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and in many cases what little there is has come from patients referred to lung transplant referral hospitals&#44; or diagnosed solely by echocardiography&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;3</span></a> Like other chronic lung diseases that can progress to respiratory failure&#44; PH &#40;generally mild or moderate&#41; is common in the advanced fibrotic stages of sarcoidosis&#44; and it generally has little impact on prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> In contrast&#44; the PH observed in patients with lesser pulmonary involvement seems to be associated with significantly lower survival rates&#44; and could perhaps benefit from specific treatment&#46; This PH does not correlate with the severity of the underlying lung disease&#44; and can appear even in the absence of radiological lung changes&#46; Various mechanisms have been proposed to explain its development&#44; such as destruction of the vascular bed and compression of the pulmonary vessels by lymphadenopathies or vasospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> We report on a series of 4 patients diagnosed with sarcoidosis-associated PH using right heart catheterization&#44; in whom pulmonary vasodilator drugs were administered&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Findings</span><p id="par0010" class="elsevierStylePara elsevierViewall">Four patients &#40;3 men and 1 woman&#41; were seen in our PH Unit for sarcoidosis diagnosed by transbronchial biopsy and suspected PH between January 2004 and January 2013&#46; Only 1 of the patients &#40;case 4&#41; had extrapulmonary involvement&#44; which consisted of various nodular cutaneous lesions on both forearms&#59; on biopsy&#44; these were found to be histologically consistent with sarcoid granulomas&#46; 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Three patients had mild or moderate interstitial involvement consisting of peribronchovascular micronodules in cases 2 and 3&#44; and fibrosis predominantly in the middle lung zones in case 4&#46; No pulmonary artery thrombi were detected in any of the patients&#46; All were receiving oral steroid treatment &#40;10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day of prednisone or equivalent&#41;&#46; The systolic pulmonary artery pressure estimated by echocardiography ranged from 68 to 105<span class="elsevierStyleHsp" style=""></span>mmHg&#44; with no significant left heart abnormalities in any of the patients&#46; The distance walked in the 6<span class="elsevierStyleHsp" style=""></span>min walk test &#40;6MWT&#41; varied widely&#46; The hemodynamic parameters obtained from diagnostic catheterization can be seen in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; In all cases&#44; the patient had severe PH&#44; with mean pulmonary artery pressure &#40;mPAP&#41; greater than 50<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Two patients had pre-capillary PH&#44; while the other two were probably mixed disease &#40;pre- and post-capillary&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Treatment with bosentan 125<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h was started in three cases &#40;cases 1&#8211;3&#41;&#44; and with tadalafil 40<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h in the other&#46; A favorable response was initially observed &#40;improvement of 1 FC and a mean of 80<span class="elsevierStyleHsp" style=""></span>m in the 6MWT&#41; in 3 patients &#40;cases 1&#44; 3 and 4&#41;&#44; although a new drug had to be added due to deterioration in cases 1 and 4 at months 5 and 7&#44; respectively &#40;case 1&#44; sildenafil 40<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h&#44; and case 4&#44; ambrisentan 5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#59; an improvement was observed only in case 4&#46; There was very little response in case 2&#44; so sildenafil and later subcutaneous treprostinil were added&#46; However&#44; the patient continued to deteriorate&#44; and was included on the lung transplant list &#40;36 months after diagnosis&#41;&#46; Two patients died&#58; case 1 died 29 months after diagnosis due to vascular disease progression&#44; and case 4 after 9 months &#40;sudden death&#41;&#46; Case 3 remains in FC II on monotherapy after 57 months of follow-up&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After obtaining informed consent&#44; a genetic study was carried out on the 4 patients&#46; In case 1&#44; a pathogenic mutation in gene <span class="elsevierStyleItalic">BMPR2</span> &#40;Bone Morphogenetic Protein Receptor 2&#41;&#44; c&#46;1467G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A &#40;p&#46;E489E&#41; was found&#46; Case 2 also had a potentially pathogenic mutation&#44; c&#46;622G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;E208&#42;&#41; in gene <span class="elsevierStyleItalic">KCNA5</span> &#40;potassium voltage-gated channel&#44; shaker-related subfamily&#44; member 5&#41;&#44; one of the voltage-dependent calcium channels that has been implicated in the pathogenesis of PH&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Case 4 was a carrier of another pathogenic mutation in <span class="elsevierStyleItalic">BMPR2</span>&#44; c&#46; 484G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>C &#40;p&#46; A162P&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">We present 4 patients with sarcoidosis-associated PH&#44; including clinical data&#44; therapeutic response and genetic study&#46; This is the first study of this kind published in Spain&#46; The prevalence of PH in this disease is not well known&#44; and values ranging from 5&#37; to 74&#37; have been reported&#44; the latter always in patients with very severe disease who have been referred for lung transplant assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> A prospective single-center study with 111 patients diagnosed with sarcoidosis by means of a protocol that included right heart catheterization following a suspicious echocardiography found only 5 cases of PH&#44; one of them post-capillary&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Although the pathogenesis is not well understood&#44; sarcoid granulomas on the pulmonary vessel walls are known to occur in over 60&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> and some cases simulating pulmonary veno-occlusive disease have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> Due to cardiac and&#47;or venous involvement&#44; PH can have both a pre-capillary &#40;30&#37; of cases&#41; and post-capillary component&#44; as was the case in 2 of our patients&#46; PH is diagnosed equally in both sexes&#44; most often in the sixth decade of life&#46; The initial symptom is usually dyspnea&#44; with a mean survival of slightly less than 6 years&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Given the paucity of published studies&#44; it is unclear which variables could be associated with the development of PH&#46; It is quite clear&#44; however&#44; that it can present with any degree of lung involvement&#46; There are no studies on the correlation with extrapulmonary forms&#44; either&#46; Our 4 patients had little lung disease and near normal lung volumes at the time of PH diagnosis&#46; A high grade of pulmonary fibrosis has been found to carry a poorer prognosis&#44; although it is difficult to separate the impact of the PH from the fibrosis itself&#46; None of our patients had any major fibrotic lesions&#44; and death or transplant was undoubtedly affected by PH&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The possible involvement of steroid treatment in the evolution of sarcoidosis-associated PH is unclear&#44; and data are contradictory&#46; The few studies investigating various PH-specific drugs usually report hemodynamic improvement&#44; especially in pulmonary vascular resistance and cardiac output&#44; reduction in natriuretic peptides&#44; increase of around 45&#8211;55<span class="elsevierStyleHsp" style=""></span>m in the distance walked in the 6MWT&#44; with wide variability and differing results in FC classification&#46; No comparative survival data are available&#46; The outcome was satisfactory and long-term in only 1 of our 4 patients&#44; with a modest response in another 2 cases and no response in the last&#46; A 16-week&#44; multicenter placebo-controlled randomized trial with bosentan was recently published&#44; in which a significant improvement in hemodynamic parameters but no changes in the 6MWT were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One relevant finding in our series was the discovery of various potentially pathogenic mutations in 3 patients&#44; particularly 2 cases with defects in <span class="elsevierStyleItalic">BMPR2</span>&#44; the main gene associated with the onset of PH&#59; one of the mutations changed the amino acid sequence of the protein and the other affected mRNA processing&#44; producing a defective protein&#46; The mutation detected in the <span class="elsevierStyleItalic">KCNA5</span> gene causes a stop codon that foreshortens the protein&#44; which may interfere in its physiological role&#46; As far as we know&#44; no other genetic studies have been conducted in patients with sarcoidosis and PH&#46; The presence of these mutations supports the multifactorial etiology of PH and sheds more light on the importance of genetics in the development of the disease&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present a small series of patients with PH and sarcoidosis treated with PH-specific drugs&#44; with variable response&#46; A genetic study showed some mutations in genes associated with this disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study has been partly funded by <span class="elsevierStyleGrantSponsor" id="gs1">Actelion</span>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of Interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">Adolfo Baloira has participated in remunerated meetings organized by Actelion&#44; GSK&#44; Pfizer and Lilly&#46; The other authors declare that they have no conflict of interests&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres468864"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec491514"
          "titulo" => "Keywords"
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        2 => array:3 [
          "identificador" => "xres468865"
          "titulo" => "Resumen"
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        3 => array:2 [
          "identificador" => "xpalclavsec491513"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Clinical Findings"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of Interests"
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        9 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-02-26"
    "fechaAceptado" => "2014-03-31"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec491514"
          "palabras" => array:3 [
            0 => "Pulmonary hypertension"
            1 => "Sarcoidosis"
            2 => "Mutations"
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec491513"
          "palabras" => array:3 [
            0 => "Hipertensi&#243;n pulmonar"
            1 => "Sarcoidosis"
            2 => "Mutaciones"
          ]
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      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sarcoidosis is a pleomorphic disease that can present with pulmonary hypertension &#40;PH&#41;&#46; What little information is available about the association of these two diseases comes mainly from small series of patients scheduled for transplant&#46; We present four cases of mild pulmonary involvement in whom right catheterisation was performed and PH-specific therapy was administered&#46; After obtaining written consent&#44; a genetic study was performed that showed mutations in PH-related genes in three of the patients&#46; This is the first study of its kind to yield genetic information for this type of PH&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La sarcoidosis es una enfermedad pleom&#243;rfica que en ocasiones puede presentar hipertensi&#243;n pulmonar &#40;HP&#41;&#46; Existe poca informaci&#243;n sobre la asociaci&#243;n de estas 2 enfermedades&#44; en muchos casos de peque&#241;as series de pacientes enviados para trasplante&#46; Presentamos 4 casos con afectaci&#243;n pulmonar leve en los que se realiz&#243; cateterismo derecho y se utiliz&#243; tratamiento espec&#237;fico para HP&#46; Tras consentimiento informado&#44; se hizo un estudio gen&#233;tico que mostr&#243; mutaciones en genes relacionados con HP en 3 pacientes&#46; Se trata del primer estudio que proporciona informaci&#243;n gen&#233;tica en este tipo de HP&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Baloira Villar A&#44; Pousada Fern&#225;ndez G&#44; N&#250;&#241;ez Fern&#225;ndez M&#44; Valverde P&#233;rez D&#46; Estudio cl&#237;nico y molecular de 4 casos de hipertensi&#243;n pulmonar asociada a sarcoidosis&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;e19&#8211;e21&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Age&#58; at the time of PH diagnosis&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Years since onset&#58; from diagnosis of sarcoidosis to diagnosis of PH&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">FC&#58; functional class&#59; DLCO&#58; CO diffusion as percentage of predicted value&#59; FVC&#58; forced vital capacity as percentage of predicted value&#59; F&#58; female&#59; 6MWT&#58; distance walked in 6<span class="elsevierStyleHsp" style=""></span>min at the time of diagnosis&#59; M&#58; male&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Years since onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">FC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">FVC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">DLCO &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">6MWT &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">260&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">425&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">366&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient Characteristics&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">CI&#58; cardiac index&#59; mPAP&#58; mean pulmonary artery pressure&#59; sPAP&#58; systolic pulmonary artery pressure&#59; PCP&#58; pulmonary capillary pressure&#59; PVR&#58; pulmonary vascular resistance&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">mPAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">sPAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">PCP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">CI &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">RVP &#40;U Wood&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vasodilator test&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
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Case report
Clinical and Molecular Study of 4 Cases of Pulmonary Hypertension Associated With Sarcoidosis
Estudio clínico y molecular de 4 casos de hipertensión pulmonar asociada a sarcoidosis
Adolfo Baloira Villara,
Corresponding author
adolfo.baloira.villar@sergas.es

Corresponding author.
, Guillermo Pousada Fernándezb, Marta Núñez Fernándeza, Diana Valverde Pérezb
a Servicio de Neumología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
b Departamento de Genética, Bioquímica e Inmunología, Facultad de Biología, Universidad de Vigo, Vigo, Pontevedra, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary hypertension &#40;PH&#41; can present as an isolated disease&#44; in most cases without a defined cause&#44; or can be associated with other diseases or exogenous agents&#44; both toxins and drugs&#46; Group 5 of the latest Nice clinical classification of the disease groups PH cases with unclear mechanisms&#44; and encompasses very different diseases or conditions with very different pathogeneses&#44; prognoses and treatment<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a>&#59; sarcoidosis-associated PH&#44; a very pleomorphic disease&#44; is one of these&#46; There is little information on the incidence&#44; underlying changes&#44; clinical presentation and therapeutic response of this type of PH&#44; and in many cases what little there is has come from patients referred to lung transplant referral hospitals&#44; or diagnosed solely by echocardiography&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;3</span></a> Like other chronic lung diseases that can progress to respiratory failure&#44; PH &#40;generally mild or moderate&#41; is common in the advanced fibrotic stages of sarcoidosis&#44; and it generally has little impact on prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> In contrast&#44; the PH observed in patients with lesser pulmonary involvement seems to be associated with significantly lower survival rates&#44; and could perhaps benefit from specific treatment&#46; This PH does not correlate with the severity of the underlying lung disease&#44; and can appear even in the absence of radiological lung changes&#46; Various mechanisms have been proposed to explain its development&#44; such as destruction of the vascular bed and compression of the pulmonary vessels by lymphadenopathies or vasospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> We report on a series of 4 patients diagnosed with sarcoidosis-associated PH using right heart catheterization&#44; in whom pulmonary vasodilator drugs were administered&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Findings</span><p id="par0010" class="elsevierStylePara elsevierViewall">Four patients &#40;3 men and 1 woman&#41; were seen in our PH Unit for sarcoidosis diagnosed by transbronchial biopsy and suspected PH between January 2004 and January 2013&#46; Only 1 of the patients &#40;case 4&#41; had extrapulmonary involvement&#44; which consisted of various nodular cutaneous lesions on both forearms&#59; on biopsy&#44; these were found to be histologically consistent with sarcoid granulomas&#46; The clinical characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The diagnosis of sarcoidosis had preceded the onset of PH by a median of 5 years &#40;4&#8211;6&#41;&#46; The initial symptom was rapidly progressive dyspnea on exertion &#40;time to diagnosis&#44; 5&#8211;8 months&#41;&#46; Three patients were classified in functional class &#40;FC&#41; III and one in FC IV&#46; Bronchoalveolar lavage performed in 2 patients &#40;2 and 3&#41; showed lymphocytosis with predominantly CD4&#43; lymphocytes&#46; Lung volumes were normal or near normal in all cases&#46; Single-breath diffusing capacity &#40;DLCO&#41; ranged from 11&#37; to 42&#37; of theoretical values&#44; with a significant decrease with respect to values prior to the onset of the PH &#40;median 28&#37; of the theoretical value&#41;&#46; Chest computed tomography &#40;CT&#41; showed lymphadenopathies of less than 3<span class="elsevierStyleHsp" style=""></span>cm in all cases&#46; Three patients had mild or moderate interstitial involvement consisting of peribronchovascular micronodules in cases 2 and 3&#44; and fibrosis predominantly in the middle lung zones in case 4&#46; No pulmonary artery thrombi were detected in any of the patients&#46; All were receiving oral steroid treatment &#40;10&#8211;20<span class="elsevierStyleHsp" style=""></span>mg&#47;day of prednisone or equivalent&#41;&#46; The systolic pulmonary artery pressure estimated by echocardiography ranged from 68 to 105<span class="elsevierStyleHsp" style=""></span>mmHg&#44; with no significant left heart abnormalities in any of the patients&#46; The distance walked in the 6<span class="elsevierStyleHsp" style=""></span>min walk test &#40;6MWT&#41; varied widely&#46; The hemodynamic parameters obtained from diagnostic catheterization can be seen in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; In all cases&#44; the patient had severe PH&#44; with mean pulmonary artery pressure &#40;mPAP&#41; greater than 50<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Two patients had pre-capillary PH&#44; while the other two were probably mixed disease &#40;pre- and post-capillary&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Treatment with bosentan 125<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h was started in three cases &#40;cases 1&#8211;3&#41;&#44; and with tadalafil 40<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h in the other&#46; A favorable response was initially observed &#40;improvement of 1 FC and a mean of 80<span class="elsevierStyleHsp" style=""></span>m in the 6MWT&#41; in 3 patients &#40;cases 1&#44; 3 and 4&#41;&#44; although a new drug had to be added due to deterioration in cases 1 and 4 at months 5 and 7&#44; respectively &#40;case 1&#44; sildenafil 40<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h&#44; and case 4&#44; ambrisentan 5<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&#59; an improvement was observed only in case 4&#46; There was very little response in case 2&#44; so sildenafil and later subcutaneous treprostinil were added&#46; However&#44; the patient continued to deteriorate&#44; and was included on the lung transplant list &#40;36 months after diagnosis&#41;&#46; Two patients died&#58; case 1 died 29 months after diagnosis due to vascular disease progression&#44; and case 4 after 9 months &#40;sudden death&#41;&#46; Case 3 remains in FC II on monotherapy after 57 months of follow-up&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After obtaining informed consent&#44; a genetic study was carried out on the 4 patients&#46; In case 1&#44; a pathogenic mutation in gene <span class="elsevierStyleItalic">BMPR2</span> &#40;Bone Morphogenetic Protein Receptor 2&#41;&#44; c&#46;1467G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A &#40;p&#46;E489E&#41; was found&#46; Case 2 also had a potentially pathogenic mutation&#44; c&#46;622G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;E208&#42;&#41; in gene <span class="elsevierStyleItalic">KCNA5</span> &#40;potassium voltage-gated channel&#44; shaker-related subfamily&#44; member 5&#41;&#44; one of the voltage-dependent calcium channels that has been implicated in the pathogenesis of PH&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Case 4 was a carrier of another pathogenic mutation in <span class="elsevierStyleItalic">BMPR2</span>&#44; c&#46; 484G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>C &#40;p&#46; A162P&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">We present 4 patients with sarcoidosis-associated PH&#44; including clinical data&#44; therapeutic response and genetic study&#46; This is the first study of this kind published in Spain&#46; The prevalence of PH in this disease is not well known&#44; and values ranging from 5&#37; to 74&#37; have been reported&#44; the latter always in patients with very severe disease who have been referred for lung transplant assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> A prospective single-center study with 111 patients diagnosed with sarcoidosis by means of a protocol that included right heart catheterization following a suspicious echocardiography found only 5 cases of PH&#44; one of them post-capillary&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Although the pathogenesis is not well understood&#44; sarcoid granulomas on the pulmonary vessel walls are known to occur in over 60&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> and some cases simulating pulmonary veno-occlusive disease have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> Due to cardiac and&#47;or venous involvement&#44; PH can have both a pre-capillary &#40;30&#37; of cases&#41; and post-capillary component&#44; as was the case in 2 of our patients&#46; PH is diagnosed equally in both sexes&#44; most often in the sixth decade of life&#46; The initial symptom is usually dyspnea&#44; with a mean survival of slightly less than 6 years&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Given the paucity of published studies&#44; it is unclear which variables could be associated with the development of PH&#46; It is quite clear&#44; however&#44; that it can present with any degree of lung involvement&#46; There are no studies on the correlation with extrapulmonary forms&#44; either&#46; Our 4 patients had little lung disease and near normal lung volumes at the time of PH diagnosis&#46; A high grade of pulmonary fibrosis has been found to carry a poorer prognosis&#44; although it is difficult to separate the impact of the PH from the fibrosis itself&#46; None of our patients had any major fibrotic lesions&#44; and death or transplant was undoubtedly affected by PH&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The possible involvement of steroid treatment in the evolution of sarcoidosis-associated PH is unclear&#44; and data are contradictory&#46; The few studies investigating various PH-specific drugs usually report hemodynamic improvement&#44; especially in pulmonary vascular resistance and cardiac output&#44; reduction in natriuretic peptides&#44; increase of around 45&#8211;55<span class="elsevierStyleHsp" style=""></span>m in the distance walked in the 6MWT&#44; with wide variability and differing results in FC classification&#46; No comparative survival data are available&#46; The outcome was satisfactory and long-term in only 1 of our 4 patients&#44; with a modest response in another 2 cases and no response in the last&#46; A 16-week&#44; multicenter placebo-controlled randomized trial with bosentan was recently published&#44; in which a significant improvement in hemodynamic parameters but no changes in the 6MWT were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">One relevant finding in our series was the discovery of various potentially pathogenic mutations in 3 patients&#44; particularly 2 cases with defects in <span class="elsevierStyleItalic">BMPR2</span>&#44; the main gene associated with the onset of PH&#59; one of the mutations changed the amino acid sequence of the protein and the other affected mRNA processing&#44; producing a defective protein&#46; The mutation detected in the <span class="elsevierStyleItalic">KCNA5</span> gene causes a stop codon that foreshortens the protein&#44; which may interfere in its physiological role&#46; As far as we know&#44; no other genetic studies have been conducted in patients with sarcoidosis and PH&#46; The presence of these mutations supports the multifactorial etiology of PH and sheds more light on the importance of genetics in the development of the disease&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present a small series of patients with PH and sarcoidosis treated with PH-specific drugs&#44; with variable response&#46; A genetic study showed some mutations in genes associated with this disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study has been partly funded by <span class="elsevierStyleGrantSponsor" id="gs1">Actelion</span>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of Interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">Adolfo Baloira has participated in remunerated meetings organized by Actelion&#44; GSK&#44; Pfizer and Lilly&#46; The other authors declare that they have no conflict of interests&#46;</p></span></span>"
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              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec491513"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Clinical Findings"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of Interests"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-02-26"
    "fechaAceptado" => "2014-03-31"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec491514"
          "palabras" => array:3 [
            0 => "Pulmonary hypertension"
            1 => "Sarcoidosis"
            2 => "Mutations"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec491513"
          "palabras" => array:3 [
            0 => "Hipertensi&#243;n pulmonar"
            1 => "Sarcoidosis"
            2 => "Mutaciones"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sarcoidosis is a pleomorphic disease that can present with pulmonary hypertension &#40;PH&#41;&#46; What little information is available about the association of these two diseases comes mainly from small series of patients scheduled for transplant&#46; We present four cases of mild pulmonary involvement in whom right catheterisation was performed and PH-specific therapy was administered&#46; After obtaining written consent&#44; a genetic study was performed that showed mutations in PH-related genes in three of the patients&#46; This is the first study of its kind to yield genetic information for this type of PH&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La sarcoidosis es una enfermedad pleom&#243;rfica que en ocasiones puede presentar hipertensi&#243;n pulmonar &#40;HP&#41;&#46; Existe poca informaci&#243;n sobre la asociaci&#243;n de estas 2 enfermedades&#44; en muchos casos de peque&#241;as series de pacientes enviados para trasplante&#46; Presentamos 4 casos con afectaci&#243;n pulmonar leve en los que se realiz&#243; cateterismo derecho y se utiliz&#243; tratamiento espec&#237;fico para HP&#46; Tras consentimiento informado&#44; se hizo un estudio gen&#233;tico que mostr&#243; mutaciones en genes relacionados con HP en 3 pacientes&#46; Se trata del primer estudio que proporciona informaci&#243;n gen&#233;tica en este tipo de HP&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Baloira Villar A&#44; Pousada Fern&#225;ndez G&#44; N&#250;&#241;ez Fern&#225;ndez M&#44; Valverde P&#233;rez D&#46; Estudio cl&#237;nico y molecular de 4 casos de hipertensi&#243;n pulmonar asociada a sarcoidosis&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;e19&#8211;e21&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Age&#58; at the time of PH diagnosis&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Years since onset&#58; from diagnosis of sarcoidosis to diagnosis of PH&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">FC&#58; functional class&#59; DLCO&#58; CO diffusion as percentage of predicted value&#59; FVC&#58; forced vital capacity as percentage of predicted value&#59; F&#58; female&#59; 6MWT&#58; distance walked in 6<span class="elsevierStyleHsp" style=""></span>min at the time of diagnosis&#59; M&#58; male&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Years since onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">FC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">FVC &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">DLCO &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">6MWT &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">260&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">425&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">366&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab726056.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient Characteristics&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">CI&#58; cardiac index&#59; mPAP&#58; mean pulmonary artery pressure&#59; sPAP&#58; systolic pulmonary artery pressure&#59; PCP&#58; pulmonary capillary pressure&#59; PVR&#58; pulmonary vascular resistance&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">mPAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">sPAP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">PCP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">CI &#40;l&#47;min&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">RVP &#40;U Wood&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vasodilator test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab726057.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Catheterization Results&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:12 [
            0 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Updated clinical classification of pulmonary hypertension"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Simonneau"
                            1 => "M&#46;A&#46; Gatzoulis"
                            2 => "I&#46; Adatia"
                            3 => "D&#46; Celermajer"
                            4 => "C&#46; Denton"
                            5 => "A&#46; Ghofrani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2013.10.029"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2013"
                        "volumen" => "62"
                        "paginaInicial" => "D34"
                        "paginaFinal" => "D41"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24355639"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary hypertension in sarcoidosis&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "T&#46;J&#46; Corte"
                            1 => "A&#46;U&#46; Wells"
                            2 => "A&#46;G&#46; Nicholson"
                            3 => "D&#46;M&#46; Hansell"
                            4 => "S&#46;J&#46; Wort"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1440-1843.2010.01872.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respirology"
                        "fecha" => "2011"
                        "volumen" => "16"
                        "paginaInicial" => "69"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20920145"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary hypertension in advanced sarcoidosis&#58; epidemiology and clinical characteristics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;F&#46; Shorr"
                            1 => "D&#46;L&#46; Helman"
                            2 => "D&#46;B&#46; Davies"
                            3 => "S&#46;D&#46; Nathan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00083404"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "25"
                        "paginaInicial" => "783"
                        "paginaFinal" => "788"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15863633"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characteristics and outcomes of patients with sarcoidosis listed for lung transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;M&#46; Arcasoy"
                            1 => "J&#46;D&#46; Christie"
                            2 => "A&#46; Pochettino"
                            3 => "B&#46;R&#46; Rosengard"
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Article information
ISSN: 15792129
Original language: English
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