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Abernethy Malformation: Possible Diagnosis for Patients with Congenital Heart Disease and Persistent Cyanosis
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Brun, Marilia Maroneze

; Cardoso, Mariana Rodero

; Borim, Bruna Cury

; Marchi, Carlos Henrique De

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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2023, Volume 38 Nº 2 Páginas 300 - 304

Resumo: En | Texto: En | PDF: En

ABSTRACT Clinical data: Infant, nine months of age, female, diagnosed with congenital heart disease, with signs of heart failure associated with cyanosis and difficulty in gaining weight. Chest radiography: Cardiomegaly with prevalence of pulmonary vascular network. Electrocardiogram: Ectopic atrial rhythm with right ventricular overload and left anterosuperior divisional block. Echocardiogram: Single atrium with absent interatrial septum, atrioventricular connection with a single valve and two orifices, with increased pulmonary pressure and high Qp/Qs. Computed tomography: Absence of portal vein and intrahepatic segment of the inferior vena cava. Infrahepatic portion continuing with the azygos system at the level of the thoracic cavity, presence of mesenteric-caval communication associated with signs suggestive of hepatic peribiliary fibrosis. Diagnosis: Abernethy malformation is a rare condition and represents an extrahepatic portosystemic shunt that develops between the mesenteric-portal vasculature and the systemic veins. It may be associated with cardiac malformations and advance with pulmonary hypertension and even the need for liver transplantation. Persistent cyanosis after corrective surgery led to a deeper investigation and correct diagnosis of this malformation. Operation: Sternotomy with 68 minutes of cardiopulmonary bypass and nine minutes of total circulatory arrest. In the postoperative period, persistence of cyanosis was evident, even though there were no immediate complications. Patient was discharged on the 10th postoperative day. An abdominal computed tomography angiography confirmed the diagnosis of Abernethy type I malformation, and the patient was transferred for liver transplantation after congenital heart disease treatment.

https://doi.org/10.21470/1678-9741-2022-0110

Tetralogy of Fallot with an Anomalous Course of the Brachiocephalic Vein
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Matos, Larissa Alves Leite

; Silva, Isaac Azevedo

; Santos, Fernando Cesar Gimenes Barbosa

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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2023, Volume 38 Nº 5 elocation e20230047

Resumo: En | Texto: En | PDF: En

ABSTRACT Clinical data: Infant, 11-month-old, male, diagnosis of Tetralogy of Fallot with retrotracheoesophageal course of the brachiocephalic vein. Usual findings of Tetralogy of Fallot on physical examination. Technical description: Chest radiography showed slightly reduced pulmonary vascular markings and no cardiomegaly. Normal preoperative electrocardiogram with postoperative right bundle branch block. Usual findings of Tetralogy of Fallot on echocardiogram. Postoperative computed tomography angiography confirmed left brachiocephalic vein with anomalous retrotracheoesophageal course, configuring a U-shaped garland vein, in addition to postoperative findings of total correction of Tetralogy of Fallot. Operation: Complete surgical repair was performed with pulmonary valve commissurotomy and placement of bovine pericardial patch to solve right ventricular outflow tract obstruction, pulmonary trunk enlargement, and ventricular septal defect closure. Comments: Systemic venous drainage may show variations in patients with Tetralogy of Fallot. These abnormalities are usually of little clinical relevance, as they are asymptomatic. We presented a rare case of retrotracheoesophageal course of an anomalous left brachiocephalic vein with intraoperative diagnosis, confirmed by imaging during postoperative follow-up, without compromising clinical management or surgical approach.

https://doi.org/10.21470/1678-9741-2023-0047

Use of Ozonized Water in the Prevention of Surgical Site Infection in Children Undergoing Cardiovascular Surgery
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Murakami, Alexandre Noboru

; Croti, Ulisses Alexandre

; Borim, Bruna Cury

; Marchi, Carlos Henrique De

; Murakami, Rouse Mary Rossini

; Almeida, Margarete Teresa Gottardo de

; Policarpo, Rafael da Silva

; Avona, Fabiana Nakamura

; Godoy, Moacir Fernandes de

Brazilian Journal of Cardiovascular Surgery

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2023, Volume 38 Nº 6 elocation e20230006

Resumo: En | Texto: En | PDF: En

ABSTRACT Introduction: Since the reduction of healthcare-associated infections has been a focus for quality patient care, this study aimed to evaluate the surgical site infection rate of children who underwent cardiovascular surgery after implementation of ozonized water system for hand and body hygiene allied to previously implemented preventive measures. Methods: Two uniformly comparable groups of pediatric patients underwent cardiovascular surgery. Group A (187) patients were operated prior to installation of ozonized water system (March 1 to August 31, 2019), and group B (214) patients were operated after installation of ozonized water system (October 1, 2019, to March 31, 2020). Ozonized water was used for professional hand hygiene and patient body hygiene. Results: There was statistical significance for surgical site infection reduction in group B (P=0.0289), with a relative risk of 0.560 (95% confidence interval = 0.298 to 0.920), inferring the risk of being diagnosed with surgical site infections in group B was 44% less than in group A. There was no statistical significance regarding mechanical ventilation time (P=0.1998) or mortality (P=0.4457). Conclusion: Ozonized water for professional hand hygiene and patient body hygiene was an adjuvant combined with traditional preventive methods to reduce the risk of surgical site infection, although no impact on hospital stay or mortality was observed.

https://doi.org/10.21470/1678-9741-2023-0006

Pediatric Heart Transplant: Initial Experience in a Tertiary Center in Brazil
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Cajueiro, Francisco Candido Monteiro

; Croti, Ulisses Alexandre

; Barufi, Alexandra Regina Siscar

; Bodini, André Luís de Andrade

; Postigo, Karolyne Barroca Sanches

; Marchi, Carlos Henrique De

; Santos, Fernando Cesar Gimenes Barbosa

; Beani, Lilian

; Borim, Bruna Cury

; Godoy, Moacir Fernandes

; Moscardini, Airton Camacho

Brazilian Journal of Cardiovascular Surgery

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Jun 2022, Volume 37 Nº 3 Páginas 281 - 291

Resumo: En | Texto: En | PDF: En

ABSTRACT Introduction: Pediatric heart transplantation is the definitive therapy for children with end-stage heart failure. This paper describes our initial experience in pediatric heart transplantation in a tertiary center in Brazil Methods: This is a historical prospective descriptive cohort study based on a review of the medical records of children undergoing heart transplantation at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto. Variables were displayed as frequency, mean, or median. Statistical analysis and Kaplan-Meier actuarial curve were obtained with the aid of Microsoft® Excel® 2019 and STATSDirect version 3.3.5. Results: Between January 2010 and December 2020, ten children underwent bicaval orthotopic heart transplantation, 30% of which were under one year of age. Nine patients had end-stage heart failure (International Society for Heart and Lung Transplantation-Heart Failure D) and 50% of the recipients were transplanted under conditions of progressive clinical deterioration (Interagency Registry for Mechanically Assisted Circulatory Support ≤ 2). Forty percent of the recipients had a panel-reactive antibody > 20% on virtual crossmatch. In the postoperative period, 80% of patients required high dose of inotropic support (vasoactive-inotropic score > 10) for > 48 hours. The death-free survival rate at 131 months was 77.1±14.4%. Most patients (88.9%) in late follow-up had an episode of active cytomegalovirus infection. Cellular rejection, with or without clinical repercussion, was present in 44.4% of the patients. Conclusion: Pediatric heart transplantation produces acceptable and feasible outcomes as definitive therapy for children with end-stage heart failure.

https://doi.org/10.21470/1678-9741-2021-0483

Common Arterial Trunk with Interrupted Aortic Arch
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Estephan, Lys Molina Hernandes

; Aranda, Aline Simões

; Marchi, Carlos Henrique De

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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Fev 2022, Volume 37 Nº 1 Páginas 131 - 134

Resumo: En | Texto: En | PDF: En

Abstract Clinical data: Patient diagnosed with common arterial trunk, submitted to pulmonary artery banding in another center and lost to clinical follow-up. Referred to our center at four years old, extremely cyanotic. Chest radiography: Cardiomegaly; attenuated peripheral vascular markings. Electrocardiography: Right ventricular hypertrophy. Echocardiography: Common arterial trunk, but it was not possible to analyze all the structures. Computed tomography angiography: Van Praagh type A4 common arterial trunk. Extremely hypoplastic right and left pulmonary arteries. Diagnosis: Association of aortic arch interruption type A is uncommon and should be considered. Operation: Debanding of pulmonary arteries allowing for possible future complete repair.

https://doi.org/10.21470/1678-9741-2021-0008

Abernethy Malformation: Possible Diagnosis for Patients with Congenital Heart Disease and Persistent Cyanosis
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Brun, Marilia Maroneze

; Cardoso, Mariana Rodero

; Borim, Bruna Cury

; Marchi, Carlos Henrique De

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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2022, Nº ahead

Resumo: En | Texto: En | PDF: En

https://doi.org/10.21470/1678-9741-2022-0110

COVID-19 in the Perioperative Period of Cardiovascular Surgery: the Brazilian Experience
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Gomes, Walter J.

; Rocco, Isadora

; Pimentel, Wallace S.

; Pinheiro, Aislan H. B.

; Souza, Paulo M. S.

; Costa, Luiz A. A.

; Teixeira, Marjory M. P.

; Ohashi, Leonardo P.

; Bublitz, Caroline

; Begot, Isis

; Moreira, Rita Simone L

; Hossne Jr, Nelson A.

; Vargas, Guilherme F.

; Branco, João Nelson R.

; Teles, Carlos A.

; Medeiros, Eduardo A. S.

; Sáfadi, Camila

; Rampinelli, Amândio

; Moratelli Neto, Leopoldo

; Rosado, Anderson Rosa

; Mesacasa, Franciele Kuhn

; Capriata, Ismael Escobar

; Segalote, Rodrigo Coelho

; Palmieri, Deborah Louize da Rocha Vianna

; Jardim, Amanda Cristina Mendes

; Vianna, Diego Sarty

; Coutinho, Joaquim Henrique de Souza Aguiar

; Jazbik, João Carlos

; Coutinho, Henrique Madureira da Rocha

; Kikuta, Gustavo

; Almeida, Zely Sant'Anna Marotti de

; Feguri, Gibran Roder

; Lima, Paulo Ruiz Lucio de

; Franco, Anna Carolina

; Borges, Danilo de Cerqueira

; Cruz, Felipe Ramos Honorato De La

; Croti, Ulisses Alexandre

; Borim, Bruna Cury

; Marchi, Carlos Henrique De

; Goraieb, Lilian

; Postigo, Karolyne Barroca Sanches

; Jucá, Fabiano Gonçalves

; Oliveira, Fátima Rosane de Almeida

; Souza, Rafael Bezerra de

; Zilli, Alexandre Cabral

; Mas, Raul Gaston Sanchez

; Bettiati Junior, Luiz Carlos

; Tranchesi, Ricardo

; Bertini Jr, Ayrton

; Franco, Leandro Vieira

; Fernandes, Priscila

; Oliveira, Fabiana

; Moraes Jr, Roberto

; Araújo, Thiago Cavalcanti Vila Nova de

; Braga, Otávio Penna

; Pedrosa Sobrinho, Antônio Cavalcanti

; Teixeira, Roberta Tavares Barreto

; Camboim, Irla Lavor Lucena

; Gomes, Eduardo Nascimento

; Reis, Pedro Horigushi

; Garcia, Luara Piovan

; Scorsioni, Nelson Henrique Goes

; Lago, Roberto

; Guizilini, Solange

Brazilian Journal of Cardiovascular Surgery

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Dez 2021, Volume 36 Nº 6 Páginas 725 - 735

Resumo: En | Texto: En | PDF: En

Abstract Introduction: We investigated the clinical course and outcomes of patients submitted to cardiovascular surgery in Brazil and who had developed symptoms/signs of coronavirus disease 2019 (COVID-19) in the perioperative period. Methods: A retrospective multicenter study including 104 patients who were allocated in three groups according to time of positive real time reverse transcriptase-polymerase chain reaction (RT-PCR) for the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2): group 1, patients who underwent cardiac surgery > 10 days after positive RT-PCR; group 2, patients with a positive RT-PCR within 10 days before or after surgery; group 3, patients who presented positive RT-PCR > 10 days after surgery. The primary outcome was mortality and secondary outcomes were postoperative complications, intensive care unit (ICU) length of stay, and postoperative days of hospitalization. Results: The three groups were similar with respect to age, the European System of Cardiac Operative Risk Evaluation score, and comorbidities, except hypertension. Postoperative complications and death were significantly higher in groups 2 and 3 than in group 1, and no significant difference between groups 2 and 3 was seen. Group 2 showed a high prevalence of surgery performed as an urgent procedure. Although no significant differences were observed in ICU length of stay, total postoperative hospitalization time was significantly higher in group 3 than in groups 1 and 2. Conclusion: COVID-19 affecting the postoperative period of patients who underwent cardiovascular surgery is associated with a higher rate of morbidity and mortality. Delaying procedures in RT-PCR-positive patients may help reduce risks of perioperative complications and death.

https://doi.org/10.21470/1678-9741-2021-0960

Isolated Coarctation Repair in Neonates and Infants Through Left Thoracotomy: Short-Term Outcomes
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Murakami, Alexandre Noboru

; Croti, Ulisses Alexandre

; Cajueiro, Francisco Candido Monteiro

; Arteaga, Grace

; Pike, Roxann Barnes

; Moscardini, Airton Camacho

; Marchi, Carlos Henrique De

; Cardoso, Mariana Ribeiro Rodero

; Santos, Fernando Cesar Gimenes Barbosa

; Borim, Bruna Cury

Brazilian Journal of Cardiovascular Surgery

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Ago 2021, Volume 36 Nº 4 Páginas 461 - 467

Resumo: En | Texto: En | PDF: En

Abstract Introduction: End-to-end anastomosis and extended end-to-end anastomosis are typically used as surgical approaches to coarctation of the aorta (CoAo) with access at the subclavian artery or an interposition graft. The objective of this study is to analyze the impact of surgical and anatomical characteristics and techniques on early outcomes after surgical treatment of CoAo without cardiopulmonary bypass through left thoracotomy. Methods: This is a quantitative, observational, and cross-sectional analysis of patients who underwent repair of CoAo between July 1, 2010 and December 31, 2017. Seventy-two patients were divided into three groups according to age: 34 in group A (≤ 30 days), 24 in group B (31 days to one year), and 14 in group C (≥ 1 year to 18 years). Results: Aortic arch hypoplasia was associated in 30.8% of the cases, followed by ventricular septal defect (13.2%). The preductal location was more frequent in group A (73.5%), ductal in group B (41.7%), and postductal in group C (71.4%). Long coarcted segment was predominant in groups A and C (61.8% and 71.4%, respectively) and localized in group B (58.3%). Extended end-to-end anastomosis technique was prevalent (68%), mainly in group A (91.2%). Mortality in 30 days was 1.4%. Conclusion: Most of the patients were children under one year of age, and extended end-to-end anastomosis was the most used technique, secondary to arch hypoplasia. Further, overall mortality was low in spite of moderate morbidity in the first 30 postoperative days.

https://doi.org/10.21470/1678-9741-2020-0554

50 Years of Children’s HeartLink and the Partnerships in Brazil
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Croti, Ulisses Alexandre

; Pinto Junior, Valdester Cavalcante

; Jatene, Marcelo Biscegli

; Tsakistos, Andreas

; Zheleva, Bistra

Brazilian Journal of Cardiovascular Surgery

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Abr 2020, Volume 35 Nº 2 Páginas IV - VI

Resumo: En | Texto: En | PDF: En

https://doi.org/10.21470/1678-9741-2019-0426 133 downloads

10.

Rare Association Between Atrioventricular Septal Defect and Partial Anomalous Pulmonary Venous Connection
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Murakami, Alexandre Noboru

; Baston, Gabriela Guimarães

; Cardoso, Mariana Ribeiro Rodero

; Marchi, Carlos Henrique De

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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Dez 2019, Volume 34 Nº 6 Páginas 765 - 768

Resumo: En | Texto: En | PDF: En

Abstract Clinical data: Infant, 7 months, female, referred to our department at one month of age, suspecting of congenital heart disease for further investigation. Chest radiography: Demonstrates cardiomegaly and prominent pulmonary vascular markings. Electrocardiography: Shows right ventricular hypertrophy and left anterior fascicular block. Echocardiography: Evidenced common atrioventricular valve with two orifices and the left superior pulmonary vein draining on the brachiocephalic vein. Computed tomography angiography: This complementary imaging exam was performed to confirm the diagnosis. Diagnosis: The patient presented an association between AVSD and PAPVC, a rare combination. The clinical picture of heart failure was preponderant, characterized by need for diuretics and complementary exams findings, and early surgical treatment was indicated. Operation: The operation was performed through a median sternotomy with 123 minutes of cardiopulmonary bypass and 89 minutes of cross-clamping time. The patient had no postoperative complications, remaining 10 days hospitalized.

https://doi.org/10.21470/1678-9741-2019-0203 291 downloads

11.

The Rare Association of Tetralogy of Fallot and ALCAPA
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Murakami, Alexandre Noboru

; Baston, Gabriela Guimarães

; Cardoso, Mariana Ribeiro Rodero

; Marchi, Carlos Henrique de

; Croti, Ulisses Alexandre

Brazilian Journal of Cardiovascular Surgery

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Out 2019, Volume 34 Nº 5 Páginas 624 - 626

Resumo: En | Texto: En | PDF: En

https://doi.org/10.21470/1678-9741-2019-0139 250 downloads

12.

Surgical Treatment for Congenital Heart Defects in Down Syndrome Patients
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Santos, Fernando Cesar Gimenes Barbosa

; Croti, Ulisses Alexandre

; Marchi, Carlos Henrique De

; Murakami, Alexandre Noboru

; Brachine, Juliana Dane Pereira

; Borim, Bruna Cury

; Finoti, Renata Geron

; Godoy, Moacir Fernandes de

Brazilian Journal of Cardiovascular Surgery

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Fev 2019, Volume 34 Nº 1 Páginas 1 - 7

Resumo: En | Texto: En | PDF: En

Abstract Objective: To analyze data related to surgical treatment in patients with congenital heart defects (CHD) and Down syndrome (DS) based on information from International Quality Improvement Collaborative Database for Congenital Heart Disease (IQIC). Methods: Between July 1, 2010 and December 31, 2017, 139 patients with CHD and DS underwent surgery at Hospital de Base and Hospital da Criança e Maternidade de São José do Rio Preto (FUNFARME)/Faculdade de Medicina de São José do Rio Preto - SP (FAMERP). A quantitative, observational and cross-sectional study was performed in which the pre, intra and postoperative data were analyzed in an IQIC database. The data included gender, age, prematurity, weight, preoperative procedures, diagnosis, associated cardiac and non-cardiac anomalies, Risk Adjustment for Congenital Heart Surgery (RACHS-1), type of surgery, cardiopulmonary bypass (CPB), perfusion time, aortic clamping time and CPB temperature, bacterial sepsis, surgical site infection and other infections, length of stay in intensive care unit (ICU), length of hospital stay and in-hospital mortality. Results: The most prevalent procedures were complete atrioventricular septal defect repair (58 - 39.45%), followed by closure of ventricular septal defect (36 - 24.49%). The RACHS-1 categories 1, 2, 3 and 4 were distributed as 22 (15%); 49 (33.3%); 72 (49%) and 4 (2.7%), respectively. There were no procedures classified as categories 5 or 6. Bacterial sepsis occurred in 10.2% of cases, surgical site infection in 6.1%, other infections in 14.3%. The median length of ICU stay was 5 days and the median length of hospital stay was 11 days. In-hospital mortality was 6.8%. Conclusion: Surgical treatment in patients with CHD and DS usually does not require highly complex surgical procedures, but are affected by infectious complications, resulting in a longer ICU and hospital length of stay with considerable mortality.

https://doi.org/10.21470/1678-9741-2018-0358 1370 downloads

13.

Double Aortic Arch Associated with Pulmonary Atresia with Ventricular Septal Defect
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Santos, Fernando Cesar Gimenes Barbosa

; Croti, Ulisses Alexandre

; Marchi, Carlos Henrique De

; Hassem Sobrinho, Sírio

Brazilian Journal of Cardiovascular Surgery

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Fev 2016, Volume 31 Nº 1 Páginas 63 - 65

Resumo: En | Texto: En | PDF: En

https://doi.org/10.5935/1678-9741.20160008 1056 downloads

14.

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of complete atrioventricular septal defect
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Kozak, Marcelo Felipe

; Kozak, Ana Carolina Leiroz Ferreira Botelho Maisano

; Marchi, Carlos Henrique De

; Hassem Sobrinho Junior, Sirio

; Croti, Ulisses Alexandre

; Moscardini, Airton Camacho

Brazilian Journal of Cardiovascular Surgery

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Set 2015, Volume 30 Nº 3 Páginas 304 - 310

Resumo: Pt En | Texto: Pt En | PDF: Pt | PDF: En

ResumoIntrodução:A insuficiência da valva atrioventricular esquerda é a lesão residual mais preocupante após o tratamento cirúrgico do defeito de septo atrioventricular.Objetivo:Determinar fatores associados à insuficiência da valva atrioventricular esquerda de grau moderado ou importante nos primeiros 30 dias após correção de defeito de defeito de septo atrioventricular total.Métodos:Avaliamos os resultados em 53 pacientes consecutivos menores de 3 anos com defeito de septo atrioventricular total, operados em nosso serviço entre 2002 e 2010. Avaliamos as seguintes variáveis: idade, peso, ausência de síndrome de Down, grau de insuficiência da valva atrioventricular esquerda antes da correção, anormalidades na valva atrioventricular e uso de anuloplastia. A mediana da idade foi de 6,7 meses e a do peso de 5,3 Kg; 86,8% tinham síndrome de Down. Antes da operação, 26 apresentavam insuficiência da valva atrioventricular esquerda pelo menos moderada (49,1%). Anormalidades na valva atroventricular foram encontradas em 11,3% dos casos; anuloplastia foi realizada em 34% dos pacientes.Resultados:Após a correção, houve 21 casos com insuficiência moderada ou grave da valva atrioventricular esquerda (39,6%). Após realização de análise multivariada, o único fator associado com esses graus de insuficiência foi a ausência da síndrome de Down (P=0,03).Conclusão:Ausência de síndrome de Down esteve associada com insuficiência moderada ou grave da valva atrioventricular esquerda após correção cirúrgica de defeito de septo atrioventricular total em nosso serviço.

AbstractIntroduction:Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defects.Objective:To determine factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of surgical repair of complete atrioventricular septal defect.Methods:We assessed the results of 53 consecutive patients 3 years-old and younger presenting with complete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. Median age was 6.7 months; median weight was 5.3 Kg; 86.8% had Down syndrome. At the time of preoperative evaluation, there were 26 cases with moderate or severe left atrioventricular valve regurgitation (49.1%). Abnormalities on the left atrioventricular valve were found in 11.3%; annuloplasty was performed in 34% of the patients.Results:At the time of postoperative evaluation, there were 21 cases with moderate or severe left atrioventricular valve regurgitation (39.6%). After performing a multivariate analysis, the only significant factor associated with moderate or severe left atrioventricular valve regurgitation was the absence of Down syndrome (P=0.03).Conclusion:Absence of Down syndrome was associated with moderate or severe postoperative left atrioventricular valve regurgitation after surgical repair of complete atrioventricular septal defect at our practice.

https://doi.org/10.5935/1678-9741.20150036 1502 downloads

15.

Pediculated myxoma from atrial septum invading atria and biventricular inlets
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Cardoso, Camila Caetano

; Croti, Ulisses Alexandre

; Marchi, Carlos Henrique De

; Moscardini, Airton Camacho

Brazilian Journal of Cardiovascular Surgery

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Ago 2015, Volume 30 Nº 4 Páginas 501 - 503

Resumo: En | Texto: En | PDF: En

https://doi.org/10.5935/1678-9741.20150048 805 downloads

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