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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ventricular septal defect &#40;VSD&#41; is a rare complication of myocardial infarction &#40;MI&#41;&#44; with an estimated incidence of 0&#46;2&#37; of all MI patients in the current era of widely available reperfusion techniques&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the low reported incidence&#44; post-MI VSD carries a high mortality risk for patients&#44; whether treated medically &#40;exceeding 90&#37;&#41; or surgically &#40;ranging from 19&#37; to 60&#37;&#41;&#46; Although there has been considerable improvement in the treatment of acute coronary disease in the past two decades&#44; VSD patients remain a challenging niche&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> In this regard&#44; several issues involving the surgical treatment of VSD patients remain controversial&#44; including the timing of surgery&#44; the surgical technique&#44; extracorporeal membrane oxygenation &#40;ECMO&#41; as a bridge to closure&#44; concomitant procedures&#44; and the role of percutaneous closure&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Most of the evidence regarding post-MI VSD is derived from small single-center studies with small sample sizes&#46; Three national registries have been reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a> These multicenter studies provide the best available evidence regarding this rare entity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">Our objective was to establish the first dedicated post-MI VSD national registry in Portugal&#46; We hope that the collective analysis of data on VSD patients on a national scale will contribute to the evidence available regarding risk factors&#44; surgical treatment&#44; perioperative management and long-term follow-up of post-MI VSD patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patient characteristics and procedural and postoperative information were retrospectively retrieved from prospectively collected data from the enrolled centers&#8217; databases&#59; therefore&#44; this information did not alter or influence patient treatment or outcome in any way&#46; In order to achieve maximal completeness of the registry&#44; patients&#8217; individual records were retrospectively consulted to retrieve any missing data&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The data were uniformly collected through an online form available to all the centers involved&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patient and center enrollment</span><p id="par0035" class="elsevierStylePara elsevierViewall">All seven public cardiac surgery centers in Portugal were individually contacted and asked to enroll in the database&#46; The response rate was 45&#8211;50&#37; of the estimated national representation &#40;calculated by the rate of individual center weight in yearly total reported national cardiac surgery numbers&#41;&#46; All patients operated with a diagnosis of post-MI VSD were included&#46; No exclusion criteria were defined&#46; These results correspond to the first 76 patients reported during a pre-specified one-year enrollment timeframe&#44; and therefore consist of a preliminary report with the potential for more patient inclusion&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descriptive statistics for outcomes and baseline patient characteristics are presented as percentages for categorical variables and as means with standard deviation &#40;SD&#41; for continuous variables&#46; Cumulative survival was analyzed using the Kaplan-Meier method&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The chi-square test or Fisher&#39;s exact test was used to compare categorical variables and the Mann-Whitney U-test and Student&#39;s t test were used to compare continuous variables&#46; Binary logistic regression was used to estimate independent risk factors for being alive at 30 days postoperatively&#46; Variables used in the logistic regression were baseline characteristics that were statistically significant at univariate analysis &#40;p&#60;0&#46;1&#41; and timing of intervention&#44; which was significant in the Kaplan-Meier analysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A p-value of &#60;0&#46;05 was considered significant&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All analysis was performed using R &#40;R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patient and procedural characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Fifty-one percent of patients were female&#46; The most common comorbidities in the cohort were hypertension &#40;68&#37;&#41; and diabetes &#40;34&#46;7&#37;&#41;&#46; The majority of patients presented no significant hemodynamic lesions in either aortic or mitral valves&#46; Left ventricular ejection fraction was normal in 53&#46;6&#37; of patients&#46; Pulmonary hypertension &#40;pulmonary arterial systolic pressure &#62;60 mmHg&#41; was present in 14&#46;7&#37; of patients&#46; Qp&#47;Qs was 1&#8211;1&#46;9 in 10&#46;5&#37; and 2&#8211;2&#46;9 in 19&#46;7&#37; of patients&#44; however&#44; Qp&#47;Qs measurement was not available for the majority of patients&#46; Regarding coronary anatomy&#44; the most commonly affected vessels were the left anterior descending and right coronary arteries &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; Seventy-three percent of patients received preoperative inotropic support&#46; Mechanical support by intra-aortic balloon pump &#40;IABP&#41; as a bridge to closure was used in 30 &#40;39&#46;5&#37;&#41; and ECMO in five &#40;6&#46;6&#37;&#41; patients&#46; The most common closure technique &#40;94&#46;5&#37;&#41; was based on the classic technique described by Daggett&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Associated percutaneous closure was necessary in four patients &#40;5&#46;3&#37;&#41;&#44; all for residual VSD after the index closure&#46; Forty-six percent of patients had a concomitant procedure at the same time as VSD closure&#44; most commonly coronary artery bypass grafting &#40;CABG&#41; &#40;36&#46;8&#37;&#41;&#46; The most common postoperative complications were infection &#40;non-specified location&#41; &#40;25&#37;&#41; and renal failure requiring dialysis &#40;18&#46;4&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig1"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cumulative survival</span><p id="par0065" class="elsevierStylePara elsevierViewall">Median survival of the cohort was 72 months &#40;95&#37; confidence interval &#91;CI&#93; 4&#8211;144 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Two-&#44; six- and 10-year survival rates were 54&#46;3&#37; &#40;95&#37; CI 44&#46;1&#8211;67&#46;0&#41;&#44; 49&#46;0&#37; &#40;95&#37; CI 38&#46;6&#8211;62&#46;3&#41;&#44; and 46&#46;9&#37; &#40;95&#37; CI 36&#46;3&#8211;60&#46;5&#41;&#44; respectively&#46; Survival at discharge was 61&#46;8&#37; and 30-day survival was 69&#46;7&#37;&#46; Patients who underwent VSD closure early rather than later after onset of symptoms seem to have performed worse &#40;first 10 days vs&#46; after 10 days&#58; log-rank p&#61;0&#46;036&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; This difference was evident even when only patients alive at the 30-day mark were considered in the analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Kaplan-Meier analysis showed no difference in cumulative survival in patients undergoing concomitant CABG &#40;log-rank p&#61;0&#46;4&#41;&#44; different closure techniques &#40;log-rank p&#61;0&#46;5&#41;&#44; ECMO as a bridge to closure &#40;log-rank p&#61;0&#46;9&#41; or IABP as a bridge to closure &#40;log-rank p&#61;0&#46;6&#41;&#44; or with different locations of the VSD &#40;log-rank p&#61;0&#46;9&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Risk factors for 30-day mortality</span><p id="par0075" class="elsevierStylePara elsevierViewall">Statistically significant differences in preoperative and operative characteristics were seen between 30-day survivors and non-survivors on univariate analysis&#58; age &#40;p&#61;0&#46;024&#41;&#59; concomitant mitral surgery &#40;p&#61;0&#46;027&#41;&#59; concomitant CABG &#40;p&#61;0&#46;023&#41;&#44; as well as in postoperative characteristics&#58; IABP support in the postoperative period &#40;p&#61;0&#46;047&#41;&#59; postoperative acute renal failure requiring dialysis &#40;p&#61;0&#46;024&#41;&#59; and postoperative cardiogenic shock or low-output syndrome &#40;p&#60;0&#46;001&#41;&#46; Multivariate analysis of baseline characteristics with p&#60;0&#46;1 &#40;age&#44; concomitant CABG and mitral surgery&#41; and timing of intervention &#40;which presented a significantly different cumulative survival on Kaplan-Meier analysis as well as clinical interest and plausibility&#41; revealed a statistically significant association between 30-day mortality and age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#59; p&#61;0&#46;27&#41; and concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41;&#46; Concomitant mitral surgery &#40;OR 9&#46;20&#59; 95&#37; CI 0&#46;90&#8211;93&#46;96&#59; p&#61;0&#46;06&#41; presented a trend toward worse 30-day outcome &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the timing of post-MI VSD surgical closure&#44; most authors agree that early surgery is indicated&#44; as it avoids prolonged exposure to congestive heart failure and cardiogenic shock leading to multiorgan dysfunction&#46; Advocates of deferred closure argue that a delayed strategy provides time to stabilize the patient&#44; permitting VSD closure in optimal clinical and tissue conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> This is an almost impossible dilemma to resolve in an observational setting&#44; as critically ill patients tend to be operated early and patients in whom surgery is delayed are usually less ill&#46; Adding to this problem is the fact that patients considered inoperable or who died waiting for surgery are not usually included in surgical cohorts&#46; According to the 2013 American College of Cardiology Foundation&#47;American Heart Association guideline for the management of ST-elevation MI&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> surgical treatment should be initiated without delay after diagnosis&#44; whereas the 2017 European Society of Cardiology guidelines on ST-elevation MI<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> recommend that delaying intervention may be considered in certain patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our analysis&#44; cumulative survival of delayed intervention was superior both for the overall cohort &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; and for patients alive at 30 days &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; This&#44; however&#44; was not apparent in the multivariate model for 30-day mortality&#46; This may be related to underpowering of our model to detect a significant difference&#46; More importantly&#44; however&#44; as previously described&#44; observational studies in the setting of VSD cannot provide a clear picture of the best surgical timing due to the fact that critically ill patients tend to be operated sooner and hemodynamically stable patients tend to be operated later&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">One reasonable conclusion is that these patients benefit from being operated as late as their hemodynamic profile permits&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">ECMO has been advocated as a bridge to VSD closure&#46; Theoretically ECMO limits the patient&#39;s exposure to the detrimental hemodynamic consequences of the VSD&#44; reducing end-organ malperfusion and unloading the heart&#44; while permitting a more opportune timing of closure&#46; However&#44; ECMO is not without its own inherent complications&#46; Morimura et al&#46; reported mechanical circulatory support&#44; including ECMO and IABP&#44; as a bridge to VSD closure in a small cohort&#44; with positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our cohort ECMO was used in five patients as a bridge to closure&#46; This strategy was not associated with different cumulative survival &#40;log-rank p&#61;0&#46;9&#41;&#59; however&#44; all ECMO patients had a follow-up of less than five years&#44; and three &#40;60&#37;&#41; were alive at discharge&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Model simulations suggest that the Impella device may present a superior hemodynamic benefit in the post-MI VSD setting compared to ECMO&#44; thus permitting a delayed closure strategy with fewer associated complications&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is further controversy relating to the benefit of concomitant CABG&#46; Although the majority of studies show no benefit of concomitant CABG regarding early and long-term mortality&#44; results with both improved and reduced survival have been reported&#46; The aforementioned registries<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a> showed no significant difference in survival for patients undergoing concomitant CABG&#44; except for mid-term survival after exclusion of patients who died in the first 30 days&#46; Perrotta et al&#46; reviewed the best available evidence regarding concomitant revascularization in this setting and found that overall&#44; it suggests that revascularization of non-infarcted areas of myocardium and consequent improvement of collateral flow may contribute to better long-term survival&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Our findings are consistent with the results reported from previous registries&#44; with no difference in cumulative survival &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; although a protective effect for 30-day mortality was found &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Various techniques of VSD closure have been described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;6&#44;13</span></a> It is unclear whether any one technique has definite advantages over any other&#46; Furthermore&#44; extent of infarcted area&#44; time of reperfusion and center&#47;surgeon case volume may be more significant factors affecting residual VSD and overall outcome&#46; Our cohort has a clear dominance of the classic technique described by Daggett&#44; with a small number of alternate techniques&#44; which precludes interpretation regarding the relation between closure technique and outcome&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Since the first percutaneous closure of a post-MI VSD in the 1980s&#44; percutaneous intervention has evolved and is viewed with renewed interest&#46; Technical success rates of over 75&#37; with associated in-hospital&#47;30-day mortality of 32&#37; have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> However&#44; patient selection is an inherent characteristic of such interventional reports&#44; with anatomical feasibility as a limiting factor and most patients not being considered candidates for surgery&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Percutaneous closure in post-MI VSD has been proposed both as a bridge to surgical treatment in patients who are not expected to survive an operation and as a definitive treatment in simple &#60;15 mm defects in the sub-acute or chronic phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Additionally&#44; percutaneous closure is an alternative for reintervention for residual VSD after index closure&#44; which itself consists of a particular subset of high-risk patients&#46; In our cohort we identified four patients in which this approach was used&#46; Three out of these four &#40;75&#37;&#41; patients were discharged alive&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Operative mortality was high in our cohort&#44; albeit in agreement with that described in previous registries&#58; 33&#46;0&#37; in the Japanese registry&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> 42&#46;9&#37; in the Society of Thoracic Surgeons Adult Cardiac Surgery Database<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> and 41&#37; in the Swedish registry<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> &#40;30-day mortality&#41; and 47&#37; in the Global Utilization of Streptokinase and T-PA for Occluded Coronary Arteries &#40;GUSTO&#41; trial&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Several risk factors for early and late death have been proposed in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5&#44;16&#44;17</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Multivariate analysis showed the significant impact of concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41; and age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#59; p&#61;0&#46;27&#41; on 30-day mortality&#44; as well as a trend regarding concomitant mitral surgery &#40;OR 9&#46;20&#59; 95&#37; CI 0&#46;90&#8211;93&#46;96&#59; p&#61;0&#46;061&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Other authors have reported similar findings regarding age<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;5</span></a> and significant mitral regurgitation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> These findings suggest that surgical complexity and frailty may play a role in early outcomes&#46; A beneficial effect of concomitant CABG has been proposed but remains controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> In our study&#44; due to the outcome being 30-day mortality&#44; long hospitalizations &#40;&#62;30 days&#41; may have skewed the influence of other important baseline characteristics&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As a side note&#44; a uniform approach regarding timing of intervention was not discernible in the three centers included in our cohort&#44; with both epoch- and surgeon-related variation found&#46; A common notion&#44; however&#44; is the need for a pragmatic rather than a dogmatic approach&#44; in the sense that the timing of intervention depends on close monitoring and patient-tailored strategies rather than a predefined timeframe&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study limitations and merits</span><p id="par0150" class="elsevierStylePara elsevierViewall">Due to its retrospective design and non-randomization of patients this study is at risk of inherent biases in data collection&#46; The large time frame it encompasses &#40;from 2000 to 2021&#41; also presents a risk of bias relating to changes in practices and perioperative care&#46; A &#8216;VSD repair registry&#8217; rather than a &#8216;VSD registry&#8217; is presented&#44; in the sense that patients considered inoperable or who died waiting for surgery are not included in this cohort&#46; Nevertheless&#44; it is one of the largest cohorts of surgically treated post-MI VSD patients studied&#46; Its multicenter design provides a reflection of the real-world population and different management strategies&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">VSD is a dreadful complication of MI&#46; Registries may provide important evidence regarding an entity for which randomized controlled trials are impractical&#46; Percutaneous closure and mechanical support are emerging techniques that may prove useful in selected patients&#46; In our study&#44; age negatively influenced and concomitant CABG positively influenced 30-day survival&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Timing of surgery remains a controversial issue&#46; Later closure seems to be advantageous but there is significant bias&#46; Overall&#44; it seems that these patients benefit from being operated as late as their hemodynamic profile permits&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Learning points</span><p id="par0165" class="elsevierStylePara elsevierViewall">VSD is a dreadful complication of MI&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Registries may provide important evidence regarding this entity&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">CABG positively influenced 30-day survival&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Age negatively influenced 30-day survival&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Later closure seems to be advantageous but an important bias exists&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">No funding was received for this project&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2022-07-31"
    "fechaAceptado" => "2022-10-10"
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          "clase" => "keyword"
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            0 => "Ventricular septal defect"
            1 => "Mechanical complication"
            2 => "Myocardial infarction"
            3 => "Registry"
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            1 => "Complica&#231;&#227;o mec&#226;nica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction and Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect &#40;VSD&#41; registry to further elucidate controversial areas of this clinical entity&#39;s surgical treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Median survival of the cohort &#40;n&#61;76&#41; was 72 months &#40;95&#37; CI 4&#8211;144 months&#41;&#46; Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction &#40;log-rank p&#61;0&#46;036&#41;&#46; Concomitant coronary artery bypass grafting &#40;CABG&#41;&#44; different closure techniques&#44; location of the VSD&#44; extracorporeal membrane oxygenation as bridge to closure&#44; or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis&#46; Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#41; and concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our results are comparable with previous reports regarding mortality&#44; risk factors and concomitant procedures&#46; Timing of surgery remains a controversial issue&#46; Later closure seems to be advantageous&#44; however&#44; there is significant observational bias&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introdu&#231;&#227;o e objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise coletiva de um registo nacional dedicado a comunica&#231;&#227;o interventricular &#40;CIV&#41; p&#243;s-enfarte &#40;EAM&#41; de forma a elucidar &#225;reas controversas do tratamento cir&#250;rgico desta entidade cl&#237;nica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analise descritiva&#59; sobrevida cumulativa utilizando o m&#233;todo de Kaplan-Meier&#59; an&#225;lise multivariada utilizando regress&#227;o log&#237;stica para fatores de risco para mortalidade a 30 dias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A sobrevida mediana da coorte &#40;n&#61;76&#41; foi de 72 meses &#40;6 anos&#44; 95&#37; CI 4-144 meses&#41;&#46; Melhor sobrevida cumulativa foi observada nos doentes submetidos a encerramento cir&#250;rgico da CIV ap&#243;s 10 dias do EAM &#40;<span class="elsevierStyleItalic">log-rank</span> p&#61;0&#44;036&#41;&#46; CABG concomitante&#44; diferentes t&#233;cnicas cir&#250;rgicas de encerramento&#44; localiza&#231;&#227;o da CIV&#44; ECMO como ponte para encerramento ou BIA como ponte para encerramento n&#227;o relevaram diferen&#231;a estatisticamente significativa na an&#225;lise de Kaplan-Meier&#46; An&#225;lise multivariada para fatores independentemente associados a mortalidade a 30 dias revelou uma diferen&#231;a estatisticamente significativa da idade &#40;OR 1&#44;08&#59; 95&#37; CI 1-011-15&#41; e CABG concomitante &#40;OR 0&#44;23&#59; 95&#37; CI 0-06-0&#44;90&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclus&#227;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Os nossos resultados s&#227;o compar&#225;veis com os resultados previamente reportados por outros autores&#46; O <span class="elsevierStyleItalic">timing</span> do encerramento cir&#250;rgico em rela&#231;&#227;o ao EAM permanece um assunto controverso&#46; No entanto&#44; um encerramento mais tardio parece ser vantajoso&#44; apesar de existir um importante vi&#233;s observacional&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><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">Female</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">39 &#40;51&#46;3&#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">Age&#44; years</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">69&#46;5&#177;10&#46;7&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="elsevierStyleItalic">Location of defect</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>Apical&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">43 &#40;58&#46;9&#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>Basal&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">27 &#40;37&#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>Mid&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">3 &#40;4&#46;1&#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="elsevierStyleItalic">Time of surgery after MI</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>First 24 h&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;17&#46;1&#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>1&#8211;5 days&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">29 &#40;38&#46;2&#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>6&#8211;10 days&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">10 &#40;13&#46;2&#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>&#62;10 days&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">24 &#40;31&#46;6&#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">Hypertension</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">51 &#40;68&#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</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">26 &#40;34&#46;7&#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">Stroke</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;6&#46;7&#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">BMI &#62;40 kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></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">11 &#40;14&#46;7&#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">eGFR &#60;30 ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></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">6 &#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">COPD</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;2&#46;7&#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">Previous MI</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;6&#46;7&#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">Hemodynamically significant aortic valve lesion</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">3 &#40;4&#46;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">Hemodynamically significant mitral valve lesion</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;7&#46;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">Ejection fraction &#60;50&#37;</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">32 &#40;46&#46;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">PASP &#62;60 mmHg</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">10 &#40;14&#46;7&#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="elsevierStyleItalic">Qp&#47;Qs</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>Not calculated&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">51 &#40;67&#46;1&#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>1&#8211;1&#46;9&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">8 &#40;10&#46;5&#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>&#62;2&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">17 &#40;22&#46;3&#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="elsevierStyleItalic">Preoperative support</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>None&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;27&#46;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="elsevierStyleHsp" style=""></span>Inotropes&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">41 &#40;54&#46;7&#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>IABP&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">30 &#40;39&#46;5&#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>ECMO&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;6&#46;6&#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>Invasive ventilation&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">16 &#40;21&#46;3&#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="elsevierStyleItalic">Procedural characteristics &#40;n&#61;76&#41;</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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69 &#40;94&#46;5&#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>Other&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\ttable-entry\n
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                  \t\t\t\t">4 &#40;5&#46;3&#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  " align="left" valign="\n
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                  \t\t\t\t">35 &#40;46&#46;1&#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">28 &#40;36&#46;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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;6&#46;6&#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\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">7 &#40;9&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Original Article
Post-infarction ventricular septal defect surgery in Portugal
Cirurgia da comunicação interventricular pós-enfarte em Portugal
Pedro Magroa,
Autor para correspondência
pedromagro@gmail.com

Corresponding author.
, André Soeirob, Nuno Guerrac, Gonçalo Coutinhob, Pedro Antunesb, Ângelo Nobrec, José Nevesa, Miguel Sousa-Uvaa
a Department of Cardio-thoracic Surgery, Hospital de Santa Cruz, Carnaxide, Portugal
b Department of Cardio-thoracic Surgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
c Department of Cardio-thoracic Surgery, Hospital Santa Maria, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ventricular septal defect &#40;VSD&#41; is a rare complication of myocardial infarction &#40;MI&#41;&#44; with an estimated incidence of 0&#46;2&#37; of all MI patients in the current era of widely available reperfusion techniques&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the low reported incidence&#44; post-MI VSD carries a high mortality risk for patients&#44; whether treated medically &#40;exceeding 90&#37;&#41; or surgically &#40;ranging from 19&#37; to 60&#37;&#41;&#46; Although there has been considerable improvement in the treatment of acute coronary disease in the past two decades&#44; VSD patients remain a challenging niche&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> In this regard&#44; several issues involving the surgical treatment of VSD patients remain controversial&#44; including the timing of surgery&#44; the surgical technique&#44; extracorporeal membrane oxygenation &#40;ECMO&#41; as a bridge to closure&#44; concomitant procedures&#44; and the role of percutaneous closure&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Most of the evidence regarding post-MI VSD is derived from small single-center studies with small sample sizes&#46; Three national registries have been reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a> These multicenter studies provide the best available evidence regarding this rare entity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Objectives</span><p id="par0020" class="elsevierStylePara elsevierViewall">Our objective was to establish the first dedicated post-MI VSD national registry in Portugal&#46; We hope that the collective analysis of data on VSD patients on a national scale will contribute to the evidence available regarding risk factors&#44; surgical treatment&#44; perioperative management and long-term follow-up of post-MI VSD patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patient characteristics and procedural and postoperative information were retrospectively retrieved from prospectively collected data from the enrolled centers&#8217; databases&#59; therefore&#44; this information did not alter or influence patient treatment or outcome in any way&#46; In order to achieve maximal completeness of the registry&#44; patients&#8217; individual records were retrospectively consulted to retrieve any missing data&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The data were uniformly collected through an online form available to all the centers involved&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patient and center enrollment</span><p id="par0035" class="elsevierStylePara elsevierViewall">All seven public cardiac surgery centers in Portugal were individually contacted and asked to enroll in the database&#46; The response rate was 45&#8211;50&#37; of the estimated national representation &#40;calculated by the rate of individual center weight in yearly total reported national cardiac surgery numbers&#41;&#46; All patients operated with a diagnosis of post-MI VSD were included&#46; No exclusion criteria were defined&#46; These results correspond to the first 76 patients reported during a pre-specified one-year enrollment timeframe&#44; and therefore consist of a preliminary report with the potential for more patient inclusion&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Descriptive statistics for outcomes and baseline patient characteristics are presented as percentages for categorical variables and as means with standard deviation &#40;SD&#41; for continuous variables&#46; Cumulative survival was analyzed using the Kaplan-Meier method&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The chi-square test or Fisher&#39;s exact test was used to compare categorical variables and the Mann-Whitney U-test and Student&#39;s t test were used to compare continuous variables&#46; Binary logistic regression was used to estimate independent risk factors for being alive at 30 days postoperatively&#46; Variables used in the logistic regression were baseline characteristics that were statistically significant at univariate analysis &#40;p&#60;0&#46;1&#41; and timing of intervention&#44; which was significant in the Kaplan-Meier analysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A p-value of &#60;0&#46;05 was considered significant&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All analysis was performed using R &#40;R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Patient and procedural characteristics are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Fifty-one percent of patients were female&#46; The most common comorbidities in the cohort were hypertension &#40;68&#37;&#41; and diabetes &#40;34&#46;7&#37;&#41;&#46; The majority of patients presented no significant hemodynamic lesions in either aortic or mitral valves&#46; Left ventricular ejection fraction was normal in 53&#46;6&#37; of patients&#46; Pulmonary hypertension &#40;pulmonary arterial systolic pressure &#62;60 mmHg&#41; was present in 14&#46;7&#37; of patients&#46; Qp&#47;Qs was 1&#8211;1&#46;9 in 10&#46;5&#37; and 2&#8211;2&#46;9 in 19&#46;7&#37; of patients&#44; however&#44; Qp&#47;Qs measurement was not available for the majority of patients&#46; Regarding coronary anatomy&#44; the most commonly affected vessels were the left anterior descending and right coronary arteries &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; Seventy-three percent of patients received preoperative inotropic support&#46; Mechanical support by intra-aortic balloon pump &#40;IABP&#41; as a bridge to closure was used in 30 &#40;39&#46;5&#37;&#41; and ECMO in five &#40;6&#46;6&#37;&#41; patients&#46; The most common closure technique &#40;94&#46;5&#37;&#41; was based on the classic technique described by Daggett&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Associated percutaneous closure was necessary in four patients &#40;5&#46;3&#37;&#41;&#44; all for residual VSD after the index closure&#46; Forty-six percent of patients had a concomitant procedure at the same time as VSD closure&#44; most commonly coronary artery bypass grafting &#40;CABG&#41; &#40;36&#46;8&#37;&#41;&#46; The most common postoperative complications were infection &#40;non-specified location&#41; &#40;25&#37;&#41; and renal failure requiring dialysis &#40;18&#46;4&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig1"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cumulative survival</span><p id="par0065" class="elsevierStylePara elsevierViewall">Median survival of the cohort was 72 months &#40;95&#37; confidence interval &#91;CI&#93; 4&#8211;144 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Two-&#44; six- and 10-year survival rates were 54&#46;3&#37; &#40;95&#37; CI 44&#46;1&#8211;67&#46;0&#41;&#44; 49&#46;0&#37; &#40;95&#37; CI 38&#46;6&#8211;62&#46;3&#41;&#44; and 46&#46;9&#37; &#40;95&#37; CI 36&#46;3&#8211;60&#46;5&#41;&#44; respectively&#46; Survival at discharge was 61&#46;8&#37; and 30-day survival was 69&#46;7&#37;&#46; Patients who underwent VSD closure early rather than later after onset of symptoms seem to have performed worse &#40;first 10 days vs&#46; after 10 days&#58; log-rank p&#61;0&#46;036&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; This difference was evident even when only patients alive at the 30-day mark were considered in the analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Kaplan-Meier analysis showed no difference in cumulative survival in patients undergoing concomitant CABG &#40;log-rank p&#61;0&#46;4&#41;&#44; different closure techniques &#40;log-rank p&#61;0&#46;5&#41;&#44; ECMO as a bridge to closure &#40;log-rank p&#61;0&#46;9&#41; or IABP as a bridge to closure &#40;log-rank p&#61;0&#46;6&#41;&#44; or with different locations of the VSD &#40;log-rank p&#61;0&#46;9&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Risk factors for 30-day mortality</span><p id="par0075" class="elsevierStylePara elsevierViewall">Statistically significant differences in preoperative and operative characteristics were seen between 30-day survivors and non-survivors on univariate analysis&#58; age &#40;p&#61;0&#46;024&#41;&#59; concomitant mitral surgery &#40;p&#61;0&#46;027&#41;&#59; concomitant CABG &#40;p&#61;0&#46;023&#41;&#44; as well as in postoperative characteristics&#58; IABP support in the postoperative period &#40;p&#61;0&#46;047&#41;&#59; postoperative acute renal failure requiring dialysis &#40;p&#61;0&#46;024&#41;&#59; and postoperative cardiogenic shock or low-output syndrome &#40;p&#60;0&#46;001&#41;&#46; Multivariate analysis of baseline characteristics with p&#60;0&#46;1 &#40;age&#44; concomitant CABG and mitral surgery&#41; and timing of intervention &#40;which presented a significantly different cumulative survival on Kaplan-Meier analysis as well as clinical interest and plausibility&#41; revealed a statistically significant association between 30-day mortality and age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#59; p&#61;0&#46;27&#41; and concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41;&#46; Concomitant mitral surgery &#40;OR 9&#46;20&#59; 95&#37; CI 0&#46;90&#8211;93&#46;96&#59; p&#61;0&#46;06&#41; presented a trend toward worse 30-day outcome &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the timing of post-MI VSD surgical closure&#44; most authors agree that early surgery is indicated&#44; as it avoids prolonged exposure to congestive heart failure and cardiogenic shock leading to multiorgan dysfunction&#46; Advocates of deferred closure argue that a delayed strategy provides time to stabilize the patient&#44; permitting VSD closure in optimal clinical and tissue conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> This is an almost impossible dilemma to resolve in an observational setting&#44; as critically ill patients tend to be operated early and patients in whom surgery is delayed are usually less ill&#46; Adding to this problem is the fact that patients considered inoperable or who died waiting for surgery are not usually included in surgical cohorts&#46; According to the 2013 American College of Cardiology Foundation&#47;American Heart Association guideline for the management of ST-elevation MI&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> surgical treatment should be initiated without delay after diagnosis&#44; whereas the 2017 European Society of Cardiology guidelines on ST-elevation MI<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> recommend that delaying intervention may be considered in certain patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our analysis&#44; cumulative survival of delayed intervention was superior both for the overall cohort &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; and for patients alive at 30 days &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; This&#44; however&#44; was not apparent in the multivariate model for 30-day mortality&#46; This may be related to underpowering of our model to detect a significant difference&#46; More importantly&#44; however&#44; as previously described&#44; observational studies in the setting of VSD cannot provide a clear picture of the best surgical timing due to the fact that critically ill patients tend to be operated sooner and hemodynamically stable patients tend to be operated later&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">One reasonable conclusion is that these patients benefit from being operated as late as their hemodynamic profile permits&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">ECMO has been advocated as a bridge to VSD closure&#46; Theoretically ECMO limits the patient&#39;s exposure to the detrimental hemodynamic consequences of the VSD&#44; reducing end-organ malperfusion and unloading the heart&#44; while permitting a more opportune timing of closure&#46; However&#44; ECMO is not without its own inherent complications&#46; Morimura et al&#46; reported mechanical circulatory support&#44; including ECMO and IABP&#44; as a bridge to VSD closure in a small cohort&#44; with positive results&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our cohort ECMO was used in five patients as a bridge to closure&#46; This strategy was not associated with different cumulative survival &#40;log-rank p&#61;0&#46;9&#41;&#59; however&#44; all ECMO patients had a follow-up of less than five years&#44; and three &#40;60&#37;&#41; were alive at discharge&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Model simulations suggest that the Impella device may present a superior hemodynamic benefit in the post-MI VSD setting compared to ECMO&#44; thus permitting a delayed closure strategy with fewer associated complications&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is further controversy relating to the benefit of concomitant CABG&#46; Although the majority of studies show no benefit of concomitant CABG regarding early and long-term mortality&#44; results with both improved and reduced survival have been reported&#46; The aforementioned registries<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a> showed no significant difference in survival for patients undergoing concomitant CABG&#44; except for mid-term survival after exclusion of patients who died in the first 30 days&#46; Perrotta et al&#46; reviewed the best available evidence regarding concomitant revascularization in this setting and found that overall&#44; it suggests that revascularization of non-infarcted areas of myocardium and consequent improvement of collateral flow may contribute to better long-term survival&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Our findings are consistent with the results reported from previous registries&#44; with no difference in cumulative survival &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; although a protective effect for 30-day mortality was found &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Various techniques of VSD closure have been described in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;6&#44;13</span></a> It is unclear whether any one technique has definite advantages over any other&#46; Furthermore&#44; extent of infarcted area&#44; time of reperfusion and center&#47;surgeon case volume may be more significant factors affecting residual VSD and overall outcome&#46; Our cohort has a clear dominance of the classic technique described by Daggett&#44; with a small number of alternate techniques&#44; which precludes interpretation regarding the relation between closure technique and outcome&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Since the first percutaneous closure of a post-MI VSD in the 1980s&#44; percutaneous intervention has evolved and is viewed with renewed interest&#46; Technical success rates of over 75&#37; with associated in-hospital&#47;30-day mortality of 32&#37; have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> However&#44; patient selection is an inherent characteristic of such interventional reports&#44; with anatomical feasibility as a limiting factor and most patients not being considered candidates for surgery&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Percutaneous closure in post-MI VSD has been proposed both as a bridge to surgical treatment in patients who are not expected to survive an operation and as a definitive treatment in simple &#60;15 mm defects in the sub-acute or chronic phase&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Additionally&#44; percutaneous closure is an alternative for reintervention for residual VSD after index closure&#44; which itself consists of a particular subset of high-risk patients&#46; In our cohort we identified four patients in which this approach was used&#46; Three out of these four &#40;75&#37;&#41; patients were discharged alive&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Operative mortality was high in our cohort&#44; albeit in agreement with that described in previous registries&#58; 33&#46;0&#37; in the Japanese registry&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> 42&#46;9&#37; in the Society of Thoracic Surgeons Adult Cardiac Surgery Database<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> and 41&#37; in the Swedish registry<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> &#40;30-day mortality&#41; and 47&#37; in the Global Utilization of Streptokinase and T-PA for Occluded Coronary Arteries &#40;GUSTO&#41; trial&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Several risk factors for early and late death have been proposed in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5&#44;16&#44;17</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Multivariate analysis showed the significant impact of concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#59; p&#61;0&#46;034&#41; and age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#59; p&#61;0&#46;27&#41; on 30-day mortality&#44; as well as a trend regarding concomitant mitral surgery &#40;OR 9&#46;20&#59; 95&#37; CI 0&#46;90&#8211;93&#46;96&#59; p&#61;0&#46;061&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Other authors have reported similar findings regarding age<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;5</span></a> and significant mitral regurgitation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> These findings suggest that surgical complexity and frailty may play a role in early outcomes&#46; A beneficial effect of concomitant CABG has been proposed but remains controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> In our study&#44; due to the outcome being 30-day mortality&#44; long hospitalizations &#40;&#62;30 days&#41; may have skewed the influence of other important baseline characteristics&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">As a side note&#44; a uniform approach regarding timing of intervention was not discernible in the three centers included in our cohort&#44; with both epoch- and surgeon-related variation found&#46; A common notion&#44; however&#44; is the need for a pragmatic rather than a dogmatic approach&#44; in the sense that the timing of intervention depends on close monitoring and patient-tailored strategies rather than a predefined timeframe&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study limitations and merits</span><p id="par0150" class="elsevierStylePara elsevierViewall">Due to its retrospective design and non-randomization of patients this study is at risk of inherent biases in data collection&#46; The large time frame it encompasses &#40;from 2000 to 2021&#41; also presents a risk of bias relating to changes in practices and perioperative care&#46; A &#8216;VSD repair registry&#8217; rather than a &#8216;VSD registry&#8217; is presented&#44; in the sense that patients considered inoperable or who died waiting for surgery are not included in this cohort&#46; Nevertheless&#44; it is one of the largest cohorts of surgically treated post-MI VSD patients studied&#46; Its multicenter design provides a reflection of the real-world population and different management strategies&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">VSD is a dreadful complication of MI&#46; Registries may provide important evidence regarding an entity for which randomized controlled trials are impractical&#46; Percutaneous closure and mechanical support are emerging techniques that may prove useful in selected patients&#46; In our study&#44; age negatively influenced and concomitant CABG positively influenced 30-day survival&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Timing of surgery remains a controversial issue&#46; Later closure seems to be advantageous but there is significant bias&#46; Overall&#44; it seems that these patients benefit from being operated as late as their hemodynamic profile permits&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Learning points</span><p id="par0165" class="elsevierStylePara elsevierViewall">VSD is a dreadful complication of MI&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Registries may provide important evidence regarding this entity&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">CABG positively influenced 30-day survival&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Age negatively influenced 30-day survival&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Later closure seems to be advantageous but an important bias exists&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">No funding was received for this project&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2022-07-31"
    "fechaAceptado" => "2022-10-10"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Ventricular septal defect"
            1 => "Mechanical complication"
            2 => "Myocardial infarction"
            3 => "Registry"
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            0 => "Comunica&#231;&#227;o interventricular"
            1 => "Complica&#231;&#227;o mec&#226;nica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction and Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect &#40;VSD&#41; registry to further elucidate controversial areas of this clinical entity&#39;s surgical treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Median survival of the cohort &#40;n&#61;76&#41; was 72 months &#40;95&#37; CI 4&#8211;144 months&#41;&#46; Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction &#40;log-rank p&#61;0&#46;036&#41;&#46; Concomitant coronary artery bypass grafting &#40;CABG&#41;&#44; different closure techniques&#44; location of the VSD&#44; extracorporeal membrane oxygenation as bridge to closure&#44; or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis&#46; Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age &#40;OR 1&#46;08&#59; 95&#37; CI 1&#46;01&#8211;1&#46;15&#41; and concomitant CABG &#40;OR 0&#46;23&#59; 95&#37; CI 0&#46;06&#8211;0&#46;90&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Our results are comparable with previous reports regarding mortality&#44; risk factors and concomitant procedures&#46; Timing of surgery remains a controversial issue&#46; Later closure seems to be advantageous&#44; however&#44; there is significant observational bias&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introdu&#231;&#227;o e objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise coletiva de um registo nacional dedicado a comunica&#231;&#227;o interventricular &#40;CIV&#41; p&#243;s-enfarte &#40;EAM&#41; de forma a elucidar &#225;reas controversas do tratamento cir&#250;rgico desta entidade cl&#237;nica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analise descritiva&#59; sobrevida cumulativa utilizando o m&#233;todo de Kaplan-Meier&#59; an&#225;lise multivariada utilizando regress&#227;o log&#237;stica para fatores de risco para mortalidade a 30 dias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A sobrevida mediana da coorte &#40;n&#61;76&#41; foi de 72 meses &#40;6 anos&#44; 95&#37; CI 4-144 meses&#41;&#46; Melhor sobrevida cumulativa foi observada nos doentes submetidos a encerramento cir&#250;rgico da CIV ap&#243;s 10 dias do EAM &#40;<span class="elsevierStyleItalic">log-rank</span> p&#61;0&#44;036&#41;&#46; CABG concomitante&#44; diferentes t&#233;cnicas cir&#250;rgicas de encerramento&#44; localiza&#231;&#227;o da CIV&#44; ECMO como ponte para encerramento ou BIA como ponte para encerramento n&#227;o relevaram diferen&#231;a estatisticamente significativa na an&#225;lise de Kaplan-Meier&#46; An&#225;lise multivariada para fatores independentemente associados a mortalidade a 30 dias revelou uma diferen&#231;a estatisticamente significativa da idade &#40;OR 1&#44;08&#59; 95&#37; CI 1-011-15&#41; e CABG concomitante &#40;OR 0&#44;23&#59; 95&#37; CI 0-06-0&#44;90&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclus&#227;o</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Os nossos resultados s&#227;o compar&#225;veis com os resultados previamente reportados por outros autores&#46; O <span class="elsevierStyleItalic">timing</span> do encerramento cir&#250;rgico em rela&#231;&#227;o ao EAM permanece um assunto controverso&#46; No entanto&#44; um encerramento mais tardio parece ser vantajoso&#44; apesar de existir um importante vi&#233;s observacional&#46;</p></span>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Kaplan-Meier curve discriminating&#58; &#40;A&#41; concomitant coronary artery bypass graft procedure &#40;log-rank p&#61;0&#46;41&#41;&#59; &#40;B&#41; location of ventricular septal defect &#40;log-rank p&#61;0&#46;86&#41;&#46;</p>"
        ]
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      5 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; COPD&#58; chronic obstructive pulmonary disease&#59; ECMO&#58; extracorporeal membrane oxygenation&#59; eGFR&#58; estimated glomerular filtration rate&#59; IABP&#58; intra-aortic balloon pump&#59; MI&#58; myocardial infarction&#59; Qp&#47;Qs&#58; pulmonary blood flow to systemic blood flow ratio&#59; PASP&#58; pulmonary arterial systolic pressure&#59; VSD&#58; ventricular septal defect&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
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                  \t\t\t\t\tvoid\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">Patient characteristics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Female</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">39 &#40;51&#46;3&#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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69&#46;5&#177;10&#46;7&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">Location of defect</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>Apical&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">43 &#40;58&#46;9&#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>Basal&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">27 &#40;37&#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>Mid&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">3 &#40;4&#46;1&#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="elsevierStyleItalic">Time of surgery after MI</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>First 24 h&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;17&#46;1&#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>1&#8211;5 days&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">29 &#40;38&#46;2&#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>6&#8211;10 days&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">10 &#40;13&#46;2&#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>&#62;10 days&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">24 &#40;31&#46;6&#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">Hypertension</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">51 &#40;68&#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</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">26 &#40;34&#46;7&#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">Stroke</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;6&#46;7&#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">BMI &#62;40 kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></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">11 &#40;14&#46;7&#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">eGFR &#60;30 ml&#47;min&#47;1&#46;73 m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></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">6 &#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">COPD</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;2&#46;7&#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">Previous MI</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;6&#46;7&#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">Hemodynamically significant aortic valve lesion</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">3 &#40;4&#46;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">Hemodynamically significant mitral valve lesion</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;7&#46;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">Ejection fraction &#60;50&#37;</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">32 &#40;46&#46;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">PASP &#62;60 mmHg</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">10 &#40;14&#46;7&#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="elsevierStyleItalic">Qp&#47;Qs</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>Not calculated&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">51 &#40;67&#46;1&#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>1&#8211;1&#46;9&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">8 &#40;10&#46;5&#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>&#62;2&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">17 &#40;22&#46;3&#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="elsevierStyleItalic">Preoperative support</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>None&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;27&#46;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="elsevierStyleHsp" style=""></span>Inotropes&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">41 &#40;54&#46;7&#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>IABP&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">30 &#40;39&#46;5&#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>ECMO&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;6&#46;6&#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\ttop\n
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                  \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">Procedural characteristics &#40;n&#61;76&#41;</span></td></tr><tr title="table-row"><td class="td" title="\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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Daggett technique&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">69 &#40;94&#46;5&#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>Other&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">4 &#40;5&#46;5&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Associated percutaneous closure</span>&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">4 &#40;5&#46;3&#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="elsevierStyleItalic">Concomitant procedure</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">35 &#40;46&#46;1&#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">CABG</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">28 &#40;36&#46;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">Mitral</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;6&#46;6&#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="elsevierStyleItalic">Postoperative characteristics &#40;n&#61;76&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&#46;3&#177;5&#46;8&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  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \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">Alive at 30 days</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">53 &#40;69&#46;7&#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\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;10&#46;5&#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>Unspecified infection&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">19 &#40;25&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low output&#47;cardiogenic shock&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">10 &#40;13&#46;2&#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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;6&#46;6&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Reintervention for residual VSD</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">8 &#40;10&#46;5&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;9&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;027&nbsp;\t\t\t\t\t\t\n
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ISSN: 08702551
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