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1.
Catheter Cardiovasc Interv ; 99(6): 1877-1885, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35289473

RESUMO

OBJECTIVES: The purpose of this study is to investigate the viability of transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis (AS) in patients with prior chest radiation therapy (cXRT). BACKGROUND: Since patients with prior cXRT perform poorly with surgical aortic valve replacement, TAVR can be a viable alternative. However, clinical outcomes after TAVR in this patient population have not been well studied. METHODS: From the pooled registry of the placement of aortic transcatheter valves II trial, we identified patients with and without prior cXRT who underwent TAVR (n = 64 and 3923, respectively). The primary outcome was a composite of all-cause death and any stroke at 2 years. Time to event analyses were shown as Kaplan-Meier event rates and compared by log-rank testing. Hazard ratios (HRs) were estimated and compared by Cox proportional hazards regression model. RESULTS: There was no significant difference in the primary outcome between the patients with and without prior cXRT (30.7% vs. 27.0%; p = 0.75; HR, 1.08; 95% confidence interval, 0.66-1.77). Rates of myocardial infarction, vascular complications, acute kidney injury, or new pacemaker implant after TAVR were not statistically different between the two groups. The rate of immediate reintervention with a second valve for aortic regurgitation after TAVR was higher among the patients with prior cXRT. However, no further difference was observed during 2 years follow-up after discharge from the index-procedure hospitalization. CONCLUSIONS: TAVR is a viable alternative for severe symptomatic AS in patients who had cXRT in the past.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento
2.
J Card Surg ; 36(9): 3410-3413, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34056779

RESUMO

BACKGROUND: Our case demonstrates a novel use of the Sentinel™ cerebral protection device (SCPD) for prevention of stroke during removal of a thrombus-adherent atrial septal occluder. CASE PRESENTATION: A 45-year-old male with multiple strokes and ostium secundum atrial septal defect closed ten years prior using an Amplatzer Septal Occluder presented with recurrent neurologic symptoms. Over the ensuing year, serial transesophageal echocardiography revealed persistent and worsening device-adherent thrombus despite trial of different anticoagulants. The device appeared to be mal-deployed, prompting the decision for surgical explant. Given concern for embolization during explant, an SCPD was placed. Excision, pericardial patch repair, and Atriclip appendage closure (AAC) were performed. The device demonstrated incomplete endothelialization and microthrombi. SCPD filtration revealed embolic debris. CONCLUSIONS: We demonstrate the first successful use of an SCPD during surgical excision of a mal-deployed occluder. With its ease of use and safety, SCPD may have utility in surgeries with high cardio-embolic risk.


Assuntos
Embolia , Comunicação Interatrial , Dispositivo para Oclusão Septal , Trombose , Cateterismo Cardíaco , Ecocardiografia Transesofagiana , Comunicação Interatrial/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Trombose/etiologia , Trombose/prevenção & controle , Resultado do Tratamento
3.
J Card Surg ; 35(6): 1168-1169, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32365415

RESUMO

To improve resource allocation in face of the COVID-19 pandemic, hospitals around the country are restricting the performance of elective surgery to preserve ventilators, operating rooms, ICU beds and protect anesthesiologists. For patients with severe aortic stenosis, efforts to bring treatment to symptomatic patients amid this pandemic might lead to favored use of catheter based management using minimalist techniques that do not require these elements. In this context, some patients with well tested surgical indications for valve replacement may be treated by catheter-based methods. It is important that outcomes for these cases are followed closely both at respective sites and in national registries. As we recover from this pandemic, surgical cases should once again be driven by multi-disciplinary discussion and clinical trial data, and not a mentality of crisis management.


Assuntos
Estenose da Valva Aórtica/cirurgia , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , COVID-19 , Infecções por Coronavirus/prevenção & controle , Feminino , Seguimentos , Humanos , Controle de Infecções/organização & administração , Masculino , Saúde Ocupacional , Pandemias/prevenção & controle , Segurança do Paciente , Pneumonia Viral/prevenção & controle , Administração da Prática Médica/tendências , Sistema de Registros , Medição de Risco , Estados Unidos
4.
J Card Surg ; 35(6): 1360-1363, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32333424

RESUMO

BACKGROUND AND AIM: Oral anticoagulation (AC) and percutaneous left atrial appendage (LAA) occlusion are the primary treatment modalities for stroke prevention in atrial fibrillation (AF), but there remains a subset of patients in whom these approaches present excess risk and isolated surgical LAA excision should be considered. We describe a 63-year-old female with AF and recurrent thromboembolic events who presented with an acute intraparenchymal hemorrhage and was found to have an intracardiac thrombus. METHODS: Given contraindications to AC and LAA occlusion, an isolated LAA surgical excision was pursued. RESULTS: She underwent successful surgical LAA excision and has since remained event-free. CONCLUSION: It is important to recall the utility of therapies that have been previously used with success for intracardiac thrombi and still remain as viable options.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Hemorragia Cerebral/etiologia , Contraindicações , Feminino , Cardiopatias/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Trombose/etiologia , Resultado do Tratamento
5.
J Card Surg ; 34(12): 1432-1433, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31693240

RESUMO

Despite the landmark release of recent transcatheter aortic valve replacement data, the gold standard of surgical therapy is here to stay. Surgery remains vital in patient populations with low coronary height raising risk of coronary occlusion, aneurysmal ascending aorta, isolated aortic regurgitation, noncalcific disease, bicuspid valves, and multivessel coronary disease, or other structural abnormality requiring cardiac surgery. Consideration of these issues highlights the ongoing importance of multidisciplinary consideration of individual patient cases, careful review of imaging, and preservation of a robust surgical program to complement transcatheter development. As the landscape of valvular heart disease management continues to evolve, the surgeon's role is changing, but by no means diminished and their engagement in heart team decision making remains paramount.


Assuntos
Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Doenças das Valvas Cardíacas/diagnóstico por imagem , Próteses Valvulares Cardíacas/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Desenho de Prótese , Reoperação , Padrão de Cuidado
6.
Vasc Med ; 19(3): 190-204, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24879715

RESUMO

Increasing use of the new oral anticoagulants (NOACs) - dabigatran, rivaroxaban, and apixaban - has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.

7.
Case Rep Cardiol ; 2024: 7430212, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38695013

RESUMO

Aortix™ is a novel percutaneous mechanical circulatory support device designed to facilitate diuresis in patients with cardiorenal syndrome. We describe for the first time the development of end-organ hypoperfusion from excess blood acceleration at the nominal setting and demonstrate through temporal-perfusion marker curves, the potential for speed modulation to optimize results. This will inform future device development and investigation of patient-specific device titration.

8.
Neurohospitalist ; 14(2): 157-165, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38666284

RESUMO

As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.

9.
Cureus ; 15(10): e47067, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-38021703

RESUMO

We present a novel complication of transcatheter aortic valve replacement (TAVR) involving prosthetic migration due to entanglement by a standard guidewire during non-large bore vascular access closure, followed by successful bail-out using a second transcatheter prosthesis. To our knowledge, this mechanism of prosthesis migration has not been previously described.

10.
EJHaem ; 4(2): 428-431, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37206280

RESUMO

Given an increased risk of both thrombosis and bleeding, thrombotic thrombocytopenic purpura (TTP) presents a unique challenge when anticoagulation is required for comorbid disease, particularly in the setting of major bleeding events. We present for the first time a patient with TTP and atrial fibrillation, presenting with recurrent stroke, but unable to tolerate anticoagulation due to prior intra-cerebral hemorrhage. To address both issues concomitantly, we describe the successful application of a novel management approach to facilitate left atrial appendage occlusion, there by offering a non-pharmacologic means of stroke prevention without added bleeding risk.

12.
JACC Heart Fail ; 11(11): 1565-1575, 2023 11.
Artigo em Inglês | MEDLINE | ID: mdl-37804307

RESUMO

BACKGROUND: Cardiorenal syndrome (CRS) complicates 33% of acute decompensated heart failure (ADHF) admissions, and patients with persistent congestion at discharge have high 30-day event rates. OBJECTIVES: The purpose of this study was to evaluate a novel catheter-deployed intra-aortic entrainment pump (IAEP) in patients with ADHF with CRS and persistent congestion. METHODS: A multicenter (n = 14), nonrandomized, single-arm, safety and feasibility study of IAEP therapy was conducted. Within patient changes (post-pre IAEP therapy) in fluid loss, hemodynamics, patient-reported dyspnea, and serum biomarkers were assessed using Wilcoxon signed-rank testing. RESULTS: Of 21 enrolled patients, 18 received Aortix therapy. Mean ± SD patient age was 60.3 ± 7.9 years. The median left ventricular ejection fraction was 22.5% (25th-75th percentile: 10.0%-53.5%); 27.8% had a left ventricular ejection fraction ≥50%. Pre-therapy, patients received 8.7 ± 4.1 days of loop diuretic agents and 44% were on inotropes. Pump therapy averaged 4.6 ± 1.6 days, yielding net fluid losses of 10.7 ± 6.5 L (P < 0.001) and significant (P < 0.01) reductions in central venous pressure (change from baseline: -8.5 mm Hg [25th-75th percentile: -3.5 to -10.0 mm Hg]), pulmonary capillary wedge pressure (-11.0 mm Hg [25th-75th percentile: -5.0 to -14.0 mm Hg]), and serum creatinine (-0.2 mg/dL [25th-75th percentile: -0.1 to -0.5 mg/dL]) with improved estimated glomerular filtration rate (+5.0 mL/min/1.73 m2 [25th-75th percentile: 2.0-9.0 mL/min/1.73 m2]) and patient-reported dyspnea score (+16 [25th-75th percentile: 3-37]). Dyspnea scores, natriuretic peptides, and renal function improvements persisted through 30 days. CONCLUSIONS: This pilot study of patients with ADHF, persistent congestion, and worsening renal function due to CRS supports the potential for safely achieving decongestion using IAEP therapy. These initial promising results provide the basis for future randomized clinical trials of this novel pump. (An Evaluation of the Safety and Performance of the Aortix System for Intra-Aortic Mechanical Circulatory Support in Patients with Cardiorenal Syndrome [The Aortix CRS Pilot Study]; NCT04145635).


Assuntos
Síndrome Cardiorrenal , Insuficiência Cardíaca , Idoso , Humanos , Pessoa de Meia-Idade , Dispneia/etiologia , Projetos Piloto , Volume Sistólico , Função Ventricular Esquerda , Estudos de Viabilidade
13.
Am J Cardiol ; 183: 137-142, 2022 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-36085056

RESUMO

Infective endocarditis (IE) is associated with marked morbidity and mortality in the United States and parallels the opioid pandemic. Few studies explore this interaction and its effect on clinical outcomes. We analyzed contemporary patients admitted with IE to determine predictors of readmission in the United States. The 2017 National Readmission Database was used to identify index admissions in adults with the diagnosis of IE, based on the International Classification of Disease, 10th Revision codes. The primary outcome of interest was 30-day readmission. Secondary outcomes were mortality, hospital charges, and predictors of hospitalization readmission. Of 40,413 index admissions for IE, 5,558 patients (13.8%) were readmitted within 30 days. Patients who were readmitted were younger (55 ± 20 vs 61 ± 19 years, p <0.001) and more likely to have end-stage renal disease (12.2% vs 10.5%, p <0.001), hepatitis C virus (19.4% vs 12.6%, p <0.001), HIV (1.8% vs 1.2%, p = 0.001), opioid abuse (23.9% vs 15%, p <0.001), cocaine use (7.3% vs 4.4%, p <0.001), and other substance abuse (8.5 vs 5.6, p <0.001). Patients readmitted were less likely to have diabetes mellitus (27.8% vs 29.4%, p = 0.01), hypertension (56.9% vs 64%, p <0.001), heart failure (37.7% vs 40%, p <0.001), chronic kidney disease (31.2% vs 32%, p <0.001), and peripheral vascular disease (3.6% vs 4.6%, p = 0.001). The median cost of index admission for the total cohort was $84,325 (39,922 to 190,492). After adjusting for age, diabetes mellitus, heart failure, hypertension, and end-stage renal disease, opioid abuse (odds ratio [OR] 1.34; 95% confidence interval [CI] 1.23 to 1.46; p <0.001), cocaine use (OR 1.32; 95% CI 1.17 to 1.48; p <0.001), other substance abuse (OR 1.16; 95% CI 1.04 to 1.30; p = 0.008), and hepatitis C virus (OR 1.32; 95% CI 1.21 to 1.43; p <0.001) correlated with higher odds of 30-day readmission. These factors may present targets for future intervention.


Assuntos
Cocaína , Diabetes Mellitus , Endocardite Bacteriana , Endocardite , Insuficiência Cardíaca , Hipertensão , Falência Renal Crônica , Transtornos Relacionados ao Uso de Opioides , Adulto , Analgésicos Opioides , Bases de Dados Factuais , Diabetes Mellitus/epidemiologia , Endocardite/diagnóstico , Endocardite Bacteriana/epidemiologia , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Readmissão do Paciente , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
14.
J Hosp Med ; 16(4): 219-222, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33734980

RESUMO

A patient's supine posture redistributes plasma into the vascular space, leading to dilution of blood constituents. The extent to which posture may influence identification of hospital-acquired anemia is unknown. Patients in this quasi-experimental study had blood obtained for hemoglobin measurement while recumbent for at least 6 hours, and then again after sitting upright for at least 1 hour. Of the 35 patients who completed the study, 13 were women (37%). Patients had a median increase in hemoglobin of 0.60 g/dL (range, -0.6 to 1.4 g/dL) with sitting, a 5.2% (range, (-4.5% to 15.1%) relative change (P < .001). Ten of 35 patients (29%) exhibited an increase in hemoglobin of 1.0 g/dL or more. Posture influences hemoglobin levels in hospitalized patients on general medicine wards; this knowledge may help curb unnecessary testing to evaluate small changes in hemoglobin concentration.


Assuntos
Anemia , Decúbito Dorsal , Anemia/diagnóstico , Feminino , Hemoglobinas , Humanos , Masculino , Fatores de Tempo
15.
Future Cardiol ; 16(6): 687-693, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32643392

RESUMO

Atrial fibrillation (AF) in the setting of malignancy poses a unique challenge given the confluent pathologies and risks of current treatments. Oral anticoagulation is recommended to reduce the risk of systemic thromboembolism in high-risk individuals with AF. The 'Watchman' device for left atrial appendage closure has shown comparable efficacy compared with anticoagulation with warfarin; however, patients with cancer were not included in trials testing Watchman safety and efficacy. We present the current treatment approaches for the management of AF in patients with malignancy. We review contemporary guidelines and propose a novel clinical decision tree by which physicians can consider left atrial appendage closure in cancer patients, and at last, suggest future investigation that might further clarify the clinical benefit of this approach.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Neoplasias , Acidente Vascular Cerebral , Tromboembolia , Anticoagulantes/uso terapêutico , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Humanos , Neoplasias/complicações , Neoplasias/terapia , Tromboembolia/epidemiologia , Tromboembolia/etiologia , Tromboembolia/prevenção & controle , Resultado do Tratamento
17.
Can J Cardiol ; 35(2): 229.e7-229.e9, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30760435

RESUMO

We describe the case of a 68-year-old woman presenting with stress cardiomyopathy (SCM), with concomitant cardiogenic shock, left ventricular outflow tract obstruction, and ventricular septal rupture. These complications have not simultaneously been reported in a single SCM case. The importance of early diagnosis of serial complications of SCM and using mechanical circulatory support as a treatment strategy are highlighted.


Assuntos
Choque Cardiogênico/etiologia , Cardiomiopatia de Takotsubo/complicações , Obstrução do Fluxo Ventricular Externo/etiologia , Ruptura do Septo Ventricular/etiologia , Idoso , Ecocardiografia Doppler em Cores , Evolução Fatal , Feminino , Humanos , Choque Cardiogênico/diagnóstico , Cardiomiopatia de Takotsubo/diagnóstico , Obstrução do Fluxo Ventricular Externo/diagnóstico , Ruptura do Septo Ventricular/diagnóstico
18.
Coron Artery Dis ; 29(8): 670-680, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30222595

RESUMO

BACKGROUND: For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy. PARTICIPANTS AND METHODS: Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis. RESULTS: Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease. CONCLUSION: Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.


Assuntos
Síndrome Coronariana Aguda/terapia , Anticoagulantes/administração & dosagem , Doença da Artéria Coronariana/terapia , Trombose Coronária/prevenção & controle , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária/administração & dosagem , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Administração Oral , Idoso , Anticoagulantes/efeitos adversos , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico por imagem , Trombose Coronária/sangue , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
Future Cardiol ; 13(3): 247-257, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28570141

RESUMO

Acute coronary syndrome (ACS) coinciding with active malignancy presents a unique clinical challenge given intersecting pathophysiology and treatment-related effects. There is little established clinical guidance on management strategies, rendering most treatment approaches anecdotal. We present a case highlighting the complexity of managing a patient being treated for malignancy who concurrently suffers from ACS. We then review the literature on co-management of ACS and malignancy, including reports of specific cancer therapies associated with ACS, unique features of clinical presentation and optimal use of dual antiplatelet therapy to minimize risks of bleeding and thrombosis. We also describe gaps in current literature, challenges in systematically studying the clinical intersection of these disease processes and propose alternative methodologies for further research.


Assuntos
Antineoplásicos/efeitos adversos , Trombose Coronária/terapia , Isquemia Miocárdica/terapia , Stents , Neoplasias da Bexiga Urinária/tratamento farmacológico , Síndrome Coronariana Aguda , Antineoplásicos/uso terapêutico , Trombose Coronária/etiologia , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Isquemia Miocárdica/induzido quimicamente , Neoplasias da Bexiga Urinária/etiologia
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