Case report
Intravenous leiomyomatosis: A rare cause of intracardiac mass
Leiomiomatose intravascular: uma causa rara de massa intra-cardíaca
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X-ray showing syndactyly between the first and second axes of the left hand and wrist; the trapezium and trapezoid cannot be differentiated (C); right hand with morphological changes of the proximal carpal row; the first finger of the right hand is morphologically similar to the others (D).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joana Chin, Salomé Pereira, Ana Camacho, Bernardo Pessoa, Dina Bento, José Amado, Jorge Pereira, Ilídio de Jesus" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Joana" "apellidos" => "Chin" ] 1 => array:2 [ "nombre" => "Salomé" "apellidos" => "Pereira" ] 2 => array:2 [ "nombre" => "Ana" "apellidos" => "Camacho" ] 3 => array:2 [ "nombre" => "Bernardo" "apellidos" => "Pessoa" ] 4 => array:2 [ "nombre" => "Dina" "apellidos" => "Bento" ] 5 => array:2 [ "nombre" => "José" "apellidos" => "Amado" ] 6 => array:2 [ "nombre" => "Jorge" "apellidos" => "Pereira" ] 7 => array:2 [ "nombre" => "Ilídio" "apellidos" => "de Jesus" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204914002682" "doi" => "10.1016/j.repce.2014.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204914002682?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114002571?idApp=UINPBA00004E" "url" => "/08702551/0000003300000011/v1_201411200056/S0870255114002571/v1_201411200056/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255114002261" "issn" => "08702551" "doi" => "10.1016/j.repc.2014.05.004" "estado" => "S300" "fechaPublicacion" => "2014-11-01" "aid" => "528" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2014;33:733.e1-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7242 "formatos" => array:3 [ "EPUB" => 202 "HTML" => 6004 "PDF" => 1036 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso Clínico</span>" "titulo" => "Implantação de <span class="elsevierStyleItalic">pacemaker</span> definitivo por via femoral" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "733.e1" "paginaFinal" => "733.e6" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Permanent pacemaker implantation using a femoral approach" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2693 "Ancho" => 2917 "Tamanyo" => 449261 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Pacemaker</span> de câmara única, Relia SR (Medtronic<span class="elsevierStyleSup">®</span>), implantado pela veia femoral direita na doente H. P.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Em cima:</span> A: elétrodo colocado no ventrículo direito (VD). B: posicionamento do gerador no flanco direito.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Em baixo:</span> fotografias durante a implantação do <span class="elsevierStyleItalic">pacemaker</span>, nomeadamente das incisões feitas a nível femoral (local de inserção do eletrocateter) e no flanco direito (onde foi colocado o gerador), bem como da tunelização subcutânea feita entre elas e o resultado final.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Patrícia Rodrigues, Hipólito Reis, Vítor Lagarto, Paulo Palma, Carla Roque, António Pinheiro‐Vieira, Diana Anjo, Severo Torres" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "Hipólito" "apellidos" => "Reis" ] 2 => array:2 [ "nombre" => "Vítor" "apellidos" => "Lagarto" ] 3 => array:2 [ "nombre" => "Paulo" "apellidos" => "Palma" ] 4 => array:2 [ "nombre" => "Carla" "apellidos" => "Roque" ] 5 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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Garcia de Orta, Almada, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital de Santa Maria, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Leiomiomatose intravascular: uma causa rara de massa intra-cardíaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1655 "Ancho" => 2042 "Tamanyo" => 259534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Enhanced computed tomography scan. Coronal (left) and sagittal (right) sections showing a filling defect image extending from the right atrium through the inferior vena cava (white arrow). A well-defined tumor arises from the uterus (black arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intracardiac masses can be classified in three basic types: tumors (rarely primary tumors such as myxoma, lipoma or sarcoma; more often cardiac metastases from melanoma or lung, breast, ovarian or kidney cancer), thrombus, or vegetation. A reasonably secure diagnosis can often be made by integrating clinical data with the echocardiographic appearance.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A specific type of cardiac involvement by tumor is that of uterine tumors in which a finger-like projection may protrude into the right atrium (RA) from the inferior vena cava (IVC). This situation is called intravenous leiomyomatosis (IVL).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old nulliparous Caucasian woman was admitted to our hospital with a three-week history of dyspnea on exertion, shortness of breath and fatigue. She had a medical history of ankylosing spondylitis, multiple sclerosis and a benign subserous uterine leiomyoma (diagnosed in 1997, not treated surgically).</p><p id="par0015" class="elsevierStylePara elsevierViewall">No notable changes were identified on physical examination and her vital signs were stable. The electrocardiogram showed sinus tachycardia and the chest radiography was normal. Arterial blood gases, serum troponin levels, and hematologic and coagulation parameters were within the normal range.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography showed a large mobile mass within the RA prolapsing into the right ventricle during diastole; left and right ventricular systolic function was preserved. Transesophageal echocardiography showed the mass extending from the IVC through the RA and crossing the tricuspid valve into the right ventricle during diastole; no adherences to cardiac walls or valves were detected (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">An enhanced chest, abdominal and pelvic computed tomography (CT) scan showed a thrombus-like filling defect image extending from the RA as far as the popliteal veins, involving the IVC and bilateral iliac and femoral veins (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Uterine fibroids were present and pulmonary embolism was excluded.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A presumptive diagnosis of large thrombus was made and the patient was started on unfractionated heparin therapy. The cardiothoracic surgery center was consulted and the patient was referred for emergency surgery. Primary median sternotomy was performed, as was cardiopulmonary bypass from the superior vena cava to the ascending aorta. Following right atriotomy, a large vermiform tumor was found occupying most of the RA and extending into the IVC; the mass was free-floating without invasion, and so it was pulled outward as far as possible and then sectioned (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Pathologic examination of the specimen showed leiomyomatous tissue. A control CT scan showed a tumoral mass within the primitive iliac veins and IVC up to the confluence of the renal veins.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The postoperative course was uneventful and the patient was discharged seven days after surgery. She was proposed for a second stage of the procedure, in which excision of the remaining tumor would be performed as well as total hysterectomy with bilateral salpingo-oophorectomy, but she refused.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">IVL is a unusual benign smooth-muscle cell tumor, which develops in the uterus and grows in a worm-like fashion into pelvic and systemic veins.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Although histologically benign, IVL has metastatic potential due to intravascular spread. The tumor is usually confined to the pelvic venous system, but can progress along the veins into the IVC in 10% of cases, and rarely into the right side of the heart (3%).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The lesions of IVL were first described by Birch-Hirschfield in 1897, and in 1907 Durck reported the first case of intracardiac extension.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There are two main theories regarding the origin and growth mechanism of IVL: intravenous projections of an uterine leiomyoma, or direct carcinogenesis from the vascular walls within the myometrium.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a> The tumor can be entirely free-floating within the vessel lumen or, less commonly, can have attachments to vessel or atrial walls.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The disease generally occurs in middle-aged women, most of whom have coexisting uterine leiomyoma, like our patient, or a history of hysterectomy. There has been no proven correlation with race, fertility or parity.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Women may experience pelvic, abdominal or cardiac symptoms, depending on the extent of the mass. Our patient had no symptoms associated with the uterine leiomyoma; her complaints were related to intracardiac involvement. According to Wu et al., the most common presentation is heart failure.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The development of collateral vessels may be one explanation for the fact that even patients with extensive intravascular masses and IVC occlusion may remain asymptomatic until direct intracardiac growth causes heart failure. Serious complications, like syncopal episodes, cardiogenic shock, pulmonary embolism or even sudden cardiac death, have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Several imaging studies may help establish the diagnosis. Intracardiac masses can be assessed by echocardiography; computed tomography (CT) and magnetic resonance (MR) imaging can provide additional information on the extension of the lesion and can also detect associated uterine leiomyoma or pulmonary emboli.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Two-dimensional echocardiography usually shows an elongated mobile mass, the most important echocardiographic feature being the penetration of the tumor from the abdominal venous system into the RA.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11–13</span></a> Transesophageal echocardiography provides better spatial resolution and information about where the tumor is attached to the atrial wall or interatrial septum and the relationship with the IVC and superior vena cava.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However, accurate preoperative diagnosis of IVL is still usually difficult.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,14</span></a> In the present case, a precise diagnosis was not obtained before surgical resection and histologic examination because the initial presentation and findings pointed to a large thrombus. In fact, mainly because of its rarity, cases of intracardiac leiomyomatosis may be misdiagnosed as primary cardiac tumor, venous thrombus-in-transit or, occasionally, as renal cell carcinoma or hepatoma, which may also extend into the right cardiac chambers via the IVC.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13,15</span></a> The characteristics and attachment site of the tumor detected by echocardiography may offer important information for the differential diagnosis of a right atrial mass.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Surgery remains the gold standard treatment; complete removal of the tumor, with hysterectomy and resection of all extra-uterine masses, is mandatory for a favorable outcome and to avoid recurrence.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7–9,16</span></a> The first successful resection of intracardiac extension of such tumors was reported by Timmis et al. in 1980.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Surgery can be performed in two stages – resection of the intrathoracic tumor and of the abdominal/pelvic tumor in two separate operations – or, more recently, through a one-stage operation, involving total resection of the tumor.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Many authors still consider the two-stage procedure to be safer and easier.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,17</span></a> The slow growth of the tumor allows for a safe interval between the two surgeries.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Bilateral oophorectomy is also considered essential, because the tumor is estrogen-dependent.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,16</span></a> For the same reason, anti-hormone therapy should be considered in cases of unresectable residual tumor, although its efficacy is still controversial.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">If the tricuspid valve has been destroyed by the tumor, tricuspid valvuloplasty or valve replacement should be carried out.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Long-term prognosis of IVL is usually good if the tumor can be completely removed. However recurrence and metastases are not unusual and can be found up to 15 years after surgery. Long-term follow-up is therefore recommended, including thorax and abdomen CT scan and serial echocardiography.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,13,15</span></a> Reintervention is recommended in cases of recurrence to achieve long-term disease-free survival.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">IVL should be suspected on detection of a right atrial mass originating from the IVC in a middle-aged woman, especially with a history of uterine fibroids or hysterectomy. Imaging studies are helpful in the diagnosis. Successful therapy is mainly dependent on total surgical resection.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres384026" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec362891" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres384025" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec362890" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-04" "fechaAceptado" => "2014-04-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec362891" "palabras" => array:3 [ 0 => "Intravenous leiomyomatosis" 1 => "Intracardiac mass" 2 => "Uterine leiomyoma" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec362890" "palabras" => array:3 [ 0 => "Leiomiomatose intravascular" 1 => "Massa intra-cardíaca" 2 => "Leiomioma uterino" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intravenous leiomyomatosis is an unusual clinical condition characterized by histologically benign smooth muscle lesions extending from the uterus into pelvic and systemic veins and, more rarely, into the right cardiac chambers. We report the case of a 45-year-old woman who presented with a three-week history of dyspnea on exertion, shortness of breath and fatigue. Echocardiography showed a large mobile mass in the right atrium prolapsing into the right ventricle and extending to the inferior vena cava. A computed tomography scan revealed a large mass extending from the right atrium to the inferior vena cava and through the systemic veins as far as the popliteal veins. A presumptive diagnosis of large thrombus was made; the correct diagnosis of intravenous leiomyomatosis with intracardiac involvement was obtained only after surgical resection and histologic examination.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A Leiomiomatose intravascular é uma situação clínica invulgar caracterizada histologicamente por lesões benignas de tecido muscular liso que se estendem a partir do útero para as veias pélvicas e suas aferentes, raramente atingindo as cavidades cardíacas direitas. Descrevemos o caso de uma mulher de 45 anos que se apresentou com dispneia de esforço, polipneia e fadiga, com três semanas de evolução. O ecocardiograma mostrou uma massa grande e móvel no interior da aurícula direita, com prolapso para o ventrículo direito e extensão para a veia cava inferior. A tomografia computorizada revelou uma massa que se estendia da aurícula direita para a veia cava inferior e ao longo das veias sistémicas até às veias popliteias. Foi feito o diagnóstico presuntivo de trombo extenso; o diagnóstico correto de leiomiomatose intravascular com envolvimento intra-cardíaco só foi possível após ressecção cirúrgica e exame histológico.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1283 "Ancho" => 2918 "Tamanyo" => 264826 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography. Bicaval (left) and 4-chamber view (right) showing an elongated mass extending from the inferior vena cava through the right atrium and crossing the tricuspid valve into the right ventricle. IVC: inferior vena cava; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1655 "Ancho" => 2042 "Tamanyo" => 259534 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Enhanced computed tomography scan. Coronal (left) and sagittal (right) sections showing a filling defect image extending from the right atrium through the inferior vena cava (white arrow). A well-defined tumor arises from the uterus (black arrow).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 547 "Ancho" => 1501 "Tamanyo" => 169610 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Operative view (left) and macroscopic view (right) of the tumor removed from the right atrium and inferior vena cava (dimensions 10.5 cm×4 cm×2.5 cm).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The echocardiographic evaluation of intracardiac masses: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.J. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 7 | 13 |
| 2024 Outubro | 63 | 29 | 92 |
| 2024 Setembro | 79 | 19 | 98 |
| 2024 Agosto | 91 | 37 | 128 |
| 2024 Julho | 45 | 35 | 80 |
| 2024 Junho | 63 | 41 | 104 |
| 2024 Maio | 63 | 26 | 89 |
| 2024 Abril | 41 | 29 | 70 |
| 2024 Maro | 50 | 33 | 83 |
| 2024 Fevereiro | 43 | 23 | 66 |
| 2024 Janeiro | 46 | 34 | 80 |
| 2023 Dezembro | 62 | 20 | 82 |
| 2023 Novembro | 54 | 25 | 79 |
| 2023 Outubro | 31 | 14 | 45 |
| 2023 Setembro | 42 | 21 | 63 |
| 2023 Agosto | 36 | 20 | 56 |
| 2023 Julho | 33 | 13 | 46 |
| 2023 Junho | 43 | 25 | 68 |
| 2023 Maio | 57 | 19 | 76 |
| 2023 Abril | 25 | 7 | 32 |
| 2023 Maro | 26 | 26 | 52 |
| 2023 Fevereiro | 40 | 15 | 55 |
| 2023 Janeiro | 25 | 18 | 43 |
| 2022 Dezembro | 27 | 18 | 45 |
| 2022 Novembro | 47 | 26 | 73 |
| 2022 Outubro | 41 | 16 | 57 |
| 2022 Setembro | 28 | 37 | 65 |
| 2022 Agosto | 52 | 33 | 85 |
| 2022 Julho | 45 | 45 | 90 |
| 2022 Junho | 26 | 17 | 43 |
| 2022 Maio | 33 | 28 | 61 |
| 2022 Abril | 43 | 31 | 74 |
| 2022 Maro | 40 | 39 | 79 |
| 2022 Fevereiro | 41 | 26 | 67 |
| 2022 Janeiro | 32 | 25 | 57 |
| 2021 Dezembro | 38 | 30 | 68 |
| 2021 Novembro | 64 | 43 | 107 |
| 2021 Outubro | 49 | 39 | 88 |
| 2021 Setembro | 41 | 32 | 73 |
| 2021 Agosto | 45 | 29 | 74 |
| 2021 Julho | 33 | 26 | 59 |
| 2021 Junho | 48 | 31 | 79 |
| 2021 Maio | 47 | 28 | 75 |
| 2021 Abril | 71 | 43 | 114 |
| 2021 Maro | 70 | 15 | 85 |
| 2021 Fevereiro | 85 | 18 | 103 |
| 2021 Janeiro | 62 | 15 | 77 |
| 2020 Dezembro | 37 | 10 | 47 |
| 2020 Novembro | 60 | 16 | 76 |
| 2020 Outubro | 60 | 20 | 80 |
| 2020 Setembro | 50 | 11 | 61 |
| 2020 Agosto | 47 | 12 | 59 |
| 2020 Julho | 61 | 4 | 65 |
| 2020 Junho | 70 | 7 | 77 |
| 2020 Maio | 53 | 14 | 67 |
| 2020 Abril | 52 | 7 | 59 |
| 2020 Maro | 54 | 3 | 57 |
| 2020 Fevereiro | 205 | 23 | 228 |
| 2020 Janeiro | 78 | 12 | 90 |
| 2019 Dezembro | 62 | 7 | 69 |
| 2019 Novembro | 71 | 4 | 75 |
| 2019 Outubro | 71 | 8 | 79 |
| 2019 Setembro | 101 | 4 | 105 |
| 2019 Agosto | 65 | 12 | 77 |
| 2019 Julho | 77 | 14 | 91 |
| 2019 Junho | 68 | 15 | 83 |
| 2019 Maio | 89 | 11 | 100 |
| 2019 Abril | 65 | 21 | 86 |
| 2019 Maro | 107 | 14 | 121 |
| 2019 Fevereiro | 117 | 15 | 132 |
| 2019 Janeiro | 98 | 19 | 117 |
| 2018 Dezembro | 107 | 17 | 124 |
| 2018 Novembro | 139 | 21 | 160 |
| 2018 Outubro | 294 | 31 | 325 |
| 2018 Setembro | 148 | 13 | 161 |
| 2018 Agosto | 194 | 15 | 209 |
| 2018 Julho | 148 | 5 | 153 |
| 2018 Junho | 116 | 7 | 123 |
| 2018 Maio | 148 | 13 | 161 |
| 2018 Abril | 157 | 11 | 168 |
| 2018 Maro | 148 | 11 | 159 |
| 2018 Fevereiro | 49 | 9 | 58 |
| 2018 Janeiro | 49 | 7 | 56 |
| 2017 Dezembro | 98 | 11 | 109 |
| 2017 Novembro | 115 | 8 | 123 |
| 2017 Outubro | 58 | 9 | 67 |
| 2017 Setembro | 91 | 13 | 104 |
| 2017 Agosto | 96 | 10 | 106 |
| 2017 Julho | 81 | 6 | 87 |
| 2017 Junho | 58 | 20 | 78 |
| 2017 Maio | 108 | 14 | 122 |
| 2017 Abril | 50 | 3 | 53 |
| 2017 Maro | 110 | 7 | 117 |
| 2017 Fevereiro | 221 | 9 | 230 |
| 2017 Janeiro | 61 | 7 | 68 |
| 2016 Dezembro | 61 | 11 | 72 |
| 2016 Novembro | 67 | 11 | 78 |
| 2016 Outubro | 68 | 7 | 75 |
| 2016 Setembro | 90 | 13 | 103 |
| 2016 Agosto | 23 | 4 | 27 |
| 2016 Julho | 10 | 10 | 20 |
| 2016 Junho | 5 | 10 | 15 |
| 2016 Maio | 20 | 5 | 25 |
| 2016 Abril | 65 | 3 | 68 |
| 2016 Maro | 72 | 14 | 86 |
| 2016 Fevereiro | 107 | 28 | 135 |
| 2016 Janeiro | 83 | 12 | 95 |
| 2015 Dezembro | 89 | 11 | 100 |
| 2015 Novembro | 90 | 16 | 106 |
| 2015 Outubro | 75 | 14 | 89 |
| 2015 Setembro | 62 | 16 | 78 |
| 2015 Agosto | 71 | 9 | 80 |
| 2015 Julho | 127 | 11 | 138 |
| 2015 Junho | 65 | 10 | 75 |
| 2015 Maio | 51 | 7 | 58 |
| 2015 Abril | 49 | 18 | 67 |
| 2015 Maro | 51 | 26 | 77 |
| 2015 Fevereiro | 62 | 16 | 78 |
| 2015 Janeiro | 51 | 30 | 81 |
| 2014 Dezembro | 94 | 60 | 154 |
| 2014 Novembro | 27 | 23 | 50 |
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