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Three-dimensional speckle tracking echocardiography: The future is now
Ecocardiografia tridimensional de speckle tracking: o futuro é agora
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A RM depende da idade e colaboração do doente.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">¿¿</span> TC feita no exterior pode ser usada se as imagens estiverem disponíveis e o estudo fornecer toda a informação necessária para a tomada de decisão.</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">£</span><span class="elsevierStyleItalic">Unroffing</span> se segmento intramural significativo, criação de um novo óstio ou translocação se segmento intramural atrás da comissura, translocação da coronária ou ostioplastia se não existir segmento intramural. Em doentes entre 10‐35 anos, os outros caso a caso.</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">**Restrição na participação em desportos competitivos ou exercícios com componente dinâmica moderada ou alta (mais de > 40% de uso de oxigénio máximo; exemplo: natação, futebol, basquetebol).</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">++ indivíduos no pós‐operatório são autorizados a praticar qualquer exercício ou desporto competitivo com base na avaliação ao 3<span class="elsevierStyleHsp" style=""></span>°mês, que inclui resultados da CPM, RM de perfusão em <span class="elsevierStyleItalic">stress</span> ou TC.</p> <p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ACOAA: artéria coronária com origem anómala na aorta, CPM: cintigrafia de perfusão miocárdica, ECG: eletrocardiograma, PCR: paragem cardiorrespiratória revertida, RM: ressonância magnética, TC: tomografia computorizada.</p> <p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Adaptado de 2015 Texas Children's Hospital. Copyright© 2015 Texas Children's Hospital. All rights reserved.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Andrea Silva, Maria João Baptista, Emanuel Araújo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Andrea" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Maria João" "apellidos" => "Baptista" ] 2 => array:2 [ "nombre" => "Emanuel" "apellidos" => "Araújo" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204918300850" "doi" => "10.1016/j.repce.2017.09.015" "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/S2174204918300850?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117301452?idApp=UINPBA00004E" "url" => "/08702551/0000003700000004/v1_201805040411/S0870255117301452/v1_201805040411/pt/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255117303773" "issn" => "08702551" "doi" => "10.1016/j.repc.2017.10.011" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1180" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2018;37:333-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1319 "formatos" => array:3 [ "EPUB" => 116 "HTML" => 888 "PDF" => 315 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Importance of three-dimensional speckle tracking in the assessment of left atrial and ventricular dysfunction in patients with myotonic dystrophy type 1" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "333" "paginaFinal" => "338" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Importância da tecnologia 3D <span class="elsevierStyleItalic">speckle tracking</span> na avaliação da disfunção auricular e ventricular esquerda em doentes com distrofia miotónica do tipo 1" ] ] "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" => 1058 "Ancho" => 3167 "Tamanyo" => 467056 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(1) LA LS (16 segments) obtained by means of 3D wall-motion tracking technology; during systole, the LA is stretched and LS increases, reaching a positive peak at the end of systole, corresponding to the end of atrial filling; during diastole, LS decreases to a plateau; (2) the 3D echocardiographic dataset is displayed in apical 4-chamber (A) and 2-chamber (B) views and three short-axis views in the basal (C3), mid-ventricular (C5), and superior (C7) regions, respectively. 3D LV cast (D) and GLS (E) are also presented; (3) LV GLS (16 segments) obtained by 3D wall-motion tracking technology. 3D: three-dimensional; GLS: global longitudinal strain; LA: left atrial; LS: longitudinal strain; LV: left ventricular.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Henrique Guedes, Nuno Moreno, Rui Pontes dos Santos, Leonor Marques, Daniel Seabra, Adriana Pereira, Aurora Andrade, Paula Pinto" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Henrique" "apellidos" => "Guedes" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Moreno" ] 2 => array:2 [ "nombre" => "Rui Pontes" "apellidos" => "dos Santos" ] 3 => array:2 [ "nombre" => "Leonor" "apellidos" => "Marques" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Seabra" ] 5 => array:2 [ "nombre" => "Adriana" "apellidos" => "Pereira" ] 6 => array:2 [ "nombre" => "Aurora" "apellidos" => "Andrade" ] 7 => array:2 [ "nombre" => "Paula" "apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204918301296" "doi" => "10.1016/j.repce.2017.10.010" "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/S2174204918301296?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303773?idApp=UINPBA00004E" "url" => "/08702551/0000003700000004/v1_201805040411/S0870255117303773/v1_201805040411/en/main.assets" ] "asociados" => array:1 [ 0 => array:20 [ "pii" => "S0870255117303773" "issn" => "08702551" "doi" => "10.1016/j.repc.2017.10.011" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1180" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2018;37:333-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1319 "formatos" => array:3 [ "EPUB" => 116 "HTML" => 888 "PDF" => 315 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Importance of three-dimensional speckle tracking in the assessment of left atrial and ventricular dysfunction in patients with myotonic dystrophy type 1" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "333" "paginaFinal" => "338" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Importância da tecnologia 3D <span class="elsevierStyleItalic">speckle tracking</span> na avaliação da disfunção auricular e ventricular esquerda em doentes com distrofia miotónica do tipo 1" ] ] "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" => 1058 "Ancho" => 3167 "Tamanyo" => 467056 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(1) LA LS (16 segments) obtained by means of 3D wall-motion tracking technology; during systole, the LA is stretched and LS increases, reaching a positive peak at the end of systole, corresponding to the end of atrial filling; during diastole, LS decreases to a plateau; (2) the 3D echocardiographic dataset is displayed in apical 4-chamber (A) and 2-chamber (B) views and three short-axis views in the basal (C3), mid-ventricular (C5), and superior (C7) regions, respectively. 3D LV cast (D) and GLS (E) are also presented; (3) LV GLS (16 segments) obtained by 3D wall-motion tracking technology. 3D: three-dimensional; GLS: global longitudinal strain; LA: left atrial; LS: longitudinal strain; LV: left ventricular.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Henrique Guedes, Nuno Moreno, Rui Pontes dos Santos, Leonor Marques, Daniel Seabra, Adriana Pereira, Aurora Andrade, Paula Pinto" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Henrique" "apellidos" => "Guedes" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Moreno" ] 2 => array:2 [ "nombre" => "Rui Pontes" "apellidos" => "dos Santos" ] 3 => array:2 [ "nombre" => "Leonor" "apellidos" => "Marques" ] 4 => array:2 [ "nombre" => "Daniel" "apellidos" => "Seabra" ] 5 => array:2 [ "nombre" => "Adriana" "apellidos" => "Pereira" ] 6 => array:2 [ "nombre" => "Aurora" "apellidos" => "Andrade" ] 7 => array:2 [ "nombre" => "Paula" "apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204918301296" "doi" => "10.1016/j.repce.2017.10.010" "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/S2174204918301296?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303773?idApp=UINPBA00004E" "url" => "/08702551/0000003700000004/v1_201805040411/S0870255117303773/v1_201805040411/en/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Three-dimensional speckle tracking echocardiography: The future is now" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "339" "paginaFinal" => "340" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Rogério Teixeira" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Rogério" "apellidos" => "Teixeira" "email" => array:1 [ 0 => "rogeriopteixeira@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Cardiology Department, Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, University of Coimbra, Coimbra, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ecocardiografia tridimensional de <span class="elsevierStyleItalic">speckle tracking</span>: o futuro é agora" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac ultrasound is an imaging modality that enables dynamic imaging of the heart and great vessels. The past decade has seen the development of two-dimensional speckle tracking echocardiography (2D-STE), a semi-automated technique based on frame-by-frame tracking of tiny echo-dense speckles within the myocardium that reveals the extent of lengthening and shortening relative to the baseline (Lagrangian strain).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> It enables assessment of motion and deformation parameters such as velocity, displacement, strain, and strain rate in the left ventricular longitudinal, radial, or circumferential axis.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> This non-Doppler methodology is therefore able to provide information on segmental and global myocardial deformation. Myocardial 2D-STE has been validated by comparison with sonomicrometry<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> and tagged magnetic resonance imaging (MRI).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">With respect to left ventricular (LV) mechanics, global longitudinal strain (GLS) is the most-studied 2D-STE parameter and is part of routine assessment in many echocardiographic laboratories. This is in contrast to analysis of radial and circumferential LV mechanics, which are probably not sufficiently reproducible.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> By convention, GLS is presented as negative values representing shortening in the longitudinal LV axis. In a meta-analysis of 24 studies which included 2597 healthy subjects, GLS varied from -15.9% to -22.1%.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> The American Society of Echocardiography suggests a value above -20% with a standard deviation of ±2% as likely to be normal.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To date, most strain data have come from non-randomized, retrospective studies. GLS has been proposed for the detection of myocardial ischemia,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> to differentiate among various hypertrophy etiologies,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> to monitor therapy, and as a tool to detect heart disease in the preclinical stage.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> A recent 2017 review identifies four settings in which GLS can provide additional (if not potentially incremental) clinical utility: undifferentiated left ventricular hypertrophy; assessment of cardiotoxicity; aortic stenosis; and ischemic heart disease.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The use of 2D-ST has been expanded and validated for the other cardiac chambers (right ventricle and left and right atrium)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> as well as the aortic wall.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound systems are now capable of acquiring real-time volumetric LV data. Three-dimensional (3D) techniques can measure all strain components in all LV segments and LV torsion from a single acquisition.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> 3D speckle tracking echocardiography (3D-STE) thus offers an opportunity to overcome a significant limitation of 2D-STE: out-of-plane speckle motion.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Nevertheless, tracking in three dimensions is challenging, as both the spatial and the temporal resolution of the 3D data set are inferior to 2D imaging, and there is the possibility of speckle decorrelation between subsequent volumes.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">12,13</span></a> Even so, 3D-STE has been validated in simulated models, in vitro and in vivo, against sonomicrometry and MRI markers.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> LV 3D-STE has been shown to be a reliable technique for the assessment of LV global systolic function, highly correlated with left ventricular ejection fraction and Doppler-derived cardiac output.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> Subsequent studies in different clinical scenarios such as ischemia and hypertensive and valvular heart disease have provided further evidence of the utility of LV 3D-STE.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Guedes et al.,<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> using both classic and advanced echocardiographic parameters, present a study of a group of patients with myotonic dystrophy type 1 (DM1) with no established cardiovascular disease plus a control group of healthy subjects. Regarding advanced imaging, the authors focused on 3D LV myocardial mechanics assessed with an Artida scanner (Toshiba<span class="elsevierStyleSup">®</span> Medical Systems). The following parameters of LV cardiac mechanics were calculated: LV longitudinal, radial and circumferential strain; LV area tracking; and twist. The authors concluded that DM1 patients had lower values of 3D LV longitudinal strain than the control group. Moreover, assessment of 2D myocardial mechanics did not identify differences between the groups, in contrast to 3D assessment. Based on previous data from clinical studies,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> 2D-STE<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> and cardiac MRI of myocardial fibrosis<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> in DM1 patients, the authors theorized that this 3D LV longitudinal strain reduction could represent subclinical myocardial damage.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although these results are of interest, some limitations are to be noted. Speckle-tracking analyses can be complex and time-consuming, and can generally only be obtained from high-quality images. It is therefore important to provide data regarding feasibility. Secondly, inter- and intra-observer variability in assessment of cardiac mechanics (and echocardiography in general) is a concern. The intra-class correlation coefficient can be used, but, for simplicity, other measures of variability may be more appropriate, such as the absolute difference divided by the mean of repeated observations, expressed as a percentage. Finally, the overlap of values between cases and controls makes it unlikely that 3D-STE will in fact add real value in clinical practice.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:2 [ "identificador" => "xack345078" "titulo" => "Acknowledgment" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. 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Vejlstrup" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12968-014-0059-z" "Revista" => array:5 [ "tituloSerie" => "J Cardiovasc Magn Reson" "fecha" => "2014" "volumen" => "16" "paginaInicial" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25086734" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack345078" "titulo" => "Acknowledgment" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">The author thanks José P Sousa, MD, for copyediting the original manuscript.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003700000004/v1_201805040411/S0870255118302129/v1_201805040411/en/main.assets" "Apartado" => array:4 [ "identificador" => "29261" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Artigos Originais" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003700000004/v1_201805040411/S0870255118302129/v1_201805040411/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255118302129?idApp=UINPBA00004E" ]
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