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Cardiovascular Involvement in Systemic Sclerosis: a Case of Atrial Septal Aneurysm Associated with Intracranial Aneurysm M

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Cardiovascular Involvement in Systemic Sclerosis: a Case of Atrial Septal Aneurysm Associated with Intracranial Aneurysm M 40 M. Oberson, S. Chevili Applied Cardiopulmonary Pathophysiology 14: 40-42, 2010 Cardiovascular involvement in systemic sclerosis: A case of atrial septal aneurysm associated with intracranial aneurysm M. Oberson1, S. Chevili2 1Department of Cardiology, University Hospital of Bern, Bern, Switzerland; 2Department of Internal Medicine, Ospedale Italiano, Lugano, Switzerland Introduction the sequelae of pulmonary hypertension (5) which is secondary to damage in the lung. There is increasing concern about vascular There has been an increased awareness and cardiac involvement in systemic sclerosis of left ventricular abnormalities in SSc pa- (SSc). This is a systemic infiltrative disorder tients, but the occurrence of cardiac that commonly affects the cardiovascular sys- aneurysms seems to be a rare complication tem and this case is presented to draw atten- of SSc, only few cases are illustrated in the lit- tion to the possibility of a pathophysiological erature (6). connection between SSc and cardiovascular Vascular abnormalities such as fingertip aneurysm formation. No data exist on the in- ulcers and Raynaud’s syndrome as well as in- cidence or natural history of aneurysm in pa- volvement of other organs including kidney tients with SSc and to the best of our knowl- and the gastrointestinal tract, are prominent edge, there is no other report to date of atri- features of the disease. Macrovascular in- al septal aneurysm associated with intracra- volvement in SSc has received relatively little nial aneurysm in SSc. attention, the prevalence of peripheral large The heart is one of the major organs in- vessel disease is increased in SSc, on the oth- volved in SSc (1,2), the involvement of which er hand, the association with vascular can be manifested by myocardial disease, aneurysm is poorly understood, few reports conduction system abnormalities and arrhyth- are sporadically described (7-9). mias, or pericardial disease. Representative is the myocardial involve- ment by patchy fibrosis (secondary to both repeated ischemia and immune-inflammatory Case report damage) that leads to ventricular diastolic dysfunction (3,4), whereas right ventricle We hereby describe an atrial septal aneurysm overload and failure may complicate pul- associated with an intracranial aneurysm in a monary hypertension. 56-year-old woman presenting with increased SSc is frequently linked to vascular and/or esophageal motility disorders and rapidly pro- parenchymal lung disease (5), determining gressive diffuse cutaneous scleroderma with symptom occurrence, particularly dyspnoea induration of all extremities and Raynaud’s and fatigue. Several vasodilator approaches phenomenon. (prostacycline or NO/endothelin) may coun- During routine TTE, an hypertrophic teract the microvascular dysfunction at pe- cardiomyopathy and an asymptomatic atrial ripheral and cardiopulmonary level and fight septal aneurysm (ASA) without shunting at Cardiovascular involvement in systemic sclerosis 41 Figure 1 two-dimensional color-Doppler echocardiog- aneurysm formation. Inflammatory reactions raphy, were detected. and endothelial damage seem to be common The ASA was protruding far away into the features in the formation and growth of in- right atrium with oscillation, and maximum tracranial aneurysms, too. displacement of ASA was evaluated between SSc is also characterized by inflammation 10 and 12 mm (Fig A). Initial pulmonary ar- and fibrosis of many organs. As previously de- tery hypertension at 45 mmHg, although a scribed, the underlying mechanism appears treatment with Bosentan since two years for related to microcirculatory impairment caus- a severe form of Raynaud’s phenomenon ing focal ischemic injury and irreversible fi- (Fig. B), was measured. Serum BNP concen- brosis (12,13). The histological alterations are tration was moderately increased (274 ng/L) primarily found on the intima of the vessel indicating an overload of the right and/or left wall, increasing its collagen content (14). Im- ventricle. An incidentally found irregular in- mune complex deposition in the disease is tracranial aneurysm (10 x 6 mm; not shown) extensive and leads to vascular damage (15). during a magnetic resonance imaging per- Most of the effect is on small vessels and cap- formed for aspecific malaise/migraine con- illaries. firms the possible mechanism whereby sys- Although the occurrence of atrial septal temic sclerosis may result in aneurysm forma- aneurysm associated with an intracranial tion. aneurysm as in this case, may be pure coinci- dence, an inflammatory process could be sus- pected to be a cause for vascular aneurysm Conclusion formation and the same process could be postulated for other cardiovascular structures There is evidence of generalized endothelial leading to aneurysm formation. inflammation in patients with SSc (10), and A better knowledge and awareness of car- this is thought to be a precondition for diovascular involvement is necessary be- aneurysm formation (11); endothelial injury cause it conveys a major risk for mortality; a to vessels, followed by platelet adhesion and meticulous search for aneurysms seems to be leukocyte activation, plays a primary role in important in patients with SSc. Vascular and aneurysm formation. These events cause cardiac involvement in SSc is often manifest, complementary activation and release of and nearly always present when accurately prostaglandins and lysosomal enzymes, with searched. additional mechanical disruption of the vessel wall. Hemodynamic stress at the sites of ves- sel disruption may result in focal wall and 42 M. Oberson, S. Chevili References 9. Seo YH, Lee SI, Yoo WH. Thoracoabdomi- nal aortic aneurysm associated with sys- 1. Seferovic PM, Ristic AD, Maksimovic R, temic sclerosis. Rheumatology (Oxford) Simeunovic DS, Ristic GG, Radovanovic G, 2005; 44 (11): 1459-61 Seferovic D, Maisch B, Matucci-Cerinic M. 10. Freemont AJ, Hoyland J, Fielding P et al. Cardiac arrhythmias and conduction distur- Studies of the microvascular endothelium in bances in autoimmune rheumatic diseases. uninvolved skin of patients with systemic Rheumatology (Oxford) 2006; 45 (Suppl. sclerosis: Direct evidence for a generalized 4): iv39-42 microangiopathy. Br J Dermatol 1992; 126: 2. Knockaert DC. Cardiac involvement in sys- 561-568 temic inflammatory diseases. Eur Heart J 11. Krex D, Schackert HK, Schackert G. Genesis 2007; 28 (15): 1797-804 of cerebral aneurysm-an update. Acta Neu- 3. Can I, Onat AM, Aytemir K, Akdogan A, rochir 2001; 143: 429-449 Ureten K, Kiraz S, Ertenli I, Tokgozoglu L, 12. Allanore Y, Kahan A. Heart involvement in Oto A. Detecting subclinical biventricular systemic sclerosis. Presse Med 2006; 35 (12 impairment in scleroderma patients by use Pt 2): 1938-42 of pulsed-wave tissue Doppler imaging. Tex. 13. Norton WL, Nardo JL. Vascular disease in Heart Inst. J 2009; 36 (1): 31-7 progressive systemic sclerosis (scleroder- 4. de Groote P, Gressin V, Hachulla E, Carpen- ma). Ann Intern Med 1970; 73: 317-324 tier P, Guillevin L, Kahan A, Cabane J, 14. Herrick AL. Vascular function in systemic Francès C, Lamblin N, Diot E, Patat F, Sibilia sclerosis. Curr Opin Rheumatol 2000; 12: J, Petit H, Cracowski JL, Clerson P, Humbert 527-533 M; ItinerAIR-Scleroderma Investigators. Eval- 15. Lee JE, Haynes JM. Carotid arteritis and uation of cardiac abnormalities by Doppler cerebral infarction due to scleroderma. Neu- echocardiography in a large nationwide rology 1967; 17: 18-22 multicentric cohort of patients with sys- temic sclerosis. Ann Rheum Dis 2008; 67 (1): 31-6 5. McLaughlin V, Humbert M, Coghlan G, Correspondence address: Nash P, Steen V. Pulmonary arterial hyper- Michel Oberson, M.D. tension: the most devastating vascular com- Department of Cardiology plication of systemic sclerosis. Rheumatol- University Hospital of Bern ogy (Oxford) 2009; 48 (Suppl 3): iii25-31 CH-3000 Bern 6. Taniguchi Y, Nishiyama S, Yoshinaga Y, Switzerland Miyawaki S, Hashimoto K. Left ventricular aneurysms developed in a patient with sys- temic sclerosis. Mod Rheumatol 2007; 17 and (6): 518-20 7 Kaku Y, Kouda K, Yoshimura S, Sakai N. Department of Cardiology Cerebral aneurysms in scleroderma. Cere- Ospedale Italiano brovasc Dis 2004; 17 (4): 339-41 CH-6900 Lugano 8. Attaran RR, Guarraia D. Ascending aortic Switzerland, aneurysm in a man with scleroderma. Clin [email protected] and Rheumatol 2007; 26 (6): 1027-8 [email protected].
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