Case Report
Yang aortic root enlargement through ministernotomy in an obese patient
Ampliación de anillo aórtico con técnica de Yang en una paciente obesa mediante mini-esternotomía
Freddy E. Paredes-Acevedo, Franklin W. Martínez-Ninanqui, Julio Morón-Castro, Josías C. Ríos-Ortega
Corresponding author
EsSalud, National Cardiovascular Institute, Cardiovascular Surgery Department, Lima, Peru
Read
594
Timeswas read the article
179
Total PDF
415
Total HTML
Share statistics
array:22 [ "pii" => "S113400962400038X" "issn" => "11340096" "doi" => "10.1016/j.circv.2024.02.004" "estado" => "S300" "fechaPublicacion" => "2024-05-01" "aid" => "820" "copyright" => "Sociedad Española de Cirugía Cardiovascular y Endovascular" "copyrightAnyo" => "2024" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Cir Cardiov. 2024;31:137-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "itemAnterior" => array:18 [ "pii" => "S1134009624000056" "issn" => "11340096" "doi" => "10.1016/j.circv.2024.01.004" "estado" => "S300" "fechaPublicacion" => "2024-05-01" "aid" => "807" "copyright" => "Sociedad Española de Cirugía Cardiovascular y Endovascular" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Cir Cardiov. 2024;31:134-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso Clínico</span>" "titulo" => "Electrodo ¿intraarterial? Caso clínico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "134" "paginaFinal" => "136" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Intra-arterial? lead. A case report" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 838 "Ancho" => 807 "Tamanyo" => 53246 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Derecha) Rx de tórax: proyección lateral: presencia de electrodo monocameral endocavitario extremo distal intraventricular.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Piercarmine Iorlano, Mehrdad Moradi, Rafael Rodríguez Lecoq" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Piercarmine" "apellidos" => "Iorlano" ] 1 => array:2 [ "nombre" => "Mehrdad" "apellidos" => "Moradi" ] 2 => array:2 [ "nombre" => "Rafael" "apellidos" => "Rodríguez Lecoq" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1134009624000056?idApp=UINPBA00004N" "url" => "/11340096/0000003100000003/v1_202405090614/S1134009624000056/v1_202405090614/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Yang aortic root enlargement through ministernotomy in an obese patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "137" "paginaFinal" => "139" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Freddy E. Paredes-Acevedo, Franklin W. Martínez-Ninanqui, Julio Morón-Castro, Josías C. Ríos-Ortega" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Freddy E." "apellidos" => "Paredes-Acevedo" ] 1 => array:2 [ "nombre" => "Franklin W." "apellidos" => "Martínez-Ninanqui" ] 2 => array:2 [ "nombre" => "Julio" "apellidos" => "Morón-Castro" ] 3 => array:4 [ "nombre" => "Josías C." "apellidos" => "Ríos-Ortega" "email" => array:1 [ 0 => "jcrioso40@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "EsSalud, National Cardiovascular Institute, Cardiovascular Surgery Department, Lima, Peru" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ampliación de anillo aórtico con técnica de Yang en una paciente obesa mediante mini-esternotomía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1922 "Ancho" => 2508 "Tamanyo" => 412133 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Preoperative TC scan showing severe aortic annulus calcification. (B) Aortic annulus measures. (C) Intersinus measurements. (D) Preoperative transesophageal echocardiography measured the AV annulus at 19<span class="elsevierStyleHsp" style=""></span>mm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">AVR through mini-invasive approaches have been gaining acceptance by many surgeons around the world. Upper ministernotomy and right minithoracotomy are the most common techniques.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a> Several studies have shown the benefits of this surgeries. Mini-approaches for AVR have been shown to reduce hospital stay, the use of blood components, have better esthetic acceptance and provide rapid recovery to the patient.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Recently, a meta-analysis showed that AVR via upper ministernotomy may have lower mortality compared with minithoracotomy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Comorbidities such as morbid obesity increase postoperative complications in cardiac surgery (more mortality, infections, respiratory complications). Full sternotomy causes greater respiratory restriction in these patients, which increases the possibility of complications.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe an AVR via upper ministernotomy in a 76-year-old woman with moderate obesity using the novel annulus enlargement technique first described by Yang.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 76-year-old woman with history of dyspnea, angina and syncope was referred to our institution for severe AV stenosis on transthoracic echocardiography. Her medical history was notable for hypertension, hyperlipidemia and obesity (weight: 80<span class="elsevierStyleHsp" style=""></span>kg and height: 150<span class="elsevierStyleHsp" style=""></span>cm; BMI: 35<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>). Diagnostic workup inside our Institution included a transthoracic echocardiography which demonstrated LVEF: 61%, peak gradient: 129<span class="elsevierStyleHsp" style=""></span>mmHg, mean gradient: 81<span class="elsevierStyleHsp" style=""></span>mmHg, AV area: 0.45<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, indexed AV area: 0.25<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>/m<span class="elsevierStyleSup">2</span> and AV annulus: 18<span class="elsevierStyleHsp" style=""></span>mm. Coronariography did not find coronary disease or abnormality and the right catheterization found postcapillary hypertension (pulmonary artery pressures: 48/15<span class="elsevierStyleHsp" style=""></span>mmHg, mean: 27, wedge pressure: 25, pulmonary vascular resistance: 0.3 Woods). Contrast-enhanced CT and preoperative transesophageal echocardiography measured the AV annulus at 19<span class="elsevierStyleHsp" style=""></span>mm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After analysis by the heart team, surgery was decided, patient was deemed for surgery using a minimally invasive approach (transcatheter aortic valve replacement was ruled out due to the bicuspid morphology and also the small annulus of the valve).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Operative technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">After induction of general anesthetic and placement of a single lumen endotracheal tube, a J-shaped (third intercostal space) upper miniesternotomy was performed. The right common femoral vein was dissected and prepared for peripheral cannulation (venous 25 Fr, high flow cannula, LivaNova, London, UK). Arterial cannulation was performed directly on ascending aorta using a 21 high flow cannulae (LivaNova, London, UK). After comfortable exposure of pericardium, placement of aortic root cardioplegia needle and right superior pulmonary vein vent and initiation of cardiopulmonary bypass, the aorta was cross-clamped and HTK cardioplegia solution was administered. An oblique aortotomy was performed, ending 2<span class="elsevierStyleHsp" style=""></span>cm above the left and non-coronary commissure. Traction sutures were placed on the aorta for better exposure. A tricuspid very calcified valve was noted. Decalcification of annulus and removal of cusps was performed. Sizing of the annulus using the Livanova measure devices demonstrated a 19<span class="elsevierStyleHsp" style=""></span>mm annulus. Due to the high risk of patient protesis mismatch, an annulus enlargement technique was in order.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The initial aortotomy ending 2<span class="elsevierStyleHsp" style=""></span>cm above the commissure between left and non-coronary cusp was extended below each cusp on the annulus on to the aorto mitral curtain and then to the right and left, making a “Y” pattern as described by Yang.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> A rectangular-shaped Bovine pericardial patch (Boston Scientific Corp, Natick, Mass) was trimmed in width slightly greater than the distance between the two cusp nadirs. This patch was sewn to the mitral annulus from left to right fibrous trigone with running 4-0 polypropylene suture (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). The suture line was positioned to the aortic annulus at the nadir of both left and non-coronary sinuses, sutured along the longitudinal length of the patch up to the level of the oblique aortotomy incision, and secured. The upsized valve sizer was placed in the enlarged root touching three nadirs of aortic annulus and the position of the sizer on the patch was marked to guide the placement of valve sutures. A 23<span class="elsevierStyleHsp" style=""></span>mm biological aortic prosthesis was placed using an automated suture system (COR-KNOT®) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B and C). The aortotomy was then closed, incorporating the pericardium patch over the entire surface of the open aorta. Intraoperative transesophageal echocardiography demonstrated preserved left ventricular ejection fraction without any evidence of aortic regurgitation, peak AV gradient: 25<span class="elsevierStyleHsp" style=""></span>mmHg, mean AV gradient: 12<span class="elsevierStyleHsp" style=""></span>mmHg. Cardiopulmonary bypass and aortic cross-clamp times were 128 and 114<span class="elsevierStyleHsp" style=""></span>min, respectively. The postoperative course was satisfactory, and patient was discharged home in good condition on the on the eighth postoperative day. After 3 months follow up, peak AV gradient: 9<span class="elsevierStyleHsp" style=""></span>mmHg and mean AV gradient: 5<span class="elsevierStyleHsp" style=""></span>mmHg (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D and E).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Aortic valve stenosis due to degenerative disease is common among older patients. The annulus, root, left ventricle outflow tract tend to be calcified to which careful examination and decalcification is needed. Additionally, older women may usually present with a small root or small annulus. A small aortic root could also be defined as the aortic sinotubular diameter indexed for height, with cutoffs of <1.4<span class="elsevierStyleHsp" style=""></span>cm/m in females and <1.5<span class="elsevierStyleHsp" style=""></span>cm/m in males. There is a strong predilection for the female gender with 88–91% of patients receiving smaller prosthesis. A small aortic annulus which has been accepted as an annulus ≤21<span class="elsevierStyleHsp" style=""></span>mm or some which would not accommodate a prosthesis larger than this size is frequent in this group.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Techniques for annulus enlargement hence have been designed for this group of patients. Yang et al., originated his technique by observation of the increase in prosthesis diameter which could be inserted after reconstruction of aortic root in patients affected by endocarditis compromising the aorto mitral curtain or removal of old mechanical prothesis. It is, up to date, the technique with the maximum increase in annulus diameter. The patient presented in our case was affected with morbid obesity additionally to the very severe aortic stenosis and was target to a bioprosthesis, a substantial risk for patient prothesis mismatch and the degenerative structural damage to the valve which this process implies.</p><p id="par0050" class="elsevierStylePara elsevierViewall">AVR with annulus enlargement through mini-invasive approaches is not new.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> However, this is the first report of a case performed with the Yang technique. In this case we accessed through ministernotomy due to the patient's obesity and because the ascending aorta was located in the midline and we cannulated the femoral vein to have better exposure of the structures to be manipulated. Ministernotomy could reduce ICU stay, bypass, cross-clamping time and reduced bleeding when compared with right thoracotomy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although other reports have mentioned minimally invasive approach for aortic valve replacement including or not annulus enlargement, we believe this report is one of the few if not the only one in our region with the novel annulus enlargement technique proposed by Yang. This report emphasizes the need for careful consideration of this kind of techniques for minimizing the feared patient prosthesis mismatch more so in patient with additional risk factors, such as obesity.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical approval</span><p id="par0060" class="elsevierStylePara elsevierViewall">Local Ethics Committee approved the publication of the case.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This work was supported by self-financing.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2142011" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1818482" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2142012" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1818481" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case report" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Operative technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical approval" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Informed consent" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-12-29" "fechaAceptado" => "2024-02-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1818482" "palabras" => array:3 [ 0 => "Aortic valve stenosis" 1 => "Minimally invasive cardiac surgery" 2 => "Annulus enlargement technique" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1818481" "palabras" => array:3 [ 0 => "Estenosis valvular aórtica" 1 => "Cirugía cardíaca mini-invasiva" 2 => "Técnica de ampliación de anillo aórtico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Minimally invasive aortic valve replacement (AVR) benefits avoiding sternal wound complications, prolonged hospitalization and reduced postoperative pain has been widely reported. The benefits of a small sternal incision in obese patients decreases the potential risk of sternal dehiscence otherwise present on a conventional sternotomy. Here we report the case of a 76-year-old woman with moderate obesity who was referred to our institution with severe degenerative aortic stenosis. She underwent aortic valve replacement with a novel technique for annulus enlargement through upper ministernotomy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El reemplazo de la válvula aórtica mediante cirugía mini-invasiva ha demostrado disminuir las infecciones del sitio quirúrgico y reducir la estancia hospitalaria, así como el dolor postoperatorio. Estos beneficios se han demostrado aun en pacientes obesos. Reportamos el caso de una paciente de 76 años con obesidad que fue referida a nuestro centro con estenosis aórtica severa sintomática. Dicha paciente fue sometida mediante mini-esternotomía a reemplazo de la válvula con ampliación de anillo con una novedosa técnica (técnica de Yang).</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1922 "Ancho" => 2508 "Tamanyo" => 412133 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Preoperative TC scan showing severe aortic annulus calcification. (B) Aortic annulus measures. (C) Intersinus measurements. (D) Preoperative transesophageal echocardiography measured the AV annulus at 19<span class="elsevierStyleHsp" style=""></span>mm.</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" => 1691 "Ancho" => 2508 "Tamanyo" => 531086 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Yang aortic root enlargement using pericardial patch. (B) Prosthesis measurement. (C) After placing the prosthesis. (D) Peak prosthesis gradient: 9<span class="elsevierStyleHsp" style=""></span>mmHg, mean: 5<span class="elsevierStyleHsp" style=""></span>mmHg. (E) 7<span class="elsevierStyleHsp" style=""></span>cm scar after three months.</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" => "Is ministernotomy superior to right anterior minithoracotomy in minimally invasive aortic valve replacement?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Balmforth" 1 => "A. Harky" 2 => "K. Lall" 3 => "R. Uppal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/icvts/ivx241" "Revista" => array:6 [ "tituloSerie" => "Interact Cardiovasc Thorac Surg" "fecha" => "2017" "volumen" => "25" "paginaInicial" => "818" "paginaFinal" => "821" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29049755" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ministernotomy compared with right anterior minithoracotomy for aortic valve surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Bonacchi" 1 => "A. Dokollari" 2 => "O. Parise" 3 => "G. Sani" 4 => "E. Prifti" 5 => "G. Bisleri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2023" "volumen" => "165" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mini-sternotomy vs right anterior thoracotomy for aortic valve replacement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Yousuf Salmasi" 1 => "H. Hamilton" 2 => "I. Rahman" 3 => "L. Chien" 4 => "P. Rival" 5 => "U. Benedetto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jocs.14607" "Revista" => array:6 [ "tituloSerie" => "J Card Surg" "fecha" => "2020" "volumen" => "35" "paginaInicial" => "1570" "paginaFinal" => "1582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32652784" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic valve replacement through minithoracotomy. Results from the Peruvian experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.C. Ríos-Ortega" 1 => "J. Sisniegas-Razón" 2 => "R. Conde-Moncada" 3 => "Y. Pérez-Valverde" 4 => "J. Morón-Castro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.47487/apcyccv.v3i2.219" "Revista" => array:5 [ "tituloSerie" => "Arch Peru Cardiol Cir Cardiovasc." "fecha" => "2022" "volumen" => "3" "paginaInicial" => "69" "paginaFinal" => "73" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Minimally invasive aortic valve replacement: how does this perform in high-risk patients?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.D. Schmitto" 1 => "F.W. Mohr" 2 => "L.H. Cohn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/HCO.0b013e328343983a" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Cardiol" "fecha" => "2011" "volumen" => "26" "paginaInicial" => "118" "paginaFinal" => "122" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21297462" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ministernotomy or minithoracotomy for minimally invasive aortic valve replacement? A Bayesian network meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Phan" 1 => "A. Xie" 2 => "Y.C. Tsai" 3 => "D. Black" 4 => "M. Di Eusanio" 5 => "T.D. Yan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hlc.2014.11.019" "Revista" => array:6 [ "tituloSerie" => "Heart Lung Circ" "fecha" => "2015" "volumen" => "24" "paginaInicial" => "e46" "paginaFinal" => "e47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25547528" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic valve replacement: understanding predictors for the optimal ministernotomy approach" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.G. Irace" 1 => "I. Chirichilli" 2 => "M. Russo" 3 => "F. Ranocchi" 4 => "M. Bergonzini" 5 => "A. Lio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3390/jcm12216717" "Revista" => array:6 [ "tituloSerie" => "J Clin Med" "fecha" => "2023" "volumen" => "12" "paginaInicial" => "6717" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37959183" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0168827813002821" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A novel simple technique to enlarge the aortic annulus by two valve sizes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. Yang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.xjtc.2020.10.038" "Revista" => array:6 [ "tituloSerie" => "JTCVS Tech" "fecha" => "2021" "volumen" => "5" "paginaInicial" => "13" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33623928" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Small aortic root in aortic valve stenosis: clinical characteristics and prognostic implications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Bahlmann" 1 => "D. Cramariuc" 2 => "J. Minners" 3 => "M.T. Lønnebakken" 4 => "S. Ray" 5 => "C. Gohlke-Baerwolf" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ehjci/jew159" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J Cardiovasc Imaging" "fecha" => "2017" "volumen" => "18" "paginaInicial" => "404" "paginaFinal" => "412" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27491438" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic stenosis and small aortic annulus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.B. Freitas-Ferraz" 1 => "G. Tirado-Conte" 2 => "F. Dagenais" 3 => "M. Ruel" 4 => "T. Al-Atassi" 5 => "E. Dumont" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.118.038408" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2019" "volumen" => "139" "paginaInicial" => "2685" "paginaFinal" => "2702" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31157994" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/11340096/0000003100000003/v1_202405090614/S113400962400038X/v1_202405090614/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/11340096/0000003100000003/v1_202405090614/S113400962400038X/v1_202405090614/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113400962400038X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 35 | 14 | 49 |
| 2024 September | 76 | 35 | 111 |
| 2024 August | 61 | 30 | 91 |
| 2024 July | 59 | 21 | 80 |
| 2024 June | 57 | 19 | 76 |
| 2024 May | 51 | 18 | 69 |
| 2024 April | 49 | 21 | 70 |
| 2024 March | 21 | 18 | 39 |
