Estratégia Antitrombótica em Próteses Teciduais - Dr. André Durães

É com grande satisfação que o Ecobahia recomenda os artigos do meu caro amigo Dr. André Durães:

 

 Arquivos Brasileiros de Cardiologia

 

Revista Brasileira de Cirurgia Cardiovascular

TARV galopando - by theheart.org

http://www.medscape.com/viewarticle/810350

New TAVR Turf? Bicuspid and Valve-in-Valve Results Show Promise


Investigators say new data presented at the European Society of Cardiology (ESC) 2013 Congress support the expansion of transcatheter valves into two areas: failing surgical bioprosthetics and congenital bicuspid aortic valves. Others, however, call for randomized trials before either of these procedures become widespread.

Use of transcatheter aortic-valve replacement (TAVR) in both these conditions has previously been considered to be "relatively" contraindicated.

Valve-in-Valve TAVR
Dr Spyridon Katsanos (Leiden University Medical Center, the Netherlands) presented results of a small series of 16 patients who underwent transcatheter-valve implantation within a failing bioprosthetic valve, using the Edwards Sapien device. All but four patients had failed aortic surgical valves; two had failed bioprosthetic mitral valves, and two had failed mitral-valve annuloplasty.

After a mean follow-up of 21 months, survival was similar between surgical redo and TAVR-treated patients, at roughly 30% in each group. Of note, TAVR-treated patients were, on average, 10 years older than those in the surgically treated group.

"High-risk patients and also elderly patients with failing bioprostheses deemed not operable may have a treatment alternative to redo cardiac surgery," he concluded.

Bicuspid Aortic-Valve Disease
In a separate presentation, Dr Timm Bauer (Heart Center Ludwigshafen, Germany) presented outcomes for 38 patients from the German TAVI registry who had congenital bicuspid valves. Baseline characteristics, he noted, were similar in this group to patients with tricuspid aortic valves.

At both 30 days and one year after TAVR, mortality was not statistically different in both the bicuspid and tricuspid valve patients. At one year, 13.2% of patients with bicuspid valves had died, compared with 20.1% of tricuspid aortic-valve patients.
Of note, however, residual aortic insufficiency of 2+ or greater was seen in 25% of bicuspid patients, compared with only 14.7% of tricuspid patients (p=0.05).

"Although the risk for relevant aortic regurgitation seems to be higher among patients with bicuspid valves, hospital and one-year mortality is not elevated in comparison with patients with tricuspid aortic valves," Bauer concluded.

Speaking with heartwire about to the two presentations, Dr Volkmar Falk (University of Zürich, Switzerland) was more enthusiastic about the valve-in-valve data, noting that younger and younger patients are being treated with surgical bioprosthetics. Implanting a TAVI inside the failing valve "makes a lot of sense, because it takes some of the trauma out of the operation. But we have to raise some cautions."

As of yet, he stressed, "we don't have randomized trials to show that one method is superior," and the current analysis used historical data for the comparison. Moreover, the previously implanted bioprosthetic needs to be large enough to accommodate a TAVR, he added. Finally, he pointed to the two mitral rings treated in Katsanos et al's study. These are particularly problematic for valve-in-valve procedures because the shape of the ring is not always suited to the cylindrical TAVR device and may lead to residual leaks.

As for using transcatheter valves in bicuspid aortic-valve disease, Falk was considerably less sanguine, pointing to the lack of "planning tools" and bench simulation to test how the implant reacts in the different biodynamics of this environment.

"It is all about calcium displacement, and some of these bicuspid valves are heavily and eccentrically calcified," he commented. He drew attention to a high degree of aortic insufficiency in one-quarter of the treated population, a number that surgeons would consider to be inexcusable.

"I think it's not a good option to put in a transcatheter valve in these cases, because you saw the number of leaks: that rate has not come down recently for the bicuspid valves [as it has for TAVR procedures more generally]. What we know is that, due to the geometry of the bicuspid valve, these patients usually get aortic stenosis more often and at a younger age, and the calcifications can be very eccentric, and then more problems occur. In the long run, residual aortic insufficiency and paravalvular leak of 2 or more has been shown in a number of trials to increase mortality," he observed.

The CoreValve (Medtronic) system received CE mark earlier this year for minimally invasive valve-in-valve procedures, the first device to obtain this indication

Retomando os Trabalhos...

De volta a ativa com nosso blog, nada melhor que um bom artigo escrito por Dra Márcia Barbosa, presidente da SIAC. Uma boa revisão sobre Doença de Chagas.

http://www.siacardio.org/default.asp?xItem=1594

Boa leitura a todos

Bioestatística para Pesquisa Científica - by Prof. Dr. Luis Cláudio Correia

Sessão Conjunta - SBC -Ba

Hospital Cardiopulmonar

Veja como chegar:

http://www.cardiopulmonar.com.br/unidades.aspx

A lei das séries...- by Fábio Soares

Há 1,5 semana postei um caso de Anomalia de Ebstein diagnosticado tardiamente em um paciente de 40 anos. E não é que hoje, no intervalo de 2 horas aparecem mais 2 adultos com o mesmo diagnóstico no nosso serviço (Hospital Santa Izabel)?

Caso 1 - Pcte masc, 38 anos:

Caso 2 - Pcte masc, 25 anos:

Revisão do tema aqui:
http://ecobahia-mitoseverdades.blogspot.com.br/2013/05/caso-clinico-da-semana-by-fabio-soares.html

Sessão Conjunta SBC/Ba - DIC/DERC/SOBRAC

Caso Clínico da Semana - by Fábio Soares

Pcte feminina, 78 anos, HAS, grande tabagista, admitida com dispnéia aos mínimos esforços. Perda ponderal de 17 Kg em 3 meses.

RCP com quem sabe...

Ecocardiofeelings - Um excelente blog sobre Ecocardiografia

 

 

http://ecocardiofeelings.blogspot.com.br/

Caso Clínico da Semana - by Fábio Soares

Paciente masculino, 40 anos, sem comorbidades previamente diagnosticadas, em "avaliação ambulatorial de rotina" com Clínico, auscultado sopro sistólico em REE. Assintomático.

 

Anomalia de Ebstein - Achados Ecocardiográficos:

• M-mode
• Movimentação paradoxal do SIV
• VD dilatado
• Atraso > 65mseg no fechamento da VT em relação à VM

• Bidimensional
• Deslocamento apical da cúspide septal> 8mm/m² (sinal mais específico)
• Anormalidades na morfologia e na inserção das cúspides anterior e septal
• Coaptação excêntrica 
• AD dilatado
• VDdilatado com função sistólica reduzida
• Associação com outras anomalias estruturais (CIA, PCA)
• Doppler
• Insuficiência tricúspide
• Graduação da severidade da IT e informações cirúrgicas ao ecocardiograma
• Área funcional do VD < 35% da ára total do VD ou uma relação VD atrializado/VD funcionante > 0,5 estão associados a pior prognóstico
• Grau de deslocamento da cúspide septal
• Graduação do "efeito Tethering" da cúspide 
• Magnitude da deformidade e/ou displasia valvar
• Dilatação aneurismática do trato de via de saída do VD (RVOT/Ao >2:1 no eixo curto) 
• IT moderada ou grave 

Dra. Janine Magalhães convida...

Endocardite Infecciosa em Prótese Cardíaca - by Fábio Soares

Guidelines on the prevention, diagnosis, and

treatment of infective endocarditis - 2009

European Heart Journal

 

 

 

 

 

 

Dra Angele Matos convida...

Estagio em Ecocardiografia - Prof. Dr. Andre Almeida

Excrescência de Lambl - by Fábio Soares

- Vilem Dusan Lambl descreveu pequenos processos  filiformes na valva aórtica em 1856, em um artigo chamado Papillare exkreszenzen an der semilunar-klappe der aorta (Weiner medicinische Wochenschrift,1856, 244).

- Ao mesmo Dr.Lambl, são creditados as descrições originais da Giardia Lamblia, Espondilólise e certa morfologia de células tumorais em bexiga.

- Margerey et al. (Path J Bact 1949; 61:203-208) estudaram 250 valvas mitral e postularam que o mecanismo de formação é a lesão da íntima devido a trauma mecânico da coaptação. A área danificada é coberta por fibrina, que subsequentemente acaba se projetando a partir da superfície valvar. Uma camada de células endoteliais cobre a superfície do depósito de fibrina.
A fibrina "encapsulada" torna-se condensada e hialina formando a excrescência. Esta substância hialina organizada posteriormente é substituída por tecido fibroso.

- Caracterícticas ecocardiográficas: Estruturas finas (espessura < 2mm) e alongadas (>3mm) com movimentação independente e ondulante vistas próximo a linha de fechamento (linha de coaptação) na face atrial (no caso das valvas mitral e tricúspide) e na face ventricular (no caso da valva aórtica). Na literatura médica, é comumente referida como STRANDS.

- O diagnóstico diferencial de Excrescências Lambl (EL) inclui fibroelastoma, mixoma, trombos, vegetações, endocardite e outras neoplasias/metástase.

 



- Estudos sobre a importância clínica das excrescências Lambl são contraditórios. Embora existem estudos sugerindo a ressecção cirúrgica de fibroelastomas em pacientes assintomáticos, o mesmo não se pode dizer para pacientes assintomáticos com EL.
 
Referências:

Roldan CA, Shively BK, Crawford MH: Valve excrescences: Prevalence, evolution and risk for cardioembolism. JACC 1997; 30: 1308-1314

 

Hort W, Horstkotte D: Fibrolelastoma and Lambl's excrescence: Localization, Morphology and pathogenesis, differential diagnosis and infection. J Heart Valv Dis 2006 ; 15: 591-59

 

Links recomendados:

 

http://www.anesthesia-analgesia.org/content/106/6/1639.full.pdf+html

 

http://www.nejm.org/doi/full/10.1056/ENEJMicm010900

 

http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8175.2007.00533.x/full

E vamos fechando... - by theheart.org

RESPECT and PC Trial published: Results of PFO closure debated again

March 20, 2013 Michael O'Riordan

 

San Francisco, CA - The Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment (RESPECT) and PC Trial, presented at TCT 2012 after many years of anticipation, are published today in the New England Journal of Medicine [1,2].

The studies, both of which were reported by heartwire, were randomized, controlled clinical trials, and both missed their primary end point, a finding that disappointed many hoping that closure of patent foramen ovale (PFO) with the Amplatzer occluder (St Jude Medical, St Paul, MN) would prevent stroke recurrence in patients who previously had a cryptogenic stroke.

However, as noted previously, the trials sparked debate and discussion about the merits of PFO closure in this patient population, given that the underpowered PC Trial was clearly negative and the RESPECT study showed a benefit only in the "per-protocol" and "as-treated" patients. In an editorial accompanying the studies [3], Dr Steven Messé (University of Pennsylvania, Philadelphia) and Dr David Kent (Tufts University, Boston, MA) said both trials have something for the believer and something for the skeptic.

"Advocates of closure will surely focus on the substantial relative effect size of the point estimates in both trials, the significance of the per-protocol and as-treated analyses in RESPECT, the arbitrariness of the conventional p value threshold of 0.05, and various other intriguing signals," they write.

However, the trials are unlikely to convince those skeptical of the procedure, given that the three trials to date, including the controversial CLOSURE I, "have failed to reject the null hypothesis in their primary intention-to-treat analyses," they add. In addition, there are concerns about potential sources of bias—namely, the uneven dropout rates and imbalanced referral for the adjudication of clinical end points. Acknowledging the uncertainty surrounding the studies, the editorialists do not advocate the routine closing of PFO in stroke patients.

"Given the prevalence of patent foramen ovale in the general population, the enormous potential for overuse of percutaneous closure of a patent foramen ovale, and the relatively low risk of stroke in patients who are treated medically, the routine use of this therapy seems unwise without a clearer view of who, if anyone, is likely to benefit," write Messé and Kent.

To heartwire, lead RESPECT investigator Dr John Carroll (University of Colorado, Denver) said the totality of clinical-trial evidence, including the positive prespecified per-protocol and as-treated results in RESPECT, moves the field forward. Although the trial missed the primary end point, he said that other significant findings, despite the inherent biases of per-protocol and as-treated analyses, help shed light on the benefits to the patients who received the device. In addition, the RESPECT and PC Trial showed there was a major improvement in the safety of PFO closure with the Amplatzer device compared with the STARFlex (NMT Medical) device tested in CLOSURE I.

"I would point out that these trials aren't like left-atrial-appendage trials looking at noninferiority of the device vs a medication strategy," he said. "PFO-closure trials for secondary prevention of ischemic stroke are superiority trials, and that is a higher level of evidence that we're after. RESPECT, with two of the three analyses showing superiority, is substantial." He added that three of the nine patients in the device arm of RESPECT who had a recurrent stroke did not have a device in place, and this raises some question as to the validity of the intention-to-treat results.

 

"We can't look at clinical trials like sporting events, where there is a score with a winner and loser," said Carroll. "The more fundamental question to ask when clinical trials are reported is whether or not the trial moves us forward in understanding the disease process, its treatments, and in whom the treatments might work with the greatest benefit. It's this kind of knowledge development that we're really after."

Dr Sanjay Kaul (Cedars-Sinai Medical Center, Los Angeles, CA), who was not involved in the studies but who commented on the results at TCT 2012, said the publication of the data doesn't really change his opinion of PFO closure. He told heartwire that he holds the same position he did a few months ago when asked if the results from the PC Trial and RESPECT moved the needle in terms of his support for PFO closure to prevent stroke recurrence and he said it did, moving it from "not to maybe not."

"An important lesson to be learned from these trials is that it is the collective responsibility of all the stakeholders (patients, physicians, payers, sponsors, and regulators) to ensure completion of randomized trials in a timely and efficient manner," he said this week in an email. "It took over a decade to enroll about 2300 patients for these three trials. Over 80 000 PFOs were closed during this time without evidence of effectiveness. A classic example of putting the cart before the horse!"

 

 

The RESPECT and PC Trial, in a nutshell

In the PC Trial, led by Dr Bernard Meier (University of Bern, Switzerland), which included 414 patients randomized to treatment with the transcatheter Amplatzer PFO occluder or medical therapy, closing the PFO failed to reduce the primary end point of death from any cause, nonfatal stroke, transient ischemic attack, and peripheral embolism. There was an 80% reduction in the risk of stroke, but this reduction did not reach statistical significance

In the RESPECT trial, a multicenter, event-driven study that enrolled 980 patients over eight years, the 46.6% reduction in the risk of stroke was not statistically significant when assessed in the intention-to-treat analysis. However, when the investigators analyzed the data among patients treated per protocol, the 63.4% reduction in stroke was statistically significant, as was the 72.7% reduction in stroke when analyzed by patients who actually received the device.

At the time of the presentation, experts noted that the two PFO closure trials have been difficult to complete, given slow enrollment. Many of the TCT discussants had difficulty interpreting how the trials would shape clinical practice, especially given the mixed bag of results. Dr Gregg Stone (Columbia University, New York), the moderator of the late-breaking clinical-trials session, said the studies failed to provide definitive answers, as did others.

Totality of the evidence

The editorialists, along with Carroll and the RESPECT investigators, highlight the need for further study of PFO closure in this patient population, something that is currently ongoing. More than 800 patients in RESPECT are still being followed, and data on these patients will eventually be reported. Second, there are plans to pool patient-level data from the RESPECT and PC Trial to address some of the issues of statistical power that have been raised with the PC Trial, as well as with the small number of events in RESPECT.

 

To heartwire, Carroll noted that recently presented neuroimaging data of the index stroke event showed that patients with transient ischemic attack and lacunar stroke were successfully excluded from the RESPECT trial, which helped produce an ideal group to study the superiority of the device compared with medical therapy alone. Second, for those with recurrent stroke, there was strong neuroimaging evidence supporting the biological effect of device closure, with patients in the medical-therapy arm who had a stroke more likely to have a stroke consistent with embolic etiology.

In the editorial, Messé and Kent praise the investigators for continuing to investigate the issue and to accrue data on the patients enrolled in these and other trials. They point out that misclassification of one or two events can have dramatic effects on clinical outcomes (and their significance) in studies with low outcome rates. While it is possible to combine RESPECT and the PC Trial, such a meta-analysis and its subsequent outcome will "depend on post hoc, data-driven design choices, such as whether to exclude CLOSURE I or which outcome measure to use in the primary analysis."

All eyes now will be on the Food and Drug Administration and Circulatory System Devices advisory panel that will hear the evidence presented again by the sponsor and investigators at a still-undecided date. Another trial, the REDUCE study, sponsored by Gore Medical, is currently ongoing, and the company received FDA approval to use its atrial septal defect (ASD) closure device in the study.

Contratilidade segmentar - by Fábio Soares

Como você descreveria a movimentação deste septo interventricular?

 

 

Resposta do Caso da Ergometria... - by Carlos Frederico

Durante o esforço observa-se o desenvolvimento de distúrbio de condução frequência dependente caracterizado por bloqueio divisional superior do ramo direito (BDSRD).


Segundo a diretriz da SBC sobre laudos de ECG, os critérios diagnósticos são:

• rS em D2 , D3 e aVF com S2 > S3 com S< 10mm.

• QRS < 120 ms .

• Presença de onda "s" em D1.

• SÂQRS entre - 45° e - 180°.

• S empastado em V1- V2 / V5 – V6 ou eventualmente rSr’ em V1 e V2.

• qR em avR com R empastado.

Deve-se salientar a diferença para o BDASE onde o S cresce de D2 para D3 e a sua ocorrência está fortemente associada a pacientes com doença coronariana grave, notadamente lesão proximal da descendente anterior.

O BDSRD é mais visto em pacientes chagásicos, podendo ocorrer em pacientes saudáveis, como no caso referido.
Pastore CA, Pinho C, Germiniani H, Samesima N, Mano R, et al. Sociedade Brasileira de Cardiologia. Diretrizes da Sociedade Brasileira de Cardiologia sobre Análise e Emissão de Laudos Eletrocardiográficos (2009). Arq Bras Cardiol 2009;93(3 supl.2):1-19

Canabrava M, França F, Murad Neto A. Aspectos Eletrocardiográficos dos Distúrbios de condução freqüência-dependentes noTeste Ergométrico. Revista do DERC 2008; 44:5-8

 
  Paciente sexo feminino, 34 anos, sem comorbidades prévias e sem queixas cardiovasculares.

Encaminhada para realização de teste ergométrico para avaliação funcional, visto querer participar de provas de atletismo

ECG de repouso:

Realizou exame sem referir sintomas, permanecendo cerca de 8 minutos no esforço, ultrapassando a frequência submáxima.

Aptidão cardiorespiratória: boa.

Abaixo os traçados

Valvotomia Percutânea Aórtica - by Fábio Soares

 

 

7.3.4. Valvuloplastia Aórtica com Cateter-balão (VACB).

A VACB é um procedimento no qual um ou mais balões são colocados através da valva aórtica e inflados com a finalidade de reduzir a gravidade da estenose aórtica. Ocasiona a fratura do cálcio depositado nos folhetos valvares, com alargamento do ânulo aórtico e separação das comissuras.

 

Apesar das altas taxas de possíveis complicações (cardiovasculares e neurológicas), os resultados imediatos normalmente produzem quedas moderadas dos gradientes transvalvares com melhora sintomática, mas com apenas um pequeno aumento da área valvar, o que determina altas taxas de reestenose e pobre resultado em médio e longo prazos

 

A VACB nunca se firmou como um substituto à CVAo, e até o advento do implante valvar aórtico percutâneo sua indicação vinha sendo muito restrita. Todavia, nessa circunstância, sua utilização adjunta é recomendada, devendo, por protocolo, preceder o implante valvar aórtico percutâneo.

 

O procedimento ainda é considerado como "ponte" para cirurgia em pacientes hemodinamicamente instáveis sem condições cirúrgicas, ou, ocasionalmente, como medida paliativa em pacientes com contraindicação à cirurgia valvar. Tem, ainda, potencial para uso como ponte para o implante percutâneo valvar aórtico .

 

 

 

 

 

Prolapso da Valva Tricúspide

"Tricuspid valve prolapse is an infrequent echocardiographic finding that is most commonly associated with mitral valve prolapse. When compared with patients exhibiting isolated prolapse of the mitral valve, patients with tricuspid valve prolapse are somewhat older individuals with a slightly higher frequency of neurologic symptoms, fatigue, weakness, supraventricular arrhythmias (especially atrial fibrillation) and skeletal deformities. Tricuspid valve prolapse may serve as a marker of more-diffuse connective tissue abnormalities, and its identification also should prompt an echocardiographic search for evidence of prolapse and regurgitation of the other heart valves."

 

 

Aneurisma do Septo Interatrial - Revista DIC

ARTIGO NA ÍNTEGRA

 

 

 

Classificação de Hanley

et al.10 :

Tipo IA

.- A membrana do aneurisma apresenta pouco movimento e abaulamento constante em direção ao interior do átrio direito.

Tipo IB.

- A membrana do aneurisma apresenta pouco movimento e abaulamento constante em direção ao interior do átrio direito, com rápidas oscilações na inspiração, mas permanecendo ainda no interior do átrio direito.

Tipo 2.
- A membrana do aneurisma apresenta ampla mobilidade e abaulamento sequencial em direção a ambos átrios, mas, preferencial em direção ao átrio esquerdo. A soma da distancia percorrida em cada átrio deve ser superior a 15mm. Em alguns casos é observada movimentação em direção ao átrio esquerdo na inspiração e ao átrio direito na expiração.

Cardiomiopatia não compactada - by Fábio Soares

- A cardiomiopatia não-compactada (CMNC) é um distúrbio congênito geneticamente heterogêneo, caracterizado por um padrão trabecular proeminente e recessos intra-trabeculares profundos que não estão conectados com a circulação coronariana e são cobertos por uma camada de endocárdio contínua com a parede ventricular, tornando-a suscetível à formação local de trombos.

- A causa da cardiomiopatia não-compactada parece ser uma anormalidade morfogenética que detém a compactação do miocárdio durante a embriogênese. No desenvolvimento normal, o coraçãocompacta-se no sentido da base para o ápice e do epicárdio para o endocárdio.

 

- Mutações no gene G4.5, no cromossomo Xq28 são responsáveis pela não compactação ventricular e resultam numa amplo espectro de fenótipos de cardiopatias graves, incluindo casos de ventrículo esquerdo não-compactado isolado, até a síndrome de Barth (cardiomiopatia dilatada, miopatia esquelética, neutropenia e anomalias mitocondriais).

- A CMNC pode resultar em disfunção sistólica e diastólica do ventrículo esquerdo. A disfunção sistólica pode estar relacionada a hipoperfusão endocárdica e disfunção da microcirculação; enquanto a disfunção diastólica está relacionada com relaxamento anormal e restrição ao enchimento do VE devido a inúmeras trabéculas. 

 

- Em adultos, um ou mais segmentos, especialmente das regiões apical, médio-lateral e médio-inferior do VE (e por vezes de ambos os ventrículos) são os mais acometidos.

 

- O diagnóstico da cardiomiopatia não-compactada é frequentemente "esquecido"ou errôneo, devido à falta de conhecimento da doença e por que outras doenças cardíacas apresentam características similares; assim, é necessário distingui-la de outras patologias nas quais o aumento da espessura da parede ventricular e um padrão trabecular proeminente são observados, como na cardiomiopatia hipertrófica e cardiopatia hipertensiva, bem como a cardiomiopatia dilatada, na qual a hipocinesia generalizada, dilatação das cavidades cardíacas e grave disfunção ventricular esquerda são encontradas.

 

- A ecocardiografia bidimensional com mapeamento de fluco a cores é o método de primeira escolha para diagnóstico. Os critérios mais utulizados são:

 

 

 

 - Outras modalidades diagnósticas podem ser utilizadas tais como a ressonância magnética, tomografia computadorizada e a ventriculografia.

 

- A  alta incidência de fenômenos tromboembólicos na CMNC eprovavelmente resulta da formação de trombos locais nos recessos intertrabeculares. Com base na elevada frequência de eventos embólicos, os pacientes devem ser submetidos a anticoagulação sistêmica, independentemente de trombos visualizados ao ecocardiograma.

 

- O tratamento medicamentoso é similar ao de outras cardiomiopatias. Certas características clínicas parecem determinar pior prognóstico: maior diâmetro ventricular, CF NYHA III/IV, FA e bloqueio de ramo esquerdo. Se o tratamento medicamentoso não for eficaz, o transplante cardíaco é uma terapêutica possível.

 

Reiniciando os trabalhos em 2013...

Para iniciar bem o ano, aproveito o espaço para chamar a atenção para o excelente artigo de revisão do nosso amigo Prof Dr. André Almeida (Feira de Santana - Bahia)
 

Speckle-Tracking

pela Ecocardiografia Bidimensional – Aplicações Clínicas

Revista do Departamento de Imagem Cardiovascular da SBC (jan 2013).


 

 

http://departamentos.cardiol.br/sbc-depeco/publicacoes/revista/2013/portugues/Revista01/09-revisao.pdf