Gastrointestinal Bleeding due to Angiodysplasia in a Patient with Severe Aortic Stenosis: Heyde’s Syndrome
Felipe Homem Valle1,
, Fernando Pivatto Júnior2, Luiz Carlos Corsetti Bergoli3, Rodrigo Vugman Wainstein4, Marco Vugman Wainstein5
Autor para correspondencia
felipehvalle@gmail.com
Felipe Homem Valle. Serviço de Cardiologia do Hospital de Clínicas de Porto Alegre. R. Ramiro Barcelos, 2.350 – Bairro Rio Branco – Porto Alegre, RS, Brazil – CEP 90035-903
Felipe Homem Valle. Serviço de Cardiologia do Hospital de Clínicas de Porto Alegre. R. Ramiro Barcelos, 2.350 – Bairro Rio Branco – Porto Alegre, RS, Brazil – CEP 90035-903
1 Resident physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brazil.
2 Resident physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brazil.
3 Hired physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre – Unidade de Hemodinâmica. Porto Alegre, RS, Brazil.
4 Hired physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre – Unidade de Hemodinâmica. Porto Alegre, RS, Brazil.
5 Adjunct professor of Faculdade de Medicina da Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brazil.
Leído
5061
Vecesse ha leído el artículo
952
Total PDF
4109
Total HTML
Compartir estadísticas
array:23 [ "pii" => "S2214123515301460" "issn" => "22141235" "doi" => "10.1016/S2214-1235(15)30146-0" "estado" => "S300" "fechaPublicacion" => "2013-06-01" "aid" => "16" "copyright" => "Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista. Published by Elsevier Editora Ltda" "copyrightAnyo" => "2013" "documento" => "simple-article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Bras Cardiol Invasiva. 2013;21:288-90" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1581 "formatos" => array:3 [ "EPUB" => 154 "HTML" => 981 "PDF" => 446 ] ] "itemSiguiente" => array:18 [ "pii" => "S2214123515301472" "issn" => "22141235" "doi" => "10.1016/S2214-1235(15)30147-2" "estado" => "S300" "fechaPublicacion" => "2013-06-01" "aid" => "17" "copyright" => "Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista. Published by Elsevier Editora Ltda" "documento" => "simple-article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Bras Cardiol Invasiva. 2013;21:291-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1492 "formatos" => array:3 [ "EPUB" => 148 "HTML" => 950 "PDF" => 394 ] ] "pt" => array:11 [ "idiomaDefecto" => true "titulo" => "Percutaneous Removal of Intravascular Catheter Fragment – an Adaptation of the Toolbox" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "291" "paginaFinal" => "294" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 1975 "Tamanyo" => 192745 ] ] "descripcion" => array:1 [ "pt" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">– Fluoroscopy showing the catheter fragment extension. (A) Proximal extremity in atributary of the subclavian vein in RAOat 45°. (B) Proximal extremity in LAO at 55°. (C) Distal extremity in the territory of supra-hepatic veins in RAO at 45°.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Igor Ribeiro de Castro Bienert, Rodolfo L.L.A.F. Chiozzi, Carlos E.C. Mota, João Saes Braga, Rubio Bombonato, Luís Junya Kajita" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Igor Ribeiro" "apellidos" => "de Castro Bienert" ] 1 => array:2 [ "nombre" => "Rodolfo L.L.A.F." "apellidos" => "Chiozzi" ] 2 => array:2 [ "nombre" => "Carlos E.C." "apellidos" => "Mota" ] 3 => array:2 [ "nombre" => "João Saes" "apellidos" => "Braga" ] 4 => array:2 [ "nombre" => "Rubio" "apellidos" => "Bombonato" ] 5 => array:2 [ "nombre" => "Luís Junya" "apellidos" => "Kajita" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515301472?idApp=UINPBA00004N" "url" => "/22141235/0000002100000003/v1_201509011255/S2214123515301472/v1_201509011255/pt/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2214123515301459" "issn" => "22141235" "doi" => "10.1016/S2214-1235(15)30145-9" "estado" => "S300" "fechaPublicacion" => "2013-06-01" "aid" => "15" "copyright" => "Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista. Published by Elsevier Editora Ltda" "documento" => "article" "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Bras Cardiol Invasiva. 2013;21:281-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2281 "formatos" => array:3 [ "EPUB" => 183 "HTML" => 1682 "PDF" => 416 ] ] "pt" => array:11 [ "idiomaDefecto" => true "titulo" => "Adipose Tissue-Derived Stem Cells and the Importance of Animal Model Standardization for Pre-Clinical Trials" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "281" "paginaFinal" => "287" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Zuttion et al., 2013 (unpublished data)." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1208 "Ancho" => 1976 "Tamanyo" => 656364 ] ] "descripcion" => array:1 [ "pt" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">– Swine adipose tissue-derived stem cells. (A) Isolation of stem cells from adipose tissue. (B) Morphology of adipose tissue-derived stem cells. (C) Colony-forming unit assay in adipose tissue-derived stem cells. (D) Adipogenic differentiation. Note the cells with lipid droplets. (E) Osteogenic differentiation (von Kossa staining); mineralization can be observed. (F) Hematoxylin-eosin staining demonstrating the chondrogenic differentiation. Scale bars: A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm; B to F<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10 micrometers. A, B, and D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>phase contrast. C, E, and F<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>optical microscopy.</p>" ] ] ] "autores" => array:2 [ 0 => array:2 [ "autoresLista" => "Marilia Sanches Santos Rizzo Zuttion, Cristiane Valverde Wenceslau, Pedro A. Lemos, Celso Takimura" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Marilia Sanches Santos Rizzo" "apellidos" => "Zuttion" ] 1 => array:2 [ "nombre" => "Cristiane Valverde" "apellidos" => "Wenceslau" ] 2 => array:2 [ "nombre" => "Pedro A." "apellidos" => "Lemos" ] 3 => array:2 [ "nombre" => "Celso" "apellidos" => "Takimura" ] ] ] 1 => array:2 [ "autoresLista" => "Irina Kerkis" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Irina" "apellidos" => "Kerkis" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515301459?idApp=UINPBA00004N" "url" => "/22141235/0000002100000003/v1_201509011255/S2214123515301459/v1_201509011255/pt/main.assets" ] "pt" => array:17 [ "idiomaDefecto" => true "titulo" => "Gastrointestinal Bleeding due to Angiodysplasia in a Patient with Severe Aortic Stenosis: Heyde’s Syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "288" "paginaFinal" => "290" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Felipe Homem Valle, Fernando Pivatto Júnior, Luiz Carlos Corsetti Bergoli, Rodrigo Vugman Wainstein, Marco Vugman Wainstein" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Felipe Homem" "apellidos" => "Valle" "email" => array:1 [ 0 => "felipehvalle@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "af0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cr0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando Pivatto" "apellidos" => "Júnior" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">2</span>" "identificador" => "af0010" ] ] ] 2 => array:3 [ "nombre" => "Luiz Carlos Corsetti" "apellidos" => "Bergoli" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">3</span>" "identificador" => "af0015" ] ] ] 3 => array:4 [ "preGrado" => "Master in Cardiology" "nombre" => "Rodrigo Vugman" "apellidos" => "Wainstein" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">4</span>" "identificador" => "af0020" ] ] ] 4 => array:3 [ "nombre" => "Marco Vugman" "apellidos" => "Wainstein" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">5</span>" "identificador" => "af0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Resident physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brazil." "etiqueta" => "1" "identificador" => "af0005" ] 1 => array:3 [ "entidad" => "Resident physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre. Porto Alegre, RS, Brazil." "etiqueta" => "2" "identificador" => "af0010" ] 2 => array:3 [ "entidad" => "Hired physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre – Unidade de Hemodinâmica. Porto Alegre, RS, Brazil." "etiqueta" => "3" "identificador" => "af0015" ] 3 => array:3 [ "entidad" => "Hired physician at the Cardiology Service of Hospital de Clínicas de Porto Alegre – Unidade de Hemodinâmica. Porto Alegre, RS, Brazil." "etiqueta" => "4" "identificador" => "af0020" ] 4 => array:3 [ "entidad" => "Adjunct professor of Faculdade de Medicina da Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brazil." "etiqueta" => "5" "identificador" => "af0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cr0005" "etiqueta" => "*" "correspondencia" => "Felipe Homem Valle. Serviço de Cardiologia do Hospital de Clínicas de Porto Alegre. R. Ramiro Barcelos, 2.350 – Bairro Rio Branco – Porto Alegre, RS, Brazil – CEP 90035-903" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 463 "Ancho" => 927 "Tamanyo" => 111816 ] ] "descripcion" => array:1 [ "pt" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">– (A) Release of Edwards SAPIEN XT valve after inflating the balloon catheter. (B) Implanted aortic valve.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Heyde’ssyndrome, an association between aortic stenosis and gastrointestinal bleeding, was first described by Edward Heyde in 1958,<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> in a series of ten patients with aortic stenosis and gastrointestinal bleeding of unknown cause, and the association with intestinal angiodysplasia was only established subsequently. Gastrointestinal bleeding appears to be caused by acquired von Willebrand disease type 2A, characterized by a reduction in high molecular weight multimers of von Willebrand factor (VWF). These multimers are important to maintain hemostasis in situations of high shear stress – predominant flow conditions in patients with angiodysplastic lesions.<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> Valve replacement appears to offer the best hope for a long-term resolution of bleeding, and should beconsidered in most cases. <a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> The case of a patient with severe aortic stenosis and gastrointestinal bleeding due to duodenal angiodysplasia is reported, successfully treated by transcatheter aortic valve implantation.</p><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">CASE REPORT</span><p id="p0010" class="elsevierStylePara elsevierViewall">Female patient, 79 years, with severe aortic stenosis (valve area of 0.6<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a>; maximum transvalvular gradient of 96<span class="elsevierStyleHsp" style=""></span>mmHg and mean of 59<span class="elsevierStyleHsp" style=""></span>mmHg; and preserved left ventricular systolic function) was hospitalized for symptomatic heart failure associated with melena. On admission, hemoglobin level was 4.6<span class="elsevierStyleHsp" style=""></span>g/dL. She was initially submitted to endoscopic gastrointestinal tract assessment, which showed no alterations, and colonoscopy, which showed diverticular disease of the colon, with no evidence of recent bleeding. After receiving transfusion of packed red blood cells, she achieved partial symptom improvement.</p><p id="p0015" class="elsevierStylePara elsevierViewall">After the case study, it was decided to perform the transcatheter aortic stenosis treatment. A 23-mm Edwards SAPIEN XT valve (Edwards Life Sciences – Irvine, USA) was implanted by transfemoral route. The procedure was successfully performed without complications, resulting in aortic transvalvular gradient of 10<span class="elsevierStyleHsp" style=""></span>mmHg with no significant aortic regurgitation (<a class="elsevierStyleCrossRef" href="#f0005">Figure 1</a>). Two days after the procedure, there was recurrence of melena. At that time, it was decided to evaluate the small bowel by enteroscopy, for clarification of the bleeding site. The enteroscopy evaluated the bowel up to the medium jejunum, showing angiodysplastic lesion in the proximal duodenum (<a class="elsevierStyleCrossRef" href="#f0010">Figure 2</a>), which was cauterized with an argon plasma catheter. The patient was discharged to be followed by her cardiologist in good clinical conditions, with hemoglobin of 8.2<span class="elsevierStyleHsp" style=""></span>g/dL, 21 days after admission. She was using acetylsalicylic acid (ASA) 100<span class="elsevierStyleHsp" style=""></span>mg/day and clopidogrel 75<span class="elsevierStyleHsp" style=""></span>mg/day was prescribed (dual antiplatelet therapy), after the absence of intestinal bleeding recurrence was confirmed, seven days after discharge.</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="f0010"></elsevierMultimedia></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">DISCUSSION</span><p id="p0020" class="elsevierStylePara elsevierViewall">Intestinal angiodysplasia and aortic stenosis are usually asymptomatic chronic–degenerative diseases, whose prevalence increases with age. Both are associated with cardiovascular risk factors. Many studies suggest that there is a greater occurrence of intestinal stenosis in subjects with aortic angiodysplasia, and vice versa.<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> The main concept behind this association is based on the fact that both angiodysplasia intestinal and aortic stenosis are related to the physiological processes of aging.<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">In 1992, an etiopathogenic mechanism was proposed by Warkentin et al.,<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> according to which the acquired deficiency of high molecular weight multimers of VWF (von Willebrand disease type 2A), necessary to maintain hemostasis in high-flow conditions,<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a> as occurs in arteriovenous angiodysplastic malformations, appeared to be the connection between the two components of this syndrome. The VWF is secreted by endothelial cells into the blood, contributing to platelet thrombus formation and acting as a mediator of platelet adhesion at the site of vascular injury.<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> The high shear stress caused by the stenotic valve results in changes in the VWF<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> molecule structure and subsequent proteolysis of the high molecular weight multimers by ADAMTS13 enzyme. The multimers with reduced size are, from the hemostatic point of view, less competent than the intact large multimers. This hypothesis is supported by the fact that the change of the stenotic aortic valve results in long–term resolution of digestive bleeding. In summary, the development of the acquired von Willebrand disease type 2A due to aortic stenosis causes hemostatic abnormalities, which predispose to intestinal angiodysplastic bleeding, previously subclinical.<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">A study by Vincentelli et al.<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> demonstrated that the degree of aortic stenosis is proportional to hemostatic changes: the higher the gradient pressure, the lower the availability of high molecular weight multimers. In this study, the aortic valve replacement ceased the depletion of these multimers, and this effect has been observed in some patients as soon as the first postoperative day.<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0035" class="elsevierStylePara elsevierViewall">Regarding gastrointestinal bleeding due to intestinal angiodysplasia, the options for treatment include the location and cauterization of lesions; however, these strategies are associated with high rate of recurrence. The improvement in hematological alterations after aortic valve replacement has been described and is also accompanied by clinical improvement: this approach seems to offer the best prospects for long-term resolution of bleeding and should be considered in most cases, especially those with symptomatic aortic stenosis. For patients at high surgical risk, in which no bleeding point was identified, the treatment of anemia with regular blood transfusions can provide some symptomatic relief.<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0040" class="elsevierStylePara elsevierViewall">Aortic valve replacement appears to reduce the risk of gastrointestinal hemorrhage in patients with Heyde’s syndrome, resolving the condition in approximately 80% of cases. Although the rates of bleeding recurrence are not significantly different between biological and mechanical valves, the increased risk of bleeding in patients receiving anticoagulants makes biological valves the choice for most patients.<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> Bleeding recurrence occurs only when the physiopathological mechanism is restored, either by aortic restenosis or by patientprosthesis mismatch (effective valvearea/bodysurface < 0.85<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>/m<span class="elsevierStyleSup">2</span> on echocardiography), with elevated gradients persisting postoperatively even with normal functioning valves.<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0045" class="elsevierStylePara elsevierViewall">This case report is the second article that addresses the percutaneous treatment of aortic stenosis in patients with Heyde’s syndrome.<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> Godino et al.<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> reported that this syndrome was present in 1.7% of 400 patients undergoing transcatheter aortic valve implantationat their institution, and that the recurrence of gastrointestinal bleeding was abolished in all successfully treated patients.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">CONFLICTS OF INTEREST</span><p id="p0050" class="elsevierStylePara elsevierViewall">Marco Vugman Wainsteinis a consultant for Biotronik, B Braun, and Terumo; board member of A esculap B Braun; researcher for Biotronik; and lector for Biosensors, B Braun, Terumo, and Astra Zeneca; he also receives scientific support from Abbott Vascular, Cordis J&J, and Boston Scientific. The remaining authors declare to have no conflicts of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres544672" "titulo" => "ABSTRACT" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "as0010" ] ] ] 1 => array:3 [ "identificador" => "xres544673" "titulo" => "RESUMO" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "as0015" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec564423" "titulo" => "DESCRIPTORS" ] 3 => array:2 [ "identificador" => "xpalclavsec564422" "titulo" => "DESCRITORES" ] 4 => array:2 [ "identificador" => "s0005" "titulo" => "CASE REPORT" ] 5 => array:2 [ "identificador" => "s0010" "titulo" => "DISCUSSION" ] 6 => array:2 [ "identificador" => "s0015" "titulo" => "CONFLICTS OF INTEREST" ] 7 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-07" "fechaAceptado" => "2013-08-31" "PalabrasClave" => array:1 [ "pt" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "DESCRITORES" "identificador" => "xpalclavsec564422" "palabras" => array:4 [ 0 => "Estenose da valva aórtica" 1 => "Hemorragia gastrointestinal" 2 => "Angiodisplasia" 3 => "Implante de prótese de valva cardíaca" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "DESCRIPTORS" "identificador" => "xpalclavsec564423" "palabras" => array:4 [ 0 => "Aortic valve stenosis" 1 => "Gastrointestinal hemorrhage" 2 => "Angiodysplasia" 3 => "Heart valve prosthesis implantation" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "ABSTRACT" "resumen" => "<span id="as0010" class="elsevierStyleSection elsevierViewall"><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">There is a frequent association between aortic valve stenosis and gastrointestinal bleeding, also known as Heyde’s syndrome. The pathophysiologic basis for this syndrome seems to be an acquired von Willebrand factor deficiency, leading to bleeding of angiodysplastic arteriovenous malformations. Treatment options include the location and cauterization of bleeding points, which is associated to high recurrence rates. Valve replacement appears to offer the best hope of long-term resolution of bleeding, and should be considered in most cases. We report a 79 year-old patient with aortic stenosis and gastrointestinal bleeding due to duodenal angiodysplasia treated by transcatheter aortic valve implantation.</p></span>" ] "pt" => array:2 [ "titulo" => "RESUMO" "resumen" => "<span id="as0015" class="elsevierStyleSection elsevierViewall"><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Sangramento Gastrintestinal por</span><span class="elsevierStyleBold">Angiodisplasia e Estenose Aórtica: Síndrome de Heyde</span></p><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Existe uma associação frequente entre estenose valvar aórtica e sangramento gastrintestinal, também conhecida como síndrome de Heyde. A base fisiopatológica dessa síndrome parece ser uma deficiência adquirida do fator de von Willebrand, que leva ao sangramento de malformações arteriovenosas angiodisplásicas. As alternativas de tratamento incluem a localização de pontos de sangramento e a cauterização, mas tal opção terapêutica está associada a alta recorrência. A substituição da válvula parece oferecer a melhor esperança de resolução a longo prazo do sangramento e deve ser considerada na maioria das vezes. Relatamos aqui o caso de uma paciente de 79 anos com estenose aórtica e sangramento gastrintestinal devido à angiodisplasia duodenal, tratada por implante transcateter de válvula aórtica.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "f0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 463 "Ancho" => 927 "Tamanyo" => 111816 ] ] "descripcion" => array:1 [ "pt" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">– (A) Release of Edwards SAPIEN XT valve after inflating the balloon catheter. (B) Implanted aortic valve.</p>" ] ] 1 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 741 "Ancho" => 928 "Tamanyo" => 141928 ] ] "descripcion" => array:1 [ "pt" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">– Angiodysplastic lesion in the proximal duodenum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bb0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastrointestinal bleeding in aortic stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.C. Heyde" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med." "fecha" => "1958" "volumen" => "259" "paginaInicial" => "196" "itemHostRev" => array:3 [ "pii" => "S0016508508004253" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bb0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aortic stenosis and bleeding gastrointestinal angiodysplasia: is acquired Von Willebrand's disease the link?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.E. Warkentin" 1 => "J.C. Moore" 2 => "D.G. Morgan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Lancet" "fecha" => "1992" "volumen" => "340" "numero" => "8810" "paginaInicial" => "35" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1351610" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bb0015" "etiqueta" => "3." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful aortic valve replacement for Heyde syndrome with confirmed hematologic recovery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Morishima" 1 => "A. Marui" 2 => "T. Shimamoto" 3 => "Y. Saji" 4 => "K. Tambara" 5 => "T. Nishina" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2006.05.082" "Revista" => array:8 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2007" "volumen" => "83" "numero" => "1" "paginaInicial" => "287" "paginaFinal" => "288" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17184682" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S016882781200044X" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bb0020" "etiqueta" => "4." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heydes syndrome: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.E. Pate" 1 => "M. Chandavimol" 2 => "S.C. Naiman" 3 => "J.G. Webb" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:8 [ "tituloSerie" => "J Heart Valve Dis" "fecha" => "2004" "volumen" => "13" "numero" => "5" "paginaInicial" => "701" "paginaFinal" => "712" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15473466" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0168827812003479" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bb0025" "etiqueta" => "5." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heyde syndrome: The link between aortic stenosis and gastrointestinal bleeding" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Vaz" 1 => "A. Correia" 2 => "B. Martins" 3 => "J. Capelo" 4 => "P. Ferreira" 5 => "P. Henriques" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2010" "volumen" => "29" "numero" => "2" "paginaInicial" => "309" "paginaFinal" => "314" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20545255" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bb0030" "etiqueta" => "6." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heyde's syndrome: case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F.C.R. Figuinha" 1 => "G.S. Spina" 2 => "F. Tarasoutchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Arq Bras Cardiol" "fecha" => "2011" "volumen" => "96" "numero" => "3" "paginaInicial" => "e42" "paginaFinal" => "e45" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21484065" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bb0035" "etiqueta" => "7." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acquired von Willebrand syndrome in aortic stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Vincentelli" 1 => "S. Susen" 2 => "T. Le Tourneau" 3 => "I. Six" 4 => "O. Fabre" 5 => "F. Juthier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa022831" "Revista" => array:8 [ "tituloSerie" => "N Engl J Med" "fecha" => "2003" "volumen" => "349" "numero" => "4" "paginaInicial" => "343" "paginaFinal" => "349" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12878741" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508511003209" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bb0040" "etiqueta" => "8." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of recurrent gastrointestinal bleeding after aortic valve replacement in patients with Heyde syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L. Thompson" 1 => "H.V. Schaff" 2 => "J.A. Dearani" 3 => "S.J. Park" 4 => "T.M. Sundt" 5 => "R.M. Suri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2011.05.034" "Revista" => array:8 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2012" "volumen" => "144" "numero" => "1" "paginaInicial" => "112" "paginaFinal" => "116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21864855" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0016508509001024" "estado" => "S300" "issn" => "00165085" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bb0045" "etiqueta" => "9." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heyde’s syndrome incidence and outcome in patients undergoing transcatheter aortic valve implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Godino" 1 => "L. Lauretta" 2 => "A.G. Pavon" 3 => "A. Mangieri" 4 => "G. Viani" 5 => "A. Chieffo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2012.10.041" "Revista" => array:7 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2013" "volumen" => "61" "numero" => "6" "paginaInicial" => "687" "paginaFinal" => "689" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23391203" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "pt" "url" => "/22141235/0000002100000003/v1_201509011255/S2214123515301460/v1_201509011255/pt/main.assets" "Apartado" => array:4 [ "identificador" => "43187" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/22141235/0000002100000003/v1_201509011255/S2214123515301460/v1_201509011255/pt/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515301460?idApp=UINPBA00004N" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Octubre | 28 | 4 | 32 |
| 2024 Septiembre | 58 | 18 | 76 |
| 2024 Agosto | 70 | 13 | 83 |
| 2024 Julio | 80 | 9 | 89 |
| 2024 Junio | 63 | 14 | 77 |
| 2024 Mayo | 67 | 7 | 74 |
| 2024 Abril | 48 | 6 | 54 |
| 2024 Marzo | 71 | 16 | 87 |
| 2024 Febrero | 71 | 21 | 92 |
| 2024 Enero | 83 | 13 | 96 |
| 2023 Diciembre | 82 | 18 | 100 |
| 2023 Noviembre | 90 | 17 | 107 |
| 2023 Octubre | 91 | 21 | 112 |
| 2023 Septiembre | 64 | 5 | 69 |
| 2023 Agosto | 54 | 19 | 73 |
| 2023 Julio | 79 | 7 | 86 |
| 2023 Junio | 49 | 0 | 49 |
| 2023 Mayo | 93 | 12 | 105 |
| 2023 Abril | 79 | 3 | 82 |
| 2023 Marzo | 95 | 6 | 101 |
| 2023 Febrero | 78 | 2 | 80 |
| 2023 Enero | 70 | 5 | 75 |
| 2022 Diciembre | 49 | 5 | 54 |
| 2022 Noviembre | 78 | 17 | 95 |
| 2022 Octubre | 60 | 7 | 67 |
| 2022 Septiembre | 69 | 20 | 89 |
| 2022 Agosto | 60 | 21 | 81 |
| 2022 Julio | 68 | 7 | 75 |
| 2022 Junio | 51 | 8 | 59 |
| 2022 Mayo | 54 | 5 | 59 |
| 2022 Abril | 40 | 4 | 44 |
| 2022 Marzo | 52 | 6 | 58 |
| 2022 Febrero | 61 | 3 | 64 |
| 2022 Enero | 81 | 8 | 89 |
| 2021 Diciembre | 37 | 11 | 48 |
| 2021 Noviembre | 84 | 15 | 99 |
| 2021 Octubre | 104 | 10 | 114 |
| 2021 Septiembre | 60 | 10 | 70 |
| 2021 Agosto | 59 | 10 | 69 |
| 2021 Julio | 47 | 8 | 55 |
| 2021 Junio | 45 | 6 | 51 |
| 2021 Mayo | 48 | 10 | 58 |
| 2021 Abril | 81 | 26 | 107 |
| 2021 Marzo | 33 | 9 | 42 |
| 2021 Febrero | 70 | 9 | 79 |
| 2021 Enero | 38 | 6 | 44 |
| 2020 Diciembre | 44 | 2 | 46 |
| 2020 Noviembre | 22 | 5 | 27 |
| 2020 Octubre | 7 | 3 | 10 |
| 2020 Septiembre | 17 | 8 | 25 |
| 2020 Agosto | 8 | 2 | 10 |
| 2020 Julio | 11 | 3 | 14 |
| 2020 Junio | 4 | 1 | 5 |
| 2020 Mayo | 5 | 2 | 7 |
| 2020 Abril | 5 | 2 | 7 |
| 2020 Marzo | 11 | 0 | 11 |
| 2020 Febrero | 10 | 1 | 11 |
| 2020 Enero | 7 | 3 | 10 |
| 2019 Diciembre | 9 | 3 | 12 |
| 2019 Noviembre | 2 | 2 | 4 |
| 2019 Octubre | 4 | 2 | 6 |
| 2019 Septiembre | 4 | 2 | 6 |
| 2019 Agosto | 2 | 0 | 2 |
| 2019 Julio | 3 | 7 | 10 |
| 2019 Junio | 13 | 11 | 24 |
| 2019 Mayo | 14 | 4 | 18 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 5 | 1 | 6 |
| 2018 Agosto | 28 | 14 | 42 |
| 2018 Julio | 21 | 10 | 31 |
| 2018 Junio | 27 | 12 | 39 |
| 2018 Mayo | 30 | 10 | 40 |
| 2018 Abril | 32 | 18 | 50 |
| 2018 Marzo | 45 | 23 | 68 |
| 2018 Febrero | 34 | 14 | 48 |
| 2018 Enero | 17 | 6 | 23 |
| 2017 Diciembre | 28 | 9 | 37 |
| 2017 Noviembre | 15 | 7 | 22 |
| 2017 Octubre | 16 | 10 | 26 |
| 2017 Septiembre | 21 | 11 | 32 |
| 2017 Agosto | 18 | 7 | 25 |
| 2017 Julio | 20 | 12 | 32 |
| 2017 Junio | 24 | 18 | 42 |
| 2017 Mayo | 58 | 24 | 82 |
| 2017 Abril | 277 | 131 | 408 |
| 2017 Marzo | 23 | 12 | 35 |
| 2017 Febrero | 20 | 9 | 29 |
| 2017 Enero | 30 | 12 | 42 |
| 2016 Diciembre | 38 | 12 | 50 |
| 2016 Noviembre | 27 | 7 | 34 |
| 2016 Octubre | 24 | 7 | 31 |
| 2016 Septiembre | 16 | 4 | 20 |
| 2016 Agosto | 13 | 6 | 19 |
| 2016 Julio | 7 | 6 | 13 |
Mostrar todo