Desenlaces cardiovasculares mayores al año de seguimiento en pacientes con diagnóstico de ectasia y aneurismas coronarios en un centro latinoamericano

Vista sencilla de ítem
dc.contributor.advisorLineros Montañez, Alberto
dc.contributor.authorCabrera Villamizar, Alfredo
dc.contributor.authorRodríguez Ariza, Carlos Daniel
dc.contributor.orcidCabrera-Villamizar, Alfredo [0009-0003-5224-5309]
dc.contributor.orcidRodríguez-Ariza, Carlos Daniel [0000-0001-8025-1851]
dc.date.accessioned2024-08-01T21:13:22Z
dc.date.available2024-08-01T21:13:22Z
dc.date.issued2017-07
dc.description.abstractLa ectasia y el aneurisma coronario son parte de la enfermedad coronaria aterosclerótica, caracterizada por el remodelado positivo del vaso. Aunque el tratamiento de la enfermedad aterosclerótica estenótica ha avanzado con la angioplastia y la terapia antitrombótica, no ha ocurrido lo mismo para la ectasia y el aneurisma. No hay consenso sobre la mejor estrategia antitrombótica para estos pacientes, lo que resulta en tratamientos basados en estudios observacionales pequeños, sin claridad sobre su impacto en desenlaces clínicos. Hemos realizado un estudio observacional retrospectivo con 93 pacientes con ectasia y/o aneurisma coronario (98.9% con ectasia, 12.9% con aneurisma). Las características de los pacientes y la distribución de factores de riesgo fueron las esperadas para la enfermedad coronaria. La principal indicación para el cateterismo fue infarto agudo de miocardio sin elevación del segmento ST. Ninguna variable se asoció con un aumento de eventos cardíacos adversos mayores (MACE) en análisis univariado ni multivariado (p>0.05). Para el desenlace de sangrado, el análisis univariado mostró una asociación significativa con el número de arterias con ectasia (OR: 2.5355, 95% CI: 1.0146-6.3366, p=0.036) y el tratamiento antitrombótico (OR: 1.3449, 95% CI: 0.9714-1.8622, p=0.042). Sin embargo, en el análisis multivariado, solo el tratamiento antitrombótico alcanzó significancia estadística (OR: 1.6825, 95% CI: 1.003-2.822, p=0.049). La capacidad del modelo para predecir eventos de sangrado fue limitada (p = 0.2).
dc.description.abstractenglishCoronary ectasia and aneurysm are part of atherosclerotic coronary artery disease, characterized by positive remodeling of the vessel. Although the treatment of stenotic atherosclerotic disease has advanced with angioplasty and antithrombotic therapy, the same has not occurred for ectasia and aneurysm. There is no consensus on the best antithrombotic strategy for these patients, resulting in treatments based on small observational studies, without clarity about their impact on clinical outcomes. We have carried out a retrospective observational study with 93 patients with ectasia and/or coronary aneurysm (98.9% with ectasia, 12.9% with aneurysm). Patient characteristics and distribution of risk factors were as expected for coronary heart disease. The main indication for catheterization was acute non-ST segment elevation myocardial infarction. No variable was associated with an increase in major adverse cardiac events (MACE) in univariate or multivariate analysis (p>0.05). For the bleeding outcome, univariate analysis showed a significant association with the number of arteries with ectasia (OR: 2.5355, 95% CI: 1.0146-6.3366, p=0.036) and antithrombotic treatment (OR: 1.3449, 95% CI: 0.9714-1.8622, p=0.042). However, in the multivariate analysis, only antithrombotic treatment reached statistical significance (OR: 1.6825, 95% CI: 1.003-2.822, p=0.049). The ability of the model to predict bleeding events was limited (p = 0.2).
dc.description.degreelevelEspecializaciónspa
dc.description.degreenameEspecialista en Cardiología de Adultosspa
dc.description.sponsorshipFundación Santa Fe de Bogotá
dc.format.mimetypeapplication/pdf
dc.identifier.instnameinstname:Universidad El Bosquespa
dc.identifier.reponamereponame:Repositorio Institucional Universidad El Bosquespa
dc.identifier.repourlrepourl:https://repositorio.unbosque.edu.co
dc.identifier.urihttps://hdl.handle.net/20.500.12495/12790
dc.language.isoes
dc.publisher.facultyFacultad de Medicinaspa
dc.publisher.grantorUniversidad El Bosquespa
dc.publisher.programEspecialización en Cardiología Adultosspa
dc.relation.references1. Jarcho S. Bougon on coronary aneurysm (1812). Am J Cardiol. 1969 Oct;24(4):551-3. doi: 10.1016/0002-9149(69)90500-1. PMID: 4897732.
dc.relation.references2. Kawsara A, Núñez Gil IJ, Alqahtani F, Moreland J, Rihal CS, Alkhouli M. Management of Coronary Artery Aneurysms. JACC Cardiovasc Interv. 2018 Jul 9;11(13):1211-1223. doi: 10.1016/j.jcin.2018.02.041. PMID: 29976357.
dc.relation.references3. Luo Y, Tang J, Liu X, Qiu J, Ye Z, Lai Y, Yao Y, et al. Coronary Artery Aneurysm Differs From Coronary Artery Ectasia: Angiographic Characteristics and Cardiovascular Risk Factor Analysis in Patients Referred for Coronary Angiography. Angiology. 2017 Oct;68(9):823-830. doi: 10.1177/0003319716665690. Epub 2016 Aug 27. PMID: 27568385.
dc.relation.references4. Maehara A, Mintz GS, Ahmed JM, Fuchs S, Castagna MT, Pichard AD, et al. An intravascular ultrasound classification of angiographic coronary artery aneurysms. Am J Cardiol. 2001 Aug 15;88(4):365-70. doi: 10.1016/s0002-9149(01)01680-0. PMID: 11545755.
dc.relation.references5. Swaye PS, Fisher LD, Litwin P, Vignola PA, Judkins MP, Kemp HG, et al. Aneurysmal coronary artery disease. Circulation. 1983 Jan;67(1):134-8. doi: 10.1161/01.cir.67.1.134. PMID: 6847792.
dc.relation.references6. Manginas A, Cokkinos DV. Coronary artery ectasias: imaging, functional assessment and clinical implications. Eur Heart J. 2006 May;27(9):1026-31. doi: 10.1093/eurheartj/ehi725. Epub 2006 Jan 16. PMID: 16415301.
dc.relation.references7. Hartnell GG, Parnell BM, Pridie RB. Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients. Br Heart J. 1985 Oct;54(4):392-5. PMID: 4074601.
dc.relation.references8. Vega M, et al. Prevalencia, caracterización clínica y paraclínica de pacientes con diagnóstico de ectasia coronaria y enfermedad de flujos lentos en el Hospital Militar Central de 2012 al 2020. Available from: http://hdl.handle.net/10654/39988.
dc.relation.references9. Syed M, Lesch M. Coronary artery aneurysm: a review. Prog Cardiovasc Dis. 1997 Jul-Aug;40(1):77-84. doi: 10.1016/s0033-0620(97)80024-2. PMID: 9247557.
dc.relation.references10. Gunes Y, Boztosun B, Yildiz A, Metin Esen A, Saglam M, Bulut M, et al. Clinical profile and outcome of coronary artery ectasia. Heart. 2006 Aug;92(8):1159-60. doi: 10.1136/hrt.2005.069633. PMID: 16844876; PMCID: PMC1861081.
dc.relation.references11. Morrad B, Yazici HU, Aydar Y, Ovali C, Nadir A. Role of gender in types and frequency of coronary artery aneurysm and ectasia. Medicine (Baltimore). 2016 Aug;95(31) doi: 10.1097/MD.0000000000004395. PMID: 27495054; PMCID: PMC4979808.
dc.relation.references12. Baman TS, Cole JH, Devireddy CM, Sperling LS. Risk factors and outcomes in patients with coronary artery aneurysms. Am J Cardiol. 2004 Jun 15;93(12):1549-51. PMID: 15194035.
dc.relation.references13. Willner NA, Ehrenberg S, Musallam A, Roguin A. Coronary artery ectasia: prevalence, angiographic characteristics and clinical outcome. Open Heart. 2020 Apr;7(1). doi: 10.1136/openhrt-2019-001096. PMID: 32515749; PMCID: PMC7254135.
dc.relation.references14. Schoenhagen P, Ziada KM, Vince DG, Nissen SE, Tuzcu EM. Arterial remodeling and coronary artery disease: the concept of "dilated" versus "obstructive" coronary atherosclerosis. J Am Coll Cardiol. 2001 Aug;38(2):297-306. doi: 10.1016/s0735-1097(01)01374-2. PMID: 11499716.
dc.relation.references15. Swanton RH, Thomas ML, Coltart DJ, Jenkins BS, Webb-Peploe MM, Williams BT. Coronary artery ectasia--a variant of occlusive coronary arteriosclerosis. Br Heart J. 1978 Apr;40(4):393-400. doi: 10.1136/hrt.40.4.393. PMID: 646906; PMCID: PMC482810.
dc.relation.references16. Eitan A, Roguin A. Coronary artery ectasia: new insights into pathophysiology, diagnosis, and treatment. Coron Artery Dis. 2016 Aug;27(5):420-8. doi: 10.1097/MCA.0000000000000379. PMID: 27218145.
dc.relation.references17. Richards GHC, Hong KL, Henein MY, Hanratty C, Boles U. Coronary Artery Ectasia: Review of the Non-Atherosclerotic Molecular and Pathophysiologic Concepts. Int J Mol Sci. 2022 May 6;23(9):5195. doi: 10.3390/ijms23095195. PMID: 35563583; PMCID: PMC9103542.
dc.relation.references18. Ramirez FD, Hibbert B, Simard T, Pourdjabbar A, Wilson KR, Hibbert R, et al. Natural history and management of aortocoronary saphenous vein graft aneurysms: a systematic review of published cases. Circulation. 2012 Oct 30;126(18):2248-56. doi: 10.1161/CIRCULATIONAHA.112.101592. PMID: 23109515.
dc.relation.references19. Yasar AS, et al. Increased platelet activity in patients with isolated coronary artery ectasia. Coron Artery Dis. 2007 Sep;18(6):451-4. PMID: 17885525.
dc.relation.references20. Gülec S, et al. Deletion polymorphism of the angiotensin I converting enzyme gene is a potent risk factor for coronary artery ectasia. Heart. 2003 Feb;89(2):213-4. PMID: 12527692.
dc.relation.references21. Khedr A, Neupane B, Proskuriakova E, Jada K, Kakieu Djossi S, Mostafa JA. Pharmacologic Management of Coronary Artery Ectasia. Cureus. 2021 Sep 8;13(9). doi: 10.7759/cureus.17832. PMID: 34660041; PMCID: PMC8502747.
dc.relation.references22. Doi T, Kataoka Y, Noguchi T, Shibata T, Nakashima T, Kawakami S, et al. Coronary Artery Ectasia Predicts Future Cardiac Events in Patients With Acute Myocardial Infarction. Arterioscler Thromb Vasc Biol. 2017. [Incomplete Reference]
dc.relation.references23. Sierra Gonzalez De Cossio A, Solis-Jimenez F, Viana Rojas JA, Villalobos Pedroza M, Terrazas Cervantes E, Jimenez Ruan LA, et al. Evaluation of management strategies in patients with coronary ectasia: a retrospective cohort study. Eur Heart J. 2021 Oct;42(Suppl_1) 1430. doi: 10.1093/eurheartj/ehab724.1430.
dc.relation.references24. Esposito L, Di Maio M, Silverio A, Cancro FP, Bellino M, Attisano T, et al. Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma. Front Cardiovasc Med. 2022 Feb 4;8:805727. doi: 10.3389/fcvm.2021.805727. PMID: 35187112; PMCID: PMC8854288.
dc.relation.references25. Joo HJ, Woong Yu C, Choi R, Park J, Lee HJ, Kim JS, et al. Clinical outcomes of patients with coronary artery aneurysm after the first generation drug-eluting stent implantation. Catheter Cardiovasc Interv. 2018 Sep 1;92(3). doi: 10.1002/ccd.27413. PMID: 29663638.
dc.relation.references26. Devabhaktuni S, Mercedes A, Diep J, Ahsan C. Coronary Artery Ectasia-A Review of Current Literature. Curr Cardiol Rev. 2016;12(4):318-323. doi: 10.2174/1573403x12666160504100159. PMID: 27142049; PMCID: PMC5304254.
dc.relation.references27. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988 Aug 13;2(8607):349-60. PMID: 2899772.
dc.relation.references28. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001 Aug 16;345(7):494-502. doi: 10.1056/NEJMoa010746. Erratum in: N Engl J Med 2001 Dec 6;345(23):1716. Erratum in: N Engl J Med 2001 Nov 15;345(20):1506. PMID: 11519503.
dc.relation.references29. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. doi: 10.1056/NEJMoa0706482. Epub 2007 Nov 4. PMID: 17982182.
dc.relation.references30. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA; PLATO Investigators; Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10;361(11):1045-57. doi: 10.1056/NEJMoa0904327. Epub 2009 Aug 30. PMID: 19717846.
dc.relation.references31. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-3826. doi: 10.1093/eurheartj/ehad191. Erratum in: Eur Heart J. 2024 Apr 1;45(13):1145. PMID: 37622654.
dc.relation.references32. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1204-1222. doi: 10.1016/S0140-6736(20)30925-9. Erratum in: Lancet. 2020 Nov 14;396(10262):1562. PMID: 33069326; PMCID: PMC7567026.
dc.relation.references33. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigos J, Lisheng L; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52. doi: 10.1016/S0140-6736(04)17018-9. PMID: 15364185.
dc.relation.references34. Balderston JR, Giri J, Kolansky DM, Bavaria JE, Gertz ZM. Coronary artery aneurysms associated with ascending aortic aneurysms and abdominal aortic aneurysms: pathophysiologic implications. Catheter Cardiovasc Interv. 2015 May;85(6):961-7. doi: 10.1002/ccd.25726. Epub 2014 Nov 22. PMID: 25379626.
dc.relation.references35. Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Boden WE, Chaitman BR, Senior R, López-Sendón J, Alexander KP, Lopes RD, Shaw LJ, Berger JS, Newman JD, Sidhu MS, Goodman SG, Ruzyllo W, Gosselin G, Maggioni AP, White HD, Bhargava B, Min JK, Mancini GBJ, Berman DS, Picard MH, Kwong RY, Ali ZA, Mark DB, Spertus JA, Krishnan MN, Elghamaz A, Moorthy N, Hueb WA, Demkow M, Mavromatis K, Bockeria O, Peteiro J, Miller TD, Szwed H, Doerr R, Keltai M, Selvanayagam JB, Steg PG, Held C, Kohsaka S, Mavromichalis S, Kirby R, Jeffries NO, Harrell FE Jr, Rockhold FW, Broderick S, Ferguson TB Jr, Williams DO, Harrington RA, Stone GW, Rosenberg Y; ISCHEMIA Research Group. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. doi: 10.1056/NEJMoa1915922. Epub 2020 Mar 30. PMID: 32227755; PMCID: PMC7263833.
dc.relation.references36. Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, Kandzari DE, Morice MC, Lembo N, Brown WM 3rd, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogáts G, Mansour S, Noiseux N, Sabaté M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Pagé P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP; EXCEL Trial Investigators. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. N Engl J Med. 2016 Dec 8;375(23):2223-2235. doi: 10.1056/NEJMoa1610227. Epub 2016 Oct 31. Erratum in: N Engl J Med. 2019 Oct 31;381(18):1789. doi: 10.1056/NEJMx190008. PMID: 27797291.
dc.relation.references37. BARI 2D Study Group; Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TL, Molitch ME, Nesto RW, Sako EY, Sobel BE. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009 Jun 11;360(24):2503-15. doi: 10.1056/NEJMoa0805796. Epub 2009 Jun 7. PMID: 19502645; PMCID: PMC2863990.
dc.relation.references38. Mehta SR, Tanguay JF, Eikelboom JW, Jolly SS, Joyner CD, Granger CB, et al.; CURRENT-OASIS 7 trial investigators. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010 Oct 9;376(9748):1233-43. doi: 10.1016/S0140-6736(10)61088-4. PMID: 20817281.
dc.relation.references39. Ferguson JJ. Clopidogrel plus aspirin in patients with acute myocardial infarction treated with fibrinolytic therapy--CLARITY-TIMI 28. Future Cardiol. 2005 Sep;1(5):605-10. doi: 10.2217/14796678.1.5.605. PMID: 19804099.
dc.relation.references40. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al.; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10;361(11):1045-57. doi: 10.1056/NEJMoa0904327. PMID: 19717846.
dc.relation.references41. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al.; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. doi: 10.1056/NEJMoa0706482. PMID: 17982182.
dc.relation.references42. Pranata R, Yonas E, Chintya V, Alkatiri AA. Is Anticoagulant Necessary in Patients with Coronary Artery Ectasia Presenting with Acute Coronary Syndrome? A Systematic Review of Case Reports. Int J Angiol. 2019 Dec;28(4):231-236. doi: 10.1055/s-0039-1692706. PMID: 31787821; PMCID: PMC6882670.
dc.relation.references43. Núñez-Gil IJ, Terol B, Feltes G, Nombela-Franco L, Salinas P, Escaned J, et al. Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results. Cardiovasc Revasc Med. 2018 Jul-Aug;19(5 Pt B):589-596. doi: 10.1016/j.carrev.2017.12.003. PMID: 29276176.
dc.relation.references44. Ipek G, Gungor B, Karatas MB, Onuk T, Keskin M, Tanik O, et al. Risk factors and outcomes in patients with ectatic infarct-related artery who underwent primary percutaneous coronary intervention after ST elevated myocardial infarction. Catheter Cardiovasc Interv. 2016 Nov;88(5):748-753. doi: 10.1002/ccd.26553. PMID: 27143640.
dc.relation.references45. Mello BH, Oliveira GB, Ramos RF, Lopes BB, Barros CB, Carvalho Ede O, et al. Validation of the Killip-Kimball classification and late mortality after acute myocardial infarction. Arq Bras Cardiol. 2014 Aug;103(2):107-17. doi: 10.5935/abc.20140091. PMID: 25014060; PMCID: PMC4150661.
dc.rightsAtribución-NoComercial-CompartirIgual 4.0 Internacional
dc.rights.accessrightsinfo:eu-repo/semantics/openAccess
dc.rights.accessrightsinfo:eu-repo/semantics/openAccess
dc.rights.localAcceso abiertospa
dc.rights.urihttp://creativecommons.org/licenses/by-nc-sa/4.0/
dc.subjectEctasia coronaria
dc.subjectAneurisma coronaria
dc.subjectTerapía antitrombótica
dc.subjectEventos adversos cardiovasculares mayores
dc.subjectSangrado
dc.subject.keywordsCoronary ectasia
dc.subject.keywordsCoronary aneurysm
dc.subject.keywordsAntithrombotic therapy
dc.subject.keywordsMajor cardiovascular adverse events
dc.subject.keywordsBleeding
dc.subject.nlmWG 100
dc.titleDesenlaces cardiovasculares mayores al año de seguimiento en pacientes con diagnóstico de ectasia y aneurismas coronarios en un centro latinoamericano
dc.title.translatedMajor cardiovascular outcomes at one year of follow-up in patients diagnosed with ectasia and coronary aneurysms in a Latin American center
dc.type.coarhttps://purl.org/coar/resource_type/c_7a1f
dc.type.coarversionhttps://purl.org/coar/version/c_ab4af688f83e57aa
dc.type.driverinfo:eu-repo/semantics/bachelorThesis
dc.type.hasversioninfo:eu-repo/semantics/acceptedVersion
dc.type.localTesis/Trabajo de grado - Monografía - Especializaciónspa

Archivos

Bloque original
Mostrando 1 - 1 de 1
No hay miniatura disponible
Nombre:
Trabajo de grado.pdf
Tamaño:
1.01 MB
Formato:
Adobe Portable Document Format
Descargar
Bloque de licencias
Mostrando 1 - 4 de 4
No hay miniatura disponible
Nombre:
license.txt
Tamaño:
1.95 KB
Formato:
Item-specific license agreed upon to submission
Descripción:
Descargar
No hay miniatura disponible
Nombre:
Carta de autorización.pdf
Tamaño:
219.42 KB
Formato:
Adobe Portable Document Format
Descripción:
Descargar
No hay miniatura disponible
Nombre:
Acta de grado.pdf
Tamaño:
857.74 KB
Formato:
Adobe Portable Document Format
Descripción:
Descargar
No hay miniatura disponible
Nombre:
Anexo 2. Probatus.pdf
Tamaño:
105.04 KB
Formato:
Adobe Portable Document Format
Descripción:
Descargar

Colecciones

Especialización en Cardiología Adultos