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Cardiac papillary fibroelastoma: Report of a surgical series
Fibroelastoma papilar cardíaco: relato de uma série cirúrgica
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"Rodrigues" "email" => array:1 [ 0 => "joaninhacatarina@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "João" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Jorge" "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Manuel" "apellidos" => "Campelo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Paulo" "apellidos" => "Pinho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Cardiology, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiothoracic Surgery Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Fibroelastoma papilar cardíaco: relato de uma série cirúrgica" ] ] "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" => 1831 "Ancho" => 2092 "Tamanyo" => 430362 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Papillary fibroelastoma of the aortic valve. (A and B) Transesophageal echocardiographic view; (C) photograph of the lesion in situ in the operating room; (D) tumor 1.0 mm×0.8 mm×0.5 mm with characteristic flower-like appearance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Papillary fibroelastoma (PFE) is a rare primary benign tumor of cardiac origin, accounting for approximately 10% of all cardiac tumors.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> They can occur anywhere on the endocardium, but are more common in the left heart and display a predilection for valve structures, the aortic valve being most commonly affected.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Although most patients are asymptomatic, serious complications may occur such as acute valve dysfunction or embolization, giving rise to a wide variety of presenting features including neurologic events, acute coronary syndrome and distal embolic events.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Thanks to improved echocardiographic resolution and modern imaging modalities, these tumors are increasingly often recognized. It is therefore possible that the real incidence of PFE is underestimated.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> Clinicians must be able to decide how to manage patients with incidental echocardiographic findings as well as those with symptoms that may be attributed to these masses. Few systematic reviews or comprehensive studies have provided results that validate either a medical or a surgical approach, although in an recent single-center retrospective study, Tamin et al. concluded that patients with echocardiographically suspected PFE who do not undergo surgical removal have higher rates of cerebrovascular accident and mortality.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> Given that there have been no randomized clinical trials aimed at defining the optimal treatment strategy, we decided to review our institution's surgical experience with PFE over an 18-year period. We present our findings and discuss demographic, clinical and echocardiographic characteristics and current treatment approaches along with results of our follow-up assessments.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a retrospective review of all patients diagnosed with cardiac PFE who underwent surgical excision at our institution between January 1997 and December 2015. Patients were identified from the cardiovascular surgery and pathology databases. Cardiac PFE was the primary indication for surgery, and therefore patients undergoing heart surgery for other reasons in which the tumor was a additional finding were excluded from our study. Clinical histories, echocardiographic reports, operative notes and histopathologic findings were reviewed. Demographic characteristics including age and gender, clinical data including presenting symptoms, concurrent cardiac disease, comorbidities, tumor location and left ventricular ejection fraction, operative procedures, and follow-up findings were collected. Since all patients with PFE diagnosed pathologically from surgical specimens had at least one transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE) leading to the diagnosis, the echocardiographic characteristics of the tumor including location, number, attachment characteristics, movement, size and valvular involvement were also collected. A presumed diagnosis of cardiac PFE by echocardiography was based on its appearance, which is usually of a small, mobile, pedunculated or sessile valvular or endocardial mass that frequently flutters or prolapses into the cardiac chambers during systole or diastole. They may appear speckled with echolucencies and a stippled pattern near the edges, which correlates with the papillary projections on the surface of the mass.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Neurologic events were attributed to the PFE in patients with no concurrent atrial fibrillation and no significant carotid or cardiac disease. Follow-up data were collected from telephone interviews of patients. The endpoints were clinical embolic events, need for further cardiac surgery due to tumor recurrence, or death at follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Results are expressed as mean ± standard deviation for continuous variables. Selected variables were compared between groups by the Student's t test for unpaired data when a normal distribution was demonstrated; otherwise, the nonparametric Mann-Whitney U test was used. Categorical variables are summarized as count and percentages and compared between groups using the Pearson chi-square or Fisher's exact test, as appropriate. Statistical significance was set at p<0.05. Data were analyzed using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, NY, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">A total of 26 patients, 18 male (69.2%), mean age 54.3±18.4 years (range 24-88 years), underwent surgical excision of one or more cardiac PFE between 1997 (first record of PFE in our database) and 2015 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Over the years, increasingly frequent identification of PFE was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), with the largest number of cases diagnosed in 2012 (n=6). None of the patients had undergone previous cardiac surgery and the most common cardiac comorbidities were hypertension, hyperlipidemia and diabetes.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">All tumors from the 26 patients included in this report were confirmed histopathologically as PFE following complete excision. In 26 patients, there were 28 lesions; 24 patients had solitary tumors located on valves (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Tumor size varied from 3 mm to 22 mm (mean 9.9±3.7), 26.9% had a pedicle and 42.37% were mobile. The valve surface was the predominant location, comprising 92.3% of the total, with 53.8% on the mitral valve, followed by the aortic valve in 34.6%, left ventricular wall in 3.8% and right atrium in 3.8%. In one case (3.8%) the aortic valve and left ventricle were simultaneously involved. The majority of tumors arose in the left heart (96.2%). Clinically, PFE presented with neurologic deficits in eight cases (in which echocardiography was performed to exclude a cardiac embolic source), 65.4% were asymptomatic and were identified by routine echocardiography, and in one patient it presented as shortness of breath not directly related to the presence of a cardiac mass. The tumor was thus an incidental finding in most patients.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Stroke was the clinical presentation in 30.8% of cases; these patients were younger, aged 42±17 years (p=0.026). Patients with neurologic events had lesions ranging in size from less than 5 mm to 11 mm in diameter, and a pedicle was present in three patients. No other differences were found between these and asymptomatic patients. All these tumors were on the left side of the heart, with 75% on the mitral valve and 25% on the aortic valve. In these cases stroke was considered secondary to tumor embolism.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of 24 patients with isolated valvular PFE, none had valve dysfunction or other associated cardiac disease, and all had preserved left ventricular systolic function. Standard open-heart surgery under cardiopulmonary bypass was performed in all patients and successful complete surgical resection of PFE was achieved in all cases. In 21 of the 24 patients simple (shave) excision of the tumor was performed, while excision with valve repair was needed in three cases, but no valve replacement. Valve-sparing surgery was thus performed all cases. No other cardiac procedure was performed concomitantly and there were no major postoperative complications. The median postoperative follow-up was 61.4 (range 7-223) months. In self-reported telephone interviews no deaths, tumor recurrence or embolic events were documented.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Grossly, PFEs appeared as a single (multiple in only two cases) small mass (the largest was 22 mm in size, found in the oldest patient), with delicate, smooth, white papillary fronds, giving a sea anemone-like appearance when placed in water or saline or a flower-like appearance in situ (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Microscopically, the papillary fronds were narrow, slender and branching. These fronds, often prominent, surround a layer of myxoid matrix rich in acid mucopolysaccharide and an inner avascular, paucicellular connective core. The peripheral rim and the core contained coarse and fragmented elastic fibers (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Given the low incidence of these tumors and the lack of longitudinal follow-up studies, their natural history remains poorly understood.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Historically, PFE was first described as a “valvular tumor” in 1931 by Yater,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> and the term “papillary fibroelastoma” was introduced in 1975 by Cheitlin et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> In the past, most knowledge of cardiac tumors was based on postmortem studies, but nowadays, with modern echocardiography, such tumors are increasingly diagnosed in vivo. In recent years, several articles have been published providing more information on PFE.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,12,13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Macroscopically, PFE are characterized by multiple frond-like fibrous projections creating a sea anemone-like appearance when immersed in saline. Histologically, the tumor consists of an avascular fibroelastic core, made up of a hyalinized collagen matrix with a rim of smooth muscle cells and elastic fibers, lined by endocardial endothelium.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14,15</span></a> Although its etiology remains largely unknown, several hypotheses have been reported, including fibroblast infiltration with organization of mural thrombi, virally induced tumor growth and an endocardial response to mechanical trauma or radiation damage.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16–18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">PFEs most often arise from the valvular endocardium. Gowda et al. found PFEs on valvular surfaces in 84% of cases, although they can also appear on the papillary muscles, chordae tendineae, ventricular septum or endocardial surface.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Although the tumor can be found anywhere within the heart, in our series it was found primarily on cardiac valves, mitral more often than aortic, unlike other studies in which the aortic valve is the most frequent valve location.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,12,13</span></a> Most tumors were solitary, less than 10 mm in diameter, and found in older patients. Multiple lesions are uncommon; they may appear in the same location or in different sites (one patient in our series had two tumors on the aortic valve, and the other had one on the aortic valve and one on the left ventricle). A case report documented up to 40 PFE in both ventricles in one patient.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> In our review, echocardiographic features that suggest PFE with a high degree of suspicion are small size (usually <1.5 cm), attachment by a pedicle or stalk to the endocardium, and some degree of mobility. These characteristics are in agreement with published descriptions.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">PFE can be incidental discoveries on echocardiograms, computed tomography scans or magnetic resonance imaging. When symptomatic, they can present in a variety of ways, most commonly with cardiovascular symptoms. Most of our patients (65.4%) were asymptomatic; symptomatic cases (30.8%) were most often due to a thromboembolic cerebrovascular accident. Other documented embolic complications include retinal artery occlusion, myocardial infarction, ischemic extremity, and mesenteric ischemia. Others report symptoms resulting from partial or complete obstruction of valves, ventricular outflow tract, or blood vessels, leading to pulmonary edema, myocardial infarction, heart failure, syncope, or sudden death. PFE has also been associated with conduction abnormalities.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The management of PFE is the subject of debate but mainly depends on its clinical presentation. Surgical excision is recommended in symptomatic patients, regardless of tumor size. Excision is also recommended in patients undergoing cardiac surgery for other reasons. There is still no consensus on the management of asymptomatic patients. Mariscalco et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> proposed a management algorithm, selecting characteristics of the lesion other than location as the determinant for intervention. They suggest that mobile lesions, regardless of size, should be surgically excised given the higher risk of thromboembolic complications. Nonmobile lesions less than 1 cm in diameter can be managed expectantly or with anticoagulation. Although thrombi have been reported on the surface of fibroelastomas, there are no guidelines for evaluating the efficacy of anticoagulation or antiplatelet therapy in affected patients. Gowda et al. identified 25 patients with presumed PFE who did not undergo surgery and were managed with anticoagulation alone, and who had a poor outcome.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Although asymptomatic PFE can be managed with close echocardiographic follow-up, we believe that surgical excision is more often prudent given the severity of potential embolization, particularly with left-sided PFE. In addition, recurrence of PFE is very low.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although the rarity of this cardiac tumor means there are limited data available, the present study, to our knowledge, includes the largest series of patients with PFE in Portugal.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study limitations</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study is retrospective and relies on the database of a single institution to identify patients. Because it is a small series the association with clinical events is based on indirect evidence.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">PFE are uncommon tumors of the endocardium, primarily valvular. They are generally small and single but may be multiple and occur on any endocardial surface. Although mostly asymptomatic they can be associated with embolic events, and may cause other cardiovascular symptoms. Their characteristic echocardiographic appearance means they can readily be recognized. Successful surgical resection of valve tumors can be performed and the native valve can frequently be preserved. Management remains difficult because of the rarity of the tumor. Clinical decisions should be individualized and further studies with longer follow-up are needed. Although the optimal surgical approach remains the subject of debate, in light of our center's experience, surgical removal of the tumor by standard median sternotomy is a safe procedure and has excellent medium- and long-term results.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding sources</span><p id="par0100" class="elsevierStylePara elsevierViewall">There were no funding sources for this project.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1131842" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1064508" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1131843" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1064507" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding sources" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack385321" "titulo" => "Acknowledgment" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-09-20" "fechaAceptado" => "2018-02-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1064508" "palabras" => array:3 [ 0 => "Cardiac tumor" 1 => "Fibroelastoma" 2 => "Cardiovascular event" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1064507" "palabras" => array:3 [ 0 => "Tumor cardíaco" 1 => "Fibroelastoma" 2 => "Evento cardiovascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Papillary fibroelastoma (PFE) is a rare primary benign tumor of cardiac origin that predominantly affects the cardiac valves. Although most patients are asymptomatic, serious complications may result given their propensity for embolization. Advances in imaging technology have enabled earlier detection and more accurate characterization of these tumors. We report a case series, describing clinical presentation, treatment and outcome.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Institutional records of a tertiary center between 1997 and 2015 were reviewed for all patients diagnosed with PFE treated surgically and confirmed histologically. Demographic and clinical characteristics, echocardiography findings and treatment modalities were analyzed and recurrence at follow-up was studied.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 26 patients (69% male), aged 54±18 years, had a PFE. Clinically, PFE presented with neurologic deficits in eight cases and was asymptomatic in 65.4%. The mitral valve surface was the predominant tumor location (53.8%), followed by the aortic valve (34.6%). Tumor size ranged between 3 mm and 22 mm, 26.9% had a pedicle and 42.4% were mobile. All patients were treated successfully by complete resection, isolated in 88.5% and with valve repair in three cases. No other cardiac procedure was performed concomitantly and there were no major postoperative complications. Median follow-up was 61±49 months and no tumor recurrence or embolic events were documented.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fibroelastomas are generally small, single and detected by chance during routine imaging exams. Complete surgical resection of the tumor has an excellent prognosis and appears to be a good strategy.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Os fibroelastomas papilares (FP) são tumores benignos primários de origem cardíaca, que afetam predominantemente as válvulas. Embora a maioria dos doentes seja assintomática, podem ocorrer complicações graves por causa de sua propensão para embolizar. A melhoria das técnicas de imagem moderna permitiu a deteção precoce e melhor caracterização desses tumores. É nosso objetivo apresentar a casuística do Serviço, descrever a apresentação clínica, o tratamento e os resultados cirúrgicos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram revistos os dados institucionais entre 1997 e 2015, de todos os doentes com o diagnóstico de FP tratados cirurgicamente, com confirmação histológica. Foram analisadas as características demográficas, clínicas, ecocardiográficas e cirúrgicas. A recorrência durante o seguimento foi também objeto do estudo.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram identificados 26 doentes (69% homens), de 54±18 anos, com FP. O FP apresentou-se com deficit neurológico em oito doentes, nos restantes casos o diagnóstico foi casual. A superfície valvular mitral foi a localização mais frequente (53,8%), seguida da válvula aórtica (34,6%). A dimensão do tumor variou de 3 a 22 mm, 26,9% eram pediculados e a mobilidade estava presente em 42,4% dos casos. Todos os doentes foram tratados com resseção completa, isolada em 88,5% e com reparação valvular em três casos. Nenhum outro procedimento cardíaco foi feito concomitantemente e não se registaram complicações cardíacas <span class="elsevierStyleItalic">major</span> no pós-operatório. O período mediano de seguimento foi de 61±49 meses, não foi documentada recorrência do tumor nem de eventos embólicos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os fibroelastomas são geralmente pequenos, isolados e mais frequentemente detetados incidentalmente em exames de rotina. A recessão cirúrgica completa do tumor tem um excelente prognóstico e parece ser uma boa estratégia.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 995 "Ancho" => 1505 "Tamanyo" => 96840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Increased diagnosis of PF over the years with a peak of cases in 2012 (n=6).</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" => 1831 "Ancho" => 2092 "Tamanyo" => 430362 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Papillary fibroelastoma of the aortic valve. (A and B) Transesophageal echocardiographic view; (C) photograph of the lesion in situ in the operating room; (D) tumor 1.0 mm×0.8 mm×0.5 mm with characteristic flower-like appearance.</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" => 484 "Ancho" => 1205 "Tamanyo" => 91061 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Microscopic appearance of papillary fibroelastoma. (A) Panoramic view of the lesion showing avascular branching fronds lined by endothelial cells (hematoxylin/eosin stain, original magnification ×16); (B) the fronds consist of a fibrous core surrounded by loose connective tissue and an endothelial lining (hematoxylin/eosin stain, original magnification ×100).</p>" ] ] 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:1 [ "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"><span class="elsevierStyleItalic">Age in years, mean ± SD</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.3±18.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>25-40, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (34.6) \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"><span class="elsevierStyleHsp" style=""></span>41-60, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>61-80, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (38.5) \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"><span class="elsevierStyleHsp" style=""></span>81-90, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Caucasian, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous cardiac surgery, n (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Cardiac comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertension, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (30.8) \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"><span class="elsevierStyleHsp" style=""></span>Hyperlipidemia, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Smoking, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (26.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Heart failure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Heart rhythm</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sinus rhythm, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (96.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atrial fibrillation, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical presentation</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Neurologic deficits, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (30.8) \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"><span class="elsevierStyleHsp" style=""></span>Asymptomatic, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (65.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1931065.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Baseline clinical characteristics of the study population (n=26).</p>" ] ] 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" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">LVEF: left ventricular ejection fraction; TTE: transthoracic echocardiography.</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="" 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">Study population, n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Reason for TTE</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Routine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (65.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exclude cardiac source of embolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (30.8) \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"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Location of lesion</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aortic valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (34.6) \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"><span class="elsevierStyleHsp" style=""></span>Mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (53.8) \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"><span class="elsevierStyleHsp" style=""></span>Right atrium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.8) \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"><span class="elsevierStyleHsp" style=""></span>Left ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.8) \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"><span class="elsevierStyleHsp" style=""></span>Aortic valve and ventricular myocardium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Number of lesions/patient</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (92.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Size</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><5 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.8) \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"><span class="elsevierStyleHsp" style=""></span>5-10 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (65.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11-15 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>15 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pedicle</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (26.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Mobility</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (57.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (19.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">LVEF >55%</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1931064.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic features of the study population (n=26).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benign cardiac tumors: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.A. Bruckner" 1 => "M.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 28 | 30 | 58 |
| 2024 September | 32 | 25 | 57 |
| 2024 August | 40 | 24 | 64 |
| 2024 July | 35 | 30 | 65 |
| 2024 June | 32 | 15 | 47 |
| 2024 May | 34 | 25 | 59 |
| 2024 April | 30 | 24 | 54 |
| 2024 March | 38 | 20 | 58 |
| 2024 February | 29 | 21 | 50 |
| 2024 January | 36 | 25 | 61 |
| 2023 December | 16 | 28 | 44 |
| 2023 November | 35 | 31 | 66 |
| 2023 October | 21 | 12 | 33 |
| 2023 September | 21 | 24 | 45 |
| 2023 August | 26 | 29 | 55 |
| 2023 July | 32 | 8 | 40 |
| 2023 June | 20 | 10 | 30 |
| 2023 May | 39 | 24 | 63 |
| 2023 April | 28 | 5 | 33 |
| 2023 March | 64 | 17 | 81 |
| 2023 February | 40 | 16 | 56 |
| 2023 January | 32 | 18 | 50 |
| 2022 December | 47 | 17 | 64 |
| 2022 November | 44 | 26 | 70 |
| 2022 October | 42 | 21 | 63 |
| 2022 September | 42 | 28 | 70 |
| 2022 August | 32 | 31 | 63 |
| 2022 July | 31 | 38 | 69 |
| 2022 June | 35 | 24 | 59 |
| 2022 May | 27 | 33 | 60 |
| 2022 April | 30 | 37 | 67 |
| 2022 March | 32 | 37 | 69 |
| 2022 February | 50 | 35 | 85 |
| 2022 January | 48 | 24 | 72 |
| 2021 December | 31 | 39 | 70 |
| 2021 November | 24 | 32 | 56 |
| 2021 October | 42 | 35 | 77 |
| 2021 September | 35 | 25 | 60 |
| 2021 August | 31 | 28 | 59 |
| 2021 July | 20 | 25 | 45 |
| 2021 June | 20 | 18 | 38 |
| 2021 May | 27 | 39 | 66 |
| 2021 April | 36 | 34 | 70 |
| 2021 March | 64 | 23 | 87 |
| 2021 February | 39 | 11 | 50 |
| 2021 January | 40 | 15 | 55 |
| 2020 December | 31 | 9 | 40 |
| 2020 November | 27 | 17 | 44 |
| 2020 October | 15 | 10 | 25 |
| 2020 September | 31 | 5 | 36 |
| 2020 August | 25 | 13 | 38 |
| 2020 July | 18 | 8 | 26 |
| 2020 June | 19 | 14 | 33 |
| 2020 May | 17 | 7 | 24 |
| 2020 April | 14 | 12 | 26 |
| 2020 March | 20 | 5 | 25 |
| 2020 February | 88 | 31 | 119 |
| 2020 January | 21 | 8 | 29 |
| 2019 December | 26 | 5 | 31 |
| 2019 November | 20 | 4 | 24 |
| 2019 October | 20 | 7 | 27 |
| 2019 September | 53 | 14 | 67 |
| 2019 August | 13 | 9 | 22 |
| 2019 July | 12 | 9 | 21 |
| 2019 June | 22 | 15 | 37 |
| 2019 May | 29 | 11 | 40 |
| 2019 April | 30 | 18 | 48 |
| 2019 March | 21 | 23 | 44 |
| 2019 February | 26 | 27 | 53 |
| 2019 January | 35 | 36 | 71 |
| 2018 December | 5 | 8 | 13 |
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