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Estas mudan&#231;as podem ter tido influ&#234;ncia nos tempos de espera para cirurgia&#44; n&#227;o havendo&#44; no entanto&#44; at&#233; &#224; data&#44; evid&#234;ncia nesse sentido&#46; V&#225;rios autores demonstraram que o aumento no tempo de espera para cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica se associa a uma eleva&#231;&#227;o na mortalidade durante o mesmo per&#237;odo<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#8211;13</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">O objetivo do nosso estudo foi determinar se estas altera&#231;&#245;es tiveram impacto nos tempos de espera dos doentes enviados para cirurgia card&#237;aca e consequ&#234;ncias desta varia&#231;&#227;o temporal na taxa de internamento e mortalidade durante o per&#237;odo de espera para cirurgia&#44; assim como as taxas de internamento e mortalidade no primeiro ano ap&#243;s a cirurgia card&#237;aca&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Foi realizado um estudo retrospetivo&#44; descritivo e correlacional&#44; englobando todos os doentes referenciados para cirurgia cardiotor&#225;cica por um servi&#231;o de cardiologia no intervalo temporal que mediou entre 1 de janeiro de 2008 e 30 de setembro de 2014&#46; Foram recolhidos dos processos cl&#237;nicos destes doentes as suas caracter&#237;sticas basais&#44; os tempos de espera para cirurgia &#40;definida como a diferen&#231;a das datas do internamento no servi&#231;o de cirurgia cardiotor&#225;cica e o dia de envio da informa&#231;&#227;o sobre os doentes para os respetivos centros cir&#250;rgicos&#41; e os eventos &#40;morte ou internamento&#41; durante o per&#237;odo de espera&#46; A indica&#231;&#227;o para cirurgia card&#237;aca urgente foi recolhida do processo dos doentes e para efeitos de an&#225;lise durante este estudo s&#243; foram considerados urgentes aqueles que foram assim referenciados&#44; tendo estes crit&#233;rios sido&#58; no caso dos doentes coron&#225;rios&#44; doentes internados por enfarte agudo do mioc&#225;rdio e doen&#231;a coron&#225;ria grave &#40;doen&#231;a de tronco comum da art&#233;ria coron&#225;ria esquerda ou art&#233;ria descendente anterior proximal ou doen&#231;a de tr&#234;s vasos&#41;&#44; e no caso dos doentes valvulares&#44; foram considerados urgentes os doentes internados por insufici&#234;ncia card&#237;aca com necessidade de ventila&#231;&#227;o e refrat&#225;rios a terap&#234;utica m&#233;dica&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Os doentes foram divididos em dois grupos&#44; o grupo A com doentes enviados para cirurgia entre 1&#47;01&#47;2008 e 31&#47;08&#47;2011 e o grupo B&#44; entre 01&#47;09&#47;2011 e 30&#47;09&#47;2014&#46; Foi escolhida a data de agosto de 2011 para dividir os grupos por ter sido nesta altura que se deram as altera&#231;&#245;es aos protocolos de referencia&#231;&#227;o&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Foram comparadas as caracter&#237;sticas basais&#44; tempos de espera e eventos entre os dois grupos&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Foi realizado o <span class="elsevierStyleItalic">follow&#8208;up</span> telef&#243;nico&#44; por cardiologista&#44; dos doentes referenciados para cirurgia cardiotor&#225;cica durante o per&#237;odo em an&#225;lise&#46; Foram comparados os eventos ao primeiro ano entre os dois grupos&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Para an&#225;lise estat&#237;stica foi utilizado o SPSS 20&#46;0&#46; Foi realizado o teste de qui&#8208;quadrado para comparar as vari&#225;veis categ&#243;ricas dos grupos&#44; o teste <span class="elsevierStyleItalic">One&#8208;Way Anova</span> para a compara&#231;&#227;o das vari&#225;veis cont&#237;nuas dos mesmos e o teste de Kaplan&#8208;Meyer para an&#225;lise de curvas de sobreviv&#234;ncia durante o per&#237;odo de espera e ao ano de <span class="elsevierStyleItalic">follow&#8208;up</span>&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0045" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo em estudo foram referenciados para cirurgia cardiotor&#225;cica 864 doentes com idade m&#233;dia de 66&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;6 anos&#44; sendo 268 &#40;31&#37;&#41; do sexo feminino e 596 &#40;69&#37;&#41; do sexo masculino&#46; Foram solicitadas pelo nosso servi&#231;o 557 cirurgias card&#237;acas entre 1 de janeiro de 2008 e 31 de agosto de 2011 &#40;grupo A&#41; e 307 entre 1 de setembro de 2011 e 30 de setembro de 2014 &#40;grupo B&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas basais dos grupos foram semelhantes &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#44; tanto a m&#233;dia do <span class="elsevierStyleItalic">score</span> de risco <span class="elsevierStyleItalic">Euroscore</span> log&#237;stico &#40;6&#44;2&#37; no grupo A e de 5&#44;7&#37; no grupo B &#91;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;36&#93;&#41; como os fatores de risco&#58; sexo masculino &#40;67&#44;6 <span class="elsevierStyleItalic">versus</span> 72&#44;2&#37;&#41;&#44; hipertens&#227;o &#40;68&#44;6 <span class="elsevierStyleItalic">versus</span> 70&#44;6&#37;&#41;&#44; diabetes <span class="elsevierStyleItalic">mellitus</span> &#40;25&#44;9 <span class="elsevierStyleItalic">versus</span> 25&#44;2&#37;&#41;&#46; A dislipidemia foi a exce&#231;&#227;o &#40;57&#44;7&#37; <span class="elsevierStyleItalic">versus</span> 65&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#46; A incid&#234;ncia de disfun&#231;&#227;o renal n&#227;o apresentou diferen&#231;as significativas entre os grupos&#46; Foram considerados doentes urgentes 27&#44;1&#37; no grupo A e 23&#44;4&#37; no grupo B&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">O n&#250;mero m&#233;dio de dias de espera para cirurgia foi de 10&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;5 dias &#40;mediana de 6&#44;0&#44; tempo m&#225;ximo de 279 e m&#237;nimo de zero dias&#41; nos doentes do grupo A e de 55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79&#44;9 dias &#40;mediana de 18&#44;0&#44; m&#225;ximo de 476 e m&#237;nimo de zero dias&#41; no grupo B &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Esta diferen&#231;a foi significativa tanto nos doentes com indica&#231;&#227;o cir&#250;rgica urgente &#40;2&#44;1 dias no grupo A e 3&#44;0 dias no grupo B&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; como nos doentes referenciados para cirurgia card&#237;aca eletiva &#40;13&#44;8 dias no grupo A e 72&#44;4 dias no grupo B&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;000&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Considerando as indica&#231;&#245;es para cirurgia dos dois grupos&#44; tamb&#233;m n&#227;o foram encontradas diferen&#231;as estatisticamente significativas entre estes&#44; como evidenciado na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46; Como indicado na <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#44; houve diferen&#231;as nos tempos de espera entre os dois grupos para os v&#225;rios tipos de indica&#231;&#227;o cir&#250;rgica&#44; tendo sido a m&#233;dia do tempo de espera para cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica eletiva de 8&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;8 dias &#40;mediana de 6seis m&#225;ximo de 59 e m&#237;nimo de um dia&#41; no grupo A e de 57&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>76&#44;0 dias &#40;mediana de 20&#44; m&#225;ximo de 352 e m&#237;nimo de zero dias&#41; no grupo B &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Nos doentes referenciados para substitui&#231;&#227;o da v&#225;lvula a&#243;rtica o grupo A teve uma espera m&#233;dia de 14&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;8 dias &#40;mediana de 10&#44;0&#44; m&#225;ximo de 100 e m&#237;nimo de zero dias&#41; e o grupo B teve uma espera m&#233;dia de 90&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>86&#44;9 dias &#40;mediana de 68&#44;5&#44; m&#225;ximo de 363 e m&#237;nimo de zero dias&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Os doentes com indica&#231;&#227;o para substitui&#231;&#227;o da v&#225;lvula mitral tiveram no grupo A uma espera em m&#233;dia de 12&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;9 dias &#40;mediana 12&#44;6&#44; m&#225;ximo de 67 e m&#237;nimo de zero dias&#41; e no grupo B 63&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>81&#44;8 dias &#40;mediana de 25&#44;0&#44; m&#225;ximo de 338 e m&#237;nimo de zero dias&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Quanto aos doentes em espera por cirurgia combinada a m&#233;dia de dias no grupo A foi 14&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#44;1 dias &#40;mediana de 8&#44;0&#44; m&#225;ximo 279 e m&#237;nimo de zero dias&#41; e no grupo B 59&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>97&#44;2 dias &#40;mediana de 20&#44;0&#44; m&#225;ximo 476 e m&#237;nimo de zero dias&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Na <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a> est&#227;o representadas as propor&#231;&#245;es de doentes operados de acordo com os tempos de espera recomendados a n&#237;vel internacional<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">14&#44;15</span></a>&#44; tendo estas diferen&#231;as sido estatisticamente significativas para os diferentes tipos de indica&#231;&#227;o cir&#250;rgica&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Quanto ao n&#250;mero de internamentos durante a espera para cirurgia registaram&#8208;se internamento de dois doentes &#40;0&#44;4&#37;&#41; no per&#237;odo do grupo A e de 28 &#40;9&#44;1&#37;&#41; doentes no grupo B&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#46; Relativamente &#224; mortalidade durante o per&#237;odo de espera para cirurgia n&#227;o foram registadas mortes no grupo A&#44; tendo sido verificadas sete mortes no grupo B &#40;0 <span class="elsevierStyleItalic">versus</span> 2&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Os doentes que faleceram tiveram um tempo m&#233;dio de espera de 72&#44;6 dias &#40;mediana de 47&#44; m&#237;nimo de 13 e m&#225;ximo de 195 dias&#41;&#46; Um destes doentes tinha indica&#231;&#227;o cir&#250;rgica urgente&#46; A indica&#231;&#227;o cir&#250;rgica era revasculariza&#231;&#227;o coron&#225;ria num doente&#44; substitui&#231;&#227;o valvular a&#243;rtica em tr&#234;s&#44; substitui&#231;&#227;o valvular mitral num doente e cirurgia combinada em dois deles&#46; Ass <a class="elsevierStyleCrossRefs" href="#fig0005">Figuras 1 e 2</a> s&#227;o curvas de Kaplan&#8208;Meier&#44; estando na <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a> representada a curva de sobrevida livre de eventos &#40;morte ou internamento&#41; durante o tempo de espera&#44; enquanto a <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a> representa a curva de sobreviv&#234;ncia dos doentes em espera nos dois grupos A e B&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Durante o per&#237;odo compreendido entre 1 de janeiro de 2008 e 31 de outubro de 2013 foram referenciados para cirurgia 755 doentes&#44; tendo sido poss&#237;vel realizar o <span class="elsevierStyleItalic">follow&#8208;up</span> a 641 destes doentes &#40;85&#37;&#41;&#46; Durante este per&#237;odo foram admitidos em internamento por causas cardiovasculares 12&#44;8&#37; dos doentes&#44; que correspondem a 16&#37; dos doentes do grupo A e 12&#44;9&#37; dos doentes do grupo B &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;2&#41;&#46; A mortalidade por causas cardiovasculares no <span class="elsevierStyleItalic">follow&#8208;up</span> foi de 4&#44;8&#37;&#44; correspondendo a 4&#44;7&#37; dos doentes do grupo A e a 5&#44;1&#37; dos doentes do grupo B&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;49&#46; A <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> representa a curva de sobrevida livre de eventos &#40;morte ou internamento&#41; um ano ap&#243;s cirurgia card&#237;aca e a <a class="elsevierStyleCrossRef" href="#fig0020">figura 4</a> representa as curvas de sobreviv&#234;ncia dos dois grupos um ano ap&#243;s cirurgia card&#237;aca&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discuss&#227;o</span><p id="par0080" class="elsevierStylePara elsevierViewall">O nosso estudo &#233; o primeiro em Portugal que procura demonstrar o impacto dos tempos de espera para cirurgia card&#237;aca em termos de mortalidade&#44; necessidade de internamento antes da cirurgia e resultados precoces e a um ano da cirurgia&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Este estudo demonstrou que a mudan&#231;a de protocolos de referencia&#231;&#227;o dos doentes do Hospital de Faro&#44; com indica&#231;&#227;o para cirurgia card&#237;aca&#44; realizada em agosto de 2011&#44; aumentou significativamente os tempos de espera para cirurgia card&#237;aca e a mortalidade durante o per&#237;odo de espera&#46; Este aumento do tempo de espera verificou&#8208;se nos v&#225;rios tipos de indica&#231;&#227;o para cirurgia card&#237;aca&#44; sendo estatisticamente significativo na cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica&#44; na cirurgia de substitui&#231;&#227;o valvular a&#243;rtica&#44; na cirurgia de substitui&#231;&#227;o valvular mitral e nas cirurgias combinadas &#40;coron&#225;rias e valvulares&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">A import&#226;ncia dos tempos de espera em cirurgia tem sido bastante debatida tendo&#44; j&#225; em 1995&#44; Carroll et al&#46; constatado a exist&#234;ncia de grandes diferen&#231;as entre pa&#237;ses Europeus e os Estados Unidos da Am&#233;rica &#40;EUA&#41;&#44; havendo orienta&#231;&#245;es&#44; a n&#237;vel do sistema de sa&#250;de dos EUA&#44; de intervencionar a maioria dos doentes para cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica em 72 horas&#44; enquanto no Reino Unido a maioria dos doentes esperava mais de tr&#234;s meses<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a>&#46; Tem sido tamb&#233;m discutida qual deve ser a defini&#231;&#227;o de tempo de espera para cirurgia&#46; Segundo a OCDE o tempo de espera deve incluir o tempo que cada doente realmente aguardou pela mesma&#44; incluindo os per&#237;odos de espera pela primeira consulta&#44; exames diagn&#243;sticos e&#44; finalmente&#44; a espera pela cirurgia card&#237;aca<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">17&#44;18</span></a>&#46; V&#225;rios trabalhos sugerem ser necess&#225;rio intervir em todos estes tempos de espera com o intuito de reduzir o tempo total e melhorar os cuidados de sa&#250;de prestados aos doentes<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">No Canad&#225;&#44; pa&#237;s que mais estudou esta problem&#225;tica&#44; foi criado o <span class="elsevierStyleItalic">score</span> de Ont&#225;rio<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a>&#44; descrito com o intuito de criar um preditor independente de mortalidade durante o per&#237;odo de espera<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a>&#46; Este <span class="elsevierStyleItalic">score</span> divide os doentes em emergentes &#40;cirurgia imediata&#41; extremamente urgentes &#40;cirurgia em 24 horas&#41;&#44; urgentes &#40;cirurgia em 24&#8208;72 horas&#41;&#44; semiurgentes &#40;72 horas a 14 dias&#41;&#44; lista curta &#40;14 dias a 6 semanas&#41;&#44; atrasadas &#40;6 semanas a 3 meses&#41;&#44; atraso marcado &#40;3&#8208;6 meses&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As <span class="elsevierStyleItalic">guidelines</span> da <span class="elsevierStyleItalic">Wait Time Alliance</span> &#40;organiza&#231;&#227;o da sociedade civil canadiana que inclui v&#225;rias sociedades cient&#237;ficas m&#233;dicas e n&#227;o profissionais&#44; com o objetivo de controlar as listas de espera&#41; para tempos de espera definem que os tempos de espera para cirurgia card&#237;aca devem ser de 24 horas para casos emergentes&#44; 14 dias para casos urgentes e de seis semanas para casos eletivos<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a>&#46; O grupo de trabalho da <span class="elsevierStyleItalic">CCS Acess to Care Working Group</span> definiu tamb&#233;m tempos para cirurgia card&#237;aca&#44; tendo sugerido que os doentes com necessidade de cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica deveriam ser submetidos a cirurgia nos primeiros 14 dias ou seis semanas&#44; dependendo da anatomia coron&#225;ria&#44; que os doentes com estenose a&#243;rtica severa deveriam ter um tempo de espera m&#225;ximo de 14 dias e os outros doentes valvulares de seis semanas<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No nosso estudo apresentamos um aumento do tempo de espera de doentes a aguardar cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica n&#227;o urgente de oito para aproximadamente 57 dias&#44; com alguns doentes a esperarem mais de tr&#234;s meses&#44; tendo o mesmo acontecido nos doentes que aguardam cirurgia valvular e cirurgia combinada&#46; Apesar dos tempos estabelecidos e descritos nos estudos acima refletirem a realidade do Canad&#225;&#44; estas s&#227;o as recomenda&#231;&#245;es dispon&#237;veis neste campo&#46; As <span class="elsevierStyleItalic">guidelines</span> da Sociedade Europeia de Cardiologia e da Associa&#231;&#227;o Europeia de Cirurgia Cadiotor&#225;cica sobre Revasculariza&#231;&#227;o Mioc&#225;rdica de 2014<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a>&#44; com suporte nos estudos supracitados&#44; tamb&#233;m apresentam recomenda&#231;&#245;es quanto aos tempos &#243;timos de interven&#231;&#227;o&#46; Estes tempos s&#227;o de duas semanas para doentes com sintomas classe CCS 3&#8208;4 ou anatomia coron&#225;ria de alto risco &#40;tronco comum ou equivalente&#44; doen&#231;a coron&#225;ria de tr&#234;s vasos ou doen&#231;a proximal da descendente anterior&#41; ou doentes com fun&#231;&#227;o VE deprimida&#46; Para todos os outros doentes com doen&#231;a coron&#225;ria est&#225;vel a revasculariza&#231;&#227;o &#40;percut&#226;nea ou cir&#250;rgica&#41; deve ser realizada num espa&#231;o de seis semanas&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Como observado pelos nossos resultados &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#44; atualmente os doentes referenciados pelo nosso centro para cirurgia card&#237;aca t&#234;m tempos de espera acima dos recomendados&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">O aumento dos tempos de espera por cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica aumenta a mortalidade dos doentes no per&#237;odo de espera por cirurgia<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;21</span></a>&#46; No nosso estudo&#44; a mortalidade cardiovascular durante um tempo m&#233;dio de espera para cirurgia de 55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79&#44;9 dias foi de 2&#44;3&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; no grupo B&#46; No grupo A o tempo m&#233;dio de espera foi de 10&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;5 dias e n&#227;o houve mortalidade entre o diagn&#243;stico e a cirurgia&#46; Nos sete doentes que morreram &#224; espera de cirurgia o tempo m&#233;dia de espera foi de 72&#44;6 dias&#44; com uma mediana de 47&#44; m&#225;ximo de 195 e m&#237;nimo de 13 dias&#46; Estes dados s&#227;o tamb&#233;m evidentes na curva de sobrevida do <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Na literatura s&#227;o v&#225;rios os estudos que descrevem o risco de morte em doentes &#224; espera de cirurgia card&#237;aca&#44; com mortalidades nos doentes &#224; espera entre 0&#44;3&#8208;5&#44;8&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Tabela 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Apesar da maioria dos estudos sobre tempos de espera serem referentes a doentes a aguardar cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica&#44; Lund et al&#46; demonstraram que a espera &#40;tempo m&#233;dio de 6&#44;3 meses&#41; por cirurgia de substitui&#231;&#227;o valvular a&#243;rtica&#44; em doentes com estenose a&#243;rtica sintom&#225;tica&#44; se associa a uma mortalidade de 13&#44;5&#37; neste per&#237;odo<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a>&#46; Mais recentemente Malaisrie et al&#46; demonstraram em doentes com estenose a&#243;rtica em lista de espera por cirurgia valvular a&#243;rtica uma mortalidade a um m&#234;s de 3&#44;7&#37; e de 11&#44;6&#37; aos seis meses de espera<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a>&#46; Outro trabalho recente&#44; em doentes com estenose a&#243;rtica severa&#44; observou uma deteriora&#231;&#227;o abrupta da classe funcional NYHA I para III&#8208;IV&#44; no m&#234;s precedendo a cirurgia&#44; em 18&#37; dos doentes&#46; Esta deteriora&#231;&#227;o teve como consequ&#234;ncia um aumento da mortalidade operat&#243;ria &#40;17 <span class="elsevierStyleItalic">versus</span> 5&#37;&#59; p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;035&#41; e uma diminui&#231;&#227;o da sobreviv&#234;ncia a longo prazo nos doentes operados em NYHA III&#8208;IV &#40;56 <span class="elsevierStyleItalic">versus</span> 72&#37;&#59; p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Foi tamb&#233;m demonstrado que em doentes com estenose a&#243;rtica severa inoper&#225;vel ou de alto risco cir&#250;rgico o aumento do tempo de espera pela substitui&#231;&#227;o valvular a&#243;rtica percut&#226;nea se associa a uma eleva&#231;&#227;o da mortalidade quer durante o per&#237;odo em que aguardavam pelo procedimento quer no primeiro ano de seguimento<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Apesar de este trabalho n&#227;o ter sido desenhado para determinar custos&#44; sabe&#8208;se que o internamento de doentes acarreta consigo custos adicionais&#46; De facto&#44; para al&#233;m da mortalidade aumentada&#44; o aumento dos tempos de espera associou&#8208;se&#44; nos nossos doentes&#44; a um acr&#233;scimo significativo no n&#250;mero de internamentos&#44; de 0&#44;4&#37; para 9&#44;1&#37;&#44; durante o per&#237;odo de espera por cirurgia&#46; Estes resultados na mortalidade e n&#250;mero de internamentos e a diferen&#231;a entre os dois grupos &#233; evidente na curva de sobrevida representada na <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46; Na popula&#231;&#227;o estudada a maioria destes internamentos foram secund&#225;rios ao agravamento da situa&#231;&#227;o cl&#237;nica&#44; com necessidade de antecipa&#231;&#227;o da cirurgia e hospitaliza&#231;&#227;o at&#233; &#224; sua realiza&#231;&#227;o&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Os tempos de espera para cirurgia card&#237;aca superiores a tr&#234;s meses foram tamb&#233;m relacionados com maior n&#250;mero de eventos adversos no per&#237;odo ap&#243;s a cirurgia<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a>&#46; No nosso estudo n&#227;o encontramos esta associa&#231;&#227;o&#44; tendo sido observadas preval&#234;ncias de internamentos &#40;12&#44;8 <span class="elsevierStyleItalic">versus</span> 16&#37;&#41; e taxas de mortalidade &#40;4&#44;7 <span class="elsevierStyleItalic">versus</span> 5&#44;1&#37;&#41; semelhantes entre os dois grupos no per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span> de um ano&#44; como fica explicito nas <a class="elsevierStyleCrossRefs" href="#fig0015">figuras 3 e 4</a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Como j&#225; referido&#44; no Canad&#225; o tema das listas de espera &#233; largamente debatido&#44; tendo j&#225; sido descrito que o investimento financeiro pode ajudar a reduzir o tempo dos doentes em lista de espera<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Com o nosso trabalho foi poss&#237;vel observar que&#44; atualmente&#44; os tempos de espera por cirurgia t&#234;m como consequ&#234;ncia internamentos e mortalidade&#46; Os dados que dispomos n&#227;o nos permitem identificar tempos ideais e&#44; portanto&#44; este n&#227;o foi um objetivo do estudo&#46; Assim&#44; os autores prop&#245;em a cria&#231;&#227;o de uma base de dados nacional para o registo de doentes inscritos para cirurgia card&#237;aca&#44; de forma a identificar e quantificar os eventos adversos que ocorrem durante o tempo de espera&#46; Baseados em dados objetivos ser&#225; poss&#237;vel alterar a referencia&#231;&#227;o de modo a eliminar tempos de espera excessivos e as suas consequ&#234;ncias nefastas&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limita&#231;&#245;es</span><p id="par0155" class="elsevierStylePara elsevierViewall">A maior limita&#231;&#227;o resulta do car&#225;cter retrospetivo e observacional&#44; al&#233;m de refletir apenas a realidade de um &#250;nico centro de referencia&#231;&#227;o&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">O seguimento conseguido no estudo foi de 85&#37;&#44; o que apesar de ser um seguimento aceit&#225;vel dado o n&#250;mero de doentes pode subestimar os eventos &#40;internamentos e mortalidade&#41; durante o per&#237;odo de seguimento&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A defini&#231;&#227;o de tempo de espera neste estudo foi a diferen&#231;a entre as datas da cirurgia e a data de referencia&#231;&#227;o para a mesma&#44; podendo estas datas subestimar o tempo de espera real de cada doente e constituir um vi&#233;s do estudo&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclus&#227;o</span><p id="par0170" class="elsevierStylePara elsevierViewall">A altera&#231;&#227;o ao protocolo de referencia&#231;&#227;o para cirurgia card&#237;aca&#44; apesar de n&#227;o ter tido como consequ&#234;ncia um aumento da mortalidade no primeiro ano de follow&#8208;up&#44; resultou num aumento estatisticamente significativo do tempo de espera para cirurgia card&#237;aca&#44; com consequente aumento da taxa de mortalidade e de internamento&#44; durante esse per&#237;odo&#44; respetivamente de zero para 2&#44;3&#37; e 0&#44;4 para 9&#44;1&#37;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Responsabilidades &#233;ticas</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Prote&#231;&#227;o dos seres humanos e animais</span><p id="par0175" class="elsevierStylePara elsevierViewall">Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos respons&#225;veis da Comiss&#227;o de Investiga&#231;&#227;o Cl&#237;nica e &#201;tica e de acordo com os da Associa&#231;&#227;o M&#233;dica Mundial e da Declara&#231;&#227;o de Helsinki&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidencialidade dos dados</span><p id="par0180" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos do seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Direito &#224; privacidade e consentimento escrito</span><p id="par0185" class="elsevierStylePara elsevierViewall">Os autores declaram que n&#227;o aparecem dados de pacientes neste artigo&#46;</p></span></span></span>"
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    "resumen" => array:2 [
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o e objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">O objetivo deste estudo foi determinar se as altera&#231;&#245;es aos protocolos de referencia&#231;&#227;o para cirurgia card&#237;aca tiveram impacto nos tempos de espera&#44; taxa de internamentos e na mortalidade durante o per&#237;odo de espera e durante o primeiro ano de seguimento ap&#243;s cirurgia&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materiais e m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo&#44; com doentes referenciados para cirurgia card&#237;aca de 1&#47;01&#47;2008 a 30&#47;09&#47;2014&#46; Avaliaram&#8208;se dois grupos de doentes antes e depois da mudan&#231;a de referencia&#231;&#227;o&#58; grupo A entre 1&#47;01&#47;2008 e 01&#47;08&#47;2011 e grupo B entre 01&#47;08&#47;2011 e 30&#47;09&#47;2014&#46; Foi realizado o <span class="elsevierStyleItalic">follow&#8208;up</span> telef&#243;nico&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram referenciados 864 doentes para cirurgia card&#237;aca&#44; 557 no grupo A e 307 no grupo B&#46; As caracter&#237;sticas dos grupos foram semelhantes&#46; O n&#250;mero m&#233;dio de dias de espera para cirurgia foi de 10&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;5 dias e de 55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79&#44;9 dias&#44; respetivamente no grupo A e B &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Durante o per&#237;odo de espera foram internados dois doentes &#40;0&#44;4&#37;&#41; no grupo A e 28 &#40;9&#44;1&#37;&#41; no grupo B &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#59; a taxa de mortalidade foi&#44; respetivamente&#44; de 0&#8208;2&#44;3&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41;&#46; Durante o per&#237;odo de <span class="elsevierStyleItalic">follow&#8208;up</span> de um ano foram admitidos em internamento 12&#44;8&#37; dos doentes do grupo A e 16&#37; dos doentes do grupo B&#46; A mortalidade neste per&#237;odo foi de cerca de 5&#37; em ambos os grupos &#40;p &#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As altera&#231;&#245;es aos protocolos de referencia&#231;&#227;o para cirurgia card&#237;aca tiveram impacto nos tempos de espera&#44; no n&#250;mero de internamentos e na mortalidade nesse per&#237;odo&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
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            "identificador" => "abst0010"
            "titulo" => "Materiais e m&#233;todos"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to determine whether changes to referral protocols for cardiac surgery have had an impact on waiting times&#44; hospitalizations and mortality during the waiting period and during the first year of follow&#8208;up after surgery&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">In this retrospective study of patients referred for cardiac surgery between January 1&#44; 2008 and September 30&#44; 2014&#44; the study population was divided into two groups&#58; those referred before &#40;group A&#44; January 1&#44; 2008 to August 31&#44; 2011&#41; and after &#40;group B&#44; September 1&#44; 2011 to September 30&#44; 2014&#41; the change in referral protocols&#46; A telephone follow&#8208;up was conducted&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">There were 864 patients referred for cardiac surgery&#44; 557 in group A and 307 in group B&#46; Patient characteristics were similar between groups&#46; The mean waiting time for surgery was 10&#46;6&#177;18&#46;5 days and 55&#46;7&#177;79&#46;9 days in groups A and B&#44; respectively &#40;p&#61;0&#46;00&#41;&#46;</p><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">During the waiting period two patients &#40;0&#46;4&#37;&#41; were hospitalized in group A and 28 &#40;9&#46;1&#37;&#41; in group B &#40;p&#61;0&#58;00&#41;&#59; mortality was&#44; respectively&#44; 0&#37; and 2&#46;3&#37; &#40;p&#61;0&#46;00&#41;&#46; During one&#8208;year follow&#8208;up 12&#46;8&#37; of group A patients and 16&#37; of group B patients were hospitalized&#46; Cardiovascular mortality in this period was around 5&#37; in both groups &#40;p&#62;0&#46;05&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Changes to referral protocols for cardiac surgery had an impact on waiting times&#44; on the number of hospitalizations and on mortality in this period&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">G&#233;nero Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#205;ndice de massa corporal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hipertens&#227;o arterial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Diabetes <span class="elsevierStyleItalic">mellitus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dislipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tabagismo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fra&#231;&#227;o de eje&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Euroscore</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Est&#225;dio de fun&#231;&#227;o renal</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Indica&#231;&#227;o cir&#250;rgica urgente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Dias de espera &#40;total&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>54&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urgentes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Eletivos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>85&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>60&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Indica&#231;&#227;o cir&#250;rgica</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Revasculariza&#231;&#227;o coron&#225;ria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#44;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#44;8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Substitui&#231;&#227;o valvular a&#243;rtica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cirurgia valvular mitral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cirurgia combinada &#40;valvular e coron&#225;ria&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#44;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#44;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Outras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#44;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grupo B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cirurgia de revasculariza&#231;&#227;o coron&#225;ria n&#227;o urgente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>76&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cirurgia de substitui&#231;&#227;o valvular a&#243;rtica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>86&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cirurgia de substitui&#231;&#227;o valvular mitral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>81&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cirurgia combinada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>97&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Outras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>27&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>49&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;06&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Tempos de espera m&#233;dios por tipo de cirurgia card&#237;aca nos dois grupos &#40;A e B&#41;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Doen&#231;a coron&#225;ria est&#225;vel &#40;tempo de espera inferior a seis semanas&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Estenose a&#243;rtica severa &#40;tempo de espera inferior a 14 dias&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Substitui&#231;&#227;o valvular mitral &#40;tempo de espera inferior a seis semanas&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">99&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#44;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;00&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Percentagem de doentes submetidos a cirurgia card&#237;aca dentro dos tempos recomendados<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">14&#44;20</span></a></p>"
        ]
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">CV&#58; cirurgia valvular&#59; ICP&#58; interven&#231;&#227;o coron&#225;ria percut&#226;nea&#59; RVM&#58; cirurgia de revasculariza&#231;&#227;o mioc&#225;rdica&#59; <span class="elsevierStyleSup">a</span>&#58; mortalidade anual&#44; <span class="elsevierStyleSup">b</span>&#58; tempo m&#233;dio de espera um m&#234;s&#59; <span class="elsevierStyleSup">c</span>&#58; mortalidade mensal&#59; <span class="elsevierStyleSup">d</span>&#58; mortalidade por semana em 1000 pacientes&#8208;semana&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tipo de cirurgia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mortalidade &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Silber et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">RVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;3<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bengtson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">RVM ou ICP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Morgan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">CV ou RVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;48<span class="elsevierStyleSup">b</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Seddon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">RVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;28<span class="elsevierStyleSup">c</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Koomen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4<span class="elsevierStyleSup">a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ray et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">CV ou RVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Rexius et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sobolev et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">RVM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sobolev et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">RVM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;9<span class="elsevierStyleSup">d</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Estudos de mortalidade em doentes &#224; espera de cirurgia card&#237;aca</p>"
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      "titulo" => "Bibliografia"
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        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0140"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Do longer delays for coronary artery bypass surgery contribute to preoperative mortality in less urgent patients&#63;"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "B&#46;G&#46; Sobolev"
                            1 => "A&#46;R&#46; Levy"
                            2 => "L&#46; Kuramoto"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.1097/01.mlr.0000220257.81482.67"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Care&#46;"
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                        "volumen" => "44"
                        "paginaInicial" => "680"
                        "paginaFinal" => "686"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16799363"
                            "web" => "Medline"
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                    ]
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              "identificador" => "bib0145"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complications prior to revascularization among patients waiting for coronary artery bypass grafting and percutaneous transluminal coronary angioplasty"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Bengtson"
                            1 => "T&#46; Karlsson"
                            2 => "A&#46; Hjalmarson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J&#46;"
                        "fecha" => "1996"
                        "volumen" => "17"
                        "paginaInicial" => "1846"
                        "paginaFinal" => "1851"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8960427"
                            "web" => "Medline"
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              "identificador" => "bib0150"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Death on the waiting list for cardiac surgery in the Netherlands in 1994 and 1995"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "J&#46; Plomp"
                            1 => "W&#46;K&#46; Redekop"
                            2 => "F&#46;W&#46; Dekker"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart&#46;"
                        "fecha" => "1999"
                        "volumen" => "81"
                        "paginaInicial" => "593"
                        "paginaFinal" => "597"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10336916"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Waiting times and prioritisation for coronary artery bypass surgery in New Zealand"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;E&#46; Seddon"
                            1 => "J&#46;K&#46; French"
                            2 => "D&#46;J&#46; Amos"
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                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "1999"
                        "volumen" => "81"
                        "paginaInicial" => "586"
                        "paginaFinal" => "592"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10336915"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analysis of deaths while waiting for cardiac surgery among 29&#44;293 consecutive patients in Ontario&#44; Canada&#46; The Steering Committee of the Cardiac Care Network of Ontario"
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                            2 => "C&#46;D&#46; Naylor"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart"
                        "fecha" => "1998"
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                        "paginaInicial" => "345"
                        "paginaFinal" => "349"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9616340"
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