Case report
Abdominal pain of cardiovascular origin
Dor abdominal de causa cardiovascular
Pedro Epifânio
, Maria Emanuel Amaral, Natália Noronha, Paula Martins, Dina Rodrigues, António Pires, Eduardo Castela
Corresponding author
Hospital Pediátrico de Coimbra, Serviço de Cardiologia Pediátrica, Coimbra, Portugal
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Chambers are color-coded; systemic chambers are red and subpulmonary chambers are blue. Atria baffles are indicated in images D to F (1, systemic baffle. 2, subpulmonary baffle. Image F, anterior and posterior view of both atria. Note the right ventricle as systemic on the whole heart rendering). In arterial switching, the abnormal position of the great vessel can be seen in images G to I (*: pulmonary artery. **: aortic root. Image I, anterior position of pulmonary artery and a subpulmonary right ventricle. Upper right, anterior view of great vessels and below, a posterior view of the subpulmonary chambers. Note the right pulmonary branch narrowing (#) between the ascending aorta and the superior vena cava).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel Barreiro-Perez, Ana García-Martin, Elena Diaz-Pelaez, Luisa Garcia-Cuenllas, Enrique Maroto-Alvaro, Pedro L. 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"apellidos" => "Sanchez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117300069" "doi" => "10.1016/j.repc.2017.01.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117300069?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918301715?idApp=UINPBA00004E" "url" => "/21742049/0000003700000005/v1_201806100418/S2174204918301715/v1_201806100418/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204918301697" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.02.019" "estado" => "S300" "fechaPublicacion" => "2018-05-01" "aid" => "1185" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2018;37:447.e1-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1515 "formatos" => array:3 [ "EPUB" => 120 "HTML" => 1170 "PDF" => 225 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Massive organ embolization from primary aortic thrombosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "447.e1" "paginaFinal" => "447.e6" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Embolização orgânica maciça de trombose primária da aorta" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1773 "Ancho" => 2501 "Tamanyo" => 477028 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CT scan of the abdomen/pelvis showing total hypodensity of the spleen representing a complete infarct, without contrast enhancement except for a fine capsule. Splenic artery occlusion. Hypodense ill-defined lesion in the pancreas tail, measuring 55×38 mm with adjacent fat densification, but without contrast enhancement leading to a differential diagnosis between ischemic infarct and malignant neoplasm. Heterogeneous contrast enhancement of both kidneys, with triangular parenchymal areas of lower attenuation, suggestive of ischemic renal foci. Heterogeneous hepatomegaly with areas of non-contrast enhancement, the biggest one in segments VII and VIII; similar area on the liver border and smaller hypodense areas that, in this context, can represent occlusive arterial conditions. Small parietal thrombus (9<span class="elsevierStyleHsp" style=""></span>mm) in the left lateral aortic wall, in the axial plane of the celiac trunk, with no evident atheromatous lesions.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Catarina Patrício, Mariana Marques Silva, Pedro Eduardo Silva, João Oliveira, Luís Bagulho" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Catarina" "apellidos" => "Patrício" ] 1 => array:2 [ "nombre" => "Mariana Marques" "apellidos" => "Silva" ] 2 => array:2 [ "nombre" => "Pedro Eduardo" "apellidos" => "Silva" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Oliveira" ] 4 => array:2 [ "nombre" => "Luís" "apellidos" => "Bagulho" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116302888" "doi" => "10.1016/j.repc.2017.02.020" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116302888?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918301697?idApp=UINPBA00004E" "url" => "/21742049/0000003700000005/v1_201806100418/S2174204918301697/v1_201806100418/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Abdominal pain of cardiovascular origin" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "449.e1" "paginaFinal" => "449.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pedro Epifânio, Maria Emanuel Amaral, Natália Noronha, Paula Martins, Dina Rodrigues, António Pires, Eduardo Castela" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Pedro" "apellidos" => "Epifânio" "email" => array:1 [ 0 => "p.pires.epifanio@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Maria Emanuel" "apellidos" => "Amaral" ] 2 => array:2 [ "nombre" => "Natália" "apellidos" => "Noronha" ] 3 => array:2 [ "nombre" => "Paula" "apellidos" => "Martins" ] 4 => array:2 [ "nombre" => "Dina" "apellidos" => "Rodrigues" ] 5 => array:2 [ "nombre" => "António" "apellidos" => "Pires" ] 6 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Castela" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Pediátrico de Coimbra, Serviço de Cardiologia Pediátrica, Coimbra, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Dor abdominal de causa cardiovascular" ] ] "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" => 1105 "Ancho" => 2501 "Tamanyo" => 246518 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CT scan. A – sagittal view showing the aortic coarctation (arrow); B – coronal view showing the splenic and renal low-density areas, suggestive of infarcts (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infective endocarditis (IE) is a microbial infection of the endocardium and it is rare in the pediatric population. In children, congenital heart disease is one of the most important risk factors for developing IE<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> and can involve other structures in addition to cardiac valves. The prognosis is generally better than in other forms of endocarditis, although the average mortality rate in the pediatric population is 15-25%. Clinical manifestations can mimic other diseases such as meningitis and collagen-vascular disease or vasculitis. Therefore, a high degree of suspicion is required to make an early diagnosis. Gram-positive bacteria, specifically alpha-hemolytic streptococci, <span class="elsevierStyleItalic">Staphylococcus aureus</span> and coagulase-negative staphylococci, are the most commonly involved bacteria.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2,3</span></a> Diagnosis is based on the modified Duke criteria, which rely mostly on clinical assessment, echocardiography and blood cultures. Antibacterial treatment should ideally be targeted. However, if no specific bacteria have been identified, patients should promptly be treated empirically with multiple drug regimens based on local resistance and the most common etiologies.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors describe a case of a seven-year-old girl with classic clinical signs of endocarditis, with a clinical twist.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors present the case of a seven-year-old girl admitted to the emergency room with a three-day history of acute onset abdominal pain, fever and recent-onset purpuric rash. On admission she was restless, tachycardic, hypertensive and had abdominal distension and hyperesthesia. A purpuric rash was also evident and limited to the buttocks, lower limbs and feet, and she also presented with tender bilateral edema (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Initial blood tests showed leukocytosis, elevated acute-phase reactants, mild anemia, abnormal renal function, thrombocytopenia, and abnormal thromboplastin and prothrombin time. Urinalysis revealed the presence of hematuria and nephrotic proteinuria.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood cultures were performed and ceftriaxone was started empirically. Abdominal ultrasound showed splenomegaly as well as small-to-medium sized hypoechogenic lesions in the spleen, liver and both kidneys, compatible with thromboembolic infarcts. Due to possible infective embolic disease she was referred for cardiac assessment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On examination, a low-grade (II/VI) systolic murmur was detected in the lower left sternal border, which radiated to the back. Echocardiogram revealed coarctation of the aorta at the isthmus with a systolic gradient of 60 mmHg with diastolic run-off. There appeared to be a movable filament-like structure adhering to the coarcted isthmus. No valvular or intracardiac vegetations were found. In order to clarify these findings, a transesophageal echocardiogram (TOE) was carried out, which showed the presence of a hyperechogenic movable “spur” at the aortic isthmus. A presumptive diagnosis of infective aortic endarteritis complicated by systemic embolization, hypertension and acute renal insufficiency was made. Vancomycin, titrated to the glomerular filtration rate, was added to the antibiotic regimen.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus schleiferi</span> was later identified as the causative agent of the infective endarteritis. This organism is easily mistaken for <span class="elsevierStyleItalic">Staphylococcus aureus</span>. Antibacterial sensitivity testing showed that this agent was more sensitive to floxacillin and, as such, the latter was added to the therapeutic regimen and vancomycin was stopped. The patient became apyretic on day 5 post-admission and subsequent blood cultures were negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Blood pressure control was achieved with bisoprolol and nifedipine, after which the transcoarctation systolic gradient was reduced to 40 mmHg.</p><p id="par0040" class="elsevierStylePara elsevierViewall">At week 2 post-admission, the clinical course was complicated by sudden onset of gastrointestinal (GI) bleeding (Hb 7.4 g/dl) leading to disseminated intravascular coagulopathy, requiring plasma and red blood cell transfusions. Normalization of hematological parameters was eventually achieved, and total parenteral nutrition was required for 10 days. Despite adequate diuresis under furosemide and spironolactone, worsening renal function ensued, which was characterized by high creatinine levels, slightly raised urea levels, nephrotic proteinuria and hematuria, and hypoalbuminemia. This was managed with prednisolone and, by week 3, renal function improved and normalized. The patient completed a total of six weeks of intravenous floxacillin and was discharged home on prednisolone, bisoprolol and nifedipine.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Additional imaging studies such as abdominal ultrasound, Computerized Tomography and Magnetic Resonance scans were performed (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">In children, aortic endarteritis is an exceedingly rare condition even in the context of congenital heart disease, particularly as a source of systemic embolization, as was the case with our patient. Due to its rarity, no precise incidence is known, with very few cases found in literature. As is the case with endocarditis, endarteritis is a severe complication in a child with a structural heart defect where the mortality rate is <10% if the diagnosis is made early or approximately 25% if made at a later stage. Mortality is mostly due to congestive heart failure or systemic embolization complications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The authors wish to highlight this rare form of endarteritis and, in particular, in the context of systemic embolization resulting in multiple organ failure. In this case, endarteritis at the coarctation site explained why systemic embolization was limited to the lower part of the body, causing a lower limb purpuric rash, renal insufficiency and GI bleeding. As congenital heart disease is a risk factor for endocarditis, it is imperative to rule out cardiovascular etiology for the embolic phenomenon.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first reported case of <span class="elsevierStyleItalic">Staphylococcus schleiferi</span> endarteritis originating at the site of a native aortic coarctation.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1041023" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec994082" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1041024" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec994081" "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" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-08" "fechaAceptado" => "2017-06-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec994082" "palabras" => array:4 [ 0 => "Infective endarteritis" 1 => "Native aortic coarctation" 2 => "Thromboembolic infarcts" 3 => "<span class="elsevierStyleItalic">Staphylococcus schleiferi</span>" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec994081" "palabras" => array:4 [ 0 => "Endarterite infecciosa" 1 => "Coartação da aorta nativa" 2 => "Enfartes tromboembólicos" 3 => "<span class="elsevierStyleItalic">Staphylococcus schleiferi</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infective endocarditis is a microbial infection of the endocardium and it is rare in the pediatric population. In children, congenital heart disease is one of the most important risk factors for developing infective endocarditis and can involve other structures in addition to cardiac valves. The prognosis is generally better than in other forms of endocarditis, although the average mortality rate in the pediatric population is 15-25%. Clinical manifestations can mimic other diseases such as meningitis and collagen-vascular disease or vasculitis. Therefore, a high degree of suspicion is required to make an early diagnosis. Gram-positive bacteria, specifically alpha-hemolytic streptococci, <span class="elsevierStyleItalic">Staphylococcus aureus</span> and coagulase-negative staphylococci, are the most commonly involved bacteria. Diagnosis is based on the modified Duke criteria, which rely mostly on clinical assessment, echocardiography and blood cultures. Antibacterial treatment should ideally be targeted. However, if no specific bacteria have been identified, patients should promptly be treated empirically with multiple drug regimens based on local resistance and the most common etiologies.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors describe a case of a seven-year-old girl with classic clinical signs of endocarditis, with a clinical twist.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite infecciosa é uma infecção microbiana do endocárdio e é rara na população pediátrica. Nessa faixa etária, a doença cardíaca congénita é um dos fatores de risco mais importantes para o desenvolvimento de endocardite infecciosa, pode envolver outras estruturas para além das válvulas cardíacas. O prognóstico é geralmente melhor do que noutras formas de endocardite, embora a taxa média de mortalidade em população pediátrica seja em torno a de 15-25%. As manifestações clínicas podem mimetizar outras doenças, tais como meningite, vasculite ou doença vascular do colagénio, e, por conseguinte, é necessário um elevado grau de suspeita para fazer um diagnóstico precoce. Os microrganismos mais frequentemente implicados são as bactérias gram-positivas, especificamente os estreptococos alfa-hemolíticos, <span class="elsevierStyleItalic">Staphylococcus aureus</span> e estafilococos coagulase-negativos. O diagnóstico baseia-se nos critérios de Duke modificados, que dependem principalmente da avaliação clínica, da ecocardiografia e de hemoculturas. O tratamento antibacteriano deve ser orientado ao microrganismo em causa. No entanto, na ausência de organismos identificados, o tratamento empírico não deve ser adiado, devem-se usar diferentes combinações de antibióticos e ter em conta as resistências locais e etiologias mais frequentes. Os autores descrevem um caso de uma menina de sete anos com sinais clínicos clássicos de endocardite, com uma reviravolta clínica.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1616 "Ancho" => 2501 "Tamanyo" => 258374 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Purpuric rash and edema of both feet.</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" => 1105 "Ancho" => 2501 "Tamanyo" => 246518 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CT scan. A – sagittal view showing the aortic coarctation (arrow); B – coronal view showing the splenic and renal low-density areas, suggestive of infarcts (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis-endarteritis complicating coarctation of the aorta" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Franco-Paredes" 1 => "K. Workowski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "2002" "volumen" => "112" "paginaInicial" => "590" "paginaFinal" => "592" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12015258" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis in the grown-up congenital heart (GUCH) population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W. Li" 1 => "J. Sommerville" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "1998" "volumen" => "19" "paginaInicial" => "166" "paginaFinal" => "173" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9503191" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infective endocarditis in congenital heart disease: Japanese national collaboration study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Niwa" 1 => "M. Nakazawa" 2 => "S. Tateno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2004.043323" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2005" "volumen" => "91" "paginaInicial" => "795" "paginaFinal" => "800" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15894782" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic coarctation endarteritis in an adult: case report with cardiovascular magnetic resonance imaging findings and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Anderson" 1 => "C.H. Cabell" 2 => "D.J. Sexton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/427147" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2005" "volumen" => "40" "paginaInicial" => "e28" "paginaFinal" => "e31" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15712067" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000005/v1_201806100418/S2174204918301703/v1_201806100418/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000005/v1_201806100418/S2174204918301703/v1_201806100418/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918301703?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 27 | 21 | 48 |
| 2024 September | 35 | 23 | 58 |
| 2024 August | 35 | 24 | 59 |
| 2024 July | 34 | 27 | 61 |
| 2024 June | 30 | 17 | 47 |
| 2024 May | 40 | 22 | 62 |
| 2024 April | 41 | 23 | 64 |
| 2024 March | 30 | 22 | 52 |
| 2024 February | 40 | 22 | 62 |
| 2024 January | 24 | 25 | 49 |
| 2023 December | 22 | 27 | 49 |
| 2023 November | 32 | 21 | 53 |
| 2023 October | 22 | 13 | 35 |
| 2023 September | 24 | 14 | 38 |
| 2023 August | 24 | 16 | 40 |
| 2023 July | 21 | 9 | 30 |
| 2023 June | 22 | 14 | 36 |
| 2023 May | 30 | 23 | 53 |
| 2023 April | 21 | 9 | 30 |
| 2023 March | 40 | 21 | 61 |
| 2023 February | 29 | 11 | 40 |
| 2023 January | 27 | 27 | 54 |
| 2022 December | 36 | 29 | 65 |
| 2022 November | 42 | 25 | 67 |
| 2022 October | 37 | 37 | 74 |
| 2022 September | 32 | 43 | 75 |
| 2022 August | 27 | 31 | 58 |
| 2022 July | 38 | 41 | 79 |
| 2022 June | 27 | 25 | 52 |
| 2022 May | 37 | 33 | 70 |
| 2022 April | 53 | 35 | 88 |
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| 2022 February | 38 | 38 | 76 |
| 2022 January | 28 | 27 | 55 |
| 2021 December | 39 | 34 | 73 |
| 2021 November | 42 | 36 | 78 |
| 2021 October | 30 | 35 | 65 |
| 2021 September | 22 | 23 | 45 |
| 2021 August | 28 | 32 | 60 |
| 2021 July | 24 | 21 | 45 |
| 2021 June | 40 | 28 | 68 |
| 2021 May | 58 | 42 | 100 |
| 2021 April | 76 | 50 | 126 |
| 2021 March | 43 | 29 | 72 |
| 2021 February | 39 | 21 | 60 |
| 2021 January | 27 | 15 | 42 |
| 2020 December | 27 | 9 | 36 |
| 2020 November | 23 | 18 | 41 |
| 2020 October | 15 | 10 | 25 |
| 2020 September | 51 | 13 | 64 |
| 2020 August | 13 | 11 | 24 |
| 2020 July | 43 | 7 | 50 |
| 2020 June | 35 | 7 | 42 |
| 2020 May | 27 | 9 | 36 |
| 2020 April | 26 | 11 | 37 |
| 2020 March | 43 | 11 | 54 |
| 2020 February | 66 | 11 | 77 |
| 2020 January | 44 | 5 | 49 |
| 2019 December | 25 | 5 | 30 |
| 2019 November | 27 | 7 | 34 |
| 2019 October | 50 | 4 | 54 |
| 2019 September | 20 | 10 | 30 |
| 2019 August | 18 | 15 | 33 |
| 2019 July | 37 | 9 | 46 |
| 2019 June | 23 | 18 | 41 |
| 2019 May | 42 | 10 | 52 |
| 2019 April | 12 | 14 | 26 |
| 2019 March | 17 | 12 | 29 |
| 2019 February | 29 | 8 | 37 |
| 2019 January | 59 | 6 | 65 |
| 2018 December | 54 | 9 | 63 |
| 2018 November | 68 | 22 | 90 |
| 2018 October | 62 | 42 | 104 |
| 2018 September | 34 | 13 | 47 |
| 2018 August | 40 | 5 | 45 |
| 2018 July | 17 | 7 | 24 |
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