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procedimento endovascular que permite dilatar as art&#233;rias pulmonares esten&#243;ticas ou obstru&#237;das&#44; surge como uma op&#231;&#227;o terap&#234;utica emergente para doentes com HPTEC que n&#227;o s&#227;o eleg&#237;veis para cirurgia ou que t&#234;m hipertens&#227;o pulmonar recorrente ou persistente ap&#243;s EAP<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleInf">&#46;</span></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ap&#243;s o primeiro caso cl&#237;nico relatado em 1988<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">18</span></a>&#44; a primeira s&#233;rie de casos sobre BPA no tratamento da HPTEC foi publicada por Feinsten et al&#46; em 2001<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">19</span></a>&#46; A t&#233;cnica mostrou ser eficaz com descida da press&#227;o arterial pulmonar &#40;PAP&#41; m&#233;dia e melhoria da classe funcional&#44; 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&#224; data publica&#231;&#227;o de dados sobre a experi&#234;ncia portuguesa em BPA&#46; Este estudo tem como objetivo apresentar os resultados da experi&#234;ncia inicial do nosso centro atrav&#233;s da avalia&#231;&#227;o do benef&#237;cio sintom&#225;tico&#44; funcional e hemodin&#226;mico a curto prazo&#44; bem como da seguran&#231;a da t&#233;cnica de BPA no tratamento de doentes com HPTEC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Sele&#231;&#227;o da popula&#231;&#227;o</span><p id="par0035" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos doentes com HPTEC n&#227;o eleg&#237;veis ou com contraindica&#231;&#245;es para EAP ap&#243;s avalia&#231;&#227;o de operabilidade por uma equipa multidisciplinar pertencente a um centro cir&#250;rgico com experi&#234;ncia na realiza&#231;&#227;o de EAP&#44; tal como recomendado pelas <span class="elsevierStyleItalic">guidelines</span> atuais<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleInf">&#46;</span> Foram ainda inclu&#237;dos os doentes com hipertens&#227;o pulmonar persistente ou recorrente ap&#243;s EAP&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Os doentes foram submetidos a um estudo diagn&#243;stico completo incluindo hist&#243;ria cl&#237;nica e avalia&#231;&#227;o de comorbilidades&#44; cintigrafia pulmonar de ventila&#231;&#227;o&#8208;perfus&#227;o&#44; angiotomografia de t&#243;rax com reconstru&#231;&#245;es biplanares&#44; angiografia pulmonar de subtra&#231;&#227;o digital e cateterismo direito&#46; Todos os doentes deram o consentimento informado escrito aprovado pelo Comit&#234; de &#201;tica do Hospital Garcia de Orta e em conformidade com a Declara&#231;&#227;o de Hels&#237;nquia&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Avalia&#231;&#227;o antes e ap&#243;s angioplastia pulmonar por bal&#227;o</span><p id="par0045" class="elsevierStylePara elsevierViewall">Todos os doentes foram submetidos a avalia&#231;&#227;o cl&#237;nica no momento do diagn&#243;stico de HPTEC &#40;nos doentes submetidos a EAP&#44; a avalia&#231;&#227;o inclu&#237;da nesta an&#225;lise foi a efetuada depois da cirurgia&#41;&#44; antes da primeira sess&#227;o de BPA &#40;<span class="elsevierStyleItalic">baseline</span>&#41; e seis meses ap&#243;s a &#250;ltima sess&#227;o &#40;<span class="elsevierStyleItalic">follow&#8208;up</span>&#41;&#46; A avalia&#231;&#227;o cl&#237;nica incluiu classifica&#231;&#227;o funcional da Organiza&#231;&#227;o Mundial de Sa&#250;de &#40;OMS&#41;&#44; teste de marcha de 6 minutos &#40;TM6<span class="elsevierStyleHsp" style=""></span>M&#41;&#44; n&#237;veis s&#233;ricos de <span class="elsevierStyleItalic">N&#8208;terminal pro&#8208;brain natriuretic peptide</span> &#40;NT&#8208;proBNP&#41;&#44; gasimetria arterial e cateterismo card&#237;aco direito completo &#40;para medi&#231;&#227;o de PAP m&#233;dia&#44; RVP e d&#233;bito card&#237;aco por m&#233;todo de termodilui&#231;&#227;o&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">T&#233;cnica de angioplastia pulmonar por bal&#227;o</span><p id="par0050" class="elsevierStylePara elsevierViewall">A BPA foi realizada de acordo com metodologia adotada pelo nosso centro e previamente publicada<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">30</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Os procedimentos foram efetuados com manuten&#231;&#227;o da terap&#234;utica de ambulat&#243;rio&#44; particularmente da terap&#234;utica anticoagulante e dos vasodilatadores pulmonares espec&#237;ficos&#46; Foram necess&#225;rias m&#250;ltiplas sess&#245;es de BPA para o tratamento completo de cada doente&#46; Nas primeiras sess&#245;es&#44; priorizou&#8208;se o tratamento de les&#245;es menos complexas como estenoses&#44; webs e les&#245;es suboclusivas&#46; Oclus&#245;es totais e les&#245;es em vasos tortuosos foram abordadas com menos frequ&#234;ncia&#46; Nos doentes com hemodin&#226;mica mais grave &#40;PAP m&#233;dia &#62; 40<span class="elsevierStyleHsp" style=""></span>mmHg e&#47;ou RVP &#62; 7 Unidades de Wood&#41;&#44; houve um subdimensionamento do di&#226;metro do bal&#227;o ao vaso&#44; sobretudo nas primeiras sess&#245;es e usaram&#8208;se t&#233;cnicas de avalia&#231;&#227;o funcional como <span class="elsevierStyleItalic">pressure&#8208;wire&#8208;guided</span> BPA<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">31</span></a>&#46; O n&#250;mero total de segmentos tratados em cada sess&#227;o variou de acordo com a gravidade hemodin&#226;mica do doente&#44; o tempo do procedimento &#40;&#60; 60 minutos de fluoroscopia&#41; e a quantidade de contraste iodado utilizado &#40;&#60; 300<span class="elsevierStyleHsp" style=""></span>ml ou menos dependendo da fun&#231;&#227;o renal basal&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sempre que poss&#237;vel&#44; cada doente foi submetido a duas sess&#245;es de BPA no mesmo internamento&#46; As sess&#245;es subsequentes de BPA foram programadas com 3&#8208;4 semanas de intervalo at&#233; &#224; PAP m&#233;dia descer abaixo de 25 mmHg e&#47;ou RVP descer abaixo de 4 unidades de Wood</p><p id="par0215" class="elsevierStylePara elsevierViewall">&#40;uWood&#41;&#44; sob terap&#234;utica vasodilatadora pulmonar e&#47;ou at&#233; todas as les&#245;es acess&#237;veis</p><p id="par0220" class="elsevierStylePara elsevierViewall">serem intervencionadas&#46;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lise de seguran&#231;a</span><p id="par0065" class="elsevierStylePara elsevierViewall">As complica&#231;&#245;es relacionadas com a BPA foram definidas como&#58; 1&#41; les&#227;o vascular angiogr&#225;fica &#40;incluindo dissec&#231;&#227;o e perfura&#231;&#227;o vascular&#41;&#59; 2&#41; hemoptises&#59; 3&#41; les&#227;o pulmonar cuja gravidade foi classificada em cinco graus utilizando um sistema de classifica&#231;&#227;o previamente publicado na literatura<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a>&#59; 4&#41; complica&#231;&#245;es do local de acesso vascular &#40;incluindo hematoma ou seroma&#41;&#59; 5&#41; nefropatia de contraste definida como um aumento de 25&#37; ou de 0&#44;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL comparativamente ao valor de creatininemia pr&#233;vio ao procedimento<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">33</span></a>&#46; Para dete&#231;&#227;o precoce de potenciais complica&#231;&#245;es&#44; os doentes foram submetidos &#224; realiza&#231;&#227;o de avalia&#231;&#227;o laboratorial e radiografia de t&#243;rax &#224;s 24 e 48 horas p&#243;s&#8208;procedimento&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Definimos complica&#231;&#245;es <span class="elsevierStyleItalic">major</span> relacionadas com o procedimento como les&#227;o pulmonar de grau maior ou igual a tr&#234;s ou outras complica&#231;&#245;es que requereram interven&#231;&#227;o&#44; ventila&#231;&#227;o n&#227;o invasiva com press&#227;o positiva&#44; ventila&#231;&#227;o mec&#226;nica&#44; suporte circulat&#243;rio mec&#226;nico &#40;ECMO&#41; ou que resultaram na morte do doente&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As complica&#231;&#245;es foram adjudicadas por um cardiologista de interven&#231;&#227;o e dois peritos em hipertens&#227;o pulmonar&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lise de efic&#225;cia</span><p id="par0080" class="elsevierStylePara elsevierViewall">O sucesso do programa de BPA foi avaliado aos seis meses atrav&#233;s da medi&#231;&#227;o invasiva da hemodin&#226;mica da vasculatura pulmonar &#40;PAP m&#233;dia e RVP&#41; e atrav&#233;s de par&#226;metros cl&#237;nicos que permitiram avaliar a toler&#226;ncia ao exerc&#237;cio &#40;classe funcional da OMS e TM6<span class="elsevierStyleHsp" style=""></span>M&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">As complica&#231;&#245;es &#40;dados de seguran&#231;a&#41; foram avaliadas em todos os procedimentos de BPA nos doentes com HPTEC&#46; Os resultados de efic&#225;cia foram avaliados em todos os doentes com HPTEC que cumpriram todas as sess&#245;es programadas de BPA e que realizaram o cateterismo de seguimento aos 6 meses ap&#243;s a &#250;ltima sess&#227;o de BPA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figura 2</a> &#8211; <span class="elsevierStyleItalic">flow chart</span>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">An&#225;lise estat&#237;stica</span><p id="par0090" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica foi realizada utilizando o <span class="elsevierStyleItalic">software</span> IBM SPSS Statistics 25&#46;0 &#40;IBM Corp&#44; Armonk&#44; NY&#44; USA&#41;&#46; As vari&#225;veis categ&#243;ricas foram apresentadas por n&#250;meros &#40;<span class="elsevierStyleItalic">n</span>&#41; e percentagens &#40;&#37;&#41; e as vari&#225;veis cont&#237;nuas atrav&#233;s da m&#233;dia &#177; desvio&#8208;padr&#227;o &#40;se distribui&#231;&#227;o normal&#41; ou mediana e <span class="elsevierStyleItalic">interquartil range</span> &#40;IQR&#44; se distribui&#231;&#227;o n&#227;o normal&#41;&#46; Para compara&#231;&#245;es&#44; foram utilizados quando apropriado o teste de qui&#8208;quadrado&#44; teste exato de Fisher e teste de McNemar &#40;se vari&#225;veis categ&#243;ricas&#41; e o teste <span class="elsevierStyleItalic">t</span> de Student emparelhado ou o teste n&#227;o param&#233;trico de Wilcoxon para amostras emparelhadas &#40;se vari&#225;veis cont&#237;nuas&#41;&#46; A an&#225;lise foi realizada para um n&#237;vel de signific&#226;ncia de 5&#37;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Resultados</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Caracteriza&#231;&#227;o da popula&#231;&#227;o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Entre dezembro de 2017 e novembro de 2019 &#40;23 meses&#41;&#44; foram realizadas 64 sess&#245;es de BPA em 13 doentes&#44; 57 das quais em doentes com o diagn&#243;stico de HPTEC&#46; As restantes sess&#245;es foram realizadas em doentes com doen&#231;a pulmonar tromboemb&#243;lica cr&#243;nica sem hipertens&#227;o pulmonar&#44; pelo que foram exclu&#237;das da an&#225;lise&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As 57 sess&#245;es inclu&#237;das foram efetuadas em 11 doentes com o diagn&#243;stico de HPTEC&#58; idade m&#233;dia 66 &#177; 12 anos&#44; 73&#37; do g&#233;nero feminino&#46; Hist&#243;ria pr&#233;via de tromboembolismo venoso agudo foi reportada em oito doentes &#40;73&#37;&#41;&#46; No momento do diagn&#243;stico de HPTEC&#44; todos os doentes tinham limita&#231;&#227;o das atividades de vida di&#225;ria &#40;100&#37; classe funcional OMS &#8805; II e dois doentes em classe funcional IV&#41;&#46; O valor mediano de NT&#8208;proBNP era de 538 &#40;192&#8208;1255&#41; pg&#47;mL e a dist&#226;ncia m&#233;dia percorrida na TM6<span class="elsevierStyleHsp" style=""></span>M foi de 326 &#177; 138 metros&#46; Todos os doentes estavam sob terap&#234;utica anticoagulante&#44; 82&#37; sob terap&#234;utica vasodilatadora pulmonar &#40;incluindo dois doentes sob an&#225;logos das prostaciclinas&#41; e dois &#40;18&#37;&#41; sob oxigenioterapia de longa dura&#231;&#227;o&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Na avalia&#231;&#227;o hemodin&#226;mica antes da primeira sess&#227;o de BPA&#44; a PAP m&#233;dia era 33&#44;5 &#177; 11&#44;8<span class="elsevierStyleHsp" style=""></span>mmHg e a RVP 5&#44;0 &#177; 3&#44;2 uWood&#46; Tr&#234;s doentes &#40;27&#37;&#41; apresentavam hemodin&#226;mica gravemente comprometida &#40;PAP m&#233;dia superior a 40<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#58; PAP m&#233;dia 50&#44;3 &#177; 0&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg e RVP 8&#44;5 &#177; 3&#44;6 uWood&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A principal indica&#231;&#227;o para integra&#231;&#227;o em programa de BPA foi a n&#227;o elegibilidade para cirurgia de EAP &#40;sete doentes&#44; 64&#37;&#41;&#44; em quatro doentes foi por doen&#231;a de predom&#237;nio distal&#44; dois por risco&#8208;benef&#237;cio para EAP desfavor&#225;vel e um recusou cirurgia&#46; Nos doentes inoper&#225;veis&#44; o tempo mediano entre o diagn&#243;stico de HPTEC e a primeira sess&#227;o de BPA foi de 10 &#40;3&#8208;58&#41; meses&#46; Quatro doentes &#40;36&#37;&#41; integraram o programa de BPA por hipertens&#227;o pulmonar residual ou recorrente p&#243;s&#8208;cirurgia&#46; O tempo mediano entre a EAP e a primeira sess&#227;o de BPA nestes doentes foi de 58 &#40;19&#8208;78&#41; meses&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas cl&#237;nicas e hemodin&#226;micas basais &#40;avalia&#231;&#227;o antes da primeira sess&#227;o de BPA&#41; encontram&#8208;se resumidas na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Caracteriza&#231;&#227;o do procedimento</span><p id="par0120" class="elsevierStylePara elsevierViewall">Num total de 57 sess&#245;es&#44; foram realizadas em m&#233;dia 5&#44;4 &#177; 1&#44;9 sess&#245;es por doente&#46; Foram tratados 220 vasos e 135 segmentos com uma m&#233;dia de 3&#44;9 &#177; 1&#44;7 vasos e 2&#44;4 &#177; 1&#44;0 segmentos por sess&#227;o&#46; Por doente foram tratados em m&#233;dia 21&#44;1 &#177; 8&#44;8 vasos e 10&#44;0 &#177; 2&#44;4 segmentos&#46; <span class="elsevierStyleItalic">Webs</span>&#44; oclus&#245;es subtotais&#44; oclus&#245;es totais e estenoses foram intervencionadas&#44; respetivamente&#44; em 153 &#40;69&#44;5&#37;&#41;&#44; 31 &#40;14&#44;1&#37;&#41;&#44; 19 &#40;8&#44;6&#37;&#41; e 17 &#40;7&#44;7&#37;&#41; dos vasos tratados&#46; O pulm&#227;o direito &#40;n &#61; 35&#59; 61&#44;4&#37;&#41; e&#44; particularmente&#44; o segmento A10 &#40;n &#61; 20&#44; 35&#44;1&#37;&#41; do lobo inferior direito foram os mais frequentemente intervencionados&#46; A imagem intravascular foi utilizada em cinco sess&#245;es &#40;8&#44;8&#37;&#41;&#46; A avalia&#231;&#227;o funcional com fio de press&#227;o foi utilizada para guiar 10 procedimentos &#40;17&#44;5&#37;&#41;&#44; maioritariamente em casos com hemodin&#226;mica grave &#40;m&#233;dia da PAP m&#233;dia e da RVP nesses procedimentos foi de 41&#44;7 &#177; 9&#44;0<span class="elsevierStyleHsp" style=""></span>mmHg e 6&#44;5 &#177; 2&#44;6 uWood&#44; respetivamente&#41;&#46; O tempo m&#233;dio de procedimento foi 124 &#177; 30 minutos&#44; o tempo m&#233;dio de fluoroscopia incluindo o cateterismo card&#237;aco direito foi de 61 &#177; 15 minutos e o volume m&#233;dio de contraste utilizado de 267 &#177; 78<span class="elsevierStyleHsp" style=""></span>mL por sess&#227;o&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">An&#225;lise de seguran&#231;a &#40;complica&#231;&#245;es do procedimento&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">A taxa de complica&#231;&#245;es relacionada com o procedimento foi de 24&#44;6&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46; Les&#245;es vasculares foram observadas em seis sess&#245;es &#40;10&#44;5&#37;&#41;&#58; tr&#234;s perfura&#231;&#245;es distais pelo fio guia acompanhadas de hemoptises ligeiras e tr&#234;s dissec&#231;&#245;es&#46; Para tratamento de duas das tr&#234;s perfura&#231;&#245;es foi necess&#225;ria insufla&#231;&#227;o de bal&#227;o prolongada&#44; que permitiu resolu&#231;&#227;o completa da les&#227;o&#46; A perfura&#231;&#227;o excedente e as dissec&#231;&#245;es resolveram sem qualquer interven&#231;&#227;o percut&#226;nea ou cir&#250;rgica&#46; A presen&#231;a de hemoptises foi registada em seis sess&#245;es &#40;10&#44;5&#37;&#41; e a les&#227;o pulmonar ocorreu em tr&#234;s &#40;5&#44;3&#37;&#41;&#44; tendo sido caracterizada como de gravidade ligeira &#40;grau 2&#41; e sem necessidade de ventila&#231;&#227;o mec&#226;nica invasiva ou ECMO&#46; Complica&#231;&#227;o do acesso vascular e nefropatia de contraste ocorreram em apenas uma sess&#227;o cada &#40;1&#44;8&#37;&#41;&#46; Nenhum doente apresentou dermatite aguda induzida pela radia&#231;&#227;o&#46; N&#227;o ocorreu complica&#231;&#227;o <span class="elsevierStyleItalic">major</span> relacionada com o procedimento e n&#227;o se registou qualquer morte periprocedimento&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">An&#225;lise de efic&#225;cia da terap&#234;utica vasodilatadora pulmonar</span><p id="par0130" class="elsevierStylePara elsevierViewall">Dos nove doentes que completaram o programa de BPA&#44; 89&#37; encontravam&#8208;se sob terap&#234;utica vasodilatadora pulmonar&#46; O tempo mediano entre o diagn&#243;stico de HPTEC e a primeira sess&#227;o de BPA nestes doentes foi de 55 &#40;8&#8208;69&#41; meses&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Foi poss&#237;vel com a terap&#234;utica vasodilatadora pulmonar uma redu&#231;&#227;o do n&#250;mero de doentes em classe funcional avan&#231;ada &#40;dois doentes em classe funcional OMS IV transitaram para classe III e dois doentes em classe III para classe II&#41;&#46; Deste modo&#44; antes de iniciar o programa de BPA nenhum doente se encontrava em classe funcional IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a>&#41;&#46; Registou&#8208;se uma melhoria do TM6<span class="elsevierStyleHsp" style=""></span>M &#40;aumento m&#233;dio de 60 metros&#59; p &#61; 0&#44;208&#41;&#44; embora sem atingimento de significado estat&#237;stico &#40;n&#227;o foi poss&#237;vel a realiza&#231;&#227;o desta prova no momento inicial em dois doentes com classes funcionais mais avan&#231;adas&#41;&#46; Houve um decr&#233;scimo do valor de NT&#8208;ProBNP &#40;mediana de 538 <span class="elsevierStyleItalic">versus</span> 204 pg&#47;mL&#59; p &#61; 0&#44;156&#41;&#44; embora sem significado estat&#237;stico&#46; Em termos de resultados hemodin&#226;micos&#44; verificou&#8208;se uma diminui&#231;&#227;o significativa de aproximadamente 20&#37; dos valores de PAP m&#233;dia &#40;43&#44;4 &#177; 11&#44;3 <span class="elsevierStyleItalic">versus</span> 34&#44;8 &#177; 12&#44;5<span class="elsevierStyleHsp" style=""></span>mmHg&#44; p &#61; 0&#44;018&#41; e uma redu&#231;&#227;o de 48&#37; dos valores de RVP &#40;10&#44;2 &#177; 4&#44;5 <span class="elsevierStyleItalic">versus</span> 5&#44;3 &#177; 3&#44;4 uWood&#44; p &#61; 0&#44;001&#41;&#46; A terap&#234;utica vasodilatadora pulmonar tamb&#233;m permitiu aumentar de forma significativa o &#237;ndice card&#237;aco &#40;2&#44;2 &#177; 0&#44;6 <span class="elsevierStyleItalic">versus</span> 2&#44;7 &#177; 0&#44;6 L&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#44; p &#61; 0&#44;041&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">An&#225;lise de efic&#225;cia da BPA &#40;seguimento a seis meses&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">O tempo mediano decorrente entre a primeira e a &#250;ltima sess&#227;o de BPA foi de quatro meses &#40;4&#8208;5&#41; meses&#46; O seguimento a seis meses foi completado em 9 dos 11 doentes&#44; os quais foram inclu&#237;dos na an&#225;lise de efic&#225;cia&#46; Uma doente com 82 anos foi exclu&#237;da da an&#225;lise de efic&#225;cia por ter recusado continuar o programa de BPA ap&#243;s a sua segunda sess&#227;o ter resultado em complica&#231;&#245;es n&#227;o <span class="elsevierStyleItalic">major</span> &#40;inclu&#237;das na an&#225;lise de seguran&#231;a&#41; e outra doente por n&#227;o ter completado os seis meses de seguimento&#44; ap&#243;s finalizado o programa de BPA&#44; &#224; data de publica&#231;&#227;o do estudo&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Nos nove doentes que completaram o programa de BPA&#44; a m&#233;dia de sess&#245;es foi de 5&#44;8 &#177; 1&#44;6 &#40;mediana de 5&#44;0&#41;&#46; Por doente&#44; o n&#250;mero de segmentos e vasos tratados na totalidade das sess&#245;es foi de 10&#44;4 &#177; 2&#44;1 e 22&#44;6 &#177; 7&#44;9&#44; respetivamente&#46; Os efeitos cl&#237;nicos&#44; laboratoriais e hemodin&#226;micos a 6 meses est&#227;o sistematizados na <a class="elsevierStyleCrossRef" href="#tbl0015">Tabela 3</a> e <a class="elsevierStyleCrossRef" href="#fig0015">Figura 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Todos os doentes apresentaram melhoria estatisticamente significativa da capacidade funcional avaliada subjetiva e objetivamente&#46; A primeira&#44; determinada atrav&#233;s da classe funcional da OMS&#44; traduziu&#8208;se na aus&#234;ncia de limita&#231;&#227;o da atividade f&#237;sica habitual &#40;classe funcional I&#41; aos seis meses ap&#243;s a &#250;ltima sess&#227;o de BPA &#40;0 <span class="elsevierStyleItalic">versus</span> 100&#37; dos doentes em classe funcional I&#44; p &#61; 0&#44;004&#41;&#46; A &#250;ltima&#44; avaliada pelo TM6<span class="elsevierStyleHsp" style=""></span>M&#44; refletiu&#8208;se na melhoria em m&#233;dia de 42 metros da dist&#226;ncia percorrida &#40;420 &#177; 51 <span class="elsevierStyleItalic">versus</span> 462 &#177; 55&#44; p &#61; 0&#44;050&#41;&#46; Foi ainda poss&#237;vel a suspens&#227;o da oxigenioterapia e dos an&#225;logos das prostaglandinas em 100&#37; dos doentes previamente medicados&#46; No entanto&#44; n&#227;o se verificaram diferen&#231;as estatisticamente significativas nos n&#237;veis s&#233;ricos de NT&#8208;proBNP&#46; Nenhuma morte foi registada no per&#237;odo de seguimento&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Em termos de resultados hemodin&#226;micos&#44; verificou&#8208;se uma diminui&#231;&#227;o de 25&#37; dos valores de PAP m&#233;dia &#40;34&#44;8 &#177; 12&#44;5 <span class="elsevierStyleItalic">versus</span> 26&#44;0 &#177; 6&#44;4<span class="elsevierStyleHsp" style=""></span>mmHg&#44; p &#61; 0&#44;082&#41; e uma redu&#231;&#227;o de 42&#37; dos valores de RVP &#40;5&#44;3 &#177; 3&#44;4 <span class="elsevierStyleItalic">versus</span> 3&#44;1 &#177; 1&#44;5 uWood&#44; p &#61; 0&#44;056&#41;&#44; com tend&#234;ncia estat&#237;stica ainda que n&#227;o atingindo o n&#237;vel de signific&#226;ncia proposto&#46; N&#227;o houve diferen&#231;as significativas no &#237;ndice card&#237;aco &#40;2&#44;7 &#177; 0&#44;6 <span class="elsevierStyleItalic">versus</span> 3&#44;0 &#177; 1&#44;0&#44; p &#61; 0&#44;501 L&#47;min&#47;m<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a>&#41;&#46; No entanto&#44; quando analisado separadamente o grupo de doentes com hemodin&#226;mica grave &#40;PAP m&#233;dia &#62; 40<span class="elsevierStyleHsp" style=""></span>mmHg&#41; no in&#237;cio do programa de BPA &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figura 4</a>&#41;&#44; observou&#8208;se uma melhoria estatisticamente significativa da PAP m&#233;dia &#40;50&#44;3 &#177; 0&#44;6 <span class="elsevierStyleItalic">versus</span> 24&#44;7 &#177; 5&#44;5<span class="elsevierStyleHsp" style=""></span>mmHg&#44; p &#61; 0&#44;013&#41; e da RVP &#40;8&#44;5 &#177; 3&#44;6 <span class="elsevierStyleItalic">versus</span> 2&#44;8 &#177; 1&#44;3 uWood&#44; p &#61; 0&#44;050&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discuss&#227;o</span><p id="par0160" class="elsevierStylePara elsevierViewall">No presente estudo&#44; reportamos a experi&#234;ncia inicial do centro e&#44; simultaneamente&#44; os primeiros dados nacionais dispon&#237;veis do tratamento de HPTEC com recurso a BPA&#46; O Hospital Garcia de Orta tornou&#8208;se Centro de Refer&#234;ncia de Hipertens&#227;o Pulmonar em 2014 e iniciou a sua experi&#234;ncia de BPA em dezembro de 2017 sob a orienta&#231;&#227;o t&#233;cnico&#8208;cient&#237;fica de peritos internacionais pertencentes a centros de elevado volume em Fran&#231;a e no Jap&#227;o&#46; Em todos os doentes&#44; a elegibilidade para BPA foi decidida em equipa multidisciplinar&#44; conforme recomendado pelas <span class="elsevierStyleItalic">guidelines</span> atuais<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Os nossos resultados reafirmam a efic&#225;cia da t&#233;cnica no tratamento de doentes com HPTEC inoper&#225;veis ou com hipertens&#227;o pulmonar residual ou recorrente p&#243;s&#8208;cirurgia&#46; Sob terap&#234;utica vasodilatadora pulmonar aprimorada&#44; a estrat&#233;gia de BPA conseguiu uma melhoria adicional da classe funcional e da capacidade de exerc&#237;cio com resultados que foram significativos em curto prazo&#46; Todos os doentes se encontraram sem limita&#231;&#227;o da atividade f&#237;sica habitual aos seis meses de seguimento&#44; apresentando um aumento m&#233;dio de 42 metros da dist&#226;ncia percorrida no TM6<span class="elsevierStyleHsp" style=""></span>M&#46; Foi ainda poss&#237;vel a suspens&#227;o de oxigenioterapia e dos an&#225;logos das prostaglandinas em 100&#37; dos doentes com a correspondente melhoria da qualidade de vida e redu&#231;&#227;o dos custos associados a estas terap&#234;uticas&#46; Globalmente&#44; observ&#225;mos uma tend&#234;ncia na melhoria dos par&#226;metros hemodin&#226;micos &#40;PAP m&#233;dia e RVP&#41;&#46; A melhoria hemodin&#226;mica refletida pela percentagem de redu&#231;&#227;o da PAP m&#233;dia no nosso estudo &#40;25&#37;&#41; foi semelhante &#224; recentemente reportada na s&#233;rie francesa<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> com uma redu&#231;&#227;o da PAP m&#233;dia de 26&#37; e superior &#224; s&#233;rie alem&#227;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a> com 18&#37;&#46; N&#227;o obstante&#44; a redu&#231;&#227;o foi menos pronunciada do que a observada no registo japon&#234;s<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a> onde se verificou uma redu&#231;&#227;o m&#233;dia de 44&#37;&#46; Relativamente &#224; RVP&#44; demonstrou&#8208;se uma redu&#231;&#227;o de 42&#37;&#44; sobrepon&#237;vel &#224; do registo franc&#234;s<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> que foi de 43&#37;&#44; superior aos 26&#37; do registo alem&#227;o<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a> e inferior aos 66&#37; do registo japon&#234;s<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Existem m&#250;ltiplas explica&#231;&#245;es poss&#237;veis para as diferen&#231;as encontradas entre a nossa s&#233;rie e o registo multic&#234;ntrico japon&#234;s&#58; 1&#41; experi&#234;ncia dos centros no Jap&#227;o largamente superior e maior dimens&#227;o amostral no respetivo registo multic&#234;ntrico com 308 doentes intervencionados<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a> &#40;contrariamente na s&#233;rie francesa&#44; embora a dimens&#227;o amostral com 154 doentes<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> tenha sido superior &#224; nossa&#44; os resultados hemodin&#226;micos foram sobrepon&#237;veis&#41;&#59; 2&#41; diferen&#231;as nas popula&#231;&#245;es estudadas&#44; por exemplo&#44; maior incid&#234;ncia de tromboembolismo venoso agudo sintom&#225;tico na nossa s&#233;rie &#40;73&#37; na nossa s&#233;rie e na s&#233;rie francesa<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> comparativamente com 35&#37; na s&#233;rie japonesa<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a>&#41;&#59; a hip&#243;tese de poder haver um fen&#243;tipo vascular mais tromb&#243;tico inflamat&#243;rio nos doentes europeus com HPTEC comparativamente com os japoneses&#44; diferen&#231;as que podem determinar diferentes respostas &#224; terap&#234;utica<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">34</span></a>&#59; diferente sele&#231;&#227;o dos doentes para BPA&#44; uma vez que a menor experi&#234;ncia cir&#250;rgica nos centros japoneses determina que muitos doentes submetidos a BPA no Jap&#227;o s&#227;o considerados oper&#225;veis em centros europeus<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">35</span></a>&#44; contrariamente &#224; maioria dos doentes submetidos a BPA no nosso estudo que foram inoper&#225;veis ou p&#243;s&#8208;cir&#250;rgicos&#59; 3&#41; intervalo relativamente longo entre o diagn&#243;stico de HPTEC e a primeira sess&#227;o de BPA &#40;mediana de 55 meses no nosso estudo&#41;&#44; &#233; poss&#237;vel que alguns doentes tenham desenvolvido arteriopatia pulmonar perif&#233;rica&#44; a qual poder&#225; mitigar o resultado hemodin&#226;mico das sess&#245;es de BPA&#59; 4&#41; a grande maioria dos doentes &#40;82&#37;&#41; encontrava&#8208;se sob terap&#234;utica vasodilatadora pulmonar &#224; data de in&#237;cio do programa de BPA comparativamente com 72&#37; dos doentes da s&#233;rie japonesa<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a> e 62&#37; dos doentes da s&#233;ria francesa<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a>&#46; A melhoria estatisticamente significativa das vari&#225;veis hemodin&#226;micas entre o momento do diagn&#243;stico e o in&#237;cio do programa de BPA por efeito da terap&#234;utica vasodilatadora pulmonar pode reduzir o benef&#237;cio absoluto observado com a t&#233;cnica percut&#226;nea&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Comparativamente com a s&#233;rie alem&#227;&#44; os resultados hemodin&#226;micos da nossa s&#233;rie foram superiores&#44; podendo ser explicado pelo n&#250;mero de vasos tratados &#40;a mediana de sess&#245;es por doente foi relativamente semelhante entre as s&#233;ries&#44; mas m&#233;dia de 3&#44;9 vasos tratados por sess&#227;o na nossa s&#233;rie comparativamente com 2&#44;0 vasos na s&#233;rie alem&#227;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a>&#41;&#46; Como referido por Matsubara<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">36</span></a>&#44; para melhorar a efic&#225;cia da BPA &#233; necess&#225;rio aumentar o n&#250;mero de vasos tratados &#40;aumentando o n&#250;mero de sess&#245;es por doente ou aumentando o n&#250;mero de vasos tratados em cada procedimento&#41;&#46; Este autor refere ainda ser importante abordar les&#245;es dif&#237;ceis como oclus&#245;es&#44; porque&#44; apesar de poderem estar relacionadas com maior risco de complica&#231;&#245;es&#44; o ganho hemodin&#226;mico ao tratar estas les&#245;es &#233; potencialmente superior &#224; dilata&#231;&#227;o de les&#245;es menos esten&#243;ticas&#46; A abordagem mais conservadora na presente s&#233;rie&#44; ao evitar o tratamento de les&#245;es muito complexas com maior risco de complica&#231;&#245;es &#40;apenas 8&#44;6&#37; das les&#245;es intervencionadas foram oclus&#245;es totais&#44; na maior parte dos casos foram dilatadas webs&#41;&#44; pode tamb&#233;m ter contribu&#237;do para uma efic&#225;cia hemodin&#226;mica inferior &#224; observada na s&#233;rie japonesa&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Comparativamente &#224;s terap&#234;uticas previamente dispon&#237;veis&#44; os efeitos hemodin&#226;micos da BPA observados no nosso estudo foram globalmente inferiores aos reportados com a cirurgia de EAP&#44; a qual reduz a PAP m&#233;dia em aproximadamente 40&#37; e a RVP em aproximadamente 60&#37;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">6&#44;8&#44;9&#44;11</span></a>&#46; N&#227;o obstante&#44; no subgrupo de doentes da nossa s&#233;rie com hemodin&#226;mica severa&#44; os benef&#237;cios hemodin&#226;micos assemelharam&#8208;se aos da cirurgia com redu&#231;&#227;o de 51&#37; da PAP m&#233;dia e 67&#37; da RVP com valores finais dentro do intervalo normal e&#44; por isso&#44; com potencial para normaliza&#231;&#227;o hemodin&#226;mica&#46; Estes dados colocam em discuss&#227;o qual ser&#225; a melhor forma de medir a efic&#225;cia da t&#233;cnica de BPA nos doentes que apresentam uma hemodin&#226;mica menos severa ou at&#233; normal&#46; Provavelmente&#44; nos doentes com uma hemodin&#226;mica menos grave o efeito da terap&#234;utica com a BPA n&#227;o deve ser medido em termos de efic&#225;cia hemodin&#226;mica em repouso&#44; mas preferencialmente por par&#226;metros com o esfor&#231;o&#44; como com a prova de esfor&#231;o cardiopulmonar ou at&#233; mesmo com cateterismo card&#237;aco direito de esfor&#231;o<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">37</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Relativamente &#224; terap&#234;utica m&#233;dica&#44; o perfil das altera&#231;&#245;es hemodin&#226;micas observadas com a BPA foi diferente das altera&#231;&#245;es hemodin&#226;micas relatadas com a terap&#234;utica vasodilatadora pulmonar&#44; dado que observ&#225;mos melhorias na PAP m&#233;dia e na RVP com altera&#231;&#245;es muito pequenas no &#237;ndice card&#237;aco&#46; A terap&#234;utica m&#233;dica&#44; pelo contr&#225;rio&#44; tende a melhorar principalmente o d&#233;bito card&#237;aco com efeitos modestos na PAP m&#233;dia<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">15&#8211;17</span></a>&#46; Possivelmente&#44; o aumento do d&#233;bito card&#237;aco que se observa com a terap&#234;utica vasodilatadora pulmonar &#233; em parte mediado pela vasodilata&#231;&#227;o sist&#233;mica<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">38</span></a>&#46; Imediatamente antes de iniciar o programa de BPA&#44; o &#237;ndice card&#237;aco na presente s&#233;rie encontra&#8208;se normalizado &#40;m&#233;dia de 2&#44;7 L&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; logo &#233; mais dif&#237;cil demonstrar melhoria deste par&#226;metro&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">A taxa de complica&#231;&#245;es relacionada com o procedimento foi 25&#37;&#44; superior &#224;s relatadas nos estudos pr&#233;vios europeus&#58; 9&#37; na s&#233;rie alem&#227;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a> e 11&#37; na s&#233;rie francesa<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a>&#59; mas inferior aos 36&#37; do registo japon&#234;s<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a>&#46; N&#227;o entanto&#44; as complica&#231;&#245;es registadas foram ligeiras sem necessidade de cuidados intensivos ou causadoras de morte&#46; Pelo contr&#225;rio&#44; a taxa de complica&#231;&#245;es fatais variou entre 2 e 4&#37; nos 3 estudos acima mencionados<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">23&#44;28&#44;29</span></a>&#46; &#192; semelhan&#231;a da s&#233;rie alem&#227;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a>&#44; e de acordo com o que est&#225; descrito na literatura<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">39&#8211;41</span></a>&#44; a complica&#231;&#227;o mais comum foi a les&#227;o vascular pulmonar com ou sem hemorragia pulmonar&#44; mas incid&#234;ncia reduzida de les&#227;o de reperfus&#227;o &#40;a complica&#231;&#227;o mais frequente nas s&#233;ries japonesa<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a> e francesa<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a>&#41;&#46; As explica&#231;&#245;es poss&#237;veis para o n&#250;mero elevado de complica&#231;&#245;es <span class="elsevierStyleItalic">minor</span>&#44; mas reduzido de complica&#231;&#245;es <span class="elsevierStyleItalic">major</span>&#44; inclu&#237;ndo les&#227;o de reperfus&#227;o&#44; podem relacionar&#8208;se com&#58; 1&#41; registo completo de todas as complica&#231;&#245;es <span class="elsevierStyleItalic">minor</span>&#59; 2&#41; planeamento das sess&#245;es com base nas imagens de angiotomografia tor&#225;cica&#44; as quais t&#234;m sido descritas como fornecendo informa&#231;&#245;es mais detalhadas das art&#233;rias pulmonares perif&#233;ricas&#44; permitindo uma avalia&#231;&#227;o mais confi&#225;vel da acessibilidade&#44; morfologia e di&#226;metros dos vasos&#44; caracter&#237;sticas das les&#245;es e melhor dimensionamento dos bal&#245;es de angioplastia a utilizar<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">42&#44;43</span></a>&#59; 3&#41; aus&#234;ncia de <span class="elsevierStyleItalic">bridging</span> com heparinas de baixo peso molecular em doentes medicados com anticoagulantes orais diretos&#44; o que parece estar associada com menor risco de hemorragia<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">44</span></a>&#59; 4&#41; utiliza&#231;&#227;o de terap&#234;utica vasodilatadora pulmonar espec&#237;fica aprimorada na quase totalidade dos doentes antes da primeira sess&#227;o de BPA&#59; 5&#41; angioplastia pulmonar guiada por fio de press&#227;o nas primeiras sess&#245;es de todos os doentes com hemodin&#226;mica mais severa&#44; porque foi demonstrado que PAP m&#233;dia e RVP mais elevadas s&#227;o preditoras de risco de les&#227;o pulmonar<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a>&#46; Um dos benef&#237;cios importantes da t&#233;cnica do fio de press&#227;o &#233; que os n&#237;veis de press&#227;o distal &#224;s les&#245;es&#8208;alvo podem ser controlados&#59; outra &#233; que &#233; poss&#237;vel obviar a sobredilata&#231;&#227;o dos vasos&#8208;alvo&#46; Isso pode contribuir para a menor taxa de complica&#231;&#245;es angiogr&#225;ficas nas sess&#245;es guiadas por fio de press&#227;o reduzindo o risco de les&#245;es vasculares durante o procedimento&#44; bem como o risco de les&#227;o pulmonar de reperfus&#227;o associado<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">45&#44;46</span></a>&#59; 6&#41; por &#250;ltimo&#44; mas n&#227;o menos importante&#44; o facto de termos iniciado o nosso programa de BPA com a t&#233;cnica j&#225; aperfei&#231;oada<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">22</span></a> e com base na experi&#234;ncia de peritos de centros de grande volume<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a>&#46; Como descrito&#44; o procedimento de BPA tem uma curva de aprendizagem e a efic&#225;cia e seguran&#231;a melhoram com a experi&#234;ncia<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">29&#44;35&#44;36</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">O nosso estudo apresenta v&#225;rias limita&#231;&#245;es&#46; Em primeiro lugar&#44; &#233; um estudo de centro &#250;nico incluindo um n&#250;mero limitado de doentes e sess&#245;es de BPA&#46; Em segundo lugar&#44; uma elevada propor&#231;&#227;o dos nossos doentes &#40;82&#37;&#41; encontrava&#8208;se com pelo menos um f&#225;rmaco vasodilatador pulmonar antes da primeira sess&#227;o de BPA&#44; podendo admitir&#8208;se que a terap&#234;utica m&#233;dica pode ter um impacto no resultado p&#243;s&#8208;procedimento como relatado anteriormente em outros estudos<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">22&#44;23&#44;47</span></a>&#46; Por fim&#44; n&#227;o foi poss&#237;vel &#40;ainda&#41; obter resultados de acompanhamento a longo prazo&#44; necess&#225;rios &#224; avalia&#231;&#227;o da efic&#225;cia do procedimento para al&#233;m dos seis meses p&#243;s&#8208;interven&#231;&#227;o&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclus&#227;o</span><p id="par0200" class="elsevierStylePara elsevierViewall">Os dados apresentados constituem a primeira s&#233;rie de doentes HPTEC tratados com BPA em Portugal descrita na literatura at&#233; &#224; data&#46; Antes da implanta&#231;&#227;o do programa de BPA no nosso centro&#44; as alternativas terap&#234;uticas dos doentes com HPTEC inoper&#225;vel ou com hipertens&#227;o pulmonar residual ou recorrente p&#243;s&#8208;cirurgia resumiam&#8208;se &#224; terap&#234;utica m&#233;dica vasodilatadora pulmonar&#46; A operacionaliza&#231;&#227;o deste programa de BPA permitiu oferecer uma estrat&#233;gia terap&#234;utica adicional com benef&#237;cio para este grupo de doentes&#46; Ap&#243;s a implanta&#231;&#227;o e operacionaliza&#231;&#227;o deste programa multidisciplinar&#44; impunha&#8208;se uma valida&#231;&#227;o de resultados&#44; tanto no n&#237;vel da efic&#225;cia como no da seguran&#231;a&#46; Os resultados descritos confirmam o benef&#237;cio significativo deste procedimento na hemodin&#226;mica vascular pulmonar&#44; assim como na sintomatologia e capacidade funcional&#44; sustentados pelo menos at&#233; aos seis meses de seguimento&#46; Este benef&#237;cio acompanha&#8208;se duma taxa significativa de complica&#231;&#245;es <span class="elsevierStyleItalic">minor</span> periprocedimento&#44; mas aus&#234;ncia de complica&#231;&#245;es <span class="elsevierStyleItalic">major</span> ou morte associada ao procedimento&#46; Por &#250;ltimo&#44; os resultados em curto e longo prazo da BPA carecem de ser adequadamente avaliados em estudo prospetivo e multic&#234;ntrico&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Financiamento</span><p id="par0205" class="elsevierStylePara elsevierViewall">O estudo n&#227;o teve qualquer financiamento&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflitos de interesse</span><p id="par0210" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A angioplastia pulmonar por bal&#227;o &#40;BPA&#41; constitui uma alternativa terap&#234;utica na hipertens&#227;o pulmonar tromboemb&#243;lica cr&#243;nica &#40;HPTEC&#41; inoper&#225;vel ou hipertens&#227;o pulmonar &#40;HP&#41; residual&#47;recorrente ap&#243;s cirurgia&#46; O objetivo deste estudo foi avaliar a efic&#225;cia e seguran&#231;a a curto prazo do programa de BPA&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo prospetivo em centro &#250;nico&#44; que incluiu todas as sess&#245;es de BPA em doentes com HPTEC entre 2017 a 2019&#46; Realizou&#8208;se avalia&#231;&#227;o da classe funcional da OMS&#44; biomarcadores plasm&#225;ticos&#44; teste de marcha de 6 minutos &#40;TM6<span class="elsevierStyleHsp" style=""></span>M&#41; e cateterismo card&#237;aco direito no in&#237;cio e seis meses ap&#243;s a &#250;ltima sess&#227;o&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Foram realizadas 57 sess&#245;es de BPA em 11 doentes com HPTEC &#40;64&#37; doen&#231;a inoper&#225;vel&#44; 82&#37; sob terap&#234;utica vasodilatadora pulmonar&#41;&#46; O programa de BPA foi conclu&#237;do com um seguimento m&#237;nimo de seis meses em nove doentes&#46; Houve uma melhoria significativa na classe funcional OMS &#40;p &#61; 0&#44;004&#41;&#44; no TM6<span class="elsevierStyleHsp" style=""></span>M &#40;aumento m&#233;dio de 42 metros&#59; p &#61; 0&#44;050&#41; e uma tend&#234;ncia para melhoria hemodin&#226;mica significativa&#58; queda de 25&#37; na press&#227;o da art&#233;ria pulmonar m&#233;dia &#40;PAPm&#59; p &#61; 0&#44;082&#41; e 42&#37; na resist&#234;ncia vascular pulmonar &#40;RVP&#59; p &#61; 0&#44;056&#41;&#46; No subgrupo de doentes que apresentavam crit&#233;rios hemodin&#226;micos de gravidade &#40;tr&#234;s doentes com PAPm &#62; 40<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; a redu&#231;&#227;o foi significativa&#58; 51&#37; na PAPm &#40;p &#61; 0&#44;013&#41; e 67&#37; na RVP &#40;p &#61; 0&#44;050&#41;&#46; Foram suspensos os an&#225;logos da prostaciclina e a oxigenoterapia de longa dura&#231;&#227;o em todos os doentes&#46; Foram registadas complica&#231;&#245;es <span class="elsevierStyleItalic">minor</span> em 25&#37;&#46; N&#227;o foram registadas complica&#231;&#245;es <span class="elsevierStyleItalic">major</span> ou mortes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Uma estrat&#233;gia de BPA em doentes sob terap&#234;utica vasodilatadora pulmonar melhora os sintomas&#44; a capacidade de exerc&#237;cio e a hemodin&#226;mica com uma rela&#231;&#227;o risco&#8208;benef&#237;cio aceit&#225;vel em doentes com HPTEC inoper&#225;vel ou HP residual&#47;recorrente ap&#243;s cirurgia&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Balloon pulmonary angioplasty &#40;BPA&#41; is an alternative therapy in patients with inoperable chronic thromboembolic pulmonary hypertension &#40;CTEPH&#41; or residual&#47;recurrent pulmonary hypertension &#40;PH&#41; after surgery&#46; The aim of this study was to assess the short&#8208;term efficacy and safety of a BPA program&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">This prospective single&#8208;center study included all BPA sessions performed in CTEPH patients between 2017 and 2019&#46; Clinical assessment including WHO functional class&#44; plasma biomarkers&#44; 6&#8208;min walk test &#40;6MWT&#41; and right heart catheterization was performed at baseline and six months after the last BPA session&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">A total of 57 BPA sessions were performed in 11 CTEPH patients &#40;64&#37; with inoperable disease&#44; 82&#37; under pulmonary vasodilator therapy&#41;&#46; Nine patients completed both the BPA program and a minimum six&#8208;month follow&#8208;up period&#46; There were significant improvements in WHO functional class &#40;p&#61;0&#46;004&#41; and 6MWT &#40;mean increase of 42 m&#59; p&#61;0&#46;050&#41; and a trend for significant hemodynamic improvement&#58; 25&#37; decrease in mean pulmonary artery pressure &#40;mPAP&#41; &#40;p&#61;0&#46;082&#41; and 42&#37; decrease in pulmonary vascular resistance &#40;PVR&#41; &#40;p&#61;0&#46;056&#41;&#46; In the group of patients with severely impaired hemodynamics &#40;three patients with mPAP &#62;40<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; the reduction was significant&#58; 51&#37; in mPAP &#40;p&#61;0&#46;013&#41; and 67&#37; in PVR &#40;p&#61;0&#46;050&#41;&#46; Prostacyclin analogs and long&#8208;term oxygen therapy were withdrawn in all patients&#46; Minor complications were recorded in 25&#37; of patients&#46; There were no major complications or deaths&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">A BPA strategy on top of pulmonary vasodilator therapy further improves symptoms&#44; exercise capacity and hemodynamics with an acceptable risk&#8208;benefit ratio in patients with inoperable CTEPH or residual&#47;recurrent PH after surgery&#46;</p></span>"
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          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Angioplastia pulmonar com bal&#227;o do segmento A7<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>8 do lobo inferior esquerdo&#46; A&#41; Angiografia pulmonar seletiva demonstrando oclus&#227;o total do segmento A8 &#40;seta amarela&#41; e web na bifurca&#231;&#227;o do segmento A7 &#40;&#42;&#41;&#59; B&#41; Passagem de fio guia <span class="elsevierStyleItalic">Whisper MS</span> &#40;Abbot Vascular&#44; Santa Clara&#44; CA&#44; USA&#41;&#44; atrav&#233;s da oclus&#227;o do segmento A8&#59; C&#41; Dilata&#231;&#227;o do vaso com bal&#227;o semicomplacente <span class="elsevierStyleItalic">Pantera Pro</span> &#40;Biotronik SE &#38; Co KG&#44; Berlin&#44; Germany&#41; 4&#46;0&#47;20<span class="elsevierStyleHsp" style=""></span>mm&#59; D&#41; Angiografia pulmonar seletiva demonstrando um bom resultado final no n&#237;vel do segmento A8 e segmento A7 ainda n&#227;o abordado &#40;&#42;&#41;&#59; E&#41; Ap&#243;s dilata&#231;&#227;o do segmento A7 no n&#237;vel da web &#40;&#42;&#41; verifica&#8208;se bom resultado angiogr&#225;fico final com aumento do fluxo arterial&#59; F&#41; Retorno venoso presente &#40;seta vermelha&#41; na angiografia seletiva final do segmento A7&#43;8 a documentar fluxo pulmonar grau 3&#46;</p>"
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          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Varia&#231;&#227;o ao longo do tempo dos valores m&#233;dios de press&#227;o arterial pulmonar m&#233;dia&#44; resist&#234;ncia vascular pulmonar&#44; &#237;ndice card&#237;aco e dist&#226;ncia percorrida no teste de marcha de 6 minutos&#46;</p>"
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          "pt" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Compara&#231;&#227;o da varia&#231;&#227;o m&#233;dia da press&#227;o arterial pulmonar m&#233;dia e resist&#234;ncia vascular pulmonar entre a primeira sess&#227;o de angioplastia pulmonar com bal&#227;o e os seis meses de <span class="elsevierStyleItalic">follow&#8208;up</span> entre todos os doentes submetidos ao procedimento &#40;n &#61; 9&#41; e os doentes com hemodin&#226;mica severa &#40;PAP m&#233;dia &#62; 40<span class="elsevierStyleHsp" style=""></span>mmHg&#41; no in&#237;cio do programa de angioplastia pulmonar com bal&#227;o &#40;n &#61; 3&#41;&#46; Verifica&#8208;se uma redu&#231;&#227;o superior da press&#227;o arterial pulmonar m&#233;dia e resist&#234;ncia vascular pulmonar atingindo signific&#226;ncia estat&#237;stica nos doentes com hemodin&#226;mica severa na <span class="elsevierStyleItalic">baseline</span>&#46;</p>"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">BPA &#8211; Angioplastia pulmonar por bal&#227;o&#59; PAP &#8211; Press&#227;o arterial pulmonar&#59; PECP &#8211; Press&#227;o de encravamento capilar pulmonar&#59; TM6<span class="elsevierStyleHsp" style=""></span>M &#8211; Teste de marcha de 6 minutos&#59; RVP &#8211; Resist&#234;ncias vasculares pulmonares&#59; SvO<span class="elsevierStyleInf">2</span> &#8211; Satura&#231;&#227;o de oxig&#233;nio venosa mista&#59; TEV &#8211; Tromboembolismo venoso&#59; WHO &#8211; World Heath Organization</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">&#35;</span>Caracter&#237;sticas hemodin&#226;micas basais imediatamente antes da realiza&#231;&#227;o da primeira sess&#227;o de BPA</p>"
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                  \t\t\t\t" scope="col">&#40;n &#61; 11 doentes&#44;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><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><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">57 procedimentos&#41;&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" 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="elsevierStyleBold">Caracter&#237;sticas cl&#237;nicas</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><span class="elsevierStyleItalic">Idade&#44; anos</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">66 &#177; 12&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><span class="elsevierStyleItalic">Mulheres&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;73&#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><span class="elsevierStyleItalic">Hist&#243;ria de TEV aguda&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;73&#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><span class="elsevierStyleItalic">Classe funcional WHO I&#47;II&#47;III&#47;IV&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#47; 9 &#40;82&#37;&#41;&#47; 2 &#40;18&#37;&#41;&#47; 0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">TM6M&#44; metros</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">407 &#177; 62&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><span class="elsevierStyleItalic">NT&#8208;proBNP&#44; pg&#47;mL</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">204 &#40;118&#8208;602&#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><span class="elsevierStyleItalic">P</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">a</span></span><span class="elsevierStyleItalic">O</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; 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">67 &#177; 21&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><span class="elsevierStyleItalic">Oxigenioterapia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Caracter&#237;sticas hemodin&#226;micas</span><span class="elsevierStyleSup">&#35;</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><span class="elsevierStyleItalic">PAP sist&#243;lica&#44; 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">54&#44;1 &#177; 20&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PAP diast&#243;lica&#44; 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">21&#44;6 &#177; 5&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PAP m&#233;dia&#44; 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">33&#44;5 &#177; 11&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">PAD m&#233;dia&#44; 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">5&#44;4 &#177; 2&#44;9&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><span class="elsevierStyleItalic">PECP&#44; 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">9&#44;5 &#177; 2&#44;2&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><span class="elsevierStyleItalic">RVP&#44; uWood</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&#44;0 &#177; 3&#44;2&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><span class="elsevierStyleItalic">D&#233;bito card&#237;aco&#44; L&#47;min</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&#44;0 &#177; 1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#205;ndice card&#237;aco&#44; L&#47;min&#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">2&#44;8 &#177; 0&#44;6&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><span class="elsevierStyleItalic">SvO</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; &#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">66&#44;0 &#177; 8&#44;6&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><span class="elsevierStyleItalic">Terap&#234;utica vasodilatadora pulmonar</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">9 &#40;82&#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><span class="elsevierStyleItalic">Estimuladores da guanilato ciclase sol&#250;vel&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;64&#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><span class="elsevierStyleItalic">Antagonistas do recetores da endotelina&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inibidores da fosfodiesterase tipo 5&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;18&#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><span class="elsevierStyleItalic">An&#225;logos das prostaciclinas&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;18&#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><span class="elsevierStyleItalic">Medica&#231;&#227;o &#40;sem&#47;monoterapia&#47;dupla&#47;tripla&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;18&#37;&#41;&#47; 5 &#40;46&#37;&#41;&#47; 3 &#40;27&#37;&#41;&#47; 1 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Indica&#231;&#245;es para a BPA</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><span class="elsevierStyleItalic">Recusa tromboendarterectomia pulmonar&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;64&#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><span class="elsevierStyleItalic">Hipertens&#227;o pulmonar residual p&#243;s&#8208;cirurgia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">N&#250;mero de sess&#245;es BPA&#44; n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">57&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><span class="elsevierStyleItalic">N&#250;mero de sess&#245;es por doente&#44; n</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">5&#44;4 &#177; 1&#44;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">N&#250;mero de segmentos tratados por sess&#227;o&#44; n</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#44;4 &#177; 1&#44;0&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="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">N&#250;mero de vasos tratados por sess&#227;o&#44; n</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;9 &#177; 1&#44;7&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><span class="elsevierStyleItalic">N&#250;mero de bal&#245;es por sess&#227;o&#44; n</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&#44;8 &#177; 1&#44;1&nbsp;\t\t\t\t\t\t\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
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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
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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="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Web&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;7 &#177; 1&#44;7&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="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Estenose&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\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><span class="elsevierStyleHsp" style=""></span>Oclus&#227;o sub&#8208;total&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
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;5&#44;3&#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">3 &#40;5&#44;3&#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>Grau &#8805; 3&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\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>Ventila&#231;&#227;o mec&#226;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Suporte mec&#226;nico circulat&#243;rio &#40;ECMO&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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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">1 &#40;1&#44;8&#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">1 &#40;1&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Outra</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">2 &#40;3&#44;5&#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">Morte intrahospitalar</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Complica&#231;&#245;es no global</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">14 &#40;24&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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            "identificador" => "at3"
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            "rol" => "short"
          ]
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">BPA &#8211; Angioplastia pulmonar de bal&#227;o&#59; PAP &#8211; Press&#227;o arterial pulmonar&#59; PAPm &#8211; press&#227;o arterial pulmonar m&#233;dia&#59; PECP &#8211; Press&#227;o de encravamento capilar pulmonar&#59; TM6<span class="elsevierStyleHsp" style=""></span>M &#8211; Teste de marcha de 6 minutos&#59; RVP &#8211; Resist&#234;ncias vasculares pulmonares&#59; SvO<span class="elsevierStyleInf">2</span> &#8211; Satura&#231;&#227;o de oxig&#233;nio venosa mista&#59; WHO &#8211; World Health Organization</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vari&#225;veis&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inicial Momento do diagn&#243;stico&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Basal Momento de in&#237;cio BPA&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 meses seguimento&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inicial <span class="elsevierStyleItalic">versus</span> basal p&#8208;valor&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Basal <span class="elsevierStyleItalic">vs&#46;</span> 6 meses seguimento p&#8208;valor&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" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Caracter&#237;sticas cl&#237;nicas</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>Classe funcional WHO I&#47;II&#47;III&#47;IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#47;5&#47;2&#47;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">0&#47;7&#47;2&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#47;0&#47;0&#47;0&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">p &#61; 0&#44;125&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">p &#61; 0&#44;004&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>TM6M &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">360 &#177; 138&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">420 &#177; 51&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">462 &#177; 55&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">p &#61; 0&#44;208&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">p &#61; 0&#44;050&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>NT&#8208;proBNP &#40;pg&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">538 &#40;314&#8208;1089&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">204 &#40;112&#8208;585&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">202 &#40;116&#8208;392&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#61; 0&#44;156&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">p &#61; 0&#44;652&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="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Caracter&#237;sticas hemodin&#226;micas</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>PAP sist&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#44;3 &#177; 19&#44;3&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">55&#44;1 &#177; 21&#44;3&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&#44;4 &#177; 14&#44;6&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">p &#61; 0&#44;028&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">p &#61; 0&#44;144&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>PAP diast&#243;lica &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#44;3 &#177; 8&#44;3&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">22&#44;9 &#177; 5&#44;3&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&#44;6 &#177; 5&#44;3&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">p &#61; 0&#44;054&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">p &#61; 0&#44;062&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>PAP m&#233;dia &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#44;4 &#177; 11&#44;3&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">34&#44;8 &#177; 12&#44;5&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&#44;0 &#177; 6&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#61; 0&#44;018&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">p &#61; 0&#44;082&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>PAD m&#233;dia &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;6 &#177; 4&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;0 &#177; 3&#44;0&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&#44;8 &#177; 2&#44;6&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">p &#61; 0&#44;196&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">p &#61; 0&#44;191&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>PECP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;0 &#177; 3&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#44;1 &#177; 2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#44;7 &#177; 4&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">p &#61; 0&#44;426&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">p &#61; 0&#44;052&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>RVP &#40;uWood&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;2 &#177; 4&#44;5&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&#44;3 &#177; 3&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;1 &#177; 1&#44;5&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">p &#61; 0&#44;001&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">p &#61; 0&#44;056&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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