Left Atrial Masses: Now You See Them, Now You Don't.

Left atrial masses are rare but clinically significant findings, which can present as diverse pathological entities, including primary tumors, thrombi, and metastases. Their diverse pathological entities contribute to a wide range of clinical manifestations, often presenting with nonspecific symptoms that pose challenges for early diagnosis. Within the realm of medicine, unique presentations emphasize the intricate interplay between the size, location, and functional impact of pathological processes. They serve as reminders to healthcare providers to approach each patient as an individual, recognizing that even seemingly minor abnormalities can have significant consequences. To illustrate this, we present two distinct cases of patients with left atrial masses, showcasing the importance of clinical suspicion and a wide knowledge base in identifying and managing these conditions effectively.

Subaortic Membranes in Patients With Hereditary Hemorrhagic Telangiectasia and Liver Vascular Malformations.

Background Patients with hereditary hemorrhagic telangiectasia have liver vascular malformations that can cause high-output cardiac failure (HOCF). Known sequelae include pulmonary hypertension, tricuspid regurgitation, and atrial fibrillation. Methods and Results The objectives of this study were to describe the clinical, echocardiographic, and hemodynamic characteristics and prognosis of hereditary hemorrhagic telangiectasia patients with HOCF who were found to have a subaortic membrane (SAoM). A retrospective observational analysis comparing patients with and without SAoM was performed. Among a cohort of patients with HOCF, 9 were found to have a SAoM in the left ventricular outflow tract by echocardiography (all female, mean age 64.8±4.0 years). The SAoM was discrete and located in the left ventricular outflow tract 1.1±0.1 cm below the aortic annular plane. It caused turbulent flow, mild obstruction (peak velocity 2.8±0.2 m/s, peak gradient 32±4 mm Hg), and no more than mild aortic insufficiency. Patients with SAoM (n=9) had higher cardiac output (12.1±1.3 versus 9.3±0.7 L/min, P=0.04) and mean pulmonary artery pressures (36±3 versus 28±2 mm Hg, P=0.03) compared with those without SAoM (n=19) during right heart catheterization. Genetic analysis revealed activin receptor-like kinase 1 mutations in each of the 8 patients with SAoM who had available test results. The presence of a SAoM was associated with a trend towards higher 5-year mortality during follow-up. Conclusions SAoM with mild obstruction occurs in patients with hereditary hemorrhagic telangiectasia and HOCF. SAoM was associated with features of more advanced HOCF and poor outcomes.

Echocardiographic indices of diastolic function relate to functional capacity and quality of life in ambulatory men with atrial fibrillation.

OBJECTIVE: We sought to explore the reliability of echocardiographic parameters of diastolic function and determine their relationship with functional capacity (New York Heart Association [NYHA] class and 6-minute walk test [6MWT]) and the domains of a health-related quality of life (HR-QOL) questionnaire (Veterans RAND 36-Item Health Survey) in a cohort of ambulatory patients with atrial fibrillation (AF). METHODS: Forty-eight male veterans with persistent or permanent AF underwent clinical examination, echocardiography, and 6MWT, and filled out a Veterans RAND 36-Item Health Survey questionnaire at two visits 1 week apart. Pairwise correlation was performed to evaluate the reliability of echocardiographic parameters and multiple regression analyses to assess the association of these parameters with functional capacity and HR-QOL. RESULTS: E/e' average had the highest correlation between the two visits (coefficient: 0.87) and had a significant relationship with NYHA, 6MWT, and physical functioning domain of HR-QOL even after adjusting for confounding variables (odds of NYHA >1: OR 1.5, 95% CI, 1.2-1.9; 6MWT coefficient: -31 ± 9 ft; physical functioning score coefficient: -1.7 ± 0.7). CONCLUSION: Average E/e' is a reliable diastolic function parameter that also independently relates with functional capacity and HR-QOL in ambulatory patients with atrial fibrillation.

The role of calcium score and CT angiography in the medical management of patients with normal myocardial perfusion imaging.

BACKGROUND: Individuals with normal myocardial perfusion imaging (MPI) may still have substantial coronary artery disease (CAD), which would benefit from aggressive medical therapy. The role of coronary artery calcium-score (CAC) and/or coronary CT Angiography (CTA) to identify additional treatment candidates in this population is unknown. METHODS: Ninety-four patients completed the study protocol and underwent CAC and CTA after MPI. RESULTS: In 81 patients who had a normal MPI, an algorithm using the clinical predictors, CAC, and then CTA was created to identify candidates for aggressive medical management; 24/81 patients had a high Framingham Risk Score (FRS) or diabetes, and need aggressive medical management, while 6/81 patients had a low FRS and low post-MPI probability of CAD. The use of CAC in 51/81 patients with intermediate clinical predictors would identify 23/51 patients with low risk (CAC < 100) and 11/51 patients (CAC > 400) for aggressive medical management. The remaining 17/51 patients with intermediate CAC scores (100-399) would require CTA, of which, would identify 8/17 additional patients with >50% stenosis for aggressive medical therapy. CONCLUSION: A stepwise approach including history, CAC and CTA can identify about 50% of the patients with normal MPI who have a higher risk and may benefit from aggressive medical management.