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1.
BMJ Case Rep ; 14(1)2021 Jan 11.
Artigo em Inglês | MEDLINE | ID: mdl-33431524

RESUMO

A 34-year-old woman was seen in the emergency department for shortness of breath and chest pain. During a pandemic, it is easy to 'think horses and not zebras', and with a patient presenting with the classic coronavirus symptoms it would have been easy to jump to that as her diagnosis. After a careful history and examination, it became clear that there was another underlying diagnosis. Chest X-ray, echocardiogram and CT scan revealed marked right ventricular dilatation and pulmonary hypertension, alongside a persistent left superior vena cava (PLSVC). Further investigation with cardiac MRI and coronary angiography at a tertiary centre demonstrated that she not only have a PLSVC but also a partial anomalous pulmonary venous drainage and sinus venosus atrial septal defect. This case highlights the importance of considering all differentials and approaching investigations in a logical manner.


Assuntos
/diagnóstico , Dor no Peito/fisiopatologia , Dispneia/fisiopatologia , Comunicação Interatrial/diagnóstico por imagem , Hipertensão Pulmonar/diagnóstico por imagem , Hipertrofia Ventricular Direita/diagnóstico por imagem , Síndrome de Cimitarra/diagnóstico por imagem , Adulto , Cateterismo Cardíaco , Dor no Peito/etiologia , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Diagnóstico Diferencial , Dilatação Patológica/complicações , Dilatação Patológica/diagnóstico por imagem , Dilatação Patológica/fisiopatologia , Dispneia/etiologia , Ecocardiografia , Eletrocardiografia , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/fisiopatologia , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/fisiopatologia , Hipertrofia Ventricular Direita/complicações , Hipertrofia Ventricular Direita/fisiopatologia , Imagem por Ressonância Magnética , /fisiopatologia , Síndrome de Cimitarra/complicações , Síndrome de Cimitarra/fisiopatologia , Tomografia Computadorizada por Raios X , Pressão Ventricular
2.
Medicine (Baltimore) ; 99(43): e22920, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120844

RESUMO

RATIONALE: Reversible splenial lesion syndrome (RESLES) is a recently identified clinico-radiological syndrome, the etiology is miscellaneous. Atrial septal defect (ASD) as an underlying etiology for RESLES has not been reported. We first report a rare case of RESLES associated with ASD. The clinical, radiological, and ultrasonic profiles were presented and the pathophysiological mechanism was analyzed. PATIENT CONCERNS: A 23-year-old man presented with headache, drowsiness, occasional paraphasia, and paroxysmal dry cough. Brain magnetic resonance imaging (MRI) on admission showed an ovoid isolated lesion in the splenium of corpus callosum, which exhibited hyperintensity on diffusion-weighted imaging and hypointensity on apparent diffusion coefficient, and completely disappeared on the follow-up MRI 14 days later. ASD was found by transthoracic echocardiography, Right-to-left shunts were detected on color Doppler of transesophageal echocardiography, and microemboli were captured by transcranial Doppler ultrasound. DIAGNOSES: According to his clinical history and imaging results, we confirmed the diagnosis of RESLES associated with ASD. INTERVENTIONS: The patient was treated by oral aspirin and lopidogrel sulfate to inhibit platelet aggregation. In addition, oral nimodipine to suppress vasoconstriction. OUTCOMES: After 14 days treatment, all the symptoms presenting on admission resolved completely. Subsequently, a repair surgery of ASD under thoracoscopy was successfully performed. LESSONS: To our knowledge, this is the first reported case of ASD may be an underlying etiology for RESLES and need require an etiotropic treatment.


Assuntos
Encefalopatias/etiologia , Corpo Caloso/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética/métodos , Comunicação Interatrial/complicações , Administração Oral , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/uso terapêutico , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Encefalopatias/diagnóstico por imagem , Encefalopatias/patologia , Corpo Caloso/patologia , Combinação de Medicamentos , Quimioterapia Combinada , Ecocardiografia/métodos , Seguimentos , Cefaleia/etiologia , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/tratamento farmacológico , Comunicação Interatrial/cirurgia , Humanos , Lopinavir/administração & dosagem , Lopinavir/uso terapêutico , Masculino , Nimodipina/administração & dosagem , Nimodipina/uso terapêutico , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/uso terapêutico , Ritonavir/administração & dosagem , Ritonavir/uso terapêutico , Síndrome , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana/métodos , Adulto Jovem
3.
Annu Int Conf IEEE Eng Med Biol Soc ; 2020: 1211-1216, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-33018205

RESUMO

We propose a robust technique for segmenting magnetic resonance images of post-atrial septal occlusion intervention in the cardiac chamber. The technique can be used to determine the surgical outcomes of atrial septal defects before and after implantation of a septal occluder, which intends to provide volume restoration of the right and left atria. A variant of the U-Net architecture is used to perform atrial segmentation via a deep convolutional neural network. The method was evaluated on a dataset containing 550 two-dimensional image slices, outperforming conventional active contouring regarding the Dice similarity coefficient, Jaccard index, and Hausdorff distance, and achieving segmentation in the presence of ghost artifacts that occlude the atrium outline. Moreover, the proposed technique is closer to manual segmentation than the snakes active contour model. After segmentation, we computed the volume ratio of right to left atria, obtaining a smaller ratio that indicates better restoration. Hence, the proposed technique allows to evaluate the surgical success of atrial septal occlusion and may support diagnosis regarding the accurate evaluation of atrial septal defects before and after occlusion procedures.


Assuntos
Aprendizado Profundo , Comunicação Interatrial , Comunicação Interatrial/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Espectroscopia de Ressonância Magnética , Redes Neurais de Computação
4.
Medicine (Baltimore) ; 99(35): e21758, 2020 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-32871896

RESUMO

INTRODUCTION: Gastroesophageal reflux disease is a common and troublesome condition. This paper reports a rare case of gastroesophageal reflux disease caused by ectopic biliary drainage accompanying the absence of a pyloric channel and duodenal bulb in a female patient with multiple underlying malformations. PATIENT CONCERNS: A 24-year-old female presented with acid regurgitation and abdominal pain for one month. She was born two weeks premature and with blindness of the right eye. Cardiac murmur was detected in the physical examination. DIAGNOSIS: Gastroendoscopy was performed, and a class D reflux esophagitis and ectopic papilla complicated with the absence of a pyloric channel and duodenal bulb were found. Doppler echocardiography further confirmed the defects of atrial and ventricular septa. Trio-based whole exome sequencing was performed on the proband and her family to find the potential association of multiple variations. However, no putative pathogenic mutations were found. INTERVENTIONS: The patient received proton pump inhibitors and prokinetic treatment and underwent surgical repair of septal defects. OUTCOMES: The symptoms were quickly relieved, and the patient was kept stable upon follow-up. CONCLUSION: The combination of an absent pylorus and ectopic papilla is a rare cause of reflux esophagitis. Unusual gastrointestinal anatomical variations may be accompanied by other malformations. Though no remarkable mutation were detected in this case, sequencing is an efficient technique worth full consideration.


Assuntos
Ampola Hepatopancreática/anormalidades , Esofagite Péptica/etiologia , Anormalidades Múltiplas , Cegueira/congênito , Esofagite Péptica/tratamento farmacológico , Feminino , Gastroscopia , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/cirurgia , Comunicação Interventricular/diagnóstico por imagem , Comunicação Interventricular/cirurgia , Humanos , Inibidores da Bomba de Prótons/uso terapêutico , Sequenciamento Completo do Exoma , Adulto Jovem
6.
Int Heart J ; 61(4): 848-850, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32728003

RESUMO

Right ventricular (RV) dysfunction may occur after cardiac surgery and it is not rare after corrective repair of tetralogy of Fallot (TOF). If traditional treatments with volume management, infusion of inotropic agents, and use of pulmonary vasodilators cannot stabilize the patient, extracorporeal membrane oxygenation (ECMO) or a ventricular assist device (VAD) will be considered as the last resort. Here, we report a young infant patient with RV failure after corrective repair of TOF and without closure of an atrial septal defect (ASD), who was rescued by veno-venous (VV) -ECMO.


Assuntos
Septo Interatrial/cirurgia , Oxigenação por Membrana Extracorpórea/métodos , Tetralogia de Fallot/cirurgia , Disfunção Ventricular Direita/terapia , Assistência ao Convalescente , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ecocardiografia/métodos , Insuficiência Cardíaca/fisiopatologia , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/fisiopatologia , Comunicação Interatrial/cirurgia , Coração Auxiliar , Humanos , Lactente , Masculino , Dispositivo para Oclusão Septal/normas , Tetralogia de Fallot/diagnóstico por imagem , Resultado do Tratamento
7.
J Card Surg ; 35(10): 2798-2799, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32652587

RESUMO

We present a case of a 12-year-old boy with discordance between the atrial arrangement and the thoracoabdominal arrangement in the setting of twisted atrioventricular connections. This case highlights the importance of a separate description of all visceral organs and venous drainage for an accurate description of visceroatrial arrangement in cases of congenital heart defects.


Assuntos
Anormalidades Múltiplas/diagnóstico por imagem , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interventricular/diagnóstico por imagem , Ventrículos do Coração/anormalidades , Levocardia/diagnóstico , Estenose da Valva Pulmonar/diagnóstico por imagem , Criança , Angiografia por Tomografia Computadorizada , Átrios do Coração/anormalidades , Átrios do Coração/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino
8.
Ann Vasc Surg ; 69: 449.e11-449.e16, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32502671

RESUMO

BACKGROUND: Structural heart defects, secondary to congenital malformations, have been commonly repaired by open cardiac surgery. Endovascular technology enables these repairs to be performed with fewer complications and better recovery. However, endovascular therapy can be associated with major complications as device dislocation or embolization. We present the case of migration of an Amplatzer occluder device into the abdominal aorta and its surgical retrieval. CLINICAL CASE: A 10-year-old child with ostium secundum-type interatrial communication underwent endovascular repair in our center. Cardiologists sorted out the atrial communication by endovascular deployment of an Amplatzer device. The 24-h ultrasound control study showed the loss of the occluder. An angio-CT scan showed the migration of the Amplatzer into the juxtarenal abdominal aorta. Initially, an endovascular rescue was attempted but was not effective. Our vascular team performed a median laparotomy, control of the abdominal aorta proximal to the renal arteries, and control of the renal arteries and the infrarenal aorta. We performed a transverse arteriotomy, and the material was removed. Subsequently, the arteriotomy was closed directly without any patch. Postoperative evolution was uneventful. COMMENTS: Most of the migrations and embolizations of the devices to close interatrial communications remain intracardiac. Although embolization of the abdominal aorta is only reported sporadically, it could cause a major vascular complication. Percutaneous retrieval of the device is currently recommended, with conventional surgery being the efficient treatment in case of endovascular failure or severe damage to the aorta.


Assuntos
Aorta Abdominal/cirurgia , Cateterismo Cardíaco/instrumentação , Remoção de Dispositivo , Migração de Corpo Estranho/cirurgia , Comunicação Interatrial/terapia , Dispositivo para Oclusão Septal , Aorta Abdominal/diagnóstico por imagem , Cateterismo Cardíaco/efeitos adversos , Criança , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/etiologia , Comunicação Interatrial/diagnóstico por imagem , Humanos , Resultado do Tratamento
9.
Medicine (Baltimore) ; 99(25): e20279, 2020 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-32569162

RESUMO

RATIONALE: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a hereditary cardiomyopathy disease discovered in 1994. Though there are advances in diagnosis of arrhythmogenic right ventricular cardiomyopathy, early diagnosis is still difficult especially when it is combined with other diseases with similar pathophysiologic changes, such as left to right shunt congenital heart disease (CHD). In this paper, we reported a case of CHD combined with ARVC. PATIENT CONCERNS: The patient was referred to us for chest tightness and shortness of breath after physical activities. His cardiac MRI indicated the possibility of arrhythmogenic right ventricular cardiomyopathy. He was diagnosed with a large atrial septal defect (ASD) through ultrasound examination. DIAGNOSIS: CHD ASD combined with arrhythmogenic right ventricular cardiomyopathy. INTERVENTIONS: The patient underwent occlusion of the ASD and he was followed-up closely. His symptoms were relieved a lot and the activity tolerance was elevated. LESSONS: CHD may accompany with arrhythmogenic right ventricular cardiomyopathy. Careful history collection and comprehensive examinations should be emphasized. We firmly believe that our work will be helpful for the medical practice of similar complicated cardiovascular diseases.


Assuntos
Displasia Arritmogênica Ventricular Direita/diagnóstico por imagem , Comunicação Interatrial/diagnóstico por imagem , Displasia Arritmogênica Ventricular Direita/complicações , Procedimentos Cirúrgicos Cardíacos , Comunicação Interatrial/complicações , Comunicação Interatrial/reabilitação , Comunicação Interatrial/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade
11.
J Card Surg ; 35(8): 2025-2026, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32557816

RESUMO

We hereby describe a rare case of partial anomalous pulmonary venous connection (PAPVC) in a patient with tetralogy of Fallot (TOF). It is imperative to identify PAPVC preoperatively in patients with TOF as it can have significant hemodynamic outcomes. This case highlights the importance of computed tomography angiography in demonstrating the same.


Assuntos
Síndrome de Cimitarra/diagnóstico por imagem , Anormalidades Múltiplas , Procedimentos Cirúrgicos Cardiovasculares , Criança , Angiografia por Tomografia Computadorizada , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interventricular/complicações , Comunicação Interventricular/diagnóstico por imagem , Humanos , Período Pré-Operatório , Síndrome de Cimitarra/complicações , Síndrome de Cimitarra/cirurgia , Tetralogia de Fallot/complicações , Tetralogia de Fallot/cirurgia
12.
J Card Surg ; 35(7): 1653-1656, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32353904

RESUMO

BACKGROUND AND AIM: Atrial septal defects with anomalous venous connections are commonly repaired via sternotomy, requiring careful baffle reconstruction to redirect pulmonary venous return and ensure a durable result. The cosmetically appealing periareolar incision may provide an esthetically superior alternative to the anterolateral minithoracotomy incision used in minimally invasive cardiac surgery. METHODS: We describe a patient with a sinus venosus atrial septal defect and partial anomalous pulmonary venous connection who underwent successful minimally invasive, endoscopic repair with apical vein translocation and autologous pericardial baffle reconstruction through a periareolar approach. RESULTS: Post-operative echocardiography demonstrated excellent results with no residual shunt and a widely patent baffle and preserved biventricular function. At 1-year post-op, our patient has had a greatly improved quality of life and an excellent cosmetic result with normal nipple-areolar sensation. CONCLUSIONS: We believe that periareolar approaches should be considered for all adult patients with simple and complex atrial septal defects.


Assuntos
Procedimentos Cirúrgicos Cardiovasculares/métodos , Endoscopia/métodos , Comunicação Interatrial/cirurgia , Veias Pulmonares/anormalidades , Veias Pulmonares/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Adulto , Ecocardiografia , Feminino , Comunicação Interatrial/diagnóstico por imagem , Humanos , Veias Pulmonares/diagnóstico por imagem , Qualidade de Vida , Esternotomia/métodos , Resultado do Tratamento
13.
Int Heart J ; 61(3): 620-623, 2020 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-32418968

RESUMO

In Ebstein's anomaly, percutaneous atrial septal defect (ASD) closure for the treatment of hypoxemia due to a right-to-left interatrial shunt remains controversial. We report the case of a 40-year-old woman with Ebstein's anomaly who developed cyanosis and shortness of breath on exercise. Her symptoms improved after percutaneous ASD closure and her clinical course has been good during follow-up. The balloon ASD occlusion test, combined with dobutamine stimulation before the procedure, is useful to confirm treatment indication. A prior electrophysiological evaluation is also important because Ebstein's anomaly is often complicated by atrioventricular recurrent tachycardia.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Anomalia de Ebstein/cirurgia , Comunicação Interatrial/cirurgia , Hipóxia/cirurgia , Adulto , Anomalia de Ebstein/complicações , Anomalia de Ebstein/diagnóstico por imagem , Ecocardiografia , Feminino , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/etiologia , Humanos , Hipóxia/etiologia , Procedimentos Cirúrgicos Minimamente Invasivos , Dispositivo para Oclusão Septal
14.
J Cardiothorac Surg ; 15(1): 105, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434521

RESUMO

BACKGROUND: Surgical closure of atrial septal defect (ASD) is contraindicated in the condition with severe pulmonary arterial hypertension (PAH), whereas ASD closure in an effective intervention to normalize the structure and function of the right heart after previously experiencing volume overload due to shunting from the defect. This study aimed to evaluate normalization of the right heart and emergence of PAH after surgical closure of ASD. METHODS: This retrospective study was carried out in 45 patients over 18 years who had undergone surgical closure of ASD. The study has the aim to evaluate the morphological and functional parameters before and after the surgical approach and the preoperative factors that influenced the development of pulmonary arterial hypertension (PAP) after the ASD closure. RESULTS: The majority of subjects were female (73.3%) although there were no significant differences between males and females from the various parameters. The average of mPAP in the group that experienced PAH was higher than non-PAH group after ASD closure (p = 0.019, 31.23 ± 12.70 mmHg vs 24.07 ± 13.08 mmHg). Significant differences were found in the Right Atrium (RA) dimension, Right Ventricle (RV) dimension, Tricuspid Regurgitation Velocity (TRV) and Tricuspid Annular Plane Systolic Excursion (TAPSE) between before and at 6 months after ASD closure (p = 0.000, p = 0.000, p = 0.000, p = 000, respectively). The sensitivity of the predictive model to estimate PAH at 6 months after surgical closure of ASD was 58%, with a specificity of 62.5%. CONCLUSION: Structural and functional normalization of the right heart occurs at 6 months after surgical closure of ASD with the decrease of RA and RV dimensions and improvement from tricuspid regurgitation. Emergence of PAH after ASD closure was influenced by higher mPAP before surgical approach.


Assuntos
Comunicação Interatrial/cirurgia , Hipertensão Arterial Pulmonar/diagnóstico , Adulto , Ecocardiografia , Feminino , Comunicação Interatrial/complicações , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Complicações Pós-Operatórias/fisiopatologia , Hipertensão Arterial Pulmonar/complicações , Hipertensão Arterial Pulmonar/diagnóstico por imagem , Hipertensão Arterial Pulmonar/fisiopatologia , Estudos Retrospectivos , Sensibilidade e Especificidade , Insuficiência da Valva Tricúspide/etiologia , Adulto Jovem
16.
J Vet Cardiol ; 28: 23-30, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32182571

RESUMO

A 5-year-old male toy poodle was referred for corrective surgery of an atrial septal defect. A sinus venosus-type atrial septal defect (ASD) with partial anomalous venous connection, suspected pulmonary hypertension, and pulmonary edema was confirmed by radiography, echocardiography, and cardiac computed tomography. Thoracic radiographs showed right heart enlargement. Echocardiography revealed right atrial and ventricular dilatation with mild flattening of the interventricular septum. Left-to-right shunt flow through the ASD was observed on color Doppler examination. Surgical correction of the sinus venosus ASD with a partial anomalous pulmonary venous connection was performed under cardiopulmonary bypass. A follow-up evaluation at 1 year after surgery showed resolution of the right-sided volume overload and no evidence of recurrence of ASD. Complications were not observed. Our findings indicate that surgical correction under cardiopulmonary bypass is a valid treatment option for an ASD with a partial anomalous pulmonary venous connection.


Assuntos
Doenças do Cão/cirurgia , Comunicação Interatrial/veterinária , Veias Pulmonares/anormalidades , Animais , Ponte Cardiopulmonar/veterinária , Doenças do Cão/congênito , Doenças do Cão/diagnóstico por imagem , Cães , Ecocardiografia/veterinária , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/cirurgia , Hipertensão Pulmonar/veterinária , Masculino , Veias Pulmonares/cirurgia , Tomografia Computadorizada por Raios X/veterinária , Resultado do Tratamento
19.
Int J Cardiovasc Imaging ; 36(5): 855-863, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32040685

RESUMO

Transesophageal echocardiography (TEE) under general anesthesia (GA) or intracardiac echocardiography (ICE) under sedation is usually used for echocardiographic guidance during transcatheter atrial septal defect (ASD) closure. However, appropriate selection of guidance has not been fully established. Our study aimed to evaluate whether selection of guidance depending on anatomic ASD features and TEE tolerability under sedation contributes to procedure success. On the basis of anatomic ASD characteristics and TEE tolerability under sedation during the pre-procedural TEE, we selected either TEE, ICE, or combined TEE and ICE under moderate-to-deep sedation or TEE under GA for guidance. Anatomic characteristics of the defect, medical costs, complications, and primary outcomes for these four different types of guidance were analyzed. A total of 154 patients were classified into four guidance groups depending on the results of diagnostic TEE under sedation; 11 patients were scheduled for the procedure under GA in advance. Procedures were successfully completed in all but two patients in whom closure guided by TEE under sedation was attempted for an extremely large defect or extensive superior rim deficiency. Two patients who underwent TEE or combined TEE and ICE guidance under sedation were converted to ICE-only guidance due to desaturation or excessive body movement. Device dislodgement was not observed during the procedure or during median follow-up of 1188 days [interquartile range 577-1831]. Appropriate selection of guidance might contribute to successful transcatheter ASD closure.


Assuntos
Cateterismo Cardíaco , Ecocardiografia Transesofagiana , Comunicação Interatrial/terapia , Adolescente , Adulto , Idoso , Anestesia Geral , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/economia , Cateterismo Cardíaco/instrumentação , Criança , Pré-Escolar , Tomada de Decisão Clínica , Sedação Consciente , Sedação Profunda , Ecocardiografia Transesofagiana/economia , Feminino , Comunicação Interatrial/diagnóstico por imagem , Comunicação Interatrial/economia , Comunicação Interatrial/fisiopatologia , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Dispositivo para Oclusão Septal , Resultado do Tratamento , Adulto Jovem
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