Case Report
Recurrent ischemic stroke caused by a cardiac tumor at a very unusual location: The importance of transesophageal echocardiography
Accidente isquémico vascular recurrente causado por un tumor cardiaco en una localización muy inusual: importancia de la ecografía transesofágica
María Fernanda Aguirre
, Hugo Auquilla, María Nieves De Antonio, Begoña Bernal, Manuel Emilio Monguió, Guillermo Reyes Copa
Corresponding author
Cardiac Surgery Department, Hospital Universitario de la Princesa, c/Diego de León 62, 28006 Madrid, Spain
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Ventana apical cuatro cámaras. A<span class="elsevierStyleBold">)</span> Tumor ubicado en aurícula izquierda. B) Tumor que protruye hacia el ventrículo izquierdo (diástole).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rodrigo Díaz-Barreto, Beatriz Rufato" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Rodrigo" "apellidos" => "Díaz-Barreto" ] 1 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Rufato" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113400962200290X?idApp=UINPBA00004N" "url" => "/11340096/0000003000000005/v1_202309220842/S113400962200290X/v1_202309220842/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Recurrent ischemic stroke caused by a cardiac tumor at a very unusual location: The importance of transesophageal echocardiography" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "311" "paginaFinal" => "313" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Fernanda Aguirre, Hugo Auquilla, María Nieves De Antonio, Begoña Bernal, Manuel Emilio Monguió, Guillermo Reyes Copa" "autores" => array:6 [ 0 => array:4 [ "nombre" => "María Fernanda" "apellidos" => "Aguirre" "email" => array:1 [ 0 => "f_aguirre_c@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Hugo" "apellidos" => "Auquilla" ] 2 => array:2 [ "nombre" => "María Nieves" "apellidos" => "De Antonio" ] 3 => array:2 [ "nombre" => "Begoña" "apellidos" => "Bernal" ] 4 => array:2 [ "nombre" => "Manuel Emilio" "apellidos" => "Monguió" ] 5 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Reyes Copa" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiac Surgery Department, Hospital Universitario de la Princesa, c/Diego de León 62, 28006 Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Accidente isquémico vascular recurrente causado por un tumor cardiaco en una localización muy inusual: importancia de la ecografía transesofágica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 721 "Ancho" => 1675 "Tamanyo" => 114644 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular magnetic resonance showing of a mass at the level of the ligament of Marshall (space of atrial tissue separating the left atrial appendage (LAA) from the left upper pulmonary vein).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac papillary fibroelastoma (PFE) is a benign primary cardiac tumor with significant propensity for embolization. Current reports indicate its increasing incidence, being considered the most frequent benign cardiac tumor in adults, probably due to the advent of transesophageal echocardiography (TEE).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Approximately 84% of PFEs arise from valve surface, especially in the aortic valve. Non-valvular PFEs are very unusual, and the location in the left atrium is exceedingly rare (1.6–2%).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> To our knowledge, there are only two cases reported to arise at the level of the ligament of Marshall.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although most cases are asymptomatic and diagnosed incidentally, symptomatic patients can present complications related to thromboembolic events, more frequently transient ischemic attack and ischemic stroke, which can be recurrent.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a> Diagnosis is suspected during echocardiography, but needs to be confirmed by histopathological examination. A transesophageal echocardiogram is usually required, due to its small size. The only available curative treatment, is complete surgical excision of the tumor.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present a case of a patient with recurrent ischemic stroke that presents with aphasia, right hemiparesis and left oculocephalic deviation, in which a mobile mass was observed at the level of the ligament of Marshall, being an extremely rare location for this tumor. Surgical resection was performed uneventfully and histopathologic examination confirmed the diagnosis of PFE.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 59-year-old woman arrived at the emergency department with acute onset of aphasia, right hemiparesis and left oculocephalic. Her medical history included smoking, dyslipidemia and an ischemic stroke 4 month prior to admission with complete functional recovery, in which an electrocardiogram (EKG), transthoracic echocardiography (TTE) and a twenty-four-hour EKG Holter monitoring were performed, without encountering the embolic source of the stroke. No usual risk factors for stroke were present, such as hypertension, diabetes or thrombophilia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">She had no symptoms of cardiac illness, and the clinical cardiovascular examination was unremarkable. An EKG showed normal sinus rhythm and a right-bundle branch block not reported previously. Chest radiography and laboratory results were within normal limits. A cerebral computed tomography angiogram demonstrated ischemic lesions on the left middle cerebral artery territory and an emergent endovascular reperfusion was performed by thrombectomy without complications. Neurologic evolution was favorable, persisting mixed aphasia. A TTE was performed showing only thickening of the free edge of the aortic valve veils generating mild aortic insufficiency, but no cardiac mass was observed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Five days after admission and without new symptoms, a control cerebral computed tomography revealed a new established ischemic lesion in the left parahippocampal gyrus and hemorrhagic transformation in the left frontal operculum. Due to high suspicion of cardiac source of emboli, a transesophageal echocardiography (TEE) was performed revealing a mobile, echogenic, 20<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm pedunculated mass adhered to the ligament of Marshall (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An MRI was also performed for better characterization of the mass (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient underwent complete surgical excision of the mass through minimally invasive approach (right anterior thoracotomy), with cardiopulmonary bypass (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Complete resection was confirmed by intraoperative TEE. Posterior histopathologic examination confirmed the diagnosis of PFE (<a class="elsevierStyleCrossRefs" href="#fig0020">Figs. 4 and 5</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Postoperative course was uneventful with progressive neurological improvement, persisting very mild dysphasia as a sequela. There was no evidence of residual mass on the TTE performed 1 week after the intervention, being discharged five days after surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are very rare, with an incidence ranging from 0.0017% to 0.28%.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a> Myxomas were traditionally thought to be the most common, nevertheless most of the supporting data was derived from autopsy series, reflecting a probable underdiagnosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,4</span></a> Recent studies report the PFE as the most frequent primary cardiac tumor in adults.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> In a study that was made in a reference center by Tamin et al., the frequency of PFE in patients undergoing TTE was greater than cardiac myxoma at a rate of approximately 2:1.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> The incidence is increasing probably due to higher quality of image with TEE, improvements in technology, enhanced awareness of PFE, and an aging population.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PFEs have high thromboembolic rate due to either the tumor itself or from adherent thrombi localized within the fronds.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2,4</span></a> Although most cases are asymptomatic and diagnosed incidentally, almost half of patients with symptomatic PFEs, presents as a transient ischemic attack or stroke (42–53%), which can be specifically recurrent.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5</span></a> Tumor mobility has been reported as an independent risk factor for embolization.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Thorough etiologic work-up after a stroke is crucial to identify the underlying cause. In a systematic review of international clinical practice guidelines in acute ischemic stroke<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>, the importance of the echocardiography is highlighted, especially when a cardiac source is suspected.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are no current guidelines, protocols of conservative or surgical treatment, nor specific indication of anticoagulation therapy. Tamin et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> reported that patients without surgical intervention after diagnosis, presented an incidence of 8.9% for having recurrent stroke, with incremental risk over time.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,8</span></a> Sun et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> also observed high incidence (6%) on presenting a thromboembolic event after diagnosis of PFE. All of this data supports the indication for surgery in patients with suspected PFE, for an accurate diagnosis and to avoid embolism.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In almost a quarter of patients, the diagnosis is obtained by TEE, which was not observed by ETT.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> There are several studies describing the importance of cardiac imaging, including 3D TEE or cardiac magnetic resonance, for better characterization of the tumor, relationships with surrounding tissues, formulation of surgical approach, and for the differential diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,5,9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The only curative treatment is complete surgical excision of the tumor, with high likelihood of valve preservation, especially if the patient is symptomatic and the tumor is on the left side of the heart.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Surgery improves prognosis and reduces the risk of stroke substantially, especially when performing primary resection of the tumor (98%). Short- and long-term prognosis after surgical removal is excellent.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Cardiac tumors, like papillary fibroelastoma, should be considered as a differential diagnosis, even in unusual locations, after an ischemic stroke. PFE has significant risk for recurrent thromboembolic events and should be adequately diagnosed. The gold standard is the TEE, which should be performed because of its higher sensitivity. It is important to emphasize the extremely rare location of our patient's tumor. Complete surgical excision as soon as possible is the treatment of choice, because of the high risk of unpredictable embolization. Surgery reduces the risk of recurrent neurologic events and increases long-term postoperative prognosis.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Ethical considerations</span><p id="par0090" class="elsevierStylePara elsevierViewall">The patient gave her consent for clinical information relating to this case to be reported in a medical publication.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1973565" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1697502" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1697501" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1973564" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1697500" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical considerations" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-17" "fechaAceptado" => "2023-05-06" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1697502" "palabras" => array:4 [ 0 => "Cardiac tumors" 1 => "Papillary fibroelastoma" 2 => "Recurrent stroke" 3 => "Echocardiography" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1697501" "palabras" => array:4 [ 0 => "EKG" 1 => "PFE" 2 => "TEE" 3 => "TTE" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1697500" "palabras" => array:4 [ 0 => "Tumores cardiacos" 1 => "Fibroelastoma papilar" 2 => "Ictus isquémico recurrente" 3 => "Ecocardiografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Papillary fibroelastoma is a benign cardiac tumor generally found on valve surfaces, although involvement of a cardiac chamber endocardium has been rarely reported. They are usually asymptomatic, but embolic events are highly associated presenting with neurological clinic. We present a case of a patient with recurrent stroke presenting with aphasia, right hemiparesis and left oculocephalic deviation, in which a mobile mass was observed in the transesophageal echocardiography at the ligament of Marshall, being a very unusual location for the tumor. Surgical resection was performed uneventfully and histopathological examination confirmed the diagnosis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El fibroelastoma papilar es un tumor cardiaco benigno que se encuentra generalmente en la superficie valvular, siendo muy infrecuente la afectación del endocardio de las cámaras cardiacas. Suelen ser asintomáticos, aunque eventos embólicos están muy asociados manifestándose con clínica neurológica importante. Presentamos el caso de una paciente con ictus embólico recurrente que presenta afasia, hemiparesia derecha y desviación oculocefálica izquierda, en la que se observó en el ecocardiograma transesofágico una masa móvil a nivel del ligamento de Marshall, una localización muy infrecuente del tumor. Se realizó resección quirúrgica completa y sin incidencias, obteniendo posteriormente el diagnóstico histopatológico de fibroelastoma papilar.</p></span>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1256 "Ancho" => 1675 "Tamanyo" => 158979 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram revealing a mobile, echogenic, pedunculated mass (22<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>mm). Speckled appearance, stippled pattern near the edges, with hypoechogenic areas, adhered to the ligament of Marshall.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 721 "Ancho" => 1675 "Tamanyo" => 114644 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular magnetic resonance showing of a mass at the level of the ligament of Marshall (space of atrial tissue separating the left atrial appendage (LAA) from the left upper pulmonary vein).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 755 "Ancho" => 1005 "Tamanyo" => 139678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Surgical excision through minimally invasive approach. Right anterior thoracotomy without cardiopulmonary bypass.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 755 "Ancho" => 1005 "Tamanyo" => 171213 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Macroscopic appearance of the mass after surgical excision.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 805 "Ancho" => 1005 "Tamanyo" => 78735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Histopathologic study of the mass corresponding to papillary fibroelastoma. Multiple avascular branching papillary fronds covered by a single layer of endothelial cells with acellular fibrous and myxoid stroma. Focally, muscle tissue was observed and also foci of dystrophic calcification (hematoxylin and eosin staining).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac papillary fibroelastomas: a 10-year single-center surgical experience and long-term echocardiographic follow-up study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Kolek" 1 => "J. Dvorackova" 2 => "O. Motyka" 3 => "R. Brat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5507/bp.2019.053" "Revista" => array:6 [ "tituloSerie" => "Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub" "fecha" => "2020" "volumen" => "164" "paginaInicial" => "84" "paginaFinal" => "91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31748759" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic and bioepidemiologic implications of papillary fibroelastomas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.S. Tamin" 1 => "J.J. Maleszewski" 2 => "C.G. Scott" 3 => "S.K. Khan" 4 => "W.D. Edwards" 5 => "C.J. Bruce" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2015.03.569" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "65" "paginaInicial" => "2420" "paginaFinal" => "2429" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26046736" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A large cardiac papillary fibroelastoma arising from the coumadin ridge: unusual location and presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B. Xu" 1 => "J. Betancor" 2 => "J. Hansen" 3 => "C.D. Tan" 4 => "C.R. Asher" 5 => "L.L. Rodriguez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.case.2017.05.006" "Revista" => array:6 [ "tituloSerie" => "CASE (Phila)" "fecha" => "2017" "volumen" => "1" "paginaInicial" => "190" "paginaFinal" => "194" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30062278" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Gowda" 1 => "I.A. Khan" 2 => "C.K. Nair" 3 => "N.J. Mehta" 4 => "B.C. Vasavada" 5 => "T.J. Sacchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am Heart J" "fecha" => "2003" "volumen" => "146" "paginaInicial" => "404" "paginaFinal" => "410" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rare nonvalvular left ventricular papillary fibroelastoma: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Kamdar" 1 => "S. Win" 2 => "J.C. Manivel" 3 => "S. Shumway" 4 => "E. Missov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jccase.2013.08.012" "Revista" => array:6 [ "tituloSerie" => "J Cardiol Cases" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "8" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24729801" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurological complications of cardiac tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Rosário" 1 => "A.C. Fonseca" 2 => "F.D. Sotero" 3 => "J.M. Ferro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11910-019-0931-1" "Revista" => array:5 [ "tituloSerie" => "Curr Neurol Neurosci Rep" "fecha" => "2019" "volumen" => "19" "paginaInicial" => "15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30806824" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Etiologic workup in cases of cryptogenic stroke: a systematic review of international clinical practice guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.E. McMahon" 1 => "M. Bangee" 2 => "V. Benedetto" 3 => "E.P. Bray" 4 => "R.F. Georgiou" 5 => "J.M.E. Gibson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/STROKEAHA.119.027123" "Revista" => array:6 [ "tituloSerie" => "Stroke" "fecha" => "2020" "volumen" => "51" "paginaInicial" => "1419" "paginaFinal" => "1427" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32279620" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.P. Sun" 1 => "C.R. Asher" 2 => "X.S. Yang" 3 => "G.G. Cheng" 4 => "G.M. Scalia" 5 => "A.G. Massed" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.cir.103.22.2687" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2001" "volumen" => "103" "paginaInicial" => "2687" "paginaFinal" => "2693" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11390338" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic valve papillary fibroelastoma: a three-dimensional transesophageal echocardiographic appearance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.G. Kelpis" 1 => "V.N. Ninios" 2 => "V.A. Economopoulos" 3 => "A.A. Pitsis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2010" "volumen" => "89" "paginaInicial" => "2043" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical treatment of cardiac papillary fibroelastoma: a single center experience with eighty-eight patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.L. Ngaage" 1 => "C.J. Mullany" 2 => "R.C. Daly" 3 => "J.A. Dearani" 4 => "W.D. Edwards" 5 => "H.D. Tazelaar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2005.04.030" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2005" "volumen" => "80" "paginaInicial" => "1712" "paginaFinal" => "1718" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16242444" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/11340096/0000003000000005/v1_202309220842/S1134009623000785/v1_202309220842/en/main.assets" "Apartado" => array:4 [ "identificador" => "93310" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/11340096/0000003000000005/v1_202309220842/S1134009623000785/v1_202309220842/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009623000785?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 35 | 15 | 50 |
| 2024 September | 62 | 19 | 81 |
| 2024 August | 58 | 13 | 71 |
| 2024 July | 42 | 20 | 62 |
| 2024 June | 51 | 23 | 74 |
| 2024 May | 62 | 16 | 78 |
| 2024 April | 32 | 15 | 47 |
| 2024 March | 40 | 9 | 49 |
| 2024 February | 23 | 11 | 34 |
| 2024 January | 41 | 8 | 49 |
| 2023 December | 21 | 14 | 35 |
| 2023 November | 25 | 11 | 36 |
| 2023 October | 57 | 26 | 83 |
| 2023 September | 32 | 5 | 37 |
| 2023 August | 18 | 2 | 20 |
| 2023 July | 21 | 17 | 38 |
| 2023 June | 11 | 16 | 27 |
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