array:24 [
  "pii" => "S0870255112003393"
  "issn" => "08702551"
  "doi" => "10.1016/j.repc.2012.06.016"
  "estado" => "S300"
  "fechaPublicacion" => "2013-03-01"
  "aid" => "234"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2011"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "sco"
  "cita" => "Rev Port Cardiol. 2013;32:257-9"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 6639
    "formatos" => array:3 [
      "EPUB" => 176
      "HTML" => 5402
      "PDF" => 1061
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S0870255113000280"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.08.012"
    "estado" => "S300"
    "fechaPublicacion" => "2013-03-01"
    "aid" => "244"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:261-3"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4056
      "formatos" => array:3 [
        "EPUB" => 178
        "HTML" => 3053
        "PDF" => 825
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Images in cardiology</span>"
      "titulo" => "Is it too late to treat me&#63;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "261"
          "paginaFinal" => "263"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "&#201; tarde demais para ser tratado&#63;"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 2033
              "Ancho" => 3167
              "Tamanyo" => 1305537
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ECG-gated cardiac computed tomography of our patient showing the natural history of a left untreated type 1 endoleak &#40;arrowhead&#41; at the proximal edge of a stent-graft in the aortic arch &#40;Ao&#41;&#46; Upper panel &#40;A1&#8211;C1&#41; presents three-dimensional reconstructions &#40;volume-rendering technique&#41;&#59; lower panel &#40;A2&#8211;C2&#41; presents the corresponding images in the axial plane &#40;maximum intensity projection&#41;&#46; Over time &#40;from A to C&#41;&#44; the aneurysmal sac &#40;&#42;&#41; continued to be pressurized and expanded towards the chest wall&#44; ultimately causing erosion of the second left rib &#40;box&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Eul&#225;lia Pereira, Pedro Braga, Gustavo Pires Morais, Nuno Bettencourt, Jo&#227;o Primo, Lu&#237;s Vouga, Vasco Gama"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "Eul&#225;lia"
              "apellidos" => "Pereira"
            ]
            1 => array:2 [
              "nombre" => "Pedro"
              "apellidos" => "Braga"
            ]
            2 => array:2 [
              "nombre" => "Gustavo"
              "apellidos" => "Pires Morais"
            ]
            3 => array:2 [
              "nombre" => "Nuno"
              "apellidos" => "Bettencourt"
            ]
            4 => array:2 [
              "nombre" => "Jo&#227;o"
              "apellidos" => "Primo"
            ]
            5 => array:2 [
              "nombre" => "Lu&#237;s"
              "apellidos" => "Vouga"
            ]
            6 => array:2 [
              "nombre" => "Vasco"
              "apellidos" => "Gama"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000280?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000003/v1_201308021313/S0870255113000280/v1_201308021313/en/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S0870255112003198"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.12.005"
    "estado" => "S300"
    "fechaPublicacion" => "2013-03-01"
    "aid" => "215"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:253-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 15622
      "formatos" => array:3 [
        "EPUB" => 156
        "HTML" => 13805
        "PDF" => 1661
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
      "titulo" => "Hipertens&#227;o pulmonar&#44; insufici&#234;ncia card&#237;aca e hipertiroidismo&#58; caso cl&#237;nico"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "253"
          "paginaFinal" => "256"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Pulmonary hypertension&#44; heart failure and hyperthyroidism&#58; A case report"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 672
              "Ancho" => 1300
              "Tamanyo" => 95785
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ecocardiograma transtor&#225;cico&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ana Baptista, Rui Pedro Costa, Catarina Ferreira, Pedro Mateus, Ant&#243;nio Trigo Faria, Il&#237;dio Moreira"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Baptista"
            ]
            1 => array:2 [
              "nombre" => "Rui Pedro"
              "apellidos" => "Costa"
            ]
            2 => array:2 [
              "nombre" => "Catarina"
              "apellidos" => "Ferreira"
            ]
            3 => array:2 [
              "nombre" => "Pedro"
              "apellidos" => "Mateus"
            ]
            4 => array:2 [
              "nombre" => "Ant&#243;nio"
              "apellidos" => "Trigo Faria"
            ]
            5 => array:2 [
              "nombre" => "Il&#237;dio"
              "apellidos" => "Moreira"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204913000561"
        "doi" => "10.1016/j.repce.2013.03.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913000561?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003198?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000003/v1_201308021313/S0870255112003198/v1_201308021313/pt/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Coronary fistula to the right atrium&#58; A challenge for the interventional cardiologist"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "257"
        "paginaFinal" => "259"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Edite S&#46; Gon&#231;alves, Cl&#225;udia C&#46; Moura, Jorge A&#46; Moreira, Jo&#227;o A&#46; Silva"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "Edite"
            "apellidos" => "S&#46; Gon&#231;alves"
            "email" => array:1 [
              0 => "editesg&#64;gmail&#46;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" => "Cl&#225;udia"
            "apellidos" => "C&#46; Moura"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Jorge A&#46;"
            "apellidos" => "Moreira"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Jo&#227;o"
            "apellidos" => "A&#46; Silva"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Servi&#231;o de Cardiologia Pedi&#225;trica&#44; Hospital de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servi&#231;o de Cardiologia&#44; Hospital de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "F&#237;stula coron&#225;ria para a aur&#237;cula direita&#58; um desafio para o cardiologista de interven&#231;&#227;o"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 848
            "Ancho" => 900
            "Tamanyo" => 55831
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">With the duct occluder device in place &#40;arrowhead&#41;&#44; a residual shunt is seen through the second orifice &#40;arrow&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary fistulas are rare congenital heart malformations that result in a connection between one or more of the coronary arteries and a cardiac chamber or great vessel&#44; bypassing the myocardial capillary bed&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In about half of cases the fistula originates from the right coronary artery&#44; in one third from the left anterior descending artery and in about one-fifth from the circumflex artery&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The majority drain to the right side of the heart&#46; Drainage&#44; which can occur through one or multiple orifices&#44; is more frequently into the right ventricle&#44; followed by drainage into the right atrium&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Either of these possibilities will cause volume overload in right-sided structures and increased pulmonary vascular flow&#44; similar to a left-to-right shunt from an atrial septal defect&#44; ventricular septal defect or patent <span class="elsevierStyleItalic">ductus arteriosus</span>&#46; Coronary fistulas are usually asymptomatic until the second decade of life&#46; Occasionally a continuous murmur can be heard or cardiomegaly may be accidentally detected on a chest X-ray&#46; Myocardial ischemia is also a possibility&#44; usually in adult patients&#44; due to coronary artery steal&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Other complications may include thrombosis&#44; embolism&#44; cardiac failure&#44; atrial fibrillation&#44; aneurysmal dilatation and rupture&#44; endocarditis&#44; endarteritis or arrhythmias&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Although the electrocardiogram &#40;ECG&#41; and chest X-ray can be helpful and cardiac magnetic resonance imaging is of increasing importance&#44; the main diagnostic technique remains cardiac catheterization and angiography&#44; which provides information regarding the hemodynamic significance&#44; location and size of the fistula&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Interventional catheterization techniques and surgery are both useful in closure of these vascular abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A ten-year-old girl with no previous relevant medical history was referred for a pediatric cardiology assessment due to increased cardiothoracic ratio of 0&#46;6&#46; On physical examination she presented a grade 2&#47;6 continuous murmur at the upper and middle sternal border and normal arterial pulses&#46; The ECG was normal and the echocardiogram revealed a tubular structure &#40;fistula&#41; from the aorta to the right atrium&#46; The right-sided chambers were slightly enlarged but ventricular contractility was normal&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was referred for a diagnostic cardiac catheterization&#46; Angiography confirmed a coronary fistula measuring 13 mm in diameter at the aortic end and draining into the right atrium &#40;RA&#41; through at least two small openings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The left anterior descending &#40;LAD&#41; and circumflex &#40;Cx&#41; arteries originated in the proximal extremity of the fistula through two separate orifices&#46; Catheterization showed normal right and left heart pressures&#44; oxygen saturation step-up in the right atrium and Qp&#58;Qs of 1&#46;7&#46; Informed consent was obtained and percutaneous closure of the fistula was attempted using a 16 mm Amplatzer<span class="elsevierStyleSup">&#174;</span> vascular plug II &#40;AGA Medical&#41;&#46; Through a femoral approach&#44; a 7 Fr venous and a 6 Fr arterial sheath were used&#46; A 6 Fr Concierge Amplatz Left 2 guiding catheter was positioned in the aorta at the fistula entrance and a 0&#46;035 in Terumo<span class="elsevierStyleSup">&#174;</span> hydrophilic guide wire was advanced along the fistula&#44; until the right atrium was reached&#46; The wire was then snared and an arteriovenous &#40;AV&#41; loop was created&#46; A 7 Fr Amplatzer Delivery System was used to deploy the device through the atrial end &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; A significant residual shunt was observed after deployment of the device&#46; Cardiac enzymes were within normal range and the ECG showed no abnormalities&#46; After this procedure anticoagulation was prescribed for six months and aspirin maintained thereafter&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Regular follow-up was performed and transthoracic echocardiography detected a residual shunt at the distal extremity of the fistula&#46; One year after the first intervention&#44; angiography was repeated and two small orifices were clearly seen in the extremity where the fistula drained into the right atrium&#46; Percutaneous closure of these orifices was attempted&#46; A 6 Fr venous sheath and a 6 Fr arterial sheath were used through a femoral approach&#46; Two guide wires were advanced from the aortic end to the atrial end&#44; one through each orifice&#44; and two arteriovenous loops were created&#46; Two 6 Fr Concierge Amplatz Left 2 guiding catheters were introduced in the distal extremity of the fistula&#46; An 8&#47;6 mm Amplatzer<span class="elsevierStyleSup">&#174;</span> duct occluder &#40;AGA Medical&#41; was deployed through the atrial end to close the lower orifice &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; The upper orifice was left open&#44; due to dislocation and instability in the position of the guiding catheter in the distal part of the fistula&#44; and the long duration of the procedure&#46; Control angiography showed a residual shunt through the upper orifice&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Nine months after the second intervention&#44; coronary angiography was repeated&#46; No fistulous flow was detected&#44; the fistula being occluded 2 cm before the emergence of the Cx artery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; LAD and Cx artery flows were normal&#46; Following the second procedure the patient remains asymptomatic and well&#46; Antiplatelet therapy with aspirin was continued&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Complications related to coronary artery fistulas have been used as an argument to justify intervention&#44; either surgical or percutaneous&#46; Indications for closure include the presence of a large left-to-right shunt&#44; left ventricular volume overload&#44; left ventricular dysfunction&#44; myocardial ischemia&#44; congestive cardiac failure&#44; and prevention of endocarditis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> Several devices have been used for percutaneous closure of these vascular malformations&#44; including the Amplatzer<span class="elsevierStyleSup">&#174;</span> vascular plug&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Amplatzer<span class="elsevierStyleSup">&#174;</span> duct occluder&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Amplatzer<span class="elsevierStyleSup">&#174;</span> muscular VSD device and coils&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> but controversy remains as to the best approach&#46; The choice of equipment&#44; device and technique clearly depend on the morphology of the lesion&#44; the experience of the attending cardiologist&#44; and the patient&#39;s age and size&#46; This case report highlights the difficulty the interventional cardiologist faces when approaching these malformations&#44; since two devices had to be implanted before occlusion of the coronary fistula could be achieved&#46; Although a small orifice was left open after the second percutaneous intervention due to technical difficulties in the placement of the catheter&#44; a successful result was achieved&#46; A possible explanation for this could be the sudden decrease of flow after occlusion of one of the orifices at the atrial extremity of the fistula&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Possible complications of closure of a coronary artery fistula include embolization of the device&#44; myocardial ischemia and ECG abnormalities including T-wave changes and bundle branch block&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:2 [
          "identificador" => "xres250657"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec238223"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres250656"
          "titulo" => "Resumo"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec238224"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case report"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conflicts of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-11-29"
    "fechaAceptado" => "2012-06-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec238223"
          "palabras" => array:4 [
            0 => "Cardiac catheterization"
            1 => "Pediatric"
            2 => "Intervention"
            3 => "Device"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec238224"
          "palabras" => array:4 [
            0 => "Cateterismo card&#237;aco"
            1 => "Pedi&#225;trico"
            2 => "Interven&#231;&#227;o"
            3 => "Dispositivo"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital coronary fistulas are rare conditions&#44; frequently diagnosed as an incidental finding when a patient is referred for cardiac surgery for another reason&#46; Treatment can be conservative&#44; surgical or more recently through transcatheter closure&#44; depending on local experience and the morphology of the fistula&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors present the case of a pediatric patient with a large coronary artery fistula from the aorta to the right atrium&#46; Transcatheter closure with a 16 mm Amplatzer<span class="elsevierStyleSup">&#174;</span> vascular plug II and a 6 mm Amplatzer<span class="elsevierStyleSup">&#174;</span> duct occluder was performed&#44; with complete occlusion&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">As f&#237;stulas coron&#225;rias cong&#233;nitas constituem uma patologia rara&#44; frequentemente de diagn&#243;stico acidental&#44; por exemplo durante uma cirurgia card&#237;aca por outro motivo&#46; A terap&#234;utica pode ser conservadora&#44; cir&#250;rgica ou por interven&#231;&#227;o percut&#226;nea&#44; dependendo da experi&#234;ncia local ou da morfologia da f&#237;stula&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#201; apresentado um caso de um paciente pedi&#225;trico com um diagn&#243;stico de f&#237;stula coron&#225;ria gigante da aorta com drenagem na aur&#237;cula direita&#46; Foi efetuado encerramento percut&#226;neo com um dispositivo Amplatzer<span class="elsevierStyleSup">&#174;</span> Vascular Plug II de 16 mm e um dispositivo Amplatzer Duct Occluder de 6 mm&#44; com oclus&#227;o total da f&#237;stula&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 935
            "Ancho" => 900
            "Tamanyo" => 63561
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aortogram with a 5 Fr pigtail angiographic catheter showing drainage of the fistula into the RA through two separate orifices&#46;</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" => 901
            "Ancho" => 900
            "Tamanyo" => 66223
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Angiography in the fistula with the device still attached &#40;arrow&#41;&#44; showing drainage into the RA through a second orifice &#40;arrowhead&#41;&#46;</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" => 848
            "Ancho" => 900
            "Tamanyo" => 55831
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">With the duct occluder device in place &#40;arrowhead&#41;&#44; a residual shunt is seen through the second orifice &#40;arrow&#41;&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 943
            "Ancho" => 900
            "Tamanyo" => 64244
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Control angiography nine months after the second intervention&#46; The fistula is closed &#40;arrow&#41; and the origin of the LAD and Cx arteries is clearly seen in two separate ostia &#40;arrowheads&#41;&#46; The devices are still in place&#44; visible on the left&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:7 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Arterio-venous fistulas and related conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;A&#46; Qureshi"
                            1 => "J&#46;F&#46; Reidy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Paediatric cardiology"
                        "paginaInicial" => "753"
                        "paginaFinal" => "774"
                        "serieFecha" => "2010"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coronary artery fistulas&#58; how to manage them"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46;A&#46; Latson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ccd.21125"
                      "Revista" => array:6 [
                        "tituloSerie" => "Catheter Cardiovasc Interv"
                        "fecha" => "2007"
                        "volumen" => "70"
                        "paginaInicial" => "110"
                        "paginaFinal" => "116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17420995"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Catheter closure of coronary artery fistulas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;A&#46; Qureshi"
                            1 => "M&#46; Tynan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Interv Cardiol"
                        "fecha" => "2001"
                        "volumen" => "14"
                        "paginaInicial" => "299"
                        "paginaFinal" => "307"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12053388"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Percutaneous closure of a giant coronary arteriovenous fistula using multiple devices in a 12-day-old neonate"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Holzer"
                            1 => "B&#46;R&#46; Waller 3rd"
                            2 => "M&#46; Kahana"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ccd.10629"
                      "Revista" => array:6 [
                        "tituloSerie" => "Catheter Cardiovasc Interv"
                        "fecha" => "2003"
                        "volumen" => "60"
                        "paginaInicial" => "291"
                        "paginaFinal" => "294"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14517942"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Occlusion of a large coronary-cameral fistula using the Amplatzer vascular plug in a 2-year old"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Balaguru"
                            1 => "A&#46; Joseph"
                            2 => "C&#46; Kimmelstiel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ccd.20706"
                      "Revista" => array:6 [
                        "tituloSerie" => "Catheter Cardiovasc Interv"
                        "fecha" => "2006"
                        "volumen" => "67"
                        "paginaInicial" => "942"
                        "paginaFinal" => "946"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16649238"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Transcatheter closure of coronary artery fistulae using the Amplatzer Duct Occluder"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46;K&#46; Behera"
                            1 => "S&#46; Danon"
                            2 => "D&#46;S&#46; Levi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ccd.20811"
                      "Revista" => array:6 [
                        "tituloSerie" => "Catheter Cardiovasc Interv"
                        "fecha" => "2006"
                        "volumen" => "68"
                        "paginaInicial" => "242"
                        "paginaFinal" => "248"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16819766"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of coronary artery fistulae&#46; Patient selection and results of transcatheter closure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "L&#46;R&#46; Armsby"
                            1 => "J&#46;F&#46; Keane"
                            2 => "M&#46;C&#46; Sherwood"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2002"
                        "volumen" => "39"
                        "paginaInicial" => "1026"
                        "paginaFinal" => "1032"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11897446"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08702551/0000003200000003/v1_201308021313/S0870255112003393/v1_201308021313/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "362"
    "tipo" => "SECCION"
    "pt" => array:2 [
      "titulo" => "Casos cl&#237;nicos"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "pt"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000003/v1_201308021313/S0870255112003393/v1_201308021313/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112003393?idApp=UINPBA00004E"
]
Partilhar
Informação da revista
Vol. 32. Núm. 3.
Páginas 257-259 (março 2013)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Visitas
10227
Vol. 32. Núm. 3.
Páginas 257-259 (março 2013)
Case report
Open Access
Coronary fistula to the right atrium: A challenge for the interventional cardiologist
Fístula coronária para a aurícula direita: um desafio para o cardiologista de intervenção
Visitas
10227
Edite S. Gonçalvesa,
Autor para correspondência
editesg@gmail.com

Corresponding author.
, Cláudia C. Mouraa, Jorge A. Moreiraa, João A. Silvab
a Serviço de Cardiologia Pediátrica, Hospital de São João, Porto, Portugal
b Serviço de Cardiologia, Hospital de São João, Porto, Portugal
Este item recebeu

Under a Creative Commons license
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (4)
Mostrar maisMostrar menos
Abstract

Congenital coronary fistulas are rare conditions, frequently diagnosed as an incidental finding when a patient is referred for cardiac surgery for another reason. Treatment can be conservative, surgical or more recently through transcatheter closure, depending on local experience and the morphology of the fistula.

The authors present the case of a pediatric patient with a large coronary artery fistula from the aorta to the right atrium. Transcatheter closure with a 16 mm Amplatzer® vascular plug II and a 6 mm Amplatzer® duct occluder was performed, with complete occlusion.

Keywords:
Cardiac catheterization
Pediatric
Intervention
Device
Resumo

As fístulas coronárias congénitas constituem uma patologia rara, frequentemente de diagnóstico acidental, por exemplo durante uma cirurgia cardíaca por outro motivo. A terapêutica pode ser conservadora, cirúrgica ou por intervenção percutânea, dependendo da experiência local ou da morfologia da fístula.

É apresentado um caso de um paciente pediátrico com um diagnóstico de fístula coronária gigante da aorta com drenagem na aurícula direita. Foi efetuado encerramento percutâneo com um dispositivo Amplatzer® Vascular Plug II de 16 mm e um dispositivo Amplatzer Duct Occluder de 6 mm, com oclusão total da fístula.

Palavras-chave:
Cateterismo cardíaco
Pediátrico
Intervenção
Dispositivo
Texto Completo
Introduction

Coronary fistulas are rare congenital heart malformations that result in a connection between one or more of the coronary arteries and a cardiac chamber or great vessel, bypassing the myocardial capillary bed.1,2 In about half of cases the fistula originates from the right coronary artery, in one third from the left anterior descending artery and in about one-fifth from the circumflex artery.1 The majority drain to the right side of the heart. Drainage, which can occur through one or multiple orifices, is more frequently into the right ventricle, followed by drainage into the right atrium.1 Either of these possibilities will cause volume overload in right-sided structures and increased pulmonary vascular flow, similar to a left-to-right shunt from an atrial septal defect, ventricular septal defect or patent ductus arteriosus. Coronary fistulas are usually asymptomatic until the second decade of life. Occasionally a continuous murmur can be heard or cardiomegaly may be accidentally detected on a chest X-ray. Myocardial ischemia is also a possibility, usually in adult patients, due to coronary artery steal.1 Other complications may include thrombosis, embolism, cardiac failure, atrial fibrillation, aneurysmal dilatation and rupture, endocarditis, endarteritis or arrhythmias.1,4 Although the electrocardiogram (ECG) and chest X-ray can be helpful and cardiac magnetic resonance imaging is of increasing importance, the main diagnostic technique remains cardiac catheterization and angiography, which provides information regarding the hemodynamic significance, location and size of the fistula.1 Interventional catheterization techniques and surgery are both useful in closure of these vascular abnormalities.3

Case report

A ten-year-old girl with no previous relevant medical history was referred for a pediatric cardiology assessment due to increased cardiothoracic ratio of 0.6. On physical examination she presented a grade 2/6 continuous murmur at the upper and middle sternal border and normal arterial pulses. The ECG was normal and the echocardiogram revealed a tubular structure (fistula) from the aorta to the right atrium. The right-sided chambers were slightly enlarged but ventricular contractility was normal.

The patient was referred for a diagnostic cardiac catheterization. Angiography confirmed a coronary fistula measuring 13 mm in diameter at the aortic end and draining into the right atrium (RA) through at least two small openings (Figure 1). The left anterior descending (LAD) and circumflex (Cx) arteries originated in the proximal extremity of the fistula through two separate orifices. Catheterization showed normal right and left heart pressures, oxygen saturation step-up in the right atrium and Qp:Qs of 1.7. Informed consent was obtained and percutaneous closure of the fistula was attempted using a 16 mm Amplatzer® vascular plug II (AGA Medical). Through a femoral approach, a 7 Fr venous and a 6 Fr arterial sheath were used. A 6 Fr Concierge Amplatz Left 2 guiding catheter was positioned in the aorta at the fistula entrance and a 0.035 in Terumo® hydrophilic guide wire was advanced along the fistula, until the right atrium was reached. The wire was then snared and an arteriovenous (AV) loop was created. A 7 Fr Amplatzer Delivery System was used to deploy the device through the atrial end (Figure 2). A significant residual shunt was observed after deployment of the device. Cardiac enzymes were within normal range and the ECG showed no abnormalities. After this procedure anticoagulation was prescribed for six months and aspirin maintained thereafter.

Figure 1.

Aortogram with a 5 Fr pigtail angiographic catheter showing drainage of the fistula into the RA through two separate orifices.

(0.06MB).
Figure 2.

Angiography in the fistula with the device still attached (arrow), showing drainage into the RA through a second orifice (arrowhead).

(0.06MB).

Regular follow-up was performed and transthoracic echocardiography detected a residual shunt at the distal extremity of the fistula. One year after the first intervention, angiography was repeated and two small orifices were clearly seen in the extremity where the fistula drained into the right atrium. Percutaneous closure of these orifices was attempted. A 6 Fr venous sheath and a 6 Fr arterial sheath were used through a femoral approach. Two guide wires were advanced from the aortic end to the atrial end, one through each orifice, and two arteriovenous loops were created. Two 6 Fr Concierge Amplatz Left 2 guiding catheters were introduced in the distal extremity of the fistula. An 8/6 mm Amplatzer® duct occluder (AGA Medical) was deployed through the atrial end to close the lower orifice (Figure 3). The upper orifice was left open, due to dislocation and instability in the position of the guiding catheter in the distal part of the fistula, and the long duration of the procedure. Control angiography showed a residual shunt through the upper orifice.

Figure 3.

With the duct occluder device in place (arrowhead), a residual shunt is seen through the second orifice (arrow).

(0.05MB).

Nine months after the second intervention, coronary angiography was repeated. No fistulous flow was detected, the fistula being occluded 2 cm before the emergence of the Cx artery (Figure 4). LAD and Cx artery flows were normal. Following the second procedure the patient remains asymptomatic and well. Antiplatelet therapy with aspirin was continued.

Figure 4.

Control angiography nine months after the second intervention. The fistula is closed (arrow) and the origin of the LAD and Cx arteries is clearly seen in two separate ostia (arrowheads). The devices are still in place, visible on the left.

(0.06MB).
Discussion

Complications related to coronary artery fistulas have been used as an argument to justify intervention, either surgical or percutaneous. Indications for closure include the presence of a large left-to-right shunt, left ventricular volume overload, left ventricular dysfunction, myocardial ischemia, congestive cardiac failure, and prevention of endocarditis.1,4 Several devices have been used for percutaneous closure of these vascular malformations, including the Amplatzer® vascular plug,5 Amplatzer® duct occluder,6 Amplatzer® muscular VSD device and coils,4,5,7 but controversy remains as to the best approach. The choice of equipment, device and technique clearly depend on the morphology of the lesion, the experience of the attending cardiologist, and the patient's age and size. This case report highlights the difficulty the interventional cardiologist faces when approaching these malformations, since two devices had to be implanted before occlusion of the coronary fistula could be achieved. Although a small orifice was left open after the second percutaneous intervention due to technical difficulties in the placement of the catheter, a successful result was achieved. A possible explanation for this could be the sudden decrease of flow after occlusion of one of the orifices at the atrial extremity of the fistula.

Possible complications of closure of a coronary artery fistula include embolization of the device, myocardial ischemia and ECG abnormalities including T-wave changes and bundle branch block.1,2,7

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
S.A. Qureshi, J.F. Reidy.
Arterio-venous fistulas and related conditions.
Paediatric cardiology, pp. 753-774
[2]
L.A. Latson.
Coronary artery fistulas: how to manage them.
Catheter Cardiovasc Interv, 70 (2007), pp. 110-116
[3]
S.A. Qureshi, M. Tynan.
Catheter closure of coronary artery fistulas.
J Interv Cardiol, 14 (2001), pp. 299-307
[4]
R. Holzer, B.R. Waller 3rd, M. Kahana, et al.
Percutaneous closure of a giant coronary arteriovenous fistula using multiple devices in a 12-day-old neonate.
Catheter Cardiovasc Interv, 60 (2003), pp. 291-294
[5]
D. Balaguru, A. Joseph, C. Kimmelstiel.
Occlusion of a large coronary-cameral fistula using the Amplatzer vascular plug in a 2-year old.
Catheter Cardiovasc Interv, 67 (2006), pp. 942-946
[6]
S.K. Behera, S. Danon, D.S. Levi, et al.
Transcatheter closure of coronary artery fistulae using the Amplatzer Duct Occluder.
Catheter Cardiovasc Interv, 68 (2006), pp. 242-248
[7]
L.R. Armsby, J.F. Keane, M.C. Sherwood, et al.
Management of coronary artery fistulae. Patient selection and results of transcatheter closure.
J Am Coll Cardiol, 39 (2002), pp. 1026-1032
Copyright © 2011. Sociedade Portuguesa de Cardiologia
Baixar PDF
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.