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and chronic excess secretion of both hormones is associated with various changes in cardiac structure and function due to cardiomyocyte apoptosis&#44; with concentric cardiac hypertrophy being a frequent finding even in young patients with short disease duration&#46; As a consequence&#44; early impairment of left ventricular &#40;LV&#41; diastolic filling has been described&#44; while impaired systolic function with heart failure may develop in later stages if the disease is untreated or unsuccessfully treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#8211;3</span></a> Other cardiovascular disorders such as hypertension&#44; coronary artery disease and ventricular arrhythmias may be present and worsen acromegalic cardiomyopathy&#44; defined as any cardiac involvement in acromegalic patients in the absence of other known causes of cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Lowering of GH and IGF-1 to age-corrected normal limits is mandatory&#59; however&#44; treatment of acromegaly appears to improve cardiac function only in the short term&#44; with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Alcohol septal ablation &#40;ASA&#41; has emerged as a minimally invasive alternative to septal myectomy for patients with obstructive hypertrophic cardiomyopathy &#40;HCM&#41; and symptoms refractory to medical therapy&#46; This procedure alleviates symptoms by producing a targeted&#44; limited infarction of the upper interventricular septum&#44; resulting in an increase in left ventricular outflow tract &#40;LVOT&#41; diameter&#44; a decrease in LVOT gradients&#44; and regression of the component of LV hypertrophy that is due to pressure overload&#46; Clinical success&#44; with significant improvement in symptoms and reduction in gradients&#44; is achieved in the great majority of patients and has been correlated with left ventricular remodeling&#46; Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association &#40;NYHA&#41; class for the two procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> To our knowledge&#44; there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly&#46; We report a case of successful ASA in acromegalic cardiomyopathy&#46;</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&#46; She had a history of hypertension&#44; multinodular goiter and atrial fibrillation under oral anticoagulation&#46; 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 &#40;NYHA class III&#41; under optimal medical therapy&#46; A complete echocardiogram revealed severe asymmetric hypertrophy of the left ventricle&#44; mostly in the basal portion of the interventricular septum &#40;19 mm&#41;&#44; without LV dilation&#44; depressed ejection fraction or wall motion abnormalities&#46; There was also a dynamic LVOT obstruction gradient of 70 mmHg at rest and of 120 mmHg with Valsalva maneuver and systolic anterior movement &#40;SAM&#41; of the mitral valve with mild regurgitation and moderate to severe tricuspid regurgitation&#46; A better characterization with magnetic resonance imaging confirmed basal interventricular septal hypertrophy without evidence of intramyocardial fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy&#46; A 24-hour Holter examination revealed permanent atrial fibrillation but no ventricular repolarization or heart rate abnormalities&#46; After a multidisciplinary discussion&#44; ASA was performed&#44; guided by myocardial contrast echocardiography&#44; with injection of 2 cc of alcohol in the first septal branch of the left coronary artery &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2&#8211;4</a>&#41;&#46; The procedure was uneventful and no atrioventricular &#40;AV&#41; conduction disturbances were detected&#46; 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&#46; The LVOT gradient was 28 mmHg at rest and the SAM of the mitral valve and the moderate to severe tricuspid regurgitation had disappeared&#46; The patient improved significantly to mild-to-moderate heart failure &#40;NYHA class I-II&#41; and no major cardiovascular events were observed during follow-up&#46;</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&#44; affecting more than 60&#37; of patients&#44; independently of hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The etiology of acromegalic cardiomyopathy has not been fully clarified&#44; 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&#46; In the present report&#44; a 38-year history of undiagnosed acromegaly could have caused this hypertrophic structural pattern responsible for the diastolic filling abnormality observed&#44; and eventually left ventricular dysfunction occurred&#44; resulting in congestive heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;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&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; as seen in this case&#44; 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&#46; In these cases treatment has to be guided from a cardiological standpoint&#46;</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&#46; The procedure has been refined over the decades since its introduction&#46; However&#44; concerns have been raised over the higher risk of complete AV block and development of a potentially arrhythmogenic scar after ASA&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Although surgical myectomy is the standard therapy for drug-resistant obstructive HCM&#44; ASA is an alternative that may be considered for many patients&#46; Data indicate that the medium-term functional and hemodynamic success of ASA is high and similar to that of surgery&#44; with the advantage that it may be performed in patients considered unsuitable for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In the case presented&#44; the coronary anatomy was favorable&#44; with the approachable septal coronary arteries required for the procedure&#44; which was performed without adverse events&#46; 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&#46;</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&#46;</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&#46;</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&#46;</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&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acromegaly is a rare disease&#44; mostly caused by a growth hormone &#40;GH&#41;-secreting benign pituitary tumor&#44; with an increased production of GH and insulin-like growth factor 1 &#40;IGF-1&#41;&#46; Cardiovascular complications are common and are associated with cardiomyocyte apoptosis and concentric cardiac hypertrophy&#46; Suppression of GH and IGF-1 appears to improve cardiac function only in the short term&#44; with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment&#46; Alcohol septal ablation &#40;ASA&#41; has emerged as a minimally invasive alternative to septal myectomy&#44; with significant improvement in symptoms&#44; gradients and left ventricular remodeling&#46; In this report&#44; 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&#46; 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&#46; Echocardiography and magnetic resonance imaging revealed severe basal hypertrophy of the interventricular septum &#40;19 mm&#41;&#44; dynamic left ventricular outflow tract obstruction with a gradient of 70 mmHg at rest and 120 mmHg with Valsalva maneuver&#44; and systolic anterior movement &#40;SAM&#41;&#46; Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy&#46; ASA was performed with injection of 2 cc of alcohol in the first septal branch of the left coronary artery&#44; without complications&#46; At one-year reassessment&#44; significant clinical and echocardiographic improvement was noted&#44; with disappearance of SAM&#46; To our knowledge&#44; there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly&#46; We report a case of successful ASA in acromegalic cardiomyopathy&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A acromegalia &#233; uma doen&#231;a rara&#44; causada essencialmente por um tumor benigno da gl&#226;ndula pituit&#225;ria secretor de hormona de crescimento &#40;HC&#41;&#44; provocando uma produ&#231;&#227;o excessiva de HC e de fator de crescimento semelhante &#224; insulina tipo 1 &#40;IGF-1&#41;&#46; As complica&#231;&#245;es cardiovasculares s&#227;o comuns e t&#234;m sido associadas &#224; apoptose de cardiomi&#243;citos e &#224; hipertrofia card&#237;aca conc&#234;ntrica&#46; A supress&#227;o de HC e de IGF-1 parece melhorar a fun&#231;&#227;o card&#237;aca apenas a curto prazo&#44; com pouco ou nenhum efeito na redu&#231;&#227;o da massa ventricular esquerda ou na melhoria da fun&#231;&#227;o card&#237;aca a longo prazo&#46; A abla&#231;&#227;o septal alco&#243;lica &#40;ASA&#41; surgiu como uma alternativa minimamente invasiva &#224; miectomia septal com melhoria significativa a n&#237;vel de sintomas&#44; gradientes e remodelagem ventricular esquerda&#46; Neste caso cl&#237;nico&#44; descrevemos as imagens de uma mulher de 73 anos de idade&#44; com acromegalia devido a um adenoma da gl&#226;ndula pituit&#225;ria diagnosticado&#44; e submetida a cirurgia aos 38 anos&#44; mas com recorr&#234;ncia e reopera&#231;&#227;o aos 50 anos&#46; A doente foi referenciada ao nosso departamento de cardiologia por um quadro com tr&#234;s meses de evolu&#231;&#227;o de dispneia de esfor&#231;o e ortopneia com agravamento progressivo sob terap&#234;utica m&#233;dica otimizada&#46; O ecocardiograma e resson&#226;ncia magn&#233;tica card&#237;aca revelaram uma hipertrofia grave da por&#231;&#227;o basal do septo interventricular &#40;19 mm&#41;&#44; com um gradiente obstrutivo din&#226;mico da c&#226;mara de sa&#237;da do ventr&#237;culo esquerdo de 70 mmHg em repouso e de 120 mmHg com a manobra de Valsalva e com movimento sist&#243;lico anterior &#40;SAM&#41; da v&#225;lvula mitral&#46; A avalia&#231;&#227;o gen&#233;tica excluiu as formas mais frequentes de cardiomiopatia hipertr&#243;fica &#40;CMH&#41; familiar&#46; A ASA foi realizada com 2 cc de inje&#231;&#227;o de &#225;lcool na primeira art&#233;ria coron&#225;ria septal&#44; sem complica&#231;&#245;es&#46; Na reavalia&#231;&#227;o do primeiro ano&#44; houve uma melhora cl&#237;nica e ecocardiogr&#225;fica significativa com o desaparecimento de SAM&#46; Tanto quanto &#233; do nosso conhecimento&#44; n&#227;o existe na literatura a descri&#231;&#227;o de casos de ASA em doentes com CMH por acromegalia&#46; Relatamos aqui o caso de uma ASA bem-sucedida numa cardiomiopatia acromeg&#225;lica&#46;</p></span>"
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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
Autor para correspondência
andreviveirosmonteiro@gmail.com

Corresponding author.
, António Fiarresga, Duarte Cacela, Lídia de Sousa, Ruben Ramos, Ana Galrinho, Luísa Branco, Rui Cruz Ferreira
Cardiology Department, Hospital of Santa Marta, Lisbon, Portugal
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    "titulo" => "Alcohol septal ablation in obstructive acromegalic hypertrophic cardiomyopathy &#8211; a first case report"
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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">Acromegaly is a rare disease that is most often caused by a growth hormone &#40;GH&#41;-secreting benign pituitary tumor and is characterized by progressive skeletal and soft tissue overgrowth&#44; frequently accompanied by cardiovascular&#44; cerebrovascular&#44; and respiratory complications that contribute to the poor prognosis observed in this condition&#46;<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&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> The increased autonomous production of GH results in increased insulin-like growth factor 1 &#40;IGF-1&#41;&#44; and chronic excess secretion of both hormones is associated with various changes in cardiac structure and function due to cardiomyocyte apoptosis&#44; with concentric cardiac hypertrophy being a frequent finding even in young patients with short disease duration&#46; As a consequence&#44; early impairment of left ventricular &#40;LV&#41; diastolic filling has been described&#44; while impaired systolic function with heart failure may develop in later stages if the disease is untreated or unsuccessfully treated&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#8211;3</span></a> Other cardiovascular disorders such as hypertension&#44; coronary artery disease and ventricular arrhythmias may be present and worsen acromegalic cardiomyopathy&#44; defined as any cardiac involvement in acromegalic patients in the absence of other known causes of cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Lowering of GH and IGF-1 to age-corrected normal limits is mandatory&#59; however&#44; treatment of acromegaly appears to improve cardiac function only in the short term&#44; with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Alcohol septal ablation &#40;ASA&#41; has emerged as a minimally invasive alternative to septal myectomy for patients with obstructive hypertrophic cardiomyopathy &#40;HCM&#41; and symptoms refractory to medical therapy&#46; This procedure alleviates symptoms by producing a targeted&#44; limited infarction of the upper interventricular septum&#44; resulting in an increase in left ventricular outflow tract &#40;LVOT&#41; diameter&#44; a decrease in LVOT gradients&#44; and regression of the component of LV hypertrophy that is due to pressure overload&#46; Clinical success&#44; with significant improvement in symptoms and reduction in gradients&#44; is achieved in the great majority of patients and has been correlated with left ventricular remodeling&#46; Non-randomized comparisons of septal ablation and septal myectomy have shown similar mortality rates and post-procedure New York Heart Association &#40;NYHA&#41; class for the two procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> To our knowledge&#44; there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly&#46; We report a case of successful ASA in acromegalic cardiomyopathy&#46;</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&#46; She had a history of hypertension&#44; multinodular goiter and atrial fibrillation under oral anticoagulation&#46; 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 &#40;NYHA class III&#41; under optimal medical therapy&#46; A complete echocardiogram revealed severe asymmetric hypertrophy of the left ventricle&#44; mostly in the basal portion of the interventricular septum &#40;19 mm&#41;&#44; without LV dilation&#44; depressed ejection fraction or wall motion abnormalities&#46; There was also a dynamic LVOT obstruction gradient of 70 mmHg at rest and of 120 mmHg with Valsalva maneuver and systolic anterior movement &#40;SAM&#41; of the mitral valve with mild regurgitation and moderate to severe tricuspid regurgitation&#46; A better characterization with magnetic resonance imaging confirmed basal interventricular septal hypertrophy without evidence of intramyocardial fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy&#46; A 24-hour Holter examination revealed permanent atrial fibrillation but no ventricular repolarization or heart rate abnormalities&#46; After a multidisciplinary discussion&#44; ASA was performed&#44; guided by myocardial contrast echocardiography&#44; with injection of 2 cc of alcohol in the first septal branch of the left coronary artery &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2&#8211;4</a>&#41;&#46; The procedure was uneventful and no atrioventricular &#40;AV&#41; conduction disturbances were detected&#46; 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&#46; The LVOT gradient was 28 mmHg at rest and the SAM of the mitral valve and the moderate to severe tricuspid regurgitation had disappeared&#46; The patient improved significantly to mild-to-moderate heart failure &#40;NYHA class I-II&#41; and no major cardiovascular events were observed during follow-up&#46;</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&#44; affecting more than 60&#37; of patients&#44; independently of hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The etiology of acromegalic cardiomyopathy has not been fully clarified&#44; 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&#46; In the present report&#44; a 38-year history of undiagnosed acromegaly could have caused this hypertrophic structural pattern responsible for the diastolic filling abnormality observed&#44; and eventually left ventricular dysfunction occurred&#44; resulting in congestive heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;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&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; as seen in this case&#44; 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&#46; In these cases treatment has to be guided from a cardiological standpoint&#46;</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&#46; The procedure has been refined over the decades since its introduction&#46; However&#44; concerns have been raised over the higher risk of complete AV block and development of a potentially arrhythmogenic scar after ASA&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Although surgical myectomy is the standard therapy for drug-resistant obstructive HCM&#44; ASA is an alternative that may be considered for many patients&#46; Data indicate that the medium-term functional and hemodynamic success of ASA is high and similar to that of surgery&#44; with the advantage that it may be performed in patients considered unsuitable for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In the case presented&#44; the coronary anatomy was favorable&#44; with the approachable septal coronary arteries required for the procedure&#44; which was performed without adverse events&#46; 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&#46;</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&#46;</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&#46;</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&#46;</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&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acromegaly is a rare disease&#44; mostly caused by a growth hormone &#40;GH&#41;-secreting benign pituitary tumor&#44; with an increased production of GH and insulin-like growth factor 1 &#40;IGF-1&#41;&#46; Cardiovascular complications are common and are associated with cardiomyocyte apoptosis and concentric cardiac hypertrophy&#46; Suppression of GH and IGF-1 appears to improve cardiac function only in the short term&#44; with little or no decrease in left ventricular mass or improvement in cardiac function after prolonged treatment&#46; Alcohol septal ablation &#40;ASA&#41; has emerged as a minimally invasive alternative to septal myectomy&#44; with significant improvement in symptoms&#44; gradients and left ventricular remodeling&#46; In this report&#44; 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&#46; 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&#46; Echocardiography and magnetic resonance imaging revealed severe basal hypertrophy of the interventricular septum &#40;19 mm&#41;&#44; dynamic left ventricular outflow tract obstruction with a gradient of 70 mmHg at rest and 120 mmHg with Valsalva maneuver&#44; and systolic anterior movement &#40;SAM&#41;&#46; Genetic testing excluded the most frequent forms of familial hypertrophic cardiomyopathy&#46; ASA was performed with injection of 2 cc of alcohol in the first septal branch of the left coronary artery&#44; without complications&#46; At one-year reassessment&#44; significant clinical and echocardiographic improvement was noted&#44; with disappearance of SAM&#46; To our knowledge&#44; there have been no previously reported cases of ASA in hypertrophic cardiomyopathy due to acromegaly&#46; We report a case of successful ASA in acromegalic cardiomyopathy&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A acromegalia &#233; uma doen&#231;a rara&#44; causada essencialmente por um tumor benigno da gl&#226;ndula pituit&#225;ria secretor de hormona de crescimento &#40;HC&#41;&#44; provocando uma produ&#231;&#227;o excessiva de HC e de fator de crescimento semelhante &#224; insulina tipo 1 &#40;IGF-1&#41;&#46; As complica&#231;&#245;es cardiovasculares s&#227;o comuns e t&#234;m sido associadas &#224; apoptose de cardiomi&#243;citos e &#224; hipertrofia card&#237;aca conc&#234;ntrica&#46; A supress&#227;o de HC e de IGF-1 parece melhorar a fun&#231;&#227;o card&#237;aca apenas a curto prazo&#44; com pouco ou nenhum efeito na redu&#231;&#227;o da massa ventricular esquerda ou na melhoria da fun&#231;&#227;o card&#237;aca a longo prazo&#46; A abla&#231;&#227;o septal alco&#243;lica &#40;ASA&#41; surgiu como uma alternativa minimamente invasiva &#224; miectomia septal com melhoria significativa a n&#237;vel de sintomas&#44; gradientes e remodelagem ventricular esquerda&#46; Neste caso cl&#237;nico&#44; descrevemos as imagens de uma mulher de 73 anos de idade&#44; com acromegalia devido a um adenoma da gl&#226;ndula pituit&#225;ria diagnosticado&#44; e submetida a cirurgia aos 38 anos&#44; mas com recorr&#234;ncia e reopera&#231;&#227;o aos 50 anos&#46; A doente foi referenciada ao nosso departamento de cardiologia por um quadro com tr&#234;s meses de evolu&#231;&#227;o de dispneia de esfor&#231;o e ortopneia com agravamento progressivo sob terap&#234;utica m&#233;dica otimizada&#46; O ecocardiograma e resson&#226;ncia magn&#233;tica card&#237;aca revelaram uma hipertrofia grave da por&#231;&#227;o basal do septo interventricular &#40;19 mm&#41;&#44; com um gradiente obstrutivo din&#226;mico da c&#226;mara de sa&#237;da do ventr&#237;culo esquerdo de 70 mmHg em repouso e de 120 mmHg com a manobra de Valsalva e com movimento sist&#243;lico anterior &#40;SAM&#41; da v&#225;lvula mitral&#46; A avalia&#231;&#227;o gen&#233;tica excluiu as formas mais frequentes de cardiomiopatia hipertr&#243;fica &#40;CMH&#41; familiar&#46; A ASA foi realizada com 2 cc de inje&#231;&#227;o de &#225;lcool na primeira art&#233;ria coron&#225;ria septal&#44; sem complica&#231;&#245;es&#46; Na reavalia&#231;&#227;o do primeiro ano&#44; houve uma melhora cl&#237;nica e ecocardiogr&#225;fica significativa com o desaparecimento de SAM&#46; Tanto quanto &#233; do nosso conhecimento&#44; n&#227;o existe na literatura a descri&#231;&#227;o de casos de ASA em doentes com CMH por acromegalia&#46; Relatamos aqui o caso de uma ASA bem-sucedida numa cardiomiopatia acromeg&#225;lica&#46;</p></span>"
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ISSN: 08702551
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