Case report
Dyspnea in antiphospholipid syndrome: Beyond pulmonary embolism
Dispneia na síndrome anticorpo antifosfolípido: para além da embolia pulmonar
Carolina Sepúlvedaa,b,
, Débora Repolhoc, Ana Margarida Antunesa, Anna Viola Taulaigoa, Filipa Carreiroa,d, Rui Cruz Ferreirae, Maria Francisca Moraes-Fontesa, Maria José Loureiroc
Corresponding author
a Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral – Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
b Serviço de Medicina Interna, Hospital de Abrantes – Centro Hospitalar Médio Tejo (CHMT), Abrantes, Portugal
c Unidade de Hipertensão Pulmonar, Serviço de Cardiologia – Hospital Garcia de Orta (HGO), Almada, Portugal
d Serviço de Medicina Interna – Hospital do Divino Espírito Santo (HDES), Ponta Delgada, Portugal
e Serviço de Cardiologia, Hospital de Santa Marta – CHLC, Lisboa, Portugal
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] ] 5 => array:3 [ "nombre" => "Rui Cruz" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "Maria Francisca" "apellidos" => "Moraes-Fontes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Maria José" "apellidos" => "Loureiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral – Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Medicina Interna, Hospital de Abrantes – Centro Hospitalar Médio Tejo (CHMT), Abrantes, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidade de Hipertensão Pulmonar, Serviço de Cardiologia – Hospital Garcia de Orta (HGO), Almada, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Serviço de Medicina Interna – Hospital do Divino Espírito Santo (HDES), Ponta Delgada, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Marta – CHLC, Lisboa, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Dispneia na síndrome anticorpo antifosfolípido: para além da embolia pulmonar" ] ] "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" => 1007 "Ancho" => 1674 "Tamanyo" => 223700 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Surgical specimen: fibrotic thrombi enveloped by thickened intima removed by pulmonary endarterectomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary embolism (PE) due to primary antiphospholipid syndrome (APS) may be associated with chronic thromboembolic pulmonary hypertension (CTEPH), a form of pulmonary hypertension (PH) characterized by impaired dissolution of thrombi due to pulmonary embolism (PE) persisting beyond 3-6 months of adequate anticoagulation.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1–4</span></a> CTEPH is a life-threatening condition of unpredictable onset,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> and, in the setting of APS, may occur soon after the thrombotic event.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> We report a young patient in whom CTEPH was diagnosed late in the course of the disease, with a favorable therapeutic outcome. Notwithstanding its rarity, we aim to raise awareness of the possibility of PH development in patients with APS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">In 1993, a previously healthy 20-year-old nulliparous female suffered a PE secondary to an unprovoked peripheral deep vein thrombosis (DVT), after which she was treated with warfarin for nine months. Three months later she suffered a second DVT. At this time inherited thrombophilia disorders were excluded, lupus anticoagulant was persistently positive and she was diagnosed with primary APS. Despite a recommendation for life-long anticoagulation with warfarin, she only adhered to the therapy for six months.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2003 (aged 30), she was referred to our unit. Although she was not taking any medication, no further thromboembolic episodes had occurred. Nevertheless, she was suffering from anorexia, anxiety and depression, and had been prescribed fluoxetine 20 mg/day. Warfarin was restarted. In 2006 (aged 33), 13 years after the PE, she began complaining of asthenia, fatigue and mild effort dyspnea, but there were no relevant findings on physical examination. Full blood count and liver and renal function tests were normal; transthoracic echocardiography (TTE) showed no anatomical or functional changes, including normal estimated pulmonary artery systolic pressure (PASP) on Doppler TTE; thoracic computed tomography (CT) revealed no signs of interstitial lung disease. Over the following years her symptoms slowly increased in severity and she was unable to work. Retrieved monthly international normalized ratio records ranged between 2.0 and 4.0 after 2006. The pattern in serial TTEs remained unchanged and her symptoms were consistently attributed to persistent depression.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2013 (aged 40), at a routine follow-up appointment, she complained of severe exertional dyspnea and palpitations. Physical examination revealed central cyanosis and tachycardia, and peripheral capillary oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) was under 90%. Blood tests showed polycythemia and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP). Doppler TTE showed an estimated PASP of 100 mmHg (normal <35 mmHg<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a>) and she was promptly referred to a specialist pulmonary hypertension center. Further investigations were as follows: pulmonary function tests were normal; the six-minute walk test (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) revealed normal chronotropic and inotropic competence on exertion but reduced functional performance (75% of normal)<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a>; the pulmonary ventilation/perfusion scan (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A) indicated subsegmental perfusion defects with preserved ventilation of all the left lobe segments and of the superior and posterior basal segments of the right lobe; CT angiography (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B) showed a subocclusive stenotic lesion at the origin of the left inferior lobar artery and bilateral involvement of lobar and peripheral branches; right heart catheterization (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) disclosed low cardiac output and index, elevated mean pulmonary artery pressure, pulmonary vascular resistance three times the upper limit of normal, and pulmonary artery wedge pressure below the threshold, overall indicative of moderate precapillary PH; and pulmonary angiography (Video 1) showed multiple filling defects with total occlusion of the left inferior lobar artery in addition to several segments of the right superior and inferior lobes.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Pulmonary endarterectomy was performed through a median sternotomy approach at an international reference center for CTEPH in March 2015, with full bilateral removal of thrombi and fibrotic material (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). There were no postoperative complications and follow-up tests (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) showed improvements in all parameters, most noticeably WHO functional class, six-minute walk distance, biochemical markers (NT-proBNP) and hemodynamic parameters on right heart catheterization.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">At the present time, more than two years after surgery, the patient is asymptomatic (WHO functional class I). Furthermore, her quality of life has improved significantly, allowing her to keep a full-time job. She remains under lifelong oral anticoagulation with warfarin without need for additional pulmonary vasodilator therapy.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion and Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">CTEPH is a rare disorder with a reported prevalence of 3 and 63 per million individuals in Europe and in the USA, respectively.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">9,10</span></a> Its incidence is low (reported as 0.57%<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> and 4-5%<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> after PE), and as it can occur up to two years after an acute thrombotic episode,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,6</span></a> routine screening for CTEPH after PE is not supported by current evidence.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Thrombus size, immune-mediated mechanisms, elevated factor VIII, thyroid replacement, structural cardiac abnormalities and malignancy have also been reported as being associated with CTEPH.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,13–15</span></a> However, its etiology remains unclear, as it may develop in the absence of PE,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16,17</span></a> despite adequate anticoagulation and in association with generalized pulmonary vasculopathy.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Of note, our patient was asymptomatic for 12 years after the last thrombotic event. Although cardiopulmonary symptoms were observed, their insidious nature led to misattribution to a depressive disorder. Detection of PH by TTE remains a challenge<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18,19</span></a> and we recognize that the patient might have benefited from an earlier diagnostic work-up. Moreover, she had various known risk factors for CTEPH, including several thrombotic episodes, a background of autoimmunity and a prolonged period of inadequate therapy, which collectively may have contributed to impaired thrombus resolution. Pulmonary endarterectomy is a complex surgical procedure, but it not only arrests the malignant natural course of the disease that results in premature mortality but also leads to hemodynamic and functional improvement.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2,5,20</span></a> Our patient requires life-long monitoring and anticoagulation, as there are no known prognostic markers that indicate the possibility of disease recurrence.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, CTEPH is rare but fatal if left untreated and there should therefore be a high level of suspicion for non-specific symptoms, despite the presence of depression and especially when there is a history of previous venous thromboembolism.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> APS and failure to adhere to anticoagulant therapy should raise the bar for CTEPH screening.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest or financial disclosures to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1336551" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1230766" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1336552" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1230765" "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 and Conclusions" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack462130" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-20" "fechaAceptado" => "2018-01-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1230766" "palabras" => array:4 [ 0 => "Antiphospholipid syndrome" 1 => "Pulmonary embolism" 2 => "Chronic thromboembolic pulmonary hypertension" 3 => "Pulmonary endarterectomy" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1230765" "palabras" => array:4 [ 0 => "Síndrome antifosfolípido" 1 => "Embolia pulmonar" 2 => "Hipertensão pulmonar tromboembólica crónica" 3 => "Hipertensão pulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary embolism due to primary antiphospholipid syndrome is rarely associated with chronic thromboembolic pulmonary hypertension, and therefore according to the latest guidelines on pulmonary hypertension, routine screening is not recommended. We describe a young patient with a late diagnosis of chronic thromboembolic pulmonary hypertension in the context of pulmonary embolism, primary antiphospholipid syndrome and suboptimal anticoagulation. Of note, mild cardiopulmonary symptoms were consistently misattributed to a depressive disorder because physical examination was normal, serial Doppler echocardiography failed to show pulmonary hypertension, and all other diagnostic tests were normal. Once symptoms became severe, positive screening tests led to the correct diagnosis and surgical referral, and bilateral pulmonary endarterectomy was successfully performed. This case demonstrates the need for extra awareness in patients with antiphospholipid syndrome and pulmonary embolism.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A embolia pulmonar devido à síndrome de anticorpo antifosfolípido raramente está associada a hipertensão pulmonar crónica tromboembólica, pelo que o seu rastreio não está recomendado pelas normas de orientação clínica atuais. Descreve-se o caso de uma doente jovem com o diagnóstico tardio de hipertensão pulmonar crónica tromboembólica no contexto de síndrome de anticorpo antifosfolípido primário e anticoagulação subterapêutica. A destacar que a sintomatologia cardiopulmonar de grau ligeiro foi incorretamente atribuída a humor depressivo devido à ausência de alterações no exame objetivo e nos meios complementares de diagnóstico, incluindo valores persistentemente normais de pressão sistólica da artéria pulmonar nos ecocardiogramas transtorácicos seriados. O agravamento sintomático progressivo conduziu à confirmação diagnóstica, após realização dos meios complementares de diagnóstico de rastreio, referenciação cirúrgica e realização de endarterectomia pulmonar bilateral com sucesso. Este caso demonstra a necessidade de uma vigilância mais apertada em doentes com síndrome de anticorpo antifosfolípido e embolia pulmonar.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0065" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1715 "Ancho" => 1740 "Tamanyo" => 210191 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Initial diagnostic procedures. (A) Pulmonary ventilation/perfusion scan with subsegmental perfusion defects (blue arrows) and preserved ventilation in the left lower lobe; (B) computed tomography angiography with a subocclusive stenotic lesion at the origin of the left inferior lobar artery (red arrows). Ant_P: anterior-posterior; L: left; Post-P: postero-posterior; R: right; RPO_P: right posterior oblique-posterior.</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" => 1007 "Ancho" => 1674 "Tamanyo" => 223700 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Surgical specimen: fibrotic thrombi enveloped by thickened intima removed by pulmonary endarterectomy.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CI (Fick): cardiac index by Fick's method; CO (Fick): cardiac output by Fick's method; MBS: modified Borg scale; mPAP: mean pulmonary arterial pressure; NT-proBNP: N-terminal pro-B-type natriuretic peptide; PASP: pulmonary artery systolic pressure; PAWP: pulmonary artery wedge pressure; PEA: pulmonary endarterectomy; PVR (Fick): pulmonary vascular resistance by Fick's method; SpO<span class="elsevierStyleInf">2</span>: peripheral capillary oxygen saturation; WHO: World Health Organization functional class.</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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnostic method \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Feature assessed \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Before PEA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 months after PEA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2 years after PEA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical symptoms</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Signs of right heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">WHO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6-min walk test</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distance, m (% of expected) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">450 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">480 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">480 (83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">600 (≥75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MBS</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>at rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><1</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>at peak effort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SpO<span class="elsevierStyleInf">2</span>, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blood test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NT-proBNP, pg/ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">489 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">165 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">193 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><153 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right heart catheterization</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">mPAP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PAWP, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CO (Fick), l/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CI (Fick), l/min/m<span class="elsevierStyleSup">2</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>2.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PVR (Fick), Wood units \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2291504.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Characterization of parameters and hemodynamics before and after pulmonary endarterectomy.</p>" ] ] 3 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Video 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1693070 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Left pulmonary angiography showing total occlusion of the left inferior lobe.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An update on the management of chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Edward" 1 => "S. Mandras" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cpcardiol.2016.11.001" "Revista" => array:6 [ "tituloSerie" => "Curr Probl Cardiol" "fecha" => "2017" "volumen" => "42" "paginaInicial" => "7" "paginaFinal" => "38" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27989311" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0110" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary endarterectomy in the management of chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Jenkins" 1 => "M. Madani" 2 => "E. Fadel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Eur Respir Rev" "fecha" => "2017" "volumen" => "26" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0115" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of the primary and secondary antiphospholipid syndrome: a European Multicenter Study of 114 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.L. Vianna" 1 => "M.A. Khamashta" 2 => "J. Ordi-Ros" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0002-9343(94)90108-2" "Revista" => array:6 [ "tituloSerie" => "Am J Med" "fecha" => "1994" "volumen" => "96" "paginaInicial" => "3" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8304360" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0120" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: the Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC) International Society for Heart and Lung Transplantation (ISHLT)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N. Galie" 1 => "M. Humbert" 2 => "J.L. Vachiery" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehv317" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "67" "paginaFinal" => "119" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26320113" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0125" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I.M. Robbins" 1 => "M.E. Pugh" 2 => "A.R. Hemnes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tcm.2016.05.010" "Revista" => array:6 [ "tituloSerie" => "Trends Cardiovasc Med" "fecha" => "2017" "volumen" => "27" "paginaInicial" => "29" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27345156" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0130" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. Pengo" 1 => "A.W. Lensing" 2 => "M.H. Prins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa032274" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2004" "volumen" => "350" "paginaInicial" => "2257" "paginaFinal" => "2264" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15163775" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0135" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Echocardiographic pulmonary artery pressure estimation and heart failure rehospitalization burden in patients with acute heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Santas" 1 => "R. de la Espriella-Juan" 2 => "A. Mollar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2017.04.055" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2017" "volumen" => "241" "paginaInicial" => "407" "paginaFinal" => "410" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28455131" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0140" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The 6-min walk test: a quick measure of functional status in elderly adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.L. Enright" 1 => "M.A. McBurnie" 2 => "V. Bittner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.123.2.387" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2003" "volumen" => "123" "paginaInicial" => "387" "paginaFinal" => "398" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12576356" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0145" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A review of clinical trial endpoints of patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension and how they relate to patient outcomes in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Divers" 1 => "D. Platt" 2 => "E. Wang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.18553/jmcp.2017.23.1.92" "Revista" => array:6 [ "tituloSerie" => "J Manag Care Spec Pharm" "fecha" => "2017" "volumen" => "23" "paginaInicial" => "92" "paginaFinal" => "104" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28025931" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0150" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Survival in pulmonary hypertension in Spain: insights from the Spanish registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Escribano-Subias" 1 => "I. Blanco" 2 => "M. Lopez-Meseguer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00101211" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2012" "volumen" => "40" "paginaInicial" => "596" "paginaFinal" => "603" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22362843" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0155" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective cardiopulmonary screening program to detect chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "F.A. Klok" 1 => "K.W. van Kralingen" 2 => "A.P. van Dijk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3324/haematol.2009.018960" "Revista" => array:6 [ "tituloSerie" => "Haematologica" "fecha" => "2010" "volumen" => "95" "paginaInicial" => "970" "paginaFinal" => "975" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20053871" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0160" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical treatment of chronic thromboembolic pulmonary hypertension: pulmonary thromboendarterectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.M. Madani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Methodist Debakey Cardiovasc J" "fecha" => "2016" "volumen" => "12" "paginaInicial" => "213" "paginaFinal" => "218" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0165" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High prevalence of elevated clotting factor VIII in chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Bonderman" 1 => "P.L. Turecek" 2 => "J. Jakowitsch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1160/TH03-02-0067" "Revista" => array:6 [ "tituloSerie" => "Thromb Haemost" "fecha" => "2003" "volumen" => "90" "paginaInicial" => "372" "paginaFinal" => "376" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12958604" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0170" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Bonderman" 1 => "H. Wilkens" 2 => "S. Wakounig" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00087608" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "325" "paginaFinal" => "331" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18799507" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0175" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors associated with diagnosis and operability of chronic thromboembolic pulmonary hypertension. A case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "I.M. Lang" 1 => "G. Simonneau" 2 => "J.W. Pepke-Zaba" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1160/TH13-02-0097" "Revista" => array:6 [ "tituloSerie" => "Thromb Haemost" "fecha" => "2013" "volumen" => "110" "paginaInicial" => "83" "paginaFinal" => "91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23677493" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0180" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Pepke-Zaba" 1 => "M. Delcroix" 2 => "I. Lang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.110.015008" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2011" "volumen" => "124" "paginaInicial" => "1973" "paginaFinal" => "1981" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21969018" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0185" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is pulmonary embolism a common cause of chronic pulmonary hypertension? Limitations of the embolic hypothesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Egermayer" 1 => "A.J. Peacock" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1034/j.1399-3003.2000.15.03.x" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2000" "volumen" => "15" "paginaInicial" => "440" "paginaFinal" => "448" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10759434" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0190" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary hypertension: echocardiographic assessment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Sciomer" 1 => "R. Badagliacca" 2 => "F. Fedele" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ital Heart J" "fecha" => "2005" "volumen" => "6" "paginaInicial" => "840" "paginaFinal" => "845" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16270477" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0195" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Follow-up of pulmonary hypertension with echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L.M. Wright" 1 => "N. Dwyer" 2 => "D. Celermajer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcmg.2016.02.022" "Revista" => array:6 [ "tituloSerie" => "JACC Cardiovasc Imaging" "fecha" => "2016" "volumen" => "9" "paginaInicial" => "733" "paginaFinal" => "746" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27282440" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0200" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on chronic thromboembolic pulmonary hypertension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I.M. Lang" 1 => "M. Madani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.114.009309" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2014" "volumen" => "130" "paginaInicial" => "508" "paginaFinal" => "518" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25092279" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack462130" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">Mr. David Jenkins, Clinical Director of Surgery and Consultant Cardiothoracic Surgeon at the Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom, was responsible for the pulmonary endarterectomy.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003900000001/v1_202005161338/S2174204920301069/v1_202005161338/en/main.assets" "Apartado" => array:4 [ "identificador" => "9914" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003900000001/v1_202005161338/S2174204920301069/v1_202005161338/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204920301069?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 58 | 40 | 98 |
| 2024 September | 45 | 26 | 71 |
| 2024 August | 109 | 41 | 150 |
| 2024 July | 43 | 31 | 74 |
| 2024 June | 23 | 23 | 46 |
| 2024 May | 36 | 20 | 56 |
| 2024 April | 22 | 23 | 45 |
| 2024 March | 24 | 23 | 47 |
| 2024 February | 33 | 24 | 57 |
| 2024 January | 35 | 28 | 63 |
| 2023 December | 49 | 18 | 67 |
| 2023 November | 47 | 38 | 85 |
| 2023 October | 16 | 12 | 28 |
| 2023 September | 20 | 27 | 47 |
| 2023 August | 33 | 14 | 47 |
| 2023 July | 28 | 13 | 41 |
| 2023 June | 24 | 10 | 34 |
| 2023 May | 30 | 32 | 62 |
| 2023 April | 21 | 4 | 25 |
| 2023 March | 35 | 20 | 55 |
| 2023 February | 20 | 18 | 38 |
| 2023 January | 18 | 18 | 36 |
| 2022 December | 40 | 29 | 69 |
| 2022 November | 38 | 22 | 60 |
| 2022 October | 46 | 27 | 73 |
| 2022 September | 31 | 38 | 69 |
| 2022 August | 18 | 14 | 32 |
| 2022 July | 26 | 39 | 65 |
| 2022 June | 25 | 29 | 54 |
| 2022 May | 30 | 26 | 56 |
| 2022 April | 18 | 31 | 49 |
| 2022 March | 22 | 34 | 56 |
| 2022 February | 25 | 39 | 64 |
| 2022 January | 18 | 29 | 47 |
| 2021 December | 19 | 34 | 53 |
| 2021 November | 28 | 38 | 66 |
| 2021 October | 43 | 51 | 94 |
| 2021 September | 24 | 28 | 52 |
| 2021 August | 21 | 27 | 48 |
| 2021 July | 13 | 17 | 30 |
| 2021 June | 25 | 27 | 52 |
| 2021 May | 27 | 30 | 57 |
| 2021 April | 66 | 47 | 113 |
| 2021 March | 18 | 18 | 36 |
| 2021 February | 16 | 11 | 27 |
| 2021 January | 27 | 16 | 43 |
| 2020 December | 29 | 18 | 47 |
| 2020 November | 29 | 17 | 46 |
| 2020 October | 24 | 22 | 46 |
| 2020 September | 41 | 13 | 54 |
| 2020 August | 16 | 13 | 29 |
| 2020 July | 29 | 6 | 35 |
| 2020 June | 18 | 12 | 30 |
| 2020 May | 24 | 10 | 34 |
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