Usefulness of multidetector computed tomography before and after pulmonary vein isolation

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A) Estenosis significativa (70% del diámetro de referencia de la vena), de 15mm de longitud, en la vena pulmonar superior izquierda (VPSI). B) Estenosis moderada (60%), de 18,7mm de longitud, en la vena pulmonar superior derecha (VPSD)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Revilla Orodea, Israel Sánchez Lite, Julio César Gallego Beuth, Teresa Sevilla Ruiz, María G. Sandín Fuentes, Ignacio Jesús Amat Santos, José Alberto San Román Calvar" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ana" "apellidos" => "Revilla Orodea" ] 1 => array:2 [ "nombre" => "Israel" "apellidos" => "Sánchez Lite" ] 2 => array:2 [ "nombre" => "Julio César" "apellidos" => "Gallego Beuth" ] 3 => array:2 [ "nombre" => "Teresa" "apellidos" => "Sevilla Ruiz" ] 4 => array:2 [ "nombre" => "María G." 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(A) Axial T2-weighted image showing one red line as the measurement of tumor contact length with a 26.5mm capsule. (B) Axial image of the apparent diffusion coefficient map (b 800) with a value of 0.798×10−3mm2/s. This injury showed microscopic extracapsular spread in the pathology report." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.F. Granja, C.M. Pedraza, D.C. Flórez, J.A. Romero, M.A. Palau, D.A. Aguirre" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.F." "apellidos" => "Granja" ] 1 => array:2 [ "nombre" => "C.M." "apellidos" => "Pedraza" ] 2 => array:2 [ "nombre" => "D.C." "apellidos" => "Flórez" ] 3 => array:2 [ "nombre" => "J.A." "apellidos" => "Romero" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Palau" ] 5 => array:2 [ "nombre" => "D.A." 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Revilla Orodea, I. Sánchez Lite, J.C. Gallego Beuth, T. Sevilla Ruiz, M.G. Sandín Fuentes, I.J. Amat Santos, J.A. San Román Calvar" "autores" => array:7 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Revilla Orodea" "email" => array:1 [ 0 => "arevillaorodea@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Sánchez Lite" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "J.C." "apellidos" => "Gallego Beuth" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "T." 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"apellidos" => "San Román Calvar" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Imagen Cardiaca, Servicio de Cardiología Hospital Clínico Universitario, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER de Enfermedades Cardiovasculares (CIBERCV), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Clínico Universitario, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la tomografía computarizada multidetector en la evaluación previa y el seguimiento de los pacientes sometidos a ablación de venas pulmonares" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2264 "Ancho" => 1626 "Tamanyo" => 247397 ] ] "descripcion" => array:1 [ "en" => "Measurement of severity and length of two (2) pulmonary vein stenoses. (A) Significant stenosis (70 per cent of the vein reference diameter) of 15mm in length in the SRPV (superior right pulmonary vein). (B) Moderate stenosis (60 per cent) of 18.7mm in length in the SRPV (superior right pulmonary vein)." ] ] ] "textoCompleto" => "IntroductionThe ablation of pulmonary veins (PV) is a more and more widely used technique in electrophysiology laboratories (EPL).<a class="elsevierStyleCrossRef" href="#bib0070">1</a> It is an effective treatment in patients with drug-resistant symptomatic atrial fibrillation, or contraindications or side effects to medication.<a class="elsevierStyleCrossRefs" href="#bib0075">2,3</a>Imaging modalities are essential in the assessment of the left atrium and pulmonary vein anatomy, both for the selection of eligible candidates (description of PV anatomy) and in the detection of complications.<a class="elsevierStyleCrossRefs" href="#bib0085">4–6</a> The detection of a blood clot in the left atrial appendage contraindicates the ablation procedure due to the impossibility of removing the clot, with the corresponding risk of systemic stroke.<a class="elsevierStyleCrossRef" href="#bib0100">7</a> Traditionally, the clinical guidelines discuss the detection of thrombi with the use of transesophageal echocardiograms (TEE),<a class="elsevierStyleCrossRef" href="#bib0070">1</a> but the multidetector computed tomography (MDCT) scan is a very good alternative modality that may be used as a diagnostic tool for its detection.<a class="elsevierStyleCrossRef" href="#bib0105">8</a> Also, there are possible long-term contraindications derived from PV ablation like the development of stenoses that may be symptomatic.Traditionally, the imaging modality of choice for assessment before and after performing one ablation procedure was the TEE. The introduction of the magnetic resonance imaging (MRI) and the MDCT scan, both imaging modalities of higher resolution, allows 3D reconstructions and a better anatomical assessment of left atrium. The integration of data and information from these modalities and anatomical and electrophysiological information obtained through the specific navigation systems used in electrophysiology units has made it possible to reduce the ablation procedure time and increase safety and effectiveness, since the application of radiofrequency inside the PVs is no longer necessary (beyond the ostium, which is the target of ablation), and all these reduces the chances of PV stenosis.<a class="elsevierStyleCrossRefs" href="#bib0095">6,9</a>The goal of our study is to assess the utility of the MDCT scan in the preliminary assessment and posterior follow-up of patients who undergo PV ablation procedures through radiofrequency, and the therapeutic attitude based on the findings.MethodPatientsRetrospective analysis of 92 MDCT scans conducted between January 2011 and June 2013 for PV assessment in 80 patients; 70 MDCT scans (76 per cent) were conducted before the first ablation procedure, and 22 (24 per cent) in patients who had already undergone one ablation procedure. The patients’ average age was 60±10 years old, and 58 patients (73 per cent) were males.TechniqueStudies were conducted using the General Electric LightSpeed VCR® MDCT scan machine (64 detectors) (General Electric Healthcare, Waukesha, WI, USA) with cardiac synchronization, total rotation time 330ms, and 40mm coverage by rotation. IV betablockers were administered at the study ward when needing to achieve heart rate target <65bpm (esmolol, average dose 60mg, in 11 patients). The protocol with the least possible radiation exposure was picked (prospective), even in the absence of low cardiac rates (<65bpm). Using two (2) orthogonal projection localizers, one cardiac acquisition field was programmed including the left atrium and PVs with 0.625mm cut thickness. Using one peripheral venous catheter, iodinated contrast was administered (350mgl/ml; from 60 to 85ml titrated based on each patient's size and renal function) at a speed of 5ml/s, and the sequence was launched when the catheter reached the aortic root. The studies were conducted with 100 at 120kV and up to 650mA depending on each patient's size. The dose of radiation administered was 6.74mSv (5.35–8.86), and the conversion coefficient for the chest was applied (×0.017).The PV ablation procedure was conducted in the EPL using sedoanalgesia (with IV propofol and fentanyl). The TEE confirmed absence of thrombi in the left atrial appendage and the transseptal puncture was guided toward the left atrium. Two (2) large inducers, one (1) circular catheter and one (1) irrigated ablation catheter were inserted into the atrium. During the procedure the patient was kept on anticoagulation using bolus of IV heparine sodium, and the activated clotting time (adequate values between 250 and 350s) was monitored.The 3D image acquired through electroanatomic mapping was integrated into the 3D image of the MDCT scan using the navigation system CARTO® (Biosense Ltd., Israel). After the electroanatomic reconstruction of the atrium, the radiofrequency ablation of left and right PVs was conducted. The electronic isolation was confirmed using the circular catheter that was placed in the pulmonary vein antrum. The procedure was completed when the electroanatomic isolation of all PVs was achieved, although at times, it was completed when conducting ablation lines in the left atrium (left atrial roof and mitral isthmus) or when isolating the superior vena cava.Data miningThe cardiac MDCT scans were analyzed at the Unidad de Imagen del Hospital Clínico Universitario de Valladolid, by one expert cardiologist and one expert radiologist in the conduction and interpretation of cardiovascular studies (over five years of experience in the acquisition and interpretation of cardiac MDCT scans.) The analysis of the images was conducted using one working station (Advantage Work Station 4.4®, General Electric Medical System) with one specific software for cardiovascular studies (VolumeViewer® 7.6.29).In each study, the number and arrangement of pulmonary veins was described, including their diameter in two (2) orthogonal projection planes 1cm away from the ostium, and the presence of thrombi in the atrium or left atrial appendage (low attenuation mass adhered to the wall of the left atrial appendage). The diffuse reduction of signal in the left atrial appendage, without the image of the thrombus, was described as self-contrast in the appendage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). One PV stenosis (reduction of normal vein caliber after an ablation procedure) was assessed in comparison to one healthy proximal or distal reference diameter. Both its severity level (<30 per cent, mild; 30–50 per cent, moderate; 50–70 per cent, significant; 70–90 per cent, serious; >90 per cent, critical; 100 per cent, obstruction) and length (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) were assessed.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Both the procedure-associated complications and clinical follow-up were gathered (recurrence of atrial fibrillation, stroke, and presence of leading symptoms of PV stenosis), as well as the therapy administered to those cases of PV stenosis.The informed written consent from all patients was obtained prior to conducting the MDCT scans and ablation procedures. Our hospital scientific committee approved the studies and it did not deem it necessary to obtain approval from the ethics committee since it was a retrospective non-interventional study.ResultsIn 24 out of the 70 patients in whom the MDCT can was indicated before a first ablation procedure, significant findings we found (34 per cent): 12 thrombi in the left atrial appendage, 1 thrombus in the right inferior pulmonary vein, 10 patients with self-contrast in the left atrial appendage without an image of the thrombis, hypodensity probably due to slow or turbulent flow, and one patient with one mass in the left atrial roof that was compatible with a small left atrial myxoma. In those patients with a thrombus or self-contrast, the most strict oral anticoagulant treatment was pursued for a minimum period of one month (increased range and target INR of 2.5–3.5 in the absence of contraindication due to hemorrhagic risk and more common controls)–a very similar strategy to the one reported by other groups.<a class="elsevierStyleCrossRef" href="#bib0115">10</a> Finally, in 14 of these patients, the PV ablation procedure was performed in 54 days (range: 42–133 days) after the MDCT can. One intraoperative TEE was conducted that ruled out the presence of thrombi in the left atrial appendage in all patients, although 4 of them showed self-contrast without the image of a thrombus. One of the patients developed one intraoperative ischemic stroke that resolved completely during the first 24h; the cranial MDCT scan showed one infarction in a distal branch of the right medial cerebral artery.In 38 out of the 46 patients whose MDCT scans were normal, the ablation procedure was performed in 57 days (range: 30–99 days). In all of them, the intraoperative TEE was normal. One patient had an early stroke after the procedure, with mild motor, sensory, and ocular sequelae; the cranial MDCT scan showed one infarction of the left posterior cerebral artery and multiple lacunary infarcts.The ablation procedure was effective (sinus rhythm after the procedure) in 100 per cent of the patients. Persistence in sinus rhythm during the follow-up at 2 years occurred in 76 per cent of the patients who received an ablation procedure for the first time, and in 85 per cent of those who underwent more than one ablation procedure.In 10 out of the 24 patients with significant findings in the MDCT scan, and in 8 out of the 46 patients with normal MDCT scans, the ablation procedure was not performed due to patient's denial or clinical criteria. No ablation procedure was ruled out because of the MDCT scan findings.In our series, the incidence of strokes associated with the procedure is 3 per cent (2 cases in 66 procedures).Of the 22 studies conducted after certain PV ablation procedure (average: 1.6 previous procedures; range: 1–3), 15 studies (68 per cent) showed relevant findings; 14 were indicated before performing another ablation procedure, and 8 studies were indicated due to symptoms after the ablation procedure in order to rule out PV stenosis. In 7 out of the 14 studies indicated before performing a second intervention there were some relevant findings: 5 thormbi in the left atrial appendage, 3 patients with self-contrast in the appendage, and 2 with insignificant PV stenosis (1 patient with mild stenosis of left PVs and another patient with moderate stenosis of the inferior PVs). Finally, the ablation procedure was performed in 12 of these patients (86 per cent) after following the protocol of strict anticoagulation we already referred to in cases with thrombi or self-contrast in the left atrial appendage, while the presence of thrombi or self-contrast was ruled out in all patients who underwent intraoperative TEEs.In five patients we performed a total of 8 MDCT scans to rule out PV stenosis after symptom onset. These symptoms were dyspnea and persistent cough after the ablation procedure and in one patient, hemoptisis. No degree of PV stenosis was detected in any patients and in four patients we found significant or major cases of stenosis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). None of the patients underwent one new ablation procedure. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the MDTC findings of these five patients and the therapy administered in each case (one patient with failed angioplasty and another patient with balloon angioplasty, and further stenting). The most commonly affected PV in our series was the intermediate right pulmonary vein and the least commonly affected PV was the inferior right pulmonary vein.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiscussionIn more than one third of the patients who underwent one MDCT scan before a first PV ablation procedure, relevant findings were found, above all, thrombi or self-contrast in the left atrial appendage. When the MDCT scan was conducted after a first ablation procedure, the percentage of relevant findings almost reached 70 per cent, yet they were different based on the indication of MDCT scan: thrombus or self-contrast in asymptomatic patients (50 per cent) and PV stenosis in 100 per cent of the MDCT scans indicated due to significant symptoms (dyspnea, cough, or hemoptisis) in 80 per cent of the cases.Despite the introduction of the MDCT scan for the management of our patients, we have not seen a lower incidence of procedural strokes compared to the time when we did not conduct these studies for the assessment of left atrium anatomy. In our series, the presence of thrombi in the left atrial appendage confirmed through MDCT scans was far more significant than shown by the TEE. However, the fact that the incidence of strokes was not reduced after the introduction of the MDCT scan makes us think that the TEE is still a powerful imaging modality for stroke prevention in this group of patients. The detection of thrombi or self-contrast in the MDCT scan makes us adopt a more intensive anticoagulation attitude that, a priori, should have an impact on the reduction of cerebral ischemic events, something that we did not detect in our series. Nevertheless, the number of cases of strokes in both periods is low, making it hard to detect significant differences.All patients underwent a perioperative TEE regardless of the detection of thrombi or self-contrast in the MDCT scan. The TEE is useful to rule out the presence of thrombi right before the procedure and guide the interatrial septum puncture. In patients with thrombi in the MDCT scan, it is not indicated to repeat the MDCT scan to rule out the presence of thrombi, since the TEE is effective enough to achieve this diagnosis and also because the MDCT associates exposure to ionizing radiation. In patients with no traces of thrombi or self-contrast in the appendage, it is also indicated to perform one perioperative TEE, since the temporal delay elapsed between the MDCT scan and the ablation procedure is not enough to be able to rule out the formation of thrombi in the appendage. Consequently, the MDCT scan for the anatomical study of the left atrium, and the perioperative TEE to rule out the presence of thrombi in the left atrial appendage is an appropriate combination in patients undergoing PV ablation procedures.Pulmonary vein stenosis is due to a not fully understood mechanism including inflammatory phenomena with intimal proliferation, local thrombosis and fibrosis secondary to the application of radiofrequency in the pulmonary vein ostia.<a class="elsevierStyleCrossRef" href="#bib0105">8</a>In our own experience, the presence of symptoms after an ablation procedure is associated with of a high probability of PV stenosis. As a matter of fact, all patients with symptoms showed some degree of PV stenosis, most of them (80 per cent) significant or serious stenosis that explained the symptoms. On the contrary, the absence of symptoms relaxes the clinician when it comes to the presence of PV stenosis. Although there was not any systematic follow-up of all the patients in our series through MDCT scans, in no asymptomatic patient undergoing another MDCT scan before another ablation procedure there was significant evidence of PV stenosis. The affectation of the intermediate right pulmonary vein is much more common in our series than in other series.<a class="elsevierStyleCrossRef" href="#bib0120">11</a> When dealing with smaller caliber veins, the administration of radiofrequency to these veins may explain why they are more commonly affected. The fact that they are close to the superior or inferior right pulmonary veins (of a larger caliber) may also promote the affectation of these nearby veins due to ablation.The management of PV stenosis is controversial.<a class="elsevierStyleCrossRefs" href="#bib0120">11,12</a> The balloon angioplasty is the first line of therapy recommended, but it has a very high incidence of restenosis. Another available option is stenting, also associated with a significant frequency of restenosis (30–50 per cent).<a class="elsevierStyleCrossRefs" href="#bib0120">11,13</a> The management of obstructions is usually defective.<a class="elsevierStyleCrossRef" href="#bib0120">11</a> In our own experience, the progression of stenoses is extremely fast; one month delays between the MDCT scan and the angioplasty lead to the complete obstruction of one patient's critically ill inferior left pulmonary vein that could not be repaired again (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). In another patient with PV obstruction, the attempt to deconstruct the veins failed. Therefore, once a PV stenosis is detected, and only if it is indicated to repair it, such a thing should be done without any further delay.<a class="elsevierStyleCrossRef" href="#bib0120">11</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>The MDCT scan had an important role when deciding the diameter and length of the stents to be implanted, since it allowed us to measure the vein reference diameter and length of stenosis. Therefore, the role of the MDCT scan is not merely diagnostic, but it is also of great utility in the decision making process when it comes to performing angioplasties.We conducted one study comparing our data to those of a similar period (from June 2008 to December, 2011) when we did not conduct any MDCT scans in our center before ablation procedures. In this period, in the electrophysiology ward, 89 TEEs were performed in 89 patients who would eventually undergo PV ablation procedures. Five (5) thrombi (6 per cent) were found, which is a lower percentage than the percentage detected by the MDCT scan in the later period (22 per cent vs 6 per cent; p=0.002). Ultimately, 84 ablation procedures were conducted. The incidence of perioperative strokes in these patients was 2.4 per cent (2 cases in 84 patients), a similar incidence to the later period when MDCT scans were conducted (3 per cent vs 2.4 per cent; p=0.999).The main limitation of our study is the number of patients in the sample, the limited number of adverse events recorded, and the fact that it was a retrospective analysis. More specific studies are needed to be able to confirm our results.In sum, the MDCT scan has great utility for the assessment of patients with atrial fibrillation prior to the performance of an ablation procedure, because of the anatomical definition that helps us conduct this procedure, and because of the detection of thrombi in the left atrial appendage, which may be one clear contraindication. Also it is useful for the follow-up of symptomatic patients post-ablation procedure because it detects relevant PV stenoses that may explain the clinical manifestations and help guide the administration of therapy.Also the combination of MDCT scans for the anatomical study of the left atrium and perioperative TEEs to rule out the presence of thrombi in the left atrial appendage is one safe adequate strategy in patients who undergo PV ablation procedures.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments with human beings or animals have been performed while conducting this investigation.Confidentiality of dataThe authors declare that they have followed the protocols from their centers on the disclosure of data from patients.Right to privacy and informed consentThe authors confirm that in this article there are no data from patients.FundingThis study has been funded by the ERDF(European Regional Development Fund).Authors’ contribution<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Manager of the integrity of the study: ARO.</li><li class="elsevierStyleListItem" id="lsti0010">2.Study Idea: ARO and TSR.</li><li class="elsevierStyleListItem" id="lsti0015">3.Study Design: ARO, ISL and TSR.</li><li class="elsevierStyleListItem" id="lsti0020">4.Data Mining: ARO, JCGB and MGSF.</li><li class="elsevierStyleListItem" id="lsti0025">5.Data Analysis and Interpretation: ARO, TSR, ISL and IJAS.</li><li class="elsevierStyleListItem" id="lsti0030">6.Statistical Analysis: ARO and TSR.</li><li class="elsevierStyleListItem" id="lsti0035">7.Reference: JCGB, IJAS and JASRC.</li><li class="elsevierStyleListItem" id="lsti0040">8.Writing: ARO, ISL and JCGB.</li><li class="elsevierStyleListItem" id="lsti0045">9.Critical review of the manuscript with intellectually relevant remarks: MGSF, ISL, TSR, IJAS and JASRC.</li><li class="elsevierStyleListItem" id="lsti0050">10.Approval of final version: ARO, ISL, TSR, JCGB, MGSF, IJAS and JASRC.</li></ul>Conflict of interestThe authors declare no conflict of interest associated with this article whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres866573" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec855854" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres866572" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec855855" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Method" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data mining" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Authors’ contribution" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "xack288908" "titulo" => "Acknowledgement" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-16" "fechaAceptado" => "2017-03-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec855854" "palabras" => array:6 [ 0 => "Imaging" 1 => "Computed tomography" 2 => "Atrial fibrillation" 3 => "Ablation" 4 => "Veins" 5 => "Stenosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec855855" "palabras" => array:6 [ 0 => "Imagen" 1 => "Tomografía" 2 => "Fibrilación auricular" 3 => "Ablación" 4 => "Venas" 5 => "Estenosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo analyze the usefulness of multidetector computed tomography (MDCT) in the preprocedural evaluation and follow-up of patients undergoing radiofrequency ablation of pulmonary veins and the impact of the MDCT findings on the approach to treatment. MethodWe retrospectively analyzed 92 consecutive MDCT studies done in 80 patients between January 2011 and June 2013; 70 (76%) studies were done before a first ablation procedure and 22 (24%) were done in patients who had undergone an ablation procedure. ResultsFindings were useful in 34% of the patients who underwent MDCT before the first ablation procedure and in 68% of the studies done after a procedure. The incidence of stroke associated with the ablation procedure was 3%, similar to the incidence recorded in our center before we started to use MDCT to evaluate the anatomy of the left atrium. All symptomatic patients had some pulmonary vein stenosis, and 80% had significant stenosis. Furthermore, the stenoses progressed very rapidly; treatment with balloon angioplasty was associated with early restenosis. Stenting was an alternative in cases of failed angioplasty. ConclusionIn the preprocedural evaluation and postprocedural follow-up of patients undergoing pulmonary vein isolation, MDCT is useful for guiding treatment and detecting complications." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEstudiar la utilidad de la tomografía computarizada multidetector (TCMD) en la evaluación previa y el seguimiento de los pacientes sometidos a ablación de venas pulmonares mediante radiofrecuencia, y la actitud terapéutica basada en los hallazgos. MétodoAnálisis retrospectivo de 92 estudios de TCMD consecutivos realizados entre enero de 2011 y junio de 2013 en 80 pacientes; de ellos, 70 (76%) antes de un primer procedimiento de ablación y 22 (24%) en pacientes que ya habían recibido algún procedimiento de ablación. ResultadosSe encontraron hallazgos relevantes en el 34% de los pacientes en quienes se realizó el estudio antes del primer procedimiento de ablación y en el 68% de los estudios realizados tras algún procedimiento. La incidencia de ictus asociado al procedimiento de ablación fue del 3%, similar a la registrada en nuestro centro antes de utilizar la TCMD para la evaluación de la anatomía de la aurícula izquierda. Todos los pacientes sintomáticos tenían algún grado de estenosis de las venas pulmonares, significativa en el 80%. Además, la progresión de estas fue muy rápida; el tratamiento con angioplastia-balón se asoció a reestenosis precoz. El implante de stent fue una alternativa en los casos de angioplastia fallida. ConclusiónLa TCMD en la evaluación previa y el seguimiento de los pacientes sometidos a un procedimiento de ablación de venas pulmonares permite guiar el tratamiento y detectar complicaciones." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Revilla Orodea A, Sánchez Lite I, Gallego Beuth JC, Sevilla Ruiz T, Sandín Fuentes MG, Amat Santos IJ, et al. Utilidad de la tomografía computarizada multidetector en la evaluación previa y el seguimiento de los pacientes sometidos a ablación de venas pulmonares. Radiología. 2017;59:321–328." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1014 "Ancho" => 2833 "Tamanyo" => 194034 ] ] "descripcion" => array:1 [ "en" => "(A) Normal left atrial appendage (LAA). (B) Left atrial appendage with self-contrast (black arrow). (C) Left atrial appendage with thrombus (asterisk) surrounded by significant self-contrast." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2264 "Ancho" => 1626 "Tamanyo" => 247397 ] ] "descripcion" => array:1 [ "en" => "Measurement of severity and length of two (2) pulmonary vein stenoses. (A) Significant stenosis (70 per cent of the vein reference diameter) of 15mm in length in the SRPV (superior right pulmonary vein). (B) Moderate stenosis (60 per cent) of 18.7mm in length in the SRPV (superior right pulmonary vein)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 649 "Ancho" => 1984 "Tamanyo" => 249422 ] ] "descripcion" => array:1 [ "en" => "Progression of pulmonary vein stenosis. The inferior right pulmonary vein (arrows) shows serious stenosis in the 1st study (A) that progresses in the 2nd study (B) and becomes occluded in the 3rd study (C). The intermediate right pulmonary vein (asterisk) shows critical stenosis in the 1st study (A) that becomes occluded in the 2nd and 3rd studies (B and C). We can also see the stents implanted in superior pulmonary veins (C)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2534 "Ancho" => 2835 "Tamanyo" => 466000 ] ] "descripcion" => array:1 [ "en" => "Inferior right pulmonary vein (IRPV) with critical stenosis, low flow, and thrombotic content (arrow in A) that becomes occluded during follow-up (arrow in C). Inferior left pulmonary vein (ILPV) (arrow in B) treated with one stent that remains patent during follow-up (arrow in D)." ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "S: stenosis; MDCT: multidetector computed tomography; IRPV: inferior right pulmonary vein; ILPV: inferior left pulmonary vein; IntRPV: intermediate right pulmonary vein; SRPV: superior right pulmonary vein; SLPV: superior left pulmonary vein." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Previous ablations (n) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MDCT findings \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Invasive therapy applied \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IntRPV: mild S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ILPV: mild S with thrombus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Atypical chest pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IntRPV: critical S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IRPV: mild S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV y IntRPV: obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV: significant S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failed angioplasty \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dry cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLPV, ILPV, IntRPV: obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV, IRPV and ILPV: mild S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Persistent cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLPV: significant S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Isolated hemoptisis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IntRPV: serious S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ILPV: moderate S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Balloon-angioplasty on SLPV, IRPV and IntRPV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV: significant S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLPV, IRPV: serious S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IntRPV: critical S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV, ILPV: significant S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Angioplasty-stent procedure on SRPV, SLPV. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLPV: serious S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failed angioplasty on IRPV (obstructed) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IRPV: critical S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IntRPV: obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SRPV and SLPV: patent stents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ILPV: significant S \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IRPV and IntRPV: obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1457469.png" ] ] ] 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735107/0000005900000004/v1_201707120030/S2173510717300381/v1_201707120030/en/main.assets" "Apartado" => array:4 [ "identificador" => "66551" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735107/0000005900000004/v1_201707120030/S2173510717300381/v1_201707120030/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510717300381?idApp=UINPBA00004N"]

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Utilidad de la tomografía computarizada multidetector en la evaluación previa y el seguimiento de los pacientes sometidos a ablación de venas pulmonares

A. Revilla Orodeaa,b,

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arevillaorodea@gmail.com

Corresponding author.

, I. Sánchez Litec, J.C. Gallego Beuthc, T. Sevilla Ruiza,b, M.G. Sandín Fuentesd, I.J. Amat Santosb,d, J.A. San Román Calvarb,d

a Unidad de Imagen Cardiaca, Servicio de Cardiología Hospital Clínico Universitario, Valladolid, Spain

b CIBER de Enfermedades Cardiovasculares (CIBERCV), Spain

c Servicio de Radiología, Hospital Clínico Universitario, Valladolid, Spain

d Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, Spain

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with the corresponding risk of systemic stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> Traditionally&#44; the clinical guidelines discuss the detection of thrombi with the use of transesophageal echocardiograms &#40;TEE&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> but the multidetector computed tomography &#40;MDCT&#41; scan is a very good alternative modality that may be used as a diagnostic tool for its detection&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> Also&#44; there are possible long-term contraindications derived from PV ablation like the development of stenoses that may be symptomatic&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Traditionally&#44; the imaging modality of choice for assessment before and after performing one ablation procedure was the TEE&#46; The introduction of the magnetic resonance imaging &#40;MRI&#41; and the MDCT scan&#44; both imaging modalities of higher resolution&#44; allows 3D reconstructions and a better anatomical assessment of left atrium&#46; The integration of data and information from these modalities and anatomical and electrophysiological information obtained through the specific navigation systems used in electrophysiology units has made it possible to reduce the ablation procedure time and increase safety and effectiveness&#44; since the application of radiofrequency inside the PVs is no longer necessary &#40;beyond the ostium&#44; which is the target of ablation&#41;&#44; and all these reduces the chances of PV stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">6&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The goal of our study is to assess the utility of the MDCT scan in the preliminary assessment and posterior follow-up of patients who undergo PV ablation procedures through radiofrequency&#44; 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&#40;General Electric Healthcare&#44; Waukesha&#44; WI&#44; USA&#41; with cardiac synchronization&#44; total rotation time 330<span class="elsevierStyleHsp" style=""></span>ms&#44; and 40<span class="elsevierStyleHsp" style=""></span>mm coverage by rotation&#46; IV betablockers were administered at the study ward when needing to achieve heart rate target &#60;65<span class="elsevierStyleHsp" style=""></span>bpm &#40;esmolol&#44; average dose 60<span class="elsevierStyleHsp" style=""></span>mg&#44; in 11 patients&#41;&#46; The protocol with the least possible radiation exposure was picked &#40;prospective&#41;&#44; even in the absence of low cardiac rates &#40;&#60;65<span class="elsevierStyleHsp" style=""></span>bpm&#41;&#46; Using two &#40;2&#41; orthogonal projection localizers&#44; one cardiac acquisition field was programmed including the left atrium and PVs with 0&#46;625<span class="elsevierStyleHsp" style=""></span>mm cut thickness&#46; Using one peripheral venous catheter&#44; 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The TEE confirmed absence of thrombi in the left atrial appendage and the transseptal puncture was guided toward the left atrium&#46; Two &#40;2&#41; large inducers&#44; one &#40;1&#41; circular catheter and one &#40;1&#41; irrigated ablation catheter were inserted into the atrium&#46; During the procedure the patient was kept on anticoagulation using bolus of IV heparine sodium&#44; and the activated clotting time &#40;adequate values between 250 and 350<span class="elsevierStyleHsp" style=""></span>s&#41; was monitored&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The 3D image acquired through electroanatomic mapping was integrated into the 3D image of the MDCT scan using the navigation system CARTO<span class="elsevierStyleSup">&#174;</span> &#40;Biosense Ltd&#46;&#44; Israel&#41;&#46; After the electroanatomic reconstruction of the atrium&#44; the radiofrequency ablation of left and right PVs was conducted&#46; The electronic isolation was confirmed using the circular catheter that was placed in the pulmonary vein antrum&#46; The procedure was completed when the electroanatomic isolation of all PVs was achieved&#44; although at times&#44; it was completed when conducting ablation lines in the left atrium &#40;left atrial roof and mitral isthmus&#41; or when isolating the superior vena cava&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data mining</span><p id="par0045" class="elsevierStylePara elsevierViewall">The cardiac MDCT scans were analyzed at the Unidad de Imagen del Hospital Cl&#237;nico Universitario de Valladolid&#44; by one expert cardiologist and one expert radiologist in the conduction and interpretation of cardiovascular studies &#40;over five years of experience in the acquisition and interpretation of cardiac MDCT scans&#46;&#41; The analysis of the images was conducted using one working station &#40;Advantage Work Station 4&#46;4<span class="elsevierStyleSup">&#174;</span>&#44; General Electric Medical System&#41; with one specific software for cardiovascular studies &#40;VolumeViewer<span class="elsevierStyleSup">&#174;</span> 7&#46;6&#46;29&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In each study&#44; the number and arrangement of pulmonary veins was described&#44; including their diameter in two &#40;2&#41; orthogonal projection planes 1<span class="elsevierStyleHsp" style=""></span>cm away from the ostium&#44; and the presence of thrombi in the atrium or left atrial appendage &#40;low attenuation mass adhered to the wall of the left atrial appendage&#41;&#46; The diffuse reduction of signal in the left atrial appendage&#44; without the image of the thrombus&#44; was described as self-contrast in the appendage &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; One PV stenosis &#40;reduction of normal vein caliber after an ablation procedure&#41; was assessed in comparison to one healthy proximal or distal reference diameter&#46; Both its severity level &#40;&#60;30 per cent&#44; mild&#59; 30&#8211;50 per cent&#44; moderate&#59; 50&#8211;70 per cent&#44; significant&#59; 70&#8211;90 per cent&#44; serious&#59; &#62;90 per cent&#44; critical&#59; 100 per cent&#44; obstruction&#41; and length &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; were assessed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Both the procedure-associated complications and clinical follow-up were gathered &#40;recurrence of atrial fibrillation&#44; stroke&#44; and presence of leading symptoms of PV stenosis&#41;&#44; as well as the therapy administered to those cases of PV stenosis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The informed written consent from all patients was obtained prior to conducting the MDCT scans and ablation procedures&#46; Our hospital scientific committee approved the studies and it did not deem it necessary to obtain approval from the ethics committee since it was a retrospective non-interventional study&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In 24 out of the 70 patients in whom the MDCT can was indicated before a first ablation procedure&#44; significant findings we found &#40;34 per cent&#41;&#58; 12 thrombi in the left atrial appendage&#44; 1 thrombus in the right inferior pulmonary vein&#44; 10 patients with self-contrast in the left atrial appendage without an image of the thrombis&#44; hypodensity probably due to slow or turbulent flow&#44; and one patient with one mass in the left atrial roof that was compatible with a small left atrial myxoma&#46; In those patients with a thrombus or self-contrast&#44; the most strict oral anticoagulant treatment was pursued for a minimum period of one month &#40;increased range and target INR of 2&#46;5&#8211;3&#46;5 in the absence of contraindication due to hemorrhagic risk and more common controls&#41;&#8211;a very similar strategy to the one reported by other groups&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> Finally&#44; in 14 of these patients&#44; the PV ablation procedure was performed in 54 days &#40;range&#58; 42&#8211;133 days&#41; after the MDCT can&#46; One intraoperative TEE was conducted that ruled out the presence of thrombi in the left atrial appendage in all patients&#44; although 4 of them showed self-contrast without the image of a thrombus&#46; One of the patients developed one intraoperative ischemic stroke that resolved completely during the first 24<span class="elsevierStyleHsp" style=""></span>h&#59; the cranial MDCT scan showed one infarction in a distal branch of the right medial cerebral artery&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In 38 out of the 46 patients whose MDCT scans were normal&#44; the ablation procedure was performed in 57 days &#40;range&#58; 30&#8211;99 days&#41;&#46; In all of them&#44; the intraoperative TEE was normal&#46; One patient had an early stroke after the procedure&#44; with mild motor&#44; sensory&#44; and ocular sequelae&#59; the cranial MDCT scan showed one infarction of the left posterior cerebral artery and multiple lacunary infarcts&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The ablation procedure was effective &#40;sinus rhythm after the procedure&#41; in 100 per cent of the patients&#46; Persistence in sinus rhythm during the follow-up at 2 years occurred in 76 per cent of the patients who received an ablation procedure for the first time&#44; and in 85 per cent of those who underwent more than one ablation procedure&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In 10 out of the 24 patients with significant findings in the MDCT scan&#44; and in 8 out of the 46 patients with normal MDCT scans&#44; the ablation procedure was not performed due to patient&#39;s denial or clinical criteria&#46; No ablation procedure was ruled out because of the MDCT scan findings&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our series&#44; the incidence of strokes associated with the procedure is 3 per cent &#40;2 cases in 66 procedures&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Of the 22 studies conducted after certain PV ablation procedure &#40;average&#58; 1&#46;6 previous procedures&#59; range&#58; 1&#8211;3&#41;&#44; 15 studies &#40;68 per cent&#41; showed relevant findings&#59; 14 were indicated before performing another ablation procedure&#44; and 8 studies were indicated due to symptoms after the ablation procedure in order to rule out PV stenosis&#46; In 7 out of the 14 studies indicated before performing a second intervention there were some relevant findings&#58; 5 thormbi in the left atrial appendage&#44; 3 patients with self-contrast in the appendage&#44; and 2 with insignificant PV stenosis &#40;1 patient with mild stenosis of left PVs and another patient with moderate stenosis of the inferior PVs&#41;&#46; Finally&#44; the ablation procedure was performed in 12 of these patients &#40;86 per cent&#41; after following the protocol of strict anticoagulation we already referred to in cases with thrombi or self-contrast in the left atrial appendage&#44; while the presence of thrombi or self-contrast was ruled out in all patients who underwent intraoperative TEEs&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In five patients we performed a total of 8 MDCT scans to rule out PV stenosis after symptom onset&#46; These symptoms were dyspnea and persistent cough after the ablation procedure and in one patient&#44; hemoptisis&#46; No degree of PV stenosis was detected in any patients and in four patients we found significant or major cases of stenosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; None of the patients underwent one new ablation procedure&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the MDTC findings of these five patients and the therapy administered in each case &#40;one patient with failed angioplasty and another patient with balloon angioplasty&#44; and further stenting&#41;&#46; The most commonly affected PV in our series was the intermediate right pulmonary vein and the least commonly affected PV was the inferior right pulmonary vein&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">In more than one third of the patients who underwent one MDCT scan before a first PV ablation procedure&#44; relevant findings were found&#44; above all&#44; thrombi or self-contrast in the left atrial appendage&#46; When the MDCT scan was conducted after a first ablation procedure&#44; the percentage of relevant findings almost reached 70 per cent&#44; yet they were different based on the indication of MDCT scan&#58; thrombus or self-contrast in asymptomatic patients &#40;50 per cent&#41; and PV stenosis in 100 per cent of the MDCT scans indicated due to significant symptoms &#40;dyspnea&#44; cough&#44; or hemoptisis&#41; in 80 per cent of the cases&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Despite the introduction of the MDCT scan for the management of our patients&#44; we have not seen a lower incidence of procedural strokes compared to the time when we did not conduct these studies for the assessment of left atrium anatomy&#46; In our series&#44; the presence of thrombi in the left atrial appendage confirmed through MDCT scans was far more significant than shown by the TEE&#46; However&#44; the fact that the incidence of strokes was not reduced after the introduction of the MDCT scan makes us think that the TEE is still a powerful imaging modality for stroke prevention in this group of patients&#46; The detection of thrombi or self-contrast in the MDCT scan makes us adopt a more intensive anticoagulation attitude that&#44; <span class="elsevierStyleItalic">a priori</span>&#44; should have an impact on the reduction of cerebral ischemic events&#44; something that we did not detect in our series&#46; Nevertheless&#44; the number of cases of strokes in both periods is low&#44; making it hard to detect significant differences&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">All patients underwent a perioperative TEE regardless of the detection of thrombi or self-contrast in the MDCT scan&#46; The TEE is useful to rule out the presence of thrombi right before the procedure and guide the interatrial septum puncture&#46; In patients with thrombi in the MDCT scan&#44; it is not indicated to repeat the MDCT scan to rule out the presence of thrombi&#44; since the TEE is effective enough to achieve this diagnosis and also because the MDCT associates exposure to ionizing radiation&#46; In patients with no traces of thrombi or self-contrast in the appendage&#44; it is also indicated to perform one perioperative TEE&#44; since the temporal delay elapsed between the MDCT scan and the ablation procedure is not enough to be able to rule out the formation of thrombi in the appendage&#46; Consequently&#44; the MDCT scan for the anatomical study of the left atrium&#44; and the perioperative TEE to rule out the presence of thrombi in the left atrial appendage is an appropriate combination in patients undergoing PV ablation procedures&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Pulmonary vein stenosis is due to a not fully understood mechanism including inflammatory phenomena with intimal proliferation&#44; local thrombosis and fibrosis secondary to the application of radiofrequency in the pulmonary vein ostia&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our own experience&#44; the presence of symptoms after an ablation procedure is associated with of a high probability of PV stenosis&#46; As a matter of fact&#44; all patients with symptoms showed some degree of PV stenosis&#44; most of them &#40;80 per cent&#41; significant or serious stenosis that explained the symptoms&#46; On the contrary&#44; the absence of symptoms relaxes the clinician when it comes to the presence of PV stenosis&#46; Although there was not any systematic follow-up of all the patients in our series through MDCT scans&#44; in no asymptomatic patient undergoing another MDCT scan before another ablation procedure there was significant evidence of PV stenosis&#46; The affectation of the intermediate right pulmonary vein is much more common in our series than in other series&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> When dealing with smaller caliber veins&#44; the administration of radiofrequency to these veins may explain why they are more commonly affected&#46; The fact that they are close to the superior or inferior right pulmonary veins &#40;of a larger caliber&#41; may also promote the affectation of these nearby veins due to ablation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The management of PV stenosis is controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">11&#44;12</span></a> The balloon angioplasty is the first line of therapy recommended&#44; but it has a very high incidence of restenosis&#46; Another available option is stenting&#44; also associated with a significant frequency of restenosis &#40;30&#8211;50 per cent&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">11&#44;13</span></a> The management of obstructions is usually defective&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> In our own experience&#44; the progression of stenoses is extremely fast&#59; one month delays between the MDCT scan and the angioplasty lead to the complete obstruction of one patient&#39;s critically ill inferior left pulmonary vein that could not be repaired again &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; In another patient with PV obstruction&#44; the attempt to deconstruct the veins failed&#46; Therefore&#44; once a PV stenosis is detected&#44; and only if it is indicated to repair it&#44; such a thing should be done without any further delay&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The MDCT scan had an important role when deciding the diameter and length of the stents to be implanted&#44; since it allowed us to measure the vein reference diameter and length of stenosis&#46; Therefore&#44; the role of the MDCT scan is not merely diagnostic&#44; but it is also of great utility in the decision making process when it comes to performing angioplasties&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We conducted one study comparing our data to those of a similar period &#40;from June 2008 to December&#44; 2011&#41; when we did not conduct any MDCT scans in our center before ablation procedures&#46; In this period&#44; in the electrophysiology ward&#44; 89 TEEs were performed in 89 patients who would eventually undergo PV ablation procedures&#46; Five &#40;5&#41; thrombi &#40;6 per cent&#41; were found&#44; which is a lower percentage than the percentage detected by the MDCT scan in the later period &#40;22 per cent <span class="elsevierStyleItalic">vs</span> 6 per cent&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46; Ultimately&#44; 84 ablation procedures were conducted&#46; The incidence of perioperative strokes in these patients was 2&#46;4 per cent &#40;2 cases in 84 patients&#41;&#44; a similar incidence to the later period when MDCT scans were conducted &#40;3 per cent <span class="elsevierStyleItalic">vs</span> 2&#46;4 per cent&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;999&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The main limitation of our study is the number of patients in the sample&#44; the limited number of adverse events recorded&#44; and the fact that it was a retrospective analysis&#46; More specific studies are needed to be able to confirm our results&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In sum&#44; the MDCT scan has great utility for the assessment of patients with atrial fibrillation prior to the performance of an ablation procedure&#44; because of the anatomical definition that helps us conduct this procedure&#44; and because of the detection of thrombi in the left atrial appendage&#44; which may be one clear contraindication&#46; Also it is useful for the follow-up of symptomatic patients post-ablation procedure because it detects relevant PV stenoses that may explain the clinical manifestations and help guide the administration of therapy&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Also the combination of MDCT scans for the anatomical study of the left atrium and perioperative TEEs to rule out the presence of thrombi in the left atrial appendage is one safe adequate strategy in patients who undergo PV ablation procedures&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no experiments with human beings or animals have been performed while conducting this investigation&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols from their centers on the disclosure of data from patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors confirm that in this article there are no data from patients&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">This study has been funded by the <span class="elsevierStyleGrantSponsor" id="gs1">ERDF</span><span class="elsevierStyleItalic">&#40;European Regional Development Fund&#41;&#46;</span></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authors&#8217; contribution</span><p id="par0175" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Manager of the integrity of the study&#58; ARO&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Study Idea&#58; ARO and TSR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Study Design&#58; ARO&#44; ISL and TSR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Data Mining&#58; ARO&#44; JCGB and MGSF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Data Analysis and Interpretation&#58; ARO&#44; TSR&#44; ISL and IJAS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Statistical Analysis&#58; ARO and TSR&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Reference&#58; JCGB&#44; IJAS and JASRC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Writing&#58; ARO&#44; ISL and JCGB&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant remarks&#58; MGSF&#44; ISL&#44; TSR&#44; IJAS and JASRC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Approval of final version&#58; ARO&#44; ISL&#44; TSR&#44; JCGB&#44; MGSF&#44; IJAS and JASRC&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest associated with this article whatsoever&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the usefulness of multidetector computed tomography &#40;MDCT&#41; in the preprocedural evaluation and follow-up of patients undergoing radiofrequency ablation of pulmonary veins and the impact of the MDCT findings on the approach to treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively analyzed 92 consecutive MDCT studies done in 80 patients between January 2011 and June 2013&#59; 70 &#40;76&#37;&#41; studies were done before a first ablation procedure and 22 &#40;24&#37;&#41; were done in patients who had undergone an ablation procedure&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Findings were useful in 34&#37; of the patients who underwent MDCT before the first ablation procedure and in 68&#37; of the studies done after a procedure&#46; The incidence of stroke associated with the ablation procedure was 3&#37;&#44; similar to the incidence recorded in our center before we started to use MDCT to evaluate the anatomy of the left atrium&#46; All symptomatic patients had some pulmonary vein stenosis&#44; and 80&#37; had significant stenosis&#46; Furthermore&#44; the stenoses progressed very rapidly&#59; treatment with balloon angioplasty was associated with early restenosis&#46; Stenting was an alternative in cases of failed angioplasty&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the preprocedural evaluation and postprocedural follow-up of patients undergoing pulmonary vein isolation&#44; MDCT is useful for guiding treatment and detecting complications&#46;</p></span>"
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            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estudiar la utilidad de la tomograf&#237;a computarizada multidetector &#40;TCMD&#41; en la evaluaci&#243;n previa y el seguimiento de los pacientes sometidos a ablaci&#243;n de venas pulmonares mediante radiofrecuencia&#44; y la actitud terap&#233;utica basada en los hallazgos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de 92 estudios de TCMD consecutivos realizados entre enero de 2011 y junio de 2013 en 80 pacientes&#59; de ellos&#44; 70 &#40;76&#37;&#41; antes de un primer procedimiento de ablaci&#243;n y 22 &#40;24&#37;&#41; en pacientes que ya hab&#237;an recibido alg&#250;n procedimiento de ablaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se encontraron hallazgos relevantes en el 34&#37; de los pacientes en quienes se realiz&#243; el estudio antes del primer procedimiento de ablaci&#243;n y en el 68&#37; de los estudios realizados tras alg&#250;n procedimiento&#46; La incidencia de ictus asociado al procedimiento de ablaci&#243;n fue del 3&#37;&#44; similar a la registrada en nuestro centro antes de utilizar la TCMD para la evaluaci&#243;n de la anatom&#237;a de la aur&#237;cula izquierda&#46; Todos los pacientes sintom&#225;ticos ten&#237;an alg&#250;n grado de estenosis de las venas pulmonares&#44; significativa en el 80&#37;&#46; Adem&#225;s&#44; la progresi&#243;n de estas fue muy r&#225;pida&#59; el tratamiento con angioplastia-bal&#243;n se asoci&#243; a reestenosis precoz&#46; El implante de <span class="elsevierStyleItalic">stent</span> fue una alternativa en los casos de angioplastia fallida&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La TCMD en la evaluaci&#243;n previa y el seguimiento de los pacientes sometidos a un procedimiento de ablaci&#243;n de venas pulmonares permite guiar el tratamiento y detectar complicaciones&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Revilla Orodea A&#44; S&#225;nchez Lite I&#44; Gallego Beuth JC&#44; Sevilla Ruiz T&#44; Sand&#237;n Fuentes MG&#44; Amat Santos IJ&#44; et al&#46; Utilidad de la tomograf&#237;a computarizada multidetector en la evaluaci&#243;n previa y el seguimiento de los pacientes sometidos a ablaci&#243;n de venas pulmonares&#46; Radiolog&#237;a&#46; 2017&#59;59&#58;321&#8211;328&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Normal left atrial appendage &#40;LAA&#41;&#46; &#40;B&#41; Left atrial appendage with self-contrast &#40;black arrow&#41;&#46; &#40;C&#41; Left atrial appendage with thrombus &#40;asterisk&#41; surrounded by significant self-contrast&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Measurement of severity and length of two &#40;2&#41; pulmonary vein stenoses&#46; &#40;A&#41; Significant stenosis &#40;70 per cent of the vein reference diameter&#41; of 15<span class="elsevierStyleHsp" style=""></span>mm in length in the SRPV &#40;superior right pulmonary vein&#41;&#46; &#40;B&#41; Moderate stenosis &#40;60 per cent&#41; of 18&#46;7<span class="elsevierStyleHsp" style=""></span>mm in length in the SRPV &#40;superior right pulmonary vein&#41;&#46;</p>"
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Progression of pulmonary vein stenosis&#46; The inferior right pulmonary vein &#40;arrows&#41; shows serious stenosis in the 1st study &#40;A&#41; that progresses in the 2nd study &#40;B&#41; and becomes occluded in the 3rd study &#40;C&#41;&#46; The intermediate right pulmonary vein &#40;asterisk&#41; shows critical stenosis in the 1st study &#40;A&#41; that becomes occluded in the 2nd and 3rd studies &#40;B and C&#41;&#46; We can also see the stents implanted in superior pulmonary veins &#40;C&#41;&#46;</p>"
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Inferior right pulmonary vein &#40;IRPV&#41; with critical stenosis&#44; low flow&#44; and thrombotic content &#40;arrow in A&#41; that becomes occluded during follow-up &#40;arrow in C&#41;&#46; Inferior left pulmonary vein &#40;ILPV&#41; &#40;arrow in B&#41; treated with one stent that remains patent during follow-up &#40;arrow in D&#41;&#46;</p>"
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      4 => array:8 [
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">S&#58; stenosis&#59; MDCT&#58; multidetector computed tomography&#59; IRPV&#58; inferior right pulmonary vein&#59; ILPV&#58; inferior left pulmonary vein&#59; IntRPV&#58; intermediate right pulmonary vein&#59; SRPV&#58; superior right pulmonary vein&#59; SLPV&#58; superior left pulmonary vein&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Previous ablations &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MDCT findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Invasive therapy applied&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IntRPV&#58; mild S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ILPV&#58; mild S with thrombus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Atypical chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IntRPV&#58; critical S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IRPV&#58; mild S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV y IntRPV&#58; obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV&#58; significant S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failed angioplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dry cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLPV&#44; ILPV&#44; IntRPV&#58; obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dyspnea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV&#44; IRPV and ILPV&#58; mild S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Persistent cough&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLPV&#58; significant S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Isolated hemoptisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IntRPV&#58; serious S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ILPV&#58; moderate S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Balloon-angioplasty on SLPV&#44; IRPV and IntRPV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV&#58; significant S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLPV&#44; IRPV&#58; serious S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IntRPV&#58; critical S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV&#44; ILPV&#58; significant S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Angioplasty-stent procedure on SRPV&#44; SLPV&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLPV&#58; serious S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failed angioplasty on IRPV &#40;obstructed&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IRPV&#58; critical S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IntRPV&#58; obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SRPV and SLPV&#58; patent stents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ILPV&#58; significant S&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IRPV and IntRPV&#58; obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Characteristics and therapy administered to patients with MDCT scan indicated in order to rule out pulmonary vein stenosis&#46;</p>"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2017.06.001

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