antiarrhythmic effect of cardiac resynchronization therapy with triple-site biventricular stimulation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Ogano" 1 => "Y. Iwasaki" 2 => "J. Tanabe" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/europace/eut134" "Revista" => array:6 [ "tituloSerie" => "Europace" "fecha" => "2013" "volumen" => "15" "paginaInicial" => "1491" "paginaFinal" => "1498" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23696627" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety, feasibility, and outcome results of cardiac resynchronization with triple-site ventricular stimulation compared to conventional cardiac resynchronization" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "F. Anselme" 1 => "P. Bordachar" 2 => "J.L. Pasquié" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Heart Rhythm" "fecha" => "2015" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A randomized double-blind crossover trial of triventricular versus biventricular pacing in heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D.P.S. Rogers" 1 => "P.D. 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Available from: <a href="https://clinicaltrials.gov/ct2/show/NCT02350842">https://clinicaltrials.gov/ct2/show/NCT02350842</a> [accessed 25.04.15]." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003500000006/v2_201704050129/S2174204916300666/v2_201704050129/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003500000006/v2_201704050129/S2174204916300666/v2_201704050129/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916300666?idApp=UINPBA00004E"]

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Original Article

Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation – Acute phase results from a prospective observational study

Pacing triple-site para ressincronização cardíaca na fibrilhação auricular permanente – resultados da fase aguda de um estudo prospetivo observacional

Pedro Marques

Corresponding author

pedroncmarques@gmail.com

Corresponding author.

, Miguel Nobre Menezes, Gustavo Lima da Silva, Ana Bernardes, Andreia Magalhães, Nuno Cortez-Dias, Luís Carpinteiro, João de Sousa, Fausto J. Pinto

Cardiology Department, University Hospital Santa Maria, Centro Hospitalar de Lisboa Norte, CCUL, University of Lisbon, Portugal

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    "titulo" => "Triple-site pacing for cardiac resynchronization in permanent atrial fibrillation &#8211; Acute phase results from a prospective observational study"
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        "titulo" => "<span class="elsevierStyleItalic">Pacing triple-site</span> para ressincroniza&#231;&#227;o card&#237;aca na fibrilha&#231;&#227;o auricular permanente &#8211; resultados da fase aguda de um estudo prospetivo observacional"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Differences in cardiac output between Tri-V and Bi-V pacing &#40;A&#41;&#44; between Bi-V pacing and RVOT septal pacing&#44; and between RVOT septal pacing and RV apical pacing &#40;B&#41;&#46; Bi-V&#58; biventricular pacing&#59; LV&#58; left ventricular&#59; RV&#58; right ventricular&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0060" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy &#40;CRT&#41; is an established therapy for patients with drug-refractory heart failure and electrical evidence of dyssynchrony&#46; Several large clinical trials have demonstrated that biventricular &#40;Bi-V&#41; pacing significantly reduces all-cause mortality and heart failure-related hospitalizations and symptoms&#44; and improves quality of life&#44; exercise tolerance and left ventricular &#40;LV&#41; systolic performance&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; even when appropriately selected&#44; 20-30&#37; of patients do not respond to CRT&#46; This may be due to incomplete resynchronization&#44; as intraventricular and interventricular dyssynchrony can persist in 25-30&#37; of patients despite CRT&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> For such non-responders&#44; multi-site and multi-point pacing are emerging as new methods of CRT&#46; The few previously published studies regarding these novel pacing modalities have shown improved LV hemodynamics and synchrony&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> However&#44; doubts remain concerning their indications and short-term and long-term efficacy and safety&#44; and thus the optimal method of resynchronization remains unknown&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the subgroup of patients with atrial fibrillation &#40;AF&#41;&#44; no fewer than 23&#37; of all those with implanted CRT devices&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> studies are still scarce&#44; and these patients are particularly challenging&#46; However&#44; currently available evidence suggests CRT may be of benefit&#46; A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> of prospective cohort studies comparing response to CRT in patients with sinus rhythm vs&#46; AF showed not only that CRT was beneficial in both groups&#44; but also that the AF group performed better in terms of reverse remodeling &#40;assessed as improvement in ejection fraction &#91;EF&#93;&#41;&#44; albeit with worse functional outcomes&#46; Because achieving high levels of pacing is harder in patients with AF&#44; there is evidence that atrioventricular &#40;AV&#41; junction ablation may further enhance CRT response and improve not only remodeling response but also functional outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Interestingly&#44; there is evidence that even AF patients without severely depressed EF&#44; prolonged QRS or severe heart failure &#40;i&#46;e&#46; in New York Heart Association &#91;NYHA&#93; class &#8804;II&#41; may benefit from CRT&#46; A randomized trial<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> assessing patients who underwent AV junction ablation due to severely symptomatic permanent AF showed that CRT was more beneficial than conventional right ventricular &#40;RV&#41; apical pacing both in patients who met the current recommendations for CRT implantation regarding EF&#44; QRS duration and functional class and in those who did not&#46; Finally&#44; only one trial of multi-site pacing has been undertaken in the subgroup of AF patients&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with good results&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Thus&#44; to date&#44; the optimal method of cardiac resynchronization remains to be established&#44; especially in patients with AF&#46; We are currently undertaking an observational prospective trial to assess this issue&#46; In this paper we present our results from the acute post-implantation phase&#44; with particular focus on hemodynamic performance&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In this study cardiac resynchronization with multi-site pacing was achieved by means of two right ventricular &#40;RV&#41; leads&#46; Most studies on multi-site pacing used two LV leads and one RV lead&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12-14</span></a> Only two trials using two RV leads have been published thus far&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;13</span></a> Given that the former approach has shown to have greater procedure duration&#44; radiation exposure and LV pacing threshold<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15</span></a> and that multi-site pacing using two RV leads has never been assessed in patients with AF&#44; we chose to use the latter approach&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Since the benefit of right ventricular outflow tract &#40;RVOT&#41; septal pacing is still regarded as controversial&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> we also assessed the performance of RVOT septal pacing vs&#46; RV apical pacing as a secondary objective&#44; in order to shed further light on this question&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objective</span><p id="par0085" class="elsevierStylePara elsevierViewall">The primary aim of this study was to assess the effects of triple-site ventricular &#40;Tri-V&#41; pacing vs&#46; Bi-V pacing on hemodynamic performance and QRS duration&#46; The secondary aim was to assess the effects of RVOT septal pacing vs&#46; RV apical pacing on hemodynamic performance and QRS duration&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patient selection</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients meeting all the following criteria were included&#58; &#40;1&#41; permanent AF&#59; &#40;2&#41; EF &#60;40&#37;&#59; &#40;3&#41; heart failure NYHA &#8805;II despite appropriate medical treatment and baseline QRS &#62;120 ms or need for anti-bradycardia pacing with an anticipated percentage of ventricular pacing &#62;40&#37;&#59; &#40;4&#41; cognitive capacity to understand the study and hence give informed consent&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Implantation and connection method</span><p id="par0095" class="elsevierStylePara elsevierViewall">When a CRT defibrillator device was implanted&#44; the defibrillator lead was positioned in the RV apex&#44; and for CRT pacemaker implantation&#44; one conventional RV lead was implanted in the RV apex&#46; In both cases&#44; a second RV lead was implanted in the RVOT septal wall meeting fluoroscopic criteria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> combined with electrocardiographic &#40;ECG&#41; criteria for correct placement&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> ensuring avoidance of the RVOT anterior or free wall&#46; Finally&#44; a coronary sinus lead for LV pacing was implanted as usual for CRT pacing &#40;i&#46;e&#46; in a posterolateral mid-basal position&#41;&#46; The RV apical lead was connected to the RV channel&#46; If the LV lead was bipolar&#44; with a pacing threshold below 2&#46;5 V and no diaphragmatic stimulation&#44; the LV lead was connected to the atrial channel and the RVOT lead connected to the LV channel&#46; If the LV lead was quadripolar&#44; if the pacing threshold was over 2&#46;5 V&#44; if specific LV vector programming was necessary&#44; or if there was any type of diaphragmatic stimulation&#44; then the LV lead was connected to the LV channel and the RVOT lead was connected to the atrial channel on the generator&#46; Any device and lead brand could be used&#46; Programming was set to DDDR with the lowest possible AV interval &#40;25-40 ms depending on device brand&#41; and a VV interval of 0 ms&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Hemodynamic assessment</span><p id="par0100" class="elsevierStylePara elsevierViewall">Up to one month after implantation&#44; all patients underwent minimally invasive hemodynamic assessment with placement of a radial arterial line using the FloTrac III&#8482; Vigileo&#8482; monitoring system &#40;Edwards Lifesciences&#44; Irvine&#44; CA&#44; USA&#41;&#44; which calculates cardiac output based on the arterial pressure waveform&#46; This system is widely used in peri- and intraoperative settings as well as in intensive care units&#44; and is useful in detecting sudden changes in cardiac output and volume status provided the cardiac rhythm is regular&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Cardiac output and systolic volume were assessed at 70 beats per minute in the following configurations&#58; RV apical&#44; RV RVOT&#44; LV&#44; Bi-V pacing using the RV apical &#40;RVA&#41; and LV leads &#40;Bi-V RVA-LV&#41;&#44; Bi-V pacing using the RVOT and LV leads &#40;Bi-V RVOT-LV&#41;&#44; and Tri-V&#46; The assessment was performed under &#8805;99&#37; pacing&#46; In order to achieve these levels&#44; AV node suppression was achieved previously by means of pharmacotherapy or by AV node ablation in drug-refractory cases&#46; Each configuration was assessed for 15 min to achieve stable measurements&#46; During transitions&#44; to avoid a potential carry-over effect&#44; the first 5 min of measurements were disregarded&#44; and only measurements from the following 15 min were considered&#46; The operator performing the hemodynamic assessment was blinded to the pacing mode used&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Electrocardiographic assessment</span><p id="par0110" class="elsevierStylePara elsevierViewall">Simultaneously with the hemodynamic assessment&#44; all patients underwent standard 12-lead ECG assessment in each of the following configurations&#58; RV apical&#44; RV RVOT&#44; LV&#44; Bi-V RVA-LV&#44; Bi-V RVOT-LV and Tri-V&#46; QRS duration was measured in each of these configurations by two blinded operators&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Echocardiographic assessment</span><p id="par0115" class="elsevierStylePara elsevierViewall">The echocardiographic study was performed with a Vivid 7 device &#40;General Electric<span class="elsevierStyleSup">&#174;</span>&#41; in each of the following configurations&#58; Tri-V&#44; Bi-V RVA-LV and Bi-V RVOT-LV&#46; The study was undertaken simultaneously with the hemodynamic assessment&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">EF was estimated by the Simpson biplane method determined from the cine loops acquired in two-dimensional mode&#44; end-diastolic and late systolic volumes being measured in three consecutive cardiac cycles&#46; Post-processing analysis was performed by two operators using EchoPAC<span class="elsevierStyleSup">&#169;</span> software &#40;General Electric&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical analysis</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mean cardiac output&#44; QRS and EF were calculated in each group&#46; Differences were assessed by a paired samples t test&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In order to assess differences in procedure duration&#44; fluoroscopy duration and radiation dosage&#44; the additional amounts of these parameters required for implantation of the second RV lead were quantified&#44; and the differences between Bi-V and Tri-V were assessed by the t test&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical considerations</span><p id="par0135" class="elsevierStylePara elsevierViewall">This paper conforms with the Helsinki Declaration on the Ethical Principles for Medical Research Involving Human Subjects and was approved by our local ethics committee&#46; Written informed consent was obtained from all patients&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Population</span><p id="par0140" class="elsevierStylePara elsevierViewall">A total of 40 patients were included&#46; Baseline pre-implantation characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Most patients were severely symptomatic&#44; with markedly depressed EF and a significantly prolonged QRS&#46; AV node ablation was necessary in six patients prior to hemodynamic assessment&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Hemodynamic results</span><p id="par0145" class="elsevierStylePara elsevierViewall">The hemodynamic results are depicted in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Figures 1A and B</a>&#46; Cardiac output was significantly higher during Tri-V compared to Bi-V pacing&#46; There was no statistically significant difference between the two Bi-V pacing configurations&#44; nor between Bi-V pacing and RVOT septal pacing&#46; The latter produced a significantly higher cardiac output than RV apical pacing&#46; These differences remain across ischemic and non-ischemic cardiomyopathy groups&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Electrocardiographic results</span><p id="par0150" class="elsevierStylePara elsevierViewall">Mean QRS duration in each pacing configuration is depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Figures 2A&#44; B and C</a>&#46; Tri-V pacing produced a significantly shorter QRS than pre-implantation QRS and both Bi-V pacing configurations&#46; Bi-V pacing also significantly shortened QRS duration compared with pre-implantation QRS&#46; There was no statistically significant difference between the two Bi-V pacing configurations&#46; RVOT septal pacing produced a significantly shorter QRS than pre-implantation QRS and RV apical pacing QRS&#44; but a significantly longer QRS than Bi-V pacing&#46; These differences remain across ischemic and non-ischemic cardiomyopathy groups&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Echocardiographic results</span><p id="par0155" class="elsevierStylePara elsevierViewall">EF results are depicted in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Figures 3A and B</a>&#46; All modes of CRT produced a statistically significant improvement in EF&#46; Tri-V produced the greatest improvement&#44; with a significant difference compared to Bi-V&#46; These differences remain across ischemic and non-ischemic cardiomyopathy groups&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Mean fluoroscopy and procedure time</span><p id="par0160" class="elsevierStylePara elsevierViewall">Although implantation of the Tri-V system resulted in longer procedure and fluoroscopy times&#44; the difference was not significant compared to conventional Bi-V implantation &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">In this study&#44; Tri-V pacing produced a superior hemodynamic performance compared to conventional Bi-V pacing&#44; as demonstrated by increased cardiac output and EF&#46; This is likely an immediate consequence of improved resynchronization&#44; given that QRS duration was significantly shorter in Tri-V pacing vs&#46; conventional Bi-V pacing&#44; and that this was an acute phase study&#44; in which reverse remodeling could not yet have occurred&#46; The reduction in QRS duration obtained by Tri-V pacing is especially remarkable&#44; QRS having been shortened almost to normal length&#46; Our fluoroscopy and procedure times were scarcely prolonged by this technique&#44; and as such were not a significant limitation&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">There have been few studies on multi-site pacing&#44; and the methodology has been very heterogeneous regarding not only pacing and implant techniques&#44; but also the method used for assessing hemodynamic response&#46; Most used two LV leads and one RV lead&#46; In one non-randomized trial one of the LV leads was connected to the atrial channel &#40;all patients had permanent AF&#41;&#44; and the other two leads were connected as usual&#46; Triple-site pacing yielded higher EF and reduced end-systolic volume&#44; without clinical improvement&#44; at three months&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Of course&#44; by connecting an LV lead to an atrial channel&#44; the use of vectors is limited&#46; Two other randomized trials used a similar approach but connected both LV leads with a Y-connector&#46; They demonstrated an additional clinical benefit&#44; but greater procedure length&#44; radiation exposure and LV pacing threshold&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15</span></a> Regarding safety&#44; none of these trials have shown significant differences between Tri-V or Bi-V pacing&#44; and Ogano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> recently demonstrated that dual LV pacing might even have a protective effect against ventricular arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Only three trials using two RV leads and one LV lead alone have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;13&#44;19</span></a> However&#44; in two of these&#44; the connection technique was different&#44; as both RV leads were connected to the atrial channel by means of a Y-connector&#46; Systolic function was assessed invasively by determining peak LV dP&#47;dt &#40;using a micromanometer-tipped pigtail angiographic catheter&#41; and also cardiac output with a Swan-Ganz catheter&#46; Dyssynchrony was assessed with tissue Doppler echocardiographic imaging&#46; QRS duration was also assessed in each pacing configuration&#46; Triple-site pacing was superior regarding all four parameters compared to conventional BiV pacing&#46; There were also no safety issues regarding this method&#46; Finally&#44; one trial used both types of triple-site pacing &#40;i&#46;e&#46; one group received two RV leads&#44; and another two LV leads&#41;&#44; with better clinical and hemodynamic results in triple-site pacing compared to conventional Bi-V pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> A very recent randomized trial compared Tri-V pacing with conventional Bi-V pacing in terms of clinical and echocardiographic data at 12-month follow-up&#46; There were no differences in adverse events or clinical benefit&#44; however Tri-V did produce higher EF at 12 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;13&#44;19</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Despite the heterogeneity of the studies&#44; and the unique methodology of our study&#44; all of these trials using triple-site pacing have demonstrated superior hemodynamic performance and increased resynchronization compared to conventional Bi-V pacing&#46; The benefit was also present in AF patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Thus&#44; our results are consistent with previous studies&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">It is worth noting that no previous trial has ever assessed the use of triple-site pacing with two RV leads in patients with permanent AF&#46; Given that these patients represent an understudied and particularly challenging group&#44; our study adds pioneering scientific data on this modality of cardiac resynchronization therapy in this subgroup&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding the results of single-site pacing&#44; our study produced interesting results&#46; RVOT septal pacing was clearly superior to RV apical pacing&#44; with improved cardiac output and much shorter QRS duration&#46; RVOT septal pacing alone even decreased baseline QRS length in our patients&#46; Studies comparing these two pacing modalities have produced conflicting results&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> However&#44; the discrepancies are largely due to the significant heterogeneity in lead placement technique&#58; few studies have been careful enough to ensure proper lead placement in both the RVOT and the septal wall&#46; This was a critical concern in our study&#46; Several trials in which the RV lead was placed under careful fluoroscopic and&#47;or electrocardiographic guidance yielded superior results for RVOT septal pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Our study adds further weight to this evidence&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Finally&#44; the absence of a statistical difference between cardiac output with Bi-V pacing and RVOT septal pacing was an unexpected finding&#44; especially considering that the QRS was significantly shorter with Bi-V pacing&#46; The clinical significance of this finding is unclear&#44; given that we were not comparing the clinical performance of these two pacing modalities&#46; Studies comparing single-site RV pacing vs&#46; Bi-V pacing used echocardiographic and clinical endpoints obtained some time after implantation&#44; and not immediate hemodynamic data&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition&#44; the majority of these studies compare RV apical pacing rather than RVOT septal pacing&#46; Thus&#44; no study can be directly compared to ours&#44; and while most studies favor Bi-V pacing&#44; the above-mentioned limitations regarding RV pacing site may be of greater importance than previously thought&#46; Therefore&#44; whatever the interpretation of our particular results&#44; they highlight the importance and potential of RVOT septal pacing&#46; Indeed&#44; in patients in whom the CRT indication is based on need for pacing rather than primarily on heart failure&#44; could RVOT septal pacing be a sustainable alternative to Bi-V pacing&#63; Our trial was neither designed nor statistically powered to answer such a question&#44; but adds further evidence to the issue&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Limitations</span><p id="par0200" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; Use of the FloTrac III&#8482; Vigileo&#8482; monitoring system is time-consuming and while it has been well validated in a variety of clinical scenarios&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> this is the first time that it has been tested in this setting&#46; Also&#44; ischemic cardiomyopathy was found in only 25&#37; of all patients&#46; Despite the fact that statistical results were similar across this subgroup of patients&#44; the absolute number of patients is small&#44; and as such this heterogeneity may have influenced our results&#46; Finally&#44; although the echocardiographic results were statistically significant&#44; the resulting differences are small and within the inter- and intraobserver variability of the technique&#46; Thus&#44; these particular results should be interpreted with caution&#46; The observed differences in cardiac output were also small&#44; and therefore we cannot yet be absolutely sure of their clinical significance&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Future directions</span><p id="par0205" class="elsevierStylePara elsevierViewall">The fact that multiple techniques&#44; including ours&#44; yielded benefit suggests that multi-site pacing should be further developed&#46; The optimal method&#44; whether with two RV leads&#44; two LV leads&#44; a single lead with multi-point pacing capabilities or a combination of these remains to be determined&#46; We believe that if three ventricular leads are to be used&#44; two RV leads are much faster and probably more stable&#46; The development of CRT generators designed specifically for multi-site pacing may also be important&#46; So far only one manufacturer has produced such a device&#44; which will be tested in non-responders in a randomized trial&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> It is worth pointing out&#44; however&#44; that in our population we deliberately did not select a subset of non-responders&#44; and still achieved superior results with this new pacing modality&#46; This raises the possibility of organizing a large trial of multi-site pacing as a first-line treatment in candidates for cardiac resynchronization therapy&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusion</span><p id="par0210" class="elsevierStylePara elsevierViewall">Triple-site pacing produced a superior hemodynamic performance with shorter QRS duration&#44; which is likely the consequence of improved resynchronization&#46; RVOT septal pacing was clearly superior to RV apical pacing&#44; with shorter QRS and greater cardiac output&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Ethical disclosures</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Protection of human and animal subjects</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">No specific funding grants were used regarding this study&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Introdu&#231;&#227;o e objetivo"
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          "titulo" => "Introduction"
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              "titulo" => "Patient selection"
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              "titulo" => "Implantation and connection method"
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              "titulo" => "Hemodynamic assessment"
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              "titulo" => "Electrocardiographic assessment"
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              "titulo" => "Electrocardiographic results"
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              "identificador" => "sec0075"
              "titulo" => "Echocardiographic results"
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              "identificador" => "sec0080"
              "titulo" => "Mean fluoroscopy and procedure time"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-10-28"
    "fechaAceptado" => "2015-12-20"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec821201"
          "palabras" => array:8 [
            0 => "Cardiac resynchronization therapy"
            1 => "Multi-site pacing"
            2 => "Triple-site pacing"
            3 => "Heart failure"
            4 => "Atrial fibrillation"
            5 => "Cardiac output"
            6 => "QRS duration"
            7 => "Ejection fraction"
          ]
        ]
      ]
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          "palabras" => array:8 [
            0 => "Terap&#234;utica de ressincroniza&#231;&#227;o card&#237;aca"
            1 => "<span class="elsevierStyleItalic">Pacing multi-site</span>"
            2 => "<span class="elsevierStyleItalic">Pacing triple-site</span>"
            3 => "Insufici&#234;ncia card&#237;aca"
            4 => "Fibrilha&#231;&#227;o auricular"
            5 => "D&#233;bito cardiaco"
            6 => "Dura&#231;&#227;o QRS"
            7 => "Fra&#231;&#227;o de eje&#231;&#227;o"
          ]
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    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multi-site pacing is emerging as a new method for improving response to cardiac resynchronization therapy &#40;CRT&#41;&#44; but has been little studied&#44; especially in patients with atrial fibrillation&#46; We aimed to assess the effects of triple-site &#40;Tri-V&#41; vs&#46; biventricular &#40;Bi-V&#41; pacing on hemodynamics and QRS duration&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a prospective observational study of patients with permanent atrial fibrillation and ejection fraction &#60;40&#37; undergoing CRT implantation &#40;n&#61;40&#41;&#46; One right ventricular &#40;RV&#41; lead was implanted in the apex and another in the right ventricular outflow tract &#40;RVOT&#41; septal wall&#46; A left ventricular &#40;LV&#41; lead was implanted in a conventional venous epicardial position&#46; Cardiac output &#40;using the FloTrac&#8482; Vigileo&#8482; system&#41;&#44; mean QRS and ejection fraction were calculated&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mean cardiac output was 4&#46;81&#177;0&#46;97 l&#47;min with Tri-V&#44; 4&#46;68&#177;0&#46;94 l&#47;min with RVOT septal and LV pacing&#44; and 4&#46;68&#177;0&#46;94 l&#47;min with RV apical and LV pacing &#40;p&#60;0&#46;001 for Tri-V vs&#46; both BiV&#41;&#46; Mean pre-implantation QRS was 170&#177;25 ms&#44; 123&#177;18 ms with Tri-V&#44; 141&#177;25 ms with RVOT septal pacing and LV pacing and 145&#177;19 with RV apical and LV pacing &#40;p&#60;0&#46;001 for Tri-V vs&#46; both BiV and pre-implantation&#41;&#46; Mean ejection fraction was significantly higher with Tri-V &#40;30&#177;11&#37;&#41; vs&#46; Bi-V pacing &#40;28&#177;12&#37; with RVOT septal and LV pacing and 28&#177;11 with RV apical and LV pacing&#41; and pre-implantation &#40;25&#177;8&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Tri-V pacing produced higher cardiac output and shorter QRS duration than Bi-V pacing&#46; This may have a significant impact on the future of CRT&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Aim"
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            "titulo" => "Methods"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">pacing multi-site</span> est&#225; a emergir como um novo m&#233;todo de ressincroniza&#231;&#227;o card&#237;aca&#46; Todavia&#44; foi pouco estudado&#44; sobretudo em fibrilha&#231;&#227;o auricular&#46; Este estudo visa aferir o efeito hemodin&#226;mico e na dura&#231;&#227;o do QRS de <span class="elsevierStyleItalic">pacing</span> Tri-V <span class="elsevierStyleItalic">versus</span> Bi-V&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo observacional de doentes com fibrilha&#231;&#227;o auricular permanente e fra&#231;&#227;o de eje&#231;&#227;o &#60; 40&#37; submetidos a implanta&#231;&#227;o de CRT &#40;n&#61;40&#41;&#46; Implantou-se um eletrocateter direito no &#225;pex&#44; outro na parede septal do trato de sa&#237;da direito e outro em posi&#231;&#227;o venosa epic&#225;rdica esquerda convencional&#46; Calcularam-se o d&#233;bito card&#237;aco &#40;usando o sistema Vigileo Flotrac<span class="elsevierStyleSup">&#174;</span>&#41;&#44; o QRS m&#233;dio e a fra&#231;&#227;o de eje&#231;&#227;o&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O d&#233;bito card&#237;aco m&#233;dio foi 4&#44;81 &#177; 0&#44;97 L&#47;min em Tri-V&#44; 4&#44;68 &#177; 0&#44;94 L&#47;min com <span class="elsevierStyleItalic">pacing</span> septal e esquerdo e 4&#44;68 &#177; 0&#44;94 L&#47;min com <span class="elsevierStyleItalic">pacing</span> apical e esquerdo &#40;p &#60; 0&#44;001 para Tri-V <span class="elsevierStyleItalic">versus</span> ambos BiV&#41;&#46; O QRS pr&#233;-implanta&#231;&#227;o m&#233;dio foi 170 &#177; 25 ms&#44; 123 &#177; 18 ms em Tri-V&#44; 141 &#177; 25 ms em <span class="elsevierStyleItalic">pacing</span> septal e esquerdo e145 &#177; 19 em <span class="elsevierStyleItalic">pacing</span> apical e esquerdo &#40;p &#60; 0&#44;001 para Tri-V <span class="elsevierStyleItalic">versus</span> ambos BiV e pr&#233;-implanta&#231;&#227;o&#41;&#46; A fra&#231;&#227;o de eje&#231;&#227;o m&#233;dia foi estatisticamente superior em Tri-V &#40;30 &#177; 11&#37;&#41; <span class="elsevierStyleItalic">versus</span> Bi-V &#40;28 &#177; 12&#37; em <span class="elsevierStyleItalic">pacing</span> septal e esquerdo e 28 &#177; 11em <span class="elsevierStyleItalic">pacing</span> apical e esquerdo&#41;&#44; e <span class="elsevierStyleItalic">versus</span> pr&#233;-implanta&#231;&#227;o &#40;25 &#177; 8&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">pacing</span> em Tri-V produziu um d&#233;bito card&#237;aco superior e QRS mais estreito do que em Bi-V&#46; Estes resultados poder&#227;o modificar o futuro da terap&#234;utica de ressincroniza&#231;&#227;o&#46;</p></span>"
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      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>"
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          0 => array:1 [
            "definicion" => array:11 [
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                "termino" => "AF"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial fibrillation</p>"
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              1 => array:2 [
                "termino" => "AV"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">atrioventricular</p>"
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                "termino" => "Bi-V"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">biventricular pacing</p>"
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              3 => array:2 [
                "termino" => "CRT"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">cardiac resynchronization therapy</p>"
              ]
              4 => array:2 [
                "termino" => "ECG"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">electrocardiographic</p>"
              ]
              5 => array:2 [
                "termino" => "EF"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">ejection fraction</p>"
              ]
              6 => array:2 [
                "termino" => "LV"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">left ventricular</p>"
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              7 => array:2 [
                "termino" => "NYHA"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">New York Heart Association</p>"
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                "termino" => "RV"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">right ventricular</p>"
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                "termino" => "RVOT"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">right ventricular outflow tract</p>"
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              10 => array:2 [
                "termino" => "Tri-V"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">triple-site ventricular pacing</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Differences in cardiac output between Tri-V and Bi-V pacing &#40;A&#41;&#44; between Bi-V pacing and RVOT septal pacing&#44; and between RVOT septal pacing and RV apical pacing &#40;B&#41;&#46; Bi-V&#58; biventricular pacing&#59; LV&#58; left ventricular&#59; RV&#58; right ventricular&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Differences in mean QRS between pre-implantation and pacing &#40;A&#41;&#44; between Tri-V and Bi-V pacing &#40;B&#41;&#44; between Bi-V and RVOT septal pacing&#44; and between the latter and RV apical pacing &#40;C&#41;&#46; Bi-V&#58; biventricular pacing&#59; LV&#58; left ventricular&#59; RV&#58; right ventricular&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differences in mean ejection fraction between pre-implantation and cardiac resynchronization therapy &#40;A&#41; and between Tri-V and Bi-V pacing &#40;B&#41;&#46; Bi-V&#58; biventricular pacing&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ACE&#58; angiotensin-converting enzyme&#59; CRT-D&#58; cardiac resynchronization therapy defibrillator&#59; CRT-P&#58; cardiac resynchronization therapy pacemaker&#59; EF&#58; ejection fraction&#59; NYHA&#58; New York Heart Association&#59; SD&#58; standard deviation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&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">Age&#44; years &#40;mean &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#177;11&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">Male&#44; n &#40;&#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">37 &#40;97&#46;5&#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">Ischemic cardiomyopathy&#44; n &#40;&#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">10 &#40;25&#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">NYHA I&#44; n &#40;&#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">3 &#40;7&#46;5&#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">NYHA II&#44; n &#40;&#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">14 &#40;34&#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">NYHA III&#44; n &#40;&#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">24 &#40;58&#46;5&#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">NYHA IV&#44; n &#40;&#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&#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">ACE inhibitor&#44; n &#40;&#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">34 &#40;85&#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">Aldosterone receptor blocker&#44; n &#40;&#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">3 &#40;7&#46;5&#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">Mineralocorticoid receptor antagonist&#44; n &#40;&#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">23 &#40;57&#46;5&#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">Beta-blocker&#44; n &#40;&#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">34 &#40;85&#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">Diuretic&#44; n &#40;&#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">36 &#40;90&#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">Digoxin&#44; n &#40;&#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">11 &#40;27&#46;5&#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">Amiodarone&#44; n &#40;&#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">7 &#40;17&#46;5&#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">Antithrombotics&#44; n &#40;&#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">6 &#40;15&#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">Vitamin K antagonist&#44; n &#40;&#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">24 &#40;60&#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">New oral anticoagulant&#44; n &#40;&#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">11 &#40;27&#46;5&#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">Pre-implantation QRS&#44; ms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">170&#177;25&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">Pre-implantation EF&#44; &#37; &#40;mean &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#177;6&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">CRT-D&#44; n &#40;&#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">26 &#40;65&#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">CRT-P&#44; n &#40;&#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">14 &#40;35&#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">AV node ablation&#44; n &#40;&#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">6 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient population details&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at2"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Bi-V&#58; biventricular pacing&#59; LV&#58; left ventricular&#59; RV&#58; right ventricular&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration&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">Cardiac output&#44; l&#47;min &#40;mean &#177; SD&#41;&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">Tri-V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;81&#177;0&#46;97&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">Bi-V with RVOT septal pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;68&#177;0&#46;94&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">Bi-V with RV apical pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;66&#177;0&#46;91&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">RVOT septal pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;56&#177;0&#46;93&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">RV apical pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;44&#177;0&#46;84&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">LV pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;47&#177;0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cardiac output in different pacing configurations&#46;</p>"
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      5 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at3"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Bi-V&#58; biventricular pacing&#59; LV&#58; left ventricular&#59; RV&#58; right ventricular&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean QRS&#44; ms &#40;mean &#177; SD&#41;&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">Tri-V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">123&#177;18&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">Bi-V with RVOT septal pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">141&#177;25&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">Bi-V with RV apical pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">145&#177;19&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">RVOT septal pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">158&#177;20&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">RV apical pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">187&#177;18&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">LV pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&#177;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">QRS duration in each pacing configuration&#46;</p>"
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      ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Bi-V&#58; biventricular pacing&#59; RV&#58; right ventricle&#59; RVOT&#58; right ventricular outflow tract&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pacing configuration&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">Ejection fraction&#44; &#37; &#40;mean &#177; SD&#41;&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">Pre-implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#177;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">Tri-V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#177;11&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">Bi-V with RVOT septal pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#177;12&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">Bi-V with RV apical pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic ejection fraction in each pacing configuration&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Bi-V&#58; biventricular pacing&#59; Tri-V&#58; triple-site pacing&#46;</p>"
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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" 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">Tri-V&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">Bi-V&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">p&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">Procedure time&#44; min &#40;mean &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&#177;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&#177;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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">Fluoroscopy time&#44; min &#40;mean &#177; SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&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">Radiation dose&#44; &#956;Gy&#47;cm<span class="elsevierStyleSup">2</span> &#40;mean &#177; SD&#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&#46;61&#177;0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;58&#177;0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Procedure and fluoroscopy times and radiation dose in Tri-V pacing vs&#46; conventional Bi-V pacing&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:22 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac resynchronization in chronic heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "W&#46;T&#46; Abraham"
                            1 => "W&#46;G&#46; Fisher"
                            2 => "A&#46;L&#46; Smith"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa013168"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2002"
                        "volumen" => "346"
                        "paginaInicial" => "1845"
                        "paginaFinal" => "1853"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12063368"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical versus echocardiographic parameters to assess response to cardiac resynchronization therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46;B&#46; Bleeker"
                            1 => "J&#46;J&#46; Bax"
                            2 => "J&#46;W&#46;-H&#46; Fung"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2005.08.030"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2006"
                        "volumen" => "97"
                        "paginaInicial" => "260"
                        "paginaFinal" => "263"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16442375"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Implantation feasibility&#44; procedure-related adverse events and lead performance during 1-year follow-up in patients undergoing triple-site cardiac resynchronization therapy&#58; a substudy of TRUST CRT randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Lenarczyk"
                            1 => "O&#46; Kowalski"
                            2 => "B&#46; Sredniawa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1540-8167.2012.02375.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cardiovasc Electrophysiol"
                        "fecha" => "2012"
                        "volumen" => "23"
                        "paginaInicial" => "1228"
                        "paginaFinal" => "1236"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22651239"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multipoint left ventricular pacing in a single coronary sinus branch improves mid-term echocardiographic and clinical response to cardiac resynchronization therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46; Pappone"
                            1 => "Z&#46; Calovi&#263;"
                            2 => "G&#46; Vicedomini"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "J Cardiovasc Electrophysiol"
                        "fecha" => "2014"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of triangle ventricular pacing on haemodynamics and dyssynchrony in patients with advanced heart failure&#58; a comparison study with conventional bi-ventricular pacing therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "K&#46; Yoshida"
                            1 => "Y&#46; Seo"
                            2 => "H&#46; Yamasaki"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehm441"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2007"
                        "volumen" => "28"
                        "paginaInicial" => "2610"
                        "paginaFinal" => "2619"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17947217"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Benefits of endocardial and multisite pacing are dependent on the type of left ventricular electric activation pattern and presence of ischemic heart disease&#58; insights from electroanatomic mapping"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;R&#46; Ginks"
                            1 => "A&#46;K&#46; Shetty"
                            2 => "P&#46;D&#46; Lambiase"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCEP.111.967505"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circ Arrhythm Electrophysiol"
                        "fecha" => "2012"
                        "volumen" => "5"
                        "paginaInicial" => "889"
                        "paginaFinal" => "897"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22832673"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The European cardiac resynchronization therapy survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "K&#46; Dickstein"
                            1 => "N&#46; Bogale"
                            2 => "S&#46; Priori"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehp359"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2009"
                        "volumen" => "30"
                        "paginaInicial" => "2450"
                        "paginaFinal" => "2460"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19723694"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac resynchronization in patients with atrial fibrillation&#58; a meta-analysis of prospective cohort studies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "G&#46;A&#46; Upadhyay"
                            1 => "N&#46;K&#46; Choudhry"
                            2 => "A&#46; Auricchio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2008.06.043"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2008"
                        "volumen" => "52"
                        "paginaInicial" => "1239"
                        "paginaFinal" => "1246"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18926327"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes of cardiac resynchronization therapy in patients with versus those without atrial fibrillation&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46;B&#46; Wilton"
                            1 => "A&#46;A&#46; Leung"
                            2 => "W&#46;A&#46; Ghali"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.hrthm.2011.02.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart Rhythm"
                        "fecha" => "2011"
                        "volumen" => "8"
                        "paginaInicial" => "1088"
                        "paginaFinal" => "1094"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21338711"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46; Brignole"
                            1 => "G&#46; Botto"
                            2 => "L&#46; Mont"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehr162"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2011"
                        "volumen" => "32"
                        "paginaInicial" => "2420"
                        "paginaFinal" => "2429"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21606084"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A randomized comparison of triple-site versus dual-site ventricular stimulation in patients with congestive heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46; Leclercq"
                            1 => "F&#46; Gadler"
                            2 => "W&#46; Kranig"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2007.11.074"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2008"
                        "volumen" => "51"
                        "paginaInicial" => "1455"
                        "paginaFinal" => "1462"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18402900"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Triple-site versus standard cardiac resynchronization therapy study &#40;TRUST CRT&#41;&#58; clinical rationale&#44; design&#44; and implementation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Lenarczyk"
                            1 => "O&#46; Kowalski"
                            2 => "B&#46; Sredniawa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1540-8167.2008.01394.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cardiovasc Electrophysiol"
                        "fecha" => "2009"
                        "volumen" => "20"
                        "paginaInicial" => "658"
                        "paginaFinal" => "662"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19635069"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and procedural characteristics of acute hemodynamic responders undergoing triple-site ventricular pacing for advanced heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Yamasaki"
                            1 => "Y&#46; Seo"
                            2 => "H&#46; Tada"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2011.06.048"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2011"
                        "volumen" => "108"
                        "paginaInicial" => "1297"
                        "paginaFinal" => "1304"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21855835"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pacing the right ventricular outflow tract septum&#58; time to embrace the future"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;J&#46; Hillock"
                            1 => "H&#46;G&#46; Mond"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/europace/eur251"
                      "Revista" => array:6 [
                        "tituloSerie" => "Europace"
                        "fecha" => "2011"
                        "volumen" => "14"
                        "paginaInicial" => "28"
                        "paginaFinal" => "35"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21846639"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Triple-site biventricular pacing in patients undergoing cardiac resynchronization therapy&#58; a feasibility study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                            2 => "T&#46; Kukulski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/europace/eum140"
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                        "tituloSerie" => "Europace"
                        "fecha" => "2007"
                        "volumen" => "9"
                        "paginaInicial" => "762"
                        "paginaFinal" => "767"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17631515"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Right ventricular outflow tract pacing&#58; radiographic and electrocardiographic correlates of lead position"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;D&#46; McGavigan"
                            1 => "K&#46;C&#46; Roberts-Thomson"
                            2 => "R&#46;J&#46; Hillock"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1540-8159.2006.00499.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pacing Clin Electrophysiol"
                        "fecha" => "2006"
                        "volumen" => "29"
                        "paginaInicial" => "1063"
                        "paginaFinal" => "1068"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17038137"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                        "paginaFinal" => "406"
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                          "autores" => array:3 [
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                        "paginaInicial" => "1491"
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                          "autores" => array:3 [
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                        "paginaFinal" => "505"
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                        "paginaInicial" => "2281"
                        "paginaFinal" => "2329"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.12.021

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Year/Month	Html	Pdf	Total

2024 November	3	5	8
2024 October	25	22	47
2024 September	30	22	52
2024 August	35	30	65
2024 July	29	31	60
2024 June	27	20	47
2024 May	27	18	45
2024 April	28	27	55
2024 March	25	17	42
2024 February	18	18	36
2024 January	22	24	46
2023 December	17	29	46
2023 November	26	17	43
2023 October	19	23	42
2023 September	29	17	46
2023 August	16	16	32
2023 July	28	15	43
2023 June	20	11	31
2023 May	42	18	60
2023 April	30	5	35
2023 March	37	14	51
2023 February	36	9	45
2023 January	25	22	47
2022 December	55	22	77
2022 November	39	28	67
2022 October	25	18	43
2022 September	29	18	47
2022 August	30	29	59
2022 July	26	34	60
2022 June	21	17	38
2022 May	23	25	48
2022 April	37	20	57
2022 March	23	29	52
2022 February	28	23	51
2022 January	45	21	66
2021 December	20	17	37
2021 November	36	33	69
2021 October	92	38	130
2021 September	64	26	90
2021 August	68	30	98
2021 July	32	29	61
2021 June	31	12	43
2021 May	46	34	80
2021 April	68	30	98
2021 March	68	19	87
2021 February	66	19	85
2021 January	70	17	87
2020 December	40	10	50
2020 November	63	18	81
2020 October	45	13	58
2020 September	68	15	83
2020 August	23	10	33
2020 July	49	15	64
2020 June	43	13	56
2020 May	38	11	49
2020 April	40	7	47
2020 March	47	13	60
2020 February	84	25	109
2020 January	38	8	46
2019 December	35	6	41
2019 November	29	7	36
2019 October	66	9	75
2019 September	48	10	58
2019 August	19	8	27
2019 July	40	11	51
2019 June	34	17	51
2019 May	29	6	35
2019 April	31	20	51
2019 March	37	12	49
2019 February	67	9	76
2019 January	33	7	40
2018 December	41	9	50
2018 November	114	14	128
2018 October	287	19	306
2018 September	75	9	84
2018 August	71	10	81
2018 July	20	8	28
2018 June	31	10	41
2018 May	37	11	48
2018 April	31	18	49
2018 March	38	9	47
2018 February	24	4	28
2018 January	27	12	39
2017 December	35	6	41
2017 November	23	13	36
2017 October	38	18	56
2017 September	38	13	51
2017 August	30	13	43
2017 July	27	14	41
2017 June	23	10	33
2017 May	55	11	66
2017 April	37	7	44
2017 March	31	58	89
2017 February	31	8	39
2017 January	37	3	40
2016 December	40	6	46
2016 November	34	9	43
2016 October	34	12	46
2016 September	31	16	47
2016 August	15	1	16
2016 July	37	35	72
2016 June	10	6	16

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