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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Curva ROC&#46; Curva ROC para predecir la ausencia de s&#237;ndrome de bajo gasto cardiaco postoperatorio con el empleo de &#237;ndice de cardioplej&#237;a infundido&#46; Es&#58; especificidad&#59; Se&#58; sensibilidad&#59; VPN&#58; valor predictivo negativo&#59; VPP&#58; valor predictivo positivo&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La disfunci&#243;n sist&#243;lica del ventr&#237;culo izquierdo &#40;VI&#41; es un importante factor pron&#243;stico en los pacientes sometidos a cirug&#237;a cardiaca<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a>&#46; El aturdimiento mioc&#225;rdico&#44; causa frecuente de disfunci&#243;n sist&#243;lica postoperatoria&#44; conlleva una disminuci&#243;n de la contractilidad secundaria al da&#241;o por isquemia&#47;reperfusi&#243;n sin llegar a provocar la muerte celular<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> y podr&#237;a contribuir a la aparici&#243;n de s&#237;ndrome de bajo gasto cardiaco &#40;SBGC&#41; postoperatorio&#46; A mayor tiempo de isquemia&#44; mayor ser&#225; el da&#241;o molecular y las alteraciones celulares secundarias<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a>&#46; Se estima que entre un 10 y 15&#37; de los pacientes sometidos a cirug&#237;a de revascularizaci&#243;n coronaria desarrollan disfunci&#243;n ventricular izquierda<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Durante la cirug&#237;a cardiaca es imprescindible la instauraci&#243;n de estrategias de cardioprotecci&#243;n con el fin de minimizar el da&#241;o por isquemia&#47;reperfusi&#243;n&#46; Entre estas estrategias&#44; la cardioplej&#237;a constituye la principal medida para la miocardioprotecci&#243;n intraoperatoria&#46; Se han desarrollado diversos m&#233;todos para optimizar la cardioplej&#237;a que abarcan desde variaciones en su contenido o temperatura hasta el uso de distintas v&#237;as y flujos de administraci&#243;n&#46; Sin embargo&#44; en nuestro conocimiento&#44; existe escasa bibliograf&#237;a sobre su ajuste con relaci&#243;n a otros factores relacionados con la susceptibilidad mioc&#225;rdica al da&#241;o por isquemia&#47;reperfusi&#243;n&#44; como el grado de afectaci&#243;n isqu&#233;mica o el aumento de la masa del VI&#46; Este &#250;ltimo&#44; asociado con un mayor trabajo mioc&#225;rdico con el consiguiente aumento de consumo mioc&#225;rdico de ox&#237;geno&#44; deber&#237;a tenerse en cuenta a la hora de dise&#241;ar estrategias eficaces de cardioprotecci&#243;n&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En este estudio&#44; por medio del &#237;ndice de cardioplej&#237;a infundido &#40;ICI&#41;&#44; hemos explorado la relaci&#243;n entre el volumen de cardioplej&#237;a&#44; el tiempo de isquemia y la masa ventricular izquierda&#44; con la aparici&#243;n de da&#241;o mioc&#225;rdico en pacientes sometidos a cirug&#237;a de revascularizaci&#243;n mioc&#225;rdica&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">El Comit&#233; de &#201;tica del hospital aprob&#243; el estudio&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio y poblaci&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">El estudio se desarroll&#243; en la Unidad de Cuidados Intensivos &#40;UCI&#41; m&#233;dico-quir&#250;rgica de 24 camas del Hospital Universitario de Canarias&#46; Es un estudio ambispectivo de cohortes en el que se incluyeron todos los pacientes sometidos a cirug&#237;a de revascularizaci&#243;n coronaria entre enero de 2013 y diciembre de 2015&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para la definici&#243;n de SBGC postoperatorio se recurri&#243; a la definici&#243;n de consenso de la SEMICYUC<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a>&#44; incluyendo a aquellos paciente que&#44; tras optimizar la precarga&#44; presentaran&#58; &#237;ndice cardiaco &#40;IC&#41; medido<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#59; cuadro cl&#237;nico compatible con SBGC&#44; en pacientes no monitorizados&#44; con oliguria &#40;diuresis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41;&#44; saturaci&#243;n venosa central<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; &#40;con saturaci&#243;n arterial normal&#41; y&#47;o lactato<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#59; aquellos que requirieron inotropos y&#47;o bal&#243;n de contrapulsaci&#243;n en el postoperatorio inmediato para garantizar una situaci&#243;n hemodin&#225;mica adecuada&#59; y por &#250;ltimo&#44; aquellos pacientes con criterios de shock cardiog&#233;nico &#40;IC<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; con presi&#243;n arterial sist&#243;lica<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg y oliguria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recogida de datos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron de forma prospectiva datos demogr&#225;ficos&#44; comorbilidades&#44; clase funcional&#44; estudio de las principales arterias coronarias afectas&#44; SYNTAX score&#44; fracci&#243;n de eyecci&#243;n del VI &#40;FEVI&#41;&#44; desplazamiento sist&#243;lico del anillo tricusp&#237;deo&#44; mediante ecocardiograf&#237;a y situaci&#243;n cr&#237;tica preoperatoria definida por la necesidad de ventilaci&#243;n mec&#225;nica&#44; soporte inotr&#243;pico&#44; asistencia ventricular y&#47;o fracaso renal agudo con diuresis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#46; El riesgo quir&#250;rgico se calcul&#243; mediante EuroSCORE<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a>&#46;Tambi&#233;n se registraron variables quir&#250;rgicas&#58; tiempo de isquemia&#44; tiempo de circulaci&#243;n extracorp&#243;rea &#40;CEC&#41;&#44; tipo y volumen de cardioplej&#237;a &#40;&#250;nico dato registrado retrospectivamente&#41;&#44; revascularizaci&#243;n completa o incompleta &#40;en base a los vasos principales&#41;&#59; y posquir&#250;rgicas&#58; par&#225;metros hemodin&#225;micos&#44; dosis de aminas&#44; disfunci&#243;n ventricular derecha &#40;definida como hipocontractilidad objetivada por el cirujano a la salida de bomba&#41;&#44; duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; necesidad de t&#233;cnicas de reemplazo renal&#44; estancia en UCI&#44; en el hospital y mortalidad a los 30 d&#237;as&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se analizaron muestras de sangre en el postoperatorio inmediato&#44; a las 24<span class="elsevierStyleHsp" style=""></span>h del ingreso y cada 24<span class="elsevierStyleHsp" style=""></span>h en aquellos pacientes que lo requirieron&#46; Como marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico se midieron&#58; troponina <span class="elsevierStyleSmallCaps">i</span>&#44; creatincinasa MB&#44; N-terminal prop&#233;ptido natriur&#233;tico cerebral&#44; y como marcador sist&#233;mico de hipoperfusi&#243;n se utiliz&#243; el lactato&#46; El estudio ecocardiogr&#225;fico preoperatorio se realiz&#243; siguiendo las gu&#237;as de la Sociedad Americana de Ecocardiograf&#237;a<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> en el laboratorio de ecocardiograf&#237;a&#46; La masa del VI se calcul&#243; mediante la f&#243;rmula modificada de Devereux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a>&#44; se index&#243; por el &#225;rea de superficie corporal y la FEVI se estim&#243; mediante el Simpson modificado&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">La principal variable independiente fue el ICI&#46; Este &#237;ndice relaciona el total de cardioplej&#237;a infundida durante el tiempo de isquemia con el &#237;ndice de masa del VI &#40;IMVI&#41; &#40;&#931;Cardioplej&#237;a&#47;tiempo de isquemia&#47;IMVI&#41;&#46; La principal variable dependiente fue la ausencia de criterios de SBGC postoperatorio&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protocolos anest&#233;sicos y quir&#250;rgicos</span><p id="par0050" class="elsevierStylePara elsevierViewall">Todos los pacientes fueron preoxigenados y se realiz&#243; la inducci&#243;n con dosis de propofol de entre 1&#44;5 y1&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; entre 0&#44;1 y 0&#44;3<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#47;min de remifentanilo y 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg de rocuronio&#46; Para el mantenimiento anest&#233;sico se utiliz&#243; sevoflurano 1&#44;5-2<span class="elsevierStyleHsp" style=""></span>vol&#37; y perfusi&#243;n continua de remifentanilo&#46; El circuito extracorp&#243;reo estaba compuesto por un oxigenador de membrana &#40;Optima XP&#44; Cobe&#44; Denver&#44; Co&#44; USA or Quantum Lifestream International&#44; Inc&#46; Woodlands&#44; TX&#44; EE&#46; UU&#46;&#41;&#44; un circuito extracorp&#243;reo Tygon &#40;Dideco&#44; Mirandola&#44; Italia&#41; y una bomba centrifuga Medtronic Biopump &#40;Minneapolis&#44; MN&#44; EE&#46; UU&#46;&#41;&#46; Bajo hipotermia de entre 30-32<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; el flujo de la bomba se ajust&#243; para garantizar presiones arteriales medias<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg e IC de 2&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#46; Todos los pacientes recibieron inicialmente cardioplej&#237;a anter&#243;grada mientras que el mantenimiento se hizo mediante cardioplej&#237;a anter&#243;grada o retr&#243;grada a criterio del cirujano&#46; Para la parada cardiaca se administraron entre 1&#46;200 y 1&#46;500<span class="elsevierStyleHsp" style=""></span>mL de cardioplej&#237;a fr&#237;a de cristaloides &#40;500<span class="elsevierStyleHsp" style=""></span>ml soluci&#243;n de Ringer&#44; 40<span class="elsevierStyleHsp" style=""></span>mEq KCl&#44; 25<span class="elsevierStyleHsp" style=""></span>mEq HCO<span class="elsevierStyleInf">3</span>Na&#44; 35<span class="elsevierStyleHsp" style=""></span>mg lidoca&#237;na&#41; mediante infusi&#243;n intermitente con una relaci&#243;n 4&#58;1 con cardioplej&#237;a sangu&#237;nea&#46; Adem&#225;s&#44; se administraron dosis adicionales de 500<span class="elsevierStyleHsp" style=""></span>ml de suero con 20<span class="elsevierStyleHsp" style=""></span>mEq de KCl cada 20-25<span class="elsevierStyleHsp" style=""></span>min o cuando se estim&#243; necesario&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Las variables continuas se expresan como medias y desviaciones est&#225;ndar&#44; medianas y percentiles 25-75&#44; usando el estad&#237;stico t de Student o el test U de Mann-Whitney de acuerdo a la naturaleza de las variables &#40;determinada por el test de Kolmogorov-Smirnov&#41;&#46; La homocedasticidad de las varianzas se test&#243; mediante el test de Levene&#46; Las variables categ&#243;ricas se presentan como frecuencias y porcentajes&#44; se us&#243; la Chi cuadrado o el test exacto de Fisher para comparar diferencias entre grupos&#46; Las variables asociadas significativamente al s&#237;ndrome de bajo gasto con una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;10 en el an&#225;lisis univariado &#40;edad&#44; dislipidemia&#44; calcioantagonistas&#44; FEVI&#44; EuroSCORE&#44; NYHA&#44; situaci&#243;n cr&#237;tica preoperatoria&#44; car&#225;cter de la cirug&#237;a&#44; grado de revascularizaci&#243;n&#44; ICI y cardioplej&#237;a retr&#243;grada&#41; se incluyeron en el an&#225;lisis de regresi&#243;n log&#237;stico con el objeto de identificar predictores independientes de SBGC&#46; El tiempo de CEC&#44; el IMVI indexada y el volumen de cardioplej&#237;a total fueron excluidos del an&#225;lisis de regresi&#243;n al estar incluidos en el c&#225;lculo del ICI con el objeto de evitar colinealidad&#46; Exploramos la asociaci&#243;n entre el ICI y el SBGC estratificando por las 2 covariables de riesgo del modelo final&#58; NYHA &#40;grado <span class="elsevierStyleSmallCaps">i</span>-<span class="elsevierStyleSmallCaps">ii</span> vs&#46; <span class="elsevierStyleSmallCaps">iii</span>-<span class="elsevierStyleSmallCaps">iv</span>&#41; y FEVI &#40;utilizando el punto de corte asociado a la aparici&#243;n de SBGC&#58; 56&#37;&#41;&#46; Las asociaciones entre el ICI&#44; biomarcadores de da&#241;o mioc&#225;rdico y dosis de inotropos se calcularon usando el estad&#237;stico Rho de Spearman&#46; El ICI se agrup&#243; en terciles y su asociaci&#243;n con las necesidades de dobutamina se estudi&#243; con el test de Kruskal-Wallis&#46; La fiabilidad del ICI para predecir la ausencia de SBGC se verific&#243; mediante el an&#225;lisis del &#225;rea bajo la curva ROC&#59; se excluyeron los casos con disfunci&#243;n severa del ventr&#237;culo derecho&#46; Para el punto de corte &#243;ptimo se calcularon la precisi&#243;n general&#44; sensibilidad&#44; especificidad&#44; valores predictivos positivos&#47;negativos y la raz&#243;n de probabilidad positiva&#47;negativa&#46; El punto de corte &#243;ptimo para la ausencia de SBGC se seleccion&#243; mediante el &#237;ndice J de Youden&#46; Finalmente&#44; un an&#225;lisis univariado del impacto cl&#237;nico del SBGC fue llevado a cabo&#46; Se consider&#243; significaci&#243;n estad&#237;stica una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5 para 2 colas&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa IBM SPSS 20&#46;0 &#40;IBM SPSS&#44; Inc&#46;&#44; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se incluyeron 362 pacientes con una media de edad de 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 a&#241;os de los que 280 &#40;77&#44;3&#37;&#41; eran hombres&#46; El EuroSCORE medio fue de 9&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;5&#46; Variables m&#233;dico-quir&#250;rgicas&#58; 348 &#40;96&#44;1&#37;&#41; fueron primointervenciones&#44; 225 &#40;62&#44;2&#37;&#41; cirug&#237;a electiva&#44; 127 &#40;35&#44;1&#37;&#41; urgente y 10 &#40;2&#44;8&#37;&#41; emergente con un tiempo medio de isquemia de 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39<span class="elsevierStyleHsp" style=""></span>min y un tiempo de CEC de 114<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>78 min&#46; Nueve &#40;2&#44;5&#37;&#41; pacientes estaban en situaci&#243;n cr&#237;tica preoperatoria&#46; Dos &#40;0&#44;5&#37;&#41; de 12 &#40;3&#37;&#41; murieron en quir&#243;fano por lo que no se incluyeron en el an&#225;lisis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ciento diecis&#233;is &#40;32&#37;&#41; pacientes cumplieron criterios de SBGC postoperatorio&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen las variables demogr&#225;ficas y preoperatorias en relaci&#243;n con la presencia de SBGC&#46; Las variables que se asociaron de forma significativa al desarrollo de SBGC fueron&#58; un menor uso de beta-bloqueo preoperatorio&#44; edad avanzada&#44; mayor IMVI&#44; mayor EuroSCORE&#44; peor clase funcional de la NYHA&#44; situaci&#243;n cr&#237;tica preoperatoria&#44; intervenci&#243;n no electiva&#44; mayores tiempos de isquemia o de CEC&#44; menor ICI&#44; mayor proporci&#243;n de cardioplej&#237;a retr&#243;gada con respecto al total de la cardioplej&#237;a infundida&#44; todas ellas con un valor p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En el modelo final de regresi&#243;n log&#237;stica&#44; la clase funcional de la NYHA y la cardioplej&#237;a retr&#243;grada fueron identificadas como factores de riesgo independientes&#44; mientras que la FEVI y el ICI aparecieron como factores protectores &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; No se encontraron interacciones de primer orden&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Tras estratificar por NYHA observamos que en los pacientes con un NYHA I-II un menor ICI de 20&#44;7 &#40;18&#44;4-28&#44;8&#41; vs&#46; 32 &#40;24-42&#44;5&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con la aparici&#243;n de SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; De modo similar&#44; en los pacientes con clase funcional NYHA III-IV&#44; un menor ICI de 20&#44;4 &#40;14&#44;6-25&#44;8&#41; vs&#46; 27&#44;6 &#40;21&#44;9-33&#44;3&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Por otro lado&#44; en los pacientes con FEVI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>56&#37;&#44; un menor ICI de 21&#44;6 &#40;18&#44;3-26&#44;4&#41; vs&#46; 31&#44;5 &#40;22&#44;9-41&#44;9&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En aquellos pacientes con una FEVI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>56&#37;&#44; un menor ICI de 19&#44;5 &#40;13&#44;9-28&#44;1&#41; vs&#46; 29&#44;4 &#40;25&#44;2-39&#44;5&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El ICI se asoci&#243; de forma directa con el IC a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y de forma inversa con las dosis de dobutamina al t&#233;rmino de la cirug&#237;a &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; dosis acumulada total &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y dosis m&#225;xima de dobutamina &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; a la dosis acumulada total de levosimendan &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y a los niveles de lactato a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>0<span class="elsevierStyleHsp" style=""></span>&#44;02&#41;&#46; Tambi&#233;n se asoci&#243; inversamente con los marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico&#44; tanto al ingreso en UCI&#44; como sus picos m&#225;ximos postoperatorios&#58; troponina <span class="elsevierStyleSmallCaps">i</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 respectivamente&#41; y creatincinasa MB &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 respectivamente&#41;&#59; y con el Nt-ProBNP a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y su pico postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">El tercil superior de ICI &#91;ml min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#93; se asoci&#243; con dosis m&#225;s bajas de dobutamina &#40;dosis m&#225;xima y tiempo de administraci&#243;n&#41;&#58; dosis m&#225;xima de dobutamina &#40;mcg&#47;kg&#47;min&#41;&#44; ICI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44;9&#58; 4&#44;85 &#40;0&#44;5-7&#44;1&#41;&#59; ICI 21&#44;9-32&#44;2&#58; 1&#44;44 &#40;0-5&#44;3&#41; e ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>32&#58; 0 &#40;0-0&#41;&#59; tiempo de dobutamina &#40;horas&#41;&#58; ICI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44;9&#58; 21 &#40;0&#44;5-67&#41;&#59; ICI 21&#44;9-32&#44;2&#58; 4 &#40;0-20&#41; e ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>32&#58; 0 &#40;0-0&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respectivamente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">El &#225;rea bajo la curva ROC para la no aparici&#243;n de SBGC en funci&#243;n de la dosis de cardioplej&#237;a por unidad de masa y tiempo de isquemia &#40;ICI&#41; fue de 0&#44;77 &#40;IC 95&#37;&#58; 0&#44;70-0&#44;83&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con un punto de corte &#243;ptimo de 23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#44; con una sensibilidad del 78&#37;&#44; una especificidad del 71&#37;&#44; un valor predictivo positivo del 84&#37;&#44; un valor predictivo negativo del 64&#37;&#44; una raz&#243;n de probabilidad positiva de 2&#44;7 y raz&#243;n de probabilidad negativa de 3&#44;27 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Los pacientes con SBGC postoperatorio mantuvieron esta situaci&#243;n cl&#237;nica una mediana de 27 &#40;20-139&#41;<span class="elsevierStyleHsp" style=""></span>h&#44; requiriendo una mediana de dosis m&#225;xima de dobutamina 9&#44;5 &#40;8-16&#41;<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#47;min&#46; Estos pacientes presentaron valores significativamente m&#225;s altos de marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico y de hipoperfusi&#243;n&#44; tanto en el per&#237;odo postoperatorio inmediato como despu&#233;s de 24<span class="elsevierStyleHsp" style=""></span>h&#59; as&#237; como niveles m&#225;s altos de N-terminal prop&#233;ptido natriur&#233;tico cerebral despu&#233;s de 24<span class="elsevierStyleHsp" style=""></span>h&#46; Nueve pacientes desarrollaron disfunci&#243;n ventricular derecha&#44; falleciendo 2 de ellos&#46; Tambi&#233;n requirieron m&#225;s tiempo de ventilaci&#243;n mec&#225;nica&#44; mostraron mayor incidencia de fracaso renal agudo con necesidad de t&#233;cnicas de reemplazo renal&#44; tuvieron estancias en UCI e intrahospitalarias m&#225;s prolongadas y mayor mortalidad&#44; siendo todas ellas diferencias estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio fue identificar un par&#225;metro que permita el ajuste de la dosis de cardioplej&#237;a seg&#250;n el IMVI&#44; creando as&#237; una herramienta&#44; el ICI&#44; que podr&#237;a ser &#250;til para optimizar la preservaci&#243;n mioc&#225;rdica durante la cirug&#237;a&#44; reduciendo el da&#241;o mioc&#225;rdico postisqu&#233;mico y el desarrollo de SBGC postoperatorio&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">El aturdimiento mioc&#225;rdico se define como una disfunci&#243;n ventricular postisqu&#233;mica que persiste tras la reperfusi&#243;n en ausencia de da&#241;o mioc&#225;rdico irreversible<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a>&#46; Cl&#237;nicamente&#44; se caracteriza por la necesidad de f&#225;rmacos inotr&#243;picos postoperatorios a pesar de que se obtengan resultados quir&#250;rgicos satisfactorios&#46; En pacientes de alto riesgo con baja reserva cardiaca&#44; el aturdimiento mioc&#225;rdico conlleva un aumento de los d&#237;as de ventilaci&#243;n mec&#225;nica&#44; del riesgo de insuficiencia renal&#44; de estancia en UCI y hospitalaria&#44; y de la mortalidad&#44; como se pudo observar en aquellos pacientes que desarrollaron SBGC&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">El SBGC postoperatorio es una de las complicaciones m&#225;s frecuentes tras la cirug&#237;a de revascularizaci&#243;n coronaria&#46; La incidencia en nuestro estudio&#44; del 32&#37;&#44; es mayor que la encontrada en otros estudios que se suele situar entre el 16&#44;1 y el 13&#44;5&#37;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a>&#46; Varias circunstancias podr&#237;an explicar esta diferencia&#46; En primer lugar&#44; el n&#250;mero de cirug&#237;as urgentes y emergentes en nuestra poblaci&#243;n fue superior al registrado en otros estudios &#40;Algarni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> recogieron un 8-10&#37; de cirug&#237;as urgentes&#44; mientras Ding et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> un 8&#44;3&#37; de cirug&#237;as emergentes en el grupo que present&#243; SBGC&#41;&#59; en segundo lugar&#44; en nuestro estudio no se realizaron cirug&#237;as sin CEC&#59; por &#250;ltimo&#44; la definici&#243;n de SBGC utilizada por otros autores es m&#225;s restrictiva&#44; quedando excluidos los pacientes que&#44; aun necesitando inotropos&#44; no superaron un determinado umbral de dosis o tiempo de tratamiento<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a>&#46; Estos criterios de inclusi&#243;n podr&#237;an limitar la sensibilidad para detectar formas menos graves de disfunci&#243;n mioc&#225;rdicas en el postoperatorio inmediato&#46; Sin embargo&#44; como recogen las gu&#237;as de monitorizaci&#243;n hemodin&#225;mica de la SEMICYUC<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a>&#44; &#171;no se recomienda la monitorizaci&#243;n rutinaria y sistem&#225;tica del GC en los pacientes con inestabilidad hemodin&#225;mica&#187;&#46; Por otra parte&#44; los criterios cl&#237;nicos son suficientes para una clasificaci&#243;n adecuada de los pacientes con SBGC postoperatorio&#44; como se ha demostrado recientemente en el estudio ESBAGA en el que el grupo clasificado cl&#237;nicamente presentaba una evoluci&#243;n postoperatoria con un claro aumento de los datos de morbimortalidad muy similar al grupo diagnosticado por par&#225;metros de monitorizaci&#243;n hemodin&#225;mica<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Aunque no existe consenso sobre las causas de la elevaci&#243;n de los marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico postoperatorio&#44; 3 importantes ensayos cl&#237;nicos han identificado la protecci&#243;n mioc&#225;rdica sub&#243;ptima como principal factor responsable del da&#241;o por isquemia&#47;reperfusi&#243;n<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a>&#46; En nuestro estudio observamos que los pacientes con menor ICI presentaron mayores concentraciones de estos marcadores &#40;troponinas&#44; creatincinasa MB y N-terminal prop&#233;ptido natriur&#233;tico cerebral&#41; y de lactato &#40;como indicador sustitutivo de hipoperfusi&#243;n&#41;&#44; precisando m&#225;s soporte inotr&#243;pico en el postoperatorio inmediato&#46; Adem&#225;s&#44; se identificaron como factores de riesgo para desarrollar SBGC postoperatorio los siguientes&#58; mayor edad&#44; mayor IMVI&#44; FEVI postoperatoria disminuida&#44; peor clase funcional de la NYHA&#44; mayor EuroSCORE&#44; cirug&#237;a urgente&#44; tiempo de CEC prolongado&#44; y el volumen y v&#237;a de administraci&#243;n de la cardioplej&#237;a&#44; todo ello acorde con estudios previos<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12&#44;16</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Como ya se ha mencionado&#44; en la etiopatogenia de la disfunci&#243;n mioc&#225;rdica postisqu&#233;mica en cirug&#237;a cardiaca se han identificado distintos factores contribuyentes&#46; De acuerdo con nuestros hallazgos&#44; el aumento del IMVI implica un aumento de la morbimortalidad del paciente sometido a cirug&#237;a cardiaca<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a>&#59; esto se debe a que el aumento del IMVI conlleva un mayor riesgo de isquemia mioc&#225;rdica perioperatoria secundario a desequilibrio entre la oferta y la demanda de ox&#237;geno mioc&#225;rdico&#46; La hipertrofia ventricular izquierda se asocia con alteraciones estructurales vasculares coronarias con aumento de las resistencias&#44; alteraciones del flujo y aumento de la presi&#243;n telediast&#243;lica del VI con la consiguiente reducci&#243;n de la perfusi&#243;n subendoc&#225;rdica&#46; Asimismo&#44; implica un aumento de demanda mioc&#225;rdica de ox&#237;geno y un mayor estr&#233;s de la pared&#46; Durante la cirug&#237;a&#44; los pacientes con hipertrofia ventricular severa tienen mayor riesgo de una preservaci&#243;n mioc&#225;rdica sub&#243;ptima&#46; La combinaci&#243;n de estos factores implica un peor pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46; Por otra parte&#44; el IMVI tambi&#233;n se ha relacionado con un incremento de las arritmias postoperatorias<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a>&#44; un aumento de la estancia media<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> e incluso se ha identificado como un predictor independiente de la mortalidad a 30 d&#237;as&#44; con una relaci&#243;n pr&#225;cticamente lineal<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dada la importancia de la preservaci&#243;n mioc&#225;rdica&#44; se han desarrollado diversas estrategias de cardioprotecci&#243;n durante la cirug&#237;a&#44; identific&#225;ndose la cardioplej&#237;a como un elemento clave&#46; Entre las diversas formas de cardioplej&#237;a&#44; el patr&#243;n oro en los &#250;ltimos 30 a&#241;os ha sido una soluci&#243;n hiperkali&#233;mica despolarizante que induce una parada cardiaca r&#225;pida y f&#225;cilmente reversible&#59; aunque no por ello exenta de inconvenientes&#46; El aumento de las concentraciones de potasio puede estar relacionado con la aparici&#243;n diferentes grados de vasoconstricci&#243;n y vasoespasmo&#44; dando lugar a una distribuci&#243;n irregular de la cardioplej&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> y&#44; por tanto&#44; una reducci&#243;n de la protecci&#243;n mioc&#225;rdica&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; las concentraciones extracelulares de potasio presentan un estrecho margen terap&#233;utico de modo que peque&#241;as variaciones de las mismas pueden dar lugar a corrientes i&#243;nicas persistentes que conllevan un aumento intracelular de calcio y sodio<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; En un intento de restaurar el equilibrio i&#243;nico&#44; se activan bombas transmembrana con el consiguiente consumo de energ&#237;a&#44; que contribuye al aturdimiento mioc&#225;rdico<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a>&#46; Esto exige mantener concentraciones extracelulares de potasio estables mediante su apropiado aporte ajustado a una masa mioc&#225;rdica en presencia de enfermedad arterial coronaria&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A pesar de los numerosos estudios que exploran los tipos y modos de administraci&#243;n de la cardioplej&#237;a&#44; en nuestro conocimiento&#44; no se han desarrollado estrategias que permitan ajustar la dosis de cardioplej&#237;a al IMVI&#46; En un estudio realizado a mediados de los a&#241;os 80&#44; Matsuda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> evaluaron las dosis &#243;ptimas iniciales de cardioplej&#237;a en pacientes con hipertrofia ventricular severa sometidos a reemplazo valvular a&#243;rtico&#46; Sin embargo&#44; no hemos encontrado estudios posteriores que validen sus conclusiones o que desarrollen estrategias de cardioprotecci&#243;n en base de sus resultados&#46; En nuestro estudio relacionamos&#44; por medio del ICI&#44; el IMVI y la cantidad de cardioplej&#237;a&#46; La conclusi&#243;n principal fue la existencia de una relaci&#243;n entre el tiempo de isquemia al que se somete una determinada masa mioc&#225;rdica&#44; la dosis de cardioplej&#237;a utilizada para su conservaci&#243;n y el desarrollo de SBGC postoperatorio&#46; Para ser exactos&#44; encontramos que un ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47; &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41; se asocia con una menor incidencia de SBGC&#44; y tambi&#233;n se asocia inversamente con los requerimientos de inotropos postoperatorios&#46; Probablemente&#44; debido a que estas dosis permiten lograr una mayor estabilidad en las concentraciones i&#243;nicas&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; nuestros resultados indican que la cardioplej&#237;a retr&#243;grada intermitente se asocia con una menor cardioprotecci&#243;n&#46; En pacientes con enfermedad arterial coronaria&#44; la administraci&#243;n retr&#243;grada de cardioplej&#237;a abarca mejor el territorio de la arteria descendente anterior que la v&#237;a anter&#243;grada<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> debido a que el territorio ventricular puede recibir flujo retr&#243;grado a trav&#233;s de los colaterales de Tebesio<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a>&#46; Sin embargo&#44; la administraci&#243;n exclusiva de cardioplej&#237;a retr&#243;grada puede proporcionar una protecci&#243;n mioc&#225;rdica insuficiente debido a la escasa perfusi&#243;n del ventr&#237;culo derecho&#44; la pared posterior y el septo interventricular&#44; salvo que se combine con administraci&#243;n anter&#243;grada a trav&#233;s del ostium coronario<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a>&#46; No obstante&#44; diversos estudios muestran que con cardioplej&#237;a retr&#243;grada de alto flujo se pueden mejorar los resultados en la preservaci&#243;n del ventr&#237;culo derecho y del tabique interventricular<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a>&#46; Los hallazgos de nuestro estudio muestran que a mayor proporci&#243;n de cardioplej&#237;a administrada por v&#237;a retr&#243;grada&#44; mayor incidencia de SBGC postoperatorio&#46; Esto podr&#237;a deberse a que el volumen de cardioplej&#237;a por v&#237;a retr&#243;grada o la combinaci&#243;n con cardioplej&#237;a intermitente fue insuficiente&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">El presente trabajo tiene ciertas limitaciones&#58; es un estudio observacional unic&#233;ntrico realizado exclusivamente con cardioplej&#237;a hiperkali&#233;mica intermitente&#44; sin compararlo con otros m&#233;todos de administraci&#243;n y sin un m&#233;todo predefinido para la administraci&#243;n de la misma &#40;ruta&#44; volumen y dosis posteriores&#41;&#44; quedando a criterio del cirujano&#46; Sin embargo&#44; cada mililitro de cardioplej&#237;a administrado por cada gramo de miocardio y minuto de isquemia redujo la probabilidad de desarrollar SBGC en algo menos del 1&#37;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En resumen&#44; 2 factores han demostrado ser clave en el desarrollo de aturdimiento mioc&#225;rdico postoperatorio&#58; el tiempo de pinzamiento a&#243;rtico y una adecuada estrategia individualizada de preservaci&#243;n del mioc&#225;rdica&#46; Nuestro estudio muestra que el ajuste de la dosis de cardioplej&#237;a seg&#250;n el tiempo de isquemia y el IMVI puede constituir una herramienta &#250;til para mejorar el grado de miocardioprotecci&#243;n durante la cirug&#237;a de revascularizaci&#243;n coronaria&#44; minimizando as&#237; los efectos delet&#233;reos de una protecci&#243;n mioc&#225;rdica sub&#243;ptima&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Una posible aplicaci&#243;n de los hallazgos de este estudio&#44; en el manejo de la cardioplej&#237;a hiperkali&#233;mica&#44; podr&#237;a consistir en el ajuste de la dosis inicial de cardioplej&#237;a en base al IMVI&#46; En pacientes con hipertrofia leve &#40;IMVI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; se administrar&#237;an 1&#44;2<span class="elsevierStyleHsp" style=""></span>l&#44; mientras que en aquellos con hipertrofia de moderada a severa se administrar&#237;an al menos 1&#44;5<span class="elsevierStyleHsp" style=""></span>l&#46; Con respecto a las dosis de mantenimiento&#44; ser&#237;a importante mantener unos intervalos de administraci&#243;n de entre 20 y 25<span class="elsevierStyleHsp" style=""></span>min&#44; dependiendo del procedimiento quir&#250;rgico&#46; Esta dosis de mantenimiento podr&#237;a calcularse como el producto de 25<span class="elsevierStyleHsp" style=""></span>ml por los minutos de isquemia &#40;20 o 25 como m&#225;ximo&#41; multiplicado por un factor de correcci&#243;n de masa mioc&#225;rdica &#40;IMVI&#47;100&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Ser&#237;a necesario desarrollar otros estudios para verificar la utilidad&#44; en la pr&#225;ctica cl&#237;nica&#44; de este esquema&#46; Tambi&#233;n ser&#237;a interesante evaluar el ICI con otra soluci&#243;n de cardioplej&#237;a&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Contribuci&#243;n de los autores</span><p id="par0165" class="elsevierStylePara elsevierViewall">JJJR&#44; CLJ y JLIS dise&#241;aron el proyecto y desarrollaron el an&#225;lisis estad&#237;stico&#46; JLA espec&#237;ficamente llev&#243; a cabo los estudios ecocardiogr&#225;ficos&#44; y GYB los estudios hemodin&#225;micos y c&#225;lculo del SYNTAX score&#46; RAP y RMS realizaron el proceso quir&#250;rgico y junto con el resto de los autores implementaron el proceso investigador&#44; discutieron los datos y contribuyeron en la redacci&#243;n final del manuscrito&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0170" class="elsevierStylePara elsevierViewall">No hay conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La cardioprotecci&#243;n es esencial en la revascularizaci&#243;n coronaria quir&#250;rgica&#46; En este estudio exploramos la relaci&#243;n existente entre el tiempo que una masa mioc&#225;rdica permanece en situaci&#243;n de isquemia y la dosis de cardioplej&#237;a utilizada para su preservaci&#243;n&#44; reflejada a trav&#233;s del &#237;ndice de cardioplej&#237;a infundida&#44; con el desarrollo de bajo gasto cardiaco postoperatorio&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron todos los pacientes sometidos a revascularizaci&#243;n coronaria quir&#250;rgica entre enero de 2013 y diciembre de 2015&#46; El s&#237;ndrome de bajo gasto cardiaco postoperatorio se defini&#243; siguiendo los criterios del documento de consenso de la SEMYCIUC&#46; Se analizaron los factores perioperatorios asociados al s&#237;ndrome de bajo gasto cardiaco y&#44; mediante la curva ROC&#44; se determin&#243; el punto de corte del &#237;ndice de cardioplej&#237;a infundida para predecir la ausencia del mismo&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De los 360 pacientes incluidos&#44; 116 &#40;32&#37;&#41; presentaron bajo gasto postoperatorio&#46; Los factores de riesgo independientes fueron&#58; clasificaci&#243;n funcional de la New York Heart Association &#40;OR 1&#44;8 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;18-2&#44;55&#93;&#41;&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;OR 0&#44;95 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;93-0&#44;98&#93;&#41;&#44; el empleo de cardioplej&#237;a retr&#243;grada &#40;OR 1&#44;2 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;03-1&#44;50&#93;&#41; y el &#237;ndice de cardioplej&#237;a infundida &#40;OR 0&#44;99 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;991-0&#44;996&#93;&#41;&#44; que mostr&#243; un &#225;rea bajo la curva ROC de 0&#44;77 &#40;0&#44;70-0&#44;83&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; para la ausencia de s&#237;ndrome de bajo gasto cardiaco postoperatorio&#44; usando como punto de corte &#243;ptimo 23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#183;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El &#237;ndice de cardioplej&#237;a infundido es inversamente proporcional a los requerimientos postoperatorios de inotropos&#44; pudiendo constituir una estrategia para optimizar la cardioprotecci&#243;n&#46; El volumen total de cardioplej&#237;a intermitente deber&#237;a calcularse&#44; de forma individualizada&#44; en base al &#237;ndice de masa del ventr&#237;culo izquierdo y el tiempo de isquemia&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Strategies for cardio-protection are essential in coronary artery bypass graft surgery&#46; The authors explored the relationship between cardioplegia volume&#44; left ventricular mass index and ischemia time by means of the infused cardioplegia index and its relationship with post-operative low cardiac output syndrome&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Design</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">All patients undergoing coronary artery bypass graft surgery between January 2013 and December 2015 were included&#46; Low cardiac output syndrome was defined according to criteria of the SEMICYUC&#39;s consensus document&#46; The perioperative factors associated with low cardiac output syndrome were estimated&#44; and using a ROC curve&#44; the optimum cut-off point for the infused cardioplegia index to predict the absence of low cardiac output syndrome was calculated&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Of 360 patients included&#44; 116 &#40;32&#37;&#41; developed low cardiac output syndrome&#46; The independent risk predictors were&#58; New York Heart Association Functional Classification &#40;OR 1&#46;8 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;18-2&#46;55&#93;&#41;&#44; left ventricle ejection fraction &#40;OR 0&#46;95 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;93-0&#46;98&#93;&#41;&#44; ICI &#40;OR 0&#46;99 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;991-0&#46;996&#93;&#41; and retrograde cardioplegia &#40;OR 1&#46;2 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;03-1&#46;50&#93;&#41;&#46; The infused cardioplegia index showed an area under the ROC curve of 0&#46;77 &#40;0&#46;70-0&#46;83&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>&#46;001&#41; for the absence of postoperative low cardiac output syndrome using the optimum cut-off point of 23&#46;6<span class="elsevierStyleHsp" style=""></span>ml&#183;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of LV&#41;<span class="elsevierStyleSup">-1</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The infused cardioplegia index presents an inverse relationship with the development of post-operative low cardiac output syndrome&#46; This index could form part of new strategies aimed at optimising cardio-protection&#46; The total volume of intermittent cardioplegia&#44; especially that of maintenance&#44; should probably be individualised&#44; adjusting for ischemia time and left ventricle mass index&#46;</p></span>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ARA-II&#58; antagonistas receptores angiotensina tipo <span class="elsevierStyleSmallCaps">ii</span>&#59; FEVI&#58; fracci&#243;n de eyecci&#243;n ventr&#237;culo izquierdo&#59; IAM&#58; infarto agudo de miocardio&#59; ICI&#58; &#237;ndice de cardioplej&#237;a infundido&#59; IECA&#58; inhibidores enzima convertidora de angiotensina&#59; IMV&#58; &#237;ndice de masa del ventr&#237;culo izquierdo&#59; NYHA&#58; New York Heart Association&#59; SBGC&#58; s&#237;ndrome de bajo gasto cardiaco&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Cardioplej&#237;a mixta&#58; anter&#243;grada y retr&#243;grada&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">b</span>Valores expresados como medias y percentiles 25 y 75&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estado cr&#237;tico preoperatorio&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intermedio&#58; 23-32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Car&#225;cter de la cirug&#237;a&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Electiva&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Pinzamiento a&#243;rtico&#44; min&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Circulaci&#243;n extracorp&#243;rea&#44; min&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a total&#44; ml&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a inicial&#44; ml&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ICI &#40;ml&#183;min</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-1</span></span><span class="elsevierStyleItalic">&#183;g</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-1</span></span><span class="elsevierStyleItalic">&#183;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-2</span></span><span class="elsevierStyleItalic">&#41;&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a anter&#243;grada&#44; n &#40;&#37;&#41;</span>&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Cardioplej&#237;a mixta</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">a</span></span><span class="elsevierStyleItalic">n &#40;&#37;&#41;</span>&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">41 &#40;35&#41;&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">0&#44;023&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">288 &#40;588&#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">514 &#40;844&#41;&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
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;21&#41;&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
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                  \t\t\t\t">18 &#40;25&#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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;18-2&#44;55&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;93-0&#44;98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Troponina I a la llegada de quir&#243;fano &#40;ng&#47;ml&#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">Troponina I pico m&#225;ximo &#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;28&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\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">CK-MB a la llegada de quir&#243;fano &#40;U&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;28&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
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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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CK-MB m&#225;xima &#40;U&#47;l&#41;&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">&#8722;0&#44;26&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\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">Nt-ProBNP a las 24h &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Nt-ProBNP pico m&#225;ximo &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  """
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                0 => "xTab2087923.png"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Correlaciones entre el ICI con par&#225;metros hemodin&#225;micos y marcadores bioqu&#237;micos de lesi&#243;n mioc&#225;rdica</p>"
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      5 => array:8 [
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        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">CK-MB&#58; creatincinasa-MB&#59; DE&#58; desviaci&#243;n est&#225;ndar&#59; IC&#58; &#237;ndice cardiaco&#59; NT-ProBNP&#58; N-terminal p&#233;ptido natriur&#233;tico cerebral&#59; PAm&#58; presi&#243;n arterial media&#59; SBGC&#58; s&#237;ndrome de bajo gasto cardiaco&#59; TAPSE&#58; desplazamiento sist&#243;lico del anillo tricusp&#237;deo&#59; UCI&#58; unidad de cuidados intensivos&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No SBGC&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>244&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SBGC&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>116&#41;&nbsp;\t\t\t\t\t\t\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">PAm 0<span class="elsevierStyleHsp" style=""></span>h &#40;mmHg&#41; &#40;DE&#41;&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">87 &#40;16&#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">0&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">PAm 4<span class="elsevierStyleHsp" style=""></span>h &#40;mmHg&#41; &#40;DE&#41;&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">79 &#40;12&#41;&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">72 &#40;10&#41;&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&#44;001&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">PAm 24<span class="elsevierStyleHsp" style=""></span>h &#40;mmHg&#41; &#40;DE&#41;&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">78 &#40;13&#41;&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">74 &#40;12&#41;&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&#44;09&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">IC 0<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">2&#44;6 &#40;2&#44;4-3&#44;4&#41;&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&#44;3 &#40;1&#44;9-2&#44;8&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">IC 4<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">2&#44;5 &#40;2&#44;1-3&#44;1&#41;&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&#44;3 &#40;2&#44;3-2&#44;4&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">IC 24<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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&#44;5-3&#44;4&#41;&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&#44;7 &#40;2&#44;3-3&#41;&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&#44;02&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">TAPSE&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">24<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&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">22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&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&#44;69&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">Dobutamina &#40;dosis m&#225;xima&#47;mcg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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">9&#44;5 &#40;8-16&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Dobutamina &#40;horas totales&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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 &#40;20-139&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Noradrenalina &#40;dosis m&#225;xima&#47;mcg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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&#44;41 &#40;0&#44;07-0&#44;98&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Noradrenalina &#40;horas totales&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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;1-100&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I llegada UCI&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#44;5 &#40;0&#44;9-2&#44;6&#41;&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&#44;2 &#40;3-10&#44;6&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I 4<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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&#44;5 &#40;2-4&#44;5&#41;&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&#44;4 &#40;4-11&#44;6&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I 24<span class="elsevierStyleHsp" style=""></span>h&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">2 &#40;1&#44;2-3&#41;&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&#44;5 &#40;5&#44;5-11&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">L&#225;ctico llegada UCI&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#44;9 &#40;1&#44;5-2&#44;4&#41;&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&#44;1 &#40;1&#44;8-3&#44;6&#41;&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&#44;01&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">L&#225;ctico 4<span class="elsevierStyleHsp" style=""></span>h&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#44;5 &#40;1&#44;3-2&#44;6&#41;&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&#44;5 &#40;1&#44;8-3&#44;8&#41;&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&#44;005&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">L&#225;ctico 24<span class="elsevierStyleHsp" style=""></span>h&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#44;4 &#40;1-2&#41;&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&#44;8 &#40;1&#44;6-2&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB llegada UCI&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">42 &#40;32-49&#41;&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">80 &#40;51-108&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB 4<span class="elsevierStyleHsp" style=""></span>h&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">37 &#40;29-50&#41;&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">83 &#40;55-136&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB 24<span class="elsevierStyleHsp" style=""></span>h&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">24 &#40;21-43&#41;&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">63 &#40;51-153&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">NT-ProBNP 4<span class="elsevierStyleHsp" style=""></span>h&#44; pg&#47;mL<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">686&#40;368-1740&#41;&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">2475&#40;115-11455&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">NT-ProBNP 24<span class="elsevierStyleHsp" style=""></span>h&#44; pg&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#46;960 &#40;1&#46;090-3&#46;140&#41;&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&#46;125&#40;2&#46;760-8&#46;860&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Ventilaci&#243;n mec&#225;nica &#40;horas&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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;1&#44;7-5&#41;&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">16 &#40;5-87&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Terapias sustituci&#243;n renal n &#40;&#37;&#41;&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 &#40;0&#44;4&#41;&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">20 &#40;18&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Estancia UCI &#40;d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">2 &#40;1-3&#41;&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 &#40;2-11&#41;&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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Índice de cardioplejía infundida: una nueva herramienta en la protección miocárdica. Un estudio de cohortes
Infused cardioplegia index: A new tool to improve myocardial protection. A cohort study
J.J. Jiménez Riveraa,
Autor para correspondencia
jjjimenezrivera@gmail.com

Autor para correspondencia.
, C. Llanos Jorgeb, J.L. Iribarren Sarríasa, M. Brouard Martína, J. Lacalzada Almeidac, J.L. Pérez Velad, R. Avalos Pintoe, R. Pérez Hernándezf, S. Ramos de la Rosab, G. Yanes Bowdenc, R. Martínez Sanze
a Servicio de Medicina Intensiva, Hospital Universitario de Canarias, La Laguna, España
b Servicio de Medicina Intensiva, Hospital Quirón salud Tenerife, Santa Cruz de Tenerife, España
c Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, España
d Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
e Servicio de Cirugía Cardiaca, Hospital Universitario de Canarias, La Laguna, España
f Servicio de Medicina Intensiva Pediátrica, Hospital Universitario de Canarias, La Laguna, España
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mayor ser&#225; el da&#241;o molecular y las alteraciones celulares secundarias<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a>&#46; Se estima que entre un 10 y 15&#37; de los pacientes sometidos a cirug&#237;a de revascularizaci&#243;n coronaria desarrollan disfunci&#243;n ventricular izquierda<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Durante la cirug&#237;a cardiaca es imprescindible la instauraci&#243;n de estrategias de cardioprotecci&#243;n con el fin de minimizar el da&#241;o por isquemia&#47;reperfusi&#243;n&#46; Entre estas estrategias&#44; la cardioplej&#237;a constituye la principal medida para la miocardioprotecci&#243;n intraoperatoria&#46; Se han desarrollado diversos m&#233;todos para optimizar la cardioplej&#237;a que abarcan desde variaciones en su contenido o temperatura hasta el uso de distintas v&#237;as y flujos de administraci&#243;n&#46; Sin embargo&#44; en nuestro conocimiento&#44; existe escasa bibliograf&#237;a sobre su ajuste con relaci&#243;n a otros factores relacionados con la susceptibilidad mioc&#225;rdica al da&#241;o por isquemia&#47;reperfusi&#243;n&#44; como el grado de afectaci&#243;n isqu&#233;mica o el aumento de la masa del VI&#46; Este &#250;ltimo&#44; asociado con un mayor trabajo mioc&#225;rdico con el consiguiente aumento de consumo mioc&#225;rdico de ox&#237;geno&#44; deber&#237;a tenerse en cuenta a la hora de dise&#241;ar estrategias eficaces de cardioprotecci&#243;n&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En este estudio&#44; por medio del &#237;ndice de cardioplej&#237;a infundido &#40;ICI&#41;&#44; hemos explorado la relaci&#243;n entre el volumen de cardioplej&#237;a&#44; el tiempo de isquemia y la masa ventricular izquierda&#44; con la aparici&#243;n de da&#241;o mioc&#225;rdico en pacientes sometidos a cirug&#237;a de revascularizaci&#243;n mioc&#225;rdica&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">El Comit&#233; de &#201;tica del hospital aprob&#243; el estudio&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dise&#241;o del estudio y poblaci&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">El estudio se desarroll&#243; en la Unidad de Cuidados Intensivos &#40;UCI&#41; m&#233;dico-quir&#250;rgica de 24 camas del Hospital Universitario de Canarias&#46; Es un estudio ambispectivo de cohortes en el que se incluyeron todos los pacientes sometidos a cirug&#237;a de revascularizaci&#243;n coronaria entre enero de 2013 y diciembre de 2015&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Para la definici&#243;n de SBGC postoperatorio se recurri&#243; a la definici&#243;n de consenso de la SEMICYUC<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a>&#44; incluyendo a aquellos paciente que&#44; tras optimizar la precarga&#44; presentaran&#58; &#237;ndice cardiaco &#40;IC&#41; medido<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#59; cuadro cl&#237;nico compatible con SBGC&#44; en pacientes no monitorizados&#44; con oliguria &#40;diuresis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41;&#44; saturaci&#243;n venosa central<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; &#40;con saturaci&#243;n arterial normal&#41; y&#47;o lactato<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#59; aquellos que requirieron inotropos y&#47;o bal&#243;n de contrapulsaci&#243;n en el postoperatorio inmediato para garantizar una situaci&#243;n hemodin&#225;mica adecuada&#59; y por &#250;ltimo&#44; aquellos pacientes con criterios de shock cardiog&#233;nico &#40;IC<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; con presi&#243;n arterial sist&#243;lica<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg y oliguria&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recogida de datos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Se recogieron de forma prospectiva datos demogr&#225;ficos&#44; comorbilidades&#44; clase funcional&#44; estudio de las principales arterias coronarias afectas&#44; SYNTAX score&#44; fracci&#243;n de eyecci&#243;n del VI &#40;FEVI&#41;&#44; desplazamiento sist&#243;lico del anillo tricusp&#237;deo&#44; mediante ecocardiograf&#237;a y situaci&#243;n cr&#237;tica preoperatoria definida por la necesidad de ventilaci&#243;n mec&#225;nica&#44; soporte inotr&#243;pico&#44; asistencia ventricular y&#47;o fracaso renal agudo con diuresis<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#46; El riesgo quir&#250;rgico se calcul&#243; mediante EuroSCORE<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a>&#46;Tambi&#233;n se registraron variables quir&#250;rgicas&#58; tiempo de isquemia&#44; tiempo de circulaci&#243;n extracorp&#243;rea &#40;CEC&#41;&#44; tipo y volumen de cardioplej&#237;a &#40;&#250;nico dato registrado retrospectivamente&#41;&#44; revascularizaci&#243;n completa o incompleta &#40;en base a los vasos principales&#41;&#59; y posquir&#250;rgicas&#58; par&#225;metros hemodin&#225;micos&#44; dosis de aminas&#44; disfunci&#243;n ventricular derecha &#40;definida como hipocontractilidad objetivada por el cirujano a la salida de bomba&#41;&#44; duraci&#243;n de la ventilaci&#243;n mec&#225;nica&#44; necesidad de t&#233;cnicas de reemplazo renal&#44; estancia en UCI&#44; en el hospital y mortalidad a los 30 d&#237;as&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se analizaron muestras de sangre en el postoperatorio inmediato&#44; a las 24<span class="elsevierStyleHsp" style=""></span>h del ingreso y cada 24<span class="elsevierStyleHsp" style=""></span>h en aquellos pacientes que lo requirieron&#46; Como marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico se midieron&#58; troponina <span class="elsevierStyleSmallCaps">i</span>&#44; creatincinasa MB&#44; N-terminal prop&#233;ptido natriur&#233;tico cerebral&#44; y como marcador sist&#233;mico de hipoperfusi&#243;n se utiliz&#243; el lactato&#46; El estudio ecocardiogr&#225;fico preoperatorio se realiz&#243; siguiendo las gu&#237;as de la Sociedad Americana de Ecocardiograf&#237;a<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> en el laboratorio de ecocardiograf&#237;a&#46; La masa del VI se calcul&#243; mediante la f&#243;rmula modificada de Devereux et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a>&#44; se index&#243; por el &#225;rea de superficie corporal y la FEVI se estim&#243; mediante el Simpson modificado&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0045" class="elsevierStylePara elsevierViewall">La principal variable independiente fue el ICI&#46; Este &#237;ndice relaciona el total de cardioplej&#237;a infundida durante el tiempo de isquemia con el &#237;ndice de masa del VI &#40;IMVI&#41; &#40;&#931;Cardioplej&#237;a&#47;tiempo de isquemia&#47;IMVI&#41;&#46; La principal variable dependiente fue la ausencia de criterios de SBGC postoperatorio&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protocolos anest&#233;sicos y quir&#250;rgicos</span><p id="par0050" class="elsevierStylePara elsevierViewall">Todos los pacientes fueron preoxigenados y se realiz&#243; la inducci&#243;n con dosis de propofol de entre 1&#44;5 y1&#44;8<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#44; entre 0&#44;1 y 0&#44;3<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#47;min de remifentanilo y 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg de rocuronio&#46; Para el mantenimiento anest&#233;sico se utiliz&#243; sevoflurano 1&#44;5-2<span class="elsevierStyleHsp" style=""></span>vol&#37; y perfusi&#243;n continua de remifentanilo&#46; El circuito extracorp&#243;reo estaba compuesto por un oxigenador de membrana &#40;Optima XP&#44; Cobe&#44; Denver&#44; Co&#44; USA or Quantum Lifestream International&#44; Inc&#46; Woodlands&#44; TX&#44; EE&#46; UU&#46;&#41;&#44; un circuito extracorp&#243;reo Tygon &#40;Dideco&#44; Mirandola&#44; Italia&#41; y una bomba centrifuga Medtronic Biopump &#40;Minneapolis&#44; MN&#44; EE&#46; UU&#46;&#41;&#46; Bajo hipotermia de entre 30-32<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; el flujo de la bomba se ajust&#243; para garantizar presiones arteriales medias<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>mmHg e IC de 2&#44;2<span class="elsevierStyleHsp" style=""></span>l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#46; Todos los pacientes recibieron inicialmente cardioplej&#237;a anter&#243;grada mientras que el mantenimiento se hizo mediante cardioplej&#237;a anter&#243;grada o retr&#243;grada a criterio del cirujano&#46; Para la parada cardiaca se administraron entre 1&#46;200 y 1&#46;500<span class="elsevierStyleHsp" style=""></span>mL de cardioplej&#237;a fr&#237;a de cristaloides &#40;500<span class="elsevierStyleHsp" style=""></span>ml soluci&#243;n de Ringer&#44; 40<span class="elsevierStyleHsp" style=""></span>mEq KCl&#44; 25<span class="elsevierStyleHsp" style=""></span>mEq HCO<span class="elsevierStyleInf">3</span>Na&#44; 35<span class="elsevierStyleHsp" style=""></span>mg lidoca&#237;na&#41; mediante infusi&#243;n intermitente con una relaci&#243;n 4&#58;1 con cardioplej&#237;a sangu&#237;nea&#46; Adem&#225;s&#44; se administraron dosis adicionales de 500<span class="elsevierStyleHsp" style=""></span>ml de suero con 20<span class="elsevierStyleHsp" style=""></span>mEq de KCl cada 20-25<span class="elsevierStyleHsp" style=""></span>min o cuando se estim&#243; necesario&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">An&#225;lisis estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Las variables continuas se expresan como medias y desviaciones est&#225;ndar&#44; medianas y percentiles 25-75&#44; usando el estad&#237;stico t de Student o el test U de Mann-Whitney de acuerdo a la naturaleza de las variables &#40;determinada por el test de Kolmogorov-Smirnov&#41;&#46; La homocedasticidad de las varianzas se test&#243; mediante el test de Levene&#46; Las variables categ&#243;ricas se presentan como frecuencias y porcentajes&#44; se us&#243; la Chi cuadrado o el test exacto de Fisher para comparar diferencias entre grupos&#46; Las variables asociadas significativamente al s&#237;ndrome de bajo gasto con una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;10 en el an&#225;lisis univariado &#40;edad&#44; dislipidemia&#44; calcioantagonistas&#44; FEVI&#44; EuroSCORE&#44; NYHA&#44; situaci&#243;n cr&#237;tica preoperatoria&#44; car&#225;cter de la cirug&#237;a&#44; grado de revascularizaci&#243;n&#44; ICI y cardioplej&#237;a retr&#243;grada&#41; se incluyeron en el an&#225;lisis de regresi&#243;n log&#237;stico con el objeto de identificar predictores independientes de SBGC&#46; El tiempo de CEC&#44; el IMVI indexada y el volumen de cardioplej&#237;a total fueron excluidos del an&#225;lisis de regresi&#243;n al estar incluidos en el c&#225;lculo del ICI con el objeto de evitar colinealidad&#46; Exploramos la asociaci&#243;n entre el ICI y el SBGC estratificando por las 2 covariables de riesgo del modelo final&#58; NYHA &#40;grado <span class="elsevierStyleSmallCaps">i</span>-<span class="elsevierStyleSmallCaps">ii</span> vs&#46; <span class="elsevierStyleSmallCaps">iii</span>-<span class="elsevierStyleSmallCaps">iv</span>&#41; y FEVI &#40;utilizando el punto de corte asociado a la aparici&#243;n de SBGC&#58; 56&#37;&#41;&#46; Las asociaciones entre el ICI&#44; biomarcadores de da&#241;o mioc&#225;rdico y dosis de inotropos se calcularon usando el estad&#237;stico Rho de Spearman&#46; El ICI se agrup&#243; en terciles y su asociaci&#243;n con las necesidades de dobutamina se estudi&#243; con el test de Kruskal-Wallis&#46; La fiabilidad del ICI para predecir la ausencia de SBGC se verific&#243; mediante el an&#225;lisis del &#225;rea bajo la curva ROC&#59; se excluyeron los casos con disfunci&#243;n severa del ventr&#237;culo derecho&#46; Para el punto de corte &#243;ptimo se calcularon la precisi&#243;n general&#44; sensibilidad&#44; especificidad&#44; valores predictivos positivos&#47;negativos y la raz&#243;n de probabilidad positiva&#47;negativa&#46; El punto de corte &#243;ptimo para la ausencia de SBGC se seleccion&#243; mediante el &#237;ndice J de Youden&#46; Finalmente&#44; un an&#225;lisis univariado del impacto cl&#237;nico del SBGC fue llevado a cabo&#46; Se consider&#243; significaci&#243;n estad&#237;stica una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5 para 2 colas&#46; El an&#225;lisis estad&#237;stico se realiz&#243; con el programa IBM SPSS 20&#46;0 &#40;IBM SPSS&#44; Inc&#46;&#44; Armonk&#44; NY&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Se incluyeron 362 pacientes con una media de edad de 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 a&#241;os de los que 280 &#40;77&#44;3&#37;&#41; eran hombres&#46; El EuroSCORE medio fue de 9&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#44;5&#46; Variables m&#233;dico-quir&#250;rgicas&#58; 348 &#40;96&#44;1&#37;&#41; fueron primointervenciones&#44; 225 &#40;62&#44;2&#37;&#41; cirug&#237;a electiva&#44; 127 &#40;35&#44;1&#37;&#41; urgente y 10 &#40;2&#44;8&#37;&#41; emergente con un tiempo medio de isquemia de 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39<span class="elsevierStyleHsp" style=""></span>min y un tiempo de CEC de 114<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>78 min&#46; Nueve &#40;2&#44;5&#37;&#41; pacientes estaban en situaci&#243;n cr&#237;tica preoperatoria&#46; Dos &#40;0&#44;5&#37;&#41; de 12 &#40;3&#37;&#41; murieron en quir&#243;fano por lo que no se incluyeron en el an&#225;lisis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ciento diecis&#233;is &#40;32&#37;&#41; pacientes cumplieron criterios de SBGC postoperatorio&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen las variables demogr&#225;ficas y preoperatorias en relaci&#243;n con la presencia de SBGC&#46; Las variables que se asociaron de forma significativa al desarrollo de SBGC fueron&#58; un menor uso de beta-bloqueo preoperatorio&#44; edad avanzada&#44; mayor IMVI&#44; mayor EuroSCORE&#44; peor clase funcional de la NYHA&#44; situaci&#243;n cr&#237;tica preoperatoria&#44; intervenci&#243;n no electiva&#44; mayores tiempos de isquemia o de CEC&#44; menor ICI&#44; mayor proporci&#243;n de cardioplej&#237;a retr&#243;gada con respecto al total de la cardioplej&#237;a infundida&#44; todas ellas con un valor p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">En el modelo final de regresi&#243;n log&#237;stica&#44; la clase funcional de la NYHA y la cardioplej&#237;a retr&#243;grada fueron identificadas como factores de riesgo independientes&#44; mientras que la FEVI y el ICI aparecieron como factores protectores &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; No se encontraron interacciones de primer orden&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Tras estratificar por NYHA observamos que en los pacientes con un NYHA I-II un menor ICI de 20&#44;7 &#40;18&#44;4-28&#44;8&#41; vs&#46; 32 &#40;24-42&#44;5&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con la aparici&#243;n de SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; De modo similar&#44; en los pacientes con clase funcional NYHA III-IV&#44; un menor ICI de 20&#44;4 &#40;14&#44;6-25&#44;8&#41; vs&#46; 27&#44;6 &#40;21&#44;9-33&#44;3&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Por otro lado&#44; en los pacientes con FEVI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>56&#37;&#44; un menor ICI de 21&#44;6 &#40;18&#44;3-26&#44;4&#41; vs&#46; 31&#44;5 &#40;22&#44;9-41&#44;9&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; En aquellos pacientes con una FEVI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>56&#37;&#44; un menor ICI de 19&#44;5 &#40;13&#44;9-28&#44;1&#41; vs&#46; 29&#44;4 &#40;25&#44;2-39&#44;5&#41;<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span> se asoci&#243; con SBGC postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">El ICI se asoci&#243; de forma directa con el IC a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y de forma inversa con las dosis de dobutamina al t&#233;rmino de la cirug&#237;a &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; dosis acumulada total &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y dosis m&#225;xima de dobutamina &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; a la dosis acumulada total de levosimendan &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y a los niveles de lactato a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>0<span class="elsevierStyleHsp" style=""></span>&#44;02&#41;&#46; Tambi&#233;n se asoci&#243; inversamente con los marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico&#44; tanto al ingreso en UCI&#44; como sus picos m&#225;ximos postoperatorios&#58; troponina <span class="elsevierStyleSmallCaps">i</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 respectivamente&#41; y creatincinasa MB &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 respectivamente&#41;&#59; y con el Nt-ProBNP a las 24<span class="elsevierStyleHsp" style=""></span>h &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; y su pico postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">El tercil superior de ICI &#91;ml min<span class="elsevierStyleSup">-1</span> &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#93; se asoci&#243; con dosis m&#225;s bajas de dobutamina &#40;dosis m&#225;xima y tiempo de administraci&#243;n&#41;&#58; dosis m&#225;xima de dobutamina &#40;mcg&#47;kg&#47;min&#41;&#44; ICI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44;9&#58; 4&#44;85 &#40;0&#44;5-7&#44;1&#41;&#59; ICI 21&#44;9-32&#44;2&#58; 1&#44;44 &#40;0-5&#44;3&#41; e ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>32&#58; 0 &#40;0-0&#41;&#59; tiempo de dobutamina &#40;horas&#41;&#58; ICI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>21&#44;9&#58; 21 &#40;0&#44;5-67&#41;&#59; ICI 21&#44;9-32&#44;2&#58; 4 &#40;0-20&#41; e ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>32&#58; 0 &#40;0-0&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respectivamente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">El &#225;rea bajo la curva ROC para la no aparici&#243;n de SBGC en funci&#243;n de la dosis de cardioplej&#237;a por unidad de masa y tiempo de isquemia &#40;ICI&#41; fue de 0&#44;77 &#40;IC 95&#37;&#58; 0&#44;70-0&#44;83&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; con un punto de corte &#243;ptimo de 23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#44; con una sensibilidad del 78&#37;&#44; una especificidad del 71&#37;&#44; un valor predictivo positivo del 84&#37;&#44; un valor predictivo negativo del 64&#37;&#44; una raz&#243;n de probabilidad positiva de 2&#44;7 y raz&#243;n de probabilidad negativa de 3&#44;27 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Los pacientes con SBGC postoperatorio mantuvieron esta situaci&#243;n cl&#237;nica una mediana de 27 &#40;20-139&#41;<span class="elsevierStyleHsp" style=""></span>h&#44; requiriendo una mediana de dosis m&#225;xima de dobutamina 9&#44;5 &#40;8-16&#41;<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#47;min&#46; Estos pacientes presentaron valores significativamente m&#225;s altos de marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico y de hipoperfusi&#243;n&#44; tanto en el per&#237;odo postoperatorio inmediato como despu&#233;s de 24<span class="elsevierStyleHsp" style=""></span>h&#59; as&#237; como niveles m&#225;s altos de N-terminal prop&#233;ptido natriur&#233;tico cerebral despu&#233;s de 24<span class="elsevierStyleHsp" style=""></span>h&#46; Nueve pacientes desarrollaron disfunci&#243;n ventricular derecha&#44; falleciendo 2 de ellos&#46; Tambi&#233;n requirieron m&#225;s tiempo de ventilaci&#243;n mec&#225;nica&#44; mostraron mayor incidencia de fracaso renal agudo con necesidad de t&#233;cnicas de reemplazo renal&#44; tuvieron estancias en UCI e intrahospitalarias m&#225;s prolongadas y mayor mortalidad&#44; siendo todas ellas diferencias estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">El objetivo de nuestro estudio fue identificar un par&#225;metro que permita el ajuste de la dosis de cardioplej&#237;a seg&#250;n el IMVI&#44; creando as&#237; una herramienta&#44; el ICI&#44; que podr&#237;a ser &#250;til para optimizar la preservaci&#243;n mioc&#225;rdica durante la cirug&#237;a&#44; reduciendo el da&#241;o mioc&#225;rdico postisqu&#233;mico y el desarrollo de SBGC postoperatorio&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">El aturdimiento mioc&#225;rdico se define como una disfunci&#243;n ventricular postisqu&#233;mica que persiste tras la reperfusi&#243;n en ausencia de da&#241;o mioc&#225;rdico irreversible<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a>&#46; Cl&#237;nicamente&#44; se caracteriza por la necesidad de f&#225;rmacos inotr&#243;picos postoperatorios a pesar de que se obtengan resultados quir&#250;rgicos satisfactorios&#46; En pacientes de alto riesgo con baja reserva cardiaca&#44; el aturdimiento mioc&#225;rdico conlleva un aumento de los d&#237;as de ventilaci&#243;n mec&#225;nica&#44; del riesgo de insuficiencia renal&#44; de estancia en UCI y hospitalaria&#44; y de la mortalidad&#44; como se pudo observar en aquellos pacientes que desarrollaron SBGC&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">El SBGC postoperatorio es una de las complicaciones m&#225;s frecuentes tras la cirug&#237;a de revascularizaci&#243;n coronaria&#46; La incidencia en nuestro estudio&#44; del 32&#37;&#44; es mayor que la encontrada en otros estudios que se suele situar entre el 16&#44;1 y el 13&#44;5&#37;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a>&#46; Varias circunstancias podr&#237;an explicar esta diferencia&#46; En primer lugar&#44; el n&#250;mero de cirug&#237;as urgentes y emergentes en nuestra poblaci&#243;n fue superior al registrado en otros estudios &#40;Algarni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> recogieron un 8-10&#37; de cirug&#237;as urgentes&#44; mientras Ding et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> un 8&#44;3&#37; de cirug&#237;as emergentes en el grupo que present&#243; SBGC&#41;&#59; en segundo lugar&#44; en nuestro estudio no se realizaron cirug&#237;as sin CEC&#59; por &#250;ltimo&#44; la definici&#243;n de SBGC utilizada por otros autores es m&#225;s restrictiva&#44; quedando excluidos los pacientes que&#44; aun necesitando inotropos&#44; no superaron un determinado umbral de dosis o tiempo de tratamiento<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12</span></a>&#46; Estos criterios de inclusi&#243;n podr&#237;an limitar la sensibilidad para detectar formas menos graves de disfunci&#243;n mioc&#225;rdicas en el postoperatorio inmediato&#46; Sin embargo&#44; como recogen las gu&#237;as de monitorizaci&#243;n hemodin&#225;mica de la SEMICYUC<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a>&#44; &#171;no se recomienda la monitorizaci&#243;n rutinaria y sistem&#225;tica del GC en los pacientes con inestabilidad hemodin&#225;mica&#187;&#46; Por otra parte&#44; los criterios cl&#237;nicos son suficientes para una clasificaci&#243;n adecuada de los pacientes con SBGC postoperatorio&#44; como se ha demostrado recientemente en el estudio ESBAGA en el que el grupo clasificado cl&#237;nicamente presentaba una evoluci&#243;n postoperatoria con un claro aumento de los datos de morbimortalidad muy similar al grupo diagnosticado por par&#225;metros de monitorizaci&#243;n hemodin&#225;mica<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Aunque no existe consenso sobre las causas de la elevaci&#243;n de los marcadores bioqu&#237;micos de da&#241;o mioc&#225;rdico postoperatorio&#44; 3 importantes ensayos cl&#237;nicos han identificado la protecci&#243;n mioc&#225;rdica sub&#243;ptima como principal factor responsable del da&#241;o por isquemia&#47;reperfusi&#243;n<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a>&#46; En nuestro estudio observamos que los pacientes con menor ICI presentaron mayores concentraciones de estos marcadores &#40;troponinas&#44; creatincinasa MB y N-terminal prop&#233;ptido natriur&#233;tico cerebral&#41; y de lactato &#40;como indicador sustitutivo de hipoperfusi&#243;n&#41;&#44; precisando m&#225;s soporte inotr&#243;pico en el postoperatorio inmediato&#46; Adem&#225;s&#44; se identificaron como factores de riesgo para desarrollar SBGC postoperatorio los siguientes&#58; mayor edad&#44; mayor IMVI&#44; FEVI postoperatoria disminuida&#44; peor clase funcional de la NYHA&#44; mayor EuroSCORE&#44; cirug&#237;a urgente&#44; tiempo de CEC prolongado&#44; y el volumen y v&#237;a de administraci&#243;n de la cardioplej&#237;a&#44; todo ello acorde con estudios previos<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;11&#44;12&#44;16</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Como ya se ha mencionado&#44; en la etiopatogenia de la disfunci&#243;n mioc&#225;rdica postisqu&#233;mica en cirug&#237;a cardiaca se han identificado distintos factores contribuyentes&#46; De acuerdo con nuestros hallazgos&#44; el aumento del IMVI implica un aumento de la morbimortalidad del paciente sometido a cirug&#237;a cardiaca<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a>&#59; esto se debe a que el aumento del IMVI conlleva un mayor riesgo de isquemia mioc&#225;rdica perioperatoria secundario a desequilibrio entre la oferta y la demanda de ox&#237;geno mioc&#225;rdico&#46; La hipertrofia ventricular izquierda se asocia con alteraciones estructurales vasculares coronarias con aumento de las resistencias&#44; alteraciones del flujo y aumento de la presi&#243;n telediast&#243;lica del VI con la consiguiente reducci&#243;n de la perfusi&#243;n subendoc&#225;rdica&#46; Asimismo&#44; implica un aumento de demanda mioc&#225;rdica de ox&#237;geno y un mayor estr&#233;s de la pared&#46; Durante la cirug&#237;a&#44; los pacientes con hipertrofia ventricular severa tienen mayor riesgo de una preservaci&#243;n mioc&#225;rdica sub&#243;ptima&#46; La combinaci&#243;n de estos factores implica un peor pron&#243;stico<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46; Por otra parte&#44; el IMVI tambi&#233;n se ha relacionado con un incremento de las arritmias postoperatorias<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a>&#44; un aumento de la estancia media<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> e incluso se ha identificado como un predictor independiente de la mortalidad a 30 d&#237;as&#44; con una relaci&#243;n pr&#225;cticamente lineal<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dada la importancia de la preservaci&#243;n mioc&#225;rdica&#44; se han desarrollado diversas estrategias de cardioprotecci&#243;n durante la cirug&#237;a&#44; identific&#225;ndose la cardioplej&#237;a como un elemento clave&#46; Entre las diversas formas de cardioplej&#237;a&#44; el patr&#243;n oro en los &#250;ltimos 30 a&#241;os ha sido una soluci&#243;n hiperkali&#233;mica despolarizante que induce una parada cardiaca r&#225;pida y f&#225;cilmente reversible&#59; aunque no por ello exenta de inconvenientes&#46; El aumento de las concentraciones de potasio puede estar relacionado con la aparici&#243;n diferentes grados de vasoconstricci&#243;n y vasoespasmo&#44; dando lugar a una distribuci&#243;n irregular de la cardioplej&#237;a<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> y&#44; por tanto&#44; una reducci&#243;n de la protecci&#243;n mioc&#225;rdica&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Adem&#225;s&#44; las concentraciones extracelulares de potasio presentan un estrecho margen terap&#233;utico de modo que peque&#241;as variaciones de las mismas pueden dar lugar a corrientes i&#243;nicas persistentes que conllevan un aumento intracelular de calcio y sodio<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; En un intento de restaurar el equilibrio i&#243;nico&#44; se activan bombas transmembrana con el consiguiente consumo de energ&#237;a&#44; que contribuye al aturdimiento mioc&#225;rdico<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a>&#46; Esto exige mantener concentraciones extracelulares de potasio estables mediante su apropiado aporte ajustado a una masa mioc&#225;rdica en presencia de enfermedad arterial coronaria&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A pesar de los numerosos estudios que exploran los tipos y modos de administraci&#243;n de la cardioplej&#237;a&#44; en nuestro conocimiento&#44; no se han desarrollado estrategias que permitan ajustar la dosis de cardioplej&#237;a al IMVI&#46; En un estudio realizado a mediados de los a&#241;os 80&#44; Matsuda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> evaluaron las dosis &#243;ptimas iniciales de cardioplej&#237;a en pacientes con hipertrofia ventricular severa sometidos a reemplazo valvular a&#243;rtico&#46; Sin embargo&#44; no hemos encontrado estudios posteriores que validen sus conclusiones o que desarrollen estrategias de cardioprotecci&#243;n en base de sus resultados&#46; En nuestro estudio relacionamos&#44; por medio del ICI&#44; el IMVI y la cantidad de cardioplej&#237;a&#46; La conclusi&#243;n principal fue la existencia de una relaci&#243;n entre el tiempo de isquemia al que se somete una determinada masa mioc&#225;rdica&#44; la dosis de cardioplej&#237;a utilizada para su conservaci&#243;n y el desarrollo de SBGC postoperatorio&#46; Para ser exactos&#44; encontramos que un ICI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47; &#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41; se asocia con una menor incidencia de SBGC&#44; y tambi&#233;n se asocia inversamente con los requerimientos de inotropos postoperatorios&#46; Probablemente&#44; debido a que estas dosis permiten lograr una mayor estabilidad en las concentraciones i&#243;nicas&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; nuestros resultados indican que la cardioplej&#237;a retr&#243;grada intermitente se asocia con una menor cardioprotecci&#243;n&#46; En pacientes con enfermedad arterial coronaria&#44; la administraci&#243;n retr&#243;grada de cardioplej&#237;a abarca mejor el territorio de la arteria descendente anterior que la v&#237;a anter&#243;grada<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> debido a que el territorio ventricular puede recibir flujo retr&#243;grado a trav&#233;s de los colaterales de Tebesio<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a>&#46; Sin embargo&#44; la administraci&#243;n exclusiva de cardioplej&#237;a retr&#243;grada puede proporcionar una protecci&#243;n mioc&#225;rdica insuficiente debido a la escasa perfusi&#243;n del ventr&#237;culo derecho&#44; la pared posterior y el septo interventricular&#44; salvo que se combine con administraci&#243;n anter&#243;grada a trav&#233;s del ostium coronario<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a>&#46; No obstante&#44; diversos estudios muestran que con cardioplej&#237;a retr&#243;grada de alto flujo se pueden mejorar los resultados en la preservaci&#243;n del ventr&#237;culo derecho y del tabique interventricular<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a>&#46; Los hallazgos de nuestro estudio muestran que a mayor proporci&#243;n de cardioplej&#237;a administrada por v&#237;a retr&#243;grada&#44; mayor incidencia de SBGC postoperatorio&#46; Esto podr&#237;a deberse a que el volumen de cardioplej&#237;a por v&#237;a retr&#243;grada o la combinaci&#243;n con cardioplej&#237;a intermitente fue insuficiente&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">El presente trabajo tiene ciertas limitaciones&#58; es un estudio observacional unic&#233;ntrico realizado exclusivamente con cardioplej&#237;a hiperkali&#233;mica intermitente&#44; sin compararlo con otros m&#233;todos de administraci&#243;n y sin un m&#233;todo predefinido para la administraci&#243;n de la misma &#40;ruta&#44; volumen y dosis posteriores&#41;&#44; quedando a criterio del cirujano&#46; Sin embargo&#44; cada mililitro de cardioplej&#237;a administrado por cada gramo de miocardio y minuto de isquemia redujo la probabilidad de desarrollar SBGC en algo menos del 1&#37;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">En resumen&#44; 2 factores han demostrado ser clave en el desarrollo de aturdimiento mioc&#225;rdico postoperatorio&#58; el tiempo de pinzamiento a&#243;rtico y una adecuada estrategia individualizada de preservaci&#243;n del mioc&#225;rdica&#46; Nuestro estudio muestra que el ajuste de la dosis de cardioplej&#237;a seg&#250;n el tiempo de isquemia y el IMVI puede constituir una herramienta &#250;til para mejorar el grado de miocardioprotecci&#243;n durante la cirug&#237;a de revascularizaci&#243;n coronaria&#44; minimizando as&#237; los efectos delet&#233;reos de una protecci&#243;n mioc&#225;rdica sub&#243;ptima&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Una posible aplicaci&#243;n de los hallazgos de este estudio&#44; en el manejo de la cardioplej&#237;a hiperkali&#233;mica&#44; podr&#237;a consistir en el ajuste de la dosis inicial de cardioplej&#237;a en base al IMVI&#46; En pacientes con hipertrofia leve &#40;IMVI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>130<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; se administrar&#237;an 1&#44;2<span class="elsevierStyleHsp" style=""></span>l&#44; mientras que en aquellos con hipertrofia de moderada a severa se administrar&#237;an al menos 1&#44;5<span class="elsevierStyleHsp" style=""></span>l&#46; Con respecto a las dosis de mantenimiento&#44; ser&#237;a importante mantener unos intervalos de administraci&#243;n de entre 20 y 25<span class="elsevierStyleHsp" style=""></span>min&#44; dependiendo del procedimiento quir&#250;rgico&#46; Esta dosis de mantenimiento podr&#237;a calcularse como el producto de 25<span class="elsevierStyleHsp" style=""></span>ml por los minutos de isquemia &#40;20 o 25 como m&#225;ximo&#41; multiplicado por un factor de correcci&#243;n de masa mioc&#225;rdica &#40;IMVI&#47;100&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Ser&#237;a necesario desarrollar otros estudios para verificar la utilidad&#44; en la pr&#225;ctica cl&#237;nica&#44; de este esquema&#46; Tambi&#233;n ser&#237;a interesante evaluar el ICI con otra soluci&#243;n de cardioplej&#237;a&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Contribuci&#243;n de los autores</span><p id="par0165" class="elsevierStylePara elsevierViewall">JJJR&#44; CLJ y JLIS dise&#241;aron el proyecto y desarrollaron el an&#225;lisis estad&#237;stico&#46; JLA espec&#237;ficamente llev&#243; a cabo los estudios ecocardiogr&#225;ficos&#44; y GYB los estudios hemodin&#225;micos y c&#225;lculo del SYNTAX score&#46; RAP y RMS realizaron el proceso quir&#250;rgico y junto con el resto de los autores implementaron el proceso investigador&#44; discutieron los datos y contribuyeron en la redacci&#243;n final del manuscrito&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicto de intereses</span><p id="par0170" class="elsevierStylePara elsevierViewall">No hay conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Background"
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              "titulo" => "Dise&#241;o del estudio y poblaci&#243;n"
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              "identificador" => "sec0020"
              "titulo" => "Recogida de datos"
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              "titulo" => "Protocolos anest&#233;sicos y quir&#250;rgicos"
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              "titulo" => "An&#225;lisis estad&#237;stico"
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          "titulo" => "Contribuci&#243;n de los autores"
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    "fechaRecibido" => "2017-11-21"
    "fechaAceptado" => "2018-03-27"
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            0 => "Cardioplej&#237;a"
            1 => "&#205;ndice de masa ventricular izquierda"
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            0 => "Cardioplegia"
            1 => "Left ventricle mass index"
            2 => "Low cardiac output syndrome"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La cardioprotecci&#243;n es esencial en la revascularizaci&#243;n coronaria quir&#250;rgica&#46; En este estudio exploramos la relaci&#243;n existente entre el tiempo que una masa mioc&#225;rdica permanece en situaci&#243;n de isquemia y la dosis de cardioplej&#237;a utilizada para su preservaci&#243;n&#44; reflejada a trav&#233;s del &#237;ndice de cardioplej&#237;a infundida&#44; con el desarrollo de bajo gasto cardiaco postoperatorio&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Dise&#241;o</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron todos los pacientes sometidos a revascularizaci&#243;n coronaria quir&#250;rgica entre enero de 2013 y diciembre de 2015&#46; El s&#237;ndrome de bajo gasto cardiaco postoperatorio se defini&#243; siguiendo los criterios del documento de consenso de la SEMYCIUC&#46; Se analizaron los factores perioperatorios asociados al s&#237;ndrome de bajo gasto cardiaco y&#44; mediante la curva ROC&#44; se determin&#243; el punto de corte del &#237;ndice de cardioplej&#237;a infundida para predecir la ausencia del mismo&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">De los 360 pacientes incluidos&#44; 116 &#40;32&#37;&#41; presentaron bajo gasto postoperatorio&#46; Los factores de riesgo independientes fueron&#58; clasificaci&#243;n funcional de la New York Heart Association &#40;OR 1&#44;8 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;18-2&#44;55&#93;&#41;&#44; la fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;OR 0&#44;95 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;93-0&#44;98&#93;&#41;&#44; el empleo de cardioplej&#237;a retr&#243;grada &#40;OR 1&#44;2 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;03-1&#44;50&#93;&#41; y el &#237;ndice de cardioplej&#237;a infundida &#40;OR 0&#44;99 &#91;IC 95&#37;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;991-0&#44;996&#93;&#41;&#44; que mostr&#243; un &#225;rea bajo la curva ROC de 0&#44;77 &#40;0&#44;70-0&#44;83&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41; para la ausencia de s&#237;ndrome de bajo gasto cardiaco postoperatorio&#44; usando como punto de corte &#243;ptimo 23&#44;6<span class="elsevierStyleHsp" style=""></span>ml&#183;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> de VI&#41;<span class="elsevierStyleSup">-1</span>&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El &#237;ndice de cardioplej&#237;a infundido es inversamente proporcional a los requerimientos postoperatorios de inotropos&#44; pudiendo constituir una estrategia para optimizar la cardioprotecci&#243;n&#46; El volumen total de cardioplej&#237;a intermitente deber&#237;a calcularse&#44; de forma individualizada&#44; en base al &#237;ndice de masa del ventr&#237;culo izquierdo y el tiempo de isquemia&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Dise&#241;o"
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            "identificador" => "abst0015"
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            "identificador" => "abst0020"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Strategies for cardio-protection are essential in coronary artery bypass graft surgery&#46; The authors explored the relationship between cardioplegia volume&#44; left ventricular mass index and ischemia time by means of the infused cardioplegia index and its relationship with post-operative low cardiac output syndrome&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Design</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">All patients undergoing coronary artery bypass graft surgery between January 2013 and December 2015 were included&#46; Low cardiac output syndrome was defined according to criteria of the SEMICYUC&#39;s consensus document&#46; The perioperative factors associated with low cardiac output syndrome were estimated&#44; and using a ROC curve&#44; the optimum cut-off point for the infused cardioplegia index to predict the absence of low cardiac output syndrome was calculated&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Of 360 patients included&#44; 116 &#40;32&#37;&#41; developed low cardiac output syndrome&#46; The independent risk predictors were&#58; New York Heart Association Functional Classification &#40;OR 1&#46;8 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;18-2&#46;55&#93;&#41;&#44; left ventricle ejection fraction &#40;OR 0&#46;95 &#40;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;93-0&#46;98&#93;&#41;&#44; ICI &#40;OR 0&#46;99 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;991-0&#46;996&#93;&#41; and retrograde cardioplegia &#40;OR 1&#46;2 &#91;95&#37; CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;03-1&#46;50&#93;&#41;&#46; The infused cardioplegia index showed an area under the ROC curve of 0&#46;77 &#40;0&#46;70-0&#46;83&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>&#46;001&#41; for the absence of postoperative low cardiac output syndrome using the optimum cut-off point of 23&#46;6<span class="elsevierStyleHsp" style=""></span>ml&#183;min<span class="elsevierStyleSup">-1</span>&#40;100<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> of LV&#41;<span class="elsevierStyleSup">-1</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The infused cardioplegia index presents an inverse relationship with the development of post-operative low cardiac output syndrome&#46; This index could form part of new strategies aimed at optimising cardio-protection&#46; The total volume of intermittent cardioplegia&#44; especially that of maintenance&#44; should probably be individualised&#44; adjusting for ischemia time and left ventricle mass index&#46;</p></span>"
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          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Curva ROC&#46; Curva ROC para predecir la ausencia de s&#237;ndrome de bajo gasto cardiaco postoperatorio con el empleo de &#237;ndice de cardioplej&#237;a infundido&#46; Es&#58; especificidad&#59; Se&#58; sensibilidad&#59; VPN&#58; valor predictivo negativo&#59; VPP&#58; valor predictivo positivo&#46;</p>"
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                  \t\t\t\t">93 &#40;38&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intermedio&#58; 23-32&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 ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a total&#44; ml&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a inicial&#44; ml&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ICI &#40;ml&#183;min</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-1</span></span><span class="elsevierStyleItalic">&#183;g</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-1</span></span><span class="elsevierStyleItalic">&#183;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">-2</span></span><span class="elsevierStyleItalic">&#41;&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a anter&#243;grada&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a mixta</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">a</span></span><span class="elsevierStyleItalic">n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cardioplej&#237;a retr&#243;grada &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  """
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">FEVI&#58; fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo&#59; IC&#58; intervalo de confianza&#59; ICI&#58; &#237;ndice de cardioplej&#237;a infundida&#59; NYHA&#58; New York Heart Association&#59; OR&#58; odds ratio&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;18-2&#44;55&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">FEVI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;95&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;93-0&#44;98&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;99&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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\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">0&#44;021&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;207&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&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">Dobutamina al final de la cirug&#237;a &#40;mcg&#47;kg&#47;min&#41;&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">&#8722;0&#44;38&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Dosis acumulada total de dobutamina &#40;mcg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dosis m&#225;xima de dobutamina &#40;mcg&#47;kg&#47;min&#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">&#8722;0&#44;40&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dosis acumulada total de levosimendan &#40;mcg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;25&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
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">&#193;cido l&#225;ctico 24<span class="elsevierStyleHsp" style=""></span>h &#40;mmol&#47;l&#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">&#8722;0&#44;17&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">Troponina I a la llegada de quir&#243;fano &#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I pico m&#225;ximo &#40;ng&#47;ml&#41;&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">&#8722;0&#44;28&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
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB a la llegada de quir&#243;fano &#40;U&#47;l&#41;&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">&#8722;0&#44;28&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB m&#225;xima &#40;U&#47;l&#41;&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">&#8722;0&#44;26&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Nt-ProBNP a las 24h &#40;pg&#47;ml&#41;&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">&#8722;0&#44;31&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nt-ProBNP pico m&#225;ximo &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&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">No SBGC&#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>244&#41;&nbsp;\t\t\t\t\t\t\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">PAm 4<span class="elsevierStyleHsp" style=""></span>h &#40;mmHg&#41; &#40;DE&#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">0&#44;001&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">PAm 24<span class="elsevierStyleHsp" style=""></span>h &#40;mmHg&#41; &#40;DE&#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">74 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;09&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">IC 0<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;6 &#40;2&#44;4-3&#44;4&#41;&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">2&#44;3 &#40;1&#44;9-2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">IC 4<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;5 &#40;2&#44;1-3&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">IC 24<span class="elsevierStyleHsp" style=""></span>h &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">3 &#40;2&#44;5-3&#44;4&#41;&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&#44;7 &#40;2&#44;3-3&#41;&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&#44;02&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">TAPSE&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
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;69&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">Dobutamina &#40;dosis m&#225;xima&#47;mcg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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">9&#44;5 &#40;8-16&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Dobutamina &#40;horas totales&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">0 &#40;0-0&#41;&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 &#40;20-139&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Noradrenalina &#40;dosis m&#225;xima&#47;mcg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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 &#40;0-0&#41;&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&#44;41 &#40;0&#44;07-0&#44;98&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Noradrenalina &#40;horas totales&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0-0&#41;&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;1-100&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I llegada UCI&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">1&#44;5 &#40;0&#44;9-2&#44;6&#41;&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">4&#44;2 &#40;3-10&#44;6&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Troponina I 4<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">6&#44;4 &#40;4-11&#44;6&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Troponina I 24<span class="elsevierStyleHsp" style=""></span>h&#44; ng&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#44;2-3&#41;&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">8&#44;5 &#40;5&#44;5-11&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">L&#225;ctico llegada UCI&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">1&#44;9 &#40;1&#44;5-2&#44;4&#41;&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&#44;1 &#40;1&#44;8-3&#44;6&#41;&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&#44;01&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">L&#225;ctico 4<span class="elsevierStyleHsp" style=""></span>h&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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
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                  \t\t\t\t">1&#44;5 &#40;1&#44;3-2&#44;6&#41;&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&#44;5 &#40;1&#44;8-3&#44;8&#41;&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
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                  \t\t\t\t">0&#44;005&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">L&#225;ctico 24<span class="elsevierStyleHsp" style=""></span>h&#44; mmol&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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
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                  \t\t\t\t">1&#44;4 &#40;1-2&#41;&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">1&#44;8 &#40;1&#44;6-2&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB llegada UCI&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">42 &#40;32-49&#41;&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">80 &#40;51-108&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">CK-MB 4<span class="elsevierStyleHsp" style=""></span>h&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">37 &#40;29-50&#41;&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">83 &#40;55-136&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CK-MB 24<span class="elsevierStyleHsp" style=""></span>h&#44; IU&#47;l<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">24 &#40;21-43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NT-ProBNP 4<span class="elsevierStyleHsp" style=""></span>h&#44; pg&#47;mL<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">686&#40;368-1740&#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">2475&#40;115-11455&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">NT-ProBNP 24<span class="elsevierStyleHsp" style=""></span>h&#44; pg&#47;ml<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">1&#46;960 &#40;1&#46;090-3&#46;140&#41;&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">4&#46;125&#40;2&#46;760-8&#46;860&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\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">Ventilaci&#243;n mec&#225;nica &#40;horas&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">3 &#40;1&#44;7-5&#41;&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
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                  \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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\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">Terapias sustituci&#243;n renal n &#40;&#37;&#41;&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 &#40;0&#44;4&#41;&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
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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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Estancia UCI &#40;d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">2 &#40;1-3&#41;&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">5 &#40;2-11&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Estancia hospital &#40;d&#237;as&#41;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</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">12 &#40;8-21&#41;&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">20 &#40;11-32&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&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">Mortalidad &#40;&#37;&#41;&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 &#40;0&#44;4&#41;&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">9 &#40;7&#44;7&#41;&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">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Horas postoperatorias&#46;</p>"
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              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Valores expresados como media y percentiles 25 y 75&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Variables postoperatorias en pacientes con y sin SBGC</p>"
        ]
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      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
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              "etiqueta" => "1"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Predictors of low cardiac output syndrome after isolated coronary artery bypass surgery&#58; Trends over 20 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46;D&#46; Algarni"
                            1 => "M&#46; Maganti"
                            2 => "T&#46;M&#46; Yau"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.athoracsur.2011.06.017"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Thorac Surg"
                        "fecha" => "2011"
                        "volumen" => "92"
                        "paginaInicial" => "1678"
                        "paginaFinal" => "1684"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21939957"
                            "web" => "Medline"
                          ]
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