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constitui uma op&#231;&#227;o terap&#234;utica para controlo do ritmo em doentes portadores de <span class="elsevierStyleItalic">pacemaker</span> definitivo dotados com esta capacidade&#44; consistindo genericamente na administra&#231;&#227;o de um n&#250;mero de impulsos fixo &#40;<span class="elsevierStyleItalic">burs</span>t&#41; ou consecutivamente mais r&#225;pidos &#40;<span class="elsevierStyleItalic">ramp</span>&#41; do que a frequ&#234;ncia auricular&#44; de modo a terminar rapidamente o epis&#243;dio&#44; conseguindo deste modo abortar precocemente os epis&#243;dios de FA&#47;<span class="elsevierStyleItalic">flutter</span> auricular&#46; Desta forma&#44; procura&#8208;se limitar o <span class="elsevierStyleItalic">remodeling</span> auricular e o fen&#243;meno de taquicardiomiopatia&#44; bem como reduzir o tempo do epis&#243;dio e a percentagem de carga arr&#237;tmica&#44; sendo esta &#250;ltima um fator predisponente para AVC<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A efic&#225;cia do ATP pode depender da frequ&#234;ncia e regularidade da arritmia&#44; contudo&#44; alguns ritmos mais r&#225;pidos e irregulares podem ser convertidos pelo ATP&#44; visto que alguns epis&#243;dios de FA podem apresentar regularidade no in&#237;cio sendo vulner&#225;veis ao ATP<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; M&#250;ltiplas varia&#231;&#245;es tanto na dura&#231;&#227;o do ciclo como na regularidade podem ocorrer durante um longo epis&#243;dio arr&#237;tmico&#44; sendo o algoritmo ATP mais eficaz no tratamento do <span class="elsevierStyleItalic">flutter</span> auricular e taquicardia auricular lenta organizada<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46; O estudo realizado por Gillis et al&#46;&#44; que incluiu 71 pacientes num <span class="elsevierStyleItalic">follow&#8208;up</span> de tr&#234;s anos&#44; mostrou que nem o algoritmo ATP isolado nem o ATP em associa&#231;&#227;o com algoritmos de preven&#231;&#227;o de FA conseguem reduzir significativamente o tempo em arritmia auricular &#40;AT&#47;AF&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">O estudo realizado por Vollmann et al&#46;&#44; que incluiu 22 pacientes e tentativa de tratamento em 10 026 epis&#243;dios de arritmia auricular&#44; mostrou que a taxa de sucesso do ATP &#233; superior nos doentes com terapia imediata comparando com terapia atrasada &#40;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#37; <span class="elsevierStyleItalic">versus</span> 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#37;&#44; p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; por&#233;m&#44; esta maior efic&#225;cia n&#227;o se traduziu numa redu&#231;&#227;o significativa da carga arr&#237;tmica<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; No estudo PITAGORA que incluiu 176 pacientes e comparou a efic&#225;cia da terapia <span class="elsevierStyleItalic">ramp versus burst&#43;</span> foi demonstrado que a sequ&#234;ncia de <span class="elsevierStyleItalic">ramp</span> provou ser mais eficaz na convers&#227;o de epis&#243;dios de taquicardia auricular &#40;53&#44;1 <span class="elsevierStyleItalic">versus</span> 44&#44;3&#37;&#44; p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; para uma dura&#231;&#227;o de ciclo &#62;<span class="elsevierStyleHsp" style=""></span>240<span class="elsevierStyleHsp" style=""></span>ms&#44; justificando&#8208;se esta vantagem com a teoria da convers&#227;o por <span class="elsevierStyleItalic">pacing</span> de taquicardia auricular com presum&#237;vel mecanismo de reentrada e tamb&#233;m devido ao facto da terapia <span class="elsevierStyleItalic">ramp</span> entregar um grande n&#250;mero de impulsos com ciclos diferentes dentro de cada sequ&#234;ncia&#44; havendo maior probabilidade de capturar a aur&#237;cula<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; Ficou ainda demonstrado melhoria da qualidade de vida sobretudo no grupo de pacientes com efic&#225;cia de ATP &#62;<span class="elsevierStyleHsp" style=""></span>60&#37;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A otimiza&#231;&#227;o do ATP auricular pode reduzir a dura&#231;&#227;o dos epis&#243;dios de taquicardia auricular e tamb&#233;m ter alguma import&#226;ncia na preven&#231;&#227;o de eventos cardioemb&#243;licos sendo&#44; no entanto&#44; necess&#225;rio manter anticoagula&#231;&#227;o em doentes com fatores de risco tromboemb&#243;lico<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">O potencial benef&#237;cio destes algoritmos&#44; aliado &#224; sua disponibilidade em alguns modelos de <span class="elsevierStyleItalic">pacemakers</span> convencionais&#44; aconselha assim &#224; demonstra&#231;&#227;o desse benef&#237;cio em doentes em contexto de pr&#225;tica cl&#237;nica corrente&#44; o que constitui o principal objetivo do presente trabalho&#46; Procuraremos avaliar a efic&#225;cia do ATP auricular na redu&#231;&#227;o da carga arr&#237;tmica&#44; bem como identificar os fatores preditores do bom desempenho deste algoritmo&#44; contribuindo deste modo para a otimiza&#231;&#227;o da sua utiliza&#231;&#227;o&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Realizou&#8208;se um estudo retrospetivo no laborat&#243;rio de <span class="elsevierStyleItalic">pacing</span> de um hospital distrital&#44; tendo sido inclu&#237;dos doentes consecutivos em que foi implantado <span class="elsevierStyleItalic">pacemaker</span> dupla c&#226;mara &#40;Enrhythm P1501DR Medtronic Inc&#46;&#44; Minneapolis&#44; Minnesota&#44; EUA&#41;&#44; no per&#237;odo compreendido entre janeiro de 2005 e dezembro de 2010&#46; A amostra ficou assim constitu&#237;da por um total de 57 pacientes &#40;28 do sexo masculino e 29 do sexo feminino&#41;&#44; com um per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span> m&#233;dio de 15 meses&#46; Em nove pacientes foi ativado o algoritmo ATP ao 1&#46;&#176; m&#234;s de implante e em 15 pacientes o algoritmo foi ativado aos tr&#234;s meses &#40;M1&#41;&#44; enquanto os restantes &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41; se mantiveram com o algoritmo inativo at&#233; ao final do <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; formando&#8208;se deste modo dois grupos de pacientes&#58; um com a terapia ATP ativa &#40;ATP&#95;ON&#41; e o outro grupo com o algoritmo desativado &#40;ATP&#95;OFF&#41;&#46; A decis&#227;o de ativar o algoritmo ATP foi tomada com base na presen&#231;a de arritmias auriculares durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; em doentes com carga arr&#237;tmica superior a 0&#44;1&#37;&#46; No grupo ATP&#95;ON apenas num doente o modo de minimiza&#231;&#227;o de <span class="elsevierStyleItalic">pacing</span> ventricular <span class="elsevierStyleItalic">managed ventricular pacing</span> &#40;MVP&#41; se encontrava inativo&#44; enquanto no grupo ATP&#95;OFF este modo encontrava&#8208;se inativo em sete pacientes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;183&#41;&#46; Na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a> sumariam&#8208;se as caracter&#237;sticas cl&#237;nicas fundamentais da amostra&#44; n&#227;o se evidenciando diferen&#231;as significativas entre os grupos na idade&#44; distribui&#231;&#227;o por g&#233;nero&#44; fatores de risco cardiovasculares e hist&#243;ria de eventos pr&#233;vios&#46; N&#227;o se encontraram tamb&#233;m diferen&#231;as significativas nas terapias farmacol&#243;gicas em curso entre os grupos&#46; Do ponto de vista das indica&#231;&#245;es para a implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span>&#44; em 80&#44;7&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#41; dos casos o motivo foi doen&#231;a do n&#243;dulo sinusal e nos restantes casos bloqueio auriculoventricular &#40;2&#46;&#176; grau&#58; 5&#44;3&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#59; 3&#46;&#176; grau&#58; 14&#44;0&#37;&#44; n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#46; A distribui&#231;&#227;o das indica&#231;&#245;es no grupo ATP&#95;OFF e ATP&#95;ON foi semelhante &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;29&#41;&#46; Cerca de 45 pacientes &#40;78&#44;9&#37;&#41; apresentavam antecedentes de FA&#47;<span class="elsevierStyleItalic">flutter</span> auricular documentados&#44; n&#227;o havendo diferen&#231;as estatisticamente significativas entre os grupos ATP&#95;ON e OFF nesta caracter&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;97&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Os doentes foram selecionados de acordo com o modelo de <span class="elsevierStyleItalic">pacemaker</span> implantado&#44; recolhendo&#8208;se toda a informa&#231;&#227;o constante do processo individual&#44; bem como dos registos das consultas de <span class="elsevierStyleItalic">follow&#8208;up</span> realizadas no laborat&#243;rio de <span class="elsevierStyleItalic">pacing</span>&#46; Todos os dados relativos ao funcionamento do <span class="elsevierStyleItalic">pacemaker</span> foram obtidos em cada uma das consultas de <span class="elsevierStyleItalic">pacing</span>&#44; atrav&#233;s do programador Medtronic Carelink modelo 2&#46;090&#44; com cabe&#231;ote de programa&#231;&#227;o 2067&#46; Recolheu&#8208;se informa&#231;&#227;o quanto &#224; percentagem de sucesso da terapia ATP&#44; percentagem de carga arr&#237;tmica&#44; percentagem de <span class="elsevierStyleItalic">pacing</span> auricular e ventricular&#44; n&#250;mero de epis&#243;dios em que ocorreu tentativa de tratamento e n&#250;mero de epis&#243;dios tratados com sucesso&#46; A recolha dos dados foi efetuada retrospetivamente e incluiu a consulta realizada ao 3&#46;&#176; m&#234;s &#40;M1&#41;&#44; ao 9&#46;&#176; m&#234;s &#40;M2&#41; e ao 15&#46;&#176; m&#234;s &#40;M3&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">No in&#237;cio do estudo &#40;M1&#41; efetuavam terap&#234;utica antiarr&#237;tmica 29 pacientes &#40;50&#44;9&#37;&#41; evoluindo para 32 &#40;56&#44;1&#37;&#41; no 2&#46;&#176; <span class="elsevierStyleItalic">follow&#8208;up</span> &#40;M2&#41; e 36 &#40;63&#44;2&#37;&#41; no 3&#46;&#176; <span class="elsevierStyleItalic">follow&#8208;up</span> &#40;M3&#41;&#44; sem diferen&#231;as estatisticamente significativas entre os grupos&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Tratamento estat&#237;stico</span><p id="par0050" class="elsevierStylePara elsevierViewall">Os dados relativos aos sujeitos da amostra foram informatizados e tratados com recurso ao programa SPSS para Windows&#44; vers&#227;o 19&#44;0&#46; A distribui&#231;&#227;o das vari&#225;veis foi testada&#44; quanto &#224; normalidade&#44; pelo teste de Kolmogorov&#8208;Smirnov&#44; e quanto &#224; homogeneidade das vari&#226;ncias pelo teste de Levene&#46; Recorreu&#8208;se a uma estat&#237;stica descritiva simples para caracteriza&#231;&#227;o geral da amostra e da distribui&#231;&#227;o das vari&#225;veis&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As compara&#231;&#245;es entre grupos foram realizadas atrav&#233;s do teste &#967;2 para vari&#225;veis categ&#243;ricas&#44; ou do teste t de Student &#40;dois grupos&#41; para vari&#225;veis quantitativas&#46; A an&#225;lise estat&#237;stica dos dados recorreu tamb&#233;m a ANOVA de medidas repetidas efetuadas sobre as v&#225;rias medidas consideradas nos diversos momentos de avalia&#231;&#227;o&#46; Nos casos em que se verificou a viola&#231;&#227;o da esfericidade foi adotada a corre&#231;&#227;o de Greenhouse&#8208;Geisser para os graus de liberdade&#46; Todas as compara&#231;&#245;es m&#250;ltiplas destinadas a localizar os efeitos significativos de um fator foram realizadas com ajustamento de Bonferroni para os n&#237;veis de signific&#226;ncia&#46; Realizaram&#8208;se frequentemente an&#225;lises de regress&#227;o linear simples complementadas com an&#225;lises de regress&#227;o linear m&#250;ltipla&#46; O crit&#233;rio de signific&#226;ncia estat&#237;stica utilizado foi um valor de p &#8804;<span class="elsevierStyleHsp" style=""></span>0&#44;05 para um intervalo de confian&#231;a de 95&#37;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Em todos os doentes inclu&#237;dos no estudo&#44; o eletrocateter auricular foi posicionado no ap&#234;ndice auricular direito &#40;AAD&#41; e o ventricular no &#225;pex do ventr&#237;culo direito &#40;VD&#41;&#46; Durante o estudo verificaram&#8208;se 12 428 tentativas cumulativas de tratamento por ATP de epis&#243;dios de FA&#47;<span class="elsevierStyleItalic">flutter</span> auricular&#44; com interrup&#231;&#227;o do epis&#243;dio arr&#237;tmico em 7420 epis&#243;dios &#40;efic&#225;cia estimada a 15 meses de 59&#44;7&#37;&#41;&#46; Particularizando por momento de <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; aos tr&#234;s meses de <span class="elsevierStyleItalic">follow&#8208;up</span> &#40;M1&#41;&#44; com nove pacientes com algoritmo de tratamento ativo&#44; verificaram&#8208;se 1019 tentativas de ATP auricular&#44; das quais se verificou sucesso terap&#234;utico em 604 epis&#243;dios &#40;59&#44;3&#37; efic&#225;cia de ATP&#41;&#46; Aos nove meses de <span class="elsevierStyleItalic">follow&#8208;up</span> &#40;M2&#41;&#44; em 5458 epis&#243;dios contabilizados&#44; foram tratados com sucesso 3019 &#40;55&#44;3&#37; de efic&#225;cia de ATP&#41;&#44; enquanto aos 15 meses &#40;M3&#41;&#44; em 5951 epis&#243;dios&#44; foram tratados 3797 &#40;63&#44;8&#37; efic&#225;cia de ATP&#41;&#46; A varia&#231;&#227;o da efic&#225;cia do ATP nos tr&#234;s momentos de <span class="elsevierStyleItalic">follow&#8208;up</span> n&#227;o foi estatisticamente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;638&#41;&#44; indicando uma estabilidade longitudinal na efic&#225;cia desta terap&#234;utica&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A m&#233;dia de carga arr&#237;tmica foi de 6&#44;64&#37; no grupo ATP&#95;OFF e 7&#44;51&#37; no grupo ATP&#95;ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;845&#41; no momento M1&#44; passando para 6&#44;57&#37; no grupo ATP&#95;OFF e 7&#44;39&#37; no grupo ATP&#95;ON no momento M2 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;867&#41;&#46; No momento M3 esta foi de 12&#44;68&#37; no grupo ATP&#95;OFF e 9&#44;5&#37; no grupo ATP&#95;ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;653&#41;&#46; Apesar de n&#227;o se encontrarem diferen&#231;as estatisticamente significativas&#44; verificou&#8208;se uma tend&#234;ncia favor&#225;vel ao grupo ATP&#95;ON&#44; na medida em que este apresentou um aumento mais discreto na percentagem de carga arr&#237;tmica&#44; conforme representado na <a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Para perceber se a presen&#231;a de algoritmos adicionais de preven&#231;&#227;o de taquiarrmitias auriculares traria algum benef&#237;cio &#224; efic&#225;cia do ATP auricular&#44; dividimos os dois grupos em subgrupos&#44; considerando a presen&#231;a ou aus&#234;ncia de algoritmos preventivos de FA&#46; A an&#225;lise dos resultados&#44; resumidos na <a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a>&#44; revelou que o algoritmo ATP programado isoladamente foi a programa&#231;&#227;o que obteve menor carga arr&#237;tmica no final do <span class="elsevierStyleItalic">follow&#8208;up</span> de 15 meses&#44; e foi tamb&#233;m o grupo em que a subida de carga arr&#237;tmica foi menor&#44; apesar da aus&#234;ncia de efeitos principais significativos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;967&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Correlacionando a evolu&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular com a evolu&#231;&#227;o da carga arr&#237;tmica auricular&#44; encontrou&#8208;se uma rela&#231;&#227;o positiva e estatisticamente significativa &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;417&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#44; indicando que o incremento do <span class="elsevierStyleItalic">pacing</span> ventricular se traduz num aumento significativo da carga arr&#237;tmica&#46; O coeficiente de determina&#231;&#227;o para esta rela&#231;&#227;o foi de 17&#44;4&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Ao compararmos a percentagem m&#233;dia de <span class="elsevierStyleItalic">pacing</span> ventricular entre os dois grupos verific&#225;mos que em M1 foi de 29&#44;47&#37; no grupo ATP&#95;OFF e de 11&#44;34&#37; no grupo ATP&#95;ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;024&#41;&#44; em M2 foi de 30&#44;67&#37; no grupo ATP&#95;OFF e de 12&#44;5&#37; no grupo ATP&#95;ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#41; e em M3 foi de 34&#44;07&#37; no grupo ATP&#95;OFF e de 14&#44;73&#37; no grupo ATP&#95;ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;037&#41;&#44;conforme representado nas <a class="elsevierStyleCrossRefs" href="#fig0020">Figuras 4 e 5</a>&#46; O grupo ATP&#95;OFF apresentou assim uma percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular apical significativamente superior quando comparado com o grupo ATP&#95;ON nos tr&#234;s momentos de <span class="elsevierStyleItalic">follow&#8208;up</span>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Quando compar&#225;mos a varia&#231;&#227;o da carga arr&#237;tmica em fun&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular entre os dois grupos verific&#225;mos uma intera&#231;&#227;o marginalmente significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;06&#41;&#44; indicando que o <span class="elsevierStyleItalic">pacing</span> ventricular &#233; um fator independentemente relacionado e determinante da carga de arritmias auriculares&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Ao compararmos a percentagem m&#233;dia de <span class="elsevierStyleItalic">pacing</span> auricular entre os dois grupos verific&#225;mos que&#44; em M1&#44; foi de 62&#44;53&#37; no grupo OFF e de 68&#44;63&#37; no grupo ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;46&#41;&#44; em M2 foi de 65&#44;02&#37; no grupo OFF e de 78&#44;22&#37; no grupo ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41; e em M3 foi de 66&#44;05&#37; no grupo OFF e de 77&#44;2&#37; no grupo ON &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;22&#41;&#44; ou seja&#44; n&#227;o ocorreram diferen&#231;as estatisticamente significativas entre os dois grupos &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figuras 6 e 7</a>&#41;&#46; Tamb&#233;m n&#227;o se encontrou nenhuma intera&#231;&#227;o significativa entre o <span class="elsevierStyleItalic">pacing</span> auricular&#44; a carga arr&#237;tmica e o ATP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;372&#41;&#44; contrariamente ao verificado para o <span class="elsevierStyleItalic">pacing</span> ventricular&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Em termos de eventos cl&#237;nicos significativos durante o <span class="elsevierStyleItalic">follow&#8208;up</span>&#44; documentaram&#8208;se apenas dois casos de AVC e um caso de insufici&#234;ncia renal aguda no grupo com ATP OFF&#44; e um caso de &#243;bito por neoplasia no grupo ATP&#95;ON&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discuss&#227;o</span><p id="par0100" class="elsevierStylePara elsevierViewall">Estudos anteriormente realizados mostraram que as terapias baseadas em <span class="elsevierStyleItalic">pacing</span> auricular antitaquicardia s&#227;o uma op&#231;&#227;o v&#225;lida e segura para o controle do ritmo em doentes com bradicardia sintom&#225;tica e necessidade de estimula&#231;&#227;o artificial&#44; permitindo terminar cerca de 40&#8208;60&#37; das arritmias auriculares&#44; tendo o nosso estudo revelado percentagens m&#233;dias de sucesso da terapia com ATP auricular ligeiramente superiores a 50&#37;&#44; sem registo de complica&#231;&#245;es<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;13&#44;14&#44;7</span></a>&#46; Contudo&#44; outros estudos demonstraram que nem o ATP auricular isolado nem associado a algoritmos de preven&#231;&#227;o consegue suprimir ou reduzir significativamente a carga arr&#237;tmica<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;15</span></a>&#46; Este aspeto foi tamb&#233;m observado no nosso estudo&#44; mesmo comparando diversas combina&#231;&#245;es de programa&#231;&#227;o&#44; n&#227;o obstante&#44; a tend&#234;ncia favor&#225;vel identificada no grupo com ATP auricular ativo isoladamente&#44; ou seja&#44; o grupo com a terapia ATP ativa e sem algoritmos de preven&#231;&#227;o ativos&#44; foi o que apresentou uma tend&#234;ncia para menor incremento de carga arr&#237;tmica&#44; quando comparado com os restantes tipos de programa&#231;&#227;o&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Considerando a literatura existente &#224; data no seu conjunto&#44; &#233; de facto patente a inconsist&#234;ncia em demonstrar benef&#237;cios inequ&#237;vocos &#224; terapia com ATP&#44; em grande medida resultado da enorme heterogeneidade de respostas individuais&#44; o que implica necessariamente que os benef&#237;cios cl&#237;nicos desta modalidade terap&#234;utica n&#227;o est&#227;o dispon&#237;veis para uma ampla gama de pacientes&#44; tendo ficado demonstrado nestes estudos que o algoritmo tem&#44; na melhor das hip&#243;teses&#44; efic&#225;cia moderada na convers&#227;o de taquicardias auriculares regulares e lentas&#44; baixa efic&#225;cia em taquicardias auriculares r&#225;pidas&#44; sendo ineficaz quando a FA se encontra estabelecida&#44; n&#227;o permitindo considerar este tipo de terap&#234;utica como primeira linha para o combate da FA parox&#237;stica nesta popula&#231;&#227;o<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;14&#8211;16</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No estudo ATTEST&#44; que incluiu 324 doentes&#44; foi colocada a hip&#243;tese de que a elevada percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular &#40;VP m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>99&#37;&#41; exerce um efeito delet&#233;rio e limita o beneficio das terapias auriculares&#44; aspeto que sai em parte refor&#231;ado com os resultados apresentados&#44; embora de forma n&#227;o t&#227;o robusta&#44; o que poder&#225; ser explicado pela utiliza&#231;&#227;o concomitante do algoritmo de minimiza&#231;&#227;o de <span class="elsevierStyleItalic">pacing</span> ventricular MVP&#44; resultando em percentagens de <span class="elsevierStyleItalic">pacing</span> abaixo do verificado no estudo ATTEST em ambos os grupos &#40;ATP&#95;ON e ATP&#95;OFF&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">N&#227;o obstante&#44; verific&#225;mos que a evolu&#231;&#227;o da carga arr&#237;tmica foi significativamente diferente no grupo ATP&#95;ON&#44; revelando este grupo uma taxa de crescimento menor na carga arr&#237;tmica&#44; o que &#233; de real&#231;ar atendendo a que este grupo apresentou tamb&#233;m uma percentagem m&#233;dia de <span class="elsevierStyleItalic">pacing</span> ventricular apical significativamente inferior&#46; Estudos anteriores mostraram tamb&#233;m que&#44; em pacientes com DNS e condu&#231;&#227;o AV intacta&#44; percentagens elevadas de estimula&#231;&#227;o ventricular &#40;VP &#62;<span class="elsevierStyleHsp" style=""></span>40&#37;&#41; aumentam significativamente o risco de internamento por insufici&#234;ncia card&#237;aca e FA&#44; tendo ficado tamb&#233;m patente no nosso estudo uma correla&#231;&#227;o significativa e positiva entre a evolu&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular e a carga arr&#237;tmica<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">No entanto&#44; e mesmo considerando a menor frequ&#234;ncia relativa de estimula&#231;&#227;o apical do VD no grupo com o algoritmo de ATP ligado&#44; a carga arr&#237;tmica ao longo do tempo de <span class="elsevierStyleItalic">follow&#8208;up</span> revelou ainda assim um crescimento&#44; refor&#231;ando a teoria de que realmente a dissincronia ventricular imposta por <span class="elsevierStyleItalic">pacing</span> ventricular &#233; delet&#233;ria&#44; mas n&#227;o influencia significativamente o desempenho do algoritmo<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> nem constitui provavelmente o &#250;nico fator de risco para o desenvolvimento de arritmias auriculares nestes doentes&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Adicionalmente&#44; existem evid&#234;ncias de que a taxa de sucesso do ATP &#233; superior nos doentes com terapia imediata comparando com terapia atrasada &#40;59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#37; <span class="elsevierStyleItalic">versus</span> 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#37;&#44; p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; embora sem influenciar de forma significativa a carga arr&#237;tmica e a sintomatologia<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; No nosso estudo&#44; em todos os doentes o par&#226;metro <span class="elsevierStyleItalic">Episode duration before RX delivery</span> encontrava&#8208;se programado nominalmente com um minuto&#44; pelo que a terapia s&#243; foi administrada ap&#243;s este per&#237;odo de tempo e n&#227;o imediatamente ap&#243;s o in&#237;cio do epis&#243;dio&#46; At&#233; que ponto este fator pode ter influenciado negativamente o desempenho do ATP auricular permanece por demonstrar e constitui uma limita&#231;&#227;o&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Por outro lado&#44; existem evid&#234;ncias indicando que o posicionamento do eletrocateter auricular &#233; fundamental para uma otimiza&#231;&#227;o do desempenho do algoritmo ATP&#44; com benef&#237;cio claro para o posicionamento ao n&#237;vel do septo interauricolar quando comparado com o posicionamento cl&#225;ssico<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a>&#46; Atendendo a que todos os nossos doentes tinham eletrocateter posicionado no AAD&#44; a performance global do algoritmo pode estar subvalorizada&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limita&#231;&#245;es</span><p id="par0135" class="elsevierStylePara elsevierViewall">O presente estudo incluiu um n&#250;mero reduzido de doentes com as terapias ativas n&#227;o permitindo estabelecer diferen&#231;as em rela&#231;&#227;o a eventuais comorbilidades&#44; taxa de internamentos e mortalidade&#46; O facto de o estudo ser retrospetivo tamb&#233;m limitou&#44; de algum modo&#44; os resultados&#44; sobretudo em rela&#231;&#227;o &#224; influ&#234;ncia da percentagem de estimula&#231;&#227;o auricular na carga arr&#237;tmica&#44; visto que n&#227;o foram encontradas diferen&#231;as estatisticamente significativas entre os dois grupos&#44; n&#227;o permitindo deste modo estabelecer uma rela&#231;&#227;o estatisticamente relevante entre a carga arr&#237;tmica e a percentagem de <span class="elsevierStyleItalic">pacing</span> auricular&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">O tempo de seguimento foi tamb&#233;m uma das limita&#231;&#245;es do estudo uma vez que&#44; apesar do estudo incluir tempo de <span class="elsevierStyleItalic">follow&#8208;up</span> superior &#224; maioria dos estudos semelhantes j&#225; realizados&#44; um incremento significativo no tempo de <span class="elsevierStyleItalic">follow&#8208;up</span> iria provavelmente acentuar significativamente a tend&#234;ncia revelada no grupo ATP&#95;ON para menor carga arr&#237;tmica&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclus&#245;es</span><p id="par0145" class="elsevierStylePara elsevierViewall">A terapia com <span class="elsevierStyleItalic">pacing</span> auricular antitaquicardia&#44; nos dispositivos utilizados e na popula&#231;&#227;o estudada&#44; mostrou&#8208;se eficaz e segura na convers&#227;o de epis&#243;dios de taquiarritmias auriculares&#46; Contudo&#44; o ATP n&#227;o demonstrou benef&#237;cios em termos de carga arr&#237;tmica e em termos cl&#237;nicos&#46; O <span class="elsevierStyleItalic">pacing</span> ventricular apical no VD demonstrou&#8208;se delet&#233;rio&#44; incrementando significativamente a carga arr&#237;tmica&#44; tendo&#8208;se demonstrado uma rela&#231;&#227;o claramente aditiva na evolu&#231;&#227;o da carga arr&#237;tmica face &#224; evolu&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Responsabilidades &#233;ticas</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prote&#231;&#227;o de pessoas e animais</span><p id="par0150" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos e&#47;ou animais&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidade dos dados</span><p id="par0155" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Direito &#224; privacidade e consentimento escrito</span><p id="par0160" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0165" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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              "titulo" => "Prote&#231;&#227;o de pessoas e animais"
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              "titulo" => "Confidencialidade dos dados"
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            2 => array:2 [
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              "titulo" => "Direito &#224; privacidade e consentimento escrito"
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    "fechaRecibido" => "2013-10-22"
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          "palabras" => array:4 [
            0 => "Fibrilha&#231;&#227;o auricular"
            1 => "<span class="elsevierStyleItalic">Pacing</span> auricular antitaquicardia"
            2 => "<span class="elsevierStyleItalic">Pacing</span> ventricular"
            3 => "Carga arr&#237;tmica"
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            0 => "Atrial fibrillation"
            1 => "Atrial antitachycardia pacing"
            2 => "Ventricular pacing"
            3 => "Arrhythmic burden"
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    "resumen" => array:2 [
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        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">O objetivo do estudo foi avaliar a efic&#225;cia do <span class="elsevierStyleItalic">pacing</span> auricular antitaquicardia &#40;ATP&#41; na convers&#227;o de epis&#243;dios de taquiarritmia auricular e seu impacto na redu&#231;&#227;o da carga arr&#237;tmica&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo que decorreu no laborat&#243;rio de <span class="elsevierStyleItalic">pacing</span> num hospital distrital&#44; incluindo consecutivamente 57 doentes que implantaram <span class="elsevierStyleItalic">pacemaker</span> dupla c&#226;mara&#44; com capacidade de realizar <span class="elsevierStyleItalic">pacing</span> auricular antitaquicardia&#44; entre 2005&#8208;2010&#46; Formaram&#8208;se dois grupos&#44; grupo ATP&#95;ON constitu&#237;do por 24 doentes e grupo ATP&#95;OFF constitu&#237;do por 33 doentes&#46; O per&#237;odo de seguimento foi de 15 meses&#44; tendo&#8208;se recolhido os dados das consultas de seguimento de <span class="elsevierStyleItalic">pacing</span> realizadas em tr&#234;s momentos distintos&#44; o primeiro ao 3&#46;&#176; m&#234;s ap&#243;s o implante &#40;M1&#41;&#44; o segundo ao 9&#46;&#176; m&#234;s &#40;M2&#41; e o &#250;ltimo ao 15&#46;&#176; m&#234;s &#40;M3&#41;&#44; incluindo este per&#237;odo&#44; tentativa de tratamento por ATP de 12 428 epis&#243;dios de taquiarritmias auriculares&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Apesar de n&#227;o ocorrerem diferen&#231;as estatisticamente significativas&#44; verificou&#8208;se uma tend&#234;ncia favor&#225;vel ao grupo ATP&#95;ON&#44; visto que&#44; o aumento de carga arr&#237;tmica foi menos acentuado neste grupo&#46; Tamb&#233;m neste grupo se verificou percentagem m&#233;dia de <span class="elsevierStyleItalic">pacing</span> ventricular apical significativamente inferior&#44; associando&#8208;se este par&#226;metro a redu&#231;&#227;o marginalmente significativa da carga arr&#237;tmica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;06&#41;&#46; Verificou&#8208;se uma rela&#231;&#227;o significativamente positiva entre a evolu&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular e a evolu&#231;&#227;o da carga arr&#237;tmica &#40;R<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;417&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O <span class="elsevierStyleItalic">pacing</span> auricular antitaquicardia converteu 59&#44;7&#37; dos epis&#243;dios de arritmia auricular&#44; mas n&#227;o reduziu significativamente a carga arr&#237;tmica&#46; Verificou&#8208;se correla&#231;&#227;o significativamente positiva entre a evolu&#231;&#227;o da percentagem de <span class="elsevierStyleItalic">pacing</span> ventricular e a evolu&#231;&#227;o da carga arr&#237;tmica&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to assess the effectiveness of atrial antitachycardia pacing &#40;ATP&#41; in the conversion of atrial tachyarrhythmia episodes&#44; and its impact in reducing arrhythmic burden&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective study in the pacing laboratory of a district hospital of 57 consecutive patients implanted with a dual chamber pacemaker&#44; capable of performing atrial antitachycardia pacing&#44; between 2005 and 2010&#46; The patients were divided into two groups&#58; ATP&#95;ON &#40;n&#61;24&#41; and ATP&#95;OFF &#40;n&#61;33&#41;&#46; The follow&#8208;up period was 15 months&#44; with data being collected at three follow&#8208;up consultations&#58; the first at three months after implantation&#44; the second at nine months and the last at 15 months&#46; In this period&#44; there were 12 428 ATP therapies of atrial tachyarrhythmias&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Although there were no statistically significant differences&#44; there was a trend in favor of the ATP&#95;ON group&#44; the increase in arrhythmic burden being less marked in this group&#46; The mean percentage of ventricular apical pacing was also significantly lower in this group&#44; which was associated with a marginally significant reduction in arrhythmic burden &#40;p&#61;0&#46;06&#41;&#46; There was a significant positive correlation between changes in the percentage of ventricular pacing and changes in arrhythmic burden &#40;r&#61;0&#46;417&#44; p&#61;0&#46;02&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Atrial antitachycardia pacing converted 59&#46;7&#37; of episodes of atrial arrhythmia&#44; but did not significantly reduce arrhythmic burden&#46; There was a significant positive correlation between changes in the percentage of ventricular pacing and changes in arrhythmic burden&#46;</p>"
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          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Representa&#231;&#227;o gr&#225;fica da varia&#231;&#227;o da &#37; de carga arr&#237;tmica em fun&#231;&#227;o da varia&#231;&#227;o da &#37; de <span class="elsevierStyleItalic">pacing</span> ventricular no grupo ATP&#95;ON&#46;</p>"
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          "pt" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Representa&#231;&#227;o gr&#225;fica da varia&#231;&#227;o da &#37; de carga arr&#237;tmica em fun&#231;&#227;o da varia&#231;&#227;o da &#37; de <span class="elsevierStyleItalic">pacing</span> auricular no grupo ATP&#95;O<span class="elsevierStyleBold">FF&#46;</span></p>"
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          "pt" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Representa&#231;&#227;o gr&#225;fica da varia&#231;&#227;o da &#37; de carga arr&#237;tmica em fun&#231;&#227;o da varia&#231;&#227;o da &#37; de <span class="elsevierStyleItalic">pacing</span> auricular no grupo ATP&#95;ON&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">ATP&#95;OFF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;entre grupos&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72&#44;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;44&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">G&#233;nero</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Masculino&#44; &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49&#44;1 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feminino&#44; &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">57&#44;6 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">41&#44;7 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&#44; &#37; &#40;n&#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"><span class="elsevierStyleHsp" style=""></span>Sim&#44; &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89&#44;5 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">90&#44;9 &#40;30&#41;&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">87&#44;5 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&#44; &#37; &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
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