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1.
G Ital Cardiol (Rome) ; 21(11): 45-47, 2020 Nov.
Artigo em Italiano | MEDLINE | ID: mdl-33295334

RESUMO

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to deferral of many non-urgent procedures in most healthcare systems worldwide. With this study we aimed to quantify the impact of COVID-19 on interventional treatment of structural heart disease (SHD) in Italy. METHODS: Numbers of transfemoral transcatheter aortic valve replacement (TAVR), percutaneous mitral valve repair (PMVR), left atrial appendage occlusion (LAAO), patent foramen ovale (PFO) closures performed over a 4-week period during the national lockdown in Italian centers performing over 60 structural heart interventions (SHI)/year were compared with the same 4-week period in 2019. Incidence rate reductions (IRR) were estimated by zero-inflated negative binomial regression. RESULTS: According to our nationwide analysis, SHIs were reduced by 79% as compared to the same period in 2019 (IRR 0.21, 95% confidence interval [CI] 0.15-0.29). This reduction was more substantial for PFO closure (IRR 0.03, 95% CI 0.01-0.07), LAAO (IRR 0.11, 95% CI 0.05-0.25) and PMVR (IRR 0.12, 95% CI 0.04-0.36) as compared to TAVR (IRR 0.31, 95% CI 0.22-0.47). CONCLUSIONS: The COVID-19 pandemic caused a 79% drop in SHI volumes in Italy. PFO closure, LAAO and PMVR decreased more significantly as compared to TAVR. Further studies are needed to evaluate the impact of this reduction on outcomes of patients with SHD.


Assuntos
/epidemiologia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Pandemias , Apêndice Atrial/cirurgia , Intervalos de Confiança , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Forame Oval Patente/cirurgia , Humanos , Itália/epidemiologia , Masculino , Valva Mitral/cirurgia , Prevalência , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos
6.
J Cardiothorac Surg ; 15(1): 255, 2020 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-32928262

RESUMO

BACKGROUND: The management of an incidental patent foramen ovale found during planned cardiac surgery remains a challenge, and current guidelines are not helpful. Although evidence is accumulating, that closure of an incidental found patent foramen ovale might be beneficial, especially in planned off-pump procedures, the diagnosis of a formerly unknown patent foramen ovale with the patient on the operation table has vast consequences by making it necessary to switch to on pump, bi-caval cannulation for patent foramen ovale closure. We therefore developed a technique for transatrial closure of a patent foramen ovale, guided by transesophageal echocardiography. RESULTS: We have performed this surgery in 9 patients. None of them had a previously diagnosed patent foramen ovale. Mean age was 74 (±5) years, Operation time was 175 min (± 34 min), Clamp time 35 min (± 16 min) and Cardiopulmonary bypass time 80 (±17 min). Mortality was 0%. Periprocedural transesophageal echocardiography revealed closure of the patent foramen ovale in all cases. CONCLUSION: We report a new surgical method for transoesophageal echocardiography controlled closure of a patent foramen ovale without the need for an atriotomy. This new technique is especially useful for the closure of patent foramen ovale in the setting of on-pump and off-pump coronary artery bypass graft surgeries alike.


Assuntos
Estenose da Valva Aórtica/cirurgia , Forame Oval Patente/cirurgia , Átrios do Coração , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Cateterismo Cardíaco , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ecocardiografia Transesofagiana , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca , Humanos , Masculino
7.
Stroke ; 51(10): 3119-3123, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32921262

RESUMO

BACKGROUND AND PURPOSE: In patients with cryptogenic stroke and patent foramen ovale (PFO), the Risk of Paradoxical Embolism (RoPE) Score has been proposed as a method to estimate a patient-specific "PFO-attributable fraction"-the probability that a documented PFO is causally-related to the stroke, rather than an incidental finding. The objective of this research is to examine the relationship between this RoPE-estimated PFO-attributable fraction and the effect of closure in 3 randomized trials. METHODS: We pooled data from the CLOSURE-I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale), RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment), and PC (Clinical Trial Comparing Percutaneous Closure of Patent Foramen Ovale [PFO] Using the Amplatzer PFO Occluder With Medical Treatment in Patients With Cryptogenic Embolism) trials. We examine the treatment effect of closure in high RoPE score (≥7) versus low RoPE score (<7) patients. We also estimated the relative risk reduction associated with PFO closure across each level of the RoPE score using Cox proportional hazard analysis. We estimated a patient-specific attributable fraction using a PC trial-compatible (9-point) RoPE equation (omitting the neuroradiology variable), as well as a 2-trial analysis using the original (10-point) RoPE equation. We examined the Pearson correlation between the estimated attributable fraction and the relative risk reduction across RoPE strata. RESULTS: In the low RoPE score group (<7, n=912), the rate of recurrent strokes per 100 person-years was 1.37 in the device arm versus 1.68 in the medical arm (hazard ratio, 0.82 [0.42-1.59] P=0.56) compared with 0.30 versus 1.03 (hazard ratio, 0.31 [0.11-0.85] P=0.02) in the high RoPE score group (≥7, n=1221); treatment-by-RoPE score group interaction, P=0.12. The RoPE score estimated attributable fraction anticipated the relative risk reduction across all levels of the RoPE score, in both the 3-trial (r=0.95, P<0.001) and 2-trial (r=0.92, P<0.001) analyses. CONCLUSIONS: The RoPE score estimated attributable fraction is highly correlated to the relative risk reduction of device versus medical therapy. This observation suggests the RoPE score identifies patients with cryptogenic stroke who are likely to have a PFO that is pathogenic rather than incidental.


Assuntos
Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Acidente Vascular Cerebral/complicações , Cateterismo Cardíaco , Forame Oval Patente/cirurgia , Humanos , Fatores de Risco , Prevenção Secundária , Resultado do Tratamento
8.
Lancet ; 396(10244): 129-142, 2020 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-32653056

RESUMO

Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.


Assuntos
Encéfalo/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Amilose/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/prevenção & controle , Encéfalo/irrigação sanguínea , Encéfalo/patologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/cirurgia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/fisiopatologia , Hemorragia Cerebral/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Intervenção Médica Precoce/métodos , Endarterectomia das Carótidas/métodos , Procedimentos Endovasculares/métodos , Forame Oval Patente/cirurgia , Humanos , Pessoa de Meia-Idade , Seleção de Pacientes , Imagem de Perfusão/métodos , Polímeros/uso terapêutico , Recidiva , Acidente Vascular Cerebral/epidemiologia , Succinatos/uso terapêutico , Trombectomia/métodos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X/métodos
11.
Ann Intern Med ; 172(11): 717-725, 2020 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-32422058

RESUMO

BACKGROUND: Residual shunt is observed in up to 25% of patients after patent foramen ovale (PFO) closure, but its long-term influence on stroke recurrence currently is unknown. OBJECTIVE: To investigate the association of residual shunt after PFO closure with the incidence of recurrent stroke and transient ischemic attack (TIA). DESIGN: Prospective cohort study comparing stroke or TIA recurrence in patients with and without residual shunt after PFO closure. SETTING: Single hospital center. PARTICIPANTS: 1078 consecutive patients (mean age, 49.3 years) with PFO-attributable cryptogenic stroke who were undergoing percutaneous PFO closure were followed for up to 11 years. MEASUREMENTS: Residual shunt was evaluated by transthoracic echocardiography with saline contrast. Primary outcome was a composite of the first recurrent ischemic stroke or TIA after PFO closure. RESULTS: Compared with complete closure, the presence of residual shunt after PFO closure was associated with an increased incidence of recurrent stroke or TIA: 2.32 versus 0.75 events per 100 patient-years (hazard ratio [HR], 3.05 [95% CI, 1.65 to 5.62]; P < 0.001). This result remained robust after adjustment for important covariates, namely age; study period; device; presence of atrial septal aneurysm, hypertension, hyperlipidemia, diabetes, hypercoagulability, or hypermobile septum; and medication use (HR, 3.01 [CI, 1.59 to 5.69]; P < 0.001). Further stratification based on shunt size revealed that moderate or large residual shunts were associated with a higher risk for stroke or TIA recurrence (HR, 4.50 [CI, 2.20 to 9.20]; P < 0.001); the result for small residual shunts was indeterminate (HR, 2.02 [CI, 0.87 to 4.69]; P = 0.102). LIMITATION: Nonrandomized study with potential unmeasured confounding. CONCLUSION: Among patients undergoing PFO closure to prevent future stroke, the presence of residual shunt, particularly a moderate or large residual shunt, was associated with an increased risk for stroke or TIA recurrence. PRIMARY FUNDING SOURCE: National Institutes of Health.


Assuntos
Forame Oval Patente/complicações , Acidente Vascular Cerebral/etiologia , Ecocardiografia , Feminino , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Acidente Vascular Cerebral/epidemiologia
12.
J Am Coll Cardiol ; 75(18): 2312-2320, 2020 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-32381162

RESUMO

BACKGROUND: In patients with patent foramen ovale (PFO)-associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence. OBJECTIVES: The purpose of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause. METHODS: The authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models. RESULTS: Of 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (pinteraction = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50). CONCLUSIONS: In patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence [CLOSE]; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale [DEFENSE-PFO]; NCT01550588).


Assuntos
Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/cirurgia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Adulto , Septo Interatrial/diagnóstico por imagem , Septo Interatrial/cirurgia , Feminino , Forame Oval Patente/epidemiologia , Aneurisma Cardíaco/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Dispositivos de Oclusão Vascular/tendências
14.
J Interv Cardiol ; 2020: 9813038, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32265599

RESUMO

Background: A patent foramen ovale (PFO) is a rare cause of hypoxemia and clinical symptoms of dyspnea. Due to a right-to-left shunt, desaturated blood enters the systemic circulation in a subset of patients resulting in dyspnea and a subsequent reduction in quality of life (QoL). Percutaneous closure of PFO is the treatment of choice. Objectives: This retrospective multicentre study evaluates short- and long-term results of percutaneous closure of PFO in patients with dyspnea and/or reduced oxygen saturation. Methods: Patients with respiratory symptoms were selected from databases containing all patients percutaneously closed between January 2000 and September 2018. Improvement in dyspnea, oxygenation, and QoL was investigated using pre- and postprocedural lung function parameters and two postprocedural questionnaires (SF-36 and PFSDQ-M). Results: The average follow-up period was 36 [12-43] months, ranging from 0 months to 14 years. Percutaneous closure was successful in 15 of the 16 patients. All patients reported subjective improvement in dyspnea immediately after device deployment, consistent with their improvement in oxygen saturation (from 90 ± 6% to 94 [92-97%] on room air and in upright position) (p < 0.05). Both questionnaires also indicated an improvement of dyspnea and QoL after closure. The two early and two late deaths were unrelated to the procedure. Conclusion: PFO-related dyspnea and/or hypoxemia can be treated successfully with a percutaneous intervention with long-lasting benefits on oxygen saturation, dyspnea, and QoL.


Assuntos
Dispneia , Forame Oval Patente , Hipóxia , Efeitos Adversos de Longa Duração , Qualidade de Vida , Adulto , Cateterismo Cardíaco/métodos , Dispneia/etiologia , Dispneia/psicologia , Dispneia/terapia , Exercício Físico/fisiologia , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/metabolismo , Forame Oval Patente/psicologia , Forame Oval Patente/cirurgia , Humanos , Hipóxia/etiologia , Hipóxia/psicologia , Hipóxia/terapia , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/psicologia , Efeitos Adversos de Longa Duração/cirurgia , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Implantação de Prótese/métodos , Descanso/fisiologia , Estudos Retrospectivos , Dispositivo para Oclusão Septal , Resultado do Tratamento
15.
J Am Coll Cardiol ; 75(15): 1804-1818, 2020 04 21.
Artigo em Inglês | MEDLINE | ID: mdl-32299593

RESUMO

Stroke is a leading cause of permanent disability. Therefore, primary prevention of first stroke and secondary prevention of recurrent stroke are a high priority. Primary prevention of ischemic stroke includes lifestyle modification and diet, treatment of risk factors including hypertension, diabetes mellitus and lipid disorders, antiplatelet therapy for high vascular risk patients, and anticoagulation in atrial fibrillation. Secondary prevention of ischemic stroke includes additional carotid surgery or stenting in selected symptomatic patients, closure of patent foramen ovale after cryptogenic stroke, treatment of insulin resistance, and best medical treatment of intracranial stenosis. The most important preventive strategies in the primary and secondary prevention of cerebral hemorrhage include the treatment of hypertension, reduction in alcohol intake, and occlusion of the left atrial appendage in patients with atrial fibrillation and permanent contraindications for oral anticoagulation.


Assuntos
Hemorragia Cerebral/prevenção & controle , Prevenção Primária , Prevenção Secundária , Anticoagulantes/uso terapêutico , Arteriopatias Oclusivas/cirurgia , Estenose das Carótidas/complicações , Estenose das Carótidas/terapia , Artérias Cerebrais/cirurgia , Hemorragia Cerebral/etiologia , Fibrinolíticos/uso terapêutico , Forame Oval Patente/cirurgia , Humanos , Hiperglicemia/complicações , Hiperglicemia/terapia , Hiperlipidemias/complicações , Hiperlipidemias/terapia , Hipertensão/complicações , Hipertensão/terapia , Estilo de Vida , Inibidores da Agregação de Plaquetas/uso terapêutico , Fatores de Risco , Stents , Insuficiência Vertebrobasilar/complicações , Insuficiência Vertebrobasilar/cirurgia , Complexo Vitamínico B/uso terapêutico
18.
Curr Pharm Des ; 26(23): 2769-2779, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32338207

RESUMO

Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.


Assuntos
Fibrinolíticos , Forame Oval Patente , Cateterismo Cardíaco , Forame Oval Patente/tratamento farmacológico , Forame Oval Patente/cirurgia , Humanos , Resultado do Tratamento
20.
Rev. esp. cardiol. (Ed. impr.) ; 73(3): 219-224, mar. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-195363

RESUMO

INTRODUCCIÓN Y OBJETIVOS: Estudios aleatorizados han mostrado la eficacia del cierre percutáneo del foramen oval permeable (FOP) en pacientes de edad ≤ 60 años con ictus criptogénico. El objetivo de este estudio es determinar la seguridad y la eficacia a largo plazo del cierre percutáneo del FOP en pacientes mayores de 60 años con ictus criptogénico. MÉTODOS: De 475 pacientes consecutivos con ictus criptogénico que se sometieron al cierre del FOP, 90 eran mayores de 60 años (media, 66+/-5 años) y se los comparó con los 385 del grupo de edad ≤ 60 años (media, 44+/-10 años). RESULTADOS: Los pacientes mayores de 60 años tuvieron mayor prevalencia de factores de riesgo cardiovascular (FRCV) (hipertensión, dislipemia y diabetes; p <0,01). No hubo diferencias en cuanto a complicaciones periprocedimiento. El seguimiento medio fue de 8 (4-12) años y hubo 17 muertes, todas de causa no cardiovascular (el 7,8% de los mayores de 60 años y el 2,6% de los de edad ≤ 60 años; HR=4,12; IC95%, 1,56-10,89). Tuvieron un ictus recurrente 4 pacientes (el 2,2% de los mayores de 60 años frente al 0,5% de los de edad ≤ 60 años; HR=5,08; IC95%, 0,71-36,2), y un accidente isquémico transitorio (AIT) 12 pacientes (el 3,3 frente al 2,3%; HR=1,71; IC95%, 0,46-6,39). Hubo tendencia a una mayor incidencia de ictus/AIT en los mayores de 60 años (el 5,5 frente al 2,6%; HR=2,62; IC95%, 0,89-7,75; p = 0,081), que no persistió tras ajustar por FRCV (HR=1,97; IC95%, 0,59-6,56; p = 0,269). CONCLUSIONES: El cierre percutáneo del FOP en pacientes mayores de 60 años con ictus criptogénico resultó seguro y se asoció con una baja incidencia de eventos isquémicos a largo plazo. Sin embargo, en los pacientes mayores de 60 años se observó una tendencia a mayor incidencia de ictus/AIT probablemente relacionada con mayor prevalencia de FRCV


INTRODUCTION AND OBJECTIVES: Randomized trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) in patients aged ≤ 60 years with cryptogenic embolism. We aimed to assess the long-term safety and efficacy of PFO closure in patients aged> 60 years. METHODS: Of 475 consecutive patients with cryptogenic embolism who underwent PFO closure, 90 older patients aged> 60 years (mean, 66+/-5 years) were compared with 385 younger patients aged ≤ 60 years (mean, 44+/-10 years). RESULTS: Older patients had a higher prevalence of cardiovascular risk factors (CVRF) (hypertension, dyslipidemia, diabetes; P <.01 for all vs younger patients). There were no differences in periprocedural complications between the 2 groups. During a median follow-up of 8 (4-12) years, there were a total of 17 deaths, all from noncardiovascular causes (7.8% and 2.6% in the older and younger patient groups, respectively; HR, 4.12; 95%CI, 1.56-10.89). Four patients had a recurrent stroke (2.2% and 0.5% in the older and younger patient groups, respectively; HR, 5.08; 95%CI, 0.71-36.2), and 12 patients had a transient ischemic attack (TIA) (3.3% and 2.3% in the older and younger patient groups, respectively; HR, 1.71; 95%CI, 0.46-6.39). There was a trend toward a higher rate of the composite of stroke/TIA in older patients (5.5% vs 2.6%; HR, 2.62; 95%CI, 0.89-7.75; P=.081), which did not persist after adjustment for CVRF (HR, 1.97; 95%CI, 0.59-6.56; P=.269). CONCLUSIONS: In older patients with cryptogenic embolism, PFO closure was safe and associated with a low rate of ischemic events at long-term. However, older patients exhibited a tendency toward a higher incidence of recurrent stroke/TIA compared with younger patients, likely related to a higher burden of CVRF


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Embolia/complicações , Forame Oval Patente/cirurgia , Ataque Isquêmico Transitório/epidemiologia , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/epidemiologia , Fatores Etários , Causas de Morte , Diabetes Mellitus/epidemiologia , Dislipidemias/epidemiologia , Forame Oval Patente/complicações , Forame Oval Patente/mortalidade , Hipertensão/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Prevalência , Recidiva , Fatores de Risco
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