Case report
Intramural coronary hematoma, a complex three-dimensional entity: Multimodality assessment
Hematoma coronário intramural, uma realidade tridimensional complexa: avaliação multimodal
Iván J. Núñez-Gil
, Mauro Echavarría-Pinto, Gisela Feltes, Antonio Fernández-Ortiz*
Autor para correspondência
Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
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Anatomy defined by the Ensite NavX™ system; electrograms recorded by basket catheter (Constellation, Boston Scientific); ablation performed by ablation catheter (yellow) located over the area of a stable CFAE (white arrow). CFAE: complex fractionated atrial electrogram; CS: coronary sinus; LIPV: left inferior pulmonary vein; LSPV: left superior pulmonary vein; RIPV: right inferior pulmonary vein; RSPV: right superior pulmonary vein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Adragão, Pedro Carmo, Diogo Cavaco, João Carmo, Francisco Costa, Francisco Morgado" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Adragão" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carmo" ] 2 => array:2 [ "nombre" => "Diogo" "apellidos" => "Cavaco" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Carmo" ] 4 => array:2 [ "nombre" => "Francisco" "apellidos" => "Costa" ] 5 => array:2 [ "nombre" => "Francisco" "apellidos" => "Morgado" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301567?idApp=UINPBA00004E" "url" => "/08702551/0000003600000004/v1_201704060057/S0870255117301567/v1_201704060057/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0870255117301531" "issn" => "08702551" "doi" => "10.1016/j.repc.2016.07.015" "estado" => "S300" "fechaPublicacion" => "2017-04-01" "aid" => "977" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2017;36:309.e1-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2371 "formatos" => array:3 [ "EPUB" => 201 "HTML" => 1675 "PDF" => 495 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Cardiac resynchronization therapy: Femoral approach" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309.e1" "paginaFinal" => "309.e3" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Terapêutica de ressincronização ventricular: implantação por via femoral" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 722 "Ancho" => 881 "Tamanyo" => 70443 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Coronary sinus venography, left anterior oblique view, demonstrating the target posterolateral branch of the coronary sinus.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luís Brandão, Rita Miranda, Sofia Almeida, Luciano Ribeiro, Carlos Alvarenga, Isabel João, Hélder Pereira" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Luís" "apellidos" => "Brandão" ] 1 => array:2 [ "nombre" => "Rita" "apellidos" => "Miranda" ] 2 => array:2 [ "nombre" => "Sofia" "apellidos" => "Almeida" ] 3 => array:2 [ "nombre" => "Luciano" "apellidos" => "Ribeiro" ] 4 => array:2 [ "nombre" => "Carlos" "apellidos" => "Alvarenga" ] 5 => array:2 [ "nombre" => "Isabel" "apellidos" => "João" ] 6 => array:2 [ "nombre" => "Hélder" "apellidos" => "Pereira" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301531?idApp=UINPBA00004E" "url" => "/08702551/0000003600000004/v1_201704060057/S0870255117301531/v1_201704060057/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Intramural coronary hematoma, a complex three-dimensional entity: Multimodality assessment" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "311.e1" "paginaFinal" => "311.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Iván J. Núñez-Gil, Mauro Echavarría-Pinto, Gisela Feltes, Antonio Fernández-Ortiz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Iván J." "apellidos" => "Núñez-Gil" "email" => array:1 [ 0 => "ibnsky@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Mauro" "apellidos" => "Echavarría-Pinto" ] 2 => array:2 [ "nombre" => "Gisela" "apellidos" => "Feltes" ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "Fernández-Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hematoma coronário intramural, uma realidade tridimensional complexa: avaliação multimodal" ] ] "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" => 3507 "Ancho" => 2500 "Tamanyo" => 880144 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A-C) Coronary angiograms, cranial view: (A) at presentation, the flow is clearly diminished (TIMI 1-2); (B) after implantation of the first stent; (C) final angiographic result; (D and E) IVUS and OCT, respectively, of the mid segment of the left anterior descending artery. White arrows indicate the intimal flap; (F and G) IVUS and OCT, respectively, after stent implantation, showing correct expansion and apposition; (H and I) IVUS and OCT, respectively, displaying the hematoma at the origin of a patent septal branch (star); (J) three-dimensional (3-D) OCT reconstruction at the same level as (I); (K) 3-D reconstruction after implantation of the first stent. The cross shows the hematoma and the luminal compromise; (L and M) final 3-D result. IVUS: intravascular ultrasound; OCT: optical coherence tomography.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 62-year-old woman was admitted with chest pain of two hours’ duration. Her medical history consisted only of dyslipidemia. The ECG presented changes (slight ST depression together with negative T waves) in the precordial leads, and the echocardiogram showed extensive and severe left ventricular anterolateral-apical hypokinesia (left ventricular ejection fraction 30%). Emergent catheterization was ordered, which showed severe left coronary flow disturbance (TIMI 1-2 flow) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A; <a class="elsevierStyleCrossRef" href="#sec0040">Video 1</a>). An intra-aortic balloon pump (IABP) and a drug-eluting stent (DES) were implanted in the mid-distal left anterior descending artery (LAD) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B). However, the flow disturbance persisted, with an apparent proximal stenosis on angiography. Optical coherence tomography (OCT) revealed diminished luminal area between the stent and the left main. Subsequent intravascular ultrasound (IVUS) provided a better view of the wall, showing an intracoronary hematoma (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D and E; <a class="elsevierStyleCrossRef" href="#sec0040">Video 5</a>), helping to establish the mechanism behind this situation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Spontaneous coronary dissection with intramural hematoma is a life-threatening condition of uncertain etiology and management. Conservative management is usually a good option if flow is preserved.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> Since our patient remained unstable, and suffered a propagation of the dissection, we decided to treat the remaining LAD/left main with two more DES, which was successful (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C, F, G and L; <a class="elsevierStyleCrossRef" href="#sec0040">Videos 2 and 4</a>). The patient progressed well and was successfully weaned from the IABP and discharged three days later. Peak troponin was 40 ng/dl (normal <0.05).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is sometimes difficult to establish a definitive diagnosis by angiography only. The superior qualities of intracoronary imaging (IVUS and OCT) can help provide the correct diagnosis and guide management. In this critical patient, multimodality intracoronary imaging provided crucial data on the mechanism responsible and helped to optimize treatment. This case depicts a complex patient, with an uncommon condition (propagation of a dissection/hematoma). It also enables a direct comparison between the capabilities of OCT and IVUS, and indicates that IVUS, which has lower definition but deeper penetration, can have a key role in intracoronary diagnosis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">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" => "xres825049" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec821518" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres825048" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec821517" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "Reference" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-13" "fechaAceptado" => "2016-05-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec821518" "palabras" => array:5 [ 0 => "Acute coronary syndrome" 1 => "Coronary dissection" 2 => "Optical coherence tomography" 3 => "Three-dimensional optical coherence tomography" 4 => "Intravascular ultrasound" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec821517" "palabras" => array:5 [ 0 => "Síndrome coronária aguda" 1 => "Disseção coronária" 2 => "Tomografia de coerência ótica" 3 => "Tomografia de coerência ótica 3-D" 4 => "Ultrassonografia intravascular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 62-year-old woman was admitted with chest pain of two hours’ duration, ECG changes in the precordial leads and left ventricular ejection fraction of 30% on the echocardiogram. Emergent catheterization demonstrated severe flow disturbance in the left coronary artery. An intra-aortic balloon pump and a drug-eluting stent were implanted. However, the flow disturbance persisted. Optical coherence tomography followed by intravascular ultrasound provided crucial data on the mechanism and helped to optimize treatment in this critical patient.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma mulher de 62 anos foi internada devido a dor torácica com duas horas de duração, associada a alterações eletrocardiográficas nas derivações precordiais e FEVE: 30% determinada por ecocardiografia. Um cateterismo emergente revelou alterações graves no fluxo da coronária esquerda. Foram implantados um balão intra-aórtico e um <span class="elsevierStyleItalic">stent</span> revestido. Contudo, o fluxo continuou com alterações. A tomografia de coerência ótica e a ultrassonografia intravascular proporcionaram os dados únicos acerca do mecanismo envolvido e contribuíram para otimizar o tratamento numa doente crítica.</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></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3507 "Ancho" => 2500 "Tamanyo" => 880144 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A-C) Coronary angiograms, cranial view: (A) at presentation, the flow is clearly diminished (TIMI 1-2); (B) after implantation of the first stent; (C) final angiographic result; (D and E) IVUS and OCT, respectively, of the mid segment of the left anterior descending artery. White arrows indicate the intimal flap; (F and G) IVUS and OCT, respectively, after stent implantation, showing correct expansion and apposition; (H and I) IVUS and OCT, respectively, displaying the hematoma at the origin of a patent septal branch (star); (J) three-dimensional (3-D) OCT reconstruction at the same level as (I); (K) 3-D reconstruction after implantation of the first stent. The cross shows the hematoma and the luminal compromise; (L and M) final 3-D result. IVUS: intravascular ultrasound; OCT: optical coherence tomography.</p>" ] ] 1 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Video 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 855448 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Initial left anterior descending artery angiogram.</p>" ] ] 2 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Video 2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1816619 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Final angiographic result.</p>" ] ] 3 => array:7 [ "identificador" => "upi0015" "etiqueta" => "Video 3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 2720472 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional optical coherence tomography rendering after implantation of the distal stent. The intraluminal compromise and the septal anchoring is shown.</p>" ] ] 4 => array:7 [ "identificador" => "upi0020" "etiqueta" => "Video 4" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 3100454 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" ] "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional optical coherence tomography rendering showing the final result.</p>" ] ] 5 => array:7 [ "identificador" => "upi0025" "etiqueta" => "Video 5" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc5.mp4" "ficheroTamanyo" => 20730329 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc5.m4v" "poster" => "mmc5.jpg" ] "flv" => array:5 [ "fichero" => "mmc5.flv" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intravascular ultrasound pullback displaying evidence for the diagnosis, after the first stent.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Reference" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:1 [ 0 => array:3 [ "identificador" => "bib0010" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolutive recanalization of spontaneous coronary artery dissection: insights from a multimodality imaging approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B.C. Das Neves" 1 => "I.J. Núñez-Gil" 2 => "F. Alfonso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.112.000101" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2014" "volumen" => "129" "paginaInicial" => "719" "paginaFinal" => "720" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24515959" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003600000004/v1_201704060057/S0870255117301336/v1_201704060057/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/08702551/0000003600000004/v1_201704060057/S0870255117301336/v1_201704060057/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301336?idApp=UINPBA00004E" ]
| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 5 | 7 | 12 |
| 2024 Outubro | 40 | 30 | 70 |
| 2024 Setembro | 47 | 23 | 70 |
| 2024 Agosto | 49 | 33 | 82 |
| 2024 Julho | 30 | 28 | 58 |
| 2024 Junho | 18 | 13 | 31 |
| 2024 Maio | 38 | 26 | 64 |
| 2024 Abril | 40 | 26 | 66 |
| 2024 Maro | 46 | 26 | 72 |
| 2024 Fevereiro | 42 | 23 | 65 |
| 2024 Janeiro | 31 | 28 | 59 |
| 2023 Dezembro | 31 | 29 | 60 |
| 2023 Novembro | 35 | 18 | 53 |
| 2023 Outubro | 22 | 14 | 36 |
| 2023 Setembro | 27 | 13 | 40 |
| 2023 Agosto | 24 | 19 | 43 |
| 2023 Julho | 25 | 11 | 36 |
| 2023 Junho | 36 | 9 | 45 |
| 2023 Maio | 39 | 22 | 61 |
| 2023 Abril | 23 | 5 | 28 |
| 2023 Maro | 23 | 19 | 42 |
| 2023 Fevereiro | 19 | 19 | 38 |
| 2023 Janeiro | 23 | 12 | 35 |
| 2022 Dezembro | 21 | 21 | 42 |
| 2022 Novembro | 48 | 20 | 68 |
| 2022 Outubro | 27 | 24 | 51 |
| 2022 Setembro | 35 | 32 | 67 |
| 2022 Agosto | 31 | 29 | 60 |
| 2022 Julho | 30 | 33 | 63 |
| 2022 Junho | 24 | 16 | 40 |
| 2022 Maio | 23 | 33 | 56 |
| 2022 Abril | 32 | 31 | 63 |
| 2022 Maro | 23 | 46 | 69 |
| 2022 Fevereiro | 28 | 32 | 60 |
| 2022 Janeiro | 27 | 21 | 48 |
| 2021 Dezembro | 24 | 31 | 55 |
| 2021 Novembro | 43 | 37 | 80 |
| 2021 Outubro | 97 | 41 | 138 |
| 2021 Setembro | 33 | 24 | 57 |
| 2021 Agosto | 32 | 31 | 63 |
| 2021 Julho | 24 | 22 | 46 |
| 2021 Junho | 28 | 17 | 45 |
| 2021 Maio | 33 | 30 | 63 |
| 2021 Abril | 50 | 28 | 78 |
| 2021 Maro | 58 | 20 | 78 |
| 2021 Fevereiro | 63 | 23 | 86 |
| 2021 Janeiro | 41 | 14 | 55 |
| 2020 Dezembro | 43 | 12 | 55 |
| 2020 Novembro | 41 | 13 | 54 |
| 2020 Outubro | 34 | 11 | 45 |
| 2020 Setembro | 65 | 16 | 81 |
| 2020 Agosto | 25 | 9 | 34 |
| 2020 Julho | 49 | 8 | 57 |
| 2020 Junho | 47 | 11 | 58 |
| 2020 Maio | 40 | 6 | 46 |
| 2020 Abril | 48 | 9 | 57 |
| 2020 Maro | 43 | 11 | 54 |
| 2020 Fevereiro | 123 | 17 | 140 |
| 2020 Janeiro | 42 | 7 | 49 |
| 2019 Dezembro | 35 | 7 | 42 |
| 2019 Novembro | 45 | 7 | 52 |
| 2019 Outubro | 34 | 5 | 39 |
| 2019 Setembro | 34 | 5 | 39 |
| 2019 Agosto | 33 | 10 | 43 |
| 2019 Julho | 54 | 11 | 65 |
| 2019 Junho | 28 | 13 | 41 |
| 2019 Maio | 45 | 9 | 54 |
| 2019 Abril | 22 | 16 | 38 |
| 2019 Maro | 90 | 11 | 101 |
| 2019 Fevereiro | 107 | 14 | 121 |
| 2019 Janeiro | 79 | 4 | 83 |
| 2018 Dezembro | 82 | 16 | 98 |
| 2018 Novembro | 98 | 14 | 112 |
| 2018 Outubro | 110 | 29 | 139 |
| 2018 Setembro | 31 | 14 | 45 |
| 2018 Agosto | 30 | 14 | 44 |
| 2018 Julho | 17 | 2 | 19 |
| 2018 Junho | 45 | 11 | 56 |
| 2018 Maio | 20 | 11 | 31 |
| 2018 Abril | 60 | 8 | 68 |
| 2018 Maro | 70 | 12 | 82 |
| 2018 Fevereiro | 38 | 14 | 52 |
| 2018 Janeiro | 49 | 9 | 58 |
| 2017 Dezembro | 54 | 18 | 72 |
| 2017 Novembro | 51 | 16 | 67 |
| 2017 Outubro | 18 | 10 | 28 |
| 2017 Setembro | 23 | 17 | 40 |
| 2017 Agosto | 28 | 13 | 41 |
| 2017 Julho | 23 | 14 | 37 |
| 2017 Junho | 50 | 15 | 65 |
| 2017 Maio | 68 | 47 | 115 |
| 2017 Abril | 59 | 49 | 108 |
| 2017 Maro | 7 | 6 | 13 |
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