Case report
Alcohol septal ablation in obstructive acromegalic hypertrophic cardiomyopathy – a first case report
Ablação septal alcoólica na cardiomiopatia hipertrófica obstrutiva acromegálica – primeiro caso descrito
André Viveiros Monteiro
, António Fiarresga, Duarte Cacela, Lídia de Sousa, Ruben Ramos, Ana Galrinho, Luísa Branco, Rui Cruz Ferreira
Corresponding author
Cardiology Department, Hospital of Santa Marta, Lisbon, Portugal
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(B) MRI, late gadolinium enhancement; (C) T1-weighted MRI; (D) T2-weighted MRI; (E) surgical approach through the pulmonary artery; (F) macroscopic appearance of the tumor; (G) follow-up MRI, late gadolinium enhancement.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sílvia Leão, Paulo Fontes, Mário Amorim, Ilídio Moreira" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sílvia" "apellidos" => "Leão" ] 1 => array:2 [ "nombre" => "Paulo" "apellidos" => "Fontes" ] 2 => array:2 [ "nombre" => "Mário" "apellidos" => "Amorim" ] 3 => array:2 [ "nombre" => "Ilídio" "apellidos" => "Moreira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116301408" "doi" => "10.1016/j.repc.2015.11.031" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116301408?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916301349?idApp=UINPBA00004E" "url" => "/21742049/0000003500000009/v2_201704020055/S2174204916301349/v2_201704020055/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204916301325" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.11.036" "estado" => "S300" "fechaPublicacion" => "2016-09-01" "aid" => "850" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Port Cardiol. 2016;35:497.e1-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2918 "formatos" => array:3 [ "EPUB" => 183 "HTML" => 2270 "PDF" => 465 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Simple mesothelial pericardial cyst in a rare location" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "497.e1" "paginaFinal" => "497.e4" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cisto pericárdico mesotelial simples numa localização rara" ] ] "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" => 1210 "Ancho" => 2000 "Tamanyo" => 347519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A-C): Images captured during surgical resection of the cyst. (A): Cyst causing bulging of the interventricular septum and protruding into the left ventricular outflow tract; (B): intramyocardial location of the cyst; (C): cyst rupture and flow of clear fluid; (D and E): transthoracic echocardiogram after surgery showing a thin interventricular septum and delineation of the previous location of the cyst; (F and G): microscopic aspects of the cyst: (F): cyst wall, H & E stain ×100; (G): cytokeratin 5/6 ×400 (left) and vimentin ×400 (right): keratin and vimentin co-expression by the cells of the internal layer of the cyst. RE: internal cell layer of the cyst; F: fibrosis; M: myocardium.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sara Ranchordás, Catarina Gomes, Miguel Abecasis, Rosa Gouveia, João Abecasis, Luís R. Lopes, Paula Fazendas" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Sara" "apellidos" => "Ranchordás" ] 1 => array:2 [ "nombre" => "Catarina" "apellidos" => "Gomes" ] 2 => array:2 [ "nombre" => "Miguel" "apellidos" => "Abecasis" ] 3 => array:2 [ "nombre" => "Rosa" "apellidos" => "Gouveia" ] 4 => array:2 [ "nombre" => "João" "apellidos" => "Abecasis" ] 5 => array:2 [ "nombre" => "Luís R." "apellidos" => "Lopes" ] 6 => array:2 [ "nombre" => "Paula" "apellidos" => "Fazendas" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916301325?idApp=UINPBA00004E" "url" => "/21742049/0000003500000009/v2_201704020055/S2174204916301325/v2_201704020055/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Alcohol septal ablation in obstructive acromegalic hypertrophic cardiomyopathy – a first case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "499.e1" "paginaFinal" => "499.e4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "André Viveiros Monteiro, António Fiarresga, Duarte Cacela, Lídia de Sousa, Ruben Ramos, Ana Galrinho, Luísa Branco, Rui Cruz Ferreira" "autores" => array:8 [ 0 => array:4 [ "nombre" => "André" "apellidos" => "Viveiros Monteiro" "email" => array:1 [ 0 => "andreviveirosmonteiro@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "António" "apellidos" => "Fiarresga" ] 2 => array:2 [ "nombre" => "Duarte" "apellidos" => "Cacela" ] 3 => array:2 [ "nombre" => "Lídia" "apellidos" => "de Sousa" ] 4 => array:2 [ "nombre" => "Ruben" "apellidos" => "Ramos" ] 5 => array:2 [ "nombre" => "Ana" "apellidos" => "Galrinho" ] 6 => array:2 [ "nombre" => "Luísa" "apellidos" => "Branco" ] 7 => array:2 [ "nombre" => "Rui" "apellidos" => "Cruz Ferreira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Hospital of Santa Marta, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ablação septal alcoólica na cardiomiopatia hipertrófica obstrutiva acromegálica – primeiro caso descrito" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 813 "Ancho" => 950 "Tamanyo" => 135651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Myocardial contrast echocardiography image after infarction of the first septal coronary artery branch.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acromegaly is a rare disease that is most often caused by a growth hormone (GH)-secreting benign pituitary tumor and is characterized by progressive skeletal and soft tissue overgrowth, frequently accompanied by cardiovascular, cerebrovascular, and respiratory complications that contribute to the poor prognosis observed in this condition.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Cardiovascular disorders are common and are mainly responsible for the two-fold increase in mortality seen in acromegalic patients.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> The increased autonomous production of GH results in increased insulin-like growth factor 1 (IGF-1), and chronic excess secretion of both hormones is associated with various changes in cardiac structure and function due to cardiomyocyte apoptosis, with concentric cardiac hypertrophy being a frequent finding even in young patients with short disease duration. As a consequence, early impairment of left ventricular (LV) diastolic filling has been described, while impaired systolic function with heart failure may develop in later stages if the disease is untreated or unsuccessfully treated.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a> Other cardiovascular disorders such as hypertension, coronary artery disease and ventricular arrhythmias may be present and worsen acromegalic cardiomyopathy, defined as any cardiac involvement in acromegalic patients in the absence of other known causes of cardiomyopathy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Lowering of GH and IGF-1 to age-corrected normal limits is mandatory; however, treatment of acromegaly appears to improve cardiac function only in the short term, with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Alcohol septal ablation (ASA) has emerged as a minimally invasive alternative to septal myectomy for patients with obstructive hypertrophic cardiomyopathy (HCM) and symptoms refractory to medical therapy. This procedure alleviates symptoms by producing a targeted, limited infarction of the upper interventricular septum, resulting in an increase in left ventricular outflow tract (LVOT) diameter, a decrease in LVOT gradients, and regression of the component of LV hypertrophy that is due to pressure overload. Clinical success, with significant improvement in symptoms and reduction in gradients, is achieved in the great majority of patients and has been correlated with left ventricular remodeling. Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association (NYHA) class for the two procedures.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> To our knowledge, there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly. We report a case of successful ASA in acromegalic cardiomyopathy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We describe the case of a 73-year-old woman with acromegaly due to a pituitary adenoma diagnosed and treated surgically at the age of 38 but with recurrence and reoperation at the age of 50. She had a history of hypertension, multinodular goiter and atrial fibrillation under oral anticoagulation. She was referred to our cardiology department due to echocardiographic evidence of obstructive hypertrophic cardiomyopathy and a three-month history of progressively worsening exercise-induced dyspnea and orthopnea (NYHA class III) under optimal medical therapy. A complete echocardiogram revealed severe asymmetric hypertrophy of the left ventricle, mostly in the basal portion of the interventricular septum (19 mm), without LV dilation, depressed ejection fraction or wall motion abnormalities. There was also a dynamic LVOT obstruction gradient of 70 mmHg at rest and of 120 mmHg with Valsalva maneuver and systolic anterior movement (SAM) of the mitral valve with mild regurgitation and moderate to severe tricuspid regurgitation. A better characterization with magnetic resonance imaging confirmed basal interventricular septal hypertrophy without evidence of intramyocardial fibrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy. A 24-hour Holter examination revealed permanent atrial fibrillation but no ventricular repolarization or heart rate abnormalities. After a multidisciplinary discussion, ASA was performed, guided by myocardial contrast echocardiography, with injection of 2 cc of alcohol in the first septal branch of the left coronary artery (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2–4</a>). The procedure was uneventful and no atrioventricular (AV) conduction disturbances were detected. The one-year echocardiographic reassessment showed a reduction of the interventricular septum to 13 mm and of 8 mm in the region treated by ASA. The LVOT gradient was 28 mmHg at rest and the SAM of the mitral valve and the moderate to severe tricuspid regurgitation had disappeared. The patient improved significantly to mild-to-moderate heart failure (NYHA class I-II) and no major cardiovascular events were observed during follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Left ventricular hypertrophy is a well-known feature of cardiac involvement in acromegaly, affecting more than 60% of patients, independently of hypertension.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The etiology of acromegalic cardiomyopathy has not been fully clarified, but long-term elevations in serum GH and IGF-I levels may cause myocardial hypertrophy and interstitial fibrosis of cardiomyocytes by acting on these cells through specific receptors. In the present report, a 38-year history of undiagnosed acromegaly could have caused this hypertrophic structural pattern responsible for the diastolic filling abnormality observed, and eventually left ventricular dysfunction occurred, resulting in congestive heart failure.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> Several studies have demonstrated a significant decrease in LV hypertrophy following successful suppression of hormone levels by surgery or somatostatin analog treatment.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2–4</span></a> However, as seen in this case, even with corrective surgery there is the suggestion that long-standing GH and IGF-I hypersecretion modifies cardiac structure in a way that can no longer be reversed by disease control. In these cases treatment has to be guided from a cardiological standpoint.</p><p id="par0025" class="elsevierStylePara elsevierViewall">ASA has emerged as a safe and attractive modality to treat patients with obstructive HCM whose symptoms are refractory to optimal medical therapy with negative inotropic agents. The procedure has been refined over the decades since its introduction. However, concerns have been raised over the higher risk of complete AV block and development of a potentially arrhythmogenic scar after ASA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Although surgical myectomy is the standard therapy for drug-resistant obstructive HCM, ASA is an alternative that may be considered for many patients. Data indicate that the medium-term functional and hemodynamic success of ASA is high and similar to that of surgery, with the advantage that it may be performed in patients considered unsuitable for surgery.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In the case presented, the coronary anatomy was favorable, with the approachable septal coronary arteries required for the procedure, which was performed without adverse events. This first report of ASA in acromegalic cardiomyopathy highlights the need to monitor cardiac performance carefully in acromegalic patients even after suppression of GH and normalization of IGF-I levels.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0045" 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" => "xres823872" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec820467" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres823871" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec820468" "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:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-28" "fechaAceptado" => "2015-11-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec820467" "palabras" => array:3 [ 0 => "Hypertrophic cardiomyopathy" 1 => "Acromegaly" 2 => "Alcohol septal ablation" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec820468" "palabras" => array:3 [ 0 => "Cardiomiopatia hipertrófica" 1 => "Acromegalia" 2 => "Ablação septal alcoólica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acromegaly is a rare disease, mostly caused by a growth hormone (GH)-secreting benign pituitary tumor, with an increased production of GH and insulin-like growth factor 1 (IGF-1). Cardiovascular complications are common and are associated with cardiomyocyte apoptosis and concentric cardiac hypertrophy. Suppression of GH and IGF-1 appears to improve cardiac function only in the short term, with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment. Alcohol septal ablation (ASA) has emerged as a minimally invasive alternative to septal myectomy, with significant improvement in symptoms, gradients and left ventricular remodeling. In this report, we describe the case of a 73-year-old woman with acromegaly due to a pituitary adenoma diagnosed and treated surgically at the age of 38 but with recurrence and reoperation at the age of 50. She was referred to our cardiology department due to a three-month history of progressively worsening exercise-induced dyspnea and orthopnea under optimal medical therapy. Echocardiography and magnetic resonance imaging revealed severe basal hypertrophy of the interventricular septum (19 mm), dynamic left ventricular outflow tract obstruction with a gradient of 70 mmHg at rest and 120 mmHg with Valsalva maneuver, and systolic anterior movement (SAM). Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy. ASA was performed with injection of 2 cc of alcohol in the first septal branch of the left coronary artery, without complications. At one-year reassessment, significant clinical and echocardiographic improvement was noted, with disappearance of SAM. To our knowledge, there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly. We report a case of successful ASA in acromegalic cardiomyopathy.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A acromegalia é uma doença rara, causada essencialmente por um tumor benigno da glândula pituitária secretor de hormona de crescimento (HC), provocando uma produção excessiva de HC e de fator de crescimento semelhante à insulina tipo 1 (IGF-1). As complicações cardiovasculares são comuns e têm sido associadas à apoptose de cardiomiócitos e à hipertrofia cardíaca concêntrica. A supressão de HC e de IGF-1 parece melhorar a função cardíaca apenas a curto prazo, com pouco ou nenhum efeito na redução da massa ventricular esquerda ou na melhoria da função cardíaca a longo prazo. A ablação septal alcoólica (ASA) surgiu como uma alternativa minimamente invasiva à miectomia septal com melhoria significativa a nível de sintomas, gradientes e remodelagem ventricular esquerda. Neste caso clínico, descrevemos as imagens de uma mulher de 73 anos de idade, com acromegalia devido a um adenoma da glândula pituitária diagnosticado, e submetida a cirurgia aos 38 anos, mas com recorrência e reoperação aos 50 anos. A doente foi referenciada ao nosso departamento de cardiologia por um quadro com três meses de evolução de dispneia de esforço e ortopneia com agravamento progressivo sob terapêutica médica otimizada. O ecocardiograma e ressonância magnética cardíaca revelaram uma hipertrofia grave da porção basal do septo interventricular (19 mm), com um gradiente obstrutivo dinâmico da câmara de saída do ventrículo esquerdo de 70 mmHg em repouso e de 120 mmHg com a manobra de Valsalva e com movimento sistólico anterior (SAM) da válvula mitral. A avaliação genética excluiu as formas mais frequentes de cardiomiopatia hipertrófica (CMH) familiar. A ASA foi realizada com 2 cc de injeção de álcool na primeira artéria coronária septal, sem complicações. Na reavaliação do primeiro ano, houve uma melhora clínica e ecocardiográfica significativa com o desaparecimento de SAM. Tanto quanto é do nosso conhecimento, não existe na literatura a descrição de casos de ASA em doentes com CMH por acromegalia. Relatamos aqui o caso de uma ASA bem-sucedida numa cardiomiopatia acromegálica.</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" => 741 "Ancho" => 950 "Tamanyo" => 79683 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance image showing basal interventricular septal hypertrophy.</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" => 815 "Ancho" => 950 "Tamanyo" => 83486 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography image before alcoholic septal ablation showing the first septal coronary artery branch (arrow).</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" => 813 "Ancho" => 950 "Tamanyo" => 135651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Myocardial contrast echocardiography image after infarction of the first septal coronary artery branch.</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" => 734 "Ancho" => 950 "Tamanyo" => 75338 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography image after alcoholic septal ablation showing proximal occlusion of the first septal coronary artery branch (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic hypertension and impaired glucose tolerance are independently correlated to the severity of the acromegalic cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 6 | 12 |
| 2024 October | 39 | 26 | 65 |
| 2024 September | 47 | 26 | 73 |
| 2024 August | 47 | 29 | 76 |
| 2024 July | 33 | 33 | 66 |
| 2024 June | 32 | 19 | 51 |
| 2024 May | 37 | 25 | 62 |
| 2024 April | 39 | 29 | 68 |
| 2024 March | 36 | 25 | 61 |
| 2024 February | 36 | 32 | 68 |
| 2024 January | 40 | 33 | 73 |
| 2023 December | 51 | 26 | 77 |
| 2023 November | 46 | 22 | 68 |
| 2023 October | 31 | 17 | 48 |
| 2023 September | 27 | 21 | 48 |
| 2023 August | 35 | 22 | 57 |
| 2023 July | 35 | 11 | 46 |
| 2023 June | 37 | 5 | 42 |
| 2023 May | 42 | 15 | 57 |
| 2023 April | 28 | 4 | 32 |
| 2023 March | 38 | 13 | 51 |
| 2023 February | 34 | 19 | 53 |
| 2023 January | 28 | 16 | 44 |
| 2022 December | 42 | 20 | 62 |
| 2022 November | 34 | 27 | 61 |
| 2022 October | 32 | 11 | 43 |
| 2022 September | 35 | 28 | 63 |
| 2022 August | 35 | 35 | 70 |
| 2022 July | 40 | 30 | 70 |
| 2022 June | 30 | 19 | 49 |
| 2022 May | 27 | 35 | 62 |
| 2022 April | 34 | 26 | 60 |
| 2022 March | 26 | 35 | 61 |
| 2022 February | 21 | 17 | 38 |
| 2022 January | 24 | 19 | 43 |
| 2021 December | 26 | 30 | 56 |
| 2021 November | 39 | 33 | 72 |
| 2021 October | 34 | 43 | 77 |
| 2021 September | 26 | 24 | 50 |
| 2021 August | 41 | 28 | 69 |
| 2021 July | 30 | 29 | 59 |
| 2021 June | 38 | 29 | 67 |
| 2021 May | 53 | 38 | 91 |
| 2021 April | 85 | 30 | 115 |
| 2021 March | 48 | 28 | 76 |
| 2021 February | 57 | 26 | 83 |
| 2021 January | 33 | 11 | 44 |
| 2020 December | 44 | 6 | 50 |
| 2020 November | 39 | 15 | 54 |
| 2020 October | 31 | 12 | 43 |
| 2020 September | 60 | 11 | 71 |
| 2020 August | 31 | 7 | 38 |
| 2020 July | 66 | 15 | 81 |
| 2020 June | 41 | 13 | 54 |
| 2020 May | 54 | 2 | 56 |
| 2020 April | 49 | 12 | 61 |
| 2020 March | 42 | 8 | 50 |
| 2020 February | 139 | 35 | 174 |
| 2020 January | 39 | 7 | 46 |
| 2019 December | 37 | 5 | 42 |
| 2019 November | 29 | 5 | 34 |
| 2019 October | 26 | 7 | 33 |
| 2019 September | 46 | 8 | 54 |
| 2019 August | 34 | 6 | 40 |
| 2019 July | 26 | 9 | 35 |
| 2019 June | 37 | 14 | 51 |
| 2019 May | 37 | 12 | 49 |
| 2019 April | 26 | 23 | 49 |
| 2019 March | 64 | 19 | 83 |
| 2019 February | 71 | 10 | 81 |
| 2019 January | 42 | 8 | 50 |
| 2018 December | 75 | 14 | 89 |
| 2018 November | 85 | 9 | 94 |
| 2018 October | 146 | 21 | 167 |
| 2018 September | 63 | 14 | 77 |
| 2018 August | 25 | 6 | 31 |
| 2018 July | 22 | 3 | 25 |
| 2018 June | 26 | 3 | 29 |
| 2018 May | 59 | 13 | 72 |
| 2018 April | 45 | 14 | 59 |
| 2018 March | 45 | 7 | 52 |
| 2018 February | 54 | 6 | 60 |
| 2018 January | 65 | 8 | 73 |
| 2017 December | 77 | 6 | 83 |
| 2017 November | 33 | 9 | 42 |
| 2017 October | 32 | 12 | 44 |
| 2017 September | 32 | 9 | 41 |
| 2017 August | 23 | 12 | 35 |
| 2017 July | 18 | 11 | 29 |
| 2017 June | 20 | 5 | 25 |
| 2017 May | 22 | 7 | 29 |
| 2017 April | 25 | 4 | 29 |
| 2017 March | 24 | 12 | 36 |
| 2017 February | 31 | 3 | 34 |
| 2017 January | 33 | 6 | 39 |
| 2016 December | 45 | 7 | 52 |
| 2016 November | 44 | 11 | 55 |
| 2016 October | 55 | 19 | 74 |
| 2016 September | 41 | 17 | 58 |
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