Case report
Heart transplant coronary artery disease: Multimodality approach in percutaneous intervention
Doença coronária no transplantado cardíaco: abordagem anatomofuncional na intervenção percutânea
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"correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença coronária no transplantado cardíaco: abordagem anatomofuncional na intervenção percutânea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1383 "Ancho" => 1402 "Tamanyo" => 372801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography: image of the mid left anterior descending artery with lipid-rich atherosclerotic plaque (asterisk: incomplete blood displacement).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0055" class="elsevierStylePara elsevierViewall">Orthotopic heart transplantation (OHT) is the current mainstay treatment for end-stage heart failure refractory to other therapies.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Heart transplant coronary artery disease is largely an immunologic phenomenon termed cardiac allograft vasculopathy (CAV), and is the most significant cause of late morbidity and mortality after OHT.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">2–4</span></a> There is an exponential growth in the incidence of CAV after five years following transplantation, and some studies have also shown an approximately 10% increase in disease incidence with every two-year interval after OHT.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Typically, cardiac transplant recipients do not experience angina because of perioperative denervation. However, they may present with left ventricular dysfunction as a consequence of myocardial ischemia. Therefore, routine surveillance for CAV is recommended by the International Society for Heart and Lung Transplantation, for which coronary angiography is considered the modality of choice.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment of CAV remains a clinical challenge. The options are limited and include the use of oral antiproliferative agents, statins, percutaneous coronary intervention (PCI) and/or repeat OHT, all with suboptimal results.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0070" class="elsevierStylePara elsevierViewall">We present the case of a 64-year-old male with ischemic cardiomyopathy who received an OHT from a 42-year-old male donor in 2009. The patient had three-vessel disease and had undergone coronary artery bypass grafting in 1998; in the pre-heart transplantation evaluation only the left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft was patent. Two pre-existing non-occlusive (<50%) stenoses in the mid LAD of the donor heart led to the decision to use the patient's LIMA to anastomose to the donor's LAD during the transplantation procedure.</p><p id="par0075" class="elsevierStylePara elsevierViewall">At five-year follow-up after transplantation, the routine coronary angiography (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) showed progression of the two mid LAD stenoses (50-70%) and revealed that the LIMA–LAD graft was no longer patent.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The functional significance of the LAD lesions was assessed by measurement of fractional flow reserve (FFR) using a 0.014″ pressure guide wire (PressureWire Aeris™, St. Jude Medical, Uppsala, Sweden). The value obtained was 0.78, suggesting the presence of functionally significant lesions.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The pressure guide wire was then replaced by a 2.7F optical coherence tomography (OCT) catheter (Dragonfly Duo™ imaging catheter, St. Jude Medical, St. Paul, MN, USA) and OCT images (Ilumien Optis™ system, St. Jude Medical, St. Paul, MN, USA) were recorded from the mid to proximal portions of the LAD at an automatic pull-back speed of 20 mm/s and a frame rate of 100/s.</p><p id="par0090" class="elsevierStylePara elsevierViewall">OCT images of the mid LAD segment (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) showed a lipid-rich plaque with atherosclerotic characteristics, and OCT of the proximal LAD segment (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) demonstrated intimal hyperproliferation compatible with CAV.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Considering these findings, we decided to treat the two lesions with 3.0 mm×15 mm and 3.0 mm×12 mm Ultimaster™ sirolimus-eluting stents. The result was assessed by OCT and revealed malapposed struts of the distal stent (maximum length of segments with malapposed struts 1.5 mm; maximum malapposition distance 0.36 mm). We therefore decided to proceed with adjunctive post-dilatation using a 3.0 mm×12 mm non-compliant balloon. Final OCT examination showed a very good result, as presented in <a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>. FFR was repeated, indicating a good physiological result of 0.89.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Heart transplant coronary artery disease represents a unique clinical challenge, due to its distinctive pathogenesis, diagnostic approach and treatment modalities. CAV is thought to be an immunologic phenomenon that involves the entire coronary vasculature diffusely, with marked intimal proliferation and concentric vascular thickening and fibrosis.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> This contrasts with conventional coronary atherosclerosis, which is marked by focal, eccentric fibrofatty atheroma.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Advances in invasive coronary imaging, such as intravascular ultrasound (IVUS) and OCT, have shown promising results in increasing knowledge of the pathophysiology of CAV. Intimal thickening is typically the initial finding on IVUS, and rapidly progressive CAV is defined as an increase of ≥0.5 mm in intimal thickness within the first year post-OHT.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> More recent studies using intracoronary OCT have demonstrated higher sensitivity for early detection of CAV,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> and have provided new insights that extend beyond the traditional concept of CAV, showing the development of atherosclerosis with vulnerable plaque and complicated coronary lesions such as intraluminal thrombus.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> Although both IVUS and OCT are more sensitive and specific in detecting early-stage CAV than coronary angiography alone and provide additional information for risk stratification,<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> routine use of these methods is limited. The current recommendation for screening and surveillance of CAV remains annual coronary angiography. Nevertheless, IVUS with a baseline study at 4-6 weeks and at one year after OHT, in order to exclude donor coronary artery disease and to detect rapidly progressive CAV, is already mentioned as an optional method.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Coronary artery disease in heart transplant recipients is often a combination of donor-transmitted atherosclerosis and de novo lesions of CAV. This distinction can be difficult to make solely on the basis of the distribution and morphology of lesions on coronary angiography. Though the lesions of CAV tend to be more diffuse and circumferential than donor-transmitted atherosclerosis, both types of lesions have a predilection for proximal segments and bifurcation sites.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> In the case reported, the progression of pre-existing non-obstructive stenoses in the mid LAD segment of the donor heart was easily detected by angiography and their nature confirmed by OCT imaging.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The etiology of the heart failure that leads to OHT may also be an important factor in the progression of transplant coronary artery disease. Guddeti et al.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> demonstrated that ischemic cardiomyopathy patients had significantly greater plaque volume index at initial and follow-up virtual histology IVUS examinations and that this was an independent predictor of plaque progression, especially within three years of transplantation.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment of CAV is truly a challenge since its pathophysiology is multifactorial, with a wide range of immunologic and non-immunologic contributors. Furthermore, patients are usually asymptomatic, but their survival after documentation of CAV is significantly reduced.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> Current immunosuppressive therapy has limited efficacy in preventing the development of CAV.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> By contrast, statins exert multiple pleiotropic effects in the transplanted heart, reducing cytokine activity, improving coronary endothelial function and increasing coronary flow reserve,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> and several statins have been associated with reduced CAV progression and improved survival after OHT.<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18–20</span></a> Repeat OHT is the only definitive therapy for CAV but it is associated with higher perioperative mortality, lower long-term survival and a higher recurrence of CAV.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> Coronary artery bypass surgery is rarely performed, because CAV is associated with poor distal targets, due to the diffuse nature of the disease, and greater perioperative mortality.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">22,23</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Hence, PCI has been routinely used as a treatment alternative in patients with focal proximal CAV.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> Although small-scale, single-center studies have demonstrated excellent procedure outcomes,<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">24,25</span></a> data on long-term mortality benefit are sparse and controversial. Recently, Agarwal et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> showed that among patients with at least moderate CAV on any coronary angiogram, long-term survival in those amenable to PCI was greater than in those with CAV not treatable with PCI.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The assessment of cardiac transplant recipients by routine coronary angiography entails interpreting the physiological significance of focal coronary stenosis, particularly of intermediate stenosis, in order to guide the need for PCI. FFR is an index that provides information on the degree to which epicardial artery disease is affecting myocardial perfusion and is well validated in non-OHT populations.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> Studies<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27,28</span></a> on the changes in coronary anatomy and physiology after heart transplantation found that soon after OHT there is a strong correlation between FFR and IVUS-determined epicardial percentage plaque volume. Late after OHT, increased microvascular resistance (as shown by a higher index of microvascular resistance) results in a decrease in the maximum achievable flow down the epicardial vessel and lessens the physiologic impact of structural abnormalities in the epicardial artery. For this reason, when significant microvascular dysfunction is present, FFR may not provide a good representation of epicardial artery plaque burden. In this case report, FFR was very useful for assessing the functional significance of the two mid LAD intermediate stenoses, guiding the decision whether to intervene. After PCI an increase in FFR was also demonstrated, proving the physiologic benefit of the PCI.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Finally, PCI in heart transplant recipients is associated with a higher incidence of restenosis, compared to the non-OHT population. Outcomes with balloon angioplasty have been less than ideal, contributing to allograft loss because of the very high incidence of restenosis.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> PCI with drug-eluting stents (DES) appears to be associated with reduced angiographic in-stent restenosis rate in transplant patients.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a> Tremmel et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">31</span></a> compared PCI with bare-metal stents (BMS) vs. DES in cardiac transplant recipients and demonstrated that DES are safer and more effective in suppressing neointimal hyperplasia after PCI for CAV. This leads to a significantly lower rate of late lumen loss and target lesion revascularization, as well as to reduced rates of cardiac death and nonfatal myocardial infarction. In the case presented, we used two new-generation DES and then assessed the result by OCT imaging. As the distal stent had an incomplete expansion, which is known to be associated with an even higher restenosis rate,<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> we performed a high-pressure post-dilation to obtain optimal stent expansion, confirmed by another OCT examination.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Heart transplant coronary artery disease is a complex disorder and remains a significant cause of morbidity and mortality in OHT patients. Invasive coronary imaging modalities such as IVUS or OCT are crucial as they provide information on early-stage CAV and can confirm the nature of coronary stenosis and help in PCI optimization. Although it is affected by microvascular dysfunction in the late stages after OHT, assessment through FFR may be valuable in making therapeutic decisions. Compared with BMS, PCI with DES is safer and reduces the restenosis rate in patients with CAV. The present case demonstrates the use of a multimodality approach and highlights its importance to achieve good outcomes in this challenging population.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres824768" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821228" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824769" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821227" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-22" "fechaAceptado" => "2015-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821228" "palabras" => array:6 [ 0 => "Heart transplantation" 1 => "Coronary artery disease" 2 => "Cardiac allograft vasculopathy" 3 => "Optical coherence tomography" 4 => "Fractional flow reserve" 5 => "Percutaneous coronary intervention" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec821227" "palabras" => array:6 [ 0 => "Transplante cardíaco" 1 => "Doença coronária" 2 => "Vasculopatia do enxerto" 3 => "Tomografia de coerência ótica" 4 => "<span class="elsevierStyleItalic">Fractional flow reserve</span>" 5 => "Intervenção coronária percutânea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary artery disease is the most important cause of late morbidity and mortality after heart transplantation. It is usually an immunologic phenomenon termed cardiac allograft vasculopathy, but can also be the result of donor-transmitted atherosclerosis. Routine surveillance by coronary angiography should be complemented by intracoronary imaging, in order to determine the nature of the coronary lesions, and also by assessment of their functional significance to guide the decision whether to perform percutaneous coronary intervention. We report a case of coronary angiography at five-year follow-up after transplantation, using optical coherence tomography and fractional flow reserve to assess and optimize treatment of coronary disease in this challenging population.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Doença coronária é a causa mais importante de morbimortalidade tardia após transplantação cardíaca. Habitualmente, representa um fenómeno imunológico designado como vasculopatia do aloenxerto, mas também pode resultar da aterosclerose transmitida pelo dador. A vigilância através de coronariografia de rotina deve ser complementada pela utilização de imagem intracoronária, de forma a determinar a natureza das lesões, e também através de uma avaliação funcional para tomada da decisão de realizar intervenção coronária percutânea. Apresentamos o caso de uma coronariografia aos cinco anos de seguimento após transplantação, utilizando tomografia de coerência ótica e <span class="elsevierStyleItalic">fractional flow reserve</span> para avaliação e otimização do tratamento da doença coronária nesta população desafiante.</p></span>" ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:10 [ 0 => array:2 [ "termino" => "BMS" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">bare-metal stents</p>" ] 1 => array:2 [ "termino" => "CAV" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">cardiac allograft vasculopathy</p>" ] 2 => array:2 [ "termino" => "DES" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">drug-eluting stents</p>" ] 3 => array:2 [ "termino" => "FFR" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">fractional flow reserve</p>" ] 4 => array:2 [ "termino" => "IVUS" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">intravascular ultrasound</p>" ] 5 => array:2 [ "termino" => "LAD" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">left anterior descending artery</p>" ] 6 => array:2 [ "termino" => "LIMA" "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">left internal mammary artery graft</p>" ] 7 => array:2 [ "termino" => "OCT" "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">optical coherence tomography</p>" ] 8 => array:2 [ "termino" => "OHT" "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">orthotopic heart transplantation</p>" ] 9 => array:2 [ "termino" => "PCI" "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">percutaneous coronary intervention</p>" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 882 "Ancho" => 950 "Tamanyo" => 98031 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography: images of the left coronary artery showing two mid left anterior descending artery intermediate stenoses (50-70%).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1383 "Ancho" => 1402 "Tamanyo" => 372801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography: image of the mid left anterior descending artery with lipid-rich atherosclerotic plaque (asterisk: incomplete blood displacement).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1156 "Ancho" => 1193 "Tamanyo" => 285012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography: image of the proximal left anterior descending artery revealing intimal hyperplasia with maximal thickness of 0.36 mm.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1464 "Ancho" => 2874 "Tamanyo" => 694233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">(A) Optical coherence tomography (OCT): image showing distal mid left anterior descending artery (LAD) stent with malapposed struts; (B) OCT image of the distal mid LAD stent after post-dilatation, revealing well-expanded and well-apposed stent struts.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 59 | 29 | 88 |
| 2024 September | 78 | 25 | 103 |
| 2024 August | 93 | 34 | 127 |
| 2024 July | 77 | 33 | 110 |
| 2024 June | 60 | 15 | 75 |
| 2024 May | 92 | 40 | 132 |
| 2024 April | 55 | 24 | 79 |
| 2024 March | 94 | 30 | 124 |
| 2024 February | 52 | 51 | 103 |
| 2024 January | 87 | 48 | 135 |
| 2023 December | 62 | 30 | 92 |
| 2023 November | 88 | 28 | 116 |
| 2023 October | 84 | 33 | 117 |
| 2023 September | 87 | 27 | 114 |
| 2023 August | 70 | 23 | 93 |
| 2023 July | 87 | 12 | 99 |
| 2023 June | 50 | 10 | 60 |
| 2023 May | 62 | 23 | 85 |
| 2023 April | 48 | 3 | 51 |
| 2023 March | 53 | 24 | 77 |
| 2023 February | 48 | 22 | 70 |
| 2023 January | 43 | 13 | 56 |
| 2022 December | 59 | 21 | 80 |
| 2022 November | 75 | 29 | 104 |
| 2022 October | 118 | 22 | 140 |
| 2022 September | 67 | 34 | 101 |
| 2022 August | 85 | 27 | 112 |
| 2022 July | 94 | 31 | 125 |
| 2022 June | 45 | 22 | 67 |
| 2022 May | 46 | 36 | 82 |
| 2022 April | 56 | 17 | 73 |
| 2022 March | 40 | 27 | 67 |
| 2022 February | 39 | 21 | 60 |
| 2022 January | 38 | 26 | 64 |
| 2021 December | 20 | 24 | 44 |
| 2021 November | 49 | 31 | 80 |
| 2021 October | 110 | 34 | 144 |
| 2021 September | 32 | 27 | 59 |
| 2021 August | 41 | 30 | 71 |
| 2021 July | 36 | 32 | 68 |
| 2021 June | 39 | 16 | 55 |
| 2021 May | 51 | 29 | 80 |
| 2021 April | 100 | 60 | 160 |
| 2021 March | 100 | 20 | 120 |
| 2021 February | 73 | 20 | 93 |
| 2021 January | 44 | 16 | 60 |
| 2020 December | 53 | 15 | 68 |
| 2020 November | 43 | 15 | 58 |
| 2020 October | 39 | 14 | 53 |
| 2020 September | 57 | 13 | 70 |
| 2020 August | 30 | 12 | 42 |
| 2020 July | 52 | 14 | 66 |
| 2020 June | 60 | 35 | 95 |
| 2020 May | 48 | 14 | 62 |
| 2020 April | 38 | 11 | 49 |
| 2020 March | 30 | 13 | 43 |
| 2020 February | 91 | 16 | 107 |
| 2020 January | 51 | 14 | 65 |
| 2019 December | 33 | 7 | 40 |
| 2019 November | 45 | 19 | 64 |
| 2019 October | 47 | 12 | 59 |
| 2019 September | 49 | 23 | 72 |
| 2019 August | 42 | 5 | 47 |
| 2019 July | 47 | 6 | 53 |
| 2019 June | 31 | 14 | 45 |
| 2019 May | 29 | 12 | 41 |
| 2019 April | 47 | 15 | 62 |
| 2019 March | 47 | 13 | 60 |
| 2019 February | 51 | 7 | 58 |
| 2019 January | 41 | 9 | 50 |
| 2018 December | 56 | 14 | 70 |
| 2018 November | 182 | 9 | 191 |
| 2018 October | 501 | 13 | 514 |
| 2018 September | 121 | 13 | 134 |
| 2018 August | 51 | 8 | 59 |
| 2018 July | 32 | 6 | 38 |
| 2018 June | 54 | 6 | 60 |
| 2018 May | 66 | 8 | 74 |
| 2018 April | 64 | 2 | 66 |
| 2018 March | 137 | 10 | 147 |
| 2018 February | 28 | 4 | 32 |
| 2018 January | 17 | 9 | 26 |
| 2017 December | 38 | 14 | 52 |
| 2017 November | 22 | 6 | 28 |
| 2017 October | 23 | 9 | 32 |
| 2017 September | 23 | 9 | 32 |
| 2017 August | 30 | 13 | 43 |
| 2017 July | 21 | 15 | 36 |
| 2017 June | 19 | 9 | 28 |
| 2017 May | 28 | 6 | 34 |
| 2017 April | 28 | 3 | 31 |
| 2017 March | 59 | 12 | 71 |
| 2017 February | 47 | 6 | 53 |
| 2017 January | 45 | 7 | 52 |
| 2016 December | 34 | 3 | 37 |
| 2016 November | 35 | 3 | 38 |
| 2016 October | 36 | 15 | 51 |
| 2016 September | 47 | 10 | 57 |
| 2016 August | 16 | 2 | 18 |
| 2016 July | 46 | 24 | 70 |
| 2016 June | 8 | 12 | 20 |
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