Case report
Simple mesothelial pericardial cyst in a rare location
Cisto pericárdico mesotelial simples numa localização rara
Sara Ranchordása,
, Catarina Gomesb, Miguel Abecasisa, Rosa Gouveiac, João Abecasise, Luís R. Lopesb,d, Paula Fazendasb
Autor para correspondência
a Cardiac Surgery Department, Santa Cruz Hospital, Carnaxide, Portugal
b Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
c Pathology Department, Santa Cruz Hospital, Carnaxide, Portugal
d CCUL, University of Lisbon, Lisbon, Portugal
e Cardiology Department, Santa Cruz Hospital, Carnaxide, Portugal
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"apellidos" => "Lopes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Paula" "apellidos" => "Fazendas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Cardiac Surgery Department, Santa Cruz Hospital, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiology Department, Hospital Garcia de Orta, Almada, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Pathology Department, Santa Cruz Hospital, Carnaxide, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "CCUL, University of Lisbon, Lisbon, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Cardiology Department, Santa Cruz Hospital, Carnaxide, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cisto pericárdico mesotelial simples numa localização rara" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1323 "Ancho" => 1750 "Tamanyo" => 209562 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Imaging of the cyst before surgery. (A-C): Magnetic resonance imaging showing the cyst with T2-weighted hyperintense signal; (D and E): transthoracic echocardiogram showing the location of the cyst in the interventricular septum and anechogenic appearance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital pericardial cysts are rare and benign intrathoracic lesions.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> The preferential location is in the cardiophrenic angles,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> but other unusual locations have been described. We present a case of a pericardial cyst in a particularly uncommon location.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 39-year-old man was referred for evaluation of an intracardiac mass. His past medical history was irrelevant except for allergic rhinitis. He worked in the environmental department of the National Republican Guard, and was thus frequently in contact with animals. There was no relevant travel abroad, consumption of potentially hazardous foods, or alcohol or drug abuse.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding family history, his mother was diagnosed with systemic hypertension in her twenties and was being followed for suspected aortic dilatation and cardiac valve disease. His father also had hypertension.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was asymptomatic and underwent routine exams, including an electrocardiogram which revealed nonspecific abnormalities due to which he was referred for a transthoracic echocardiogram (TTE). This showed an intracardiac cystic mass. A transesophageal echocardiogram (TEE) and additional blood tests were performed. The latter only revealed eosinophilia of 3.1%, while the former confirmed the presence of a cystic mass with a diameter of 4.5 cm located in the interventricular septum, protruding into the left ventricular outflow tract and extending to 1 cm below the aortic valve, with associated septal hypokinesia, and without continuity with the cardiac chambers. A bicuspid aortic valve with moderate aortic regurgitation and a dilated ascending aorta were also observed. Magnetic resonance imaging (MRI) showed the mass to be hyperintense in T2, revealed moderate aortic regurgitation and confirmed the other echocardiographic findings (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The patient was asymptomatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">He was then referred for cardiac surgery evaluation, and underwent a new TTE in our hospital, which confirmed the previous findings. The case was discussed and accepted for surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient underwent surgery, the cyst being excised through enucleation by blunt dissection with (at times unsuccessful) attempts to preserve the capsule (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A-C) plus aortic valve replacement with a mechanical valve (27 mm St. Jude Medical Regent<span class="elsevierStyleSup">®</span>). The ascending proximal aorta and the aortic root (noncoronary sinus) were replaced with a 28 mm Gelseal<span class="elsevierStyleSup">®</span> graft by a modified Bentall procedure. There were no complications during surgery. The postoperative echocardiogram showed that the inferior part of the septum was thin and dyskinetic, but there were no other abnormalities. The patient was discharged 10 days after surgery (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>D-E).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Pathological examination of the cyst revealed that macroscopically it was a cystic formation 4 cm in its largest diameter and microscopically a cyst with a sheath composed of a single cell layer, positive for keratin and vimentin. The wall was thin and fibrous with focal and scattered calcifications and in continuity with the adjacent myocardium. The diagnosis was a simple mesothelial pericardial cyst (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>F-G).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Congenital pericardial cysts occur in 1/100<span class="elsevierStyleHsp" style=""></span>000 individuals and account for 7% of mediastinal masses.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Pericardial cysts are usually detected in middle-aged adults.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Pericardial cysts are commonly located in the left (51-70%) and right (28-38%) cardiophrenic angles and a small percentage are located in the upper mediastinum, hilum or cardiac border.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this case, the cyst was diagnosed in the fourth decade of life. To our knowledge, this is the first reported case of a pericardial cyst with an intramyocardial location.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Congenital pericardial cysts arise when a portion of the pericardium pinches off during embryonic development.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Lambert proposed a new causal concept, the “lacuna theory”, suggesting that cysts derive from disconnected mesenchymal lacunae, which later unite to form the pericardial cavity. Failure of one of these lacunae to merge with the others would result in the formation of a congenital cyst.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Wessels and Pérez-Pomares<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> draw attention to the transmural migration and differentiation pathways of epicardially derived cells, which act as cardiac stem cells. Such cellular behavior could explain unusual intracardiac, including intramyocardial, locations of pericardial cysts, as in our patient.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The classic description of a pericardial cyst is a unilocular, smooth-walled cyst with an outer layer of endothelial or mesothelial cells. Their serous fluid-filled center and lack of solidity distinguishes them from other pericardial masses.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The majority of pericardial cysts are asymptomatic, but they can cause symptoms of dyspnea, thoracic pain, and cough.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Pericardial cysts are usually incidental findings, appearing as a round mass on chest radiography or as a homogeneous echolucent mass on TTE.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> TEE can be useful if TTE is insufficient to establish the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> On MRI their contents are hyperintense on T2-weighted images and hypointense on T1-weighted images.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The diagnosis of pericardial cysts is not always straightforward since they may present in atypical locations. Furthermore, neither of the available non-invasive imaging modalities is sufficiently reliable to differentiate pericardial cysts from other pericardial masses with similar appearances but with different prognosis and treatments.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The differential diagnosis should take into consideration solid tumors,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> hydatid cysts and mesotheliomas.</p><p id="par0090" class="elsevierStylePara elsevierViewall">This patient denied any symptoms and the cyst was an incidental finding. None of the imaging exams performed aided in establishing the correct diagnosis, probably due to the extremely unlikely location, although the imaging description corresponded largely to that of a pericardial cyst. The main differential diagnosis considered before surgery was hydatid cyst, due to the patient's occupational background, local epidemiology and eosinophilia. The latter could have been related to allergic rhinitis.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Rarely, pericardial cysts can have a complicated course with rupture, erosion into adjacent structures, cardiac tamponade, and even sudden death.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The management of pericardial cysts may be conservative or surgical, or involve percutaneous aspiration. Surgical resection is widely accepted as the treatment of choice when a patient has symptoms related to a mediastinal mass or if the diagnosis is uncertain.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Due to the patient's indication for surgical treatment for aortic ectasia and bicuspid aortic valve disease, the cyst was resected concomitantly. The suspicion of a hydatid cyst was an additional motive for excision, due to the risk of rupture and consequent anaphylaxis.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion, to the best of our knowledge this is probably the first description of an intramyocardial pericardial cyst. The explanation for this unexpected location is uncertain, despite the above-mentioned evidence and theories. This case indicates the need to consider alternative diagnoses, even if in an unlikely location.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres719057" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec724236" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres719058" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec724235" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack238851" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-08-31" "fechaAceptado" => "2015-11-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec724236" "palabras" => array:4 [ 0 => "Pericardial cyst" 1 => "Echocardiography" 2 => "Magnetic resonance imaging" 3 => "Pathology" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec724235" "palabras" => array:4 [ 0 => "Cisto pericárdico" 1 => "Ecocardiograma" 2 => "Ressonância magnética" 3 => "Patologia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pericardial cysts are rare and generally benign intrathoracic lesions, most frequently located in the cardiophrenic angles, but other locations have been described. We present a case of a pericardial cyst in a previously undescribed site. Our patient presented with a cyst in the interventricular septum which was discovered as an incidental finding. After surgical excision of the cyst, it was described pathologically as a simple mesothelial pericardial cyst. The explanation of this rare condition is uncertain, but some hypotheses can be outlined.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os cistos pericárdicos são lesões intratorácicas raras e geralmente benignas, mais frequentemente localizadas nos ângulos cardiofrénicos, no entanto, outras localizações têm sido descritas. Apresentamos o caso de um cisto pericárdico num local não descrito previamente. O nosso doente apresentou-se com um cisto no septo interventricular que foi detetado como achado incidental. Após a excisão cirúrgica do cisto, este foi descrito anatomopatologicamente como um cisto pericárdico mesotelial simples. A explicação para esta localização incomum é incerta, mas algumas hipóteses podem ser delineadas.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1323 "Ancho" => 1750 "Tamanyo" => 209562 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Imaging of the cyst before surgery. (A-C): Magnetic resonance imaging showing the cyst with T2-weighted hyperintense signal; (D and E): transthoracic echocardiogram showing the location of the cyst in the interventricular septum and anechogenic appearance.</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" => 1210 "Ancho" => 2000 "Tamanyo" => 347519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A-C): Images captured during surgical resection of the cyst. (A): Cyst causing bulging of the interventricular septum and protruding into the left ventricular outflow tract; (B): intramyocardial location of the cyst; (C): cyst rupture and flow of clear fluid; (D and E): transthoracic echocardiogram after surgery showing a thin interventricular septum and delineation of the previous location of the cyst; (F and G): microscopic aspects of the cyst: (F): cyst wall, H & E stain ×100; (G): cytokeratin 5/6 ×400 (left) and vimentin ×400 (right): keratin and vimentin co-expression by the cells of the internal layer of the cyst. RE: internal cell layer of the cyst; F: fibrosis; M: myocardium.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis of pericardial cysts using diffusion weighted magnetic resonance imaging: a case series" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Raja" 1 => "J.R. Walker" 2 => "M. Sud" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1752-1947-5-479" "Revista" => array:5 [ "tituloSerie" => "J Med Case Rep" "fecha" => "2011" "volumen" => "5" "paginaInicial" => "479" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21943086" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pericardial cysts: an analysis of 12 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Alar" 1 => "A.S. Bayram" 2 => "C. Gebitekin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/lap.2011.0034" "Revista" => array:6 [ "tituloSerie" => "J Laparoendosc Adv Surg Tech A" "fecha" => "2011" "volumen" => "21" "paginaInicial" => "595" "paginaFinal" => "598" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21657941" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The tale of spring water cysts: a historical outline of surgery for congenital pericardial diverticula and cysts" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Schweigert" 1 => "A. Dubecz" 2 => "M. Beron" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Tex Heart Inst J" "fecha" => "2012" "volumen" => "39" "paginaInicial" => "330" "paginaFinal" => "334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22719140" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital pericardial cyst" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.H. De Gouveia" 1 => "A.P. Martins" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2007" "volumen" => "26" "paginaInicial" => "65" "paginaFinal" => "67" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17427837" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0889852915000079" "estado" => "S300" "issn" => "08898529" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epicardium and epicardially derived cells (EPDCs) as cardiac stem cells" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Wessels" 1 => "J.M. Pérez-Pomares" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ar.a.10129" "Revista" => array:6 [ "tituloSerie" => "Anat Rec A Discov Mol Cell Evol Biol" "fecha" => "2004" "volumen" => "276" "paginaInicial" => "43" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14699633" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack238851" "titulo" => "Acknowledgements" "texto" => "<p id="par0135" class="elsevierStylePara elsevierViewall">The authors wish to thank Carlos Aguiar, MD, for helping in the revision of the manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003500000009/v1_201608170044/S087025511630138X/v1_201608170044/en/main.assets" "Apartado" => array:4 [ "identificador" => "29263" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos Clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003500000009/v1_201608170044/S087025511630138X/v1_201608170044/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511630138X?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 11 | 4 | 15 |
| 2024 Outubro | 52 | 31 | 83 |
| 2024 Setembro | 63 | 22 | 85 |
| 2024 Agosto | 50 | 32 | 82 |
| 2024 Julho | 39 | 37 | 76 |
| 2024 Junho | 35 | 32 | 67 |
| 2024 Maio | 52 | 24 | 76 |
| 2024 Abril | 39 | 25 | 64 |
| 2024 Maro | 41 | 24 | 65 |
| 2024 Fevereiro | 51 | 32 | 83 |
| 2024 Janeiro | 33 | 39 | 72 |
| 2023 Dezembro | 36 | 25 | 61 |
| 2023 Novembro | 39 | 22 | 61 |
| 2023 Outubro | 36 | 15 | 51 |
| 2023 Setembro | 36 | 25 | 61 |
| 2023 Agosto | 37 | 18 | 55 |
| 2023 Julho | 36 | 9 | 45 |
| 2023 Junho | 31 | 9 | 40 |
| 2023 Maio | 31 | 20 | 51 |
| 2023 Abril | 23 | 3 | 26 |
| 2023 Maro | 34 | 13 | 47 |
| 2023 Fevereiro | 36 | 23 | 59 |
| 2023 Janeiro | 19 | 4 | 23 |
| 2022 Dezembro | 30 | 20 | 50 |
| 2022 Novembro | 55 | 27 | 82 |
| 2022 Outubro | 38 | 11 | 49 |
| 2022 Setembro | 27 | 33 | 60 |
| 2022 Agosto | 36 | 33 | 69 |
| 2022 Julho | 35 | 30 | 65 |
| 2022 Junho | 21 | 13 | 34 |
| 2022 Maio | 19 | 31 | 50 |
| 2022 Abril | 26 | 26 | 52 |
| 2022 Maro | 21 | 31 | 52 |
| 2022 Fevereiro | 27 | 28 | 55 |
| 2022 Janeiro | 24 | 23 | 47 |
| 2021 Dezembro | 20 | 24 | 44 |
| 2021 Novembro | 43 | 37 | 80 |
| 2021 Outubro | 37 | 42 | 79 |
| 2021 Setembro | 30 | 26 | 56 |
| 2021 Agosto | 31 | 35 | 66 |
| 2021 Julho | 27 | 26 | 53 |
| 2021 Junho | 27 | 15 | 42 |
| 2021 Maio | 31 | 33 | 64 |
| 2021 Abril | 40 | 43 | 83 |
| 2021 Maro | 84 | 15 | 99 |
| 2021 Fevereiro | 79 | 25 | 104 |
| 2021 Janeiro | 67 | 9 | 76 |
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| 2020 Novembro | 46 | 22 | 68 |
| 2020 Outubro | 42 | 16 | 58 |
| 2020 Setembro | 79 | 14 | 93 |
| 2020 Agosto | 37 | 10 | 47 |
| 2020 Julho | 71 | 7 | 78 |
| 2020 Junho | 45 | 9 | 54 |
| 2020 Maio | 64 | 4 | 68 |
| 2020 Abril | 54 | 10 | 64 |
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| 2020 Fevereiro | 179 | 60 | 239 |
| 2020 Janeiro | 56 | 10 | 66 |
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| 2019 Novembro | 36 | 7 | 43 |
| 2019 Outubro | 47 | 9 | 56 |
| 2019 Setembro | 90 | 13 | 103 |
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| 2019 Junho | 53 | 21 | 74 |
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| 2019 Janeiro | 117 | 12 | 129 |
| 2018 Dezembro | 149 | 14 | 163 |
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| 2018 Outubro | 239 | 18 | 257 |
| 2018 Setembro | 51 | 10 | 61 |
| 2018 Agosto | 35 | 13 | 48 |
| 2018 Julho | 37 | 10 | 47 |
| 2018 Junho | 38 | 4 | 42 |
| 2018 Maio | 67 | 13 | 80 |
| 2018 Abril | 56 | 2 | 58 |
| 2018 Maro | 59 | 15 | 74 |
| 2018 Fevereiro | 31 | 7 | 38 |
| 2018 Janeiro | 68 | 8 | 76 |
| 2017 Dezembro | 57 | 18 | 75 |
| 2017 Novembro | 67 | 9 | 76 |
| 2017 Outubro | 38 | 15 | 53 |
| 2017 Setembro | 28 | 13 | 41 |
| 2017 Agosto | 45 | 14 | 59 |
| 2017 Julho | 28 | 7 | 35 |
| 2017 Junho | 41 | 10 | 51 |
| 2017 Maio | 44 | 10 | 54 |
| 2017 Abril | 25 | 4 | 29 |
| 2017 Maro | 25 | 20 | 45 |
| 2017 Fevereiro | 29 | 7 | 36 |
| 2017 Janeiro | 31 | 11 | 42 |
| 2016 Dezembro | 54 | 15 | 69 |
| 2016 Novembro | 42 | 13 | 55 |
| 2016 Outubro | 44 | 28 | 72 |
| 2016 Setembro | 60 | 56 | 116 |
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