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which in turn is associated with abnormal vasoreactivity of the small vessels&#46; This process can produce repeated focal ischemia&#44; eventually leading to fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several imaging methods can be used to detect cardiac involvement in SSc&#44; including echocardiography and myocardial perfusion scanning&#46; However&#44; both lack sensitivity for certain tissue characteristics&#44; particularly inflammation and fibrosis&#44; which can be accurately identified by cardiac magnetic resonance &#40;CMR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Here&#44; we present a rare case of a patient recently diagnosed with SSc admitted with heart failure&#44; which was ultimately found to be associated with diffuse and severe intramyocardial fibrosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 40-year-old Caucasian man presented to the emergency room with asthenia&#44; dyspnea on mild exertion and peripheral edema&#46; The symptoms had started three weeks previously and had been worsening progressively&#46; He also had complaints suggestive of Raynaud phenomenon and hardening of the skin in the previous eight months&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two years before this episode&#44; following an abrupt onset of peripheral edema in both hands and lower limbs&#44; he had been diagnosed with SSc&#46; At the time&#44; immunological tests were performed&#44; which were positive for anti-Scl-70 antibodies&#46; He also underwent lung function tests&#44; which were normal except for mildly reduced carbon monoxide diffusion capacity&#44; and high-resolution chest tomography&#44; which was negative for pulmonary fibrosis&#46; Since then he had been treated with mycophenolate mofetil&#44; prednisolone and monthly cyclophosphamide pulses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On admission&#44; physical examination revealed hardened skin on the hands&#44; forearms&#44; legs&#44; feet and abdominal wall &#40;Rodnan skin score &#62;20&#41;&#46; Raynaud phenomenon was also present on both hands and feet&#46; Lung auscultation demonstrated slight rales in both pulmonary bases&#46; Signs of overt right heart failure were also present&#44; including increased jugular venous pressure of 16 cm H<span class="elsevierStyleInf">2</span>O&#44; Kussmaul&#39;s sign&#44; ascites and lower limb edema&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Laboratory workup was notable for markedly elevated brain natriuretic peptide &#40;BNP&#41; of 2340 pg&#47;ml &#40;normal &#60;100 pg&#47;ml&#41; and hepatic congestion&#44; with alkaline phosphatase &#40;ALP&#41; of 467 U&#47;l &#40;normal &#60;120 U&#47;l&#41; and gamma-glutamyl transpeptidase &#40;GGT&#41; of 367 U&#47;l &#40;normal &#60;45 U&#47;l&#41;&#46; The admission electrocardiogram showed sinus rhythm with right axis deviation&#44; with no signs of right or left ventricular &#40;LV&#41; hypertrophy&#46; Transthoracic echocardiography revealed severe right ventricular &#40;RV&#41; systolic dysfunction &#40;tricuspid annular plane excursion &#91;TAPSE&#93; 13 mm&#44; S&#8217; 6 cm&#47;s&#44; fractional area change &#91;FAC&#93; 24&#37;&#44; RV ejection fraction &#91;RVEF&#93; 39&#37;&#41;&#44; paradoxical ventricular septal motion suggestive of volume&#47;pressure overload&#44; severe tricuspid regurgitation and pulmonary artery systolic pressure &#40;PASP&#41; of 16 mmHg &#40;likely underestimated&#41;&#46; There was also mild LV systolic dysfunction &#40;LV ejection fraction &#91;LVEF&#93; 45&#37; estimated by the Simpson biplane method&#41;&#44; impaired global longitudinal strain &#40;GLS&#41; -8&#37;&#44; type 2 diastolic dysfunction with elevated filling pressures &#40;E&#47;E&#8217; ratio 15&#41;&#44; and moderate mitral regurgitation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to suboptimal clinical response to initial diuretic therapy&#44; the patient was transferred to an advanced heart failure unit to further optimize treatment&#44; with intensive diuretic therapy and vasopressor support with noradrenaline&#46; During admission&#44; the patient suffered two cardiopulmonary arrests in ventricular fibrillation&#46; In both episodes&#44; there was full neurologic recovery after advanced cardiac life support and prompt defibrillation&#46; Coronary angiography showed no coronary artery disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In order to better understand the hemodynamics&#44; right heart catheterization was performed and revealed poor RV function with high filling pressures&#44; normal pulmonary artery pressures&#44; mildly depressed cardiac index&#44; normal pulmonary capillary wedge pressure and normal pulmonary vascular resistance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Importantly&#44; a deep y descent with a rapid upstroke was noted &#40;&#8216;square root&#8217; sign&#41;&#44; suggesting severe diastolic filling impairment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; To further clarify the myocardial disorder in the absence of pulmonary hypertension&#44; CMR was performed&#44; which showed diffuse infiltration of the myocardium &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; This was later confirmed by endomyocardial biopsy which was notable for diffuse myocardial fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Due to the patient&#39;s susceptibility to arrhythmias&#44; an implantable cardioverter-defibrillator &#40;ICD&#41; was placed&#46; A significant clinical response to intensive decongestive therapy was achieved&#46; At discharge&#44; a total net weight loss of 15 kg was recorded&#46; Combined treatment for heart failure and SSc was instituted&#44; including intravenous immunoglobulin G &#40;400 mg&#47;kg&#47;day&#41; initially for five consecutive continuous days and then monthly&#44; and&#44; in a second phase&#44; rituximab&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At six-month follow-up&#44; the patient had had one appropriate ICD shock&#46; Echocardiography showed an improved LVEF of 56&#37; and GLS of -15&#37;&#44; with continuing type 2 diastolic dysfunction&#44; and depressed but improved RV function &#40;TAPSE 14 mm&#44; S&#8217; 7 cm&#47;s&#44; FAC 31&#37;&#44; RVEF 40&#37;&#41;&#46; Laboratory workup revealed reduced BNP &#40;350 pg&#47;ml&#41;&#44; normal transaminases and ALP&#44; and elevated GGT of 300 U&#47;l&#46; No other admissions to the emergency department&#44; episodes of decompensated heart failure or arrhythmic events were recorded at 14 months of follow-up&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">We present a rare case of SSc with clinically overt right heart failure due to severe fibrotic involvement of the myocardium&#44; occurring early in the disease course&#46; While diffuse myocardial fibrosis is known to be present histologically early in SSc&#44; it is usually clinically silent until the late stages of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In several studies&#44; a reduced LVEF was found in only a minority of SSc patients&#44; ranging from 1&#46;4&#37; to 5&#46;4&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; a study of 100 patients using a more sensitive echocardiographic technique to assess systolic function based on tissue Doppler demonstrated that 14&#37; and 15&#37; of patients with SSc had impaired LV and RV contractility&#44; respectively&#46; Moreover&#44; this study found that 30&#37; of patients had definite abnormal LV filling patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> It can thus be concluded that diastolic dysfunction is more prevalent than systolic dysfunction in both ventricles in SSc patients&#46; Another study investigated cardiac function in 46 SSc patients with normal pulmonary arterial pressures and less than five years of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> The authors found that 16 patients had reduced RVEF and 10 had reduced peak filling rate&#44; demonstrating early right systolic and left diastolic dysfunction&#46; Nevertheless&#44; no correlation was found with pulmonary function impairment or pulmonary arterial pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> This type of cardiac involvement differs from that caused by pulmonary arterial hypertension&#44; the prevalence of which ranges from 8&#37; to 12&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our patient had mildly reduced LVEF &#40;45&#37;&#41; and severely impaired RVEF&#44; with paradoxical ventricular septal motion but normal PASP&#46; The congestive symptoms were attributed to the early impairment of RV systolic and LV systolic and diastolic dysfunction&#59; notably&#44; RV dysfunction appeared without the development of pulmonary vascular disease&#44; a much more obvious clinical correlation in SSc&#44; and was solely the consequence of the myocardial fibrotic process&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">CMR is currently the noninvasive method of choice to assess diffuse myocarditis&#44; providing information on the stage&#44; degree&#44; and extent of reversible and irreversible myocardial injury&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> T1- and T2-weighted CMR are novel techniques for quantitative tissue characterization&#44; which may overcome the limitations of current CMR criteria for assessing diffuse myocardial damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a> Recent studies indicate that native myocardial T1&#44; myocardial T2&#44; and extracellular volume &#40;ECV&#41; imaging could improve the diagnostic performance of CMR&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The therapeutic strategy was changed in the case presented to a more aggressive off-label immunosuppressive treatment&#46; There is in fact no evidence that intravenous immunoglobulin G and rituximab are more effective than other immunosuppressant drugs&#44; though some recent studies support their use in SSc patients&#44; particularly those with severe skin and lung involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Unfortunately&#44; no immunomodulatory strategy has yet been shown to specifically reduce myocardial fibrosis&#46; Although there is no formal contraindication to heart transplantation&#44; it is usually not performed in these cases&#44; since the transplanted heart may be involved by the same infiltrative process&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">When approaching SSc patients presenting with heart failure it is important to recognize that pulmonary hypertension is not the cause in all cases&#44; and to bear in mind other possible forms of cardiac involvement in this disease&#46; Early detection of cardiac involvement&#44; including diffuse myocardial fibrosis&#44; is essential in SSc patients&#44; since it is associated with poor prognosis&#46; Use of accurate diagnostic tools such as echocardiography and CMR help establish the cause of heart failure and enable initiation of an appropriate therapeutic strategy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this case report and any accompanying images&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors&#8217; contributions</span><p id="par0105" class="elsevierStylePara elsevierViewall">PA&#58; conception and design&#44; analysis and interpretation of data&#44; manuscript writing&#46; RB&#44; CC&#44; FF&#58; attending physician&#44; acquisition and analysis of data&#44; critical revision for important intellectual content&#46; LS and MP&#58; interpretation of data&#44; critical revision for important intellectual content&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Availability of data and materials</span><p id="par0110" class="elsevierStylePara elsevierViewall">Supporting data is available to researchers in a repository&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2017-03-04"
    "fechaAceptado" => "2017-07-24"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Heart failure"
            1 => "Systemic sclerosis"
            2 => "Myocardial fibrosis"
          ]
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      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1174824"
          "palabras" => array:3 [
            0 => "Insufici&#234;ncia card&#237;aca"
            1 => "Esclerose sist&#233;mica"
            2 => "Fibrose mioc&#225;rdica"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis &#40;SSc&#41; is a systemic autoimmune disease involving multiple organs&#46; We present a rare case of SSc in which clinical manifestations of cardiac fibrosis occurred early in the disease course&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 40-year-old Caucasian man&#44; previously diagnosed with SSc&#44; who presented with decompensated heart failure&#46; Transthoracic echocardiography was remarkable for severe right ventricular systolic dysfunction&#44; abnormal ventricular septal motion&#44; severe functional tricuspid regurgitation and normal pulmonary artery systolic pressure&#46; Left ventricular ejection fraction was 45&#37;&#46; Right heart catheterization revealed no signs of pulmonary hypertension&#46; Cardiac magnetic resonance &#40;CMR&#41; showed diffuse myocardial infiltration&#44; later confirmed as myocardial fibrosis by endomyocardial biopsy&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Myocardial fibrosis is an important cause of early heart failure in SSc patients and is associated with poor prognosis&#46; Echocardiography and CMR help establish the diagnosis and enable an appropriate therapeutic strategy to be developed in such cases&#46;</p></span>"
        "secciones" => array:3 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A esclerose sist&#233;mica &#40;ES&#41; &#233; uma doen&#231;a autoimune sist&#233;mica que pode envolver m&#250;ltiplos &#243;rg&#227;os&#46; Apresentamos um caso raro de ES associada a manifesta&#231;&#227;o cl&#237;nica de fibrose mioc&#225;rdica no decurso precoce da evolu&#231;&#227;o da doen&#231;a&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#58; Reportamos um caso de um homem de 40 anos&#44; com antecedentes de ES e que se apresenta com um quadro de insufici&#234;ncia card&#237;aca descompensada&#46; O ecocardiograma transtor&#225;cico revelou disfun&#231;&#227;o sist&#243;lica severa do ventr&#237;culo direito&#44; movimento an&#243;malo do septo interventricular&#44; insufici&#234;ncia tric&#250;spide severa e press&#227;o sist&#243;lica da art&#233;ria pulmonar normal&#46; A fra&#231;&#227;o da eje&#231;&#227;o era de 45&#37;&#46; O cateterismo direito n&#227;o identificou sinais de hipertens&#227;o pulmonar&#46; A resson&#226;ncia magn&#233;tica card&#237;aca &#40;RMC&#41; demonstrou infiltra&#231;&#227;o mioc&#225;rdica difusa&#44; confirmada com bi&#243;psia endomioc&#225;rdica como fibrose mioc&#225;rdica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A fibrose mioc&#225;rdica &#233; uma causa importante de insufici&#234;ncia card&#237;aca na ES e est&#225; associada a mau progn&#243;stico&#46; O ecocardiograma e a RMC podem ajudar a estabelecer o diagn&#243;stico e a desenvolver a estrat&#233;gia terap&#234;utica adequada&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Right heart catheterization&#46; Right ventricular pressure curve with a &#8216;square root&#8217; pattern&#44; suggestive of early&#44; severely impaired diastolic filling&#46; Note also the elevated v wave&#44; reflecting severe tricuspid regurgitation in a congested right atrium&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance&#58; delayed enhancement sequence showing diffuse intramyocardial enhancement of both ventricles&#44; suggesting presence of fibrosis&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Endomyocardial biopsy&#58; diffuse infiltrative fibrosis process &#40;&#42;&#41; involving cardiomyocytes &#40;arrows&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BD&#58; beginning diastolic&#59; CI&#58; cardiac index&#59; CO&#58; cardiac output&#59; D&#58; diastolic&#59; ED&#58; end-diastolic&#59; M&#58; mean&#59; PA&#58; pulmonary artery&#59; PCWP&#58; pulmonary capillary wedge pressure&#59; PVR&#58; pulmonary vascular resistance&#59; RA&#58; right atrium&#59; RV&#58; right ventricle&#59; S&#58; systolic&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Aorta &#40;S&#47;D&#47;M&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">104&#47;57&#47;72 mmHg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">PA &#40;S&#47;D&#47;M&#41;&nbsp;\t\t\t\t\t\t\n
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Case report
Early manifestation of myocardial involvement in systemic sclerosis
Envolvimento cardíaco na esclerose sistémica: uma manifestação precoce rara
Patrícia Marques-Alvesa,
Autor para correspondência
pat.marques.alves@gmail.com

Corresponding author.
, Rui Baptistaa,b, Catarina Canhac, Fátima Francoa, Lèlita Santosc, Mariano Pêgoa
a Department of Cardiology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
b CNC.IBILI Research Consortium, University of Coimbra, Coimbra, Portugal
c Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic sclerosis &#40;SSc&#41; is a chronic systemic autoimmune disease characterized by diffuse microvascular damage and fibrosis involving multiple organs&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Although cardiac involvement may be detected early in the disease course&#44; clinical manifestations are a late finding and are associated with poor prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> The prevalence of cardiovascular symptoms ranges between 10&#37; and 35&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiac involvement can be primary&#44; affecting all layers of the heart &#40;endocardium&#44; myocardium and pericardium&#41;&#44; or secondary to the impairment of other organs&#44; such as the lungs and kidneys&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a> All cardiac structures may be involved&#44; leading to conduction system defects&#44; atrial and ventricular arrhythmias&#44; valvular defects&#44; myocardial ischemia and&#47;or hypertrophy&#44; pericardial effusion or constrictive pericarditis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2&#44;6&#44;7</span></a> Heart failure may develop as a consequence of diffuse myocardial fibrosis or secondary to pulmonary hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Diffuse myocardial fibrosis develops long before the onset of heart failure symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;3</span></a> Vascular lesions in SSc result in general impairment of the microcirculation&#44; which in turn is associated with abnormal vasoreactivity of the small vessels&#46; This process can produce repeated focal ischemia&#44; eventually leading to fibrosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several imaging methods can be used to detect cardiac involvement in SSc&#44; including echocardiography and myocardial perfusion scanning&#46; However&#44; both lack sensitivity for certain tissue characteristics&#44; particularly inflammation and fibrosis&#44; which can be accurately identified by cardiac magnetic resonance &#40;CMR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Here&#44; we present a rare case of a patient recently diagnosed with SSc admitted with heart failure&#44; which was ultimately found to be associated with diffuse and severe intramyocardial fibrosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 40-year-old Caucasian man presented to the emergency room with asthenia&#44; dyspnea on mild exertion and peripheral edema&#46; The symptoms had started three weeks previously and had been worsening progressively&#46; He also had complaints suggestive of Raynaud phenomenon and hardening of the skin in the previous eight months&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Two years before this episode&#44; following an abrupt onset of peripheral edema in both hands and lower limbs&#44; he had been diagnosed with SSc&#46; At the time&#44; immunological tests were performed&#44; which were positive for anti-Scl-70 antibodies&#46; He also underwent lung function tests&#44; which were normal except for mildly reduced carbon monoxide diffusion capacity&#44; and high-resolution chest tomography&#44; which was negative for pulmonary fibrosis&#46; Since then he had been treated with mycophenolate mofetil&#44; prednisolone and monthly cyclophosphamide pulses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">On admission&#44; physical examination revealed hardened skin on the hands&#44; forearms&#44; legs&#44; feet and abdominal wall &#40;Rodnan skin score &#62;20&#41;&#46; Raynaud phenomenon was also present on both hands and feet&#46; Lung auscultation demonstrated slight rales in both pulmonary bases&#46; Signs of overt right heart failure were also present&#44; including increased jugular venous pressure of 16 cm H<span class="elsevierStyleInf">2</span>O&#44; Kussmaul&#39;s sign&#44; ascites and lower limb edema&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Laboratory workup was notable for markedly elevated brain natriuretic peptide &#40;BNP&#41; of 2340 pg&#47;ml &#40;normal &#60;100 pg&#47;ml&#41; and hepatic congestion&#44; with alkaline phosphatase &#40;ALP&#41; of 467 U&#47;l &#40;normal &#60;120 U&#47;l&#41; and gamma-glutamyl transpeptidase &#40;GGT&#41; of 367 U&#47;l &#40;normal &#60;45 U&#47;l&#41;&#46; The admission electrocardiogram showed sinus rhythm with right axis deviation&#44; with no signs of right or left ventricular &#40;LV&#41; hypertrophy&#46; Transthoracic echocardiography revealed severe right ventricular &#40;RV&#41; systolic dysfunction &#40;tricuspid annular plane excursion &#91;TAPSE&#93; 13 mm&#44; S&#8217; 6 cm&#47;s&#44; fractional area change &#91;FAC&#93; 24&#37;&#44; RV ejection fraction &#91;RVEF&#93; 39&#37;&#41;&#44; paradoxical ventricular septal motion suggestive of volume&#47;pressure overload&#44; severe tricuspid regurgitation and pulmonary artery systolic pressure &#40;PASP&#41; of 16 mmHg &#40;likely underestimated&#41;&#46; There was also mild LV systolic dysfunction &#40;LV ejection fraction &#91;LVEF&#93; 45&#37; estimated by the Simpson biplane method&#41;&#44; impaired global longitudinal strain &#40;GLS&#41; -8&#37;&#44; type 2 diastolic dysfunction with elevated filling pressures &#40;E&#47;E&#8217; ratio 15&#41;&#44; and moderate mitral regurgitation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to suboptimal clinical response to initial diuretic therapy&#44; the patient was transferred to an advanced heart failure unit to further optimize treatment&#44; with intensive diuretic therapy and vasopressor support with noradrenaline&#46; During admission&#44; the patient suffered two cardiopulmonary arrests in ventricular fibrillation&#46; In both episodes&#44; there was full neurologic recovery after advanced cardiac life support and prompt defibrillation&#46; Coronary angiography showed no coronary artery disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In order to better understand the hemodynamics&#44; right heart catheterization was performed and revealed poor RV function with high filling pressures&#44; normal pulmonary artery pressures&#44; mildly depressed cardiac index&#44; normal pulmonary capillary wedge pressure and normal pulmonary vascular resistance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Importantly&#44; a deep y descent with a rapid upstroke was noted &#40;&#8216;square root&#8217; sign&#41;&#44; suggesting severe diastolic filling impairment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; To further clarify the myocardial disorder in the absence of pulmonary hypertension&#44; CMR was performed&#44; which showed diffuse infiltration of the myocardium &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; This was later confirmed by endomyocardial biopsy which was notable for diffuse myocardial fibrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Due to the patient&#39;s susceptibility to arrhythmias&#44; an implantable cardioverter-defibrillator &#40;ICD&#41; was placed&#46; A significant clinical response to intensive decongestive therapy was achieved&#46; At discharge&#44; a total net weight loss of 15 kg was recorded&#46; Combined treatment for heart failure and SSc was instituted&#44; including intravenous immunoglobulin G &#40;400 mg&#47;kg&#47;day&#41; initially for five consecutive continuous days and then monthly&#44; and&#44; in a second phase&#44; rituximab&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At six-month follow-up&#44; the patient had had one appropriate ICD shock&#46; Echocardiography showed an improved LVEF of 56&#37; and GLS of -15&#37;&#44; with continuing type 2 diastolic dysfunction&#44; and depressed but improved RV function &#40;TAPSE 14 mm&#44; S&#8217; 7 cm&#47;s&#44; FAC 31&#37;&#44; RVEF 40&#37;&#41;&#46; Laboratory workup revealed reduced BNP &#40;350 pg&#47;ml&#41;&#44; normal transaminases and ALP&#44; and elevated GGT of 300 U&#47;l&#46; No other admissions to the emergency department&#44; episodes of decompensated heart failure or arrhythmic events were recorded at 14 months of follow-up&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">We present a rare case of SSc with clinically overt right heart failure due to severe fibrotic involvement of the myocardium&#44; occurring early in the disease course&#46; While diffuse myocardial fibrosis is known to be present histologically early in SSc&#44; it is usually clinically silent until the late stages of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In several studies&#44; a reduced LVEF was found in only a minority of SSc patients&#44; ranging from 1&#46;4&#37; to 5&#46;4&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; a study of 100 patients using a more sensitive echocardiographic technique to assess systolic function based on tissue Doppler demonstrated that 14&#37; and 15&#37; of patients with SSc had impaired LV and RV contractility&#44; respectively&#46; Moreover&#44; this study found that 30&#37; of patients had definite abnormal LV filling patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> It can thus be concluded that diastolic dysfunction is more prevalent than systolic dysfunction in both ventricles in SSc patients&#46; Another study investigated cardiac function in 46 SSc patients with normal pulmonary arterial pressures and less than five years of disease&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> The authors found that 16 patients had reduced RVEF and 10 had reduced peak filling rate&#44; demonstrating early right systolic and left diastolic dysfunction&#46; Nevertheless&#44; no correlation was found with pulmonary function impairment or pulmonary arterial pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> This type of cardiac involvement differs from that caused by pulmonary arterial hypertension&#44; the prevalence of which ranges from 8&#37; to 12&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Our patient had mildly reduced LVEF &#40;45&#37;&#41; and severely impaired RVEF&#44; with paradoxical ventricular septal motion but normal PASP&#46; The congestive symptoms were attributed to the early impairment of RV systolic and LV systolic and diastolic dysfunction&#59; notably&#44; RV dysfunction appeared without the development of pulmonary vascular disease&#44; a much more obvious clinical correlation in SSc&#44; and was solely the consequence of the myocardial fibrotic process&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">CMR is currently the noninvasive method of choice to assess diffuse myocarditis&#44; providing information on the stage&#44; degree&#44; and extent of reversible and irreversible myocardial injury&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> T1- and T2-weighted CMR are novel techniques for quantitative tissue characterization&#44; which may overcome the limitations of current CMR criteria for assessing diffuse myocardial damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a> Recent studies indicate that native myocardial T1&#44; myocardial T2&#44; and extracellular volume &#40;ECV&#41; imaging could improve the diagnostic performance of CMR&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The therapeutic strategy was changed in the case presented to a more aggressive off-label immunosuppressive treatment&#46; There is in fact no evidence that intravenous immunoglobulin G and rituximab are more effective than other immunosuppressant drugs&#44; though some recent studies support their use in SSc patients&#44; particularly those with severe skin and lung involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Unfortunately&#44; no immunomodulatory strategy has yet been shown to specifically reduce myocardial fibrosis&#46; Although there is no formal contraindication to heart transplantation&#44; it is usually not performed in these cases&#44; since the transplanted heart may be involved by the same infiltrative process&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">When approaching SSc patients presenting with heart failure it is important to recognize that pulmonary hypertension is not the cause in all cases&#44; and to bear in mind other possible forms of cardiac involvement in this disease&#46; Early detection of cardiac involvement&#44; including diffuse myocardial fibrosis&#44; is essential in SSc patients&#44; since it is associated with poor prognosis&#46; Use of accurate diagnostic tools such as echocardiography and CMR help establish the cause of heart failure and enable initiation of an appropriate therapeutic strategy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this case report and any accompanying images&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors&#8217; contributions</span><p id="par0105" class="elsevierStylePara elsevierViewall">PA&#58; conception and design&#44; analysis and interpretation of data&#44; manuscript writing&#46; RB&#44; CC&#44; FF&#58; attending physician&#44; acquisition and analysis of data&#44; critical revision for important intellectual content&#46; LS and MP&#58; interpretation of data&#44; critical revision for important intellectual content&#46; All authors read and approved the final manuscript&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Availability of data and materials</span><p id="par0110" class="elsevierStylePara elsevierViewall">Supporting data is available to researchers in a repository&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Heart failure"
            1 => "Systemic sclerosis"
            2 => "Myocardial fibrosis"
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          "palabras" => array:3 [
            0 => "Insufici&#234;ncia card&#237;aca"
            1 => "Esclerose sist&#233;mica"
            2 => "Fibrose mioc&#225;rdica"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis &#40;SSc&#41; is a systemic autoimmune disease involving multiple organs&#46; We present a rare case of SSc in which clinical manifestations of cardiac fibrosis occurred early in the disease course&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 40-year-old Caucasian man&#44; previously diagnosed with SSc&#44; who presented with decompensated heart failure&#46; Transthoracic echocardiography was remarkable for severe right ventricular systolic dysfunction&#44; abnormal ventricular septal motion&#44; severe functional tricuspid regurgitation and normal pulmonary artery systolic pressure&#46; Left ventricular ejection fraction was 45&#37;&#46; Right heart catheterization revealed no signs of pulmonary hypertension&#46; Cardiac magnetic resonance &#40;CMR&#41; showed diffuse myocardial infiltration&#44; later confirmed as myocardial fibrosis by endomyocardial biopsy&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Myocardial fibrosis is an important cause of early heart failure in SSc patients and is associated with poor prognosis&#46; Echocardiography and CMR help establish the diagnosis and enable an appropriate therapeutic strategy to be developed in such cases&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A esclerose sist&#233;mica &#40;ES&#41; &#233; uma doen&#231;a autoimune sist&#233;mica que pode envolver m&#250;ltiplos &#243;rg&#227;os&#46; Apresentamos um caso raro de ES associada a manifesta&#231;&#227;o cl&#237;nica de fibrose mioc&#225;rdica no decurso precoce da evolu&#231;&#227;o da doen&#231;a&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#58; Reportamos um caso de um homem de 40 anos&#44; com antecedentes de ES e que se apresenta com um quadro de insufici&#234;ncia card&#237;aca descompensada&#46; O ecocardiograma transtor&#225;cico revelou disfun&#231;&#227;o sist&#243;lica severa do ventr&#237;culo direito&#44; movimento an&#243;malo do septo interventricular&#44; insufici&#234;ncia tric&#250;spide severa e press&#227;o sist&#243;lica da art&#233;ria pulmonar normal&#46; A fra&#231;&#227;o da eje&#231;&#227;o era de 45&#37;&#46; O cateterismo direito n&#227;o identificou sinais de hipertens&#227;o pulmonar&#46; A resson&#226;ncia magn&#233;tica card&#237;aca &#40;RMC&#41; demonstrou infiltra&#231;&#227;o mioc&#225;rdica difusa&#44; confirmada com bi&#243;psia endomioc&#225;rdica como fibrose mioc&#225;rdica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A fibrose mioc&#225;rdica &#233; uma causa importante de insufici&#234;ncia card&#237;aca na ES e est&#225; associada a mau progn&#243;stico&#46; O ecocardiograma e a RMC podem ajudar a estabelecer o diagn&#243;stico e a desenvolver a estrat&#233;gia terap&#234;utica adequada&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Right heart catheterization&#46; Right ventricular pressure curve with a &#8216;square root&#8217; pattern&#44; suggestive of early&#44; severely impaired diastolic filling&#46; Note also the elevated v wave&#44; reflecting severe tricuspid regurgitation in a congested right atrium&#46;</p>"
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                  \t\t\t\t">Aorta &#40;S&#47;D&#47;M&#41;&nbsp;\t\t\t\t\t\t\n
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ISSN: 08702551
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