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resulting in right ventricular failure&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Furthermore&#44; some studies suggest that the overexpression of vascular endothelial growth factor may play a role in impairing the development of the right ventricular myocardium&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Uhl&#39;s disease&#44; the absence of the right ventricular myocardium leads to a lack of contraction and&#44; consequently&#44; the chamber acts as a transition zone between the right atrium and pulmonary artery&#46; Pulmonary circulation is maintained by the pumping action of the right atrium&#44; whereas the right ventricle &#40;RV&#41; balloons aneurysmally in systole&#46; The right atrium is enormous in size&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the past&#44; diagnosis was performed during autopsy&#46; However&#44; nowadays&#44; given the development of imaging techniques&#44; diagnosis is carried out via echocardiography or more sensitive and specific cardiac magnetic resonance &#40;CMR&#41; imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Moreover&#44; there are also published cases where diagnosis took place during prenatal screening&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors report the case of a 28-year-old man&#44; with no known heart disease and an insignificant personal and family medical history&#46; However&#44; he did note that he had suffered cyanosis over the past three years&#44; which was never investigated&#44; and had no other symptoms&#46; The patient was admitted to the hospital due to a respiratory infection&#44; presenting with fever&#44; dyspnea and hypoxemia &#40;peripheral oxygen saturation of 55&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Electrocardiogram &#40;ECG&#41; showed atrial fibrillation &#40;&#177;77 bpm&#41;&#44; right bundle branch block and a fragmented QRS complex &#8211; despite normal left ventricular activation&#44; right ventricular depolarization was delayed and prolonged &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A chest X-ray revealed cardiomegaly&#44; with a narrow vascular pedicle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Computed tomography of the chest showed dilated right heart chambers&#44; inferior vena cava and hepatic veins&#44; with no dilatation of the pulmonary artery&#46; Pulmonary ventilation&#47;perfusion scintigraphy ruled out a pulmonary embolism and indicated a right-to-left shunt&#46; Transthoracic echocardiography confirmed severe dilation of the right heart chambers and impaired right ventricular systolic function &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#59; a tricuspid valve with normal implantation and moderate regurgitation&#59; an estimated pulmonary artery systolic pressure of 36 mmHg&#59; a normal pulmonary artery diameter&#59; and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect &#40;ASD&#41; &#40;38 mm&#41;&#44; confirmed by transesophageal echocardiography&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cardiac catheterization was performed&#44; revealing an absence of gradient between the RV and pulmonary artery and post-capillary pulmonary hypertension &#40;mean pulmonary artery pressure of 32 mmHg&#44; with an elevated pulmonary capillary wedge pressure of 19 mmHg&#41;&#46; A pulmonary blood flow&#58;systemic blood flow ratio of 0&#46;88&#58;1 was also calculated&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">At this point&#44; the authors felt that ASD as the primary diagnosis could not explain the clinical features or hemodynamic data&#46; On one hand&#44; there was no anomalous venous return to justify the cyanosis and mild postcapillary pulmonary hypertension was not compatible with Eisenmenger&#39;s syndrome and the consequent right-to-left shunt&#46; On the other hand&#44; there was no evidence of a significant past or present left-to-right shunt&#44; since the pulmonary artery was normal in size&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Primary right ventricular disease was the most likely hypothesis and CMR was performed&#44; revealing severe dilation of the right atrium &#40;91&#215;72 mm&#41; and right ventricle &#40;end-diastolic volume 355 ml&#44; 207&#46;9 ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; an extremely thin-walled RV with almost complete absence of the right ventricular free wall myocardium&#44; a paucity of apical trabeculations and impaired systolic function &#40;ejection fraction &#91;EF&#93; 25&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The left ventricle was dilated with normal wall thickness and an EF of 41&#37;&#46; An ASD measuring over 30 mm was identified and late gadolinium enhancement was observed in the right ventricle and right atrium walls &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; These findings were compatible with Uhl&#39;s anomaly&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cardiopulmonary exercise testing showed a moderate exercise capacity with a peak oxygen uptake of 27&#46;6 ml&#47;kg&#47;min &#40;55&#37; of the value predicted for the patient&#39;s gender and age&#41; as well as an oxygen uptake at anaerobic threshold of 20&#46;5 ml&#47;kg&#47;min and a minute ventilation-to-carbon dioxide output slope of 46&#46;2&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient initiated anticoagulation therapy with warfarin and received a subcutaneous implantable cardioverter-defibrillator for primary prevention of sudden cardiac death&#44; due to severe right ventricular dysfunction&#46; The patient will be closely monitored and heart transplantation will be considered in the event his functional capacity deteriorates&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Uhl&#39;s disease is characterized by the absence of the RV myocardium and the direct apposition of endocardium to epicardium&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Histological examination confirms cardiac muscle wastage and replacement by fibrous tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> However&#44; despite this anomaly in the RV myocardium&#44; the septal and left ventricular myocardium is preserved&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In severe forms&#44; RV failure develops during childhood&#44; with pulmonary circulation being dependent on the right atrium&#46; Cyanosis is also present in the event of an atrial shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Prior to the advent of current imaging methods&#44; diagnosis was performed during autopsy&#46; Nowadays&#44; CMR is the method of choice for diagnosis&#44; as well as for morphologic and functional evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The association of Uhl&#39;s disease with other congenital heart defects had rarely been reported&#44; namely with tricuspid valve dysplasia or absence&#44; Ebstein&#39;s anomaly&#44; pulmonary atresia or regurgitation&#44; patent ductus arteriosus&#44; ASD and hypoplasia of the mitral valve and left ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;8&#8211;12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A differential diagnosis should be performed with ARVD&#46; From a histological point of view&#44; ARVD is characterized by fibrofatty infiltration of the right ventricular free wall which is absent in Uhl&#39;s disease&#44; where fibrosis predominates&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> Unlike ARVD&#44; the major clinical finding in Uhl&#39;s disease is heart failure&#44; rather than arrhythmic events and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10</span></a> Family history is also more common in ARVD than in Uhl&#39;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding electrocardiographic studies&#44; in ARVD&#44; T-wave inversions in V1 and V2 are noted&#44; along with Epsilon waves&#46; Uhl&#39;s disease&#44; on the other hand&#44; presents a fragmented QRS complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;13</span></a> In CMR&#44; Uhl&#39;s disease is characterized by an extremely dilated thin-walled RV with severe hypokinesis&#44; a paucity of trabeculations and no fat signal in the RV wall&#44; as seen in ARVD&#46; In ARVD&#44; focal wall motion abnormalities are more frequent&#44; contrasting with the global hypokinesis seen in Uhl&#39;s disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;7&#44;13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Ebstein&#39;s anomaly should also be considered in differential diagnosis&#46; In Uhl&#39;s disease the tricuspid valve hinges normally and is not dysplastic&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regard to surgical treatment&#44; a right heart bypass can be performed&#46; However&#44; this procedure carries a risk of clots forming in the right ventricle as well as embolization&#44; particularly in the presence of a bidirectional Glenn shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Another option involves almost entirely resecting the RV free wall&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Possible complications include recurrent ventricular dilatation and arrhythmias&#46; In these cases&#44; a residual RV free wall must be ruled out and a total cavopulmonary connection performed&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">If clinical deterioration persists&#44; the treatment approach should be orthotopic cardiac transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In our case&#44; the association of RV myocardium disease with a large ASD explains the patient&#39;s unique clinical evolution&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cyanosis in the presence of an ASD &#40;with a &#8220;normal&#8221; RV&#41; may occur in two circumstances that were not present in this case&#58; severe pulmonary hypertension with Eisenmenger&#39;s syndrome and the consequent right-to-left shunt&#44; or when an anomalous systemic venous return exists&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Furthermore&#44; the lack of pulmonary artery dilation shows that&#44; although the ASD is large&#44; there was probably no significant left-to-right shunt&#46; The inexistence of such a shunt is due to the fact that a shunt is dependent of the compliance of both ventricles in ASDs&#44; and in this case only the RV was affected&#46; Over the years&#44; progressive RV dysfunction led to a right-to-left shunt and consequent cyanosis&#46; Moreover&#44; the defect acts as an escape&#44; which has until now prevented the occurrence of overt right-sided heart failure&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The ECG is also notable&#44; with a fragmented QRS complex&#44; reflecting the delay and prolongation of right ventricular depolarization&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion&#44; this case shows that clinical symptoms&#44; hemodynamic data and imaging findings must be comprehensively and thoroughly reviewed in congenital heart disease in order to enable correct diagnosis&#46; Primary RV disease should be considered when RV failure is present in the absence of valve disease and pulmonary hypertension&#46; Uhl&#39;s anomaly is a rare disease that consists in the absence of the RV myocardium and progressive RV failure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2017-02-28"
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            0 => "Uhl&#39;s disease"
            1 => "Primary right ventricular disease"
            2 => "Cardiac magnetic resonance imaging"
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            0 => "Doen&#231;a de Uhl"
            1 => "Doen&#231;a prim&#225;ria do ventr&#237;culo direito"
            2 => "Resson&#226;ncia magn&#233;tica card&#237;aca"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Uhl&#39;s disease&#44; also known as Uhl anomaly&#44; is a rare disease secondary to selective but uncontrolled apoptosis of right ventricular myocytes during the perinatal period&#44; after complete cardiac development&#44; leading to the absence of right ventricular myocardium and the direct apposition of endocardium to epicardium without a myocardial layer in between&#44; resulting in right ventricular failure&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The present paper describes a case of Uhl&#39;s disease with an uncommon presentation&#46; A 28-year-old man was admitted with dyspnea and cyanosis&#46; Transthoracic echocardiography showed severe dilation of the right chambers&#44; impaired right ventricular systolic function and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect &#40;ASD&#41;&#46; Cardiac catheterization revealed pulmonary hypertension&#44; with increased pulmonary capillary wedge pressure &#40;mean 19<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and Qp&#58;QS 0&#46;88&#58;1&#46; At this point&#44; the authors considered that a main diagnosis of ASD could not explain the clinical features and hemodynamic data&#46; A primary disease of the right ventricle was the most likely hypothesis and cardiac magnetic resonance imaging was performed&#44; which demonstrated an extremely thin-walled right ventricle&#44; with almost complete absence of right ventricular free wall myocardium&#44; compatible with Uhl&#39;s disease&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A anomalia de Ulh &#233; uma doen&#231;a rara&#44; secund&#225;ria &#224; seletiva&#44; contudo descontrolada apoptose dos mi&#243;citos do ventr&#237;culo direito durante o per&#237;odo perinatal&#44; ap&#243;s o desenvolvimento card&#237;aco completo&#44; o que explica a aus&#234;ncia de mioc&#225;rdio do ventr&#237;culo direito e a direta aposi&#231;&#227;o do endoc&#225;rdio e epic&#225;rdio&#44; resultando em fal&#234;ncia do ventr&#237;culo direito&#46; O presente artigo descreve um caso de doen&#231;a de Uhl com apresenta&#231;&#227;o incomum&#46; Homem de 28 anos admitido por dispneia e cianose&#46; O ecocardiograma transtor&#225;cico documentou dilata&#231;&#227;o grave das cavidades direitas&#44; compromisso da fun&#231;&#227;o sist&#243;lica do ventr&#237;culo direito e uma grande comunica&#231;&#227;o interauricular <span class="elsevierStyleItalic">ostium secundum&#46;</span> O cateterismo card&#237;aco revelou hipertens&#227;o pulmonar com aumento da press&#227;o capilar &#40;m&#233;dia 19mmHg&#41;&#59; Qp&#58;Qs 0&#44;88&#58;1&#46; Neste momento&#44; os autores consideraram que a comunica&#231;&#227;o interauricular como diagn&#243;stico principal n&#227;o explicava a apresenta&#231;&#227;o cl&#237;nica e os dados hemodin&#226;micos&#46; Doen&#231;a prim&#225;ria do ventr&#237;culo direito tornou-se a hip&#243;tese mais prov&#225;vel&#44; pelo que se realizou uma resson&#226;ncia magn&#233;tica card&#237;aca que demonstrou um ventr&#237;culo direito com parede extremamente fina&#44; com aus&#234;ncia praticamente total do mioc&#225;rdio da parede livre&#44; compat&#237;vel com doen&#231;a de Uhl&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#58; Chest X-ray revealing cardiomegaly with no pulmonary artery dilatation&#59; B&#58; Electrocardiogram showing atrial fibrillation and right bundle branch block&#46; C&#58; Transthoracic echocardiography showing severe right chambers dilation&#44; particularly of the right atrium&#44; and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular magnetic resonance&#58; Steady-state free precession imaging documenting severe dilation of the right atrium and right ventricle&#44; an extremely thin-walled right ventricle with almost complete absence of the right ventricular free wall myocardium&#44; with a paucity of apical trabeculations&#44; in a four-chamber view in diastole &#40;A&#41; and systole &#40;B&#41;&#44; and coronal view &#40;C&#41;&#46; An atrial septal defect measuring over 30 mm was also identified&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Late gadolinium enhancement &#40;LGE&#41; acquired 10 minutes after intravenous gadolinium administration&#46; LGE is evident in the right ventricular and right atrium walls&#44; in the four-chamber view &#40;A&#41;&#44; right ventricle view &#40;B&#41; and short axis view &#40;C&#41;&#46;</p>"
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Case report
Uhl's disease: An uncommon presentation of a rare disease
Doença de Uhl, uma doença rara com uma apresentação incomum
Sílvia Aguiar Rosaa,
Autor para correspondência
silviaguiarosa@gmail.com

Corresponding author.
, Ana Figueiredo Agapitoa, Marta Antóniob,c, Lídia de Sousaa, José Alberto Oliveiraa, Sérgio Laranjob, Susana Martinsd, Nuno Jalles Tavaresc, Fátima F. Pintob, Rui Cruz Ferreiraa
a Cardiology Department, Santa Marta Hospital, Lisbon, Portugal
b Paediatric Cardiology Department, Santa Marta Hospital, Lisbon, Portugal
c Centro de Ressonância Caselas, Lisbon, Portugal
d Cardiology Department, Santa Maria Hospital, Lisbon, Portugal
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Late gadolinium enhancement &#40;LGE&#41; acquired 10 minutes after intravenous gadolinium administration&#46; LGE is evident in the right ventricular and right atrium walls&#44; in the four-chamber view &#40;A&#41;&#44; right ventricle view &#40;B&#41; and short axis view &#40;C&#41;&#46;</p>"
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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">Uhl&#39;s anomaly was first described by Osler in 1905&#46; The exact incidence of this rare condition is unknown&#46; In 1993&#44; Gerlis et al&#46; concluded that many cases of arrhythmogenic right ventricular dysplasia &#40;ARVD&#41; were incorrectly classified as Uhl&#39;s anomaly&#46; In said paper&#44; the authors discussed 84 real Uhl&#39;s disease cases&#44; and since then fewer cases have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Uhl&#39;s anomaly is a rare disease secondary to the selective but uncontrolled apoptosis of right ventricular myocytes during the perinatal period&#44; following complete cardiac development&#46; This explains the absence of the right ventricular myocardium and the direct apposition of endocardium to epicardium without a myocardial layer in between&#44; resulting in right ventricular failure&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Furthermore&#44; some studies suggest that the overexpression of vascular endothelial growth factor may play a role in impairing the development of the right ventricular myocardium&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Uhl&#39;s disease&#44; the absence of the right ventricular myocardium leads to a lack of contraction and&#44; consequently&#44; the chamber acts as a transition zone between the right atrium and pulmonary artery&#46; Pulmonary circulation is maintained by the pumping action of the right atrium&#44; whereas the right ventricle &#40;RV&#41; balloons aneurysmally in systole&#46; The right atrium is enormous in size&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the past&#44; diagnosis was performed during autopsy&#46; However&#44; nowadays&#44; given the development of imaging techniques&#44; diagnosis is carried out via echocardiography or more sensitive and specific cardiac magnetic resonance &#40;CMR&#41; imaging&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> Moreover&#44; there are also published cases where diagnosis took place during prenatal screening&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors report the case of a 28-year-old man&#44; with no known heart disease and an insignificant personal and family medical history&#46; However&#44; he did note that he had suffered cyanosis over the past three years&#44; which was never investigated&#44; and had no other symptoms&#46; The patient was admitted to the hospital due to a respiratory infection&#44; presenting with fever&#44; dyspnea and hypoxemia &#40;peripheral oxygen saturation of 55&#37;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Electrocardiogram &#40;ECG&#41; showed atrial fibrillation &#40;&#177;77 bpm&#41;&#44; right bundle branch block and a fragmented QRS complex &#8211; despite normal left ventricular activation&#44; right ventricular depolarization was delayed and prolonged &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A chest X-ray revealed cardiomegaly&#44; with a narrow vascular pedicle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Computed tomography of the chest showed dilated right heart chambers&#44; inferior vena cava and hepatic veins&#44; with no dilatation of the pulmonary artery&#46; Pulmonary ventilation&#47;perfusion scintigraphy ruled out a pulmonary embolism and indicated a right-to-left shunt&#46; Transthoracic echocardiography confirmed severe dilation of the right heart chambers and impaired right ventricular systolic function &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#59; a tricuspid valve with normal implantation and moderate regurgitation&#59; an estimated pulmonary artery systolic pressure of 36 mmHg&#59; a normal pulmonary artery diameter&#59; and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect &#40;ASD&#41; &#40;38 mm&#41;&#44; confirmed by transesophageal echocardiography&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Cardiac catheterization was performed&#44; revealing an absence of gradient between the RV and pulmonary artery and post-capillary pulmonary hypertension &#40;mean pulmonary artery pressure of 32 mmHg&#44; with an elevated pulmonary capillary wedge pressure of 19 mmHg&#41;&#46; A pulmonary blood flow&#58;systemic blood flow ratio of 0&#46;88&#58;1 was also calculated&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">At this point&#44; the authors felt that ASD as the primary diagnosis could not explain the clinical features or hemodynamic data&#46; On one hand&#44; there was no anomalous venous return to justify the cyanosis and mild postcapillary pulmonary hypertension was not compatible with Eisenmenger&#39;s syndrome and the consequent right-to-left shunt&#46; On the other hand&#44; there was no evidence of a significant past or present left-to-right shunt&#44; since the pulmonary artery was normal in size&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Primary right ventricular disease was the most likely hypothesis and CMR was performed&#44; revealing severe dilation of the right atrium &#40;91&#215;72 mm&#41; and right ventricle &#40;end-diastolic volume 355 ml&#44; 207&#46;9 ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; an extremely thin-walled RV with almost complete absence of the right ventricular free wall myocardium&#44; a paucity of apical trabeculations and impaired systolic function &#40;ejection fraction &#91;EF&#93; 25&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The left ventricle was dilated with normal wall thickness and an EF of 41&#37;&#46; An ASD measuring over 30 mm was identified and late gadolinium enhancement was observed in the right ventricle and right atrium walls &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; These findings were compatible with Uhl&#39;s anomaly&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Cardiopulmonary exercise testing showed a moderate exercise capacity with a peak oxygen uptake of 27&#46;6 ml&#47;kg&#47;min &#40;55&#37; of the value predicted for the patient&#39;s gender and age&#41; as well as an oxygen uptake at anaerobic threshold of 20&#46;5 ml&#47;kg&#47;min and a minute ventilation-to-carbon dioxide output slope of 46&#46;2&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient initiated anticoagulation therapy with warfarin and received a subcutaneous implantable cardioverter-defibrillator for primary prevention of sudden cardiac death&#44; due to severe right ventricular dysfunction&#46; The patient will be closely monitored and heart transplantation will be considered in the event his functional capacity deteriorates&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Uhl&#39;s disease is characterized by the absence of the RV myocardium and the direct apposition of endocardium to epicardium&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Histological examination confirms cardiac muscle wastage and replacement by fibrous tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> However&#44; despite this anomaly in the RV myocardium&#44; the septal and left ventricular myocardium is preserved&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In severe forms&#44; RV failure develops during childhood&#44; with pulmonary circulation being dependent on the right atrium&#46; Cyanosis is also present in the event of an atrial shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Prior to the advent of current imaging methods&#44; diagnosis was performed during autopsy&#46; Nowadays&#44; CMR is the method of choice for diagnosis&#44; as well as for morphologic and functional evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The association of Uhl&#39;s disease with other congenital heart defects had rarely been reported&#44; namely with tricuspid valve dysplasia or absence&#44; Ebstein&#39;s anomaly&#44; pulmonary atresia or regurgitation&#44; patent ductus arteriosus&#44; ASD and hypoplasia of the mitral valve and left ventricle&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;8&#8211;12</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A differential diagnosis should be performed with ARVD&#46; From a histological point of view&#44; ARVD is characterized by fibrofatty infiltration of the right ventricular free wall which is absent in Uhl&#39;s disease&#44; where fibrosis predominates&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> Unlike ARVD&#44; the major clinical finding in Uhl&#39;s disease is heart failure&#44; rather than arrhythmic events and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;10</span></a> Family history is also more common in ARVD than in Uhl&#39;s disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding electrocardiographic studies&#44; in ARVD&#44; T-wave inversions in V1 and V2 are noted&#44; along with Epsilon waves&#46; Uhl&#39;s disease&#44; on the other hand&#44; presents a fragmented QRS complex&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;13</span></a> In CMR&#44; Uhl&#39;s disease is characterized by an extremely dilated thin-walled RV with severe hypokinesis&#44; a paucity of trabeculations and no fat signal in the RV wall&#44; as seen in ARVD&#46; In ARVD&#44; focal wall motion abnormalities are more frequent&#44; contrasting with the global hypokinesis seen in Uhl&#39;s disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">4&#44;7&#44;13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Ebstein&#39;s anomaly should also be considered in differential diagnosis&#46; In Uhl&#39;s disease the tricuspid valve hinges normally and is not dysplastic&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regard to surgical treatment&#44; a right heart bypass can be performed&#46; However&#44; this procedure carries a risk of clots forming in the right ventricle as well as embolization&#44; particularly in the presence of a bidirectional Glenn shunt&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> Another option involves almost entirely resecting the RV free wall&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> Possible complications include recurrent ventricular dilatation and arrhythmias&#46; In these cases&#44; a residual RV free wall must be ruled out and a total cavopulmonary connection performed&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">If clinical deterioration persists&#44; the treatment approach should be orthotopic cardiac transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In our case&#44; the association of RV myocardium disease with a large ASD explains the patient&#39;s unique clinical evolution&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cyanosis in the presence of an ASD &#40;with a &#8220;normal&#8221; RV&#41; may occur in two circumstances that were not present in this case&#58; severe pulmonary hypertension with Eisenmenger&#39;s syndrome and the consequent right-to-left shunt&#44; or when an anomalous systemic venous return exists&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Furthermore&#44; the lack of pulmonary artery dilation shows that&#44; although the ASD is large&#44; there was probably no significant left-to-right shunt&#46; The inexistence of such a shunt is due to the fact that a shunt is dependent of the compliance of both ventricles in ASDs&#44; and in this case only the RV was affected&#46; Over the years&#44; progressive RV dysfunction led to a right-to-left shunt and consequent cyanosis&#46; Moreover&#44; the defect acts as an escape&#44; which has until now prevented the occurrence of overt right-sided heart failure&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The ECG is also notable&#44; with a fragmented QRS complex&#44; reflecting the delay and prolongation of right ventricular depolarization&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion&#44; this case shows that clinical symptoms&#44; hemodynamic data and imaging findings must be comprehensively and thoroughly reviewed in congenital heart disease in order to enable correct diagnosis&#46; Primary RV disease should be considered when RV failure is present in the absence of valve disease and pulmonary hypertension&#46; Uhl&#39;s anomaly is a rare disease that consists in the absence of the RV myocardium and progressive RV failure&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0140" 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="spar0035" class="elsevierStyleSimplePara elsevierViewall">Uhl&#39;s disease&#44; also known as Uhl anomaly&#44; is a rare disease secondary to selective but uncontrolled apoptosis of right ventricular myocytes during the perinatal period&#44; after complete cardiac development&#44; leading to the absence of right ventricular myocardium and the direct apposition of endocardium to epicardium without a myocardial layer in between&#44; resulting in right ventricular failure&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The present paper describes a case of Uhl&#39;s disease with an uncommon presentation&#46; A 28-year-old man was admitted with dyspnea and cyanosis&#46; Transthoracic echocardiography showed severe dilation of the right chambers&#44; impaired right ventricular systolic function and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect &#40;ASD&#41;&#46; Cardiac catheterization revealed pulmonary hypertension&#44; with increased pulmonary capillary wedge pressure &#40;mean 19<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and Qp&#58;QS 0&#46;88&#58;1&#46; At this point&#44; the authors considered that a main diagnosis of ASD could not explain the clinical features and hemodynamic data&#46; A primary disease of the right ventricle was the most likely hypothesis and cardiac magnetic resonance imaging was performed&#44; which demonstrated an extremely thin-walled right ventricle&#44; with almost complete absence of right ventricular free wall myocardium&#44; compatible with Uhl&#39;s disease&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A anomalia de Ulh &#233; uma doen&#231;a rara&#44; secund&#225;ria &#224; seletiva&#44; contudo descontrolada apoptose dos mi&#243;citos do ventr&#237;culo direito durante o per&#237;odo perinatal&#44; ap&#243;s o desenvolvimento card&#237;aco completo&#44; o que explica a aus&#234;ncia de mioc&#225;rdio do ventr&#237;culo direito e a direta aposi&#231;&#227;o do endoc&#225;rdio e epic&#225;rdio&#44; resultando em fal&#234;ncia do ventr&#237;culo direito&#46; O presente artigo descreve um caso de doen&#231;a de Uhl com apresenta&#231;&#227;o incomum&#46; Homem de 28 anos admitido por dispneia e cianose&#46; O ecocardiograma transtor&#225;cico documentou dilata&#231;&#227;o grave das cavidades direitas&#44; compromisso da fun&#231;&#227;o sist&#243;lica do ventr&#237;culo direito e uma grande comunica&#231;&#227;o interauricular <span class="elsevierStyleItalic">ostium secundum&#46;</span> O cateterismo card&#237;aco revelou hipertens&#227;o pulmonar com aumento da press&#227;o capilar &#40;m&#233;dia 19mmHg&#41;&#59; Qp&#58;Qs 0&#44;88&#58;1&#46; Neste momento&#44; os autores consideraram que a comunica&#231;&#227;o interauricular como diagn&#243;stico principal n&#227;o explicava a apresenta&#231;&#227;o cl&#237;nica e os dados hemodin&#226;micos&#46; Doen&#231;a prim&#225;ria do ventr&#237;culo direito tornou-se a hip&#243;tese mais prov&#225;vel&#44; pelo que se realizou uma resson&#226;ncia magn&#233;tica card&#237;aca que demonstrou um ventr&#237;culo direito com parede extremamente fina&#44; com aus&#234;ncia praticamente total do mioc&#225;rdio da parede livre&#44; compat&#237;vel com doen&#231;a de Uhl&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#58; Chest X-ray revealing cardiomegaly with no pulmonary artery dilatation&#59; B&#58; Electrocardiogram showing atrial fibrillation and right bundle branch block&#46; C&#58; Transthoracic echocardiography showing severe right chambers dilation&#44; particularly of the right atrium&#44; and a large <span class="elsevierStyleItalic">ostium secundum</span> atrial septal defect&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular magnetic resonance&#58; Steady-state free precession imaging documenting severe dilation of the right atrium and right ventricle&#44; an extremely thin-walled right ventricle with almost complete absence of the right ventricular free wall myocardium&#44; with a paucity of apical trabeculations&#44; in a four-chamber view in diastole &#40;A&#41; and systole &#40;B&#41;&#44; and coronal view &#40;C&#41;&#46; An atrial septal defect measuring over 30 mm was also identified&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Late gadolinium enhancement &#40;LGE&#41; acquired 10 minutes after intravenous gadolinium administration&#46; LGE is evident in the right ventricular and right atrium walls&#44; in the four-chamber view &#40;A&#41;&#44; right ventricle view &#40;B&#41; and short axis view &#40;C&#41;&#46;</p>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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