Case report
Identification of a critical isthmus in complex macroreentrant atrial tachycardia using Ripple mapping in a patient with surgically repaired Ebstein's anomaly
Identificação do istmo crítico de uma taquicardia auricular complexa por macroreentrada utilizando o mapeamento Ripple num doente com anomalia de Ebstein corrigida cirurgicamente
Gustavo Lima da Silva
, Nuno Cortez-Dias, Luís Carpinteiro, João de Sousa
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Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, Lisboa, Portugal
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ARA: antagonista do recetor da angiotensina; BB: beta‐bloqueadores; ECG: eletrocardiograma; FC: frequência cardíaca; Fej: fração de ejeção; FR: frequência respiratória; IC: insuficiência cardíaca; IECA: inibidor da enzima conversora da angiotensina; SpO<span class="elsevierStyleInf">2</span>: saturação periférica de oxigénio; SvcO<span class="elsevierStyleInf">2</span>: saturação central de oxigénio; TAS: tensão arterial sistólica; VE: ventrículo esquerdo; VI: ventilação invasiva; VNI: ventilação não invasiva. Adaptado de Bauersachs et al.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">12</span></a>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tatiana Guimarães, Andreia Magalhães, Arminda Veiga, Manuela Fiuza, Walkíria Ávila, Fausto J. 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"apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204919301503" "doi" => "10.1016/j.repce.2019.06.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204919301503?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511730536X?idApp=UINPBA00004E" "url" => "/08702551/0000003800000005/v3_201911281014/S087025511730536X/v3_201911281014/pt/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Identification of a critical isthmus in complex macroreentrant atrial tachycardia using Ripple mapping in a patient with surgically repaired Ebstein's anomaly" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "385.e1" "paginaFinal" => "385.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gustavo Lima da Silva, Nuno Cortez-Dias, Luís Carpinteiro, João de Sousa" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Gustavo" "apellidos" => "Lima da Silva" "email" => array:1 [ 0 => "gustavolssilva@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cortez-Dias" ] 2 => array:2 [ "nombre" => "Luís" "apellidos" => "Carpinteiro" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "de Sousa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Maria, Centro Académico Médico de Lisboa, Lisboa, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Identificação do istmo crítico de uma taquicardia auricular complexa por macroreentrada utilizando o mapeamento Ripple num doente com anomalia de Ebstein corrigida cirurgicamente" ] ] "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" => 1748 "Ancho" => 2333 "Tamanyo" => 245086 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ripple map displayed over a bipolar voltage map depicting the circuit of the initial flutter, showing an activation front ascending anteriorly to the crista terminalis (parallel yellow lines), going around the right atrial appendage and descending between the crista terminalis and the intercaval line (A to D) to a slow conducting isthmus. As the isthmus is a cicatricial zone, the Ripple bars are smaller in number and in amplitude. As such, four Ripple marks and corresponding electrograms are displayed and marked from 1 to 4 (D and E). The slow conduction through the critical isthmus began at mark 1 and spread to mark 4.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mapping post-surgical and post-ablation complex atrial tachycardia with the routinely used electroanatomical systems is quite challenging. Ripple mapping (RM) is a novel 3D mapping system that displays each electrogram at its corresponding 3D coordinate as a dynamic moving bar that changes in length according to the electrogram voltage-time relationship.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 43-year-old male patient with Ebstein's anomaly (<a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Video 1</a>) who previously underwent tricuspid valve repair, right anterior accessory pathway surgical dissection and two unsuccessful ablation procedures for right atrial flutter (cavotricuspid isthmus and intercaval lines). The patient was admitted for recurrent atrial flutter (<a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Figure 1</a>) refractory to high-dose amiodarone and a repeat procedure was scheduled.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A high density and evenly spread map (2610 points [<a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Video 2</a>]) of the severely enlarged right atrium was created using the Pentaray® mapping catheter with a CARTO® 3 v4 CONFIDENSE™ module (Biosense Webster Inc., CA, USA). The color-coded activation map, documenting over 95% of the arrhythmia cycle length, was not interpretable, in particular due to the presence of various “early meets late” areas in distant areas of the atrium. Entrainment mapping was attempted, but a second atrial flutter emerged during pacing maneuvers, rendering the map uninformative. The second atrial flutter was also fully mapped and the color-coded activation map was also unclear. Both maps were then reanalyzed using the RM algorithm. Ripple bars were clipped at 0.25 mV and excluded if less than 0.03 mV in order to remove noise from the signal. A bipolar voltage map was displayed and scar threshold was adjusted to show those areas without Ripple wavefront as scar region. The optimal atrial threshold in this patient was 0.2 mV. Extensive scars related to previous ablation were evident in the cavotricuspid isthmus and throughout the lateral wall, extending from the inferior to the superior vena cava. Visualization of the Ripple bars’ activation direction clarified the mechanism of the first flutter (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> and <a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Video 3</a>): macroreentrant anti-clockwise circuit ascending anteriorly to the crista terminalis, going around the right atrial appendage and descending between the crista terminalis and the intercaval line to the lateral aspect of the scar. RM enables numerous electrograms of interest to be simultaneously displayed in a separate window, with these points marked over the 3D surface as color-coded bars (Ripple marks). This function enabled tracking the propagation of the very low-voltage signals within the scar, throughout the slow conduction isthmus. RM also depicted the second flutter macroreentrant circuit, which was similar to the first but in a clockwise rotation (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> and <a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Video 4</a>). In addition, it revealed a previously unapparent gap at the superior aspect of the intercaval line. Radiofrequency ablation at the critical isthmus terminated the tachycardia. Additional radiofrequency applications were delivered at the intercaval line gap (<a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Figure 2</a>). At the end of the procedure, no further arrhythmias were inducible and at 6 months of follow-up, the patient is free of arrhythmic events (<a class="elsevierStyleCrossRef" href="#sec0030">Supplemental Figure 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion and conclusion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Mapping complex atrial tachycardia is often challenging due to the limitations of the routinely used electroanatomical systems. Color-coded activation maps are often uninterpretable or even misleading as a result of inappropriate settings for the “window of interest” and incorrect annotation of the low-voltage signals usually present in critical areas, such as the surgical scars, ablation lines and disease-related atrial fibrotic regions. In addition, multiple zones of slow conduction and conduction block can lead to very delayed activation of bystander areas, leading to misinterpretation of the resultant color-coded activation map. Entrainment mapping is also challenging due to the possibility of transformation or termination of the tachycardia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">When superimposed on a surface bipolar voltage map, RM allows the wave propagation to not only be visualized by the relative motion of each ripple bar, but also facilitates understanding the relationship between the arrhythmia's mechanism and the underlying substrate. More importantly, RM does not require a “window of interest” to be set, does not require local activation time annotation, avoids interpolation between points, minimizes the user's post-processing and facilitates the distinction between the arrhythmia's critical circuit and the passive activation of bystander regions.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In this case of complex atrial tachycardia, RM was decisive, enabling the arrhythmia mechanism to be appropriately recognized, as well as a distinction to be made between critical areas of the circuit and delayed activated bystander regions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1269353" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1174869" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1269354" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1174870" "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 and conclusion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-11" "fechaAceptado" => "2017-08-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1174869" "palabras" => array:5 [ 0 => "Ripple mapping" 1 => "3-dimensional mapping systems" 2 => "Atrial arrhythmias" 3 => "Catheter ablation" 4 => "Ebstein's anomaly" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1174870" "palabras" => array:5 [ 0 => "Mapeamento Ripple" 1 => "Sistemas de mapeamento tridimensionais" 2 => "Arritmias auriculares" 3 => "Ablação por cateter" 4 => "Anomalia de Ebstein" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ripple mapping is a novel, three-dimensional, electroanatomic mapping tool that displays each electrogram at its corresponding 3-dimensional coordinate as a dynamic moving bar, which changes in length according to the electrogram voltage-time relationship. We present the case of a 43-year-old male patient with surgically repaired Ebstein's anomaly who previously underwent two unsuccessful ablation procedures for right atrial flutter (cavotricuspid isthmus and intercaval lines). Ripple mapping was decisive, enabling the arrhythmia mechanism to be appropriately recognized, and a distinction to be made between critical areas of the circuit and delayed activated bystander regions.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O mapeamento Ripple é uma nova ferramenta de mapeamento eletroanatómico tridimensional que permite visualizar cada eletrograma na sua coordenada 3D correspondente na forma de uma barra com movimento dinâmico que altera a sua amplitude de acordo com a relação voltagem-tempo do eletrograma. É apresentado um caso de um doente de 43 anos com anomalia de Ebstein corrigida cirurgicamente e previamente submetido a dois procedimentos de ablação por <span class="elsevierStyleItalic">fluter</span> auricular direito (linhas do istmo cavo-tricúspide e intercava) sem sucesso. O mapeamento Ripple foi decisivo, permitiu o reconhecimento apropriado do mecanismo da arritmia e a distinção entre as áreas críticas do circuito e áreas <span class="elsevierStyleItalic">bystander</span> ativadas tardiamente.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0045" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia><elsevierMultimedia ident="upi0040"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1748 "Ancho" => 2333 "Tamanyo" => 245086 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ripple map displayed over a bipolar voltage map depicting the circuit of the initial flutter, showing an activation front ascending anteriorly to the crista terminalis (parallel yellow lines), going around the right atrial appendage and descending between the crista terminalis and the intercaval line (A to D) to a slow conducting isthmus. As the isthmus is a cicatricial zone, the Ripple bars are smaller in number and in amplitude. As such, four Ripple marks and corresponding electrograms are displayed and marked from 1 to 4 (D and E). The slow conduction through the critical isthmus began at mark 1 and spread to mark 4.</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" => 1751 "Ancho" => 2333 "Tamanyo" => 234887 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ripple map of the second flutter, displayed over a bipolar voltage map: the wavefront ascended between the crista terminalis and the intercaval line, went around the right atrial appendage and descended anteriorly to the crista terminalis (A to D) through the slow conducting isthmus. As the isthmus is a cicatricial zone, the Ripple bars are smaller in number and in amplitude. As such, six Ripple marks and corresponding electrograms are displayed and marked (D and E). The slow conduction through the critical isthmus began at mark 1 and spread to mark 6.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 308205 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 3 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1543572 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 4 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 5318135 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 5 => array:5 [ "identificador" => "upi0020" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 5330246 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 6 => array:5 [ "identificador" => "upi0025" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc5.docx" "ficheroTamanyo" => 13034 ] ] 7 => array:5 [ "identificador" => "upi0030" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc6.docx" "ficheroTamanyo" => 76570 ] ] 8 => array:5 [ "identificador" => "upi0035" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc7.docx" "ficheroTamanyo" => 59453 ] ] 9 => array:5 [ "identificador" => "upi0040" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc8.docx" "ficheroTamanyo" => 76155 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac ripple mapping: a novel three-dimensional visualization method for use with electroanatomic mapping of cardiac arrhythmias" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N.W. Linton" 1 => "M. Koa-Wing" 2 => "D.P. Francis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hrthm.2009.08.038" "Revista" => array:6 [ "tituloSerie" => "Heart Rhythm." "fecha" => "2009" "volumen" => "6" "paginaInicial" => "1754" "paginaFinal" => "1762" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19959125" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A Prospective Study of Ripple Mapping in Atrial Tachycardias: A Novel Approach to Interpreting Activation in Low-Voltage Areas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. Luther" 1 => "N.W. Linton" 2 => "M. Koa-Wing" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCEP.115.003582" "Revista" => array:5 [ "tituloSerie" => "Circ Arrhythm Electrophysiol." "fecha" => "2016" "volumen" => "9" "paginaInicial" => "e003582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26757985" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003800000005/v3_201911281014/S0870255117300203/v3_201911281014/en/main.assets" "Apartado" => array:4 [ "identificador" => "75833" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Caso Clínico" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003800000005/v3_201911281014/S0870255117300203/v3_201911281014/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117300203?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 7 | 2 | 9 |
| 2024 Outubro | 38 | 32 | 70 |
| 2024 Setembro | 49 | 20 | 69 |
| 2024 Agosto | 39 | 28 | 67 |
| 2024 Julho | 47 | 29 | 76 |
| 2024 Junho | 39 | 23 | 62 |
| 2024 Maio | 46 | 20 | 66 |
| 2024 Abril | 52 | 33 | 85 |
| 2024 Maro | 48 | 17 | 65 |
| 2024 Fevereiro | 44 | 17 | 61 |
| 2024 Janeiro | 33 | 27 | 60 |
| 2023 Dezembro | 38 | 23 | 61 |
| 2023 Novembro | 63 | 40 | 103 |
| 2023 Outubro | 40 | 24 | 64 |
| 2023 Setembro | 30 | 23 | 53 |
| 2023 Agosto | 37 | 17 | 54 |
| 2023 Julho | 32 | 16 | 48 |
| 2023 Junho | 46 | 22 | 68 |
| 2023 Maio | 48 | 43 | 91 |
| 2023 Abril | 38 | 3 | 41 |
| 2023 Maro | 45 | 24 | 69 |
| 2023 Fevereiro | 39 | 24 | 63 |
| 2023 Janeiro | 47 | 19 | 66 |
| 2022 Dezembro | 48 | 17 | 65 |
| 2022 Novembro | 70 | 34 | 104 |
| 2022 Outubro | 50 | 24 | 74 |
| 2022 Setembro | 43 | 33 | 76 |
| 2022 Agosto | 32 | 35 | 67 |
| 2022 Julho | 38 | 42 | 80 |
| 2022 Junho | 35 | 29 | 64 |
| 2022 Maio | 41 | 29 | 70 |
| 2022 Abril | 47 | 36 | 83 |
| 2022 Maro | 44 | 46 | 90 |
| 2022 Fevereiro | 29 | 29 | 58 |
| 2022 Janeiro | 43 | 34 | 77 |
| 2021 Dezembro | 32 | 34 | 66 |
| 2021 Novembro | 47 | 42 | 89 |
| 2021 Outubro | 52 | 52 | 104 |
| 2021 Setembro | 38 | 36 | 74 |
| 2021 Agosto | 46 | 43 | 89 |
| 2021 Julho | 40 | 20 | 60 |
| 2021 Junho | 43 | 25 | 68 |
| 2021 Maio | 47 | 33 | 80 |
| 2021 Abril | 74 | 34 | 108 |
| 2021 Maro | 62 | 23 | 85 |
| 2021 Fevereiro | 74 | 17 | 91 |
| 2021 Janeiro | 47 | 14 | 61 |
| 2020 Dezembro | 59 | 14 | 73 |
| 2020 Novembro | 38 | 20 | 58 |
| 2020 Outubro | 41 | 14 | 55 |
| 2020 Setembro | 72 | 28 | 100 |
| 2020 Agosto | 40 | 8 | 48 |
| 2020 Julho | 45 | 11 | 56 |
| 2020 Junho | 51 | 27 | 78 |
| 2020 Maio | 56 | 28 | 84 |
| 2020 Abril | 47 | 12 | 59 |
| 2020 Maro | 44 | 21 | 65 |
| 2020 Fevereiro | 185 | 24 | 209 |
| 2020 Janeiro | 40 | 16 | 56 |
| 2019 Dezembro | 49 | 11 | 60 |
| 2019 Novembro | 48 | 10 | 58 |
| 2019 Outubro | 71 | 13 | 84 |
| 2019 Setembro | 65 | 10 | 75 |
| 2019 Agosto | 51 | 16 | 67 |
| 2019 Julho | 107 | 40 | 147 |
| 2019 Junho | 48 | 36 | 84 |
| 2019 Maio | 23 | 18 | 41 |
| 2019 Abril | 36 | 19 | 55 |
| 2019 Maro | 44 | 27 | 71 |
| 2019 Fevereiro | 29 | 16 | 45 |
| 2019 Janeiro | 27 | 11 | 38 |
| 2018 Dezembro | 34 | 21 | 55 |
| 2018 Novembro | 38 | 14 | 52 |
| 2018 Outubro | 37 | 25 | 62 |
| 2018 Setembro | 17 | 11 | 28 |
| 2018 Agosto | 12 | 19 | 31 |
| 2018 Julho | 6 | 8 | 14 |
| 2018 Junho | 1 | 1 | 2 |
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