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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Focal lymphocytic myocarditis&#46; Slight edema and a prominent lymphocytic infiltrate are present in the interstitium&#46; Absence of fibrosis &#40;hematoxylin and eosin&#41;&#46; &#40;B&#41; Interstitial lymphocytic infiltration and myocyte damage in the form of apoptosis are present &#40;hematoxylin and eosin&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The development of endomyocardial biopsy in the 1960s facilitated percutaneous sampling of the myocardium without the need for a grossly invasive procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> However&#44; in recent decades&#44; significant advances in both invasive and non-invasive cardiac imaging have enabled the study of a wide array of cardiac diseases&#44; without the need for a histopathological analysis of the heart&#46; As a result&#44; enthusiasm for myocardial biopsy has waned&#46; Indeed&#44; the most recent recommendations regarding endomyocardial biopsy date back to 2007&#44; and a high level of recommendation applies in only a handful of settings&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> However&#44; these guidelines base their recommendations on efficacy and safety data in existence at that time&#46; Since then&#44; two main changes have occurred&#58; Firstly&#44; several authors have published extensive data on an approach via the left ventricle rather than just the right ventricle&#44; allowing for more extended myocardial sampling&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Secondly&#44; several operators started performing left ventricular &#40;LV&#41; biopsy using the radial approach&#44; widely popular in the interventional community for its simplicity&#44; comfort and increased safety&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> As a result&#44; more recent documents call for a wider use of this technique&#44; particularly in myocarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;7</span></a> dilated cardiomyopathy<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> and myocardial infarction with non-obstructive coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper&#44; we report our initial experience of the feasibility&#44; safety and usefulness of transradial endomyocardial biopsy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General features</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study involved a single-center registry of consecutive patients undergoing intended transradial endomyocardial biopsy&#46; Patients were selected for endomyocardial biopsy of the left ventricle and screened for the feasibility of radial access individually&#44; based on the operator&#39;s clinical judgment&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clinical data included demographics&#44; clinical setting&#44; imaging&#44; complications&#44; and final biopsy results&#46; Technical data included access site&#44; sheath&#47;catheter size and shape&#44; biopsy model and size&#44; procedural time&#44; fluoroscopy time&#44; success rate and cross-over rate to femoral approach&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a descriptive registry&#59; complex statistical analysis was not performed&#46; Qualitative variables are expressed both numerically and in percentages&#46; Continuous variables are depicted as mean &#177; standard deviation and range&#44; where appropriate&#46; SPSS Statistics 24 was used for analysis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedure overview</span><p id="par0030" class="elsevierStylePara elsevierViewall">Detailed information on technique has been published in recent papers&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#8211;13</span></a> However&#44; because minor variation occurs across centers and operators&#44; an overview of the technique as it was performed is provided&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The procedure was always undertaken by the same operator&#44; who had been previously trained in transradial intervention and in performing left myocardial biopsies&#46; During the procedure&#44; the patient was continuously monitored as in a routine coronary angiography &#40;i&#46;e&#46; with continuous 12-lead electrocardiogram and invasive blood pressure measurement&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Routine transthoracic echocardiography was performed before&#44; during and after the procedure&#46; Particular attention was given to documenting and quantifying pericardial effusion and mitral regurgitation&#44; as well as excluding the presence of LV thrombus or masses which might contraindicate the procedure&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Spasm prophylaxis with intra-arterial 0&#46;5-1 mg of isosorbide dinitrate and&#47;or 2&#46;5 mg of verapamil and 5000 units of unfractionated heparin were administered&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">If the patient required a coronary angiogram&#44; a standard transradial coronary angiogram was performed using a Terumo 5&#47;6 Fr slender sheath &#40;external diameter 5 Fr&#41; and standard Judkins 5 Fr coronary diagnostic catheters&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Afterwards&#44; a 7&#46;5 Fr &#40;external diameter 6 Fr&#41; Asahi Eaucath sheathless guide catheter was advanced over a standard 0&#46;035&#8221; J wire to the ascending aorta&#46; An MP 1 or JR 3&#46;5&#47;4 curve was used according to operator choice&#46; The dilator was removed and a 5 Fr pigtail catheter was then used inside the 7&#46;5 Fr for crossing the aortic valve and safely&#8221;landing&#8221; in the left ventricle&#46; The guide catheter was advanced over the pigtail&#44; which was then removed&#44; and placed in the mid-cavity of the left ventricle&#46; The catheter was connected to the pressure system&#44; initial LV pressure was recorded and a minimal amount of contrast was injected &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; A 5&#46;5 Fr Cordis 104 cm or 5&#46;4 Fr Maslanka 120 cm bioptome was advanced and the myocardial wall was sampled &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Back-bleed from the catheter and&#44; if necessary&#44; aspiration&#44; were then performed to ensure no air bubbles were in the system&#46; These steps were then repeated several times until the desired number of samples was obtained &#8211; a minimum of five &#8211; of which at least one was frozen for further analysis&#44; if necessary&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All mid-apical segments of all the walls of the left ventricle were sampled by gently directing the catheter during the procedure&#44; guided by fluoroscopy and echocardiography&#46; First the guide is positioned using fluoroscopy and then confirmed by transthoracic echocardiography by an assisting physician&#46; This enables detailed guide and bioptome positioning and early identification of possible complications&#46; The process was repeated for all samples&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Hemostasis was obtained using the Terumo TR-Band&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Baseline population characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">Twenty-five patients were selected for intended LV endomyocardial biopsy&#46; Two patients underwent the procedure in the setting of cardiogenic shock of unknown etiology and were deemed better suited to a transfemoral approach&#44; as mechanical circulatory support was being considered post procedure&#46; Transradial endomyocardial biopsy was thus attempted in 25 patients&#46; The baseline data are illustrated in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Technical data&#44; success and complications</span><p id="par0075" class="elsevierStylePara elsevierViewall">All patients scheduled for transradial biopsy underwent the procedure successfully&#44; with no cases of cross-over to a femoral approach&#46; There were no major complications&#44; and only two cases of minor radial spasm&#46; One of these two patients also had a run of non-sustained ventricular tachycardia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the two above-mentioned patients who underwent programmed transfemoral LV endomyocardial biopsy&#44; the procedure was also successful with no major or minor complications&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Biopsy indication&#44; results and final clinical diagnosis</span><p id="par0085" class="elsevierStylePara elsevierViewall">There were two main clinical settings for performing the procedure&#58; myocarditis and cardiomyopathy&#46; The details are provided in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding myocarditis&#44; eight studies were performed in the setting of suspected acute myocarditis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and <a class="elsevierStyleCrossRef" href="#fig0015">3</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Three patients presented with acute coronary syndrome chest pain-like symptoms&#46; Two of them underwent the procedure because of recurrent myocarditis&#46; The third patient underwent the procedure due to very high troponin levels and mildly impaired LV function&#44; despite the absence of clinical signs of heart failure&#46; All had a favorable clinical outcome with normalization of LV function after a few weeks&#46; Their final diagnosis was acute lymphocytic myocarditis&#46; One patient had a mildly positive parvovirus B19 result in the polymerase chain reaction &#40;PCR&#41; test&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Four patients underwent the procedure because of new-onset heart failure of unknown etiology&#46; They had no other characteristics of acute myocarditis but a potentially treatable type of myocarditis&#44; such as giant cell myocarditis&#44; was ruled out&#44; thereby excluding an indication for immunosuppression therapy&#46; Two of these patients tested positive for acute lymphocytic myocarditis&#44; one in the setting of Takayasu arteritis&#44; and progressed favorably&#44; with normalization of LV function after a few weeks&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One patient was a 46-year-old patient with new-onset third degree atrioventricular &#40;AV&#41; block&#46; The biopsy ruled out myocarditis&#44; but showed some degree of fibrosis&#44; possibly related to past radiotherapy years earlier in the setting of Hodgkin&#39;s lymphoma&#46; The result helped to explain the etiology of the AV block at such a young age and reinforced the need for a permanent pacemaker&#44; as the cause of the bradycardia was not reversible&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Six patients underwent the procedure in the setting of dilated cardiomyopathy for ruling out chronic myocarditis&#46; They were young patients &#40;age range 23-56 years&#41; refractory to medical therapy for heart failure titrated to maximum doses&#46; Only one met the formal pathological criteria of chronic myocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> The study of viral genomes by PCR was negative&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding those patients who underwent the procedure in the setting of cardiomyopathy&#44; there were two cases of apical hypertrophy with imaging and clinical features of concomitant amyloidosis&#46; Therefore&#44; the exact etiology of their cardiomyopathy was not fully understood&#46; Their final diagnosis was familial transthyretin &#40;ATTR&#41; amyloidosis &#40;V30M mutation&#41; cardiomyopathy&#46; Nine patients underwent endomyocardial biopsy due to amyloidosis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>A&#44; and <a class="elsevierStyleCrossRef" href="#fig0020">4</a>C&#41; of unknown etiology after earlier studies&#44; which included laboratory workup and an abdominal fat biopsy&#46; The echocardiograms of eight patients were highly suggestive of amyloidosis&#46; The final diagnosis was amyloid light-chain amyloidosis in four cases &#40;resulting in hematology referral for the study of lymphoproliferative diseases&#41;&#44; wild type ATTR amyloidosis in four patients&#46; One patient was referred by another institution to the amyloidosis clinic because of an inconclusive echocardiogram together with a cardiac magnetic resonance raising the possibility of amyloidosis&#44; which was ruled out in the cardiac biopsy&#46; It is noteworthy that all six patients with ATTR amyloid deposits had their TTR gene sequenced&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; the two previously mentioned patients&#44; who underwent the transfemoral procedure&#44; were also new-onset heart failure cases with cardiogenic shock after cardiac arrest&#59; myocarditis was ruled out in both&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">In our initial experience&#44; transradial endomyocardial biopsy achieved excellent results&#44; both regarding procedural success and complications&#46; Our research is supported by an increasing amount of published data on this particular approach to endomyocardial biopsy&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Safety is the major concern when performing this technique&#44; as many patients are often young &#40;especially in the setting of myocarditis&#41; and others have large ventricles with thin walls&#46; We did not encounter safety issues&#44; especially perforation&#44; embolization or mitral regurgitation&#46; This was likely the result of specific operator training both in radial intervention and LV biopsy&#44; as well as technical safety precautions&#46; We highlight the use of pressure monitoring&#44; extensive back bleed and catheter aspiration&#44; as well as peri and intra-procedural echocardiography guidance&#46; All of these enable constant monitoring of the procedure and minimize risks&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As mentioned above&#44; current guidelines regarding endomyocardial biopsy are now over a decade old and base their safety considerations on even older data&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Indeed&#44; these recommendations highlight a large series of transvenous RV biopsies with an overall 6&#37; complication rate&#44; a 1&#46;2&#37; possible or definite perforation rate and 0&#46;4&#37; death rate&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> Over the past decade&#44; however&#44; several authors from experienced European centers have published more extensive experience &#40;ranging from 755 to 4221 procedures&#41; totaling more than 8000 procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4&#44;15</span></a> In addition&#44; two of these publications provide extensive data on both left and RV biopsy&#44; thereby providing clearer data&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Overall&#44; the published major and minor complication rate of these authors ranges from 0&#46;12&#37; to 0&#46;82&#37; and 1&#46;35 to 5&#46;2&#37;&#44; respectively&#44; regarding RV biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4&#44;15</span></a> The rate of LV biopsy major and minor complications in LV biopsies was 0&#46;33 to 0&#46;64&#37; and 2&#46;2&#37; to 2&#46;89&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Importantly&#44; there were no deaths in any of these series&#46; Most major complications were perforation with subsequent tamponade&#46; A very small number were cases of embolization&#46; Several minor complications included bleeding or vascular-related&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">These data provide valuable insights into safety&#46; Firstly&#44; the risk of the procedure when performed in experienced centers is low&#44; and seemingly lower than previously published studies&#59; secondly&#44; LV biopsy seems at least as safe&#44; if not safer&#44; than RV biopsy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Published transradial endomyocardial biopsy experience is quite recent&#46; The earliest publications date back to 2014<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> and 2015&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#44;11</span></a> The largest series published to date was multicenter data comprising over 100 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In all of these recent case series&#44; there were no major complications&#46; Furthermore&#44; the latter group published the largest radial versus femoral case series comparing both approaches&#44; with 129 cases via radial and 134 cases via femoral access&#46; There were no major complications and bleeding occurred exclusively in the transfemoral group&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Our experience thus reflects the findings in contemporary data&#46; Endomyocardial biopsy is a largely safe technique&#44; all the more so when performed via the left ventricle&#44; especially with the added safety benefits of the transradial approach&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In the series presented herein&#44; the feasibility rate was 100&#37;&#44; with no cross-overs and only mild radial spasm observed in two patients&#46; This was likely the result of patient selection&#44; spasm prophylaxis administration&#44; the use of hydrophilic catheters and the use of large size intra-luminal sheathless catheters&#44; which allow for comfortable bioptome passage and have a reduced external caliper&#46; Importantly&#44; patient feedback was very positive and one patient&#44; who had previously undergone a transjugular RV biopsy at another institution&#44; actively voiced his preference for the transradial technique&#44; because of improved comfort&#46; When the procedure is performed electively&#44; and if no complications occur&#44; same-day discharge is possible&#46; Our results are similar to previously published data&#46; In fact&#44; in the largest series published to date&#44; cross-over to the femoral technique was required in only one patient &#40;0&#46;98&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The last issue regarding this technique is its diagnostic yield and clinical usefulness&#46; In our experience&#44; in which LV biopsy was always performed outside the setting of transplant&#44; the results were clinically meaningful&#44; as they added to the clinical question at hand&#46; Indeed&#44; the suspected diagnosis was either confirmed or ruled out&#44; such as in the setting of myocarditis&#46; Additionally&#44; a doubtful diagnosis was clarified&#44; such as the etiology of a cardiomyopathy&#44; or amyloidosis infiltration and&#47;or type in cases with predominant heart involvement and previously inconclusive studies&#46; Finally&#44; atypical forms of LV hypertrophy &#40;i&#46;e&#46; apical&#41; were observed in patients with ATTR&#44; and tissue biopsy was most useful for confirming amyloidosis and ruling out hypertrophy&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Importantly&#44; our pathologist&#39;s feedback was also very positive&#44; as the quality and size of the samples was deemed excellent and better than when we had previously used the RV approach&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The abovementioned papers from the transfemoral era suggest that the LV approach is superior to the RV approach outside the transplant setting&#46; Indeed&#44; in the setting of myocarditis&#44; the largest published series reports a 92&#46;1&#37; vs&#46; 81&#46;3&#37; diagnostic yield&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and in the setting of predominant LV disease&#44; the difference is quite large and the LV approach is favored with 97&#46;8&#37; vs&#46; 53&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Published data from the transradial approach do not allow for a comparison of left versus right approaches&#44; however the conclusions are similar to ours&#58; the results added to the clinical dilemma&#44; confirming&#44; excluding or clarifying a diagnostic hypothesis&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Despite its advantages&#44; the transradial LV endomyocardial biopsy technique is not without limitations&#46; This approach requires the use of heparin&#44; which may add to the risk of bleeding&#46; In cases in which repeated biopsy is required&#44; such as transplant patients&#44; radial patency and the risk of vascular complications may become an issue with frequent procedures&#46; In addition&#44; the LV approach&#44; while apparently less prone to perforation&#44; regardless of the access site&#44; may lead to a more dangerous scenario should perforation occur&#44; given the much higher intracavitary pressure of the left ventricle&#46; Also&#44; the risk of cerebral embolization is essentially a concern of the left&#44; rather than the right&#44; approach&#44; and thus it cannot be performed in the presence of LV intracavitary masses&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">It is also important to point out the particular limitations of this paper&#46; This an observational single-center study&#46; Additionally&#44; the sample size is relatively small given the single-center nature of the data&#46; And finally&#44; an ultrasound study of the radial artery was not performed after the procedure&#46; Thus&#44; although there was no clinical evidence of radial patency complications&#44; these cannot be completely ruled out&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Transradial LV endomyocardial biopsy provides a safe and feasible method of sampling the myocardium for histopathological analysis&#44; with a good diagnostic yield and clinically meaningful results in properly selected patients&#46; This technique should probably be the default method for endomyocardial biopsy in patients undergoing a single biopsy procedure outside the setting of cardiac transplant in a radial center&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Keypoints</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">What is known about the topic&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8728;</span><p id="par0200" class="elsevierStylePara elsevierViewall">The indications for endomyocardial biopsy are still debated&#44; partly because of safety concerns and doubts about the clinical usefulness of the results&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8728;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Recent papers suggest the safety of LV biopsy is superior to RV biopsy&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8728;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Very recent data suggest that the transradial approach is a new and better method of sampling the left ventricle when compared to the transfemoral approach&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">What does this study add&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8728;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Additional data confirming that transradial LV biopsy is feasible and safe&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8728;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Clinical data explaining how the results were useful in a variety of clinical scenarios&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8728;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Data to support the growing indications for endomyocardial biopsy&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Left endomyocardial biopsy"
            1 => "Transradial"
            2 => "Myocarditis"
            3 => "Cardiomyopathy"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Over the last decade&#44; several studies have suggested that left ventricular endomyocardial biopsy is safer and has a higher diagnostic yield than transvenous right ventricular biopsy&#46; In addition&#44; recent publications indicate that the transradial approach is a feasible and safe alternative to the transfemoral approach for sampling the left ventricle&#46; We report our initial experience with transradial endomyocardial biopsy with regards to feasibility&#44; safety and usefulness&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Single-center registry of consecutive patients undergoing intended transradial left endomyocardial biopsy&#46; Clinical and technical data were collected prospectively&#44; with a particular focus on success rate and complications&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-seven patients were screened for left ventricle biopsy&#46; Twenty &#40;25&#41; were selected for an intended transradial approach &#40;mean age 51&#177;18 years old&#44; 22 male&#41;&#46; Success rate was 100&#37; with no crossover to femoral approach&#46; There were no major complications&#46; Two patients experienced mild radial spasm&#46; One of them also had a run of non-sustained ventricular tachycardia&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Indication for biopsy was either myocarditis or cardiomyopathy of unknown etiology&#46; The final diagnosis was acute lymphocytic myocarditis in five patients&#44; chronic myocarditis in one patient&#44; amyloid light-chain amyloidosis in four patients and transthyretin amyloidosis in six patients&#46; Myocarditis was ruled out in eight patients and amyloidosis in one patient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transradial left ventricle endomyocardial biopsy is a very safe and feasible method of sampling the myocardium for histopathological analysis&#44; with a good diagnostic yield and clinically meaningful results in properly selected patients&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Durante a &#250;ltima d&#233;cada&#44; v&#225;rios estudos t&#234;m sugerido que a bi&#243;psia endomioc&#225;rdica ventricular esquerda &#233; mais segura e de superior rentabilidade diagn&#243;stica do que a do ventr&#237;culo direito&#46; Adicionalmente&#44; v&#225;rias publica&#231;&#245;es recentes t&#234;m introduzido a abordagem transradial como uma alternativa exequ&#237;vel e segura &#224; transfemoral&#44; para amostrar o ventr&#237;culo esquerdo&#46; O objetivo deste estudo &#233; reportar a experi&#234;ncia inicial de um centro em bi&#243;psia endomioc&#225;rdica ventricular esquerda transradial&#44; relativamente a exequibilidade&#44; seguran&#231;a e utilidade&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Registo unic&#234;ntrico de doentes consecutivos submetidos a bi&#243;psia endomioc&#225;rdica ventricular esquerda&#44; com acesso de primeira inten&#231;&#227;o radial&#46; Registaram-se os dados cl&#237;nicos e t&#233;cnicos&#44; com particular foco na taxa de sucesso e complica&#231;&#245;es&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foram submetidos a bi&#243;psia endomioc&#225;rdica ventricular esquerda 27 doentes&#44; 25 dos quais pr&#233;-selecionados para acesso transradial &#40;idade m&#233;dia 51&#177;18&#44; 22 homens&#41;&#46; A taxa de sucesso foi de 100&#37;&#46; N&#227;o ocorreram complica&#231;&#245;es <span class="elsevierStyleItalic">major</span>&#44; apenas espasmo radial em dois doentes&#44; num dos quais se observou uma salva de taquicardia ventricular n&#227;o mantida&#46; A indica&#231;&#227;o foi miocardite ou miocardiopatia de etiologia a esclarecer&#46; O diagn&#243;stico final foi de miocardite aguda em cinco doentes&#44; miocardite cr&#243;nica em um doente&#44; amiloidose AL em quatro doentes e ATTR em seis doentes&#46; Excluiu-se miocardite em oito doentes e amiloidose em um doente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A bi&#243;psia endomioc&#225;rdica ventricular esquerda transradial demonstrou ser segura&#44; exequ&#237;vel e de boa rentabilidade diagn&#243;stica&#44; com resultados clinicamente relevantes em doentes selecionados&#46;</p></span>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Light-chain cardiac amyloidosis&#46; Hyalin widening of the interstitial space in the myocardial tissue &#40;hematoxylin and eosin&#41;&#46; &#40;B&#41; Extracellular amyloid deposits in the endocardium and surrounding the cardiomyocytes &#40;Congo red staining&#41;&#46; &#40;C&#41; Lambda light-chain immunostaining of the pericellular amyloid deposits &#40;immunohistochemical method with an anti-lambda light-chain antibody&#41;&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4 &#40;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">11 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">22 &#40;88&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">De novo or increased mitral regurgitation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Embolization</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Permanent AV block</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tachycardia requiring termination by cardioversion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Minor complications</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Arrhythmias</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sinus bradycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Transient AV block</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Other conduction disturbance</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Supra-ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Non-sustained ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sustained ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radial spasm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Bleeding</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Access site hematoma</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pseudoaneurysm or aneurysm formation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Right radial &#47; Left radial</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;92&#37;&#41;&#47;2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Concomitant coronary angiography</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guide Catheter</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MP 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>JR 3&#46;5&#47;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Bioptome</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cordis 5&#46;5 Fr 104 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maslanka 5&#46;4 Fr 120 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Procedural time<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fluroscopy time<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#177;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of myocardium samples</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mean&#177;SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#177;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5-10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">AHCM&#58; apical hypertrophic cardiomyopathy&#59; ATTR&#58; transthyretin&#59; AL&#58; amyloid light-chain&#59; AV&#58; atrioventricular&#59; DCM&#58; dilated cardiomyopathy&#59; HF&#58; heart failure&#46;</p>"
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                0 => """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indication &#8211; N&#40;&#37;&#41;</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Final Result&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Acute myocarditis &#40;clinically suspected myocarditis&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 confirmed3 ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">New-onset HF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4 &#40;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 confirmed2 ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3<span class="elsevierStyleSup">rd</span> degree AV block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 Ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">No signs of HF or serious arrythmias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3 confirmed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Chronic myocarditis&#40;clinically suspected - DCM with HF&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 confirmed5 ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Hypertrophic cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">11 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHCM with clinical features of amyloidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 ATTR amyloidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Suspected cardiac amyloidosis with previous inconclusive studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 AL amyloidosis4 ATTR amyloidosis1 ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
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Original Article
Transradial left ventricular endomyocardial biopsy feasibility, safety and clinical usefulness: Initial experience of a tertiary university center
Exequibilidade, segurança e utilidade da biópsia endomiocárdica ventricular esquerda por acesso transradial: experiência inicial de um centro universitário terciário
Miguel Nobre Menezesa,b,
Autor para correspondência
mnmenezes.gm@gmail.com

Corresponding author.
, Eduardo Infante Oliveiraa,b, Artur Costa e Silvac, Dulce Britoa,b, Maria da Conceição Azevedo Coutinhoa,b, Pedro Canas da Silvaa,b, Fausto J. Pintoa,b
a Serviço de Cardiologia, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
b CAML, CCUL, Faculdade de Medicina de Lisboa, Universidade de Lisboa, Portugal
c Serviço de Anatomia Patológica, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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these guidelines base their recommendations on efficacy and safety data in existence at that time&#46; Since then&#44; two main changes have occurred&#58; Firstly&#44; several authors have published extensive data on an approach via the left ventricle rather than just the right ventricle&#44; allowing for more extended myocardial sampling&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Secondly&#44; several operators started performing left ventricular &#40;LV&#41; biopsy using the radial approach&#44; widely popular in the interventional community for its simplicity&#44; comfort and increased safety&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> As a result&#44; more recent documents call for a wider use of this technique&#44; particularly in myocarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;7</span></a> dilated cardiomyopathy<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> and myocardial infarction with non-obstructive coronary artery disease&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper&#44; we report our initial experience of the feasibility&#44; safety and usefulness of transradial endomyocardial biopsy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">General features</span><p id="par0015" class="elsevierStylePara elsevierViewall">This study involved a single-center registry of consecutive patients undergoing intended transradial endomyocardial biopsy&#46; Patients were selected for endomyocardial biopsy of the left ventricle and screened for the feasibility of radial access individually&#44; based on the operator&#39;s clinical judgment&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clinical data included demographics&#44; clinical setting&#44; imaging&#44; complications&#44; and final biopsy results&#46; Technical data included access site&#44; sheath&#47;catheter size and shape&#44; biopsy model and size&#44; procedural time&#44; fluoroscopy time&#44; success rate and cross-over rate to femoral approach&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a descriptive registry&#59; complex statistical analysis was not performed&#46; Qualitative variables are expressed both numerically and in percentages&#46; Continuous variables are depicted as mean &#177; standard deviation and range&#44; where appropriate&#46; SPSS Statistics 24 was used for analysis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Procedure overview</span><p id="par0030" class="elsevierStylePara elsevierViewall">Detailed information on technique has been published in recent papers&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#8211;13</span></a> However&#44; because minor variation occurs across centers and operators&#44; an overview of the technique as it was performed is provided&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The procedure was always undertaken by the same operator&#44; who had been previously trained in transradial intervention and in performing left myocardial biopsies&#46; During the procedure&#44; the patient was continuously monitored as in a routine coronary angiography &#40;i&#46;e&#46; with continuous 12-lead electrocardiogram and invasive blood pressure measurement&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Routine transthoracic echocardiography was performed before&#44; during and after the procedure&#46; Particular attention was given to documenting and quantifying pericardial effusion and mitral regurgitation&#44; as well as excluding the presence of LV thrombus or masses which might contraindicate the procedure&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Spasm prophylaxis with intra-arterial 0&#46;5-1 mg of isosorbide dinitrate and&#47;or 2&#46;5 mg of verapamil and 5000 units of unfractionated heparin were administered&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">If the patient required a coronary angiogram&#44; a standard transradial coronary angiogram was performed using a Terumo 5&#47;6 Fr slender sheath &#40;external diameter 5 Fr&#41; and standard Judkins 5 Fr coronary diagnostic catheters&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Afterwards&#44; a 7&#46;5 Fr &#40;external diameter 6 Fr&#41; Asahi Eaucath sheathless guide catheter was advanced over a standard 0&#46;035&#8221; J wire to the ascending aorta&#46; An MP 1 or JR 3&#46;5&#47;4 curve was used according to operator choice&#46; The dilator was removed and a 5 Fr pigtail catheter was then used inside the 7&#46;5 Fr for crossing the aortic valve and safely&#8221;landing&#8221; in the left ventricle&#46; The guide catheter was advanced over the pigtail&#44; which was then removed&#44; and placed in the mid-cavity of the left ventricle&#46; The catheter was connected to the pressure system&#44; initial LV pressure was recorded and a minimal amount of contrast was injected &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; A 5&#46;5 Fr Cordis 104 cm or 5&#46;4 Fr Maslanka 120 cm bioptome was advanced and the myocardial wall was sampled &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Back-bleed from the catheter and&#44; if necessary&#44; aspiration&#44; were then performed to ensure no air bubbles were in the system&#46; These steps were then repeated several times until the desired number of samples was obtained &#8211; a minimum of five &#8211; of which at least one was frozen for further analysis&#44; if necessary&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All mid-apical segments of all the walls of the left ventricle were sampled by gently directing the catheter during the procedure&#44; guided by fluoroscopy and echocardiography&#46; First the guide is positioned using fluoroscopy and then confirmed by transthoracic echocardiography by an assisting physician&#46; This enables detailed guide and bioptome positioning and early identification of possible complications&#46; The process was repeated for all samples&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Hemostasis was obtained using the Terumo TR-Band&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Baseline population characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">Twenty-five patients were selected for intended LV endomyocardial biopsy&#46; Two patients underwent the procedure in the setting of cardiogenic shock of unknown etiology and were deemed better suited to a transfemoral approach&#44; as mechanical circulatory support was being considered post procedure&#46; Transradial endomyocardial biopsy was thus attempted in 25 patients&#46; The baseline data are illustrated in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Technical data&#44; success and complications</span><p id="par0075" class="elsevierStylePara elsevierViewall">All patients scheduled for transradial biopsy underwent the procedure successfully&#44; with no cases of cross-over to a femoral approach&#46; There were no major complications&#44; and only two cases of minor radial spasm&#46; One of these two patients also had a run of non-sustained ventricular tachycardia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the two above-mentioned patients who underwent programmed transfemoral LV endomyocardial biopsy&#44; the procedure was also successful with no major or minor complications&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Biopsy indication&#44; results and final clinical diagnosis</span><p id="par0085" class="elsevierStylePara elsevierViewall">There were two main clinical settings for performing the procedure&#58; myocarditis and cardiomyopathy&#46; The details are provided in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding myocarditis&#44; eight studies were performed in the setting of suspected acute myocarditis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A and <a class="elsevierStyleCrossRef" href="#fig0015">3</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Three patients presented with acute coronary syndrome chest pain-like symptoms&#46; Two of them underwent the procedure because of recurrent myocarditis&#46; The third patient underwent the procedure due to very high troponin levels and mildly impaired LV function&#44; despite the absence of clinical signs of heart failure&#46; All had a favorable clinical outcome with normalization of LV function after a few weeks&#46; Their final diagnosis was acute lymphocytic myocarditis&#46; One patient had a mildly positive parvovirus B19 result in the polymerase chain reaction &#40;PCR&#41; test&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Four patients underwent the procedure because of new-onset heart failure of unknown etiology&#46; They had no other characteristics of acute myocarditis but a potentially treatable type of myocarditis&#44; such as giant cell myocarditis&#44; was ruled out&#44; thereby excluding an indication for immunosuppression therapy&#46; Two of these patients tested positive for acute lymphocytic myocarditis&#44; one in the setting of Takayasu arteritis&#44; and progressed favorably&#44; with normalization of LV function after a few weeks&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One patient was a 46-year-old patient with new-onset third degree atrioventricular &#40;AV&#41; block&#46; The biopsy ruled out myocarditis&#44; but showed some degree of fibrosis&#44; possibly related to past radiotherapy years earlier in the setting of Hodgkin&#39;s lymphoma&#46; The result helped to explain the etiology of the AV block at such a young age and reinforced the need for a permanent pacemaker&#44; as the cause of the bradycardia was not reversible&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Six patients underwent the procedure in the setting of dilated cardiomyopathy for ruling out chronic myocarditis&#46; They were young patients &#40;age range 23-56 years&#41; refractory to medical therapy for heart failure titrated to maximum doses&#46; Only one met the formal pathological criteria of chronic myocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> The study of viral genomes by PCR was negative&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Regarding those patients who underwent the procedure in the setting of cardiomyopathy&#44; there were two cases of apical hypertrophy with imaging and clinical features of concomitant amyloidosis&#46; Therefore&#44; the exact etiology of their cardiomyopathy was not fully understood&#46; Their final diagnosis was familial transthyretin &#40;ATTR&#41; amyloidosis &#40;V30M mutation&#41; cardiomyopathy&#46; Nine patients underwent endomyocardial biopsy due to amyloidosis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>A&#44; and <a class="elsevierStyleCrossRef" href="#fig0020">4</a>C&#41; of unknown etiology after earlier studies&#44; which included laboratory workup and an abdominal fat biopsy&#46; The echocardiograms of eight patients were highly suggestive of amyloidosis&#46; The final diagnosis was amyloid light-chain amyloidosis in four cases &#40;resulting in hematology referral for the study of lymphoproliferative diseases&#41;&#44; wild type ATTR amyloidosis in four patients&#46; One patient was referred by another institution to the amyloidosis clinic because of an inconclusive echocardiogram together with a cardiac magnetic resonance raising the possibility of amyloidosis&#44; which was ruled out in the cardiac biopsy&#46; It is noteworthy that all six patients with ATTR amyloid deposits had their TTR gene sequenced&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Finally&#44; the two previously mentioned patients&#44; who underwent the transfemoral procedure&#44; were also new-onset heart failure cases with cardiogenic shock after cardiac arrest&#59; myocarditis was ruled out in both&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">In our initial experience&#44; transradial endomyocardial biopsy achieved excellent results&#44; both regarding procedural success and complications&#46; Our research is supported by an increasing amount of published data on this particular approach to endomyocardial biopsy&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Safety is the major concern when performing this technique&#44; as many patients are often young &#40;especially in the setting of myocarditis&#41; and others have large ventricles with thin walls&#46; We did not encounter safety issues&#44; especially perforation&#44; embolization or mitral regurgitation&#46; This was likely the result of specific operator training both in radial intervention and LV biopsy&#44; as well as technical safety precautions&#46; We highlight the use of pressure monitoring&#44; extensive back bleed and catheter aspiration&#44; as well as peri and intra-procedural echocardiography guidance&#46; All of these enable constant monitoring of the procedure and minimize risks&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As mentioned above&#44; current guidelines regarding endomyocardial biopsy are now over a decade old and base their safety considerations on even older data&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Indeed&#44; these recommendations highlight a large series of transvenous RV biopsies with an overall 6&#37; complication rate&#44; a 1&#46;2&#37; possible or definite perforation rate and 0&#46;4&#37; death rate&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> Over the past decade&#44; however&#44; several authors from experienced European centers have published more extensive experience &#40;ranging from 755 to 4221 procedures&#41; totaling more than 8000 procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4&#44;15</span></a> In addition&#44; two of these publications provide extensive data on both left and RV biopsy&#44; thereby providing clearer data&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Overall&#44; the published major and minor complication rate of these authors ranges from 0&#46;12&#37; to 0&#46;82&#37; and 1&#46;35 to 5&#46;2&#37;&#44; respectively&#44; regarding RV biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4&#44;15</span></a> The rate of LV biopsy major and minor complications in LV biopsies was 0&#46;33 to 0&#46;64&#37; and 2&#46;2&#37; to 2&#46;89&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> Importantly&#44; there were no deaths in any of these series&#46; Most major complications were perforation with subsequent tamponade&#46; A very small number were cases of embolization&#46; Several minor complications included bleeding or vascular-related&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">These data provide valuable insights into safety&#46; Firstly&#44; the risk of the procedure when performed in experienced centers is low&#44; and seemingly lower than previously published studies&#59; secondly&#44; LV biopsy seems at least as safe&#44; if not safer&#44; than RV biopsy&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Published transradial endomyocardial biopsy experience is quite recent&#46; The earliest publications date back to 2014<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> and 2015&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10&#44;11</span></a> The largest series published to date was multicenter data comprising over 100 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> In all of these recent case series&#44; there were no major complications&#46; Furthermore&#44; the latter group published the largest radial versus femoral case series comparing both approaches&#44; with 129 cases via radial and 134 cases via femoral access&#46; There were no major complications and bleeding occurred exclusively in the transfemoral group&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Our experience thus reflects the findings in contemporary data&#46; Endomyocardial biopsy is a largely safe technique&#44; all the more so when performed via the left ventricle&#44; especially with the added safety benefits of the transradial approach&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In the series presented herein&#44; the feasibility rate was 100&#37;&#44; with no cross-overs and only mild radial spasm observed in two patients&#46; This was likely the result of patient selection&#44; spasm prophylaxis administration&#44; the use of hydrophilic catheters and the use of large size intra-luminal sheathless catheters&#44; which allow for comfortable bioptome passage and have a reduced external caliper&#46; Importantly&#44; patient feedback was very positive and one patient&#44; who had previously undergone a transjugular RV biopsy at another institution&#44; actively voiced his preference for the transradial technique&#44; because of improved comfort&#46; When the procedure is performed electively&#44; and if no complications occur&#44; same-day discharge is possible&#46; Our results are similar to previously published data&#46; In fact&#44; in the largest series published to date&#44; cross-over to the femoral technique was required in only one patient &#40;0&#46;98&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The last issue regarding this technique is its diagnostic yield and clinical usefulness&#46; In our experience&#44; in which LV biopsy was always performed outside the setting of transplant&#44; the results were clinically meaningful&#44; as they added to the clinical question at hand&#46; Indeed&#44; the suspected diagnosis was either confirmed or ruled out&#44; such as in the setting of myocarditis&#46; Additionally&#44; a doubtful diagnosis was clarified&#44; such as the etiology of a cardiomyopathy&#44; or amyloidosis infiltration and&#47;or type in cases with predominant heart involvement and previously inconclusive studies&#46; Finally&#44; atypical forms of LV hypertrophy &#40;i&#46;e&#46; apical&#41; were observed in patients with ATTR&#44; and tissue biopsy was most useful for confirming amyloidosis and ruling out hypertrophy&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Importantly&#44; our pathologist&#39;s feedback was also very positive&#44; as the quality and size of the samples was deemed excellent and better than when we had previously used the RV approach&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The abovementioned papers from the transfemoral era suggest that the LV approach is superior to the RV approach outside the transplant setting&#46; Indeed&#44; in the setting of myocarditis&#44; the largest published series reports a 92&#46;1&#37; vs&#46; 81&#46;3&#37; diagnostic yield&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and in the setting of predominant LV disease&#44; the difference is quite large and the LV approach is favored with 97&#46;8&#37; vs&#46; 53&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Published data from the transradial approach do not allow for a comparison of left versus right approaches&#44; however the conclusions are similar to ours&#58; the results added to the clinical dilemma&#44; confirming&#44; excluding or clarifying a diagnostic hypothesis&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Despite its advantages&#44; the transradial LV endomyocardial biopsy technique is not without limitations&#46; This approach requires the use of heparin&#44; which may add to the risk of bleeding&#46; In cases in which repeated biopsy is required&#44; such as transplant patients&#44; radial patency and the risk of vascular complications may become an issue with frequent procedures&#46; In addition&#44; the LV approach&#44; while apparently less prone to perforation&#44; regardless of the access site&#44; may lead to a more dangerous scenario should perforation occur&#44; given the much higher intracavitary pressure of the left ventricle&#46; Also&#44; the risk of cerebral embolization is essentially a concern of the left&#44; rather than the right&#44; approach&#44; and thus it cannot be performed in the presence of LV intracavitary masses&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">It is also important to point out the particular limitations of this paper&#46; This an observational single-center study&#46; Additionally&#44; the sample size is relatively small given the single-center nature of the data&#46; And finally&#44; an ultrasound study of the radial artery was not performed after the procedure&#46; Thus&#44; although there was no clinical evidence of radial patency complications&#44; these cannot be completely ruled out&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Transradial LV endomyocardial biopsy provides a safe and feasible method of sampling the myocardium for histopathological analysis&#44; with a good diagnostic yield and clinically meaningful results in properly selected patients&#46; This technique should probably be the default method for endomyocardial biopsy in patients undergoing a single biopsy procedure outside the setting of cardiac transplant in a radial center&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Keypoints</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">What is known about the topic&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8728;</span><p id="par0200" class="elsevierStylePara elsevierViewall">The indications for endomyocardial biopsy are still debated&#44; partly because of safety concerns and doubts about the clinical usefulness of the results&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8728;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Recent papers suggest the safety of LV biopsy is superior to RV biopsy&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8728;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Very recent data suggest that the transradial approach is a new and better method of sampling the left ventricle when compared to the transfemoral approach&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">What does this study add&#63;</p></li></ul><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8728;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Additional data confirming that transradial LV biopsy is feasible and safe&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8728;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Clinical data explaining how the results were useful in a variety of clinical scenarios&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8728;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Data to support the growing indications for endomyocardial biopsy&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Over the last decade&#44; several studies have suggested that left ventricular endomyocardial biopsy is safer and has a higher diagnostic yield than transvenous right ventricular biopsy&#46; In addition&#44; recent publications indicate that the transradial approach is a feasible and safe alternative to the transfemoral approach for sampling the left ventricle&#46; We report our initial experience with transradial endomyocardial biopsy with regards to feasibility&#44; safety and usefulness&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Single-center registry of consecutive patients undergoing intended transradial left endomyocardial biopsy&#46; Clinical and technical data were collected prospectively&#44; with a particular focus on success rate and complications&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-seven patients were screened for left ventricle biopsy&#46; Twenty &#40;25&#41; were selected for an intended transradial approach &#40;mean age 51&#177;18 years old&#44; 22 male&#41;&#46; Success rate was 100&#37; with no crossover to femoral approach&#46; There were no major complications&#46; Two patients experienced mild radial spasm&#46; One of them also had a run of non-sustained ventricular tachycardia&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Indication for biopsy was either myocarditis or cardiomyopathy of unknown etiology&#46; The final diagnosis was acute lymphocytic myocarditis in five patients&#44; chronic myocarditis in one patient&#44; amyloid light-chain amyloidosis in four patients and transthyretin amyloidosis in six patients&#46; Myocarditis was ruled out in eight patients and amyloidosis in one patient&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transradial left ventricle endomyocardial biopsy is a very safe and feasible method of sampling the myocardium for histopathological analysis&#44; with a good diagnostic yield and clinically meaningful results in properly selected patients&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
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            "titulo" => "Methods"
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            "titulo" => "Results"
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            "titulo" => "Conclusions"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Durante a &#250;ltima d&#233;cada&#44; v&#225;rios estudos t&#234;m sugerido que a bi&#243;psia endomioc&#225;rdica ventricular esquerda &#233; mais segura e de superior rentabilidade diagn&#243;stica do que a do ventr&#237;culo direito&#46; Adicionalmente&#44; v&#225;rias publica&#231;&#245;es recentes t&#234;m introduzido a abordagem transradial como uma alternativa exequ&#237;vel e segura &#224; transfemoral&#44; para amostrar o ventr&#237;culo esquerdo&#46; O objetivo deste estudo &#233; reportar a experi&#234;ncia inicial de um centro em bi&#243;psia endomioc&#225;rdica ventricular esquerda transradial&#44; relativamente a exequibilidade&#44; seguran&#231;a e utilidade&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Registo unic&#234;ntrico de doentes consecutivos submetidos a bi&#243;psia endomioc&#225;rdica ventricular esquerda&#44; com acesso de primeira inten&#231;&#227;o radial&#46; Registaram-se os dados cl&#237;nicos e t&#233;cnicos&#44; com particular foco na taxa de sucesso e complica&#231;&#245;es&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foram submetidos a bi&#243;psia endomioc&#225;rdica ventricular esquerda 27 doentes&#44; 25 dos quais pr&#233;-selecionados para acesso transradial &#40;idade m&#233;dia 51&#177;18&#44; 22 homens&#41;&#46; A taxa de sucesso foi de 100&#37;&#46; N&#227;o ocorreram complica&#231;&#245;es <span class="elsevierStyleItalic">major</span>&#44; apenas espasmo radial em dois doentes&#44; num dos quais se observou uma salva de taquicardia ventricular n&#227;o mantida&#46; A indica&#231;&#227;o foi miocardite ou miocardiopatia de etiologia a esclarecer&#46; O diagn&#243;stico final foi de miocardite aguda em cinco doentes&#44; miocardite cr&#243;nica em um doente&#44; amiloidose AL em quatro doentes e ATTR em seis doentes&#46; Excluiu-se miocardite em oito doentes e amiloidose em um doente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A bi&#243;psia endomioc&#225;rdica ventricular esquerda transradial demonstrou ser segura&#44; exequ&#237;vel e de boa rentabilidade diagn&#243;stica&#44; com resultados clinicamente relevantes em doentes selecionados&#46;</p></span>"
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            "identificador" => "abst0025"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
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            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Contrast injection into the left ventricle after guide catheter placement&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Bioptome deployment with open forceps&#44; immediately before sampling&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Focal lymphocytic myocarditis&#46; Slight edema and a prominent lymphocytic infiltrate are present in the interstitium&#46; Absence of fibrosis &#40;hematoxylin and eosin&#41;&#46; &#40;B&#41; Interstitial lymphocytic infiltration and myocyte damage in the form of apoptosis are present &#40;hematoxylin and eosin&#41;&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Light-chain cardiac amyloidosis&#46; Hyalin widening of the interstitial space in the myocardial tissue &#40;hematoxylin and eosin&#41;&#46; &#40;B&#41; Extracellular amyloid deposits in the endocardium and surrounding the cardiomyocytes &#40;Congo red staining&#41;&#46; &#40;C&#41; Lambda light-chain immunostaining of the pericellular amyloid deposits &#40;immunohistochemical method with an anti-lambda light-chain antibody&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CrCl&#58; creatinine clearance&#59; CAD&#58; coronary artery disease&#59; EF&#58; ejection fraction&#59; LV&#58; left ventricular&#59; NYHA&#58; New York Heart Association&#59; RV&#58; right ventricular&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#40;&#37;&#41; or mean &#177; standard deviation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">51&#177;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Male</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;88&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Hypertension</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dyslipidemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes mellitus</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Smoking habits</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chronic kidney disease &#40;CrCl&#60;60&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Heart failure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">NYHA I</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NYHA II</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NYHA III</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">NYHA IV</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Reduced EF &#40;&#60;52&#37; male&#44; &#60;54&#37; female&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Previous CAD</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sinus&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">22 &#40;88&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Temporary pacing&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Permanent pacing&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Elective procedures&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous RV biopsy&#47;Previous LV biopsy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;5&#37;&#41;&#47;0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#40;&#37;&#41; or mean &#177; standard deviation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Permanent AV block</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tachycardia requiring termination by cardioversion</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Minor complications</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sinus bradycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Transient AV block</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Other conduction disturbance</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Supra-ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Non-sustained ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sustained ventricular tachycardia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radial spasm</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;8&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Bleeding</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Right radial &#47; Left radial</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;92&#37;&#41;&#47;2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Guide Catheter</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MP 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;76&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>JR 3&#46;5&#47;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cordis 5&#46;5 Fr 104 cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maslanka 5&#46;4 Fr 120 cm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Procedural time<a class="elsevierStyleCrossRef" href="#tblfn0015">&#42;&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35&#177;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#177;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 confirmed2 ruled out&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 Ruled out&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">No signs of HF or serious arrythmias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Chronic myocarditis&#40;clinically suspected - DCM with HF&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;24&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">1 confirmed5 ruled out&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hypertrophic cardiomyopathy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AHCM with clinical features of amyloidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 ATTR amyloidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Suspected cardiac amyloidosis with previous inconclusive studies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 AL amyloidosis4 ATTR amyloidosis1 ruled out&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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                      "titulo" => "Endomyocardial biopsy"
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Jpn Heart J"
                        "fecha" => "1962"
                        "paginaInicial" => "537"
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                    0 => array:2 [
                      "titulo" => "The role of endomyocardial biopsy in the management of cardiovascular disease&#58; A Scientific Statement from the American Heart Association&#44; the American College of Cardiology&#44; and the European Society of Cardiology Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Heart J"
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              "etiqueta" => "3"
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                  "contribucion" => array:1 [
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                      "titulo" => "Contribution and risks of left ventricular endomyocardial biopsy in patients with cardiomyopathies&#58; a retrospective study over a 28-year period"
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                        0 => array:2 [
                          "etal" => false
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                            2 => "M&#46; Kindermann"
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                      "Revista" => array:5 [
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