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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cardiac and pericardial tumors are rare entities with an autopsy frequency of 0&#46;001-0&#46;03&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Metastases to the heart and pericardium are much more common &#40;100-1000 times&#41; than primary tumors&#44; with the underlying malignant origin&#44; in most cases&#44; being carcinoma of the lung&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Primary cardiac tumors present with one or more symptoms of the classic triad of cardiac symptoms and signs resulting from intracardiac obstruction&#44; signs of systemic embolization&#44; and systemic or constitutional symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> Unlike primary malignant cardiac tumors&#44; which account for up to 25&#37; of cases&#44; malignant pericardial mesotheliomas account for up to 50&#37; of primary pericardial tumors&#46; The mean age of presentation is 46 years and they are twice as common in males than in females&#46; We present the case of a patient with a primary pericardial mesothelioma presenting with ST-elevation myocardial infarction&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 75-year-old Caucasian woman with a previous history of hypertension&#44; dyslipidemia and a left total hip replacement&#46; She was medicated with lisinopril-hydrochlorothiazide&#44; bisoprolol and atorvastatin&#46; Additionally&#44; she was recently diagnosed with atrial fibrillation and was on warfarin&#46; She had no previous symptoms of cardiac disease&#46; She went to the emergency department of the local hospital due to nonspecific thoracic discomfort and malaise of over six hours duration associated with an episode of syncope&#46; She also reported dyspnea on moderate exertion of two weeks duration&#46; A complete blood count &#40;CBC&#41; and biochemistry revealed anemia and thrombocytopenia&#44; with no other changes&#46; The patient denied other signs or symptoms&#46; Physical examination revealed a low-amplitude arrhythmic pulse&#44; no heart murmurs and no signs of pulmonary congestion&#44; blood pressure of 95&#47;56 mmHg&#44; heart rate of 101 beats per minute&#44; and peripheral oxygen saturation of 85&#37;&#46; The CBC revealed anemia &#40;Hg 8&#46;9 g&#47;dl&#41; and thrombocytopenia &#40;80 000 U&#47;l&#41;&#46; Biochemistry results revealed elevated serum cardiac troponin I &#40;0&#46;9 ng&#47;ml&#59; normal &#60;0&#46;04 ng&#47;ml&#41;&#46; A chest X-ray revealed a cardiothoracic index of &#62;50&#37; with widening of the mediastinum&#46; The ECG revealed atrial fibrillation with ST-segment elevation in V2-V6&#44; I and aVL&#46; The patient was immediately transferred to a tertiary centre for emergent coronary angiography&#44; which revealed a long stenosis of 50&#37; in the mid-distal portion of the left anterior descending artery &#40;with TIMI 3 flow&#41; and a focal 30&#37; stenosis in the mid segment of the right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Left ventriculography revealed a hyperkinetic left ventricle and apical akinesia but otherwise normal systolic function&#46; In the minutes after cardiac catheterization&#44; the patient developed hypotension &#40;systolic blood pressure of 85-90 mmHg&#41; and slight chest discomfort persisted&#46; An echocardiogram was performed and revealed a large pericardial effusion with diffuse thickening of the myocardium&#44; mainly in the anterolateral wall and apex&#44; which was assumed to be adherent fibrin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Due to worsening hemodynamic status and echocardiographic findings in a patient with chest pain&#44; ST-elevation on the ECG and elevated cardiac troponin&#44; cardiac rupture was suspected and the patient underwent urgent sternotomy and pericardiotomy with drainage of a large quantity of bloody fluid followed by hemodynamic recovery&#46; The surgeons then identified a large unresectable tumor occupying the distal half of the anterior portion of the heart&#44; which was biopsied &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; The patient was admitted to the cardiothoracic intensive care unit and was extubated on day 2 after surgery&#44; and was then transferred to an intermediate care unit&#44; with a favorable clinical status&#46; A cervical-thoraco-abdominal-pelvic computed tomography &#40;CT&#41; scan was performed that identified myocardial tumor infiltration &#40;measuring 6 cm&#215;7 cm&#215;11 cm&#41; and pulmonary&#44; cervical and abdominal wall metastases&#46; The pathological study revealed a malignant mesothelioma&#46; The immunohistochemical study documented diffuse expression of AE1&#47;AE3&#44; vimentin and MDM2 in tumor cells and focal expression of calretinin&#44; EMA&#44; podoplanin&#44; desmin and p53 &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An oncological group meeting decided to start chemotherapy with pemetrexed and carboplatin on the eighth day of hospitalization&#46; The patient was transferred to the medical oncology department after 14 days of hospitalization &#40;sixth day of chemotherapy&#41;&#46; She remained clinically stable but showed a gradual deterioration in her general condition&#44; with anorexia and asthenia&#44; and died suddenly on the 30th day of hospitalization&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is&#44; to our knowledge&#44; the first case report of primary pericardial mesothelioma presenting with suspected ST-elevation myocardial infarction &#40;STEMI&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are rare entities&#44; with an estimated prevalence of 0&#46;001-0&#46;056&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;4</span></a> Primary pericardial tumors are even rarer&#44; with an estimated prevalence of 0&#46;001-0&#46;007&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> These can be benign &#40;teratoma&#44; fibroma&#44; angioma&#44; lipoma&#41; or malignant &#40;mesothelioma&#44; sarcoma&#41;&#46; Pericardial mesothelioma is extremely rare&#44; although it is the most common primary malignant pericardial tumor&#44; accounting for 50&#37; of primary pericardial tumors&#46; Its incidence was 0&#46;0022&#37; among 500 000 cases in a large necropsy study&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Metastatic tumors are much more common&#44; arising mostly from the lung&#44; breast&#44; skin or blood &#40;lymphoma or leukemia&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;6</span></a> Age at presentation ranges from 2 to 78 years and they are more frequent in men &#40;2&#58;1 male to female ratio&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Common clinical manifestations of pericardial mesothelioma include heart failure &#40;due to cardiac tamponade&#44; constrictive pericarditis and in some cases myocardial infiltration&#41;&#59; pericardial effusion and ischemic cardiac pain &#40;angina&#41; may also be present due to coronary artery compression by the tumor&#46; The onset of symptoms is usually insidious&#46; Distant metastasis&#44; conduction block due to myocardial infiltration and tumor embolism causing neurological deficits have also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pericardial mesotheliomas usually grow as a bulky mass that encircles the heart with few foci of myocardial infiltration&#46; Magnetic resonance imaging &#40;MRI&#41; and CT are useful in showing the extent of involvement of contiguous structures and the degree of constriction&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In several case reports the most common mode of presentation of pericardial mesothelioma was the development of pericarditis that evolved to constrictive pericarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#8211;11</span></a> sometimes associated with a circumferential pericardial effusion for which diagnostic pericardiocentesis was not conclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> In the case presented&#44; the clinical presentation was sudden&#44; mimicking an anterior wall STEMI&#46; The suspicion of left ventricular rupture was founded on the observation of a pericardial effusion&#44; with a suspected large quantity of fibrin adjacent to the myocardium&#44; associated with hypotension&#44; indicating cardiac tamponade&#46; As previously described&#44; the sensitivity of echocardiography in the identification of pericardial mesothelioma is low&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> and CT scanning and MRI are preferable since these techniques not only detect invasion of adjacent structures and the presence of metastases but also&#44; in the case of MRI&#44; can assess the presence of constriction and ventricular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case&#44; direct observation of the tumor led to biopsy and the final diagnosis&#46; At the histological level&#44; pericardial and pleural mesotheliomas are similar&#46; The tumor cells can have three distinct patterns&#58; &#40;1&#41; predominance of epithelioid cells&#59; &#40;2&#41; predominance of fibrous &#40;spindle&#41; cells&#59; and &#40;3&#41; mixed-type &#40;which was the pattern observed in this case&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Unlike pleural mesothelioma&#44; which has a well-established association with previous exposure to asbestos&#44; in pericardial mesothelioma this association is less strong&#44; and our patient had no history of present or past contact with asbestos products&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">These are highly malignant tumors and when diagnosed are usually already at an advanced stage&#46; Mesotheliomas respond poorly to radiotherapy and chemotherapy is usually employed to reduce tumor mass&#46; Resection may be curative but only in small&#44; localized tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Surgical intervention in pericardial mesothelioma is primarily for effusion control&#44; for cytoreduction before multimodal therapy&#44; or to deliver and monitor innovative intrapericardial therapies&#46; Chemotherapy and pericardiotomy &#40;for prevention of cardiac tamponade and relief of constriction&#41; are the bases of palliative care&#46; A pericardial window can be formed to introduce chemotherapeutic agents&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">With regards to prognosis&#44; survival is extremely low&#44; between 3&#46;5 and 6 months after diagnosis&#46; The most common causes of death are cardiac tamponade and heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></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="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Mesothelioma"
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            1 => "Mesotelioma"
            2 => "Tumor card&#237;aco"
            3 => "Mesotelioma peric&#225;rdico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary cardiac and pericardial tumors are rare entities with an autopsy frequency of 0&#46;001-0&#46;03&#37;&#46; Metastases to the heart and pericardium are much more common than primary tumors&#46; Malignant pericardial mesotheliomas account for up to 50&#37; of primary pericardial tumors&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 75-year-old woman with hypertension&#44; dyslipidemia and atrial fibrillation who went to the emergency department due to nonspecific thoracic discomfort of over six hours duration associated with syncope&#46; Physical examination revealed a low-amplitude arrhythmic pulse&#44; no heart murmurs and no signs of pulmonary congestion&#46; The ECG revealed atrial fibrillation with ST-segment elevation in V2-V6&#44; I and aVL&#46; The patient was transferred for emergent coronary angiography&#44; which revealed a long stenosis in the mid-distal portion of the left anterior descending artery&#46; The echocardiogram showed a large pericardial effusion with diffuse thickening of the myocardium&#46; Due to worsening hemodynamics&#44; cardiac rupture was suspected and the patient underwent urgent sternotomy and pericardiotomy with drainage of a large quantity of hematic fluid&#46; The surgeons then identified a large&#44; unresectable tumor occupying the distal half of the anterior portion of the heart&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This is&#44; to our knowledge&#44; the first case report of primary pericardial mesothelioma presenting with suspected ST-elevation myocardial infarction&#46; In this case&#44; direct observation of the tumor led to biopsy and the final diagnosis&#46; These are highly malignant tumors and when diagnosed are usually already at an advanced stage&#46;</p></span>"
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      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Os tumores prim&#225;rios do cora&#231;&#227;o e peric&#225;rdio s&#227;o entidades raras&#44; com uma frequ&#234;ncia estimada em aut&#243;psias de 0&#44;001-0&#44;03&#37;&#46; A metastiza&#231;&#227;o do cora&#231;&#227;o e peric&#225;rdio &#233; muito mais comum do que os tumores prim&#225;rios&#46; O mesotelioma maligno do peric&#225;rdio pode atingir 50&#37; dos casos de tumores prim&#225;rios do peric&#225;rdio&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mulher de 75 anos&#44; com hipertens&#227;o arterial&#44; dislipidemia e fibrilha&#231;&#227;o auricular&#46; Recorreu ao servi&#231;o de urg&#234;ncia por desconforto tor&#225;cico inespec&#237;fico&#44; com mais de seis horas de dura&#231;&#227;o&#44; associado a s&#237;ncope&#46; No exame objetivo foi detetado pulso arr&#237;tmico de baixa amplitude&#44; aus&#234;ncia de sons card&#237;acos&#44; sem sinais de congest&#227;o pulmonar&#46; O ECG mostrou fibrilha&#231;&#227;o auricular e eleva&#231;&#227;o do segmento ST em V2-V6&#44; I e aVL&#46; A doente foi transferida para angiografia coron&#225;ria urgente&#44; que mostrou estenose na por&#231;&#227;o m&#233;dio-distal da art&#233;ria descendente anterior esquerda&#46; O ecocardiograma revelou derrame peric&#225;rdico de grande volume com espessamento difuso do mioc&#225;rdio&#46; Devido a agravamento hemodin&#226;mico&#44; houve suspeita de rutura card&#237;aca e a doente foi submetida a esternotomia e pericardiotomia emergentes&#44; com drenagem de grande quantidade de l&#237;quido hem&#225;tico&#46; Foi observada exist&#234;ncia de volumoso tumor irressec&#225;vel&#44; ocupando a metade distal da face anterior do cora&#231;&#227;o&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O nosso caso &#233; o primeiro&#44; de que temos conhecimento&#44; que descreve um caso de mesotelioma do peric&#225;rdio prim&#225;rio que se apresenta como suspeita inicial de enfarte do mioc&#225;rdio com supra-ST&#46; Neste caso&#44; a observa&#231;&#227;o direta do tumor permitiu a realiza&#231;&#227;o de biopsia e o diagn&#243;stico final&#46; Estes tumores s&#227;o altamente malignos e&#44; quando diagnosticados&#44; est&#227;o habitualmente num est&#225;dio avan&#231;ado&#46;</p></span>"
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                          "etal" => false
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                      "titulo" => "A ball in the heart&#58; an interesting discovery in a very rare cardiac tumor"
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                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Jodati"
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Case report
Pericardial mesothelioma presenting as a suspected ST-elevation myocardial infarction
Apresentação de mesotelioma do pericárdio como suspeita de enfarte agudo do miocárdio com elevação de ST
Ana Sofia Barrosoa,
Corresponding author
anasofiapbarroso@gmail.com

Corresponding author.
, Sérgio Leiteb, Fernando Friõesa, Mariana Vasconcelosb, Daniela Azevedoc, Helena Baldaiad, Mário Jorge Amorime, Paula Diasa
a Unidade de Cuidados Intermédios de Medicina, Centro Hospitalar São João, Porto, Portugal
b Serviço de Cardiologia, Centro Hospitalar São João, Porto, Portugal
c Serviço de Oncologia, Centro Hospitalar São João, Porto, Portugal
d Serviço de Anatomia Patológica, Centro Hospitalar São João, Porto, Portugal
e Serviço de Cirurgia Cardiotorácica, Centro Hospitalar São João, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cardiac and pericardial tumors are rare entities with an autopsy frequency of 0&#46;001-0&#46;03&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Metastases to the heart and pericardium are much more common &#40;100-1000 times&#41; than primary tumors&#44; with the underlying malignant origin&#44; in most cases&#44; being carcinoma of the lung&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Primary cardiac tumors present with one or more symptoms of the classic triad of cardiac symptoms and signs resulting from intracardiac obstruction&#44; signs of systemic embolization&#44; and systemic or constitutional symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> Unlike primary malignant cardiac tumors&#44; which account for up to 25&#37; of cases&#44; malignant pericardial mesotheliomas account for up to 50&#37; of primary pericardial tumors&#46; The mean age of presentation is 46 years and they are twice as common in males than in females&#46; We present the case of a patient with a primary pericardial mesothelioma presenting with ST-elevation myocardial infarction&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 75-year-old Caucasian woman with a previous history of hypertension&#44; dyslipidemia and a left total hip replacement&#46; She was medicated with lisinopril-hydrochlorothiazide&#44; bisoprolol and atorvastatin&#46; Additionally&#44; she was recently diagnosed with atrial fibrillation and was on warfarin&#46; She had no previous symptoms of cardiac disease&#46; She went to the emergency department of the local hospital due to nonspecific thoracic discomfort and malaise of over six hours duration associated with an episode of syncope&#46; She also reported dyspnea on moderate exertion of two weeks duration&#46; A complete blood count &#40;CBC&#41; and biochemistry revealed anemia and thrombocytopenia&#44; with no other changes&#46; The patient denied other signs or symptoms&#46; Physical examination revealed a low-amplitude arrhythmic pulse&#44; no heart murmurs and no signs of pulmonary congestion&#44; blood pressure of 95&#47;56 mmHg&#44; heart rate of 101 beats per minute&#44; and peripheral oxygen saturation of 85&#37;&#46; The CBC revealed anemia &#40;Hg 8&#46;9 g&#47;dl&#41; and thrombocytopenia &#40;80 000 U&#47;l&#41;&#46; Biochemistry results revealed elevated serum cardiac troponin I &#40;0&#46;9 ng&#47;ml&#59; normal &#60;0&#46;04 ng&#47;ml&#41;&#46; A chest X-ray revealed a cardiothoracic index of &#62;50&#37; with widening of the mediastinum&#46; The ECG revealed atrial fibrillation with ST-segment elevation in V2-V6&#44; I and aVL&#46; The patient was immediately transferred to a tertiary centre for emergent coronary angiography&#44; which revealed a long stenosis of 50&#37; in the mid-distal portion of the left anterior descending artery &#40;with TIMI 3 flow&#41; and a focal 30&#37; stenosis in the mid segment of the right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Left ventriculography revealed a hyperkinetic left ventricle and apical akinesia but otherwise normal systolic function&#46; In the minutes after cardiac catheterization&#44; the patient developed hypotension &#40;systolic blood pressure of 85-90 mmHg&#41; and slight chest discomfort persisted&#46; An echocardiogram was performed and revealed a large pericardial effusion with diffuse thickening of the myocardium&#44; mainly in the anterolateral wall and apex&#44; which was assumed to be adherent fibrin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Due to worsening hemodynamic status and echocardiographic findings in a patient with chest pain&#44; ST-elevation on the ECG and elevated cardiac troponin&#44; cardiac rupture was suspected and the patient underwent urgent sternotomy and pericardiotomy with drainage of a large quantity of bloody fluid followed by hemodynamic recovery&#46; The surgeons then identified a large unresectable tumor occupying the distal half of the anterior portion of the heart&#44; which was biopsied &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; The patient was admitted to the cardiothoracic intensive care unit and was extubated on day 2 after surgery&#44; and was then transferred to an intermediate care unit&#44; with a favorable clinical status&#46; A cervical-thoraco-abdominal-pelvic computed tomography &#40;CT&#41; scan was performed that identified myocardial tumor infiltration &#40;measuring 6 cm&#215;7 cm&#215;11 cm&#41; and pulmonary&#44; cervical and abdominal wall metastases&#46; The pathological study revealed a malignant mesothelioma&#46; The immunohistochemical study documented diffuse expression of AE1&#47;AE3&#44; vimentin and MDM2 in tumor cells and focal expression of calretinin&#44; EMA&#44; podoplanin&#44; desmin and p53 &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An oncological group meeting decided to start chemotherapy with pemetrexed and carboplatin on the eighth day of hospitalization&#46; The patient was transferred to the medical oncology department after 14 days of hospitalization &#40;sixth day of chemotherapy&#41;&#46; She remained clinically stable but showed a gradual deterioration in her general condition&#44; with anorexia and asthenia&#44; and died suddenly on the 30th day of hospitalization&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is&#44; to our knowledge&#44; the first case report of primary pericardial mesothelioma presenting with suspected ST-elevation myocardial infarction &#40;STEMI&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are rare entities&#44; with an estimated prevalence of 0&#46;001-0&#46;056&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;4</span></a> Primary pericardial tumors are even rarer&#44; with an estimated prevalence of 0&#46;001-0&#46;007&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> These can be benign &#40;teratoma&#44; fibroma&#44; angioma&#44; lipoma&#41; or malignant &#40;mesothelioma&#44; sarcoma&#41;&#46; Pericardial mesothelioma is extremely rare&#44; although it is the most common primary malignant pericardial tumor&#44; accounting for 50&#37; of primary pericardial tumors&#46; Its incidence was 0&#46;0022&#37; among 500 000 cases in a large necropsy study&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Metastatic tumors are much more common&#44; arising mostly from the lung&#44; breast&#44; skin or blood &#40;lymphoma or leukemia&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">2&#44;6</span></a> Age at presentation ranges from 2 to 78 years and they are more frequent in men &#40;2&#58;1 male to female ratio&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Common clinical manifestations of pericardial mesothelioma include heart failure &#40;due to cardiac tamponade&#44; constrictive pericarditis and in some cases myocardial infiltration&#41;&#59; pericardial effusion and ischemic cardiac pain &#40;angina&#41; may also be present due to coronary artery compression by the tumor&#46; The onset of symptoms is usually insidious&#46; Distant metastasis&#44; conduction block due to myocardial infiltration and tumor embolism causing neurological deficits have also been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pericardial mesotheliomas usually grow as a bulky mass that encircles the heart with few foci of myocardial infiltration&#46; Magnetic resonance imaging &#40;MRI&#41; and CT are useful in showing the extent of involvement of contiguous structures and the degree of constriction&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In several case reports the most common mode of presentation of pericardial mesothelioma was the development of pericarditis that evolved to constrictive pericarditis&#44;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9&#8211;11</span></a> sometimes associated with a circumferential pericardial effusion for which diagnostic pericardiocentesis was not conclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> In the case presented&#44; the clinical presentation was sudden&#44; mimicking an anterior wall STEMI&#46; The suspicion of left ventricular rupture was founded on the observation of a pericardial effusion&#44; with a suspected large quantity of fibrin adjacent to the myocardium&#44; associated with hypotension&#44; indicating cardiac tamponade&#46; As previously described&#44; the sensitivity of echocardiography in the identification of pericardial mesothelioma is low&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> and CT scanning and MRI are preferable since these techniques not only detect invasion of adjacent structures and the presence of metastases but also&#44; in the case of MRI&#44; can assess the presence of constriction and ventricular dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this case&#44; direct observation of the tumor led to biopsy and the final diagnosis&#46; At the histological level&#44; pericardial and pleural mesotheliomas are similar&#46; The tumor cells can have three distinct patterns&#58; &#40;1&#41; predominance of epithelioid cells&#59; &#40;2&#41; predominance of fibrous &#40;spindle&#41; cells&#59; and &#40;3&#41; mixed-type &#40;which was the pattern observed in this case&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Unlike pleural mesothelioma&#44; which has a well-established association with previous exposure to asbestos&#44; in pericardial mesothelioma this association is less strong&#44; and our patient had no history of present or past contact with asbestos products&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">These are highly malignant tumors and when diagnosed are usually already at an advanced stage&#46; Mesotheliomas respond poorly to radiotherapy and chemotherapy is usually employed to reduce tumor mass&#46; Resection may be curative but only in small&#44; localized tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> Surgical intervention in pericardial mesothelioma is primarily for effusion control&#44; for cytoreduction before multimodal therapy&#44; or to deliver and monitor innovative intrapericardial therapies&#46; Chemotherapy and pericardiotomy &#40;for prevention of cardiac tamponade and relief of constriction&#41; are the bases of palliative care&#46; A pericardial window can be formed to introduce chemotherapeutic agents&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">With regards to prognosis&#44; survival is extremely low&#44; between 3&#46;5 and 6 months after diagnosis&#46; The most common causes of death are cardiac tamponade and heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></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="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary cardiac and pericardial tumors are rare entities with an autopsy frequency of 0&#46;001-0&#46;03&#37;&#46; Metastases to the heart and pericardium are much more common than primary tumors&#46; Malignant pericardial mesotheliomas account for up to 50&#37; of primary pericardial tumors&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 75-year-old woman with hypertension&#44; dyslipidemia and atrial fibrillation who went to the emergency department due to nonspecific thoracic discomfort of over six hours duration associated with syncope&#46; Physical examination revealed a low-amplitude arrhythmic pulse&#44; no heart murmurs and no signs of pulmonary congestion&#46; The ECG revealed atrial fibrillation with ST-segment elevation in V2-V6&#44; I and aVL&#46; The patient was transferred for emergent coronary angiography&#44; which revealed a long stenosis in the mid-distal portion of the left anterior descending artery&#46; The echocardiogram showed a large pericardial effusion with diffuse thickening of the myocardium&#46; Due to worsening hemodynamics&#44; cardiac rupture was suspected and the patient underwent urgent sternotomy and pericardiotomy with drainage of a large quantity of hematic fluid&#46; The surgeons then identified a large&#44; unresectable tumor occupying the distal half of the anterior portion of the heart&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This is&#44; to our knowledge&#44; the first case report of primary pericardial mesothelioma presenting with suspected ST-elevation myocardial infarction&#46; In this case&#44; direct observation of the tumor led to biopsy and the final diagnosis&#46; These are highly malignant tumors and when diagnosed are usually already at an advanced stage&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Os tumores prim&#225;rios do cora&#231;&#227;o e peric&#225;rdio s&#227;o entidades raras&#44; com uma frequ&#234;ncia estimada em aut&#243;psias de 0&#44;001-0&#44;03&#37;&#46; A metastiza&#231;&#227;o do cora&#231;&#227;o e peric&#225;rdio &#233; muito mais comum do que os tumores prim&#225;rios&#46; O mesotelioma maligno do peric&#225;rdio pode atingir 50&#37; dos casos de tumores prim&#225;rios do peric&#225;rdio&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mulher de 75 anos&#44; com hipertens&#227;o arterial&#44; dislipidemia e fibrilha&#231;&#227;o auricular&#46; Recorreu ao servi&#231;o de urg&#234;ncia por desconforto tor&#225;cico inespec&#237;fico&#44; com mais de seis horas de dura&#231;&#227;o&#44; associado a s&#237;ncope&#46; No exame objetivo foi detetado pulso arr&#237;tmico de baixa amplitude&#44; aus&#234;ncia de sons card&#237;acos&#44; sem sinais de congest&#227;o pulmonar&#46; O ECG mostrou fibrilha&#231;&#227;o auricular e eleva&#231;&#227;o do segmento ST em V2-V6&#44; I e aVL&#46; A doente foi transferida para angiografia coron&#225;ria urgente&#44; que mostrou estenose na por&#231;&#227;o m&#233;dio-distal da art&#233;ria descendente anterior esquerda&#46; O ecocardiograma revelou derrame peric&#225;rdico de grande volume com espessamento difuso do mioc&#225;rdio&#46; Devido a agravamento hemodin&#226;mico&#44; houve suspeita de rutura card&#237;aca e a doente foi submetida a esternotomia e pericardiotomia emergentes&#44; com drenagem de grande quantidade de l&#237;quido hem&#225;tico&#46; Foi observada exist&#234;ncia de volumoso tumor irressec&#225;vel&#44; ocupando a metade distal da face anterior do cora&#231;&#227;o&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O nosso caso &#233; o primeiro&#44; de que temos conhecimento&#44; que descreve um caso de mesotelioma do peric&#225;rdio prim&#225;rio que se apresenta como suspeita inicial de enfarte do mioc&#225;rdio com supra-ST&#46; Neste caso&#44; a observa&#231;&#227;o direta do tumor permitiu a realiza&#231;&#227;o de biopsia e o diagn&#243;stico final&#46; Estes tumores s&#227;o altamente malignos e&#44; quando diagnosticados&#44; est&#227;o habitualmente num est&#225;dio avan&#231;ado&#46;</p></span>"
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ISSN: 21742049
Original language: English
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2020 April 51 13 64
2020 March 42 8 50
2020 February 137 34 171
2020 January 51 7 58
2019 December 58 7 65
2019 November 53 10 63
2019 October 53 2 55
2019 September 91 7 98
2019 August 47 7 54
2019 July 49 7 56
2019 June 48 15 63
2019 May 53 6 59
2019 April 41 14 55
2019 March 150 9 159
2019 February 143 7 150
2019 January 115 3 118
2018 December 64 11 75
2018 November 184 14 198
2018 October 417 27 444
2018 September 128 11 139
2018 August 61 9 70
2018 July 42 3 45
2018 June 42 5 47
2018 May 60 5 65
2018 April 71 11 82
2018 March 85 6 91
2018 February 44 3 47
2018 January 66 4 70
2017 December 74 7 81
2017 November 35 6 41
2017 October 34 14 48
2017 September 18 15 33
2017 August 32 11 43
2017 July 18 9 27
2017 June 53 9 62
2017 May 72 34 106
2017 April 15 6 21
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Revista Portuguesa de Cardiologia (English edition)
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