Case report
Right-sided scimitar syndrome in a patient with a single aortic trunk and coronary-cameral venous fistula
Síndrome de Cimitarra direita num doente com truncus arteriosus e fístula venosa coronário-ventricular
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Plano axial (b-SSFP): seta azul: veia cava superior; seta amarela: veia inominada; seta branca: veia pulmonar anómala vertical. B. Plano axial (b-SSFP); seta azul: veia cava superior; seta vermelha: arco aórtico; seta branca: veia pulmonar anómala vertical.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Rita Almeida, Luís Lopes, João Palas, Rui Lopes, Cecília Bagulho, Hélder Pereira" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ana Rita" "apellidos" => "Almeida" ] 1 => array:2 [ "nombre" => "Luís" "apellidos" => "Lopes" ] 2 => array:2 [ "nombre" => "João" "apellidos" => "Palas" ] 3 => array:2 [ "nombre" => "Rui" "apellidos" => "Lopes" ] 4 => array:2 [ "nombre" => "Cecília" "apellidos" => "Bagulho" ] 5 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204912002036" "doi" => "10.1016/j.repce.2012.11.004" "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/S2174204912002036?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112002533?idApp=UINPBA00004E" "url" => "/08702551/0000003200000001/v1_201308021254/S0870255112002533/v1_201308021254/pt/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255112002570" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.05.019" "estado" => "S300" "fechaPublicacion" => "2013-01-01" "aid" => "186" "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;32:59-62" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8462 "formatos" => array:3 [ "EPUB" => 172 "HTML" => 7124 "PDF" => 1166 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Marfan syndrome with ascending aortic aneurysm: Value of cardiac computed tomography" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "62" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome de Marfan com aneurisma da aorta ascendente – importância da angioTC cardíaca" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1990 "Ancho" => 3155 "Tamanyo" => 375602 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cardiac computed tomography: multiplanar reconstructions ruling out significant coronary artery disease. LAD: left anterior descending artery; LCX: left circumflex artery; OM: obtuse marginal artery; RCA: right coronary artery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Jerónimo Sousa, Pedro Araújo Gonçalves, Sérgio Boshoff, Hugo Marques, Salomé Carvalho, João Moradas Ferreira, Miguel Mota Carmo, Ana Aleixo, José Pedro Neves, Miguel Mendes" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Pedro Jerónimo" "apellidos" => "Sousa" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Araújo Gonçalves" ] 2 => array:2 [ "nombre" => "Sérgio" "apellidos" => "Boshoff" ] 3 => array:2 [ "nombre" => "Hugo" "apellidos" => "Marques" ] 4 => array:2 [ "nombre" => "Salomé" "apellidos" => "Carvalho" ] 5 => array:2 [ "nombre" => "João" "apellidos" => "Moradas Ferreira" ] 6 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mota Carmo" ] 7 => array:2 [ "nombre" => "Ana" "apellidos" => "Aleixo" ] 8 => array:2 [ "nombre" => "José Pedro" "apellidos" => "Neves" ] 9 => array:2 [ "nombre" => "Miguel" "apellidos" => "Mendes" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255112002570?idApp=UINPBA00004E" "url" => "/08702551/0000003200000001/v1_201308021254/S0870255112002570/v1_201308021254/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Right-sided scimitar syndrome in a patient with a single aortic trunk and coronary-cameral venous fistula" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "63" "paginaFinal" => "66" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mehmet Cilingiroglu, Nuri Ilker Akkus" "autores" => array:2 [ 0 => array:3 [ "nombre" => "Mehmet" "apellidos" => "Cilingiroglu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] ] ] 1 => array:4 [ "nombre" => "Nuri Ilker" "apellidos" => "Akkus" "email" => array:1 [ 0 => "iakkus@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, United States" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "LSU Shreveport Health Sciences Center, Shreveport, LA, United States" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome de Cimitarra direita num doente com <span class="elsevierStyleItalic">truncus arteriosus</span> e fístula venosa coronário-ventricular" ] ] "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" => 947 "Ancho" => 945 "Tamanyo" => 120206 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Aortic arch angiography. Takeoff of large vessels from the aortic arch via a single trunk (white arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Scimitar syndrome (SS) is a rare and complex congenital anomaly, characterized by partial or complete anomalous pulmonary venous drainage from the right or left lung into the inferior vena cava (IVC), though drainage into the hepatic vein, right atrium (RA) or left atrium (LA), or the portal vein can also occur. According to the original definition, the syndrome is commonly associated with hypoplasia of the right lung, pulmonary sequestration, persistent left superior vena cava, and dextroposition of the heart.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In two-thirds of cases, the scimitar vein provides drainage for the entire right lung, but in one third, this vein drains only the lower portion of the right lung.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Partial abnormalities of pulmonary venous return (PAPVR) are seen in 0.4–0.7% of adult autopsies, while patients with SS account for 3–5% of these cases.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> SS constitutes 0.5–1% of all congenital heart defects. This rare anomaly has an incidence of approximately 1-3 per 100<span class="elsevierStyleHsp" style=""></span>000 live births; however, the true incidence may be higher because many patients remain asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The etiology is not completely understood. In several patients with total anomalous pulmonary venous return, the gene locus has been mapped to chromosome 4q12,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and females are more frequently affected than males. The scimitar sign refers to the crescent (resembling the Turkish sword) described by the descent of the anomalous pulmonary vein (the tip of the crescent points inferiorly and medially to the diaphragm/right heart border junction). The concavity of the crescent is adjacent to the junction of the diaphragm and right heart border.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 44-year-old man presented with several weeks of palpitations. He also described symptoms of dyspnea with mild exertion and substernal chest discomfort at rest. He had a history of long-standing systemic hypertension. The 12-lead ECG showed atrial fibrillation with rapid ventricular rate. His 2D Doppler echocardiogram revealed a mildly enlarged RA and right ventricle (RV). He subsequently underwent right and left heart catheterization with selective coronary angiography. Right and left heart catheterization with a full oximetry run to calculate shunts revealed Qp/Qs of 1.3. Selective coronary angiography was performed using right radial artery access, and showed no significant coronary disease. However, angiography of the aortic arch showed a single trunk takeoff for the large vessels from the aortic arch (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Using right femoral vein access, a 5-Fr multipurpose diagnostic catheter was advanced into the upper (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and middle (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) right pulmonary veins as they opened into the superior vena cava (SVC). To exclude any possible associated atrial septal defect, an MP-1 catheter was engaged into what proved to be a coronary-cameral fistula (CCF) opening into the RA separately from the coronary sinus (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>), the CCF went from the coronary vein to the RA and the coronary sinus was also filled with contrast retrogradely from the vein (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). Pulmonary angiography using a 5-Fr pigtail catheter showed a moderately dilated pulmonary trunk (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). Following consultations with the cardiothoracic surgery and pediatric cardiology teams, it was felt that the best course of management would be to follow the patient clinically with serial echocardiography, as there was no significant right-to-left shunt.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">SS is a complex form of PAPVR, which is a connection failure between the right pulmonary veins and the LA during fetal development. Variations in PAPVR include the right pulmonary veins draining into the SVC-LA junction, RA, or IVC, or as in our case, separately to a high SVC. In SS, an anomalous right pulmonary vein generally draining the entire right lung but occasionally the middle and superior lobes, may descend in a cephalad-to-caudal direction toward the diaphragm with a crescent (scimitar) shape. This vein then curves sharply to the left just above or below the IVC-RA junction.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The anomalous right pulmonary venous trunk usually courses anterior to the hilum of the right lung and connects to the IVC just superior to the orifices of the hepatic veins. Rarely, it drains into the left atrium, with normal venous return.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this patient, the right upper and middle pulmonary veins drained into the high SVC and then ultimately into the RA, leading to increased pulmonary circulation as shown by the enlarged right chambers and main pulmonary artery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most common aortic arch branching pattern in humans consists of three great vessels originating from the arch of the aorta: the innominate, left common carotid and left subclavian arteries. In “bovine” aortic arch, rather than arising directly from the aortic arch as a separate branch, the left common carotid artery origin is moved to the right and merges with the origin of the innominate artery, or the left common carotid artery originates directly from the innominate artery rather than as a common trunk. A single brachiocephalic trunk originating from the aortic arch and then dividing into right and left brachiocephalic trunks or trifurcating to brachiocephalic, left common carotid and subclavian artery is a very rare anomaly, with few cases reported in the literature,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> and there is no previously reported case of SS with this anomaly.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Our patient had a venous CCF draining into the RA from the coronary vein in addition to the right upper and middle pulmonary veins draining through the SVC. There is no previously reported case of SS associated with venous CCF in the literature. Coronary-cameral fistulas are unusual congenital or acquired anomalous communications between an epicardial coronary artery and a cardiac chamber: the RA, coronary sinus, right ventricle, left atrium, or left ventricle. In a review of 304 patients with CCF and coronary vascular fistula (CVF), a continuous cardiac murmur was heard in 82% of the subjects. Dyspnea, chest pain and angina pectoris, palpitations, and fatigue are reported symptoms in clinical presentations. Although rare, infective endocarditis has been reported in patients with CCF, but not in those with CVF.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Surgical repair of SS consists of redirecting the pulmonary venous drainage into the LA, by either baffling the anomalous drainage into the LA via a tunnel or transecting the “scimitar drainage” near its entrance into the IVC and then reimplanting it directly into the LA.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The surgical option is, however, associated with a relatively high incidence of interruption failure, reinserted pulmonary vein stenosis, surgical complications, and redo procedures. Surgical correction is considered in symptomatic patients or in those with increased pulmonary blood flow and signs of right heart dilation with a significant shunt (Qp/Qs ≥1.5).</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the most common form of SS, there is anomalous right pulmonary vein drainage into the IVC with anomalous systemic arterial supply (ASAS) from the abdominal aorta toward the affected pulmonary parenchyma, leading to pulmonary hypertension and subsequent volume overload and heart failure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">If the presence of a large ASAS to the right lung with pulmonary overcirculation is detected preoperatively (which it was not in our case), occlusion of the ASAS is frequently performed percutaneously to encourage compensatory growth of the remaining normal lung tissue and to reduce both the associated left-to-right shunt and the risk of chronic and recurrent infection in the abnormal lung in later life. Successful percutaneous occlusion of ASAS in infants with SS has emerged as an acceptable treatment using the Amplatzer™ vascular plug device (AGA Medical, Golden Valley, MN).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> In a study of 16 infants who underwent percutaneous ASAS interruption, Uthaman et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> reported significant reduction in left-to-right shunt and pulmonary artery pressures in >90% of the patients, which translated into symptomatic improvement as well as growth of the right lung in follow-up. Furthermore, this approach leads to sustained long-term clinical improvement without need for further surgical correction in the majority of patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, in this case report we describe a patient with scimitar syndrome with very unusual associated anomalies of a single aortic trunk and venous CCF.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres250283" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec237851" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250282" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec237852" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-04-02" "fechaAceptado" => "2012-05-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec237851" "palabras" => array:3 [ 0 => "Scimitar syndrome" 1 => "Abnormal pulmonary venous return" 2 => "Coronary venous fistula" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec237852" "palabras" => array:3 [ 0 => "Síndrome de Cimitarra" 1 => "Drenagem pulmonar anómala" 2 => "Fístula coronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Scimitar syndrome (SS) is a rare congenital anomaly characterized by partial or complete anomalous pulmonary venous drainage of the right or left lung into the inferior vena cava. The syndrome is commonly associated with hypoplasia of the right lung, pulmonary sequestration, persistent left superior vena cava, and dextroposition of the heart. We report a rare variant of SS in a 44-year-old man together with a single aortic trunk, as well as a coronary-cameral venous fistula.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome de Cimitarra (SC) é uma malformação congénita rara, caracterizada por uma drenagem pulmonar anómala parcial ou total do pulmão direito ou esquerdo, na veia cava inferior. Esta síndrome é frequentemente associada a hipoplasia do pulmão direito, sequestração pulmonar, persistência de veia cava superior esquerda e dextroposição do coração. Reportamos uma variante rara de SC num homem de 44 anos com tronco supra-aórtico único e fistula coronário-auricular.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 947 "Ancho" => 945 "Tamanyo" => 120206 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Aortic arch angiography. Takeoff of large vessels from the aortic arch via a single trunk (white arrow).</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" => 945 "Ancho" => 945 "Tamanyo" => 109562 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Right upper pulmonary venous angiography. Abnormal pulmonary venous drainage from the upper lobe of the right lung draining into the high SVC via the right upper pulmonary vein (white arrow).</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" => 947 "Ancho" => 945 "Tamanyo" => 124547 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Right middle pulmonary venous angiography. Abnormal pulmonary venous drainage from the middle lobe of the right lung draining into the high SVC via the right upper pulmonary vein (white arrow).</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" => 951 "Ancho" => 945 "Tamanyo" => 132565 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary venous-cameral fistula. Using a 5-Fr MP diagnostic catheter, angiography of the coronary-venous cameral fistula (white arrow) was performed. The fistula itself drains into the high RA.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 943 "Ancho" => 945 "Tamanyo" => 122356 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Pulmonary angiography. Using a 5-Fr pig tail catheter, pulmonary angiography was performed, which showed a moderately enlarged main PA.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Scimitar vein draining to the left atrium and a historical review of the scimitar syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P.D. Holt" 1 => "W.E. Berdon" 2 => "Z. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 11 | 8 | 19 |
| 2024 Outubro | 62 | 50 | 112 |
| 2024 Setembro | 82 | 34 | 116 |
| 2024 Agosto | 80 | 53 | 133 |
| 2024 Julho | 53 | 36 | 89 |
| 2024 Junho | 44 | 33 | 77 |
| 2024 Maio | 54 | 34 | 88 |
| 2024 Abril | 56 | 34 | 90 |
| 2024 Maro | 55 | 25 | 80 |
| 2024 Fevereiro | 47 | 29 | 76 |
| 2024 Janeiro | 57 | 31 | 88 |
| 2023 Dezembro | 43 | 34 | 77 |
| 2023 Novembro | 57 | 33 | 90 |
| 2023 Outubro | 34 | 24 | 58 |
| 2023 Setembro | 45 | 33 | 78 |
| 2023 Agosto | 34 | 18 | 52 |
| 2023 Julho | 29 | 15 | 44 |
| 2023 Junho | 47 | 14 | 61 |
| 2023 Maio | 68 | 31 | 99 |
| 2023 Abril | 46 | 9 | 55 |
| 2023 Maro | 37 | 24 | 61 |
| 2023 Fevereiro | 41 | 25 | 66 |
| 2023 Janeiro | 36 | 19 | 55 |
| 2022 Dezembro | 34 | 31 | 65 |
| 2022 Novembro | 48 | 27 | 75 |
| 2022 Outubro | 48 | 30 | 78 |
| 2022 Setembro | 29 | 29 | 58 |
| 2022 Agosto | 41 | 36 | 77 |
| 2022 Julho | 51 | 35 | 86 |
| 2022 Junho | 29 | 25 | 54 |
| 2022 Maio | 31 | 27 | 58 |
| 2022 Abril | 36 | 26 | 62 |
| 2022 Maro | 23 | 32 | 55 |
| 2022 Fevereiro | 26 | 18 | 44 |
| 2022 Janeiro | 32 | 17 | 49 |
| 2021 Dezembro | 29 | 34 | 63 |
| 2021 Novembro | 48 | 35 | 83 |
| 2021 Outubro | 41 | 49 | 90 |
| 2021 Setembro | 39 | 38 | 77 |
| 2021 Agosto | 42 | 29 | 71 |
| 2021 Julho | 50 | 21 | 71 |
| 2021 Junho | 55 | 21 | 76 |
| 2021 Maio | 39 | 33 | 72 |
| 2021 Abril | 48 | 40 | 88 |
| 2021 Maro | 68 | 18 | 86 |
| 2021 Fevereiro | 58 | 10 | 68 |
| 2021 Janeiro | 43 | 10 | 53 |
| 2020 Dezembro | 44 | 11 | 55 |
| 2020 Novembro | 49 | 13 | 62 |
| 2020 Outubro | 40 | 15 | 55 |
| 2020 Setembro | 60 | 12 | 72 |
| 2020 Agosto | 21 | 12 | 33 |
| 2020 Julho | 57 | 6 | 63 |
| 2020 Junho | 40 | 12 | 52 |
| 2020 Maio | 59 | 5 | 64 |
| 2020 Abril | 42 | 23 | 65 |
| 2020 Maro | 56 | 12 | 68 |
| 2020 Fevereiro | 115 | 24 | 139 |
| 2020 Janeiro | 46 | 14 | 60 |
| 2019 Dezembro | 42 | 17 | 59 |
| 2019 Novembro | 39 | 7 | 46 |
| 2019 Outubro | 52 | 9 | 61 |
| 2019 Setembro | 26 | 12 | 38 |
| 2019 Agosto | 33 | 11 | 44 |
| 2019 Julho | 51 | 14 | 65 |
| 2019 Junho | 52 | 13 | 65 |
| 2019 Maio | 49 | 32 | 81 |
| 2019 Abril | 40 | 23 | 63 |
| 2019 Maro | 106 | 30 | 136 |
| 2019 Fevereiro | 101 | 17 | 118 |
| 2019 Janeiro | 48 | 6 | 54 |
| 2018 Dezembro | 72 | 11 | 83 |
| 2018 Novembro | 97 | 9 | 106 |
| 2018 Outubro | 203 | 31 | 234 |
| 2018 Setembro | 78 | 14 | 92 |
| 2018 Agosto | 44 | 14 | 58 |
| 2018 Julho | 21 | 8 | 29 |
| 2018 Junho | 47 | 6 | 53 |
| 2018 Maio | 80 | 10 | 90 |
| 2018 Abril | 52 | 6 | 58 |
| 2018 Maro | 91 | 6 | 97 |
| 2018 Fevereiro | 27 | 5 | 32 |
| 2018 Janeiro | 31 | 3 | 34 |
| 2017 Dezembro | 59 | 13 | 72 |
| 2017 Novembro | 42 | 12 | 54 |
| 2017 Outubro | 40 | 19 | 59 |
| 2017 Setembro | 37 | 7 | 44 |
| 2017 Agosto | 54 | 8 | 62 |
| 2017 Julho | 36 | 10 | 46 |
| 2017 Junho | 65 | 13 | 78 |
| 2017 Maio | 40 | 7 | 47 |
| 2017 Abril | 31 | 3 | 34 |
| 2017 Maro | 32 | 26 | 58 |
| 2017 Fevereiro | 33 | 8 | 41 |
| 2017 Janeiro | 30 | 9 | 39 |
| 2016 Dezembro | 34 | 6 | 40 |
| 2016 Novembro | 34 | 6 | 40 |
| 2016 Outubro | 67 | 7 | 74 |
| 2016 Setembro | 28 | 7 | 35 |
| 2016 Agosto | 28 | 2 | 30 |
| 2016 Julho | 13 | 3 | 16 |
| 2016 Junho | 4 | 0 | 4 |
| 2016 Maio | 14 | 5 | 19 |
| 2016 Abril | 16 | 4 | 20 |
| 2016 Maro | 45 | 8 | 53 |
| 2016 Fevereiro | 68 | 13 | 81 |
| 2016 Janeiro | 54 | 14 | 68 |
| 2015 Dezembro | 53 | 7 | 60 |
| 2015 Novembro | 55 | 3 | 58 |
| 2015 Outubro | 68 | 14 | 82 |
| 2015 Setembro | 68 | 12 | 80 |
| 2015 Agosto | 67 | 18 | 85 |
| 2015 Julho | 37 | 3 | 40 |
| 2015 Junho | 34 | 0 | 34 |
| 2015 Maio | 59 | 8 | 67 |
| 2015 Abril | 63 | 10 | 73 |
| 2015 Maro | 45 | 5 | 50 |
| 2015 Fevereiro | 53 | 8 | 61 |
| 2015 Janeiro | 44 | 8 | 52 |
| 2014 Dezembro | 57 | 11 | 68 |
| 2014 Novembro | 52 | 11 | 63 |
| 2014 Outubro | 88 | 19 | 107 |
| 2014 Setembro | 53 | 10 | 63 |
| 2014 Agosto | 54 | 17 | 71 |
| 2014 Julho | 57 | 12 | 69 |
| 2014 Junho | 63 | 6 | 69 |
| 2014 Maio | 56 | 6 | 62 |
| 2014 Abril | 52 | 9 | 61 |
| 2014 Maro | 73 | 17 | 90 |
| 2014 Fevereiro | 74 | 13 | 87 |
| 2014 Janeiro | 78 | 13 | 91 |
| 2013 Dezembro | 65 | 17 | 82 |
| 2013 Novembro | 56 | 16 | 72 |
| 2013 Outubro | 65 | 8 | 73 |
| 2013 Setembro | 71 | 21 | 92 |
| 2013 Agosto | 74 | 23 | 97 |
| 2013 Julho | 112 | 26 | 138 |
| 2013 Junho | 65 | 14 | 79 |
| 2013 Maio | 71 | 15 | 86 |
| 2013 Abril | 90 | 32 | 122 |
| 2013 Maro | 70 | 38 | 108 |
| 2013 Fevereiro | 53 | 40 | 93 |
| 2013 Janeiro | 42 | 19 | 61 |
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