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1.
Heart Rhythm ; 2020 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-32333973

RESUMO

Managing arrhythmias from the left ventricular summit and interventricular septum is a major challenge for the clinical electrophysiologist requiring intimate knowledge of cardiac anatomy, advanced training and expertise. Novel mapping and ablation strategies are needed to treat arrhythmias originating from these regions given the suboptimal long-term success rates. Herein, we describe innovative approaches to improve acute and long-term clinical outcomes such as mapping and ablation using the septal coronary venous system, the septal coronary arteries, alcohol ablation, ablation of all early sites, among others.

3.
JACC Clin Electrophysiol ; 6(3): 272-281, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32192677

RESUMO

OBJECTIVES: This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs). BACKGROUND: In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique. METHODS: This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019. RESULTS: Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients. CONCLUSIONS: In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.

4.
Circ Arrhythm Electrophysiol ; 13(1): e007611, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31922914

RESUMO

BACKGROUND: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.

5.
J Interv Card Electrophysiol ; 57(1): 1-3, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31493123

RESUMO

The CABANA trial reported that catheter ablation, when compared with drug therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest in patients with atrial fibrillation. Despite multiple limitations in study design, the CABANA trial still confirmed that catheter ablation of atrial fibrillation led to clinically important and significant improvements in quality of life at 12 months without increasing the risk of complications.

7.
Artigo em Inglês | MEDLINE | ID: mdl-31673901

RESUMO

BACKGROUND: The posterior wall of the left atrium may promote atrial fibrillation (AF) due to its propensity for fibrosis, in addition to a high prevalence of non-pulmonary vein triggers. Multiple smaller studies have assessed the incremental value of posterior wall isolation (PWI) in addition to standard atrial fibrillation. Similarly, this method has shown promise as an ablation strategy for patients with persistent AF, when PVI alone has shown only modest efficacy. METHODS: We performed an extensive literature search and systematic review of studies that compared AF ablation plus PWI versus control. We separately assessed the recurrence rates of all atrial arrhythmias (AF/AFL/AT), as well as separate recurrence rates of AF and atrial tachycardia/atrial flutter (AT/AFL) after ablation. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used due to heterogeneity (I2) > 25%. RESULTS: Seven studies with a total of 1151 patients were included. Patients who underwent concomitant PWI experienced less recurrence of all atrial arrhythmias post ablation (RR 0.77; 95% CI 0.62-0.96, p = 0.02) and less recurrence of AF (RR 0.55; 95% CI 0.39-0.77, p < 0.01). There was no difference in onset of AT/AFL (RR 0.96; 95% CI 0.62-1.48, p = 0.85) after ablation. These results were replicated in subgroup analysis of patients with persistent AF. CONCLUSIONS: Based on the results of this meta-analysis, concomitant PWI is associated with less recurrence of AF and all atrial arrhythmias after ablation, without an increase in the risk for post-ablation AFL/AT.

11.
J Am Coll Cardiol ; 74(8): 1019-1028, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31439209

RESUMO

BACKGROUND: Loss of contractility leading to stasis of blood flow following left atrial appendage electrical isolation (LAAEI) could lead to thrombus formation. OBJECTIVES: This study evaluated the incidence of thromboembolic events (TE) in post-LAAEI cases "on" and "off" oral anticoagulation (OAC). METHODS: A total of 1,854 consecutive post-LAAEI patients with follow-up transesophageal echocardiography (TEE) performed in sinus rhythm at 6 months to assess left atrial appendage (LAA) function were included in this analysis. RESULTS: The TEE at 6 months revealed preserved LAA velocity, contractility, and consistent A waves in 336 (18%) and abnormal parameters in the remaining 1,518 patients. In the post-ablation period, all 336 patients with preserved LAA function were off OAC. At long-term follow-up, patients with normal LAA function did not experience any stroke events. Of the 1,518 patients with abnormal LAA contractility, 1,086 remained on OAC, and the incidence of stroke/transient ischemic attack (TIA) in this population was 18 of 1,086 (1.7%), whereas the number of TE events in the off-OAC patients (n = 432) was 72 (16.7%); p < 0.001. Of the 90 patients with stroke, 84 received left atrial appendage occlusion (LAAO) devices. At median 12.4 months (interquartile range: 9.8 to 15.3 months) of device implantation, 2 (2.4%) patients were on OAC because of high stroke risk or personal preference, whereas 81 patients discontinued OAC after LAAO device implantation without any TE events. CONCLUSIONS: LAAEI is associated with a significant risk of stroke that can be effectively reduced by optimal uninterrupted OAC or LAAO devices.

12.
JACC Clin Electrophysiol ; 5(7): 833-842, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31320012

RESUMO

OBJECTIVES: This study sought to characterize ventricular arrhythmia (VA) ablated from the basal inferoseptal left ventricular endocardium (BIS-LVe) and identify electrocardiographic characteristics to differentiate from inferobasal crux (IBC) VA. BACKGROUND: The inferior basal septum is an uncommon source of idiopathic VAs, which can arise from its endocardial or epicardial (crux) aspect. Because the latter are often targeted from the coronary venous system or epicardium, distinguishing between the 2 is important for successful ablation. METHODS: Consecutive patients undergoing ablation of idiopathic VA from the BIS-LVe or IBC from 2009 to 2018 were identified and clinical characteristics and electrocardiographs of VA were compared. RESULTS: Of 931 patients undergoing idiopathic VA ablation, Virginia was eliminated from the BIS-LVe in 19 patients (2%) (17 male, age 63.7 ± 9.2 years, LV ejection fraction: 45.0 ± 9.3%). QRS complexes typically manifested right bundle branch block morphology with "reverse V2 pattern break" and left superior axis (more negative in lead III than II). VA elimination was achieved after median of 2 lesions (interquartile range [IQR]: 1-6; range 1 to 20) (radiofrequency ablation time: 123 s [IQR: 75-311]). Compared with 7 patients with IBC VA (3 male, age 51.9 ± 20.1 years, LV ejection fraction: 51.4 ± 17.7%), BIS-LVe VA less frequently had initial negative forces (QS pattern) in leads II, III, and/or aVF (p < 0.001), R-S ratio <1 in lead V1 (p = 0.005), and notching in lead II (p = 0.006) were narrower (QRS duration: 178.2 ± 22.4 vs. 221.1 ± 41.9 ms; p = 0.04) and more frequently had maximum deflection index of <0.55 (p < 0.001). CONCLUSIONS: The BIS-LVe region is an uncommon source of idiopathic VA. Distinguishing these from IBC VA is important for procedural planning and ablation success.

13.
Heart Rhythm ; 16(9): 1421-1428, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31226487

RESUMO

BACKGROUND: The slow pathway region (SPR) is commonly targeted during ablation of atrioventricular nodal reentrant tachycardia. However, its role in idiopathic ventricular arrhythmias (IVAs) remains unknown. OBJECTIVE: The purpose of this study was to describe the electrocardiographic and electrophysiological characteristics of IVAs that were successfully ablated from the SPR. METHODS: Medical records of consecutive patients undergoing ablation of IVAs in the para-Hisian region between 2010 and 2018 were reviewed to identify subjects whose ventricular arrhythmias were targeted from the SPR. RESULTS: Among 63 patients with para-Hisian IVAs undergoing ablation, the SPR was targeted in 12 (20%; mean age 64 ± 7 years; 9 men). All patients presented with ventricular premature depolarizations manifesting left bundle branch block morphology with variable precordial transition (leads V2-V5) and a mean QRS duration of 131 ± 11 ms. In all cases, leads I and aVL had positive forces (R or Rs) and lead aVR had negative forces (QS or Qr). In the majority of cases, lead II had positive forces (R or Rs; n = 9 [75%]) and lead III had negative forces (rS or QS; n = 9 [75%]). Mean activation at the SPR was 31 ± 5 ms pre-QRS. All patients had initial ablation with radiofrequency, resulting in junctional rhythm in 9 (75%); 3 (25%) patients required additional cryoablation. Ablation was successful in 11 patients (92%). One patient required a permanent pacemaker for heart block but subsequently recovered intrinsic conduction. CONCLUSION: The SPR can be a source of IVAs, which can be safely and successfully ablated in most cases using radiofrequency energy. IVAs arising from this location manifest unique electrocardiographic features.

14.
JACC Clin Electrophysiol ; 5(7): 789-800, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31068260

RESUMO

OBJECTIVES: This study describes the use of septal coronary venous mapping to facilitate substrate characterization and ablation of intramural septal ventricular arrhythmia (VA). BACKGROUND: Intramural septal VA represents a challenge for substrate definition and catheter ablation. METHODS: Between 2015 and 2018, 12 patients with structural heart disease, recurrent VA, and suspected intramural septal substrate underwent a septal coronary venous procedure in which mapping was performed by advancement of a wire into the septal perforator branches of the anterior interventricular vein. A total of 5 patients with idiopathic VA were also included as control subjects to compare substrate characteristics. RESULTS: Patients were 63 ± 14 years of age, and 11 (92%) were men. Most patients with structural heart disease had nonischemic cardiomyopathy (83%). Six patients underwent ablation for premature ventricular contractions (PVC) and 6 for ventricular tachycardia. All patients had larger septal unipolar voltage abnormalities than bipolar voltage abnormalities (mean area 35.3 ± 16.8 cm2 vs. 10.7 ± 8.4 cm2, respectively; p = 0.01), Patients with idiopathic VA had normal voltage. Septal coronary venous mapping revealed low-voltage, fractionated, and multicomponent electrograms in sinus rhythm in all patients with substrate compared to that in patients with idiopathic VA (amplitude 0.9 ± 0.9 mV vs. 4.4 ± 3.7 mV, respectively; p = 0.007; and duration 147 ± 48 ms vs. 92 ± 10 ms, respectively; p = 0.03). Ablation targeted early activation, pace map match, and/or good entrainment sites from intraseptal recording. Over a mean follow-up of 339 ± 240 days, the PVC and insertable cardioverter-defibrillator therapies burden were significantly reduced (from a mean of 22 ± 11% to 4 ± 8%; p = 0.005; and a mean 5 ± 2 to 1 ± 1; p = 0.001, respectively). Most patients (80%) with idiopathic VA remained arrhythmia free. CONCLUSIONS: In patients with suspected intramural septal VA, mapping of the septal coronary veins may be helpful to characterize the arrhythmia substrate, identify ablation targets, and guide endocardial ablation.

15.
Heart Rhythm ; 16(8): 1174-1181, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31085181

RESUMO

BACKGROUND: In patients with ischemic ventricular tachycardia (VT), substrate may be "protected" by the posteromedial papillary muscle (PMPM), explaining failure of endocardial-only ablation. OBJECTIVE: We sought to characterize the arrhythmogenic substrate and ablation approach in patients with ischemic VT mapped to the inferior left ventricle in which endocardial ablation failed because of inaccessible substrate underlying the PMPM. METHODS: We included 10 patients with recurrent ischemic VT, evidence of inferior scar, and failed endocardial ablation. In all patients, epicardial mapping was performed via a percutaneous (n = 9) or surgical (n = 1) approach, and VT elimination was achieved by ablation opposite to the PMPM. Clinical characteristics, electrocardiographic characteristics, and procedural data were analyzed. RESULTS: In all patients, intracardiac echocardiography showed hyperechoic scar below the PMPM, and 5 exhibited a pattern characterized by subendocardial basal scar that became intramural and epicardial at distal segments. In 4 patients, VT remained inducible despite endocardial scar isolation, manifested by the absence of electrograms, dissociated potentials, and/or exit block. Eleven inducible VTs were mapped to the epicardium underlying the PMPM: 8 had a right bundle branch block configuration with variable transition, while 3 exhibited left bundle branch block with negative concordance. An inferior QS pattern was present in 10 of 11 VTs. Noninducibility was achieved in 8 patients, and 7 patients remained arrhythmia-free after a mean follow-up of 27 ± 23 months. CONCLUSION: In patients with inferior ischemic scar, VT may arise from the area underneath the PMPM, limiting endocardial ablation. Intracardiac echocardiography accurately defines the substrate distribution, and an epicardial approach may eliminate VT. A pattern of "basal-endocardial/apical-epicardial" ischemic involvement is described.

16.
Heart Rhythm ; 16(10): 1538-1544, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30954600

RESUMO

Idiopathic ventricular arrhythmias may arise from anywhere in the heart, and the majority of them can be effectively treated with catheter ablation. The 12-lead electrocardiogram (ECG) is the initial mapping tool to predict the most likely site of origin and is valuable to choose the appropriate ablation strategy. Crucial to ECG interpretation is understanding the attitudinal orientation of the heart within the chest and the relationship between the different cardiac structures. In this review, we provide a stepwise anatomical approach for the localization of idiopathic ventricular arrhythmias based on sequential analysis of the most relevant ECG features.

17.
J Cardiovasc Electrophysiol ; 30(6): 827-835, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30843306

RESUMO

BACKGROUND: Mitral valve prolapse (MVP) is a common valve condition and has been associated with sudden cardiac death. Premature ventricular contractions (PVCs) from the papillary muscles (PMs) may play a role as triggers for ventricular fibrillation (VF) in these patients. OBJECTIVES: To characterize the electrophysiological substrate and outcomes of catheter ablation in patients with MVP and PM PVCs. METHODS: Of 597 patients undergoing ablation of ventricular arrhythmias during the period 2012-2015, we identified 25 patients with MVP and PVCs mapped to the PMs (64% female). PVC-triggered VF was the presentation in 4 patients and a fifth patient died suddenly during follow-up. The left ventricle ejection fraction (LVEF) was 50.5% ± 11.8% and PVC burden was 24.4% ± 13.1%. A cardiac magnetic resonance imaging was performed in nine cases and areas of late gadolinium enhancement were found in four of them. A detailed LV voltage map was performed in 11 patients, three of which exhibited bipolar voltage abnormalities. Complete PVC elimination was achieved in 19 (76%) patients and a significant reduction in PVC burden was observed in two (8%). In patients in which the ablation was successful, the PVC burden decreased from 20.4% ± 10.8% to 6.3% ± 9.5% (P = 0.001). In 5/6 patients with depressed LVEF and successful ablation, the LV function improved postablation. No significant differences were identified between patients with and without VF. CONCLUSIONS: PM PVCs are a source of VF in patients with MVP and can induce PVC-mediated cardiomyopathy that reverses after PVC suppression. Catheter ablation is highly successful with more than 80% PVC elimination or burden reduction.

18.
Heart Rhythm ; 16(7): 1039-1046, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30763785

RESUMO

BACKGROUND: Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. OBJECTIVE: The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). METHODS: A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. RESULTS: In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. CONCLUSION: These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

19.
JACC Clin Electrophysiol ; 5(1): 28-38, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30678784

RESUMO

OBJECTIVES: This study sought to investigate the substrate, procedural strategies, safety, and outcomes of catheter ablation (CA) for ventricular tachycardia (VT) in patients with aortic valve replacement (AVR). BACKGROUND: VT ablation in patients with AVR is challenging, particularly when mapping and ablation in the periaortic region are necessary. METHODS: We identified consecutive patients with mechanical, bioprosthetic, and transcatheter AVR who underwent CA for VT refractory to antiarrhythmic drugs and analyzed VT substrate, approach to LV access, complications, and long-term outcomes. RESULTS: Overall, 29 patients (87% men, mean age 67.9 ± 9.8 years, left ventricular ejection fraction 39 ± 10%) with prior AVR (13 mechanical, 15 bioprosthetic, 1 transcatheter AVR) underwent 40 ablations from 2004 to 2016. Left-sided mapping/CA was performed in 27 patients (36 procedures). Access was retrograde aortic in 11 procedures (all bioprosthetic), transseptal in 24 (13 mechanical; 10 bioprosthetic; 1 transcatheter AVR), or transventricular septal in 1. Periaortic bipolar or unipolar scar was detected in all 24 patients in whom detailed periaortic mapping was performed. Clinical VT circuit(s) involved the periaortic region in 10 patients (34%), 2 (7%) had bundle branch re-entry VT, and 17 (59%) had substrate unrelated to AVR. There were 2 major complications (both related to vascular access). Only 2 patients (9.1%) had VT recurrence. Over median follow-up of 12.8 months, 11 patients died (none as a result of recurrent VT). CONCLUSIONS: Whereas most patients undergoing CA for VT after AVR had VT from substrate unrelated to AVR, periaortic scar is universally present and bundle branch re-entry can be the VT mechanism. CA can be safely performed with excellent long-term VT elimination.

20.
Vascular ; 27(1): 90-97, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30056785

RESUMO

BACKGROUND: To study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation. METHODS: We performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected. RESULTS: We identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%. CONCLUSIONS: A review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.


Assuntos
Angiografia por Tomografia Computadorizada , Ecocardiografia , Eletrocardiografia , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Artéria Pulmonar/efeitos dos fármacos , Artéria Pulmonar/fisiopatologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Terapia Trombolítica , Resultado do Tratamento
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