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Ruiz Torres, C. Ramos Paesa, T. Rivero Salvador, C. Marín Zaldivar, D. Gil Pérez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Ruiz Torres" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Ramos Paesa" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Rivero Salvador" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Marín Zaldivar" ] 4 => array:2 [ "nombre" => "D." 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Delgado-Sánchez, G.M. Gutiérrez, J.L. López Romero, M.M. Martínez Gómez, A. Domínguez Blanco" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "de la Matta" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Delgado-Sánchez" ] 2 => array:2 [ "nombre" => "G.M." "apellidos" => "Gutiérrez" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López Romero" ] 4 => array:2 [ "nombre" => "M.M." "apellidos" => "Martínez Gómez" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Domínguez Blanco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S003493562030267X" "doi" => "10.1016/j.redar.2020.10.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493562030267X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000883?idApp=UINPBA00004N" "url" => "/23411929/0000006800000006/v1_202106271045/S2341192921000883/v1_202106271045/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "353" "paginaFinal" => "356" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Rodríguez Alcalá, A. Maestro Borbolla, E. Rodríguez Pérez, P. Sanabria Carretero, F. Reinoso Barbero" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Rodríguez Alcalá" "email" => array:1 [ 0 => "cristinarodriguezalcala@hotmail.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Maestro Borbolla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Rodríguez Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "P." "apellidos" => "Sanabria Carretero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "F." "apellidos" => "Reinoso Barbero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación Infantil, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 649 "Ancho" => 900 "Tamanyo" => 121152 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">VATS left cardiac sympathetic denervation showing the stellate ganglion (upper left) and the first 4 left thoracic ganglia of the sympathetic chain.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Inherited cardiovascular disease encompasses a group of cardiovascular diseases (cardiomyopathies, channelopathies, some aortic diseases and other syndromes) that share a series of common characteristics<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">They have a familial presentation that requires a comprehensive study of all family members.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">They have a genetic basis (genetic diagnosis).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">They cause sudden cardiac death in the population under 35 years of age, and as such have a major social impact.</p></li></ul></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therapeutic options include medical treatment with antiarrhythmic drugs and beta-blockers, implantable cardioverter-defibrillators (ICD) for primary and/or secondary prevention, and radiofrequency catheter ablation in the subgroup of patients with apical aneurysm and obstructive hypertrophic cardiomyopathy (HCM) with recurrent monomorphic ventricular tachycardia.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In refractory cases, the surgical treatment of choice is left cardiac sympathetic denervation (LCSD).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> In LCSD, the lower half of the left stellate ganglion is removed, thus achieving a defibrillator effect associated with few complications by denervating the afferent and efferent nerve fibres of the cervical paravertebral sympathetic trunk corresponding to the first 4 or 5 thoracic ganglia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the latest recommendations, the technique is most effective and therefore mainly indicated in patients diagnosed with long QT syndrome and catecholaminergic polymorphic ventricular tachycardia.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> However, it should be considered in all cases of arrhythmic syncope refractory to optimal medical therapy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Video-assisted thoracoscopy (VATS), a minimally invasive approach, is the technique of choice.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> VATS was first developed for upper thoracic sympathectomy (1990) to treat hyperhidrosis. The first report of VATS for LCSD was published in 2003.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The technique has several advantages, including: lower rate of complications, shorter hospital stays (1–2 days) and less pleural drainage compared to extrapleural thoracotomy. It provides the most extensive and precise resection of the sympathetic chain, with a lower risk of Horner's syndrome (less traction on the stellate ganglion and sympathetic chain).<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0050" class="elsevierStylePara elsevierViewall">We describe the case of a 12-year-old boy, weight 46 kg, with no personal history of note and a family history of nonobstructive HCM with no cases of SD who came to the emergency room following out-of-hospital cardiopulmonary resuscitation (CPR) while playing basketball. He had required 18 min of basic CPR and two automated external defibrillator shocks to treat ventricular escape beats. He was admitted to paediatric intensive care for 5 days with mild neurological sequelae.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After a complete cardiology study, nonobstructive HCM with the sarcomeric mutation of the cardiac troponin 1 gene (cTN1) was diagnosed. The familial study was negative. A single chamber ICD was implanted in the right ventricle as secondary prevention, and treatment with 25 mg/8 h atenolol and 200 mg/8 h amiodarone was started. However, over the past year he presented 3 episodes of syncope and was admitted for arrhythmic storm. This effectively exhausted ICD therapies, and he was schedule for VATS LCSD.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Once the preoperative evaluation had been performed, the anaesthesia plan was drawn up and family members were asked to sign the informed consent form. On the day of the intervention, the ICD was inactivated before entering the operating room and the adhesive paddles of the external defibrillator were placed. General anaesthesia was induced with 6%–8% sevoflurane and 150 mg propofol, 30 mg atracurium, and 150 mcg fentanyl were administered. The patient was intubated with a number 28 left double lumen tube, and correct positioning was verified by fibreoptic bronchoscopy. The right radial artery and right internal jugular vein were cannulated under ultrasound guidance, and a 16-gauge peripheral venous line was placed. Anaesthesia was maintained with sevoflurane (minimum alveolar concentration [MAC] 0.9) for a target bispectral index of between 40–45, 300 mcg fentanyl and 20 mg atracurium. One-lung ventilation was delivered in pressure control (PC) mode with an inspiratory pressure of 23 cmH<span class="elsevierStyleInf">2</span>0, tidal volume 6−7 mL/kg, respiratory rate 18 rpm, PEEP 5cmH<span class="elsevierStyleInf">2</span>0, EtCO<span class="elsevierStyleInf">2</span> 35 mmHg, and FiO<span class="elsevierStyleInf">2</span> 0.7 to maintain SpO<span class="elsevierStyleInf">2</span> 95%–96%. After induction, systolic blood pressure was 65−70 mmHg and heart rate 35–40 bpm, so continuous perfusion (CP) of 0.03 mcg/kg/min norepinephrine was started. Antibiotic prophylaxis with 2 g cefazolin and multimodal analgesia with 1 g paracetamol were administered. Laparoscopic ports were infiltrated with 10 mL 0.5% bupivacaine, and 4 mg ondansetron was given for postoperative nausea and vomiting prophylaxis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Cardiac denervation was performed by VATS sympathectomy with the patient in the right lateral decubitus position, removing the lower half of the stellate ganglion and the first 4 thoracic ganglia (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>); the patient remained hemodynamically stable at all times. After 2 h 35 min of surgery, the patient was extubated in the operating room without incident and was transferred to the paediatric surgical intensive care unit (ICU) without the need for inotropics and vasopressors.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Twenty four hours after admission to the surgical ICU, the patient presented with left-sided Horner syndrome, which was followed up by ophthalmology. He remained hemodynamically stable with no arrhythmias on electrocardiographic monitoring. The ICD was reprogrammed to the baseline settings and he restarted his usual treatment 4 h after the intervention. The chest tube was removed 8 h after surgery. The only complication was postoperative nausea and vomiting during the first few postoperative hours, which subsided with infusion of 2 mL/h propofol. He was discharged from hospital on the third day with partial resolution of Horner syndrome.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The main challenges to consider in the perioperative evaluation of these patients include the risk of intraoperative and postoperative cardiac events (haemodynamic instability, arrhythmia, and cardiac arrest),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> the impact of one-lung ventilation and heart-lung interactions,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the need for adequate inotropic and vasopressor therapy. These patients are generally classed as ASA (American Society of Anesthesiologists) III/IV and routinely require additional tests with complete labs, cardiological study and chest X-ray. Pre-operative algorithms do not include lung function tests.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Double lumen endotracheal tubes can only be used in children aged over 8 years weighing over 30 kg. It is important for paediatric anaesthesiologists to be aware of this<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and to consider other one-lung ventilation options, for example, bronchial blockers such as the fogarthy catheter (for use in infants), ARNDT (from 2 years of age) and UNIVENT (from 6 years of age) blockers, or selective intubation using a conventional endotracheal tube, which carries a risk of contamination and slower lung collapse.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The anaesthesiologist should use standard monitoring with arterial and central venous lines, and place the defibrillator paddles anteroposterior at 10 cm from the ICD.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> Whenever intravenous access is available, intravenous induction using a non-depolarizing agent is preferred over inhalational anaesthesia. Anaesthesia can be maintained with inhalational agents with between 0.7 and 1.3 MAC or with total intravenous anaesthesia (TIVA), depending on the experience of the anaesthesiologist and the tolerance of the patient.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Given the low cardiac output that characterises these patients, it is essential to guarantee good oxygenation and ventilation, so correct positioning of the endotracheal tube must be verified by fibreoptic bronchoscopy, depending on the diameter of the tube used, in order to avoid hypoxaemia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Protective lung ventilation is recommended, with a tidal volume of around 4−6 mL/kg, continuous positive pressure in the non-ventilated lung, and PEEP between 5−10 cmH<span class="elsevierStyleInf">2</span>0 in the ventilated lung to prevent and/or treat hypoxaemia should it arise.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Transoesophageal echocardiography is steadily gaining ground among anaesthesiologists, and is currently the most effective method for assessing cardiac function and performing goal-directed fluid therapy.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The first consideration in the immediate postoperative period is to restart antiarrhythmic therapy with the ICD as soon as possible after transfer to the surgical ICU or postanaesthesia care unit.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Perioperative management of complex haemodynamic disorders calls for anaesthesiologists to be familiar with transoesophageal ultrasound, invasive monitoring, inotropics, vasopressors, ICDs, one-lung ventilation, and advanced life support (ALS) protocols.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Whenever arrhythmic syncope occurs in the context of certain familial heart diseases, VATS LCSD should be considered the next step in the treatment plan.</p><p id="par0115" class="elsevierStylePara elsevierViewall">As our patient was a minor, his parents were asked to sign the informed consent form.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Authors/collaborators</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Cristina Rodríguez Alcalá: performed the intervention.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Emilio Rodríguez Pérex: performed the intervention.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Alejandro Maestro Borbolla: prepared the draft of the article.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Pascual Sanabria Carretero: performed the critical review of the intellectual content.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Frascisco Reinoso Barbero: gave final approval of the version presented.</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interests</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1534433" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1391150" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1534434" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1391151" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors/collaborators" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-23" "fechaAceptado" => "2020-07-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1391150" "palabras" => array:6 [ 0 => "Autonomic denervation" 1 => "Sympathectomy" 2 => "Thoracoscopic surgical procedure" 3 => "Arrest cardiac" 4 => "Arrhythmogenic hereditary syndromes" 5 => "Stellate ganglion" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1391151" "palabras" => array:6 [ 0 => "Denervación autonómica" 1 => "Simpatectomía" 2 => "Toracoscopia" 3 => "Parada cardiocirculatoria" 4 => "Síndromes arritmogénicos familiares" 5 => "Ganglio estrellado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.<span class="elsevierStyleSup">1</span> We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD).</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.<span class="elsevierStyleSup">2</span></p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las cardiopatías familiares relacionadas con la muerte súbita son un grupo de enfermedades cardiovasculares (miocardiopatías, canalopatías, enfermedades aórticas…) que requieren familiaridad del anestesiólogo con el tratamiento perioperatorio de los trastornos hemodinámicos complejos, así como con el tratamiento quirúrgico de los mismos.<span class="elsevierStyleSup">1</span> Presentamos el caso de un varón de 12 años diagnosticado de miocardiopatía hipertrófica no obstructiva (MHNO), tras una parada cardiorrespiratoria (PCR), al que se le practicó una simpatectomía izquierda guiada por videotoracoscopia (VATS) por síncopes frecuentes, a pesar de tratamiento farmacológico e implantación de un desfibrilador automático implantable (DAI).</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Siempre que se produzca un síncope arrítmico en el contexto de enfermedades cardiacas familiares, la denervación cardiaca izquierda debe considerarse como el siguiente paso en el plan de tratamiento.<span class="elsevierStyleSup">2</span></p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez Alcalá C, Maestro Borbolla A, Rodríguez Pérez E, Sanabria Carretero P, Reinoso Barbero F. Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico. Rev Esp Anestesiol Reanim. 2021;68:353–356.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 649 "Ancho" => 900 "Tamanyo" => 121152 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">VATS left cardiac sympathetic denervation showing the stellate ganglion (upper left) and the first 4 left thoracic ganglia of the sympathetic chain.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 640 "Ancho" => 900 "Tamanyo" => 92065 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">VATS left cardiac sympathetic denervation. 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