Mitral valve replacement combined with coronary artery bypass graft surgery in patients with moderate-to-severe ischemic mitral regurgitation

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A curva em J deve preocupar-nos?" 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Sá, Evelyn F. Soares, Cecília A. Santos, Omar J. Figueiredo, Renato O.A. Lima, Rodrigo R. Escobar, Frederico P. Vasconcelos, Ricardo C. Lima" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Michel Pompeu B.O." "apellidos" => "Sá" "email" => array:1 [ 0 => "michel_pompeu@yahoo.com.br" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Evelyn F." "apellidos" => "Soares" ] 2 => array:2 [ "nombre" => "Cecília A." "apellidos" => "Santos" ] 3 => array:2 [ "nombre" => "Omar J." "apellidos" => "Figueiredo" ] 4 => array:2 [ "nombre" => "Renato O.A." "apellidos" => "Lima" ] 5 => array:2 [ "nombre" => "Rodrigo R." "apellidos" => "Escobar" ] 6 => array:2 [ "nombre" => "Frederico P." "apellidos" => "Vasconcelos" ] 7 => array:2 [ "nombre" => "Ricardo C." "apellidos" => "Lima" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco, University of Pernambuco, Pernanbuco, Brazil" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Substituição da valva mitral combinada com cirurgia de revascularização do miocárdio em pacientes com regurgitação mitral isquémica moderada a grave" ] ] "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" => 1266 "Ancho" => 1548 "Tamanyo" => 87546 ] ] "descripcion" => array:1 [ "en" => "Analysis of left ventricular ejection fraction by echocardiography before and after surgery. Values expressed as mean±standard deviation. CABG: coronary artery bypass grafting; MVR: mitral valve replacement; Preop: preoperative; Postop: postoperative." ] ] ] "textoCompleto" => "IntroductionIschemic mitral regurgitation (IMR) is defined as mitral valve (MV) insufficiency precipitated by myocardial infarction, with normal leaflet and chordal morphology. IMR usually occurs with right or circumflex coronary infarction involving the posterior ventricular wall, posterior papillary muscle, and adjacent mitral annulus.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Common anatomic features include annular dilatation, displacement of papillary muscles, and varying degrees of leaflet restriction or tethering.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> There is a clear association between IMR and increased late mortality.<a class="elsevierStyleCrossRefs" href="#bib0010">2–7</a> Even after revascularization, IMR reduces late survival.<a class="elsevierStyleCrossRefs" href="#bib0010">2–7</a>Several studies have shown increased perioperative mortality for valve replacement in this situation, but the subject remains controversial.<a class="elsevierStyleCrossRefs" href="#bib0040">8–12</a>The objective of this study was to investigate the differences in immediate postoperative results (in-hospital complications and evolution) in patients with IMR undergoing coronary artery bypass grafting (CABG) with intraoperative correction of valve dysfunction by mitral valve replacement (MVR) compared with those undergoing CABG only.MethodsStudy populationWe studied 42 consecutive patients with coronary artery disease associated with moderate-to-severe IMR undergoing CABG at the Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco (PROCAPE), between May 2007 and April 2010.Definition of ischemic mitral regurgitationIMR was defined as valve insufficiency caused by coronary artery disease. All patients had a history of myocardial infarction, ejection fraction <50% by echocardiography and moderate-to-severe functional MVR (without intrinsic changes in valve leaflets and/or subvalvular apparatus). All patients had one or more left ventricular (LV) segmental wall motion abnormalities and significant coronary disease in the territory supplying the wall motion abnormality.Exclusion criteriaPatients with rheumatic, myxomatous, infectious, or congenital diseases of the mitral valve were excluded. Patients with mitral regurgitation due to papillary muscle rupture, torn or elongated chordae tendineae, or ballooning or scalloping of the mitral leaflets were not considered to have IMR. Patients with mild MVR were also not considered for the study.Study designWe performed a retrospective study using medical records and initially generated two groups: CABG+MVR (biological valve prosthesis) or CABG only. In each instance, the operative approach for concomitant MVR had been chosen by the attending surgeon.Variables and outcomesThe following variables were compared:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">(1)Preoperative clinical characteristics: age >70 years, gender (male or female), obesity (body mass index≥30kg/m2), hypertension, diabetes, smoking, chronic obstructive pulmonary disease (dyspnea or chronic cough and prolonged use of bronchodilators or corticosteroids and/or radiological changes including opacification due to hyperinflation and/or elevation of the ribs and/or flattening of the diaphragm), renal disease (creatinine ≥2.3mg/dl or preoperative dialysis), myocardial infarction <30 days previously, EuroSCORE ≥6 (high risk), and New York Heart Association (NYHA) functional class I, II, III or IV;</li><li class="elsevierStyleListItem" id="lsti0010">(2)Procedural characteristics: number of aortocoronary bypasses; as all patients underwent on-pump surgery, we assessed cardiopulmonary bypass (CPB) duration (in min) and aortic clamp time (in min);</li><li class="elsevierStyleListItem" id="lsti0015">(3)Major procedure-related complications: hemorrhagic shock, neurologic complications (stroke or transient ischemic attack), low cardiac output (signs of poor peripheral and/or central perfusion including cold extremities, oliguria/anuria or decreased level of consciousness, and need for inotropic support with dopamine 4μg/kg/min for at least 12hours or intra-aortic balloon pump to maintain systolic blood pressure greater than 90mmHg), and renal complications (creatinine ≥2.3mg/dl or postoperative dialysis);</li><li class="elsevierStyleListItem" id="lsti0020">(4)Minor procedure-related complications: respiratory complications (pulmonary infection, acute respiratory distress syndrome, atelectasis, need for intubation for more than 48hours), atrial fibrillation (AF) after surgery, need for multiple transfusions (more than three units of packed red blood cells);</li><li class="elsevierStyleListItem" id="lsti0025">(5)Preoperative and postoperative left ventricular ejection fraction (LVEF) by echocardiography performed during hospitalization;</li><li class="elsevierStyleListItem" id="lsti0030">(6)Length of stay in intensive care unit (days) and hospital (days);</li><li class="elsevierStyleListItem" id="lsti0035">(7)Outcome (survivor or death).</li></ul>Statistical analysisStatistical analysis and interpretation were performed in SPSS (Statistical Package for the Social Sciences) version 15. Data were stored in duplicate to validate the consistency of the data and the analysis in order to minimize error.Univariate analysis for categorical variables was performed with the chi-square test or Fisher's exact test, as appropriate. The Student's t test was used for continuous variables. Verification of the hypothesis of equality of variances was performed using Levene's F test. Values of p<0.05 were considered statistically significant.Ethical considerationsThis study was approved by the Research Ethics Committee of Complexo Hospitalar do Hospital Universitário Oswaldo Cruz/Pronto Socorro Cardiológico de Pernambuco – HUOC/PROCAPE, file no. 132/2009.ResultsPopulation characteristicsMean patient age was 63.4±8.5 years; 64.8% (n=23) were male and 35.2% (n=19) female.The 42 patients with moderate-to-severe IMR were among 542 patients who underwent CABG consecutively during the study period, and thus the prevalence of moderate-to-severe IMR was 8.1% among operated patients. Of these, 38.1% (n=16) underwent CABG+MVR and 61.9% (n=26) underwent CABG only.For almost all the preoperative variables (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), there were no statistically significant differences, except for the proportion of patients in NYHA class III/IV, with more patients in this class in the CABG+MVR group than in the CABG-only group (68.7% vs. 30.8%, p=0.012).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Procedural characteristicsAs expected (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), patients undergoing CABG+MVR showed a higher proportion with prolonged CPB time (p=0.001) and prolonged aortic clamp time (p<0.001). There was no difference in the proportion of the number of coronary bypasses as a categorical variable; however, when analyzed as a continuous variable, the CABG+MVR group underwent more coronary bypasses than the CABG-only group (3.06±0.85 vs. 2.46±0.81, p=0.028).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Postoperative evolutionThe CABG+MVR group showed lower rates of low cardiac output (6.3% vs. 42.3%, p=0.014) and atrial fibrillation (6.3% vs. 38.5%, p=0.021). The other variables showed no statistically significant differences (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>There were no statistically significant differences between groups in length of stay in intensive care (7.81±5.86 vs. 8.35±7.10 days, p=0.802) or in hospital (44.06±18.61 vs. 40.54±19.66 days, p=0.568).Assessment of left ventricular functionBoth the CABG+MVR group (54.13±4.51 vs. 45.25±4.54, p=0.041) and the CABG-only group (50.92±3.25 vs. 46.62±3.19, p=0.049) had higher mean LVEF in the postoperative period than in the preoperative period (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Both groups thus had higher mean LVEF in the postoperative than in the preoperative period, showing an improvement in LV function after surgical procedures. However, the average gain in LVEF in the CABG+MVR group was higher than that in the CABG-only group (8.88±2.39 vs. 4.31±1.23, p<0.001) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>MortalityThere was no significant difference between groups in operative mortality (6.3% vs. 7.7%, p=0.679) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).DiscussionThe prevalence of moderate-to-severe IMR detected by transthoracic echocardiography and/or cardiac catheterization in myocardial infarction patients with coronary artery disease ranges from 3% to 12%.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> The prevalence of 8.1% observed in our study is within the range reported in the literature.Mitral regurgitation causes atrial hemodynamic overload, which leads to tissue fibrosis; consequently, a non-homogenous distribution of diastolic depolarization potentials, refractory periods, and conduction properties occurs within the atrial muscle.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> All of these factors enhance the probability of reentry circuits forming around areas with longer refractory periods.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> MVR eliminates regurgitation, thereby reducing atrial hemodynamic overload and interrupting the cascade of events that culminates in the development of postoperative atrial fibrillation. In our study, the CABG+MVR group, despite longer exposure to CPB (known as a risk factor for developing postoperative AF<a class="elsevierStyleCrossRef" href="#bib0080">16</a>) showed a lower rate of AF than the CABG-only group (6.3% vs. 38.5%, p=0.021).It seems logical to assume that the volume overload associated with mitral regurgitation will be particularly detrimental to patients with compromised LV function.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> There is also a loss of flow to the aorta, since part of the ejected volume is directed to the left atrium. MVR eliminates the volume overload and the loss of volume ejected toward the left atrium, displacing the entire cardiac output in the correct direction (to the aorta). This explains the lower rate of low cardiac output in the CABG+MVR group (despite longer exposure to CPB, known as a risk factor for development of postoperative low cardiac output<a class="elsevierStyleCrossRef" href="#bib0080">16</a>) compared to CABG only (6.3% vs. 42.3%; p=0.014).Segmental wall motion abnormalities and LV distortion and remodeling after myocardial infarction displace the papillary muscles from the mitral annulus.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> This displacement puts excessive tension on the chordae, resulting in apical mitral leaflet tethering, restricting coaptation during systole.<a class="elsevierStyleCrossRefs" href="#bib0095">19–21</a> Leaflet tethering is compounded by LV contractile dysfunction, which decreases the closing force on the leaflets.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Once IMR begins, end-diastolic LV volume and wall stress increase in tandem with preload.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> LV mass also increases progressively without a concomitant increase in end-diastolic wall thickness, resulting in generalized loss of myocardial contractile function.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Increased wall stress causes further LV dysfunction,<a class="elsevierStyleCrossRef" href="#bib0110">22</a> which in turn results in further papillary muscle displacement and leaflet tenting. If LV dilation occurs, it leads to annular enlargement and dysfunction, thereby increasing valvular incompetence.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Chronic IMR therefore begets MR in a self-perpetuating manner. CABG surgery may interrupt the perpetuation and/or progression of this vicious cycle.MVR is still a reasonable surgical option in many patients with IMR, mainly because of its reliability and reproducibility. It should be considered for patients with acute IMR, and for those with chronic IMR and multiple comorbidities, complex regurgitant jets (noncentral or more than one jet), or severe tethering of both MV leaflets.<a class="elsevierStyleCrossRefs" href="#bib0045">9,24,25</a>Some studies indicate greater perioperative mortality associated with this procedure, suggesting that preference should be given to less aggressive procedures such as CABG only or CABG associated with MVR.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> However, in our study, although the CABG+MVR group had a statistically significant higher prevalence of patients with worse functional class, there was no difference in operative mortality (6.3% vs. 7.7%; p=0.679) between groups. A possible explanation for this is that, unlike in other studies, MVR was the first choice for mitral valve surgery, and not a result of initial unsuccessful mitral valve repair (reoperation and/or prolonged CPB time as a function of failed valve repair might have increased operative mortality in this group). In addition, surgical intervention can prevent the LV overload and remodeling that results from mitral regurgitation, which may improve surgical outcomes.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Goland et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> studied changes in LVEF in 83 patients with moderate IMR who underwent CABG associated with MVR (n=28) or CABG only (n=55). Patients who underwent CABG only showed significant improvement in LVEF in the early postoperative period (39±11 vs. 45±13; p=0.002), as did the CABG+MVR group (37±11 vs. 44±11; p=0.02). We also observed the same results of MVR, with the CABG+MVR group showing higher mean LVEF in the postoperative than in the preoperative period (54.13±4.51 vs. 45.25±4.54, p=0.041), as did the CABG-only group (52.92±4.25 vs. 48.62±4.19, p=0.049). So we observed improvement in postoperative LVEF in both groups. Furthermore, we found that the average gain in LVEF in the CABG+MVR group was higher than in the CABG-only group (8.88±2.39 vs. 4.31±1.23, p<0.001). As can be seen, in the case of LVEF, CABG+MVR provides better improvement than CABG only.Although we did not analyze the approach to mitral valve repair, some considerations should be borne in mind. This is a technique intended to reduce or eliminate mitral regurgitation, while preserving the valve. Several investigators have suggested that repair is better than replacement for patients with IMR.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Others, however, have documented similar survival after repair and after replacement.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> Late survival is poor for all approaches, with most patients dying within seven years of surgery.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> However, choice of surgical procedure has an important impact on survival. Among the most severely ill patients, the survival benefit of mitral valve surgery (by either valve repair or replacement) is diminished, which leads us to conclude that clinical status is an important determinant of survival.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> It seems that the “repair vs. replacement” debate remains undecided, although there is a strong tendency in the medical community in favor of repair.Study limitationsThe chief limitation of this study is its retrospective nature, with various sources of bias. Selection bias and lack of a uniform surgical experience (different surgeons operating) are important limitations. In many cases the surgeon did not opt for valve repair because of the unavailability of intraoperative transesophageal echocardiography at our institution. Decisions to perform concomitant MVR were made on the basis of surgical considerations and preferences. The surgeons may have selected replacement for patients who had worse heart failure, and thus may have replaced valves in the more severe or symptomatic patients. A randomized prospective design would overcome this limitation.Another limitation is the lack of uniformity of echocardiographic evaluation of mitral regurgitation grade and complete follow-up, since the echocardiograms were performed by several operators using different equipment and our results are restricted to the in-hospital period.An important limitation is that ventricular diameters (systolic and diastolic) were not taken into consideration, which may well have influenced the results to some extent.Small sample size is another limitation of this study. This is the consequence of selecting a very homogeneous group with only moderate-to-severe mitral regurgitation, a history of myocardial infarction, impaired LV function, and a single mitral valve surgical approach (valve replacement). This prevented the application of multivariate logistic regression analysis, so the study is limited to the use of univariate analysis, which may affect the consistency of the presented evidence.ConclusionTaking into account the severity of this population, patients who underwent CABG only or CABG+MVR surgery experienced no statistically different mortality rates, despite the presence of multiple comorbidities and impaired LVEF. MVR can be performed safely, concomitantly with CABG, in patients with moderate-to-severe IMR. In such patients, the combined procedure resulted in lower rates of postoperative atrial fibrillation and low cardiac output than CABG only. Both surgical approaches resulted in significant improvement in postoperative LVEF. However, there was greater improvement in the combined surgery group, which may result in greater benefit to this group. Despite being a more aggressive approach, the combined surgical procedure did not increase morbidity or mortality.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres250517" "titulo" => array:6 [ 0 => "Abstract" 1 => "Introduction" 2 => "Objective" 3 => "Methods" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec238084" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250518" "titulo" => array:6 [ 0 => "Resumo" 1 => "Introdução" 2 => "Objetivo" 3 => "Métodos" 4 => "Resultados" 5 => "Conclusões" ] ] 3 => array:2 [ "identificador" => "xpalclavsec238085" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Definition of ischemic mitral regurgitation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Exclusion criteria" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Study design" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Variables and outcomes" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical considerations" ] ] ] 6 => array:3 [ "identificador" => "sec0050" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Population characteristics" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Procedural characteristics" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Postoperative evolution" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Assessment of left ventricular function" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Mortality" ] ] ] 7 => array:3 [ "identificador" => "sec0080" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Study limitations" ] ] ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-02-04" "fechaAceptado" => "2012-07-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec238084" "palabras" => array:3 [ 0 => "Mitral valve insufficiency" 1 => "Coronary artery bypass" 2 => "Myocardial ischemia" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec238085" "palabras" => array:3 [ 0 => "Insuficiência da valva mitral" 1 => "Ponte de artéria coronária" 2 => "Isquemia miocárdica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionIschemic mitral regurgitation (IMR) is associated with increased mortality. Even after coronary artery bypass grafting (CABG), IMR reduces survival. Several studies have shown increased perioperative mortality for mitral valve replacement (MVR) in this situation, but the subject remains controversial. ObjectiveTo investigate the impact of MVR on immediate outcomes in patients with moderate-to-severe IMR undergoing concomitant CABG compared with those undergoing CABG only. MethodsWe performed a retrospective study of 42 patients undergoing CABG+MVR (n=16) or CABG only (n=26) at the Division of Cardiovascular Surgery of PROCAPE, between May 2007 and April 2010. Preoperative clinical characteristics, procedural characteristics, major and minor complications after surgery, preoperative and postoperative left ventricular ejection fraction (LVEF) by echocardiography, and outcome (survivor or death) were assessed. ResultsMean patient age was 63.4±8.5 years, and 64.8% (n=23) were male. The CABG+MVR group showed lower rates of postoperative low cardiac output (6.3% vs. 42.3%, p=0.014) and atrial fibrillation (6.3% vs. 38.5%, p=0.021). Both groups had higher mean LVEF in the postoperative compared with the preoperative period, but the average gain in LVEF in the CABG+MVR group was higher than in the CABG-only group (8.88±2.39 vs. 4.31±1.23, p<0.001). There was no significant difference in operative mortality (6.3% vs. 7.7%, p=0.679). ConclusionsCABG+MVR can be performed safely in patients with moderate-to-severe IMR. CABG+MVR resulted in lower rates of complications than CABG only. Both surgical approaches resulted in significant improvement of postoperative LVEF. However, there was greater improvement in the CABG+MVR group." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "IntroduçãoA Regurgitação mitral isquémica (RMI) está associada ao aumento da mortalidade. Mesmo após a cirurgia de revascularização miocárdica (CRM), reduz a sobrevida. Vários estudos enfatizam o aumento da mortalidade perioperatória com troca valvar mitral (TVM) nesta situação, mas isto ainda é controverso. ObjetivoInvestigar o impacto da TVM nos resultados imediatos em pacientes com RMI moderada a grave submetidos à CRM em comparação com aqueles submetidos à CRM apenas. MétodosEstudo retrospetivo de 42 pacientes submetidos à CRM+TVM (n=16) ou CRM isolada (n=26) na Divisão de Cirurgia Cardiovascular do PROCAPE, de maio de 2007 a abril de 2010. Foram avaliadas características clínicas pré-operatórias, características do procedimento, complicações após a cirurgia, fração de ejeção do ventrículo esquerdo (FEVE) pré e pós-operatório pelo ecocardiograma e evolução (sobrevivência ou óbito). ResultadosA idade média dos pacientes foi de 63,4 anos (±8,5), sendo 64,8% (n=23) do sexo masculino. O grupo CRM+TVM apresentou menores taxas de baixo débito cardíaco no pós-operatório (6,3 versus 42,3%, p=0,014) e fibrilação atrial (6,3% versus 38,5%, p=0,021). Ambos os grupos apresentaram maior média de FEVE no pós-operatório em comparação com o período pré-operatório; no entanto, o ganho médio da FEVE no grupo CRM+TVM foi maior em comparação com o grupo CRM isolada (8,88±2,39 versus 4,31±1,23, p<0,001). Não houve diferença significativa nas taxas de mortalidade operatória (6,3 versus 7,7%, p=0,679). ConclusõesCRM+TVM pode ser realizada com segurança em pacientes que têm RMI moderada a grave. CRM+TVM resultou em menores taxas de complicações do que a CRM isolada. Ambas as abordagens cirúrgicas resultaram em melhoria significativa da FEVE pós-operatória, por outro lado, houve maior ganho no grupo CRM+TVM." ] ] "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" => 1266 "Ancho" => 1548 "Tamanyo" => 87546 ] ] "descripcion" => array:1 [ "en" => "Analysis of left ventricular ejection fraction by echocardiography before and after surgery. Values expressed as mean±standard deviation. CABG: coronary artery bypass grafting; MVR: mitral valve replacement; Preop: preoperative; Postop: postoperative." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1232 "Ancho" => 1595 "Tamanyo" => 64326 ] ] "descripcion" => array:1 [ "en" => "Improvement in left ventricular ejection fraction by echocardiography after surgery. Values expressed as mean±standard deviation. CABG: coronary artery bypass grafting; MVR: mitral valve replacement; Postop: postoperative." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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"><td 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">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG+MVR</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total</td><td 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">p \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-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age >70 years \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male gender \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.879<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity \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="char" 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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.1 \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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.633<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.256<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.8 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.8 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.394<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">COPD \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.139<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal disease \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.8 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.1 \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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.320<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MI <30 days \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.808<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EuroSCORE ≥6 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.380<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NYHA class \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.012<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I/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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54.8 \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="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III/IV \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.7 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.2 \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="" 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></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab354807.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Fisher's exact test." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Pearson's chi-square test. CABG: coronary artery bypass grafting; COPD: chronic obstructive pulmonary disease; MI: myocardial infarction; MVR: mitral valve replacement; NYHA: New York Heart Association." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients undergoing coronary artery bypass grafting with and without mitral valve replacement." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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"><td 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">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG+MVR</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total</td><td 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">p \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-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of bypasses \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.058<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \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 " 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 " align="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 \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="char" 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 " align="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.2 \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="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 or more \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.4 \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="" 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 " colspan="8" align="char" valign="\n \t\t\t\t\ttop\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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPB time (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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.001<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \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 " 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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.1 \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 " align="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91–120 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.5 \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="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>120 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.9 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.2 \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="" 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 " colspan="8" align="char" valign="\n \t\t\t\t\ttop\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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aortic clamp time (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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤60 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.4 \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="" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61–90 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.2 \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="" 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 " 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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.4 \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="" 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></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab354806.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Fisher's exact test." ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "Fisher's chi-square test. CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; MVR: mitral valve replacement." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of coronary artery bypass grafting procedures with and without mitral valve replacement." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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"><td 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">Variable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG+MVR</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CABG</td><td 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">p \t\t\t\t\t\t\n \t\t\t\t</td><td 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">OR (CI 95%) \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-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shock/hemorrhage \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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="char" 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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low cardiac output \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="char" 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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.014<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.09 (0.01–0.81) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal complications \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.138<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.11 (0.01–1.68) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neurologic complications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.5 \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.10 (0.08–10.82) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrial fibrillation \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="char" 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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.021<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.11 (0.01–0.96) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory complications \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.8 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.316<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.44 (0.06–2.28) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple transfusion \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="char" 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><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.8 \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="char" 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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.116<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 (0.05–1.64) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death \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="char" 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 " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.7 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.679<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 (0.03–12.98) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab354808.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "Pearson's chi-square test." ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "Fisher's exact test. CABG: coronary artery bypass grafting; CI: confidence interval; MVR: mitral valve replacement; OR: odds ratio calculated for CABG+MVR compared to CABG only." ] ] ] "descripcion" => array:1 [ "en" => "Complications and mortality in patients undergoing coronary artery bypass grafting with and without mitral valve replacement." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Heub" 1 => "F. Jatene" 2 => "L. 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Estatísticas

Original article

Substituição da valva mitral combinada com cirurgia de revascularização do miocárdio em pacientes com regurgitação mitral isquémica moderada a grave

Michel Pompeu B.O. Sá

Autor para correspondência

michel_pompeu@yahoo.com.br

Corresponding author.

, Evelyn F. Soares, Cecília A. Santos, Omar J. Figueiredo, Renato O.A. Lima, Rodrigo R. Escobar, Frederico P. Vasconcelos, Ricardo C. Lima

Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco, University of Pernambuco, Pernanbuco, Brazil

Lido

14941

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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Analysis of left ventricular ejection fraction by echocardiography before and after surgery&#46; Values expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; CABG&#58; coronary artery bypass grafting&#59; MVR&#58; mitral valve replacement&#59; Preop&#58; preoperative&#59; Postop&#58; postoperative&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ischemic mitral regurgitation &#40;IMR&#41; is defined as mitral valve &#40;MV&#41; insufficiency precipitated by myocardial infarction&#44; with normal leaflet and chordal morphology&#46; IMR usually occurs with right or circumflex coronary infarction involving the posterior ventricular wall&#44; posterior papillary muscle&#44; and adjacent mitral annulus&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Common anatomic features include annular dilatation&#44; displacement of papillary muscles&#44; and varying degrees of leaflet restriction or tethering&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There is a clear association between IMR and increased late mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;7</span></a> Even after revascularization&#44; IMR reduces late survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Several studies have shown increased perioperative mortality for valve replacement in this situation&#44; but the subject remains controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this study was to investigate the differences in immediate postoperative results &#40;in-hospital complications and evolution&#41; in patients with IMR undergoing coronary artery bypass grafting &#40;CABG&#41; with intraoperative correction of valve dysfunction by mitral valve replacement &#40;MVR&#41; compared with those undergoing CABG only&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population</span><p id="par0020" class="elsevierStylePara elsevierViewall">We studied 42 consecutive patients with coronary artery disease associated with moderate-to-severe IMR undergoing CABG at the Division of Cardiovascular Surgery of Pronto Socorro Cardiol&#243;gico de Pernambuco &#40;PROCAPE&#41;&#44; between May 2007 and April 2010&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Definition of ischemic mitral regurgitation</span><p id="par0025" class="elsevierStylePara elsevierViewall">IMR was defined as valve insufficiency caused by coronary artery disease&#46; All patients had a history of myocardial infarction&#44; ejection fraction &#60;50&#37; by echocardiography and moderate-to-severe functional MVR &#40;without intrinsic changes in valve leaflets and&#47;or subvalvular apparatus&#41;&#46; All patients had one or more left ventricular &#40;LV&#41; segmental wall motion abnormalities and significant coronary disease in the territory supplying the wall motion abnormality&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Exclusion criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with rheumatic&#44; myxomatous&#44; infectious&#44; or congenital diseases of the mitral valve were excluded&#46; Patients with mitral regurgitation due to papillary muscle rupture&#44; torn or elongated chordae tendineae&#44; or ballooning or scalloping of the mitral leaflets were not considered to have IMR&#46; Patients with mild MVR were also not considered for the study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a retrospective study using medical records and initially generated two groups&#58; CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR &#40;biological valve prosthesis&#41; or CABG only&#46; In each instance&#44; the operative approach for concomitant MVR had been chosen by the attending surgeon&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables and outcomes</span><p id="par0040" class="elsevierStylePara elsevierViewall">The following variables were compared&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Preoperative clinical characteristics&#58; age &#62;70 years&#44; gender &#40;male or female&#41;&#44; obesity &#40;body mass index<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; hypertension&#44; diabetes&#44; smoking&#44; chronic obstructive pulmonary disease &#40;dyspnea or chronic cough and prolonged use of bronchodilators or corticosteroids and&#47;or radiological changes including opacification due to hyperinflation and&#47;or elevation of the ribs and&#47;or flattening of the diaphragm&#41;&#44; renal disease &#40;creatinine &#8805;2&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or preoperative dialysis&#41;&#44; myocardial infarction &#60;30 days previously&#44; EuroSCORE &#8805;6 &#40;high risk&#41;&#44; and New York Heart Association &#40;NYHA&#41; functional class I&#44; II&#44; III or IV&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Procedural characteristics&#58; number of aortocoronary bypasses&#59; as all patients underwent on-pump surgery&#44; we assessed cardiopulmonary bypass &#40;CPB&#41; duration &#40;in min&#41; and aortic clamp time &#40;in min&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Major procedure-related complications&#58; hemorrhagic shock&#44; neurologic complications &#40;stroke or transient ischemic attack&#41;&#44; low cardiac output &#40;signs of poor peripheral and&#47;or central perfusion including cold extremities&#44; oliguria&#47;anuria or decreased level of consciousness&#44; and need for inotropic support with dopamine 4<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;min for at least 12<span class="elsevierStyleHsp" style=""></span>hours or intra-aortic balloon pump to maintain systolic blood pressure greater than 90<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; and renal complications &#40;creatinine &#8805;2&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or postoperative dialysis&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Minor procedure-related complications&#58; respiratory complications &#40;pulmonary infection&#44; acute respiratory distress syndrome&#44; atelectasis&#44; need for intubation for more than 48<span class="elsevierStyleHsp" style=""></span>hours&#41;&#44; atrial fibrillation &#40;AF&#41; after surgery&#44; need for multiple transfusions &#40;more than three units of packed red blood cells&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;5&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Preoperative and postoperative left ventricular ejection fraction &#40;LVEF&#41; by echocardiography performed during hospitalization&#59;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;6&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Length of stay in intensive care unit &#40;days&#41; and hospital &#40;days&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#40;7&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Outcome &#40;survivor or death&#41;&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analysis and interpretation were performed in SPSS &#40;Statistical Package for the Social Sciences&#41; version 15&#46; Data were stored in duplicate to validate the consistency of the data and the analysis in order to minimize error&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Univariate analysis for categorical variables was performed with the chi-square test or Fisher&#39;s exact test&#44; as appropriate&#46; The Student&#39;s <span class="elsevierStyleItalic">t</span> test was used for continuous variables&#46; Verification of the hypothesis of equality of variances was performed using Levene&#39;s <span class="elsevierStyleItalic">F</span> test&#46; Values of p&#60;0&#46;05 were considered statistically significant&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical considerations</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study was approved by the Research Ethics Committee of Complexo Hospitalar do Hospital Universit&#225;rio Oswaldo Cruz&#47;Pronto Socorro Cardiol&#243;gico de Pernambuco &#8211; HUOC&#47;PROCAPE&#44; file no&#46; 132&#47;2009&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Population characteristics</span><p id="par0095" class="elsevierStylePara elsevierViewall">Mean patient age was 63&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;5 years&#59; 64&#46;8&#37; &#40;n&#61;23&#41; were male and 35&#46;2&#37; &#40;n&#61;19&#41; female&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The 42 patients with moderate-to-severe IMR were among 542 patients who underwent CABG consecutively during the study period&#44; and thus the prevalence of moderate-to-severe IMR was 8&#46;1&#37; among operated patients&#46; Of these&#44; 38&#46;1&#37; &#40;n&#61;16&#41; underwent CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR and 61&#46;9&#37; &#40;n&#61;26&#41; underwent CABG only&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">For almost all the preoperative variables &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; there were no statistically significant differences&#44; except for the proportion of patients in NYHA class III&#47;IV&#44; with more patients in this class in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group than in the CABG-only group &#40;68&#46;7&#37; vs&#46; 30&#46;8&#37;&#44; p&#61;0&#46;012&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Procedural characteristics</span><p id="par0110" class="elsevierStylePara elsevierViewall">As expected &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; patients undergoing CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR showed a higher proportion with prolonged CPB time &#40;p&#61;0&#46;001&#41; and prolonged aortic clamp time &#40;p&#60;0&#46;001&#41;&#46; There was no difference in the proportion of the number of coronary bypasses as a categorical variable&#59; however&#44; when analyzed as a continuous variable&#44; the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group underwent more coronary bypasses than the CABG-only group &#40;3&#46;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;85 vs&#46; 2&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;81&#44; p&#61;0&#46;028&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Postoperative evolution</span><p id="par0115" class="elsevierStylePara elsevierViewall">The CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group showed lower rates of low cardiac output &#40;6&#46;3&#37; vs&#46; 42&#46;3&#37;&#44; p&#61;0&#46;014&#41; and atrial fibrillation &#40;6&#46;3&#37; vs&#46; 38&#46;5&#37;&#44; p&#61;0&#46;021&#41;&#46; The other variables showed no statistically significant differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">There were no statistically significant differences between groups in length of stay in intensive care &#40;7&#46;81<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;86 vs&#46; 8&#46;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;10 days&#44; p&#61;0&#46;802&#41; or in hospital &#40;44&#46;06<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;61 vs&#46; 40&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;66 days&#44; p&#61;0&#46;568&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Assessment of left ventricular function</span><p id="par0125" class="elsevierStylePara elsevierViewall">Both the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group &#40;54&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;51 vs&#46; 45&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;54&#44; p&#61;0&#46;041&#41; and the CABG-only group &#40;50&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;25 vs&#46; 46&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;19&#44; p&#61;0&#46;049&#41; had higher mean LVEF in the postoperative period than in the preoperative period &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Both groups thus had higher mean LVEF in the postoperative than in the preoperative period&#44; showing an improvement in LV function after surgical procedures&#46; However&#44; the average gain in LVEF in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group was higher than that in the CABG-only group &#40;8&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;39 vs&#46; 4&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;23&#44; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortality</span><p id="par0135" class="elsevierStylePara elsevierViewall">There was no significant difference between groups in operative mortality &#40;6&#46;3&#37; vs&#46; 7&#46;7&#37;&#44; p&#61;0&#46;679&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The prevalence of moderate-to-severe IMR detected by transthoracic echocardiography and&#47;or cardiac catheterization in myocardial infarction patients with coronary artery disease ranges from 3&#37; to 12&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> The prevalence of 8&#46;1&#37; observed in our study is within the range reported in the literature&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Mitral regurgitation causes atrial hemodynamic overload&#44; which leads to tissue fibrosis&#59; consequently&#44; a non-homogenous distribution of diastolic depolarization potentials&#44; refractory periods&#44; and conduction properties occurs within the atrial muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> All of these factors enhance the probability of reentry circuits forming around areas with longer refractory periods&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> MVR eliminates regurgitation&#44; thereby reducing atrial hemodynamic overload and interrupting the cascade of events that culminates in the development of postoperative atrial fibrillation&#46; In our study&#44; the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group&#44; despite longer exposure to CPB &#40;known as a risk factor for developing postoperative AF<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#41; showed a lower rate of AF than the CABG-only group &#40;6&#46;3&#37; vs&#46; 38&#46;5&#37;&#44; p&#61;0&#46;021&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It seems logical to assume that the volume overload associated with mitral regurgitation will be particularly detrimental to patients with compromised LV function&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> There is also a loss of flow to the aorta&#44; since part of the ejected volume is directed to the left atrium&#46; MVR eliminates the volume overload and the loss of volume ejected toward the left atrium&#44; displacing the entire cardiac output in the correct direction &#40;to the aorta&#41;&#46; This explains the lower rate of low cardiac output in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group &#40;despite longer exposure to CPB&#44; known as a risk factor for development of postoperative low cardiac output<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#41; compared to CABG only &#40;6&#46;3&#37; vs&#46; 42&#46;3&#37;&#59; p&#61;0&#46;014&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Segmental wall motion abnormalities and LV distortion and remodeling after myocardial infarction displace the papillary muscles from the mitral annulus&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This displacement puts excessive tension on the chordae&#44; resulting in apical mitral leaflet tethering&#44; restricting coaptation during systole&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> Leaflet tethering is compounded by LV contractile dysfunction&#44; which decreases the closing force on the leaflets&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Once IMR begins&#44; end-diastolic LV volume and wall stress increase in tandem with preload&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> LV mass also increases progressively without a concomitant increase in end-diastolic wall thickness&#44; resulting in generalized loss of myocardial contractile function&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Increased wall stress causes further LV dysfunction&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> which in turn results in further papillary muscle displacement and leaflet tenting&#46; If LV dilation occurs&#44; it leads to annular enlargement and dysfunction&#44; thereby increasing valvular incompetence&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Chronic IMR therefore begets MR in a self-perpetuating manner&#46; CABG surgery may interrupt the perpetuation and&#47;or progression of this vicious cycle&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">MVR is still a reasonable surgical option in many patients with IMR&#44; mainly because of its reliability and reproducibility&#46; It should be considered for patients with acute IMR&#44; and for those with chronic IMR and multiple comorbidities&#44; complex regurgitant jets &#40;noncentral or more than one jet&#41;&#44; or severe tethering of both MV leaflets&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;24&#44;25</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Some studies indicate greater perioperative mortality associated with this procedure&#44; suggesting that preference should be given to less aggressive procedures such as CABG only or CABG associated with MVR&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> However&#44; in our study&#44; although the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group had a statistically significant higher prevalence of patients with worse functional class&#44; there was no difference in operative mortality &#40;6&#46;3&#37; vs&#46; 7&#46;7&#37;&#59; p&#61;0&#46;679&#41; between groups&#46; A possible explanation for this is that&#44; unlike in other studies&#44; MVR was the first choice for mitral valve surgery&#44; and not a result of initial unsuccessful mitral valve repair &#40;reoperation and&#47;or prolonged CPB time as a function of failed valve repair might have increased operative mortality in this group&#41;&#46; In addition&#44; surgical intervention can prevent the LV overload and remodeling that results from mitral regurgitation&#44; which may improve surgical outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Goland et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> studied changes in LVEF in 83 patients with moderate IMR who underwent CABG associated with MVR &#40;n&#61;28&#41; or CABG only &#40;n&#61;55&#41;&#46; Patients who underwent CABG only showed significant improvement in LVEF in the early postoperative period &#40;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 vs&#46; 45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#59; p&#61;0&#46;002&#41;&#44; as did the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group &#40;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 vs&#46; 44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#59; p&#61;0&#46;02&#41;&#46; We also observed the same results of MVR&#44; with the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group showing higher mean LVEF in the postoperative than in the preoperative period &#40;54&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;51 vs&#46; 45&#46;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;54&#44; p&#61;0&#46;041&#41;&#44; as did the CABG-only group &#40;52&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;25 vs&#46; 48&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;19&#44; p&#61;0&#46;049&#41;&#46; So we observed improvement in postoperative LVEF in both groups&#46; Furthermore&#44; we found that the average gain in LVEF in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group was higher than in the CABG-only group &#40;8&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;39 vs&#46; 4&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;23&#44; p&#60;0&#46;001&#41;&#46; As can be seen&#44; in the case of LVEF&#44; CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR provides better improvement than CABG only&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Although we did not analyze the approach to mitral valve repair&#44; some considerations should be borne in mind&#46; This is a technique intended to reduce or eliminate mitral regurgitation&#44; while preserving the valve&#46; Several investigators have suggested that repair is better than replacement for patients with IMR&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Others&#44; however&#44; have documented similar survival after repair and after replacement&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Late survival is poor for all approaches&#44; with most patients dying within seven years of surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However&#44; choice of surgical procedure has an important impact on survival&#46; Among the most severely ill patients&#44; the survival benefit of mitral valve surgery &#40;by either valve repair or replacement&#41; is diminished&#44; which leads us to conclude that clinical status is an important determinant of survival&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It seems that the &#8220;repair vs&#46; replacement&#8221; debate remains undecided&#44; although there is a strong tendency in the medical community in favor of repair&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">The chief limitation of this study is its retrospective nature&#44; with various sources of bias&#46; Selection bias and lack of a uniform surgical experience &#40;different surgeons operating&#41; are important limitations&#46; In many cases the surgeon did not opt for valve repair because of the unavailability of intraoperative transesophageal echocardiography at our institution&#46; Decisions to perform concomitant MVR were made on the basis of surgical considerations and preferences&#46; The surgeons may have selected replacement for patients who had worse heart failure&#44; and thus may have replaced valves in the more severe or symptomatic patients&#46; A randomized prospective design would overcome this limitation&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Another limitation is the lack of uniformity of echocardiographic evaluation of mitral regurgitation grade and complete follow-up&#44; since the echocardiograms were performed by several operators using different equipment and our results are restricted to the in-hospital period&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">An important limitation is that ventricular diameters &#40;systolic and diastolic&#41; were not taken into consideration&#44; which may well have influenced the results to some extent&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Small sample size is another limitation of this study&#46; This is the consequence of selecting a very homogeneous group with only moderate-to-severe mitral regurgitation&#44; a history of myocardial infarction&#44; impaired LV function&#44; and a single mitral valve surgical approach &#40;valve replacement&#41;&#46; This prevented the application of multivariate logistic regression analysis&#44; so the study is limited to the use of univariate analysis&#44; which may affect the consistency of the presented evidence&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">Taking into account the severity of this population&#44; patients who underwent CABG only or CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR surgery experienced no statistically different mortality rates&#44; despite the presence of multiple comorbidities and impaired LVEF&#46; MVR can be performed safely&#44; concomitantly with CABG&#44; in patients with moderate-to-severe IMR&#46; In such patients&#44; the combined procedure resulted in lower rates of postoperative atrial fibrillation and low cardiac output than CABG only&#46; Both surgical approaches resulted in significant improvement in postoperative LVEF&#46; However&#44; there was greater improvement in the combined surgery group&#44; which may result in greater benefit to this group&#46; Despite being a more aggressive approach&#44; the combined surgical procedure did not increase morbidity or mortality&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Definition of ischemic mitral regurgitation"
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    "fechaRecibido" => "2012-02-04"
    "fechaAceptado" => "2012-07-12"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ischemic mitral regurgitation &#40;IMR&#41; is associated with increased mortality&#46; Even after coronary artery bypass grafting &#40;CABG&#41;&#44; IMR reduces survival&#46; Several studies have shown increased perioperative mortality for mitral valve replacement &#40;MVR&#41; in this situation&#44; but the subject remains controversial&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To investigate the impact of MVR on immediate outcomes in patients with moderate-to-severe IMR undergoing concomitant CABG compared with those undergoing CABG only&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study of 42 patients undergoing CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR &#40;n&#61;16&#41; or CABG only &#40;n&#61;26&#41; at the Division of Cardiovascular Surgery of PROCAPE&#44; between May 2007 and April 2010&#46; Preoperative clinical characteristics&#44; procedural characteristics&#44; major and minor complications after surgery&#44; preoperative and postoperative left ventricular ejection fraction &#40;LVEF&#41; by echocardiography&#44; and outcome &#40;survivor or death&#41; were assessed&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mean patient age was 63&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;5 years&#44; and 64&#46;8&#37; &#40;n&#61;23&#41; were male&#46; The CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group showed lower rates of postoperative low cardiac output &#40;6&#46;3&#37; vs&#46; 42&#46;3&#37;&#44; p&#61;0&#46;014&#41; and atrial fibrillation &#40;6&#46;3&#37; vs&#46; 38&#46;5&#37;&#44; p&#61;0&#46;021&#41;&#46; Both groups had higher mean LVEF in the postoperative compared with the preoperative period&#44; but the average gain in LVEF in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group was higher than in the CABG-only group &#40;8&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;39 vs&#46; 4&#46;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;23&#44; p&#60;0&#46;001&#41;&#46; There was no significant difference in operative mortality &#40;6&#46;3&#37; vs&#46; 7&#46;7&#37;&#44; p&#61;0&#46;679&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR can be performed safely in patients with moderate-to-severe IMR&#46; CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR resulted in lower rates of complications than CABG only&#46; Both surgical approaches resulted in significant improvement of postoperative LVEF&#46; However&#44; there was greater improvement in the CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR group&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A Regurgita&#231;&#227;o mitral isqu&#233;mica &#40;RMI&#41; est&#225; associada ao aumento da mortalidade&#46; Mesmo ap&#243;s a cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica &#40;CRM&#41;&#44; reduz a sobrevida&#46; V&#225;rios estudos enfatizam o aumento da mortalidade perioperat&#243;ria com troca valvar mitral &#40;TVM&#41; nesta situa&#231;&#227;o&#44; mas isto ainda &#233; controverso&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Investigar o impacto da TVM nos resultados imediatos em pacientes com RMI moderada a grave submetidos &#224; CRM em compara&#231;&#227;o com aqueles submetidos &#224; CRM apenas&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo de 42 pacientes submetidos &#224; CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#41; ou CRM isolada &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#41; na Divis&#227;o de Cirurgia Cardiovascular do PROCAPE&#44; de maio de 2007 a abril de 2010&#46; Foram avaliadas caracter&#237;sticas cl&#237;nicas pr&#233;-operat&#243;rias&#44; caracter&#237;sticas do procedimento&#44; complica&#231;&#245;es ap&#243;s a cirurgia&#44; fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo &#40;FEVE&#41; pr&#233; e p&#243;s-operat&#243;rio pelo ecocardiograma e evolu&#231;&#227;o &#40;sobreviv&#234;ncia ou &#243;bito&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A idade m&#233;dia dos pacientes foi de 63&#44;4 anos &#40;&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;5&#41;&#44; sendo 64&#44;8&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41; do sexo masculino&#46; O grupo CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM apresentou menores taxas de baixo d&#233;bito card&#237;aco no p&#243;s-operat&#243;rio &#40;6&#44;3 <span class="elsevierStyleItalic">versus</span> 42&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#41; e fibrila&#231;&#227;o atrial &#40;6&#44;3&#37; <span class="elsevierStyleItalic">versus</span> 38&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;021&#41;&#46; Ambos os grupos apresentaram maior m&#233;dia de FEVE no p&#243;s-operat&#243;rio em compara&#231;&#227;o com o per&#237;odo pr&#233;-operat&#243;rio&#59; no entanto&#44; o ganho m&#233;dio da FEVE no grupo CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM foi maior em compara&#231;&#227;o com o grupo CRM isolada &#40;8&#44;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;39 <span class="elsevierStyleItalic">versus</span> 4&#44;31<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;23&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; N&#227;o houve diferen&#231;a significativa nas taxas de mortalidade operat&#243;ria &#40;6&#44;3 <span class="elsevierStyleItalic">versus</span> 7&#44;7&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;679&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#245;es</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM pode ser realizada com seguran&#231;a em pacientes que t&#234;m RMI moderada a grave&#46; CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM resultou em menores taxas de complica&#231;&#245;es do que a CRM isolada&#46; Ambas as abordagens cir&#250;rgicas resultaram em melhoria significativa da FEVE p&#243;s-operat&#243;ria&#44; por outro lado&#44; houve maior ganho no grupo CRM<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>TVM&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Analysis of left ventricular ejection fraction by echocardiography before and after surgery&#46; Values expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; CABG&#58; coronary artery bypass grafting&#59; MVR&#58; mitral valve replacement&#59; Preop&#58; preoperative&#59; Postop&#58; postoperative&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">CABG<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MVR</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Shock&#47;hemorrhage&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Low cardiac output&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;014<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;09 &#40;0&#46;01&#8211;0&#46;81&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Renal complications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">19&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;11 &#40;0&#46;01&#8211;1&#46;68&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Neurologic complications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;10 &#40;0&#46;08&#8211;10&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;021<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;11 &#40;0&#46;01&#8211;0&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Respiratory complications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;316<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;44 &#40;0&#46;06&#8211;2&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple transfusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42&#46;3&nbsp;\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="char" valign="\n
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                  \t\t\t\t">0&#46;116<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;31 &#40;0&#46;05&#8211;1&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Death&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;679<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;80 &#40;0&#46;03&#8211;12&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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Informação do artigo

ISSN: 08702551
Idioma original: Inglês

DOI:10.1016/j.repc.2012.12.002

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2022 Novembro	75	22	97
2022 Outubro	56	25	81
2022 Setembro	49	27	76
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2022 Julho	55	24	79
2022 Junho	42	16	58
2022 Maio	53	30	83
2022 Abril	79	29	108
2022 Mar�o	67	35	102
2022 Fevereiro	70	16	86
2022 Janeiro	95	22	117
2021 Dezembro	54	34	88
2021 Novembro	72	37	109
2021 Outubro	84	45	129
2021 Setembro	87	36	123
2021 Agosto	106	25	131
2021 Julho	74	30	104
2021 Junho	100	50	150
2021 Maio	71	30	101
2021 Abril	124	41	165
2021 Mar�o	153	25	178
2021 Fevereiro	163	32	195
2021 Janeiro	81	13	94
2020 Dezembro	85	4	89
2020 Novembro	99	19	118
2020 Outubro	129	11	140
2020 Setembro	78	8	86
2020 Agosto	70	14	84
2020 Julho	109	12	121
2020 Junho	74	19	93
2020 Maio	82	13	95
2020 Abril	76	23	99
2020 Mar�o	126	12	138
2020 Fevereiro	180	23	203
2020 Janeiro	83	20	103
2019 Dezembro	87	14	101
2019 Novembro	90	8	98
2019 Outubro	173	9	182
2019 Setembro	188	14	202
2019 Agosto	57	3	60
2019 Julho	65	16	81
2019 Junho	42	8	50
2019 Maio	62	5	67
2019 Abril	72	19	91
2019 Mar�o	71	11	82
2019 Fevereiro	87	8	95
2019 Janeiro	80	5	85
2018 Dezembro	92	9	101
2018 Novembro	156	11	167
2018 Outubro	178	20	198
2018 Setembro	60	10	70
2018 Agosto	54	17	71
2018 Julho	44	13	57
2018 Junho	77	11	88
2018 Maio	65	8	73
2018 Abril	57	7	64
2018 Mar�o	70	9	79
2018 Fevereiro	46	4	50
2018 Janeiro	47	4	51
2017 Dezembro	79	12	91
2017 Novembro	65	11	76
2017 Outubro	45	8	53
2017 Setembro	62	11	73
2017 Agosto	58	10	68
2017 Julho	30	12	42
2017 Junho	50	16	66
2017 Maio	54	20	74
2017 Abril	33	11	44
2017 Mar�o	37	21	58
2017 Fevereiro	122	10	132
2017 Janeiro	33	14	47
2016 Dezembro	34	18	52
2016 Novembro	84	11	95
2016 Outubro	110	17	127
2016 Setembro	116	16	132
2016 Agosto	87	17	104
2016 Julho	30	21	51
2016 Junho	4	10	14
2016 Maio	19	8	27
2016 Abril	71	3	74
2016 Mar�o	122	18	140
2016 Fevereiro	120	31	151
2016 Janeiro	110	24	134
2015 Dezembro	125	18	143
2015 Novembro	114	17	131
2015 Outubro	117	26	143
2015 Setembro	122	21	143
2015 Agosto	142	21	163
2015 Julho	117	13	130
2015 Junho	127	8	135
2015 Maio	107	14	121
2015 Abril	99	20	119
2015 Mar�o	88	7	95
2015 Fevereiro	96	7	103
2015 Janeiro	94	14	108
2014 Dezembro	112	10	122
2014 Novembro	100	14	114
2014 Outubro	129	12	141
2014 Setembro	162	10	172
2014 Agosto	138	12	150
2014 Julho	226	15	241
2014 Junho	138	18	156
2014 Maio	152	16	168
2014 Abril	152	15	167
2014 Mar�o	207	23	230
2014 Fevereiro	186	19	205
2014 Janeiro	211	20	231
2013 Dezembro	153	22	175
2013 Novembro	159	27	186
2013 Outubro	128	20	148
2013 Setembro	85	29	114
2013 Agosto	102	46	148
2013 Julho	83	33	116
2013 Junho	82	25	107
2013 Maio	82	34	116
2013 Abril	96	48	144
2013 Mar�o	93	58	151
2013 Fevereiro	37	21	58

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