Case report
Giant high-pressure pulmonary artery aneurysm in an elderly patient with chronic obstructive pulmonary disease
Aneurisma gigante da artéria pulmonar de altas pressões em idoso com doença obstrutiva pulmonar crónica
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Há «fendas» e fendas" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2030 "Ancho" => 2917 "Tamanyo" => 477042 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A and B) Two-dimensional transesophageal echocardiography, transgastric view, showing mitral valve anterior leaflet cleft (*) in diastole (A) and in systole (B); (C and D) real-time three-dimensional zoom, cropped images: in diastole, anterior leaflet cleft in atrial view (C) and ventricular view (D). 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Morais, Hugo M. Oliveira, José R. de Almeida, Eduardo Eiras, Ana Catarina Silva, Cristina Gavina" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Sandra A." "apellidos" => "Morais" "email" => array:1 [ 0 => "sandramorais13@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Hugo M." "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "José R." "apellidos" => "de Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Eiras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Ana Catarina" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Cristina" "apellidos" => "Gavina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Serviço de Medicina Interna, ULSM – Hospital Pedro Hispano, Matosinhos, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Radiologia, ULSM – Hospital Pedro Hispano, Matosinhos, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Cardiologia, ULSM – Hospital Pedro Hispano, Matosinhos, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aneurisma gigante da artéria pulmonar de altas pressões em idoso com doença obstrutiva pulmonar crónica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 649 "Ancho" => 1500 "Tamanyo" => 117503 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography scan, February 2011, revealing pronounced dilatation of the pulmonary trunk, with a maximum diameter of 72 mm, and enlargement of the main pulmonary arteries, 40 mm in diameter on the right and 33 mm in diameter on the left.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary artery aneurysm (PAA) is a rare condition appearing in 1/14<span class="elsevierStyleHsp" style=""></span>000 of autopsies.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> However, there are no prospective studies focusing on PAA, so its precise incidence is unknown.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Many patients are completely asymptomatic and are diagnosed incidentally in imaging studies.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> A high index of suspicion is thus required for an accurate diagnosis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The treatment of high-pressure PAA remains controversial but most case reports support a trend for surgical intervention due to the high risk of complications.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a 74-year-old Caucasian male followed in our hospital for the past two decades. The patient had a history of chronic obstructive pulmonary disease (COPD), Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging system grade 3, high blood pressure, chronic atrial fibrillation (CAF), chronic right heart failure (HF) classified as New York Heart Association (NYHA) functional class II, and a 60 pack-year history of cigarette smoking.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Reviewing the patient's medical record we found a chest radiograph from 1992 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>, left), on which mediastinal enlargement was already present.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During the first decade of follow-up the patient remained stable under standard medical treatment for COPD and HF, and anticoagulation for CAF.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2000 the patient had a gastrointestinal hemorrhage forcing the suspension of anticoagulation. Pharmacological rate control with digoxin was started for treatment of CAF.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In February 2011 a routine transthoracic echocardiogram revealed moderate to severe dilatation of both atria and mild dilatation of both ventricles with normal thickness of the ventricular walls. There was no significant morphological alteration in valve structures. Moderate mitral regurgitation, mild aortic and pulmonary regurgitation, and mild to moderate tricuspid regurgitation were observed. Pulmonary artery systolic pressure (PASP) was 60 mmHg. Biventricular systolic function was preserved.</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the basis of the echocardiographic findings, pulmonary hypertension due to lung disease (GOLD grade 3) was diagnosed.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A routine thoracic computed tomography (CT) scan (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) was also performed in February 2011 and revealed pronounced dilatation of the pulmonary trunk, with a maximum diameter of 72 mm, and dilatation of the main pulmonary arteries, 40 mm in diameter on the right and 33 mm in diameter on the left. There was no evidence of thrombus in the central pulmonary arteries.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The imaging exams led to a diagnosis of a giant pulmonary artery aneurysm (PAA). Closer examination of the recent chest radiographs (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>, right) confirmed the persistence of mediastinal enlargement, without significant increase, which, in comparison with the oldest chest radiograph, showed that the evolution of the PAA had been stable for the previous 20 years.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite the patient's stable evolution under medical treatment for the last 10 years, he was admitted to our hospital in March 2012 with severe right HF.</p><p id="par0065" class="elsevierStylePara elsevierViewall">On admission, physical examination revealed blood pressure of 112/63 mmHg, mild peripheral cyanosis, and increased expiratory time, jugular venous distention, and crackles in both lung bases on pulmonary auscultation; cardiac auscultation revealed arrhythmia with a mean ventricular rate of 70 bpm, and severe lower limb edema was observed.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Laboratory tests performed in the emergency department showed leukocyte count of 4100/μl, 59.7% neutrophils, 12.2 g/dl hemoglobin, and C-reactive protein 5.6 mg/l. On biochemical analysis, electrolytes, renal and liver function, cardiac enzymes and coagulation were all within normal limits, but serum brain natriuretic peptide (BNP) level was elevated (577.4 pg/ml).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Electrocardiography showed atrial fibrillation with a ventricular rhythm of 63/min, and no significant ST-T abnormalities (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The chest radiograph (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) showed an increased cardiothoracic index, mainly due to enlargement of the right atrium and pulmonary artery.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Thoracic CT angiography revealed a PAA 72 mm in diameter but no signs of thromboembolism or thrombosis in the main pulmonary arteries and branches (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The transthoracic echocardiogram showed a PAA (not quantified because of a poor acoustic window), mild tricuspid regurgitation and PASP of 52 mmHg. The right atrial chamber was dilated and right ventricular systolic function was preserved.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The patient was admitted to the medical ward with a diagnosis of HF and was started on high-dose diuretics, with significant clinical improvement.</p><p id="par0095" class="elsevierStylePara elsevierViewall">A history of major thoracic trauma or significant clinical infection was ruled out, and antinuclear autoantibodies, serology for HIV1 and 2, and the Venereal Disease Research Laboratory and <span class="elsevierStyleItalic">Treponema pallidum</span> hemagglutination tests for syphilis were negative.</p><p id="par0100" class="elsevierStylePara elsevierViewall">After optimization of medical therapy the patient underwent right cardiac catheterization, which revealed mean pulmonary arterial pressure of 26 mmHg, right atrial pressure of 8 mmHg, pulmonary capillary wedge pressure of 12 mmHg, pulmonary vascular resistance of 3.8 Wood units and cardiac index of 2.0 l/min/m<span class="elsevierStyleSup">2</span>, which is compatible with mild precapillary pulmonary hypertension.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The diagnosis was of a giant PAA with precapillary pulmonary hypertension, possibly related to COPD (GOLD grade 3). Since there is no specific evidence-based treatment for this condition, the patient was discharged on standard HF medication, with the indication for clinical surveillance and specific treatment for COPD. At two-year follow-up he was in a stable condition and the control thoracic CT scan showed no increase in the size of the PAA.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the literature, several etiologies have been described in the pathogenesis of PAA, including congenital cardiac malformations with intracardiac shunt, vascular abnormalities such as arteritis (e.g., Takayasu disease) and primary pulmonary hypertension, vasculitis (e.g., Behçet's disease), connective tissue disorders (such as Marfan, Ehlers-Danlos and Hughes-Stovin syndromes and systemic lupus erythematosus), tuberous sclerosis, atherosclerosis, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), vascular trauma, tuberculosis, syphilis, and bacterial, fungal or other infections.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Since the introduction of antibiotics, non-infectious causes of PAA have become more common,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> with recent studies revealing an association in more than 50% of cases with congenital heart disease.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">PAA is defined by pulmonary artery dilatation of >40 mm,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> with some authors considering that dilatation >50 mm defines a giant aneurysm.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The clinical manifestations of PAA are diverse and non-specific. Symptoms include chest pain, dyspnea, cough, hemoptysis or palpitations.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,8</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Nevertheless, it can be asymptomatic, only found incidentally on a routine imaging study such as a chest radiograph, as in our patient.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Imaging studies such as CT, echocardiography and cardiac catheterization aid in the diagnosis and prediction of complications, however the gold standard for establishing a diagnosis of PAA is pulmonary angiography.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">There is no consensus on the management of PAA, as different etiologies lead to different management approaches.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> In fact, since PAA is a rare lesion, there are no clear guidelines on treatment and patients have been managed individually.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Surgical intervention is generally recommended for symptomatic patients and in those with underlying diseases or complications, left-to-right shunt, pulmonary arterial hypertension and large aneurysm size (≥60 mm diameter).<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5,13–15</span></a> Nevertheless, some authors consider that PAA, even when very large, confer low risk in the presence of low pulmonary pressures, absence of congenital or acquired significant right shunt and no association with collagenopathies.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7,15</span></a> As these patients have a relatively benign prognosis with an uncomplicated course, some authors, not surprisingly, argue that conservative management is a reasonable strategy.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">However, little is known about the natural history of PAA, and whatever treatment is chosen, close follow-up is essential.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The approach to high-pressure PAA is even more controversial. Many authors support an aggressive surgical approach in a presence of severe complications such as airway compression,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> pulmonary artery dissection<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> and intravascular thrombosis, with most reports describing an unfavorable evolution, such as low quality of life or even death, with medical treatment only.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,9,20</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In the case presented, we describe the longest reported history of an uncomplicated giant high-pressure PAA, with at least 20 years of evolution without significant complications, favoring a conservative approach for such cases.</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our case we suspect that the recent unfavorable evolution of COPD may have contributed to the patient's HF.</p><p id="par0170" class="elsevierStylePara elsevierViewall">According to the literature, intensification of specific pulmonary hypertension treatment improves airway compression. Maintenance of anticoagulation, although controversial, is usually needed due to the risk of PAA thrombosis. Nevertheless this may be need to be suspended in cases of hemoptysis, progressive growth of the PAA or concomitant dissection.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> In our case, although indicated, we decided not to start anticoagulation as we believed that the risk of death due to rupture of the PAA in a patient under anticoagulation was higher than the risk of thrombus formation.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Treatment with conventional vasodilators is not recommended in this case since they may impair gas exchange due to the inhibition of hypoxic pulmonary vasoconstriction. In addition, loss of efficacy is observed after long-term use.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Therefore, as the patient had a stable evolution for more than 20 years and his current clinical condition was being treated medically, we decided to maintain a conservative approach and monitor the other clinical conditions.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">In the case presented, the recent onset of HF was explained by precapillary pulmonary hypertension associated with COPD in a patient with a giant high-pressure PAA.</p><p id="par0190" class="elsevierStylePara elsevierViewall">A surgical approach was considered, nevertheless, since our patient has severe lung disease which would have significantly increased the surgical risk, we decided not to follow this approach.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion, giant high-pressure PAA is a rare condition for which in most cases surgical intervention is recommended, nevertheless, since our patient has had a stable evolution for more than 20 years, contradicting the accepted belief found in the literature, we decided to maintain a conservative approach and monitor the patient's comorbidities closely.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres617692" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec631904" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres617691" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec631905" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-02" "fechaAceptado" => "2015-06-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec631904" "palabras" => array:5 [ 0 => "Pulmonary artery aneurysm" 1 => "High pressure" 2 => "Pulmonary hypertension" 3 => "Chronic obstructive pulmonary disease" 4 => "Heart failure" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec631905" "palabras" => array:5 [ 0 => "Aneurisma da artéria pulmonar" 1 => "Altas pressões" 2 => "Hipertensão pulmonar" 3 => "Doença obstrutiva pulmonar crónica" 4 => "Insuficiência cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors report the case of a 74-year-old man, with a history of chronic obstructive pulmonary disease (COPD), GOLD grade 3, stable for the past two decades, who was admitted to our center with severe right heart failure.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The chest radiograph showed moderate heart enlargement mainly of the right atrium and pulmonary artery, similar to previous chest radiographs in the previous 20 years. The transthoracic echocardiogram showed a pulmonary artery aneurysm (PAA), dilatation of the right chambers with pulmonary artery systolic pressure of 52 mmHg, and preserved right ventricular systolic function. A thoracic computed tomography scan confirmed the presence of a giant PAA 72 mm in diameter.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patient was started on high-dose diuretics, with significant clinical improvement.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">After optimization of medical therapy right heart catheterization was carried out with the patient in optimal clinical condition, which revealed mild precapillary pulmonary hypertension with a mean pulmonary artery pressure of 26 mmHg.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">On the basis of the clinical and imaging findings a stable, giant, high-pressure, PAA was diagnosed secondary to pulmonary hypertension induced by COPD, with a 20-year follow-up without need for surgical repair, which helped in our decision to maintain medical surveillance. The recent onset of heart failure is explained by the unfavorable evolution of COPD.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This case may change the attitude expressed in previous studies favoring the choice of an invasive approach to treat giant high-pressure PAAs, instead supporting the maintenance of medical treatment.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Os autores relatam o caso de um homem de 74 anos, com história de doença obstrutiva pulmonar crónica (DPOC), categoria C de GOLD, estável nas últimas duas décadas, admitido por insuficiência cardíaca grave de câmaras direitas.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Na radiografia torácica era evidente o alargamento da silhueta cardíaca, em particular da aurícula direita e artéria pulmonar, sendo sobreponível a radiografias torácicas realizadas ao longo dos últimos 20 anos. O ecocardiograma transtorácico documentou um aneurisma da artéria pulmonar (AAP), dilatação das câmaras direitas, com pressão sistólica da artéria pulmonar de 52 mmHg e função sistólica do ventrículo direito preservada. A TC torácica confirmou a presença de um aneurisma gigante da artéria pulmonar com 72 mm de diâmetro.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Iniciou-se terapêutica diurética intensiva, com melhoria clínica.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Após otimização e com o doente clinicamente estável, foi realizado cateterismo cardíaco, que revelou hipertensão pulmonar pré-capilar ligeira com uma pressão da artéria pulmonar média de 26 mmHg.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Acreditamos que os dados clínicos e imagiológicos permitiram diagnosticar um aneurisma gigante da artéria pulmonar de altas pressões secundário a hipertensão pulmonar em contexto de DPOC, atualmente estável e com um seguimento de 20 anos sem necessidade de intervenção cirúrgica, que fundamentou a decisão de manter a vigilância médica, sendo a instalação recente de insuficiência cardíaca explicada pela progressão da DPOC.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Este caso poderá alterar a ideia defendida em estudos prévios, que favorecia a escolha de uma abordagem invasiva no tratamento de aneurismas gigantes da artéria pulmonar de altas pressões, dando mais robustez à manutenção de um tratamento médico.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 633 "Ancho" => 1490 "Tamanyo" => 68143 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Chest radiographs from 1992 (left) and 2011 (right) showing mediastinal enlargement.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 649 "Ancho" => 1500 "Tamanyo" => 117503 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography scan, February 2011, revealing pronounced dilatation of the pulmonary trunk, with a maximum diameter of 72 mm, and enlargement of the main pulmonary arteries, 40 mm in diameter on the right and 33 mm in diameter on the left.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 869 "Ancho" => 1800 "Tamanyo" => 532581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram, February 2012, showing atrial fibrillation with a ventricular rhythm of 63/min, and no significant ST-T abnormalities.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 645 "Ancho" => 1500 "Tamanyo" => 106509 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography, March 2012, revealing a pulmonary artery aneurysm 72 mm in diameter.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aneurysm of the pulmonary artery: review of literature and report of a case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 4 | 17 |
| 2024 October | 65 | 30 | 95 |
| 2024 September | 69 | 21 | 90 |
| 2024 August | 49 | 25 | 74 |
| 2024 July | 30 | 28 | 58 |
| 2024 June | 28 | 22 | 50 |
| 2024 May | 41 | 26 | 67 |
| 2024 April | 21 | 21 | 42 |
| 2024 March | 45 | 21 | 66 |
| 2024 February | 33 | 29 | 62 |
| 2024 January | 25 | 30 | 55 |
| 2023 December | 28 | 28 | 56 |
| 2023 November | 20 | 21 | 41 |
| 2023 October | 18 | 12 | 30 |
| 2023 September | 28 | 25 | 53 |
| 2023 August | 31 | 23 | 54 |
| 2023 July | 20 | 12 | 32 |
| 2023 June | 25 | 9 | 34 |
| 2023 May | 37 | 22 | 59 |
| 2023 April | 20 | 3 | 23 |
| 2023 March | 23 | 26 | 49 |
| 2023 February | 21 | 17 | 38 |
| 2023 January | 23 | 7 | 30 |
| 2022 December | 28 | 17 | 45 |
| 2022 November | 33 | 26 | 59 |
| 2022 October | 29 | 15 | 44 |
| 2022 September | 20 | 19 | 39 |
| 2022 August | 28 | 22 | 50 |
| 2022 July | 36 | 24 | 60 |
| 2022 June | 19 | 16 | 35 |
| 2022 May | 29 | 33 | 62 |
| 2022 April | 34 | 21 | 55 |
| 2022 March | 32 | 24 | 56 |
| 2022 February | 22 | 22 | 44 |
| 2022 January | 30 | 18 | 48 |
| 2021 December | 23 | 28 | 51 |
| 2021 November | 34 | 46 | 80 |
| 2021 October | 36 | 38 | 74 |
| 2021 September | 34 | 33 | 67 |
| 2021 August | 38 | 25 | 63 |
| 2021 July | 24 | 25 | 49 |
| 2021 June | 29 | 18 | 47 |
| 2021 May | 30 | 28 | 58 |
| 2021 April | 55 | 29 | 84 |
| 2021 March | 70 | 23 | 93 |
| 2021 February | 93 | 16 | 109 |
| 2021 January | 31 | 15 | 46 |
| 2020 December | 39 | 7 | 46 |
| 2020 November | 38 | 11 | 49 |
| 2020 October | 28 | 12 | 40 |
| 2020 September | 29 | 10 | 39 |
| 2020 August | 31 | 12 | 43 |
| 2020 July | 58 | 8 | 66 |
| 2020 June | 43 | 3 | 46 |
| 2020 May | 52 | 4 | 56 |
| 2020 April | 34 | 7 | 41 |
| 2020 March | 35 | 8 | 43 |
| 2020 February | 92 | 10 | 102 |
| 2020 January | 33 | 3 | 36 |
| 2019 December | 27 | 5 | 32 |
| 2019 November | 43 | 6 | 49 |
| 2019 October | 39 | 6 | 45 |
| 2019 September | 63 | 6 | 69 |
| 2019 August | 23 | 7 | 30 |
| 2019 July | 40 | 14 | 54 |
| 2019 June | 28 | 5 | 33 |
| 2019 May | 51 | 7 | 58 |
| 2019 April | 32 | 11 | 43 |
| 2019 March | 94 | 13 | 107 |
| 2019 February | 75 | 12 | 87 |
| 2019 January | 83 | 12 | 95 |
| 2018 December | 68 | 14 | 82 |
| 2018 November | 184 | 9 | 193 |
| 2018 October | 459 | 23 | 482 |
| 2018 September | 112 | 12 | 124 |
| 2018 August | 94 | 6 | 100 |
| 2018 July | 36 | 6 | 42 |
| 2018 June | 42 | 3 | 45 |
| 2018 May | 36 | 8 | 44 |
| 2018 April | 64 | 4 | 68 |
| 2018 March | 69 | 5 | 74 |
| 2018 February | 30 | 9 | 39 |
| 2018 January | 39 | 10 | 49 |
| 2017 December | 69 | 21 | 90 |
| 2017 November | 32 | 11 | 43 |
| 2017 October | 40 | 15 | 55 |
| 2017 September | 45 | 10 | 55 |
| 2017 August | 32 | 10 | 42 |
| 2017 July | 21 | 16 | 37 |
| 2017 June | 38 | 11 | 49 |
| 2017 May | 46 | 7 | 53 |
| 2017 April | 21 | 10 | 31 |
| 2017 March | 23 | 22 | 45 |
| 2017 February | 34 | 14 | 48 |
| 2017 January | 30 | 3 | 33 |
| 2016 December | 28 | 10 | 38 |
| 2016 November | 22 | 2 | 24 |
| 2016 October | 41 | 3 | 44 |
| 2016 September | 37 | 5 | 42 |
| 2016 August | 19 | 1 | 20 |
| 2016 July | 22 | 2 | 24 |
| 2016 June | 15 | 8 | 23 |
| 2016 May | 17 | 12 | 29 |
| 2016 April | 23 | 1 | 24 |
| 2016 March | 30 | 11 | 41 |
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