Case report
Combined venoarterial extracorporeal membrane oxygenation and transcatheter aortic valve implantation for the treatment of acute aortic prosthesis dysfunction in a high-risk patient
Uso combinado de oxigenação da membrana extracorporal e implantação percutânea da válvula aórtica para o tratamento de disfunção prostética aórtica aguda num doente de alto risco
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APV: apical posterior vein; IBV: inferior basilar vein; IPV: inferior pulmonary vein; LA: left atrium; SBV: superior basilar vein; SPV: superior pulmonary vein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge Haddad, André Badran, Rafael Pavão, Adriana I. de Padua, Igor Lago, Jose A. Marin Neto" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Jorge" "apellidos" => "Haddad" ] 1 => array:2 [ "nombre" => "André" "apellidos" => "Badran" ] 2 => array:2 [ "nombre" => "Rafael" "apellidos" => "Pavão" ] 3 => array:2 [ "nombre" => "Adriana I." "apellidos" => "de Padua" ] 4 => array:2 [ "nombre" => "Igor" "apellidos" => "Lago" ] 5 => array:2 [ "nombre" => "Jose A." "apellidos" => "Marin Neto" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916301052?idApp=UINPBA00004E" "url" => "/21742049/0000003500000078/v2_201704060238/S2174204916301052/v2_201704060238/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Combined venoarterial extracorporeal membrane oxygenation and transcatheter aortic valve implantation for the treatment of acute aortic prosthesis dysfunction in a high-risk patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "445.e1" "paginaFinal" => "445.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Amedeo Pergolini, Giordano Zampi, Maria Denitza Tinti, Vincenzo Polizzi, Paolo Giuseppe Pino, Daniele Pontillo, Francesco Musumeci, Giampaolo Luzi" "autores" => array:8 [ 0 => array:3 [ "nombre" => "Amedeo" "apellidos" => "Pergolini" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Giordano" "apellidos" => "Zampi" "email" => array:1 [ 0 => "giordano.zampi@alice.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Maria Denitza" "apellidos" => "Tinti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Vincenzo" "apellidos" => "Polizzi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Paolo Giuseppe" "apellidos" => "Pino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Daniele" "apellidos" => "Pontillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Francesco" "apellidos" => "Musumeci" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Giampaolo" "apellidos" => "Luzi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Cardiovascular Science, “S. Camillo-Forlanini” Hospital, Rome, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Cardiology, Belcolle Hospital, Viterbo, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Cardiomyopathies and Heart Failure, Belcolle Hospital, Montefiascone Facility, Montefiascone (VT), Italy" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Uso combinado de oxigenação da membrana extracorporal e implantação percutânea da válvula aórtica para o tratamento de disfunção prostética aórtica aguda num doente de alto risco" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1025 "Ancho" => 1589 "Tamanyo" => 125489 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, 4-chamber mid-esophageal view, showing prosthesis degeneration and cusp tears (red arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation (TAVI) is used to treat high-risk patients with bioprosthetic valve degeneration (valve-in-valve technique). We describe the case of a patient with acute bioprosthesis dysfunction in cardiogenic shock, in whom hemodynamic support was provided by venoarterial extracorporeal membrane oxygenation (ECMO), and successfully treated by TAVI.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old Caucasian male underwent conventional aortic valve replacement using a stented bioprosthesis (standard 23 mm Carpentier-Edwards Perimount) six years ago, as suggested by the cardiac surgeons, in order to avoid oral anticoagulation. Transthoracic echocardiography performed six months before admission showed normal left ventricular ejection fraction with a normally functioning aortic bioprosthesis and slightly elevated gradients (mean pressure gradient 18 mmHg). The patient was referred to the emergency department of our hospital in cardiogenic shock complicated by pulmonary edema (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) and was immediately treated with diuretics and high-dose inotropes to achieve stabilization.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Eventually transesophageal echocardiography was performed, showing severe eccentric aortic regurgitation (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>, Video 1) due to prosthesis degeneration and cusp tears (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>, Video 2) together with depressed left ventricular ejection fraction (about 20%).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The presence of active endocarditis was ruled out by a completely normal blood count, a procalcitonin value within normal limits and negative blood cultures.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the Society of Thoracic Surgeons (STS) predicted 30-day mortality score of 13% and a EuroSCORE II of 28%, our heart team decided on urgent TAVI, with a valve-in-valve procedure through a transapical approach.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Due to life-threatening cardiogenic shock, miniaturized venoarterial ECMO was used as a bridging therapy to stabilize the patient, and on the following day he underwent TAVI with a 26 mm SAPIEN aortic bioprosthesis through a left anterior minithoracotomy by a transapical approach (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">There were no periprocedural complications and following progressive hemodynamic improvement, the ECMO was removed on day two after TAVI.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient's clinical course was favorable and uneventful, and he was discharged to a cardiac rehabilitation facility two weeks after the procedure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">At three-month follow-up, the patient was in stable clinical conditions, in New York Heart Association class II, with improved left ventricular ejection fraction (about 40%), no significant aortic regurgitation and a mean transprosthetic gradient of 13 mmHg.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">We believe there are several important issues in our case. Firstly, the prophylactic use of venoarterial ECMO during TAVI procedures is only anecdotal and there are no data on its systematic use, particularly in the context of a valve-in-valve redo operation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Nonetheless, there are favorable reports on the use of cardiopulmonary bypass (CPB) in very high-risk patients with cardiogenic shock to achieve hemodynamic stability during TAVI.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Similarly, modern ECMO has been used as a bridging therapy in cardiogenic shock. Specifically, Husser et al. report that in the event of procedural complications in TAVI, emergency implantation of venoarterial ECMO for circulatory support appears feasible to stabilize the patient for additional treatment, the best results being achieved with prophylactic venoarterial ECMO in patients with exceedingly high perioperative risk; procedural success and 30-day mortality in patients with prophylactic compared to emergency venoarterial ECMO was 100% vs. 44% and 0% vs. 44%, respectively.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Another interesting aspect of our report, besides bridging therapy, lies in the pathophysiology of bioprosthesis dysfunction, i.e. cusp perforation, which was rare in a series by Forcillo et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> reporting long-term follow-up of Carpentier-Edwards aortic bioprostheses in patients undergoing valve replacement for prosthesis dysfunction. In their series, only 21% showed evidence of cusp tear, which is the rarest cause of prosthesis dysfunction, less frequent than dehiscence, endocarditis, stenosis or calcification.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Cusp perforations and tears are primarily related to calcification, hemodynamic stress and valve tissue deterioration<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> and often cause acute valve failure, as in our patient.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Elective conventional redo aortic valve surgery has an operative mortality from 2% to 7%, but this can rise to 30% in high-risk, hemodynamically unstable patients.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Moreover, redo surgery is also associated with increased morbidity and prolonged recovery. Given the less invasive nature of TAVI, the procedure appears to be a suitable interventional option, particularly for patients who present with a degenerated and failing bioprosthetic valve.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although severe LVEF depression (<20%) and hemodynamic instability have been considered absolute contraindications for TAVI,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> this option, with either a transapical or transfemoral approach, has been proven feasible, safe, and associated with hemodynamic improvement in patients not eligible for conventional surgery. D’Ancona et al. performed transapical TAVI on 21 patients in acute cardiogenic shock, achieving technical procedural success in all patients, with an acceptable early mortality (19% at 30 days). However, the observed one-year survival of 46%<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> represents a suboptimal outcome compared to that of non-cardiogenic shock patients undergoing valve-in-valve TAVI<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> but is still better than the outcome observed after conventional aortic valve replacement.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Transapical access has been adopted in the majority of procedures on failing aortic bioprosthetic valves. In high-risk patients, however, a transfemoral approach may be preferred for a better safety profile since mechanical ventilation is not required and it is clearly less invasive.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our case the transapical route was preferred to take advantage of some technical aspects, such as better control and fine adjustment during valve placement. Crossing a stented bioprosthesis is easier via the transapical route and is independent of the size of the peripheral vessels; additionally, it should be emphasized that the disease affecting the implanted valve can have varying effects on internal diameter, including thickening of the tissue leaflets, calcification and pannus growth, reducing the internal diameter of the stent and making the placement of a valve-in-valve prosthesis via a femoral approach wide harder to perform. The Edwards SAPIEN valve presents advantages with respect to the CoreValve, notably the balloon-expandable system, which has better sealing and lower risk of embolization.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion, TAVI in association with CPB or venoarterial ECMO may emerge as a valuable treatment option in inoperable patients with acute severe prosthesis dysfunction and become an acceptable alternative to surgical redo in a selected group of non-elderly patients with high surgical risk. However, before TAVI can be recommended in this subset of patients, the risk of periprocedural complications (especially conduction abnormalities and stroke) and long-term percutaneous valve durability in patients with longer life expectancies should be taken into consideration.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The combined use of TAVI and venoarterial ECMO in our patient represented an innovative and clinically acceptable compromise solution to a complicated surgical and medical issue, the challenge being whether to perform an emergency redo or first to stabilize this relatively young and shocked patient. In this acute prosthesis failure scenario venoarterial ECMO may be helpful in establishing hemodynamic stabilization and may give time for the choice of the preferred strategy of valve-in-valve TAVI.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres825320" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821808" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres825319" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821807" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-05" "fechaAceptado" => "2015-10-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821808" "palabras" => array:4 [ 0 => "Extracorporeal membrane oxygenation" 1 => "Transcatheter aortic valve implantation" 2 => "Prosthesis dysfunction" 3 => "Cardiogenic shock" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec821807" "palabras" => array:4 [ 0 => "Oxigenação da membrana extracorporal" 1 => "Implantação percutânea da válvula aórtica" 2 => "Disfunção protética" 3 => "Choque cardiogénico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a patient with acute bioprosthesis dysfunction in cardiogenic shock, in whom hemodynamic support was provided by venoarterial extracorporeal membrane oxygenation, and successfully treated by transcatheter aortic valve implantation.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de um doente com disfunção aguda de bioprótese em choque cardiogénico com suporte hemodinâmico através de oxigenação da membrana extracorporal (vaECMO) e tratado com sucesso através de implantação percutânea da válvula aórtica (TAVI).</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0130" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1355 "Ancho" => 1587 "Tamanyo" => 133518 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray showing cephalization of pulmonary veins and indistinctness of the vascular margins. The heart is enlarged.</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" => 1004 "Ancho" => 1589 "Tamanyo" => 167358 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, long-axis mid-esophageal view, showing severe eccentric aortic regurgitation.</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" => 1015 "Ancho" => 1588 "Tamanyo" => 157148 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, transgastric view.</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" => 1025 "Ancho" => 1589 "Tamanyo" => 125489 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, 4-chamber mid-esophageal view, showing prosthesis degeneration and cusp tears (red arrow).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1267 "Ancho" => 2501 "Tamanyo" => 225009 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Aortic angiography before (a) and after (b) transcatheter aortic valve implantation.</p>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1404465 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 6 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1617477 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Elective use of femoro-femoral cardiopulmonary bypass during transcatheter aortic valve implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 8 | 12 |
| 2024 October | 32 | 33 | 65 |
| 2024 September | 35 | 23 | 58 |
| 2024 August | 41 | 29 | 70 |
| 2024 July | 42 | 33 | 75 |
| 2024 June | 32 | 23 | 55 |
| 2024 May | 44 | 27 | 71 |
| 2024 April | 30 | 26 | 56 |
| 2024 March | 38 | 28 | 66 |
| 2024 February | 26 | 30 | 56 |
| 2024 January | 26 | 36 | 62 |
| 2023 December | 31 | 20 | 51 |
| 2023 November | 28 | 24 | 52 |
| 2023 October | 27 | 19 | 46 |
| 2023 September | 26 | 20 | 46 |
| 2023 August | 31 | 14 | 45 |
| 2023 July | 25 | 6 | 31 |
| 2023 June | 28 | 16 | 44 |
| 2023 May | 44 | 19 | 63 |
| 2023 April | 32 | 1 | 33 |
| 2023 March | 39 | 20 | 59 |
| 2023 February | 32 | 21 | 53 |
| 2023 January | 20 | 9 | 29 |
| 2022 December | 39 | 17 | 56 |
| 2022 November | 41 | 26 | 67 |
| 2022 October | 35 | 17 | 52 |
| 2022 September | 34 | 26 | 60 |
| 2022 August | 19 | 49 | 68 |
| 2022 July | 37 | 28 | 65 |
| 2022 June | 28 | 20 | 48 |
| 2022 May | 20 | 35 | 55 |
| 2022 April | 35 | 21 | 56 |
| 2022 March | 27 | 28 | 55 |
| 2022 February | 25 | 24 | 49 |
| 2022 January | 39 | 20 | 59 |
| 2021 December | 20 | 36 | 56 |
| 2021 November | 39 | 31 | 70 |
| 2021 October | 37 | 33 | 70 |
| 2021 September | 30 | 27 | 57 |
| 2021 August | 34 | 29 | 63 |
| 2021 July | 18 | 23 | 41 |
| 2021 June | 25 | 16 | 41 |
| 2021 May | 41 | 42 | 83 |
| 2021 April | 78 | 22 | 100 |
| 2021 March | 31 | 20 | 51 |
| 2021 February | 43 | 24 | 67 |
| 2021 January | 34 | 29 | 63 |
| 2020 December | 42 | 10 | 52 |
| 2020 November | 40 | 17 | 57 |
| 2020 October | 33 | 13 | 46 |
| 2020 September | 43 | 11 | 54 |
| 2020 August | 36 | 11 | 47 |
| 2020 July | 44 | 11 | 55 |
| 2020 June | 36 | 10 | 46 |
| 2020 May | 27 | 5 | 32 |
| 2020 April | 32 | 17 | 49 |
| 2020 March | 40 | 4 | 44 |
| 2020 February | 60 | 19 | 79 |
| 2020 January | 32 | 5 | 37 |
| 2019 December | 32 | 7 | 39 |
| 2019 November | 34 | 9 | 43 |
| 2019 October | 42 | 9 | 51 |
| 2019 September | 14 | 8 | 22 |
| 2019 August | 27 | 9 | 36 |
| 2019 July | 29 | 10 | 39 |
| 2019 June | 26 | 14 | 40 |
| 2019 May | 25 | 10 | 35 |
| 2019 April | 30 | 17 | 47 |
| 2019 March | 64 | 7 | 71 |
| 2019 February | 36 | 8 | 44 |
| 2019 January | 23 | 6 | 29 |
| 2018 December | 49 | 15 | 64 |
| 2018 November | 143 | 6 | 149 |
| 2018 October | 332 | 26 | 358 |
| 2018 September | 80 | 16 | 96 |
| 2018 August | 61 | 2 | 63 |
| 2018 July | 30 | 6 | 36 |
| 2018 June | 49 | 4 | 53 |
| 2018 May | 47 | 14 | 61 |
| 2018 April | 66 | 8 | 74 |
| 2018 March | 75 | 8 | 83 |
| 2018 February | 14 | 6 | 20 |
| 2018 January | 32 | 5 | 37 |
| 2017 December | 41 | 3 | 44 |
| 2017 November | 40 | 11 | 51 |
| 2017 October | 26 | 12 | 38 |
| 2017 September | 24 | 18 | 42 |
| 2017 August | 20 | 18 | 38 |
| 2017 July | 20 | 10 | 30 |
| 2017 June | 19 | 9 | 28 |
| 2017 May | 39 | 14 | 53 |
| 2017 April | 27 | 4 | 31 |
| 2017 March | 46 | 4 | 50 |
| 2017 February | 48 | 7 | 55 |
| 2017 January | 32 | 2 | 34 |
| 2016 December | 47 | 5 | 52 |
| 2016 November | 28 | 5 | 33 |
| 2016 October | 17 | 3 | 20 |
| 2016 September | 32 | 6 | 38 |
| 2016 August | 16 | 1 | 17 |
| 2016 July | 3 | 0 | 3 |
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