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Artigo Original
Implante transcateter valve‐in‐valve para disfunção de biopróteses cirúrgicas aórticas
Transcatheter valve‐in‐valve implantation for surgical aortic bioprosthesis dysfunction
Rafael Alexandre Meneguz‐Morenoa,
Autor para correspondencia
rafael.meneguz@yahoo.com.br

Autor para correspondência: Av. Dr. Dante Pazzanese, 500, Vila Mariana, CEP: 04012‐909, São Paulo, SP, Brasil.
, Dimytri A. Siqueiraa,b, Auristela Isabel de Oliveira Ramosa, Antônio de Castro Filhoa, Andreia Dias Jeronimoa, Tannas Jatenea, David Le Bihana, Rodrigo Barrettoa,b, Magaly Arraisa,b, Adriana Moreirab, Alexandre Abizaida,b, Amanda Guerra M.R. Sousaa,b, J. Eduardo M.R. Sousaa,b
a Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
b Hospital do Coração, São Paulo, SP, Brasil
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Classe funcional <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41; pr&#233; e 1 ano ap&#243;s procedimento <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span>&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pacientes com disfun&#231;&#227;o de biopr&#243;tese valvar cir&#250;rgica representam um desafio cl&#237;nico&#44; pois&#44; apesar de uma nova troca cir&#250;rgica ser considerada o tratamento padr&#227;o&#44; a reopera&#231;&#227;o associa&#8208;se &#224; elevada morbimortalidade&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Tais pacientes s&#227;o caracterizados como de alto risco cir&#250;rgico ou inoper&#225;veis&#44; devido a m&#250;ltiplas comorbidades&#44; idade avan&#231;ada&#44; fragilidade cl&#237;nica ou redu&#231;&#227;o da fra&#231;&#227;o de eje&#231;&#227;o ventricular&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Originalmente desenvolvido para a abordagem da estenose de valva nativa&#44; o implante de pr&#243;tese a&#243;rtica por cateter constitui o tratamento padr&#227;o para pacientes sintom&#225;ticos e considerados inoper&#225;veis&#44; al&#233;m de representar uma estrat&#233;gia terap&#234;utica alternativa &#224; cirurgia de troca valvar em indiv&#237;duos de alto risco cir&#250;rgico&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;8</span></a> Estudos recentes demonstram a efic&#225;cia cl&#237;nica do implante de pr&#243;tese transcateter <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> &#40;VIV&#41; para o tratamento das biopr&#243;teses cir&#250;rgicas a&#243;rticas com disfun&#231;&#227;o&#46; Essa modalidade representa uma op&#231;&#227;o de tratamento menos invasiva&#44; principalmente por n&#227;o expor o paciente &#224; circula&#231;&#227;o cardiopulmonar extracorp&#243;rea e nem aos riscos inerentes &#224; reopera&#231;&#227;o&#46; Apesar de as pr&#243;teses n&#227;o terem sido desenhadas para essa finalidade&#44; os resultados publicados t&#234;m sido encorajadores&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Este estudo teve como objetivo caracterizar a experi&#234;ncia inicial de equipe cardiovascular multidisciplinar no emprego de procedimentos VIV para pacientes com disfun&#231;&#227;o de biopr&#243;teses cir&#250;rgicas em posi&#231;&#227;o a&#243;rtica&#46; S&#227;o descritos os perfis cl&#237;nico e ecocardiogr&#225;fico&#44; e os aspectos relacionados ao procedimento&#44; bem como os resultados cl&#237;nicos do seguimento de m&#233;dio prazo&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075"><span class="elsevierStyleItalic">Sele&#231;&#227;o de pacientes e indica&#231;&#227;o do procedimento</span> valve&#8208;in&#8208;valve</span><p id="par0020" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos nesta an&#225;lise pacientes maiores de 18 anos com disfun&#231;&#227;o de biopr&#243;tese a&#243;rtica sintom&#225;tica&#44; submetidos consecutivamente ao procedimento VIV em dois centros cardiol&#243;gicos terci&#225;rios no Estado de S&#227;o Paulo entre janeiro de 2009 e junho de 2015&#46; Pacientes com pr&#243;tese valvar transcateter pr&#233;via ou com endocardite infecciosa ativa foram exclu&#237;dos da amostra&#46; O projeto foi aprovado pelo Comit&#234; de &#201;tica institucional&#44; e os pacientes assinaram o Termo de Consentimento Livre e Esclarecido&#46; As informa&#231;&#245;es foram registradas prospectivamente em formul&#225;rios apropriados desenvolvidos para o estudo&#44; armazenadas em planilhas eletr&#244;nicas e coletadas do banco de dados de cada institui&#231;&#227;o&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Avalia&#231;&#227;o cl&#237;nica pr&#233;&#8208;procedimento</span><p id="par0025" class="elsevierStylePara elsevierViewall">Em geral&#44; a avalia&#231;&#227;o do paciente para o procedimento VIV foi similar &#224;quela realizada em ind&#237;v&#237;duos portadores de estenose a&#243;rtica e candidatos ao implante de pr&#243;tese por cateter em posi&#231;&#227;o nativa&#46; A indica&#231;&#227;o desse tratamento foi baseada no risco cir&#250;rgico&#44; determinado por caracter&#237;sticas cl&#237;nicas ou por raz&#245;es t&#233;cnicas&#46; Para a estimativa de risco&#44; foram utilizados os escores <span class="elsevierStyleItalic">Society of Thoracic Surgeons</span> &#40;STS&#44; dispon&#237;vel em <a id="intr0005" class="elsevierStyleInterRef" href="http://riskcalc.sts.org/de.aspx">http&#58;&#47;&#47;riskcalc&#46;sts&#46;org&#47;de&#46;aspx</a>&#41; e <span class="elsevierStyleItalic">European System for Cardiac Operative Risk Evaluation</span> &#40;EuroSCORE log&#237;stico&#44; conforme <a id="intr0010" class="elsevierStyleInterRef" href="http://www.euroscore.org/calcold.html">http&#58;&#47;&#47;www&#46;euroscore&#46;org&#47;calcold&#46;html</a>&#41;&#46; Fatores de risco n&#227;o contemplados nesses escores&#44; como a presen&#231;a de &#8220;aorta em porcelana&#8221;&#44; fragilidade&#44; t&#243;rax hostil consequente &#224; irradia&#231;&#227;o tor&#225;cica pr&#233;via&#44; hepatopatias e dist&#250;rbios da coagula&#231;&#227;o&#44; tamb&#233;m foram considerados nessa decis&#227;o&#46; Todos os casos foram analisados e discutidos por grupo multidisciplinar &#40;<span class="elsevierStyleItalic">Heart Team</span>&#41;&#44; composto por cardiologistas cl&#237;nicos e intervencionistas&#44; cirurgi&#245;es cardiovasculares e cardiologistas especialistas em imagens&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Caracter&#237;sticas espec&#237;ficas a respeito da pr&#243;tese cir&#250;rgica previamente utilizada foram pesquisadas para embasar a indica&#231;&#227;o do procedimento VIV&#46; Foram identificados tipo&#44; modelo&#44; tamanho e posi&#231;&#227;o &#40;intra&#8208; ou supra&#8208;anular&#41; da pr&#243;tese valvar cir&#250;rgica&#46; O di&#226;metro interno de cada biopr&#243;tese foi obtido conforme informa&#231;&#245;es do fabricante&#46; Aspectos t&#233;cnicos da cirurgia empregada&#44; como a necessidade de reconstru&#231;&#227;o da raiz de aorta e a presen&#231;a de enxertos venosos ou arteriais&#44; tamb&#233;m foram elucidados&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Exames complementares pr&#233;&#8208;procedimento</span><p id="par0035" class="elsevierStylePara elsevierViewall">Foram realizados exames laboratoriais&#44; eletrocardiograma de repouso&#44; radiografia de t&#243;rax&#44; ecocardiograma transesof&#225;gico&#44; angiotomografia &#40;angio&#8208;TC&#41; do cora&#231;&#227;o e aorta total&#44; e coronariografia&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O principal par&#226;metro considerado para a escolha da pr&#243;tese a&#243;rtica transcateter a ser implantada foi o di&#226;metro interno da biopr&#243;tese cir&#250;rgica pr&#233;via&#44; obtido junto ao fabricante ou conforme informado pelo aplicativo <span class="elsevierStyleItalic">VIV Aortic</span>&#44; desenvolvido por Bapat e pela empresa UBQO Ltda&#46; &#40;Londres&#44; Reino Unido&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> O ecocardiograma foi utilizado para avalia&#231;&#227;o do mecanismo e das consequ&#234;ncias da disfun&#231;&#227;o prot&#233;tica&#44; definindo&#8208;se a integridade e mobilidade dos folhetos&#44; a fun&#231;&#227;o ventricular esquerda&#44; e a presen&#231;a de hipertens&#227;o pulmonar e de valvopatias associadas&#46; Nos casos de disfun&#231;&#227;o por insufici&#234;ncia da pr&#243;tese&#44; o ecocardiograma transesof&#225;gico excluiu a presen&#231;a de refluxo paravalvar&#46; A angio&#8208;TC da aorta foi o m&#233;todo utilizado para determina&#231;&#227;o da melhor via de acesso&#46; Em caso de n&#227;o disponibilidade dos dados da cirurgia pr&#233;via&#44; a angio&#8208;TC auxiliou na an&#225;lise dos di&#226;metros da pr&#243;tese cir&#250;rgica e na escolha da pr&#243;tese transcateter mais adequada para o procedimento VIV&#46; A cinecoronariografia foi empregada para a avalia&#231;&#227;o de doen&#231;a arterial coron&#225;ria associada e na estimativa do risco de oclus&#227;o coron&#225;ria durante o implante valvar&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aspectos t&#233;cnicos do procedimento</span><p id="par0045" class="elsevierStylePara elsevierViewall">Dupla antiagrega&#231;&#227;o plaquet&#225;ria &#40;&#225;cido acetilsalic&#237;lico 300<span class="elsevierStyleHsp" style=""></span>mg e clopidogrel 300<span class="elsevierStyleHsp" style=""></span>mg&#41; era iniciada com uma dose de ataque 24 horas antes do procedimento&#46; Os procedimentos foram realizados preferencialmente em sala h&#237;brida&#46; A decis&#227;o a respeito do emprego de anestesia geral e do ecocardiograma transesof&#225;gico ficou a crit&#233;rio dos operadores&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">O acesso vascular femoral foi a primeira escolha para o implante&#44; sendo utilizado dispositivo hemost&#225;tico espec&#237;fico de reparo arterial mediado por sutura ProGlide<span class="elsevierStyleSup">&#174;</span> &#40;Abbott Vascular<span class="elsevierStyleSup">&#174;</span>&#44; Santa Clara&#44; EUA&#41;&#46; Em caso da impossibilidade do emprego da via femoral&#44; utilizou&#8208;se o acesso transapical&#46; Ap&#243;s o estabelecimento do acesso vascular&#44; foi utilizada dose em b&#243;lus de heparina n&#227;o fracionada &#40;80 a 100 U&#47;kg&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Considerando o fato de que&#44; na maioria dos casos&#44; o anel da biopr&#243;tese cir&#250;rgica &#233; radiopaco&#44; a identifica&#231;&#227;o da melhor proje&#231;&#227;o angiogr&#225;fica para o implante foi obtida por fluoroscopia&#58; a angula&#231;&#227;o coplanar foi buscada e tomada como refer&#234;ncia para o adequado posicionamento da pr&#243;tese transcateter&#46; Aortografia com visualiza&#231;&#227;o dos &#243;stios coron&#225;rios foi obtida com o intuito de se avaliar a ocorr&#234;ncia de obstru&#231;&#227;o coron&#225;ria no procedimento&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Foram utilizados o sistema autoexpans&#237;vel CoreValve &#40;Medtronic&#44; Minneapolis&#44; EUA&#41; e o sistema bal&#227;o&#8208;expans&#237;vel Edwards Sapien XT &#40;Edwards Lifesciences&#44; Irvine&#44; EUA&#41;&#46; Tanto a escolha de uma ou outra pr&#243;tese&#44; bem como a necessidade ou n&#227;o de pr&#233;&#8208;dilata&#231;&#227;o ou p&#243;s&#8208;dilata&#231;&#227;o foram baseadas no julgamento dos operadores&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Seguimento</span><p id="par0065" class="elsevierStylePara elsevierViewall">Foram coletados dados cl&#237;nicos&#44; laboratoriais e ecocardiogr&#225;ficos 30 dias e 6 meses ap&#243;s a alta hospitalar&#46; Dupla antiagrega&#231;&#227;o plaquet&#225;ria foi recomendada em doses de manuten&#231;&#227;o &#40;clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg ao dia por 6 meses e &#225;cido acetilsalic&#237;lico 100<span class="elsevierStyleHsp" style=""></span>mg ao dia&#44; continuamente&#41;&#46; Nos pacientes com indica&#231;&#227;o de uso de anticoagulantes orais&#44; o esquema farmacol&#243;gico consistia na associa&#231;&#227;o de clopidogrel &#224; varfarina&#44; de acordo com o <span class="elsevierStyleItalic">International Normalized Ratio</span> &#40;INR&#41;&#44; com alvo entre 2&#44;0 e 3&#44;0&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Defini&#231;&#245;es</span><p id="par0070" class="elsevierStylePara elsevierViewall">Os desfechos foram categorizados de acordo com os crit&#233;rios <span class="elsevierStyleItalic">Valve Academic Research Consortium</span> &#40;VARC&#41;&#8208;2&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> e os eventos adjudicados por dois cardiologistas experientes&#46; Analisou&#8208;se como desfecho prim&#225;rio o sucesso do dispositivo&#44; definido como o implante de uma &#250;nica pr&#243;tese em local planejado&#44; com aus&#234;ncia de despropor&#231;&#227;o pr&#243;tese&#8208;paciente &#40;<span class="elsevierStyleItalic">mismatch</span>&#41;&#44; gradiente transvalvar a&#243;rtico m&#233;dio &#60; 20<span class="elsevierStyleHsp" style=""></span>mmHg ou velocidade de pico &#60; 3 m&#47;s&#44; e aus&#234;ncia de regurgita&#231;&#227;o a&#243;rtica &#8805; moderada&#44; avaliada pela aortografia e ecocardiografia&#46; O desfecho de seguran&#231;a precoce &#40;at&#233; 30 dias p&#243;s&#8208;procedimento&#41; foi definido como a combina&#231;&#227;o de mortalidade por todas as causas&#59; acidente vascular cerebral &#40;AVC&#41;&#59; sangramento com risco de vida&#59; insufici&#234;ncia renal aguda est&#225;gios 2 ou 3&#44; conforme o escore <span class="elsevierStyleItalic">Acute Kidney Injury Network</span> &#40;AKIN&#41;&#59;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> complica&#231;&#227;o vascular maior ou disfun&#231;&#227;o valvar com necessidade de reinterven&#231;&#227;o&#46; Os crit&#233;rios de efic&#225;cia cl&#237;nica &#40;30 dias ap&#243;s o procedimento&#41; consistiram no desfecho combinado envolvendo mortalidade por todas as causas&#44; AVC&#44; re&#8208;hospitaliza&#231;&#227;o por insufici&#234;ncia card&#237;aca&#44; classe funcional <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41; III ou IV&#44; ou disfun&#231;&#227;o de pr&#243;tese VIV &#40;estenose ou regurgita&#231;&#227;o&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Foram avaliadas tamb&#233;m outras complica&#231;&#245;es&#44; como necessidade de convers&#227;o para cirurgia convencional&#44; ocorr&#234;ncia de obstru&#231;&#227;o coron&#225;ria&#44; tamponamento card&#237;aco&#44; comunica&#231;&#227;o interventricular&#44; mau posicionamento valvar&#44; endocardite&#44; trombose valvar&#44; dist&#250;rbios de condu&#231;&#227;o e necessidade de implante de marca&#8208;passo definitivo&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">An&#225;lise estat&#237;stica</span><p id="par0080" class="elsevierStylePara elsevierViewall">As vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o normal foram descritas como m&#233;dia e desvio padr&#227;o&#44; ou mediana e intervalo interquartil para as vari&#225;veis assim&#233;tricas&#46; As vari&#225;veis categ&#243;ricas foram descritas como n&#250;meros absolutos e porcentuais&#46; A compara&#231;&#227;o entre as vari&#225;veis cont&#237;nuas foi realizada pelo teste <span class="elsevierStyleItalic">t</span> de Student pareado&#46; Valores de <span class="elsevierStyleItalic">p</span> &#8804; 0&#44;05 foram considerados estatisticamente significantes&#46; Foi utilizado o programa R&#44; vers&#227;o 3&#46;1 &#40;<span class="elsevierStyleItalic">The R Foundation for Statistical Computing</span>&#44; Viena&#44; &#193;ustria&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Caracter&#237;sticas cl&#237;nicas basais</span><p id="par0085" class="elsevierStylePara elsevierViewall">Todos os pacientes eram do sexo masculino&#44; com m&#233;dia de idade de 72&#44;6 &#177; 10&#44;0 anos e de alto risco cir&#250;rgico&#44; com escore STS de 9&#44;6 &#177; 10&#44;5&#37; e EuroSCORE log&#237;stico 22&#44;7 &#177; 14&#44;7&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#41;&#46; A maioria dos pacientes &#40;71&#37;&#41; estava em classe funcional NYHA III ou IV&#46; Quatro dos sete pacientes tinham sido submetidos previamente a cirurgia de revasculariza&#231;&#227;o do mioc&#225;rdio&#46; O intervalo decorrido entre o implante cir&#250;rgico da biopr&#243;tese e o procedimento VIV foi de 9&#44;5 &#177; 2&#44;0 anos&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Dados ecocardiogr&#225;ficos pr&#233;&#8208;procedimento</span><p id="par0090" class="elsevierStylePara elsevierViewall">Tr&#234;s pacientes apresentavam disfun&#231;&#227;o da biopr&#243;tese cir&#250;rgica do tipo dupla&#8208;les&#227;o&#59; dois tinham insufici&#234;ncia prot&#233;tica&#59; e dois pacientes apresentaram estenose da pr&#243;tese&#46; Um paciente j&#225; tinha sido submetido &#224; troca valvar mitral previamente&#46; Todas as pr&#243;teses cir&#250;rgicas eram de peric&#225;rdio bovino&#44; sendo SJ Medical Biocor&#8482; &#40;St&#46; Jude Medical Biocor&#44; St&#46; Paul&#44; EUA&#41; em cinco pacientes&#44; SJ Medical Epic&#8482; &#40;St&#46; Jude Medical Biocor&#44; St&#46; Paul&#44; EUA&#41; em um paciente e pr&#243;tese Braile&#8482; &#40;Braile Biom&#233;dica&#44; S&#227;o Jos&#233; do Rio Preto&#44; SP&#44; Brasil&#41; em outro&#44; cujos di&#226;metros variaram de 21 a 25<span class="elsevierStyleHsp" style=""></span>mm&#46; A m&#233;dia dos di&#226;metros internos das biopr&#243;teses foi de 24&#44;0 &#177; 3&#44;9<span class="elsevierStyleHsp" style=""></span>mm&#44; obtida com a angio&#8208;TC&#46; Os gradientes m&#225;ximo e m&#233;dio&#44; conforme a ecocardiografia&#44; foram de 73&#44;7 &#177; 25&#44;9<span class="elsevierStyleHsp" style=""></span>mmHg e 38&#44;2 &#177; 9&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg&#44; respectivamente&#46; A m&#233;dia das &#225;reas das pr&#243;teses cir&#250;rgicas foi de 1&#44;2 &#177; 0&#44;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#46; A fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo variou de 39 a 66&#37;&#44; com m&#233;dia de 53&#44;3 &#177; 8&#44;9&#37;&#46; Quatro pacientes apresentavam hipertens&#227;o arterial pulmonar importante&#44; com m&#233;dia de press&#227;o sist&#243;lica de art&#233;ria pulmonar &#40;PSAP&#41; de 58&#44;3 &#177; 14&#44;0<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Aspectos t&#233;cnicos da interven&#231;&#227;o</span><p id="par0095" class="elsevierStylePara elsevierViewall">A maioria dos procedimentos &#40;seis pacientes&#41; foi realizada sob anestesia geral e com monitoriza&#231;&#227;o por ecocardiograma transesof&#225;gico&#59; em um paciente&#44; optou&#8208;se por seda&#231;&#227;o e anestesia local &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46; A via transfemoral foi utilizada em seis casos&#59; nesses indiv&#237;duos&#44; a hemostasia foi obtida sem complica&#231;&#245;es vasculares&#44; por meio do dispositivo Perclose<span class="elsevierStyleSup">TM</span>&#46; Devido &#224; presen&#231;a de endopr&#243;tese em aorta descendente&#44; a via transapical foi empregada em um paciente&#46; A pr&#233;&#8208;dilata&#231;&#227;o foi realizada em dois pacientes&#44; e a p&#243;s&#8208;dilata&#231;&#227;o tamb&#233;m foi necess&#225;ria em dois pacientes&#46; O tempo do procedimento foi de 112&#44;3 &#177; 57&#44;0 minutos&#44; e o volume de contraste foi 63&#44;3 &#177; 45&#44;4<span class="elsevierStyleHsp" style=""></span>mL&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Ao ecocardiograma&#44; o gradiente m&#225;ximo ventr&#237;culo esquerdo&#47;aorta reduziu&#8208;se de 73&#44;7 &#177; 25&#44;9<span class="elsevierStyleHsp" style=""></span>mmHg para 38&#44;2 &#177; 9&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;01&#41; e o gradiente m&#233;dio&#44; de 38&#44;2 &#177; 9&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg para 20&#44;9 &#177; 5&#44;9<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;02&#41;&#46; Houve queda significativa da PSAP de 58&#44;3 &#177; 14&#44;0<span class="elsevierStyleHsp" style=""></span>mmHg para 37&#44;1 &#177; 6&#44;0<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;01&#41; e aumento da &#225;rea valvar de 1&#44;2 &#177; 0&#44;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> para 1&#44;5 &#177; 0&#44;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;p &#61; 0&#44;18&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">O sucesso do dispositivo ocorreu em seis dos sete pacientes &#40;85&#44;7&#37;&#41;&#46; O primeiro paciente da s&#233;rie apresentou despropor&#231;&#227;o paciente&#8208;pr&#243;tese &#40;<span class="elsevierStyleItalic">mismatch</span>&#41; moderada&#44; com &#225;rea do orif&#237;cio efetivo indexado de 0&#44;67<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#44; insufici&#234;ncia a&#243;rtica moderada&#44; regurgita&#231;&#227;o paravalvular moderada e necessidade de uma segunda pr&#243;tese imediatamente ap&#243;s o procedimento&#46; Durante a interna&#231;&#227;o hospitalar&#44; este paciente evoluiu com choque cardiog&#234;nico&#44; insufici&#234;ncia renal aguda &#40;est&#225;gio AKIN 3&#41; com necessidade de hemodi&#225;lise&#44; e insufici&#234;ncia respirat&#243;ria&#44; vindo a falecer 48 horas ap&#243;s o procedimento&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Dois pacientes apresentaram bloqueio de ramo esquerdo ap&#243;s o procedimento&#44; sem necessidade de implante de marca&#8208;passo definitivo&#46; A recupera&#231;&#227;o intra&#8208;hospitalar dos seis pacientes ocorreu sem intercorr&#234;ncias&#44; e todos obtiveram alta hospitalar no s&#233;timo dia p&#243;s&#8208;procedimento&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Seguimento cl&#237;nico</span><p id="par0115" class="elsevierStylePara elsevierViewall">Ao final de 30 dias&#44; o desfecho de seguran&#231;a precoce foi atingido em 85&#44;7&#37; dos pacientes&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Ap&#243;s m&#233;dia de acompanhamento de 585 dias &#40;288 a 776 dias&#41;&#44; somente um dos pacientes ainda n&#227;o havia atingido 1 ano de evolu&#231;&#227;o p&#243;s&#8208;procedimento&#46; Ao final de 12 meses&#44; n&#227;o houve necessidade de re&#8208;hospitaliza&#231;&#227;o&#44; e 80&#37; dos pacientes estavam em classe funcional NYHA I ou II &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;03&#41;&#44; tendo sido atingido&#44; dessa forma&#44; o desfecho de efic&#225;cia cl&#237;nica&#46; Neste per&#237;odo&#44; n&#227;o foram encontradas diferen&#231;as significativas nos gradientes transvalvares&#44; na &#225;rea valvar&#44; na fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo ou na PSAP&#44; quando comparados aos resultados imediatos&#58; o gradiente ventr&#237;culo esquerdo&#8208;aorta m&#233;dio foi de 29&#44;0 &#177; 8&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;17&#41;&#59; a &#225;rea valvar da pr&#243;tese a&#243;rtica de 1&#44;5 &#177; 0&#44;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;61&#41;&#59; a fra&#231;&#227;o de eje&#231;&#227;o de ventr&#237;culo esquerdo de 56&#44;0 &#177; 6&#44;5&#37; &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;25&#41;&#59; e a PSAP de 37&#44;4 &#177; 4&#44;3<span class="elsevierStyleHsp" style=""></span>mmHg &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#44;36&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; N&#227;o foram identificados sinais de disfun&#231;&#227;o estrutural e nem de deterioriza&#231;&#227;o hemodin&#226;mica em nenhum dos casos&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discuss&#227;o</span><p id="par0125" class="elsevierStylePara elsevierViewall">O presente estudo descreveu a experi&#234;ncia inicial de um grupo multidisciplinar com o implante transcateter VIV para tratamento de disfun&#231;&#227;o de biopr&#243;tese cir&#250;rgica em posi&#231;&#227;o a&#243;rtica em pacientes de alto risco cir&#250;rgico&#46; Os dados foram obtidos em um ambiente da pr&#225;tica cl&#237;nica e confirmam sua viabilidade t&#233;cnica&#44; proporcionando aos indiv&#237;duos tratados benef&#237;cios cl&#237;nicos e hemodin&#226;micos nos primeiros 30 dias&#44; os quais foram sustentados ao final de 1 ano&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Descrito primeiramente por Wenaweser et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> o implante VIV tem sido aplicado a pacientes em todo o mundo&#44; e seus desfechos cl&#237;nicos foram analisados em diversas s&#233;ries<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;19&#8211;22</span></a> e por estudos multic&#234;ntricos&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14</span></a> Nestes registros&#44; a idade m&#233;dia foi de 78 anos&#44; e as estimativas de risco cir&#250;rgico por EuroSCORE log&#237;stico e escore STS foram 31&#44;3&#37; e 11&#44;3&#37;&#44; respectivamente&#46; Tal perfil cl&#237;nico assemelha&#8208;se ao de nossa coorte&#44; tamb&#233;m constitu&#237;da por pacientes considerados de alto risco cir&#250;rgico &#40;EuroSCORE log&#237;stico &#62; 20&#37; e escore STS &#62; 8&#37;&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">No maior registro at&#233; ent&#227;o publicado&#44; o VIVID &#40;<span class="elsevierStyleItalic">Valve In Valve International Data</span>&#41;&#44; com 429 pacientes&#44; o &#237;ndice de sucesso do procedimento foi de 93&#44;1&#37;&#44; com mortalidade aos 30 dias de 7&#44;6&#37;&#46; Dos sobreviventes&#44; 92&#44;6&#37; evolu&#237;ram no per&#237;odo com classe I&#47;II NYHA&#46; A sobrevida foi de 83&#44;2&#37; aos 12 meses&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Em nossa casu&#237;stica&#44; o sucesso do procedimento traduziu&#8208;se em significativa melhora cl&#237;nica&#44; com a maioria dos pacientes &#40;80&#37;&#41; em classe funcional NYHA I&#47;II ap&#243;s o primeiro ano&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Em geral&#44; o sucesso cl&#237;nico do implante percut&#226;neo de pr&#243;tese valvar a&#243;rtica transcateter &#40;TAVI&#41; est&#225; fundamentalmente relacionado &#224;s caracter&#237;sticas basais dos pacientes tratados&#44; &#224; t&#233;cnica empregada e aos dispositivos utilizados&#46; Os conhecimentos acumulados desempenham papel de destaque para melhoria de seus resultados&#46; Nos &#250;ltimos anos&#44; em particular&#44; importantes conceitos t&#234;m sido aplicados nos procedimentos VIV&#46; Em nossa s&#233;rie&#44; o primeiro paciente tratado apresentou <span class="elsevierStyleItalic">mismatch</span> e refluxo paraprot&#233;tico moderados&#44; potencialmente associados ao tamanho da pr&#243;tese transcateter utilizada e seu posicionamento&#46; Este paciente apresentou evolu&#231;&#227;o desfavor&#225;vel&#44; com choque cardiog&#234;nico p&#243;s&#8208;procedimento&#46; Naquela fase da curva de aprendizado&#44; particularidades hoje reconhecidas como fundamentais dos procedimentos VIV ainda n&#227;o tinham sido estudadas ou descritas&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Dessa maneira&#44; importantes aspectos&#44; como modelo&#44; <span class="elsevierStyleItalic">design</span> e tamanho da biopr&#243;tese cir&#250;rgica que apresenta disfun&#231;&#227;o&#44; devem ser valorizados para a escolha do tamanho da pr&#243;tese transcateter a ser implantada&#46; A determina&#231;&#227;o do di&#226;metro interno verdadeiro da pr&#243;tese cir&#250;rgica &#233; um dos fatores mais importantes nesse cen&#225;rio entende&#8208;se por di&#226;metro verdadeiro o di&#226;metro do anel interno da biopr&#243;tese menos o espa&#231;o ocupado pelos folhetos &#40;porcinos ou de peric&#225;rdio bovino&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">O conhecimento do aspecto fluorosc&#243;pico de determinada pr&#243;tese cir&#250;rgica define a posi&#231;&#227;o ideal para o implante da biopr&#243;tese transcateter &#40;em geral&#44; de 15&#37; abaixo do anel de sutura para a pr&#243;tese Sapien XT e de zero a 4<span class="elsevierStyleHsp" style=""></span>mm para a CoreValve&#41;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">fig&#46; 4</a>&#41;&#46; Atualmente&#44; o aplicativo para <span class="elsevierStyleItalic">smartphones</span> desenvolvido em 2013 por Bapat<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> permite acessar as informa&#231;&#245;es estruturais necess&#225;rias das diversas biopr&#243;teses cir&#250;rgicas&#44; auxiliando na escolha do tamanho e no posicionamento mais adequado da pr&#243;tese VIV&#44; e reduzindo a possibilidade de <span class="elsevierStyleItalic">mismatch</span> e de refluxo a&#243;rtico&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Nesta s&#233;rie&#44; o gradiente transvalvar m&#233;dio ap&#243;s o procedimento VIV foi de 20&#44;9 &#177; 5&#44;9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; e 42&#37; dos pacientes apresentaram gradiente m&#233;dio &#8805; 20<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Tais valores s&#227;o maiores do que os comumente observados ap&#243;s TAVI em estenose valvar nativa &#40;&#8804; 10<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46; Estudos apontam que a ocorr&#234;ncia de <span class="elsevierStyleItalic">mismatch</span> grave &#40;&#60; 0&#44;65<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#41; ap&#243;s VIV a&#243;rtico &#233; de 32&#44;1&#37;&#46; Gradientes transvalvares mais altos s&#227;o&#44; portanto&#44; de alguma forma esperados nesses procedimentos&#58; a pr&#243;tese VIV &#233; implantada dentro de estrutura n&#227;o distens&#237;vel &#40;no caso&#44; o anel da pr&#243;tese cir&#250;rgica&#41;&#44; resultando em uma menor &#225;rea efetiva de fluxo&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;25</span></a> Alguns pacientes apresentam&#44; ainda&#44; <span class="elsevierStyleItalic">mismatch</span> e gradiente m&#233;dio basal elevado ap&#243;s a troca valvar cir&#250;rgica &#40;principalmente com biopr&#243;teses &#60; 23<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; Esse fato tamb&#233;m contribui para a observa&#231;&#227;o de gradientes mais altos ap&#243;s VIV&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;26</span></a> Na s&#233;rie atual&#44; contudo&#44; mesmo pacientes com gradiente m&#233;dio &#62; 20<span class="elsevierStyleHsp" style=""></span>mmHg ap&#243;s VIV obtiveram melhora significativa dos sintomas de insufici&#234;ncia card&#237;aca&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Devido &#224; reduzida casu&#237;stica&#44; n&#227;o foi observada diferen&#231;a estatisticamente significativa entre o gradiente m&#233;dio obtido ap&#243;s VIV com pr&#243;teses autoexpans&#237;vel vs&#46; bal&#227;o&#8208;expans&#237;vel&#46; Na s&#233;rie de Dvir et al&#46;&#44; tanto o tratamento da disfun&#231;&#227;o de pr&#243;tese cir&#250;rgica do tipo estenose como o implante de pr&#243;tese bal&#227;o&#8208;expans&#237;vel estiveram associados a maiores gradientes transvalvares p&#243;s&#8208;procedimento&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Neste estudo&#44; n&#227;o observamos complica&#231;&#245;es como AVC ou necessidade de marca&#8208;passo permanente&#46; De fato&#44; evid&#234;ncias apontam que o procedimento VIV n&#227;o eleva o risco de dist&#250;rbios de condu&#231;&#227;o&#44; a necessidade de marca&#8208;passo e nem de AVC&#44; quando comparado ao tratamento de estenose valvar nativa&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> As taxas de regurgita&#231;&#227;o paravalvar s&#227;o substancialmente menores quando comparadas ao TAVI&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">N&#227;o foram detectados casos de insufici&#234;ncia a&#243;rtica&#44; aumento progressivo de gradiente valvar ap&#243;s o implante ou evid&#234;ncias de degenera&#231;&#227;o de folhetos nas avalia&#231;&#245;es ecocardiogr&#225;ficas seriadas&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclus&#245;es</span><p id="par0175" class="elsevierStylePara elsevierViewall">Nesta casu&#237;stica inicial&#44; o procedimento <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> foi clinicamente eficaz&#44; traduzindo&#8208;se em resultados imediatos favor&#225;veis a pacientes com disfun&#231;&#227;o de biopr&#243;teses a&#243;rticas e de alto risco cir&#250;rgico&#46; Os benef&#237;cios cl&#237;nicos e hemodin&#226;micos auferidos mantiveram&#8208;se sustentados em seguimento de m&#233;dio prazo&#46; Estudos com maior n&#250;mero de pacientes e seguimento de mais longo prazo ainda s&#227;o necess&#225;rios para consolidar sua indica&#231;&#227;o&#44; principalmente em indiv&#237;duos de menor risco cir&#250;rgico&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Fonte de financiamento</span><p id="par0185" class="elsevierStylePara elsevierViewall">N&#227;o h&#225;&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflitos de interesse</span><p id="par0190" class="elsevierStylePara elsevierViewall">Dr&#46; Dimytri A&#46; Siqueira &#233; <span class="elsevierStyleItalic">proctor</span> das empresas Edwards&#44; Medtronic e Symetis&#46; O Dr&#46; Alexandre Abizaid &#233; <span class="elsevierStyleItalic">proctor</span> das empresas Edwards&#44; Medtronic e Symetis&#46; A Dra&#46; Magaly Arrais &#233; <span class="elsevierStyleItalic">proctor</span> das empresas Edwards e Medtronic&#46; Os demais autores declaram n&#227;o haver conflito de interesses relacionado a este manuscrito&#46;</p></span></span>"
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          "identificador" => "sec0075"
          "titulo" => "Discuss&#227;o"
        ]
        8 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conclus&#245;es"
        ]
        9 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Fonte de financiamento"
        ]
        10 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Conflitos de interesse"
        ]
        11 => array:2 [
          "identificador" => "xack261700"
          "titulo" => "Agradecimentos"
        ]
        12 => array:1 [
          "titulo" => "Refer&#234;ncias"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-06-22"
    "fechaAceptado" => "2015-08-31"
    "PalabrasClave" => array:2 [
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras&#8208;chave"
          "identificador" => "xpalclavsec780735"
          "palabras" => array:3 [
            0 => "Biopr&#243;tese"
            1 => "Estenose da valva a&#243;rtica"
            2 => "Substitui&#231;&#227;o da valva a&#243;rtica transcateter"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec780736"
          "palabras" => array:3 [
            0 => "Bioprosthesis"
            1 => "Aortic valve stenosis"
            2 => "Transcatheter aortic valve replacement"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "pt" => array:3 [
        "titulo" => "RESUMO"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introdu&#231;&#227;o</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estudos recentes t&#234;m demonstrado a efic&#225;cia do implante transcateter <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> para o tratamento de disfun&#231;&#227;o de biopr&#243;teses em pacientes de alto risco cir&#250;rgico&#46; Apresentamos nossa experi&#234;ncia inicial com o implante <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span>&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">M&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Caracterizamos o perfil cl&#237;nico&#44; ecocardiogr&#225;fico e do procedimento&#44; e reportamos os resultados de m&#233;dio prazo de pacientes com disfun&#231;&#227;o de biopr&#243;tese submetidos a implante <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> em posi&#231;&#227;o a&#243;rtica&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Inclu&#237;mos sete pacientes do sexo masculino&#44; com idade de 72&#44;6 &#177; 10&#44;0 anos&#46; O escore STS foi 9&#44;6 &#177; 10&#44;5&#37;&#44; e o EuroSCORE log&#237;stico foi 22&#44;7 &#177; 14&#44;7&#37;&#46; Tr&#234;s pacientes apresentavam dupla disfun&#231;&#227;o&#59; dois tinham insufici&#234;ncia&#59; e dois exibiam estenose isolada&#46; A via transfemoral foi utilizada em seis casos&#44; e a transapical&#44; em um caso&#46; Os dispositivos implantados inclu&#237;ram as pr&#243;teses Sapien XT &#40;n &#61; 5&#41; e CoreValve &#40;n &#61; 2&#41;&#46; O sucesso do procedimento foi obtido em seis &#40;85&#44;7&#37;&#41; casos&#46; Ap&#243;s o procedimento&#44; o gradiente m&#233;dio reduziu&#8208;se de 38&#44;2 &#177; 9&#44;6<span class="elsevierStyleHsp" style=""></span>mmHg para 20&#44;9 &#177; 5&#44;9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; e a &#225;rea valvar elevou&#8208;se de 1&#44;2 &#177; 0&#44;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> para 1&#44;5 &#177; 0&#44;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#46; Ao final de 1 ano&#44; n&#227;o ocorreram &#243;bitos e nem outros desfechos adversos significativos&#59; 80&#37; dos pacientes encontravam&#8208;se em classe funcional NYHA I&#47;II&#46; Os gradientes transvalvares e a &#225;rea valvar permaneceram inalterados nesse per&#237;odo&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">O procedimento <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> foi eficaz na maioria dos pacientes de alto risco cir&#250;rgico com disfun&#231;&#227;o de biopr&#243;tese&#46; Quando realizado em pacientes bem selecionados&#44; resulta em desfechos cl&#237;nicos e hemodin&#226;micos satisfat&#243;rios&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introdu&#231;&#227;o"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "ABSTRACT"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Recent studies have demonstrated the efficacy of the transcatheter valve&#8208;in&#8208;valve implantation for the treatment of bioprosthesis dysfunction in high&#8208;risk surgical patients&#46; This study presents the initial experience with valve&#8208;in&#8208;valve implantation&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; echocardiographic&#44; and procedural profiles were characterized&#44; and the mid&#8208;term results of patients with surgical bioprosthesis dysfunction submitted to valve&#8208;in&#8208;valve implantation in the aortic position were reported&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Seven male patients were included&#44; aged 72&#46;6 &#177; 10&#46;0 years&#46; The STS score was 9&#44;6 &#177; 10&#44;5&#37;&#44; and the logistic EuroSCORE was 22&#46;7 &#177; 14&#46;7&#37;&#46; Three patients had combined aortic bioprosthesis failure&#59; two had isolated regurgitation&#59; and two had isolated stenosis&#46; The transfemoral access was used in six cases&#44; and the transapical access in one case&#46; Implanted devices included Sapien XT &#40;n &#61; 5&#41; and CoreValve &#40;n &#61; 2&#41; prostheses&#46; Procedural success was achieved in six &#40;85&#46;7&#37;&#41; cases&#46; After the procedure&#44; the mean gradient decreased from 38&#46;2 &#177; 9&#46;6<span class="elsevierStyleHsp" style=""></span>mmHg to 20&#46;9 &#177; 5&#46;9<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and the valve area increased from 1&#46;2 &#177; 0&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> to 1&#46;5 &#177; 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>&#46; After 1 year&#44; there were no deaths and no other significant adverse outcomes&#59; 80&#37; of patients were in NYHA functional class I&#47;II&#46; The transvalvular gradients and valve area remained unchanged in this period&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The valve&#8208;in&#8208;valve procedure was effective in most high&#8208;risk surgical patients with bioprosthesis dysfunction&#46; When performed in well&#8208;selected patients&#44; it results in satisfactory clinical and hemodynamic outcomes&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Background"
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            "identificador" => "abst0030"
            "titulo" => "Methods"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">A revis&#227;o por pares &#233; de responsabilidade da Sociedade Brasileira de Hemodin&#226;mica e Cardiologia Intervencionista&#46;</p>"
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    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
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            "Alto" => 2617
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gradientes ventr&#237;culo esquerdo&#8208;aorta &#40;VE&#8208;Ao&#41; m&#225;ximo e m&#233;dio&#44; &#225;rea valvar a&#243;rtica&#44; fra&#231;&#227;o de eje&#231;&#227;o do VE e press&#227;o sist&#243;lica de art&#233;ria pulmonar &#40;PSAP&#41; 1 ano ap&#243;s <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span>&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "pt" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Classe funcional <span class="elsevierStyleItalic">New York Heart Association</span> &#40;NYHA&#41; pr&#233; e 1 ano ap&#243;s procedimento <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span>&#46;</p>"
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">&#40;<span class="elsevierStyleBold">A</span>&#41; Biopr&#243;tese cir&#250;rgica com folhetos porcinos&#46; &#40;<span class="elsevierStyleBold">B</span>&#41; Aferi&#231;&#227;o do di&#226;metro interno da biopr&#243;tese com aux&#237;lio de um paqu&#237;metro&#46; &#40;<span class="elsevierStyleBold">C</span>&#41; Sutil distor&#231;&#227;o da valva causada pelo paqu&#237;metro&#44; podendo levar a medidas incorretas&#46; Primeira medida&#58; 22&#44;31<span class="elsevierStyleHsp" style=""></span>mm&#46; &#40;<span class="elsevierStyleBold">D</span>&#41; Segunda medida&#58; 25&#44;74<span class="elsevierStyleHsp" style=""></span>mm&#44; evidenciando o efeito causado pela distor&#231;&#227;o&#46; &#40;<span class="elsevierStyleBold">E</span>&#41; Pr&#243;teses de folhetos porcinos&#58; o di&#226;metro interno &#40;DI&#41; verdadeiro &#233; pelo menos 2<span class="elsevierStyleHsp" style=""></span>mm menor que o DI do stent&#46; &#40;<span class="elsevierStyleBold">F</span>&#41; Valvas de peric&#225;rdio bovino com folhetos suturados internamente ao stent&#58; o DI &#233; pelo menos 1<span class="elsevierStyleHsp" style=""></span>mm menor que o DI intra&#8208;stent&#46; &#40;<span class="elsevierStyleBold">G</span>&#41; Valvas de peric&#225;rdio bovino com folhetos suturados externamente ao stent&#58; DI verdadeiro &#233; o mesmo que o DI intra&#8208;stent&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Adaptado de Bapat et al&#46;&#44; <a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figura 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1160
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            "Tamanyo" => 232552
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Procedimento <span class="elsevierStyleItalic">valve&#8208;in&#8208;valve</span> com as pr&#243;teses CoreValve &#40;<span class="elsevierStyleBold">A&#8208;C</span>&#41; e Sapien XT &#40;<span class="elsevierStyleBold">D&#8208;F</span>&#41;&#46; &#40;<span class="elsevierStyleBold">A</span>&#41; O anel de sutura radiopaco da biopr&#243;tese &#233; visualizado por fluoroscopia&#44; sendo verificadas a angula&#231;&#227;o adequada antes do procedimento e a <span class="elsevierStyleItalic">landing zone</span>&#46; &#40;<span class="elsevierStyleBold">B</span>&#41; Libera&#231;&#227;o da pr&#243;tese autoexpans&#237;vel CoreValve&#44; lenta e gradualmente&#44; e controle por fluoroscopia&#46; &#40;<span class="elsevierStyleBold">C</span>&#41; Posi&#231;&#227;o final da pr&#243;tese&#46; &#40;<span class="elsevierStyleBold">D</span>&#41; Posicionamento da pr&#243;tese bal&#227;o&#8208;expans&#237;vel Sapien XT&#46; &#40;<span class="elsevierStyleBold">E</span>&#41; libera&#231;&#227;o sob fluoroscopia e resultado ap&#243;s o implante &#40;<span class="elsevierStyleBold">F</span>&#41;&#46;</p>"
        ]
      ]
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        "etiqueta" => "Tabela 1"
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            "identificador" => "at1"
            "detalle" => "Tabela "
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                  <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  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Casos</th><th class="td" title="table-head  " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Paciente</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&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">2&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">3&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">4&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">5&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">6&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">7&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">Idade&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&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">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Masculino&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">IMC&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#44;6&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">EuroSCORE log&#237;stico&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#44;9&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">EuroSCORE II&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;2&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">Escore STS&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;8&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">Classe funcional NYHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&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">Outros sintomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nenhum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nenhum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nenhum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nenhum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;ncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nenhum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Angina&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">Comorbidades associadas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS&#44; DLP e IRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS&#44; DLP&#44; dissec&#231;&#227;o de aorta e car&#243;tida pr&#233;via corrigidas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS e hemorragia digestiva pr&#233;via&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS e DLP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS&#44; aneurisma de aorta e MP definitivo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS&#44; DLP&#44; DM&#44; tabagismo e c&#226;ncer de pr&#243;stata&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HAS&#44; DLP&#44; DM&#44; DPOC&#44; HPB e troca valvar mitral h&#225; 9 anos&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">Coronariopatia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&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">Interven&#231;&#245;es cardiovasculares pr&#233;vias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICP &#40;h&#225; 2 anos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RMC &#40;h&#225; 12 anos&#41;&#44; ICP &#40;h&#225; 2 anos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RMC &#40;h&#225; 10 anos&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICP &#40;h&#225; 18 anos&#41;&#44; RMC &#40;h&#225; 8 anos&#41;&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">Troca valvar&#44; anos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;7&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">Tipo de pr&#243;tese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biocor&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Braile&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biocor&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biocor&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biocor&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biocor&#8482;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epic&#8482;&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">Creatinina pr&#233;&#44; mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;0&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"><span class="elsevierStyleItalic">Clearance</span> de creatinina pr&#233;&#44; mL&#46;min&#46;1&#46;73<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">134&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#44;1&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">AVA pr&#233;&#44; cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&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">FEVE pr&#233;&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&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">&#916; M&#225;ximo pr&#233;&#44; mmHg<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">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&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">&#916; M&#233;dio pr&#233;&#44; mmHg<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">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&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">Insufici&#234;ncia a&#243;rtica pr&#233;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Importante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Importante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Importante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discreta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Importante&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Importante&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">PSAP&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Valores medidos pelo ecocardiograma&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">IMC&#58; &#237;ndice de massa corporal&#59; EuroSCORE&#58; <span class="elsevierStyleItalic">European System for Cardiac Operative Risk Evaluation</span>&#59; Escore STS&#58; <span class="elsevierStyleItalic">Society of Thoracic Surgeons</span>&#59; NYHA&#58; <span class="elsevierStyleItalic">New York Heart Association</span>&#59; HAS&#58; hipertens&#227;o arterial sist&#234;mica&#59; DLP&#58; dislipidemia&#59; IRC&#58; insufici&#234;ncia renal cr&#244;nica&#59; DM&#58; diabetes melito&#59; DPOC&#58; doen&#231;a pulmonar obstrutiva cr&#244;nica&#59; HPB&#58; hiperplasia prost&#225;tica benigna&#59; ICP&#58; interven&#231;&#227;o coron&#225;ria percut&#226;nea&#59; RMC&#58; revasculariza&#231;&#227;o mioc&#225;rdica cir&#250;rgica&#59; AVA&#58; &#225;rea valvar a&#243;rtica&#59; FEVE&#58; fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo&#59; &#916;&#58; gradiente&#59; PSAP&#58; press&#227;o sist&#243;lica de art&#233;ria pulmonar&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "pt" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas demogr&#225;ficas e cl&#237;nicas</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Tabela 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Tabela "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "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  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Casos</th><th class="td" title="table-head  " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Paciente</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&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">2&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">3&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">4&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">5&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">6&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">7&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">Pr&#243;tese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sapien XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sapien XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sapien XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sapien XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CoreValve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sapien XT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CoreValve&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">Tamanho da pr&#243;tese&#44; mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&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">Acesso vascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral direito&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral direito&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral direito&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral esquerdo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral esquerdo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Femoral esquerdo&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">ETE durante procedimento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&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">Tempo de procedimento&#44; minutos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&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">Volume de contraste&#44; mL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&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">P&#243;s&#8208;dilata&#231;&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&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">AVA p&#243;s&#44; cm<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&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">FEVE p&#243;s&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&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">&#916; M&#225;ximo p&#243;s&#44; mmHg<a class="elsevierStyleCrossRef" href="#tblfn0010"><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">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&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">&#916; M&#233;dio p&#243;s&#44; mmHg<a class="elsevierStyleCrossRef" href="#tblfn0010"><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">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&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">Insufici&#234;ncia a&#243;rtica p&#243;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#237;nima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&#237;nima&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">Regurgita&#231;&#227;o paraprot&#233;tica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discreto&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ausente&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">PSAP p&#243;s&#44; mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&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">BRE novo p&#243;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#227;o&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">Creatinina p&#243;s&#44; mg&#47;dL<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</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">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;7&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"><span class="elsevierStyleItalic">Clearance</span> de creatinina pr&#233;&#44; mL&#46;min&#46;1&#46;73<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "pt" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas do procedimento</p>"
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Información del artículo
ISSN: 01041843
Idioma original: Portugués
DOI:10.1016/j.rbci.2016.06.004
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2018 Junio 86 7 93
2018 Mayo 93 11 104
2018 Abril 85 9 94
2018 Marzo 111 10 121
2018 Febrero 66 9 75
2018 Enero 40 10 50
2017 Diciembre 37 13 50
2017 Noviembre 42 14 56
2017 Octubre 47 20 67
2017 Septiembre 34 19 53
2017 Agosto 48 17 65
2017 Julio 49 20 69
2017 Junio 60 22 82
2017 Mayo 119 30 149
2017 Abril 452 151 603
2017 Marzo 58 19 77
2017 Febrero 78 27 105
2017 Enero 71 20 91
2016 Diciembre 93 24 117
2016 Noviembre 71 43 114
2016 Octubre 113 35 148
2016 Septiembre 215 41 256
2016 Agosto 134 53 187
2016 Julio 17 5 22
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