Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

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It allows point-of-care (at the patient bedside), real-time dynamic imaging of the heart and also provides morphological and functional information. The data afforded by echocardiography often allow us to identify the causes of shock, and offer useful guidance for assessing treatment. Some studies have shown that echocardiography can provide information leading to significant modification of treatment in up to 52% of all critical patients. As a result, some groups have developed TTE protocols designed to optimize the treatment of these patients.<a class="elsevierStyleCrossRefs" href="#bib0005">1–20</a>Although studies have been made by intensivists on the usefulness of transesophageal echocardiography (TEE) in critical patients,<a class="elsevierStyleCrossRefs" href="#bib0105">21,22</a> very few publications have assessed the applicability and impact of specific goal-directed basic TTE upon the diagnostic and therapeutic management of patients in the postoperative period of heart surgery.<a class="elsevierStyleCrossRefs" href="#bib0005">1,23–25</a> Recently, our group has published a study showing that basic TTE can be performed in most such patients, with the generation of interpretable data.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>The present study was carried out to prospectively evaluate the impact of specific goal-directed basic TTE upon the diagnosis and treatment of patients following heart surgery.Material and methodsSelection of patientsThe study was carried out in the Department of Intensive Care Medicine of a University general hospital with 16 polyvalent beds that attends 100 post-heart surgery patients a year.We included all patients over 18 years of age subjected to heart surgery and consecutively admitted to the Intensive Care Unit (ICU) between November 2014 and April 2016, with the physical presence of an intensivist with certified training in basic echocardiography.The study protocol was approved by the local Clinical Research Ethics Committee. All patients gave written informed consent to participation in the study.Clinical characteristicsAt the time of patient admission, we recorded the general demographic characteristics, the reason for admission, main comorbidities, severity scores (APACHE II, EuroSCORE) and hemodynamic and echocardiographic data prior to surgery, if available.A clinical and hemodynamic evaluation of the patient was made by one of the 6 intensivists of the Department to establish an initial diagnosis, in accordance with routine clinical practice in post-heart surgery patients: hypovolemia, left ventricular dysfunction, right ventricular dysfunction, biventricular dysfunction, vasoplegia, massive mitral valve insufficiency or tamponade, and treatment was prescribed based on the diagnosis.Basic echocardiographyFollowing the initial clinical evaluation and within the first 8 h of admission, another intensivist trained in basic echocardiography performed basic TTE. At the time of the exploration, the use of mechanical ventilation was documented, as well as the administration of vasoactive medication, and the hemodynamic parameters (heart rate, blood pressure, central venous oxygen saturation, lactate concentration).The echocardiographic study was repeated daily in the presence of signs of tissue hypoperfusion (arterial hypotension, evidence of poor peripheral perfusion, elevated lactate levels, oliguria). The professional performing the echocardiographic evaluation was blinded to the initial tentative diagnosis.The echocardiographic analysis comprised systematic assessment of the long and short axes parasternal projections and four-chambers apical and four-chambers subcostal projections with visualization of the inferior vena cava. For each acoustic window, imaging difficulty was rated as either high or low. All explorations were made using the 1.5–4.6 MHz M5S-D echocardiographic probe of the Vivid-e (General Electrics) system, available 24 h in the ICU of our center.The analyzed echocardiographic parameters were:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)Left ventricle: visual size defined as normal or dilated, visual systolic function classified as normal (≥ 50%) or depressed (< 50%), and contraction pattern defined as either homogeneous or heterogeneous.</li><li class="elsevierStyleListItem" id="lsti0010">2)Right ventricle: visual size defined as normal or dilated, and visual systolic function (normal or depressed).</li><li class="elsevierStyleListItem" id="lsti0015">3)Valves: presence of massive mitral valve insufficiency.</li><li class="elsevierStyleListItem" id="lsti0020">4)Inferior vena cava: classified as normal, dilated or not visualized.</li><li class="elsevierStyleListItem" id="lsti0025">5)Pericardial fluid with or without cardiac tamponade, classified as either present or absent.</li></ul>The echocardiographic patterns were defined as<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,27</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">•Severe hypovolemia: small hyperdynamic ventricles, with obliteration of the left ventricular cavity (kissing walls), and small inferior vena cava showing great variation with respiratory movements (under mechanical ventilation, inferior vena cava < 1.5 cm with collapse > 50%; under spontaneous ventilation, inferior vena cava < 1 cm with collapse > 50%).</li><li class="elsevierStyleListItem" id="lsti0035">•Left ventricular failure: reduction of global left ventricular motility, heterogeneous contractility pattern suggesting myocardial ischemia, or dilatation of the left ventricular cavity suggesting chronic heart disease.</li><li class="elsevierStyleListItem" id="lsti0040">•Right ventricular failure: dilatation of the right ventricle and paradoxical motion of the interventricular septum - which in the critical patient is basically associated to acute respiratory distress syndrome (ARDS) or severe pulmonary thromboembolism. Isolated right ventricular dilatation is suggestive of right ventricular infarction. Other associated findings may be a dilated inferior vena cava without collapse.</li><li class="elsevierStyleListItem" id="lsti0045">•Tamponade: presence of pericardial effusion with diastolic collapse of the right atrium and ventricle, and dilated inferior vena cava without respiratory collapse under spontaneous breathing conditions.</li><li class="elsevierStyleListItem" id="lsti0050">•Acute massive mitral valve insufficiency: left ventricle of normal size (indicative of acute valve disease), left ventricle with normal or hyperdynamic systolic function secondary to volume overload of the left ventricle and massive reflow in the color Doppler exploration.</li></ul>All the explorations were digitally recorded and later evaluated by an intensivist with advanced training in TTE (A.O.), rating the quality of the images as optimal (complete identification of the endocardial margins of the left ventricle), suboptimal (identification of > 50% of the endocardial margins of the left ventricle) or poor (identification of < 50% of the endocardial margins of the left ventricle, or visualization not possible). The analysis was based only on the optimal and suboptimal echocardiographic images. We determined the percentage of cases in which echocardiography confirmed the initial tentative or suspected diagnosis. If this diagnosis was not confirmed, we determined the percentage of cases in which echocardiography afforded an alternative diagnosis and the percentage of changes in treatment. Lastly, clinical improvement associated to the different therapeutic changes was analyzed.In the event of doubt regarding the echocardiographic data, a second echocardiographic assessment was made by a cardiologist with expertise in advanced echocardiography.Statistical analysisA descriptive study was made, analyzing percentage clinical improvement secondary to treatment optimization. Continuous variables were reported as the median and standard deviation (SD), or as percentages.ResultsPatient characteristicsThe study sample consisted of 136 post-heart surgery patients consecutively enrolled in the period between November 2014 and April 2016, and representing a total of 203 echocardiographic studies. No patients were excluded during the study period. The demographic and clinical data of the sample are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>With regard to the type of heart surgery, most patients underwent valve replacement either isolatedly (51 patients; 37.5%) or associated to other procedures (22 patients; 16.3%). A total of 64 coronary revascularization surgeries were performed (47.1%), either isolatedly or associated to other procedures. Seven patients underwent other types of surgery (5.1%).With regard to the valve replacements, 49 (67.12%) comprised biological valves, 21 (28.77%) mechanical valves, and three (4.11%) corresponded to annuloplasties. There were 54 aortic valve replacements (39.7%), 17 mitral valve replacements (12.5%), four mitral annuloplasties (2.94%) and 15 tricuspid annuloplasties (11.03%).All patients were subjected to preoperative TTE performed by a cardiologist during admission or on an ambulatory basis a few days before admission. This echocardiographic study showed that most patients had a left ventricle with no hypertrophy (72 patients; 52.94%) or dilatation (115 patients; 84.56%), and with a normal ejection fraction (Simpson’s rule 4C) (127 patients; 93.38%). The right ventricle was not dilated in most patients (131 patients; 96.32%), and exhibited normal function in all cases. Most of the patients had a non-dilated inferior vena cava (128 patients; 94.11%).Postoperative echocardiographyA total of 203 TTEs were performed, distributed as follows: 97 patients (71.3%) underwent a single echocardiographic study; 19 (14%) underwent two echocardiographic studies; 14 (10.3%) underwent three echocardiographic studies; four (2.9%) underwent four echocardiographic studies; and two patients (1.5%) underwent 5 echocardiographic studies. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical data at the time of echocardiography. The main indication of the first echocardiographic study was hemodynamic instability (74 cases; 54.4%), and the main initially suspected diagnosis was hypovolemia (54 cases; 26.6%). The other 62 echocardiographic studies (45.6%) were performed with some other suspected diagnosis, or as controls. The echocardiographic studies performed on the following days were due to hemodynamic instability. With regard to the contemplated initial management based on the clinical data, in most cases (100 cases; 49.3%) no surgery was foreseeable. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> reports the suspected diagnoses, the contemplated management before echocardiography and the echocardiographic diagnosis.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Most of the echocardiographic studies were made with the patient in supine decubitus (197 patients; 97%), and the mean duration of the exploration was 14.46 ± 2.16 min. Evaluation was made of imaging difficulty and imaging quality in each of the planes. In most cases, difficulty was low in all planes, and imaging quality was found to be optimal or suboptimal in most patients. The poorest imaging quality corresponded to the subcostal plane for visualizing the inferior vena cava. On analyzing imaging quality in each plane, we found the long axis parasternal plane to yield 85 echocardiographic studies (41.9%) of optimal quality, 81 (39.9%) of suboptimal quality and 37 (18.2%) of poor quality. The short axis parasternal plane in turn yielded 80 echocardiographic studies (39.4%) of optimal quality, 82 (40.4%) of suboptimal quality, and 41 (20.2%) of poor quality. The four-chambers apical plane yielded 135 echocardiographic studies (66.5%) of optimal quality, 42 (20.7%) of suboptimal quality, and 26 (12.8%) of poor quality. The subcostal plane yielded 122 echocardiographic studies (60.1%) of optimal quality, 29 (14.3%) of suboptimal quality, and 52 (25.6%) of poor quality. Lastly, with regard to visualization of the inferior vena cava, there were 116 echocardiographic studies (57.1%) of optimal quality, 19 (9.4%) of suboptimal quality, and 68 (33.5%) of poor quality. All the echocardiographic studies had some plane of optimal or suboptimal imaging quality, thus allowing echocardiographic assessment in all cases.On analyzing the different echocardiographic parameters, we found the left ventricle to be of normal size (175 cases; 86.2%) and with normal ventricular function in most cases (151 cases; 74.4%), but with heterogeneous contractility in most patients (111 cases; 54.7%). Only 12 patients (5.9%) presented kissing walls. The right ventricle in turn was of normal size and function in most of the cases (184 cases; 90.6%). Sixty patients (29.6%) showed the presence of pericardial fluid, but only two (1.5%) presented signs of tamponade, and thus underwent surgery again.<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> compares the suspected diagnoses based on the clinical findings versus the echocardiographic diagnosis. Overall, the echocardiographic diagnosis was consistent with the suspected clinical diagnosis in 102 cases (50.2%). In one-half of the cases (101 cases, 49.8%), echocardiography differed from the clinical diagnosis. In these 101 cases, echocardiography proved normal in 45 (44.6%); no alternative diagnosis therefore could be established. In 56 cases (55.4%), echocardiography offered a diagnosis different from the suspected clinical diagnosis, and treatment changes were decided in 30 of these cases (53.6%). The changes predominantly involved the start of inotropic treatment (14 cases, 25%). In relation to whether the changes were made on occasion of the first echocardiographic study or as a result of the subsequent echocardiographic explorations, we found that in a large percentage of cases in which a change in diagnosis occurred (34 cases, 60.71%), the change took place on occasion of the first echocardiographic study and implied a modification of the patient management approach in 22 cases (64.71%). In the other 22 cases with discrepancies between the echocardiographic diagnosis and the clinical diagnosis, the treatment changes occurred on occasion of the subsequent echocardiographic studies. All the changes made can be seen in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>In one case presenting diagnostic uncertainty, we contacted the Cardiology Department, which performed a new echocardiographic study that confirmed our own echocardiographic suspicion (severe pericardial effusion with signs of tamponade). We therefore consulted Heart Surgery, which decided repeat surgery, followed by clinical improvement.Of the 30 cases in which treatment was modified on the basis of the echocardiographic diagnosis, 26 (86.67%) showed significant clinical improvement, with amelioration of the hemodynamic parameters (blood pressure, central venous oxygen saturation, increased diuresis, with a lesser need for inotropic and vasoactive drugs) over the following 30-60 min. On examining the treatment changes, we found that 14 patients (46.7%) started inotropic or vasoactive drug treatment, while another 14 patients (46.7%) underwent some other intervention such as the suspension of volume replacement measures or of inotropic medication. One patient (3.3%) received volume replacement measures, and another (3.3%) required repeat surgery because of tamponade. Four patients (13.33%) experienced no clear improvement as a result of the treatment adjustments. Two of them had started inotropic or vasoactive drug treatment (one with poor tolerance of dobutamine due to tachycardia, and another with scant hemodynamic improvement after dobutamine dosing). In another case, due to the presence of bradycardia, we decided to increase the heart rate by means of a pacemaker, though the tissue hypoperfusion parameters did not improve as a result. Lastly, in the fourth case, the clinical suspicion was hypovolemia with normal echocardiographic findings; we therefore decided not to administer volume replacement measures - though no significant clinical changes were observed.DiscussionFollowing demonstration of the feasibility of basic echocardiography in the most extreme situations after heart surgery,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> it was important to study the impact of basic echocardiography on the management of post-heart surgery patients. In the present study, echocardiography did not confirm the clinically suspected diagnosis in almost one-half of the cases. On the other hand, echocardiography offered an alternative diagnosis in over 50% of these cases. In turn, the clinicians decided a change in treatment based on the result of the echocardiographic exploration in 30 cases (14.8% of the total patients and 53.6% with a change in diagnosis). This percentage corresponds to the lower range of the data reported in other studies, with treatment modification rates of up to 52%.<a class="elsevierStyleCrossRefs" href="#bib0005">1,21,24,28</a> This may be because patients with different clinical characteristics were involved. The previous studies included medical-surgical patients in which cardiac disorders not foreseeable on the basis of the initial clinical condition could be involved. In contrast, all of our patients were in the postoperative period of heart surgery, and consequently the fundamental causes of shock were easier to suspect on the basis of the clinical data. In some cases the clinical suspicion was hypovolemia, though with basic echocardiography we are only able to detect the presence of severe hypovolemia. Other studies in heart surgery patients offer similar data referred to the impact of transesophageal echocardiography,<a class="elsevierStyleCrossRefs" href="#bib0145">29–31</a> though these studies were made during the actual operation, resulting changes in management approach during surgery. In our case we used basic transthoracic echocardiography, which is totally noninvasive, during the immediate postoperative period.Heiberg et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> conducted a meta-analysis of 15 studies evaluating the use of transthoracic and transesophageal echocardiography in the postoperative period of heart surgery. The authors concluded that echocardiography is increasingly used in the postoperative period of heart surgery, and that its use results in significant changes in the diagnosis and management of these patients – though the mentioned studies were not designed to assess the patient course over time. Of the studies included in the meta-analysis, 7 analyzed the use of transthoracic echocardiography,<a class="elsevierStyleCrossRefs" href="#bib0010">2,32–37</a> and documented changes in diagnosis and management in 10-52% of the cases. Our own findings fall within this range. Of note is the observation that the treatment introduced after echocardiography resulted in clinical improvement in 86.67% of our patients – thus confirming the clinical usefulness of echocardiography in patients following heart surgery.An interesting observation in our series is the fact that 74% of the echocardiographic explorations showed a normal left ventricular ejection fraction (LVEF), and that 90% recorded a right ventricular ejection fraction (RVEF) within normal ranges. This could be because in most of our patients the preoperative LVEF and RVEF values were respectively normal in 125 patients (92%) and in all patients – thus explaining that these parameters were preserved in the postoperative period. Nevertheless, we found the introduction of vasoactive medication due to the echocardiographic diagnosis to be the most frequent change in treatment, resulting in clinical improvement of the patient.Thus, our results show that the echocardiographic study results in a change in diagnosis in up to 50% of all heart surgery patients. Furthermore, in over one-half of these cases changes in patient management are decided as a consequence of the echocardiographic findings - and this in turn is associated to clinical improvement in the great majority of cases. Nevertheless, in the event of doubts, advanced echocardiography should be performed by an adequately trained intensivist or a cardiologist, as required.Our study has some limitations. In effect, it is a single-center investigation involving one same surgical team; our findings therefore cannot be extrapolated to other centers. All surgeries were elective and were performed in clinically stable patients; the risk of postoperative complications was therefore lower. Some patients already presented ventricular dysfunction at preoperative echocardiography; as a result, in the postoperative period, such dysfunction persisted in the echocardiographic study – without this having clinical repercussions. Likewise, basic echocardiography is only able to detect severe hypovolemia, and thus some patients could have presented hypovolemia that was not evidenced in the echocardiographic study. These circumstances may have influenced the observation of a low percentage change in the echocardiographic diagnosis versus the clinical diagnosis.ConclusionsBasic transthoracic echocardiography is useful for the diagnostic and therapeutic management of patients following heart surgery. In most cases in which a change in diagnosis was made based on the echocardiographic findings, clinical improvement was noted as a result of the modification of treatment.Financial supportNone.Author contributionsStudy conception and design: Dr. Olga Moreno, Dr. Ana Ochagavía, Dr. Antonio Artigas, Dr. Francisco Baigorri.Data acquisition, analysis and interpretation: Dr. Olga Moreno, Dr. Ana Ochagavía, Dr. Sandra Barbadillo, Dr. Roser Tomás, Dr. Maria Dolores Bosque, Dr. Cristina Fortià.Drafting of the manuscript: Dr. Olga Moreno, Dr. Ana Ochagavía, Dr. Antonio Artigas, Dr. Francisco Baigorri.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1429525" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1305549" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1429524" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1305548" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Selection of patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical characteristics" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Basic echocardiography" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Postoperative echocardiography" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Author contributions" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 12 => array:2 [ "identificador" => "xack498900" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-19" "fechaAceptado" => "2019-06-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1305549" "palabras" => array:4 [ 0 => "Basic transthoracic echocardiography" 1 => "Heart surgery" 2 => "Critically ill patients" 3 => "Impact on diagnosis and treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1305548" "palabras" => array:4 [ 0 => "Ecocardiografía transtorácica básica" 1 => "Cirugía cardíaca" 2 => "Pacientes críticos" 3 => "Impacto diagnóstico y terapéutico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveFew studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients. DesignOver an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis. ResultsWe included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30 patients (53.6%). We found clinical improvement in 26 patients (86.76%) in the following 30−60 min. ConclusionsBasic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoPocos estudios han evaluado el impacto en el diagnóstico y tratamiento de la ecocardiografía transtorácica básica en los pacientes postoperados de cirugía cardíaca. El objetivo de nuestro estudio fue valorar el impacto de la ecocardiografía transtorácica básica en el manejo diagnóstico y terapéutico de estos pacientes. DiseñoDurante 18 meses se estudiaron prospectivamente todos los pacientes postoperados de cirugía cardíaca que ingresaron en el Servicio de Medicina Intensiva de un hospital universitario. Se realizó una valoración clínica a todos ellos para establecer un diagnóstico y tratamiento inicial. Se realizó una ecocardiografía transtorácica básica para valoración diagnóstica, que se comparó con la valoración clínica. En caso de discrepancia, se valoró cambiar el tratamiento en función a la ecocardiografía y se evaluó la respuesta terapéutica. Se realizó un análisis descriptivo de los hallazgos. ResultadosSe incluyeron 136 pacientes y se realizaron 203 ecocardiografías. La ecocardiografía transtorácica difería del diagnóstico inicial en 101 (49,8%) ecocardiografías. En 56 de éstas (55,44%) se obtuvo un diagnóstico alternativo, lo que comportó un cambio en el tratamiento en 30 pacientes (53,6%). Encontramos mejoría clínica significativa en 26 de estos pacientes (86,76%) en los siguientes 30-60 minutos. ConclusionesLa ecocardiografía transtorácica básica es útil en el manejo diagnóstico y terapéutico de los pacientes postoperados de cirugía cardíaca. En la mitad de las ecocardiografías realizadas no se pudo confirmar el diagnóstico clínico. En la mayoría de pacientes en los que observamos cambio en el diagnóstico debido a la ecocardiografía, se observó mejoría clínica tras el cambio de tratamiento." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moreno O, Ochagavía A, Artigas A, Barbadillo S, Tomás R, Bosque MD, et al. Impacto en el manejo diagnóstico/terapéutico de la ecocardiografía básica dirigida a objetivos concretos en una UCI de cirugía cardíaca. Med Intensiva. 2020;155:534–541." ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "DLP: dyslipidemia; DM2: type 2 diabetes mellitus; AHT: arterial hypertension.The figures express the mean (standard deviation) or frequency (percentage)." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 (68.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (54−76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight, kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 (65−87) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Height, cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">166 (157−175) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Body mass index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (24−32) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EuroScore \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (2−10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">APACHE II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (3−11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116 (85.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AHT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97 (71.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 (33.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DLP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78 (57.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart surgery</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valve replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary bypass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 (39%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valve replacement and coronary bypass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (5.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valve replacement and other procedures<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (10.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary bypass and other procedures<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other procedures<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2452909.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The other procedures included pericardiectomy, interatrial septal resection, myxoma removal." ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical data, and severity predictors." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The figures express the mean (standard deviation) or frequency (percentage)." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiac rhythm (patients)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sinus rhythm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">148 (72.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (16.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrioventricular block \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pacemaker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (9.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heart rate, bpm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 (66−94) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean blood pressure, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 (68−90) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central venous pressure, mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10(6−14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central venous oxygen saturation, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63 (53−73) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lactate, mg/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (6−24) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 (25.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vasoactive drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">125 (61.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Noradrenalin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 (25.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nitroglycerin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (21.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dopamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dobutamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 (22.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Milrinone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (0.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary artery catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (20.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2452908.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical data at the time of echocardiography." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "The figures express the mean (standard deviation) or frequency (percentage)." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected diagnosis</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypovolemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (26.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left ventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (12.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (2.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vasoplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (6.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">101 (49.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Foreseeable treatment</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume replacement measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 (27.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inotropic/vasoactive drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (21.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No treatment intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (49.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Echocardiographic diagnosis</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypovolemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (6.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left ventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 (18.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (3.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal echocardiographic findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126 (62%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inconclusive<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (7.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2452907.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Inconclusive: most major problems can be ruled out, though not certain concrete problems such as severe hypovolemia, due to the inability to obtain adequate images in all the echocardiographic windows." ] ] ] "descripcion" => array:1 [ "en" => "Suspected diagnosis and foreseeable treatment before echocardiography, and echocardiographic diagnosis." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LV: left ventricle." "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0,<a class="elsevierStyleCrossRefs" href="#bib0005">1–8]</a>Echocardiographic diagnosis</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hypovolemia \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LV dysfunction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tamponade \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Normal \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inconclusive \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspected diagnosis</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypovolemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LV dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Biventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vasoplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">203 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2452905.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of the clinical diagnoses versus the echocardiographic diagnoses." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "The figures express frequency (percentage)." "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume replacement measures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3.33%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Start of inotropic/vasoactive drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (46.67%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3.33%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (46.67%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2452906.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "No surgery, suspension or start of inotropic drugs, optimization of heart rate, no volume replacement measures." ] ] ] "descripcion" => array:1 [ "en" => "Changes in treatment due to the echocardiographic findings." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Rml Orme" 1 => "Mp Oram" 2 => "Ce. 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Statistics

Original

Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

Impacto en el manejo diagnóstico/terapéutico de la ecocardiografía básica dirigida a objetivos concretos en una UCI de cirugía cardíaca

O. Morenoa,b,

Corresponding author

olgamfon@icloud.com

Corresponding author.

, A. Ochagavíac,d, A. Artigasa,b,c,d,e, S. Barbadilloa, R. Tomása, M.D. Bosquea, C. Fortiac, F. Baigorrib,c

a Servicio de Medicina Intensiva, Hospital Universitari General de Catalunya, Sant Cugat del Vallès, Barcelona, Spain

b Universidad Autónoma de Barcelona, Barcelona, Spain

c Servicio de Medicina Intensiva, Corporación Sanitaria Universitaria Parc Taulí, Sabadell, Barcelona, Spain

d CIBER de Enfermedades Respiratorias, Madrid, Spain

e Servicio de Medicina Intensiva, Hospital Universitari Sagrat Cor, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography &#40;TTE&#41; is a noninvasive imaging technique that proves very useful in the critical care setting&#46; It allows point-of-care &#40;at the patient bedside&#41;&#44; real-time dynamic imaging of the heart and also provides morphological and functional information&#46; The data afforded by echocardiography often allow us to identify the causes of shock&#44; and offer useful guidance for assessing treatment&#46; Some studies have shown that echocardiography can provide information leading to significant modification of treatment in up to 52&#37; of all critical patients&#46; As a result&#44; some groups have developed TTE protocols designed to optimize the treatment of these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;20</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although studies have been made by intensivists on the usefulness of transesophageal echocardiography &#40;TEE&#41; in critical patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> very few publications have assessed the applicability and impact of specific goal-directed basic TTE upon the diagnostic and therapeutic management of patients in the postoperative period of heart surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;23&#8211;25</span></a> Recently&#44; our group has published a study showing that basic TTE can be performed in most such patients&#44; with the generation of interpretable data&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study was carried out to prospectively evaluate the impact of specific goal-directed basic TTE upon the diagnosis and treatment of patients following heart surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Selection of patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study was carried out in the Department of Intensive Care Medicine of a University general hospital with 16 polyvalent beds that attends 100 post-heart surgery patients a year&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We included all patients over 18 years of age subjected to heart surgery and consecutively admitted to the Intensive Care Unit &#40;ICU&#41; between November 2014 and April 2016&#44; with the physical presence of an intensivist with certified training in basic echocardiography&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The study protocol was approved by the local Clinical Research Ethics Committee&#46; All patients gave written informed consent to participation in the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical characteristics</span><p id="par0035" class="elsevierStylePara elsevierViewall">At the time of patient admission&#44; we recorded the general demographic characteristics&#44; the reason for admission&#44; main comorbidities&#44; severity scores &#40;APACHE II&#44; EuroSCORE&#41; and hemodynamic and echocardiographic data prior to surgery&#44; if available&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A clinical and hemodynamic evaluation of the patient was made by one of the 6 intensivists of the Department to establish an initial diagnosis&#44; in accordance with routine clinical practice in post-heart surgery patients&#58; hypovolemia&#44; left ventricular dysfunction&#44; right ventricular dysfunction&#44; biventricular dysfunction&#44; vasoplegia&#44; massive mitral valve insufficiency or tamponade&#44; and treatment was prescribed based on the diagnosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Basic echocardiography</span><p id="par0045" class="elsevierStylePara elsevierViewall">Following the initial clinical evaluation and within the first 8&#8239;h of admission&#44; another intensivist trained in basic echocardiography performed basic TTE&#46; At the time of the exploration&#44; the use of mechanical ventilation was documented&#44; as well as the administration of vasoactive medication&#44; and the hemodynamic parameters &#40;heart rate&#44; blood pressure&#44; central venous oxygen saturation&#44; lactate concentration&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The echocardiographic study was repeated daily in the presence of signs of tissue hypoperfusion &#40;arterial hypotension&#44; evidence of poor peripheral perfusion&#44; elevated lactate levels&#44; oliguria&#41;&#46; The professional performing the echocardiographic evaluation was blinded to the initial tentative diagnosis&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The echocardiographic analysis comprised systematic assessment of the long and short axes parasternal projections and four-chambers apical and four-chambers subcostal projections with visualization of the inferior vena cava&#46; For each acoustic window&#44; imaging difficulty was rated as either high or low&#46; All explorations were made using the 1&#46;5&#8211;4&#46;6&#8239;MHz M5S-D echocardiographic probe of the Vivid-e &#40;General Electrics&#41; system&#44; available 24&#8239;h in the ICU of our center&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The analyzed echocardiographic parameters were&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Left ventricle&#58; visual size defined as normal or dilated&#44; visual systolic function classified as normal &#40;&#8805; 50&#37;&#41; or depressed &#40;&#60; 50&#37;&#41;&#44; and contraction pattern defined as either homogeneous or heterogeneous&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Right ventricle&#58; visual size defined as normal or dilated&#44; and visual systolic function &#40;normal or depressed&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Valves&#58; presence of massive mitral valve insufficiency&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Inferior vena cava&#58; classified as normal&#44; dilated or not visualized&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pericardial fluid with or without cardiac tamponade&#44; classified as either present or absent&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The echocardiographic patterns were defined as<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;27</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Severe hypovolemia&#58; small hyperdynamic ventricles&#44; with obliteration of the left ventricular cavity &#40;kissing walls&#41;&#44; and small inferior vena cava showing great variation with respiratory movements &#40;under mechanical ventilation&#44; inferior vena cava &#60; 1&#46;5&#8239;cm with collapse &#62; 50&#37;&#59; under spontaneous ventilation&#44; inferior vena cava &#60; 1&#8239;cm with collapse &#62; 50&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Left ventricular failure&#58; reduction of global left ventricular motility&#44; heterogeneous contractility pattern suggesting myocardial ischemia&#44; or dilatation of the left ventricular cavity suggesting chronic heart disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Right ventricular failure&#58; dilatation of the right ventricle and paradoxical motion of the interventricular septum - which in the critical patient is basically associated to acute respiratory distress syndrome &#40;ARDS&#41; or severe pulmonary thromboembolism&#46; Isolated right ventricular dilatation is suggestive of right ventricular infarction&#46; Other associated findings may be a dilated inferior vena cava without collapse&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Tamponade&#58; presence of pericardial effusion with diastolic collapse of the right atrium and ventricle&#44; and dilated inferior vena cava without respiratory collapse under spontaneous breathing conditions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Acute massive mitral valve insufficiency&#58; left ventricle of normal size &#40;indicative of acute valve disease&#41;&#44; left ventricle with normal or hyperdynamic systolic function secondary to volume overload of the left ventricle and massive reflow in the color Doppler exploration&#46;</p></li></ul></p><p id="par0120" class="elsevierStylePara elsevierViewall">All the explorations were digitally recorded and later evaluated by an intensivist with advanced training in TTE &#40;A&#46;O&#46;&#41;&#44; rating the quality of the images as optimal &#40;complete identification of the endocardial margins of the left ventricle&#41;&#44; suboptimal &#40;identification of &#62; 50&#37; of the endocardial margins of the left ventricle&#41; or poor &#40;identification of &#60; 50&#37; of the endocardial margins of the left ventricle&#44; or visualization not possible&#41;&#46; The analysis was based only on the optimal and suboptimal echocardiographic images&#46; We determined the percentage of cases in which echocardiography confirmed the initial tentative or suspected diagnosis&#46; If this diagnosis was not confirmed&#44; we determined the percentage of cases in which echocardiography afforded an alternative diagnosis and the percentage of changes in treatment&#46; Lastly&#44; clinical improvement associated to the different therapeutic changes was analyzed&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the event of doubt regarding the echocardiographic data&#44; a second echocardiographic assessment was made by a cardiologist with expertise in advanced echocardiography&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0130" class="elsevierStylePara elsevierViewall">A descriptive study was made&#44; analyzing percentage clinical improvement secondary to treatment optimization&#46; Continuous variables were reported as the median and standard deviation &#40;SD&#41;&#44; or as percentages&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patient characteristics</span><p id="par0135" class="elsevierStylePara elsevierViewall">The study sample consisted of 136 post-heart surgery patients consecutively enrolled in the period between November 2014 and April 2016&#44; and representing a total of 203 echocardiographic studies&#46; No patients were excluded during the study period&#46; The demographic and clinical data of the sample are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">With regard to the type of heart surgery&#44; most patients underwent valve replacement either isolatedly &#40;51 patients&#59; 37&#46;5&#37;&#41; or associated to other procedures &#40;22 patients&#59; 16&#46;3&#37;&#41;&#46; A total of 64 coronary revascularization surgeries were performed &#40;47&#46;1&#37;&#41;&#44; either isolatedly or associated to other procedures&#46; Seven patients underwent other types of surgery &#40;5&#46;1&#37;&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">With regard to the valve replacements&#44; 49 &#40;67&#46;12&#37;&#41; comprised biological valves&#44; 21 &#40;28&#46;77&#37;&#41; mechanical valves&#44; and three &#40;4&#46;11&#37;&#41; corresponded to annuloplasties&#46; There were 54 aortic valve replacements &#40;39&#46;7&#37;&#41;&#44; 17 mitral valve replacements &#40;12&#46;5&#37;&#41;&#44; four mitral annuloplasties &#40;2&#46;94&#37;&#41; and 15 tricuspid annuloplasties &#40;11&#46;03&#37;&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">All patients were subjected to preoperative TTE performed by a cardiologist during admission or on an ambulatory basis a few days before admission&#46; This echocardiographic study showed that most patients had a left ventricle with no hypertrophy &#40;72 patients&#59; 52&#46;94&#37;&#41; or dilatation &#40;115 patients&#59; 84&#46;56&#37;&#41;&#44; and with a normal ejection fraction &#40;Simpson&#8217;s rule 4C&#41; &#40;127 patients&#59; 93&#46;38&#37;&#41;&#46; The right ventricle was not dilated in most patients &#40;131 patients&#59; 96&#46;32&#37;&#41;&#44; and exhibited normal function in all cases&#46; Most of the patients had a non-dilated inferior vena cava &#40;128 patients&#59; 94&#46;11&#37;&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Postoperative echocardiography</span><p id="par0155" class="elsevierStylePara elsevierViewall">A total of 203 TTEs were performed&#44; distributed as follows&#58; 97 patients &#40;71&#46;3&#37;&#41; underwent a single echocardiographic study&#59; 19 &#40;14&#37;&#41; underwent two echocardiographic studies&#59; 14 &#40;10&#46;3&#37;&#41; underwent three echocardiographic studies&#59; four &#40;2&#46;9&#37;&#41; underwent four echocardiographic studies&#59; and two patients &#40;1&#46;5&#37;&#41; underwent 5 echocardiographic studies&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the clinical data at the time of echocardiography&#46; The main indication of the first echocardiographic study was hemodynamic instability &#40;74 cases&#59; 54&#46;4&#37;&#41;&#44; and the main initially suspected diagnosis was hypovolemia &#40;54 cases&#59; 26&#46;6&#37;&#41;&#46; The other 62 echocardiographic studies &#40;45&#46;6&#37;&#41; were performed with some other suspected diagnosis&#44; or as controls&#46; The echocardiographic studies performed on the following days were due to hemodynamic instability&#46; With regard to the contemplated initial management based on the clinical data&#44; in most cases &#40;100 cases&#59; 49&#46;3&#37;&#41; no surgery was foreseeable&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> reports the suspected diagnoses&#44; the contemplated management before echocardiography and the echocardiographic diagnosis&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Most of the echocardiographic studies were made with the patient in supine decubitus &#40;197 patients&#59; 97&#37;&#41;&#44; and the mean duration of the exploration was 14&#46;46&#8239;&#177;&#8239;2&#46;16&#8239;min&#46; Evaluation was made of imaging difficulty and imaging quality in each of the planes&#46; In most cases&#44; difficulty was low in all planes&#44; and imaging quality was found to be optimal or suboptimal in most patients&#46; The poorest imaging quality corresponded to the subcostal plane for visualizing the inferior vena cava&#46; On analyzing imaging quality in each plane&#44; we found the long axis parasternal plane to yield 85 echocardiographic studies &#40;41&#46;9&#37;&#41; of optimal quality&#44; 81 &#40;39&#46;9&#37;&#41; of suboptimal quality and 37 &#40;18&#46;2&#37;&#41; of poor quality&#46; The short axis parasternal plane in turn yielded 80 echocardiographic studies &#40;39&#46;4&#37;&#41; of optimal quality&#44; 82 &#40;40&#46;4&#37;&#41; of suboptimal quality&#44; and 41 &#40;20&#46;2&#37;&#41; of poor quality&#46; The four-chambers apical plane yielded 135 echocardiographic studies &#40;66&#46;5&#37;&#41; of optimal quality&#44; 42 &#40;20&#46;7&#37;&#41; of suboptimal quality&#44; and 26 &#40;12&#46;8&#37;&#41; of poor quality&#46; The subcostal plane yielded 122 echocardiographic studies &#40;60&#46;1&#37;&#41; of optimal quality&#44; 29 &#40;14&#46;3&#37;&#41; of suboptimal quality&#44; and 52 &#40;25&#46;6&#37;&#41; of poor quality&#46; Lastly&#44; with regard to visualization of the inferior vena cava&#44; there were 116 echocardiographic studies &#40;57&#46;1&#37;&#41; of optimal quality&#44; 19 &#40;9&#46;4&#37;&#41; of suboptimal quality&#44; and 68 &#40;33&#46;5&#37;&#41; of poor quality&#46; All the echocardiographic studies had some plane of optimal or suboptimal imaging quality&#44; thus allowing echocardiographic assessment in all cases&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">On analyzing the different echocardiographic parameters&#44; we found the left ventricle to be of normal size &#40;175 cases&#59; 86&#46;2&#37;&#41; and with normal ventricular function in most cases &#40;151 cases&#59; 74&#46;4&#37;&#41;&#44; but with heterogeneous contractility in most patients &#40;111 cases&#59; 54&#46;7&#37;&#41;&#46; Only 12 patients &#40;5&#46;9&#37;&#41; presented kissing walls&#46; The right ventricle in turn was of normal size and function in most of the cases &#40;184 cases&#59; 90&#46;6&#37;&#41;&#46; Sixty patients &#40;29&#46;6&#37;&#41; showed the presence of pericardial fluid&#44; but only two &#40;1&#46;5&#37;&#41; presented signs of tamponade&#44; and thus underwent surgery again&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> compares the suspected diagnoses based on the clinical findings versus the echocardiographic diagnosis&#46; Overall&#44; the echocardiographic diagnosis was consistent with the suspected clinical diagnosis in 102 cases &#40;50&#46;2&#37;&#41;&#46; In one-half of the cases &#40;101 cases&#44; 49&#46;8&#37;&#41;&#44; echocardiography differed from the clinical diagnosis&#46; In these 101 cases&#44; echocardiography proved normal in 45 &#40;44&#46;6&#37;&#41;&#59; no alternative diagnosis therefore could be established&#46; In 56 cases &#40;55&#46;4&#37;&#41;&#44; echocardiography offered a diagnosis different from the suspected clinical diagnosis&#44; and treatment changes were decided in 30 of these cases &#40;53&#46;6&#37;&#41;&#46; The changes predominantly involved the start of inotropic treatment &#40;14 cases&#44; 25&#37;&#41;&#46; In relation to whether the changes were made on occasion of the first echocardiographic study or as a result of the subsequent echocardiographic explorations&#44; we found that in a large percentage of cases in which a change in diagnosis occurred &#40;34 cases&#44; 60&#46;71&#37;&#41;&#44; the change took place on occasion of the first echocardiographic study and implied a modification of the patient management approach in 22 cases &#40;64&#46;71&#37;&#41;&#46; In the other 22 cases with discrepancies between the echocardiographic diagnosis and the clinical diagnosis&#44; the treatment changes occurred on occasion of the subsequent echocardiographic studies&#46; All the changes made can be seen in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">In one case presenting diagnostic uncertainty&#44; we contacted the Cardiology Department&#44; which performed a new echocardiographic study that confirmed our own echocardiographic suspicion &#40;severe pericardial effusion with signs of tamponade&#41;&#46; We therefore consulted Heart Surgery&#44; which decided repeat surgery&#44; followed by clinical improvement&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Of the 30 cases in which treatment was modified on the basis of the echocardiographic diagnosis&#44; 26 &#40;86&#46;67&#37;&#41; showed significant clinical improvement&#44; with amelioration of the hemodynamic parameters &#40;blood pressure&#44; central venous oxygen saturation&#44; increased diuresis&#44; with a lesser need for inotropic and vasoactive drugs&#41; over the following 30-60&#8239;min&#46; On examining the treatment changes&#44; we found that 14 patients &#40;46&#46;7&#37;&#41; started inotropic or vasoactive drug treatment&#44; while another 14 patients &#40;46&#46;7&#37;&#41; underwent some other intervention such as the suspension of volume replacement measures or of inotropic medication&#46; One patient &#40;3&#46;3&#37;&#41; received volume replacement measures&#44; and another &#40;3&#46;3&#37;&#41; required repeat surgery because of tamponade&#46; Four patients &#40;13&#46;33&#37;&#41; experienced no clear improvement as a result of the treatment adjustments&#46; Two of them had started inotropic or vasoactive drug treatment &#40;one with poor tolerance of dobutamine due to tachycardia&#44; and another with scant hemodynamic improvement after dobutamine dosing&#41;&#46; In another case&#44; due to the presence of bradycardia&#44; we decided to increase the heart rate by means of a pacemaker&#44; though the tissue hypoperfusion parameters did not improve as a result&#46; Lastly&#44; in the fourth case&#44; the clinical suspicion was hypovolemia with normal echocardiographic findings&#59; we therefore decided not to administer volume replacement measures - though no significant clinical changes were observed&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Following demonstration of the feasibility of basic echocardiography in the most extreme situations after heart surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> it was important to study the impact of basic echocardiography on the management of post-heart surgery patients&#46; In the present study&#44; echocardiography did not confirm the clinically suspected diagnosis in almost one-half of the cases&#46; On the other hand&#44; echocardiography offered an alternative diagnosis in over 50&#37; of these cases&#46; In turn&#44; the clinicians decided a change in treatment based on the result of the echocardiographic exploration in 30 cases &#40;14&#46;8&#37; of the total patients and 53&#46;6&#37; with a change in diagnosis&#41;&#46; This percentage corresponds to the lower range of the data reported in other studies&#44; with treatment modification rates of up to 52&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;21&#44;24&#44;28</span></a> This may be because patients with different clinical characteristics were involved&#46; The previous studies included medical-surgical patients in which cardiac disorders not foreseeable on the basis of the initial clinical condition could be involved&#46; In contrast&#44; all of our patients were in the postoperative period of heart surgery&#44; and consequently the fundamental causes of shock were easier to suspect on the basis of the clinical data&#46; In some cases the clinical suspicion was hypovolemia&#44; though with basic echocardiography we are only able to detect the presence of severe hypovolemia&#46; Other studies in heart surgery patients offer similar data referred to the impact of transesophageal echocardiography&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;31</span></a> though these studies were made during the actual operation&#44; resulting changes in management approach during surgery&#46; In our case we used basic transthoracic echocardiography&#44; which is totally noninvasive&#44; during the immediate postoperative period&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Heiberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> conducted a meta-analysis of 15 studies evaluating the use of transthoracic and transesophageal echocardiography in the postoperative period of heart surgery&#46; The authors concluded that echocardiography is increasingly used in the postoperative period of heart surgery&#44; and that its use results in significant changes in the diagnosis and management of these patients &#8211; though the mentioned studies were not designed to assess the patient course over time&#46; Of the studies included in the meta-analysis&#44; 7 analyzed the use of transthoracic echocardiography&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32&#8211;37</span></a> and documented changes in diagnosis and management in 10-52&#37; of the cases&#46; Our own findings fall within this range&#46; Of note is the observation that the treatment introduced after echocardiography resulted in clinical improvement in 86&#46;67&#37; of our patients &#8211; thus confirming the clinical usefulness of echocardiography in patients following heart surgery&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">An interesting observation in our series is the fact that 74&#37; of the echocardiographic explorations showed a normal left ventricular ejection fraction &#40;LVEF&#41;&#44; and that 90&#37; recorded a right ventricular ejection fraction &#40;RVEF&#41; within normal ranges&#46; This could be because in most of our patients the preoperative LVEF and RVEF values were respectively normal in 125 patients &#40;92&#37;&#41; and in all patients &#8211; thus explaining that these parameters were preserved in the postoperative period&#46; Nevertheless&#44; we found the introduction of vasoactive medication due to the echocardiographic diagnosis to be the most frequent change in treatment&#44; resulting in clinical improvement of the patient&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Thus&#44; our results show that the echocardiographic study results in a change in diagnosis in up to 50&#37; of all heart surgery patients&#46; Furthermore&#44; in over one-half of these cases changes in patient management are decided as a consequence of the echocardiographic findings - and this in turn is associated to clinical improvement in the great majority of cases&#46; Nevertheless&#44; in the event of doubts&#44; advanced echocardiography should be performed by an adequately trained intensivist or a cardiologist&#44; as required&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; In effect&#44; it is a single-center investigation involving one same surgical team&#59; our findings therefore cannot be extrapolated to other centers&#46; All surgeries were elective and were performed in clinically stable patients&#59; the risk of postoperative complications was therefore lower&#46; Some patients already presented ventricular dysfunction at preoperative echocardiography&#59; as a result&#44; in the postoperative period&#44; such dysfunction persisted in the echocardiographic study &#8211; without this having clinical repercussions&#46; Likewise&#44; basic echocardiography is only able to detect severe hypovolemia&#44; and thus some patients could have presented hypovolemia that was not evidenced in the echocardiographic study&#46; These circumstances may have influenced the observation of a low percentage change in the echocardiographic diagnosis versus the clinical diagnosis&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Basic transthoracic echocardiography is useful for the diagnostic and therapeutic management of patients following heart surgery&#46; In most cases in which a change in diagnosis was made based on the echocardiographic findings&#44; clinical improvement was noted as a result of the modification of treatment&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Financial support</span><p id="par0215" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Author contributions</span><p id="par0220" class="elsevierStylePara elsevierViewall">Study conception and design&#58; Dr&#46; Olga Moreno&#44; Dr&#46; Ana Ochagav&#237;a&#44; Dr&#46; Antonio Artigas&#44; Dr&#46; Francisco Baigorri&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Data acquisition&#44; analysis and interpretation&#58; Dr&#46; Olga Moreno&#44; Dr&#46; Ana Ochagav&#237;a&#44; Dr&#46; Sandra Barbadillo&#44; Dr&#46; Roser Tom&#225;s&#44; Dr&#46; Maria Dolores Bosque&#44; Dr&#46; Cristina Forti&#224;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Drafting of the manuscript&#58; Dr&#46; Olga Moreno&#44; Dr&#46; Ana Ochagav&#237;a&#44; Dr&#46; Antonio Artigas&#44; Dr&#46; Francisco Baigorri&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            1 => array:2 [
              "identificador" => "abst0030"
              "titulo" => "Dise&#241;o"
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            2 => array:2 [
              "identificador" => "abst0035"
              "titulo" => "Resultados"
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            3 => array:2 [
              "identificador" => "abst0040"
              "titulo" => "Conclusiones"
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        3 => array:2 [
          "identificador" => "xpalclavsec1305548"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Material and methods"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Selection of patients"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Clinical characteristics"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Basic echocardiography"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
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          "identificador" => "sec0035"
          "titulo" => "Results"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Patient characteristics"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Postoperative echocardiography"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Financial support"
        ]
        10 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Author contributions"
        ]
        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
        ]
        12 => array:2 [
          "identificador" => "xack498900"
          "titulo" => "Acknowledgements"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2019-03-19"
    "fechaAceptado" => "2019-06-28"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1305549"
          "palabras" => array:4 [
            0 => "Basic transthoracic echocardiography"
            1 => "Heart surgery"
            2 => "Critically ill patients"
            3 => "Impact on diagnosis and treatment"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1305548"
          "palabras" => array:4 [
            0 => "Ecocardiograf&#237;a transtor&#225;cica b&#225;sica"
            1 => "Cirug&#237;a card&#237;aca"
            2 => "Pacientes cr&#237;ticos"
            3 => "Impacto diagn&#243;stico y terap&#233;utico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery&#46; The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Over an 18-month period&#44; we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery&#46; We evaluated clinically all of them to establish a diagnosis and an initial treatment&#46; We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis&#46; If they differed&#44; we assessed to change treatment and evaluate the therapeutic response&#46; We performed a descriptive analysis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">We included 136 patients and performed 203 echocardiographies&#46; Transthoracic echocardiography differed of initial diagnosis in 101 &#40;49&#46;8&#37;&#41; echocardiographies&#46; In 56 of these echocardiographies &#40;55&#46;44&#37;&#41;&#44; we could give an alternative diagnosis with a change in the treatment in 30 patients &#40;53&#46;6&#37;&#41;&#46; We found clinical improvement in 26 patients &#40;86&#46;76&#37;&#41; in the following 30&#8722;60&#8239;min&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients&#46; We could not confirm the clinical diagnosis in half of the performed echocardiographies&#46; In most patients in whom we observe a change in the diagnosis due to echocardiography&#44; we observed a clinical improvement after changing the treatment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Design"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Pocos estudios han evaluado el impacto en el diagn&#243;stico y tratamiento de la ecocardiograf&#237;a transtor&#225;cica b&#225;sica en los pacientes postoperados de cirug&#237;a card&#237;aca&#46; El objetivo de nuestro estudio fue valorar el impacto de la ecocardiograf&#237;a transtor&#225;cica b&#225;sica en el manejo diagn&#243;stico y terap&#233;utico de estos pacientes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Dise&#241;o</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Durante 18 meses se estudiaron prospectivamente todos los pacientes postoperados de cirug&#237;a card&#237;aca que ingresaron en el Servicio de Medicina Intensiva de un hospital universitario&#46; Se realiz&#243; una valoraci&#243;n cl&#237;nica a todos ellos para establecer un diagn&#243;stico y tratamiento inicial&#46; Se realiz&#243; una ecocardiograf&#237;a transtor&#225;cica b&#225;sica para valoraci&#243;n diagn&#243;stica&#44; que se compar&#243; con la valoraci&#243;n cl&#237;nica&#46; En caso de discrepancia&#44; se valor&#243; cambiar el tratamiento en funci&#243;n a la ecocardiograf&#237;a y se evalu&#243; la respuesta terap&#233;utica&#46; Se realiz&#243; un an&#225;lisis descriptivo de los hallazgos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 136 pacientes y se realizaron 203 ecocardiograf&#237;as&#46; La ecocardiograf&#237;a transtor&#225;cica difer&#237;a del diagn&#243;stico inicial en 101 &#40;49&#44;8&#37;&#41; ecocardiograf&#237;as&#46; En 56 de &#233;stas &#40;55&#44;44&#37;&#41; se obtuvo un diagn&#243;stico alternativo&#44; lo que comport&#243; un cambio en el tratamiento en 30 pacientes &#40;53&#44;6&#37;&#41;&#46; Encontramos mejor&#237;a cl&#237;nica significativa en 26 de estos pacientes &#40;86&#44;76&#37;&#41; en los siguientes 30-60&#8239;minutos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">La ecocardiograf&#237;a transtor&#225;cica b&#225;sica es &#250;til en el manejo diagn&#243;stico y terap&#233;utico de los pacientes postoperados de cirug&#237;a card&#237;aca&#46; En la mitad de las ecocardiograf&#237;as realizadas no se pudo confirmar el diagn&#243;stico cl&#237;nico&#46; En la mayor&#237;a de pacientes en los que observamos cambio en el diagn&#243;stico debido a la ecocardiograf&#237;a&#44; se observ&#243; mejor&#237;a cl&#237;nica tras el cambio de tratamiento&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Dise&#241;o"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Moreno O&#44; Ochagav&#237;a A&#44; Artigas A&#44; Barbadillo S&#44; Tom&#225;s R&#44; Bosque MD&#44; et al&#46; Impacto en el manejo diagn&#243;stico&#47;terap&#233;utico de la ecocardiograf&#237;a b&#225;sica dirigida a objetivos concretos en una UCI de cirug&#237;a card&#237;aca&#46; Med Intensiva&#46; 2020&#59;155&#58;534&#8211;541&#46;</p>"
      ]
    ]
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      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DLP&#58; dyslipidemia&#59; DM2&#58; type 2 diabetes mellitus&#59; AHT&#58; arterial hypertension&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The figures express the mean &#40;standard deviation&#41; or frequency &#40;percentage&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Male gender</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">93 &#40;68&#46;4&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65 &#40;54&#8722;76&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Weight&#44; kg</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76 &#40;65&#8722;87&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Height&#44; cm</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">166 &#40;157&#8722;175&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Body mass index</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">28 &#40;24&#8722;32&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">EuroScore</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6 &#40;2&#8722;10&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">APACHE II</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;3&#8722;11&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">116 &#40;85&#46;3&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AHT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97 &#40;71&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DM2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">45 &#40;33&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">78 &#40;57&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;5&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Valve replacement and other procedures<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coronary bypass and other procedures<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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#46;2&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other procedures<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="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mean blood pressure&#44; mmHg</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">79 &#40;68&#8722;90&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">10&#40;6&#8722;14&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Lactate&#44; mg&#47;dl</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">51 &#40;25&#46;1&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vasoactive drugs</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">125 &#40;61&#46;6&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Noradrenalin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52 &#40;25&#46;6&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nitroglycerin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 &#40;21&#46;7&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dopamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dobutamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;22&#46;2&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Milrinone&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1 &#40;0&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">42 &#40;20&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tamponade&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;2&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101 &#40;49&#46;8&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Foreseeable treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Volume replacement measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;27&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inotropic&#47;vasoactive drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgery&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No treatment intervention&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100 &#40;49&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypovolemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;6&#46;9&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38 &#40;18&#46;7&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Biventricular dysfunction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;3&#46;9&#37;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal echocardiographic findings&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126 &#40;62&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inconclusive<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;7&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#44;<a class="elsevierStyleCrossRefs" href="#bib0005">1&#8211;8&#93;</a>Echocardiographic diagnosis</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biventricular dysfunction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypovolemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LV dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Biventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vasoplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2019.06.019

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Year/Month	Html	Pdf	Total

2024 November	4	4	8
2024 October	40	57	97
2024 September	46	64	110
2024 August	46	59	105
2024 July	38	34	72
2024 June	42	47	89
2024 May	50	37	87
2024 April	47	30	77
2024 March	42	23	65
2024 February	39	38	77
2024 January	38	44	82
2023 December	38	48	86
2023 November	58	55	113
2023 October	60	41	101
2023 September	44	43	87
2023 August	46	20	66
2023 July	61	36	97
2023 June	33	24	57
2023 May	49	47	96
2023 April	28	30	58
2023 March	42	37	79
2023 February	45	51	96
2023 January	67	49	116
2022 December	66	51	117
2022 November	63	57	120
2022 October	80	68	148
2022 September	51	47	98
2022 August	46	47	93
2022 July	49	59	108
2022 June	35	28	63
2022 May	49	46	95
2022 April	58	48	106
2022 March	45	57	102
2022 February	37	39	76
2022 January	42	45	87
2021 December	45	52	97
2021 November	35	46	81
2021 October	74	84	158
2021 September	32	42	74
2021 August	32	77	109
2021 July	35	40	75
2021 June	45	44	89
2021 May	36	56	92
2021 April	74	90	164
2021 March	64	39	103
2020 November	1	2	3
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