Letter to the Editor
Haemoptysis and Pulmonary Vein Stenosis After Ablation for Atrial Fibrillation: Pathophysiology and Therapeutic Options
Hemoptisis y estenosis de venas pulmonares tras ablación por fibrilación auricular: fisiopatología y opciones terapéuticas
Pablo Demelo-Rodríguez
, Jorge del Toro-Cervera, Belén Andrés-del Olmo
Corresponding author
Departamento de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Read
8321
Timeswas read the article
2255
Total PDF
6066
Total HTML
Share statistics
array:24 [ "pii" => "S1579212913001080" "issn" => "15792129" "doi" => "10.1016/j.arbr.2013.06.005" "estado" => "S300" "fechaPublicacion" => "2013-08-01" "aid" => "748" "copyright" => "SEPAR" "copyrightAnyo" => "2012" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Arch Bronconeumol. 2013;49:366-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4923 "formatos" => array:3 [ "EPUB" => 129 "HTML" => 3936 "PDF" => 858 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0300289613000537" "issn" => "03002896" "doi" => "10.1016/j.arbres.2013.01.010" "estado" => "S300" "fechaPublicacion" => "2013-08-01" "aid" => "748" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Arch Bronconeumol. 2013;49:366-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 11649 "formatos" => array:3 [ "EPUB" => 126 "HTML" => 10815 "PDF" => 708 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Director</span>" "titulo" => "Hemoptisis y estenosis de venas pulmonares tras ablación por fibrilación auricular: fisiopatología y opciones terapéuticas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "366" "paginaFinal" => "367" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Haemoptysis and Pulmonary Vein Stenosis After Ablation for Atrial Fibrillation: Pathophysiology and Therapeutic Options" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 928 "Ancho" => 3195 "Tamanyo" => 305445 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Angiografía pulmonar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pablo Demelo-Rodríguez, Jorge del Toro-Cervera, Belén Andrés-del Olmo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Pablo" "apellidos" => "Demelo-Rodríguez" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "del Toro-Cervera" ] 2 => array:2 [ "nombre" => "Belén" "apellidos" => "Andrés-del Olmo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212913001080" "doi" => "10.1016/j.arbr.2013.06.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001080?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289613000537?idApp=UINPBA00003Z" "url" => "/03002896/0000004900000008/v1_201308011253/S0300289613000537/v1_201308011253/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1579212913001031" "issn" => "15792129" "doi" => "10.1016/j.arbr.2012.12.004" "estado" => "S300" "fechaPublicacion" => "2013-08-01" "aid" => "728" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Arch Bronconeumol. 2013;49:367-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2678 "formatos" => array:3 [ "EPUB" => 121 "HTML" => 1893 "PDF" => 664 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "GesEPOC Guidelines and Elderly Patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "367" "paginaFinal" => "368" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guía GesEPOC y pacientes ancianos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nicolás Martínez Velilla" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Nicolás" "apellidos" => "Martínez Velilla" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289612003389" "doi" => "10.1016/j.arbres.2012.12.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289612003389?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001031?idApp=UINPBA00003Z" "url" => "/15792129/0000004900000008/v1_201307270144/S1579212913001031/v1_201307270144/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1579212913001110" "issn" => "15792129" "doi" => "10.1016/j.arbr.2013.04.003" "estado" => "S300" "fechaPublicacion" => "2013-08-01" "aid" => "773" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Arch Bronconeumol. 2013;49:365-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2817 "formatos" => array:3 [ "EPUB" => 133 "HTML" => 1979 "PDF" => 705 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Care Mechanisms to Avoid Readmission of Patients With Chronic Obstructive Pulmonar Disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "365" "paginaFinal" => "366" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Acerca de los mecanismos asistenciales para evitar el reingreso de los pacientes con enfermedad pulmonar obstructiva crónica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Òscar Miró" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Òscar" "apellidos" => "Miró" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289613001191" "doi" => "10.1016/j.arbres.2013.04.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289613001191?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001110?idApp=UINPBA00003Z" "url" => "/15792129/0000004900000008/v1_201307270144/S1579212913001110/v1_201307270144/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Haemoptysis and Pulmonary Vein Stenosis After Ablation for Atrial Fibrillation: Pathophysiology and Therapeutic Options" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "366" "paginaFinal" => "367" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pablo Demelo-Rodríguez, Jorge del Toro-Cervera, Belén Andrés-del Olmo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Pablo" "apellidos" => "Demelo-Rodríguez" "email" => array:1 [ 0 => "pbdemelo@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "del Toro-Cervera" ] 2 => array:2 [ "nombre" => "Belén" "apellidos" => "Andrés-del Olmo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemoptisis y estenosis de venas pulmonares tras ablación por fibrilación auricular: fisiopatología y opciones terapéuticas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 928 "Ancho" => 3195 "Tamanyo" => 305445 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary angiography.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Radiofrequency ablation is an effective procedure for patients with paroxysmal atrial fibrillation refractory to treatment with anti-arrhythmic drugs.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its use is increasingly widespread, with some 40<span class="elsevierStyleHsp" style=""></span>000–50<span class="elsevierStyleHsp" style=""></span>000 procedures performed annually in the United States. One of the most commonly described serious complications is pulmonary vein stenosis, which presents in up to 1%–3% of cases.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 49-year-old male, ex-smoker, with a history of hypertension and thrombotic thrombocytopenic purpura resolved with plasmapheresis and prednisone. He had undergone pulmonary vein ablation in another hospital due to paroxysmal atrial fibrillation. After remaining asymptomatic for 2 years, he was admitted to our centre for study after presenting 2 episodes of spontaneous haemoptysis, as well as dyspnoea on moderate exertion. A complete blood count, coagulation study, basal arterial blood gases, electrocardiogram, chest radiograph and autoimmunity study were carried out, but did not show any noteworthy abnormalities.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the chest computed tomography (CT) study, a “cuff-like” soft tissue lesion with peribronchovascular distribution was identified in the left upper lobe, which was initially interpreted as a possible tumour (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A, arrow). Although there was clinical suspicion of pulmonary vein stenosis as the cause of the haemoptysis, due to the radiological finding, it was decided to perform bronchoscopy with a flexible endoscope to take a biopsy in order to exclude a tumour at that level; the bronchoscopy revealed a mucosa with petechiae which bled easily as the bronchoscope passed. During the procedure, the patient experienced major bleeding from the left main bronchus, which required selective orotracheal intubation of the right main bronchus and transfer to the intensive care unit.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A pulmonary angiography was performed, showing stenosis of the left upper pulmonary vein (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B, in which a decrease in the vascular calibre can be observed at the level of this vein). Balloon angioplasty was then performed at this level, achieving repermeabilisation, with subsequent good angiographic results (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). After the patient had been stabilised and then discharged, he was admitted on a scheduled basis 2 months later for angioplasty with stent placement.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Haemoptysis has been described in the literature as a rare form of presentation of pulmonary vein stenosis,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but the aetiopathogenesis of the haemoptysis in these patients has not yet been clarified. Aguilar-Cabello et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>described a similar case in which histopathological examination of a lobectomy sample showed congested lung tissue. The increase in venous pressure in the pre-stenotic zone would explain the lung tissue congestion and the risk of bleeding at the level of the mucosa in this area. In our patient, the image observed initially on the chest CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) appears to correspond to oedema and peribronchovascular fibrosis secondary to congestion due to thrombosis of the vein. This radiological finding may help to understand the pathophysiology a little more, and serve as a reference to help other clinicians to support the diagnosis of this entity.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Pulmonary vein ablation is a relatively safe procedure, although it is not free of complications. Among the late complications of this procedure are: cardiac tamponade, pulmonary vein stenosis, embolisms, vascular complications, phrenic nerve lesion, gastro-oesophageal fistula and gastric hypomotility secondary to lesion of the vagus nerve at peri-oesophageal level. All these complications, although rare, should be included in the differential diagnosis of unexplained symptoms in patients who have undergone pulmonary vein ablation in the past.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pulmonary vein stenosis, although it presents asymptomatically in most cases,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> can manifest, as well as with haemoptysis, as dyspnoea on exertion, cough, chest pain or repeated infections,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which appear between 2 and 5 months after the procedure. For this reason, it is important to be aware of this complication, and to suspect it when these symptoms are present, in order for its early diagnosis and correction.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The therapeutic option in these patients is balloon angioplasty, with or without stent placement. At present, there are no definitive data that suggest that stenting obtains better results than balloon dilation alone.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our patient, we initially opted for isolated angioplasty, although given the serious clinical repercussions, it was finally decided to place a stent in a second procedure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Regardless of the therapeutic procedure chosen, and despite the high re-stenosis rate, recent studies show that early intervention is recommended in symptomatic patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In the case of asymptomatic patients, the treatment appears to show benefits, although the indication is not as clear.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our patient's subsequent progress to date has been favourable, with no new episodes of haemoptysis and remission of the dyspnoea on exertion.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Demelo-Rodríguez P, et al. Hemoptisis y estenosis de venas pulmonares tras ablación por fibrilación auricular: fisiopatología y opciones terapéuticas. Arch Bronconeumol. 2013;49:366–7.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 928 "Ancho" => 3195 "Tamanyo" => 305445 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary angiography.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical predictors and outcomes associated with acute return of pulmonary vein conduction during pulmonary vein isolation for treatment of atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "W.H. Sauer" 1 => "M.L. McKernan" 2 => "D. Lin" 3 => "E.P. Gerstenfeld" 4 => "D.J. Callans" 5 => "F.E. Marchlinski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hrthm.2006.05.007" "Revista" => array:6 [ "tituloSerie" => "Heart Rhythm" "fecha" => "2006" "volumen" => "3" "paginaInicial" => "1024" "paginaFinal" => "1028" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16945795" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemoptisis como forma de presentación de estenosis de las venas pulmonares secundaria a ablación por radiofrecuencia de la fibrilación auricular" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Calero Acuña" 1 => "T. Elías Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2010.09.015" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2011" "volumen" => "47" "paginaInicial" => "162" "paginaFinal" => "163" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21281996" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Threatening hemoptysis and pulmonary vein stenosis after ablation due to atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Aguilar-Cabello" 1 => "R. Martín-Bermúdez" 2 => "J. Jiménez-Jiménez" 3 => "J.J. Egea-Guerrero" 4 => "A.M. García-Lombardo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2011.03.014" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "56" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21621305" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Di Biase" 1 => "T.S. Fahmy" 2 => "O.M. Wazni" 3 => "R. Bai" 4 => "D. Patel" 5 => "D. Lakkireddy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2006.08.038" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2006" "volumen" => "48" "paginaInicial" => "2493" "paginaFinal" => "2499" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17174188" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.R. Holmes Jr." 1 => "K.H. Monahan" 2 => "D. Packer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcin.2008.12.014" "Revista" => array:6 [ "tituloSerie" => "JACC Cardiovasc Interv" "fecha" => "2009" "volumen" => "2" "paginaInicial" => "267" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19463436" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How to identify and treat patients with pulmonary vein stenosis post atrial fibrillation ablation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.D. Barrett" 1 => "L. di Biase" 2 => "A. Natale" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Curr Opin Cardiol" "fecha" => "2008" "volumen" => "24" "paginaInicial" => "42" "paginaFinal" => "49" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19102037" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000004900000008/v1_201307270144/S1579212913001080/v1_201307270144/en/main.assets" "Apartado" => array:4 [ "identificador" => "14576" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000004900000008/v1_201307270144/S1579212913001080/v1_201307270144/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001080?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 5 | 9 |
| 2024 October | 39 | 19 | 58 |
| 2024 September | 45 | 25 | 70 |
| 2024 August | 68 | 34 | 102 |
| 2024 July | 50 | 21 | 71 |
| 2024 June | 121 | 32 | 153 |
| 2024 May | 86 | 27 | 113 |
| 2024 April | 45 | 25 | 70 |
| 2024 March | 44 | 15 | 59 |
| 2024 February | 36 | 28 | 64 |
| 2023 March | 9 | 2 | 11 |
| 2023 February | 38 | 24 | 62 |
| 2023 January | 45 | 40 | 85 |
| 2022 December | 38 | 46 | 84 |
| 2022 November | 61 | 29 | 90 |
| 2022 October | 59 | 42 | 101 |
| 2022 September | 34 | 29 | 63 |
| 2022 August | 45 | 48 | 93 |
| 2022 July | 49 | 38 | 87 |
| 2022 June | 38 | 43 | 81 |
| 2022 May | 49 | 52 | 101 |
| 2022 April | 37 | 30 | 67 |
| 2022 March | 44 | 49 | 93 |
| 2022 February | 62 | 35 | 97 |
| 2022 January | 51 | 37 | 88 |
| 2021 December | 59 | 40 | 99 |
| 2021 November | 57 | 44 | 101 |
| 2021 October | 48 | 56 | 104 |
| 2021 September | 35 | 51 | 86 |
| 2021 August | 39 | 34 | 73 |
| 2021 July | 39 | 30 | 69 |
| 2021 June | 62 | 40 | 102 |
| 2021 May | 51 | 32 | 83 |
| 2021 April | 72 | 75 | 147 |
| 2021 March | 72 | 18 | 90 |
| 2021 February | 33 | 20 | 53 |
| 2021 January | 23 | 20 | 43 |
| 2020 December | 35 | 15 | 50 |
| 2020 November | 29 | 11 | 40 |
| 2020 October | 31 | 18 | 49 |
| 2020 September | 26 | 13 | 39 |
| 2020 August | 25 | 17 | 42 |
| 2020 July | 44 | 24 | 68 |
| 2020 June | 32 | 7 | 39 |
| 2020 May | 36 | 15 | 51 |
| 2020 April | 29 | 21 | 50 |
| 2020 March | 41 | 20 | 61 |
| 2020 February | 49 | 12 | 61 |
| 2020 January | 40 | 22 | 62 |
| 2019 December | 52 | 21 | 73 |
| 2019 November | 38 | 17 | 55 |
| 2019 October | 34 | 7 | 41 |
| 2019 September | 36 | 9 | 45 |
| 2019 August | 35 | 14 | 49 |
| 2019 July | 49 | 14 | 63 |
| 2019 June | 33 | 12 | 45 |
| 2019 May | 59 | 16 | 75 |
| 2019 April | 78 | 23 | 101 |
| 2019 March | 78 | 21 | 99 |
| 2019 February | 52 | 16 | 68 |
| 2019 January | 46 | 15 | 61 |
| 2018 December | 52 | 20 | 72 |
| 2018 November | 81 | 25 | 106 |
| 2018 October | 92 | 22 | 114 |
| 2018 September | 38 | 16 | 54 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 35 | 0 | 35 |
| 2018 April | 50 | 6 | 56 |
| 2018 March | 69 | 4 | 73 |
| 2018 February | 56 | 5 | 61 |
| 2018 January | 92 | 7 | 99 |
| 2017 December | 100 | 5 | 105 |
| 2017 November | 44 | 5 | 49 |
| 2017 October | 35 | 8 | 43 |
| 2017 September | 46 | 17 | 63 |
| 2017 August | 71 | 9 | 80 |
| 2017 July | 58 | 9 | 67 |
| 2017 June | 61 | 8 | 69 |
| 2017 May | 60 | 7 | 67 |
| 2017 April | 56 | 15 | 71 |
| 2017 March | 60 | 30 | 90 |
| 2017 February | 52 | 8 | 60 |
| 2017 January | 36 | 4 | 40 |
| 2016 December | 66 | 7 | 73 |
| 2016 November | 96 | 12 | 108 |
| 2016 October | 97 | 16 | 113 |
| 2016 September | 140 | 18 | 158 |
| 2016 August | 84 | 18 | 102 |
| 2016 July | 47 | 16 | 63 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 81 | 3 | 84 |
| 2015 September | 57 | 9 | 66 |
| 2015 August | 78 | 8 | 86 |
| 2015 July | 79 | 13 | 92 |
| 2015 June | 60 | 9 | 69 |
| 2015 May | 67 | 10 | 77 |
| 2015 April | 52 | 15 | 67 |
| 2015 March | 59 | 25 | 84 |
| 2015 February | 55 | 12 | 67 |
| 2015 January | 58 | 17 | 75 |
| 2014 December | 67 | 15 | 82 |
| 2014 November | 60 | 10 | 70 |
| 2014 October | 76 | 22 | 98 |
| 2014 September | 59 | 11 | 70 |
| 2014 August | 63 | 14 | 77 |
| 2014 July | 48 | 15 | 63 |
| 2014 June | 70 | 17 | 87 |
| 2014 May | 66 | 13 | 79 |
| 2014 April | 51 | 8 | 59 |
| 2014 March | 66 | 14 | 80 |
| 2014 February | 66 | 13 | 79 |
| 2014 January | 58 | 19 | 77 |
| 2013 December | 51 | 12 | 63 |
| 2013 November | 40 | 13 | 53 |
| 2013 October | 3 | 1 | 4 |
| 2013 September | 0 | 1 | 1 |
| 2013 August | 1 | 4 | 5 |
Show all
