Case report
Cerebral oximetry monitoring in the management of severe hypoxaemia associated with transposition of the great arteries with balloon atrial septostomy
Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón
J.C. Pérez Morenoa,
, D.C. Nájera Losadaa, P. Sanabria Carreterob, Á. Paredes Lacaveb, F. Benito Bartoloméc
Corresponding author
a Servicio de Anestesiología y Reanimación, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
b Servicio de Anestesiología y Cuidados Críticos Quirúrgicos Pediátricos, Hospital Universitario Infantil La Paz, Madrid, Spain
c Servicio de Cardiología Pediátrica, Hospital Universitario Infantil La Paz, Madrid, Spain
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Se observa una mejoría importante en la oxigenación tras realizar la atrioseptostomía con balón al pasar la saturación regional de oxígeno cerebral (rSO<span class="elsevierStyleInf">2</span>) del 23 al 68%.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.C. Pérez Moreno, D.C. Nájera Losada, P. Sanabria Carretero, Á. Paredes Lacave, F. Benito Bartolomé" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Pérez Moreno" ] 1 => array:2 [ "nombre" => "D.C." "apellidos" => "Nájera Losada" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Sanabria Carretero" ] 3 => array:2 [ "nombre" => "Á." "apellidos" => "Paredes Lacave" ] 4 => array:2 [ "nombre" => "F." 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"apellidos" => "Benito Bartolomé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Cuidados Críticos Quirúrgicos Pediátricos, Hospital Universitario Infantil La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cardiología Pediátrica, Hospital Universitario Infantil La Paz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón" ] ] "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" => 801 "Ancho" => 1583 "Tamanyo" => 98112 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Case 2. A positive correlation was observed between regional cerebral oxygen saturation (rSO<span class="elsevierStyleInf">2</span>) and serum lactate levels after balloon atrioseptostomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The transposition of the great arteries or D-TGA (D refers to the dextroposition of the bulboventricular loop) is one of the most common neonatal congenital heart diseases that require surgical intervention, and accounts for 7%–8% of all congenital heart diseases. D-TGA is characterised by an atrioventricular concordance and ventriculoarterial discordance, in such a way that the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Because the systemic and pulmonary circulations run in parallel, to be compatible with life they must communicate in some way, either by means of an atrial or ventricular septal defect, or at the arterial level in the form of patent ductus arteriosus.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The gold standard surgical treatment is anatomical correction or arterial switch. Before this can be performed, however, steps must be taken to improve circulatory mixing, decrease oxygen consumption and optimise flow-volume rate with the administration of, for example, prostaglandin E1, colloids, inotropics, sedation and respiratory assistance.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> If prostaglandin infusion is not accompanied by a frank increase in oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) and the foramen ovale is restrictive or the neonate is unstable, the atrial septal defect must be enlarged. This should be done by interventional catheterisation through the femoral vein using a balloon catheter (described by Rashkind and Miller in 1966), a new method that has replaced the surgical opening of the interatrial septum (Blalock–Hanlon method).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> Rashkind and Miller observed that the intra-artrial pressure gradient decreased and arterial oxygen saturation increased after balloon atrioseptostomy (BAS), and concluded that BSA is an effective procedure in D-TGA associated with severe hypoxaemia, acidosis and congestive heart failure.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present 2 cases of neonates with D-TGA that were treated with a non-invasive method known as near infrared spectroscopy (NIRS), in which a cranial sensor was placed in the frontal position to measure regional oxygen saturation (rSO<span class="elsevierStyleInf">2</span>), thus showing brain oxygenation and the balance between oxygen delivery and consumption before and after performing BAS. This allowed us to evaluate the efficacy of the therapy, defined as an improvement cerebral oxygenation or the balance between cerebral oxygen delivery and consumption. Most studies performed with NIRS involve repair surgery (arterial switch), and very little is known about the effects of presurgical interventions on cerebral oxygenation and the effectiveness of BAS with non-invasive NIRS technology in neonates with D-TGA.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A full-term male neonate with a gestational age of 37.5 weeks, weight 3500<span class="elsevierStyleHsp" style=""></span>g, delivered by caesarean section due to prolonged labour in a mother with high-risk pregnancy due to type 1 diabetes, with no prenatal diagnosis of heart disease. At birth, the infant was hypotonic, with central cyanosis that required resuscitation with intermittent positive pressure, with poor response to oxygen therapy (pre- and postductal SpO<span class="elsevierStyleInf">2</span> 50%). Ultrasound examination led to a diagnosis of D-TGA with intact ventricular septum, severely restrictive foramen ovale and 2<span class="elsevierStyleHsp" style=""></span>mm ductus. The infant was intubated and treatment was started with prostaglandin E1 0.1<span class="elsevierStyleHsp" style=""></span>g/kg/min, which increased ductus size to 4<span class="elsevierStyleHsp" style=""></span>mm and SpO<span class="elsevierStyleInf">2</span> to 65%. Inotropic therapy was started with dobutamine 10<span class="elsevierStyleHsp" style=""></span>μg/kg/min, and the patient was referred to our hospital. The infant arrived at our unit at 6<span class="elsevierStyleHsp" style=""></span>h of life, unstable, with BP 43/23<span class="elsevierStyleHsp" style=""></span>mmHg, HR 150<span class="elsevierStyleHsp" style=""></span>bpm, RR 45<span class="elsevierStyleHsp" style=""></span>rpm, preductal SpO<span class="elsevierStyleInf">2</span> 36% and posductal 45%, with FiO<span class="elsevierStyleInf">2</span> 100% and hyperlactacidaemia of 21<span class="elsevierStyleHsp" style=""></span>mmol/l. BAS was performed, leaving an 8<span class="elsevierStyleHsp" style=""></span>mm wall defect with unrestricted flow between the left and right atrium. This normalised rSO<span class="elsevierStyleInf">2</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which increased from 23% to 68%, improved hypoxaemia in the first hour with SpO<span class="elsevierStyleInf">2</span> of 83%, and reduced lactate levels to 9<span class="elsevierStyleHsp" style=""></span>mmol/h in the first the 24. In the ICU, he continued with inotropic support and nitric oxide was started (16<span class="elsevierStyleHsp" style=""></span>ppm) due to persistent pulmonary hypertension. At 11 days of life, an anatomical repair (Jatene technique or arterial switch) was successfully performed. The patient made good progress.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a full-term male neonate weighing 3100<span class="elsevierStyleHsp" style=""></span>g, with a prenatal diagnosis of D-TGA with intact septum and unrestrictive patent foramen ovale, who required intubation at 6<span class="elsevierStyleHsp" style=""></span>min of life to deliver an FiO<span class="elsevierStyleInf">2</span> of 80% for a preductal SpO of 66%. At 2<span class="elsevierStyleHsp" style=""></span>h of life, rSO<span class="elsevierStyleInf">2</span> was 45%, with hyperlactacidaemia of 8.7<span class="elsevierStyleHsp" style=""></span>mmol/l. BAS was performed to correct a restrictive foramen ovale and ductus arteriosus of insufficient size observed on the postnatal ultrasound. During the procedure, he presented an episode of supraventricular tachycardia followed by bradycardia that required the administration of adrenaline and calcium. Perfusion of prostaglandin E1 0.03<span class="elsevierStyleHsp" style=""></span>μg/kg/min was started. In the ICU he was treated with nitric oxide (20<span class="elsevierStyleHsp" style=""></span>ppm<span class="elsevierStyleMonospace">)</span>for the first 2 days of life due to a pre-postductal SpO<span class="elsevierStyleInf">2</span> gradient <span class="elsevierStyleMonospace">></span>10%. In this patient, rSO<span class="elsevierStyleInf">2</span> and lactate levels took longer to improve (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) due to his haemodynamic instability during the BAS. Eventually, however, rSO<span class="elsevierStyleInf">2</span> reached 62% and lactate decreased to 4.1<span class="elsevierStyleHsp" style=""></span>mmol/l within 24<span class="elsevierStyleHsp" style=""></span>h of the BAS. During his stay in the ICU, he presented haemodynamic instability due to a haematoma associated with a pseudoaneurysm of the right iliac artery. This was treated with inotropic support with dobutamine, milrinone, dopamine and adrenaline, which was discontinued on the sixth day of life. After this, he made good progress, and a successful anatomical repair was performed at 20 days of life.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The methods currently used to evaluate tissue oxygen delivery and consumption are non-specific, some are highly invasive, and others, such as blood pressure, state of consciousness, urinary output, capillary refill, thermal gradient, venous oxygen saturation, etc. provide non-specific indicators.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">NIRS is a non-invasive technique that can provide continuous measurement of tissue oxygenation. This shows perfusion status, and changes in the balance between oxygen delivery and consumption.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Although NIRS measurements are regional, the placement of several somatic (splanchnic and lumbar) or cranial sensors can give an overall picture of systemic status. Some authors describe it as a non-invasive method of monitoring cardiac output.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> This technology uses near infrared wave lengths (700–900<span class="elsevierStyleHsp" style=""></span>nm<span class="elsevierStyleMonospace">)</span>that allows light to penetrate several centimetres through the underlying tissue (skin, soft tissue, bone and part of the brain parenchyma). The value obtained shows the number of chromophores in the area scanned, and thus determines the concentration of oxygenated and deoxygenated haemoglobin. The values, therefore, depend on oxygenation (SpO<span class="elsevierStyleInf">2</span>) levels and chromophore concentration (haematocrit, blood volume and regional blood flow). The tissue from the venous, capillary and arterial beds is scanned in a proportion of 75%–20%–5%, respectively. The value obtained, therefore, is more similar to venous oxygen saturation, with which it is closely correlated, and is expressed as regional saturation of cerebral oxygen (rSO<span class="elsevierStyleInf">2</span>). Unlike pulse oximetry, which only measures the arterial pulse signal strength, NIRS does not rely on a pulsatile wave or body temperature.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–6</span></a> Several studies in animals and humans have shown that rSO<span class="elsevierStyleInf">2</span> positively correlates with jugular venous oxygen saturation (SjO<span class="elsevierStyleInf">2</span>), serum lactate levels, base excess, and central venous saturation (SvO<span class="elsevierStyleInf">2</span>).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Normal values of rSO<span class="elsevierStyleInf">2</span> vary greatly between individuals, and for this reason NIRS should be used to monitor trends from a baseline value.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Evidence has shown that rSO<span class="elsevierStyleInf">2</span> values of less than 50%, or a 20% decrease from the baseline value is associated with a high likelihood of cognitive deterioration, cerebral ischaemia, situations of low cardiac output and hypoperfusion, and other complications associated with these conditions, such as prolonged mechanical ventilation and prolonged stay in critical care units.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the advantages of this monitoring technique (non-invasive, real time, continuous, correlated with anaerobic metabolism parameters in hypoxic situations, administered at the bedside, etc.), we decided to use rSO<span class="elsevierStyleInf">2</span> to monitor cerebral oxygenation in our patients. Both cases presented patent ductus arteriosus, but this was insufficient to maintain adequate oxygenation despite perfusion of prostaglandins E1, so BAS was indicated in both patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the first case, we observed a significant improvement in rSO<span class="elsevierStyleInf">2</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which increased from 23% to 68% immediately after the BAS. The improvement was maintained for 2 days and correlated with an improvement in lactate levels, showing the immediate effectiveness of the procedure.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the second patient (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), rSO<span class="elsevierStyleInf">2</span> initially increased from 45% to 53% with a decrease in serum lactate. Later, however, rSO<span class="elsevierStyleInf">2</span> again fell accompanied by a further lactate peak secondary to haemodynamic instability associated with heart disease. Twenty four hours after the procedure rSO<span class="elsevierStyleInf">2</span> gradually increased to over 60%, accompanied by a sustained decrease in serum lactate levels. These findings are similar to those reported by Van der Laan et al. in a group of 12 infants who underwent BAS, namely, initial improvement in rSO<span class="elsevierStyleInf">2</span> (from 42% to 48%) and complete normalisation of brain oxygenation after 24<span class="elsevierStyleHsp" style=""></span>h (rSO<span class="elsevierStyleInf">2</span> of 64%), which correlated positively with the gradual decrease in lactate levels.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We believe that in these patients it is important to complement haemodynamic data obtained by means of conventional monitoring with rSO<span class="elsevierStyleInf">2</span> levels measured with NIRS. This will facilitate decision-making, indicate the need for prompt BAS, and demonstrate the effectiveness of the procedure. This is important, because acidosis and severe preoperative hypoxia in neonates with D-TGA predispose to brain damage and psychomotor retardation in school-age children.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> This has been evidenced by signs of brain damage found in images obtained by magnetic resonance imaging in patients with rSO<span class="elsevierStyleInf">2</span> of under 45%.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Nevertheless, more studies with larger samples are needed to evaluate the usefulness of NIRS monitoring in the early indication of BAS and its neuroprotective effect in this group of neonates, and to confirm our findings and those of other authors such as Van der Laan et al.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Measuring rSO<span class="elsevierStyleInf">2</span> levels using NIRS is a non-invasive, continuous, real time method of monitoring the balance between oxygen delivery and consumption, which is positively correlated with serum lactate levels. Being a good marker of tissue hypoperfusion, it can give immediate confirmation of the effect of BAS on tissue oxygenation and perfusion. BAS improves oxygenation and cardiac output in neonates with D-TGA by mixing deoxygenated with oxygenated blood at the atrial level. NIRS monitoring can show the increase in rSO<span class="elsevierStyleInf">2</span> after BAS in real time.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1024792" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec982682" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1024791" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec982683" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report 1" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case report 2" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-05-15" "fechaAceptado" => "2017-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec982682" "palabras" => array:5 [ 0 => "Cerebral perfusion" 1 => "Cerebral oxygen saturation" 2 => "Near infrared spectroscopy" 3 => "Balloon atrial septostomy" 4 => "Transposition of the great arteries" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec982683" "palabras" => array:5 [ 0 => "Perfusión cerebral" 1 => "Saturación cerebral de oxígeno" 2 => "Espectroscopia cercana al infrarrojo" 3 => "Atrioseptostomía con balón" 4 => "Transposición de grandes arterias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transposition of the great arteries (D-TGA) is one of the most common congenital heart diseases requiring neonatal surgical intervention. In the desperately ill neonate with TGA and the resultant hypoxaemia, acidemia, and congestive heart failure, improvement is often obtained with balloon atrial septostomy (BAS). Current methods employed to evaluate oxygen delivery and tissue consumption are frequently nonspecific. Near infrared spectroscopy (NIRS) allows a continuous non-invasive measurement of tissue oxygenation which reflects perfusion status in real time. Because little is known about the direct effect of BAS on the neonatal brain and on cerebral oxygenation, we measured the effectiveness of BAS in two patients with D-TGA using NIRS before and after BAS. We concluded BAS improves cerebral oxygen saturation in neonates with D-TGA.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La transposición de las grandes arterias (D-TGA) es una de las cardiopatías congénitas más comunes que requieren una intervención quirúrgica en la etapa neonatal. En neonatos muy afectados por una D-TGA, la hipoxemia, la acidemia y la insuficiencia cardiaca congestiva secundaria se mejora a menudo con una atrioseptostomía con balón (ASB). Los métodos actuales empleados para evaluar el aporte y el consumo de oxígeno tisular, con frecuencia no son específicos. La espectroscopia cercana al infrarrojo o near infrared spectroscopy (NIRS) permite una medición continua no invasiva de la oxigenación tisular, reflejando el estado de la perfusión tisular en tiempo real. Debido a que se sabe poco sobre el efecto directo de la ASB en el cerebro neonatal y en la oxigenación cerebral de los mismos, nosotros medimos la eficacia de la ASB en 2 pacientes con D-TGA utilizando el NIRS antes y después de la ASB. Concluimos que la ASB mejora la saturación cerebral de oxígeno en neonatos con D-TGA.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Moreno JC, Nájera Losada DC, Sanabria Carretero P, Paredes Lacave Á, Benito Bartolomé F. Monitorización de la oximetría cerebral en el manejo de la hipoxemia severa asociada a la transposición de grandes arterias mediante atrioseptostomía con balón. Rev Esp Anestesiol Reanim. 2018;65:294–297.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 887 "Ancho" => 1560 "Tamanyo" => 75321 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Case 1. A major improvement in oxygenation is observed after balloon atrioseptostomy, with regional cerebral oxygen saturation (rSO<span class="elsevierStyleInf">2</span>) increasing from 23% to 68%.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 801 "Ancho" => 1583 "Tamanyo" => 98112 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Case 2. A positive correlation was observed between regional cerebral oxygen saturation (rSO<span class="elsevierStyleInf">2</span>) and serum lactate levels after balloon atrioseptostomy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transposition of the great arteries" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C.A. 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