Atrial angioleiomyoma with myopericytoma-like features: a case report.

A 66-year-old female patient was referred to our hospital for resection of a right atrial mass. Four months earlier, she had suffered an acute cerebrovascular accident due to occlusion of the sylvian segment of the right middle cerebral artery from atheromatous tight stenosis in the right internal carotid artery. Later, investigations with transthoracic and transesophageal echocardiography revealed a 3.4-cm right atrial mass that was resected surgically. Microscopic evaluation revealed a well-circumscribed nodular tumor, located within the interatrial septum, and corresponding to an angioleiomyoma (ALM). This tumor differs histologically from atrial myxoma. ALM is a ubiquitous benign tumor but has never been reported to occur in the atrium. ALM can mimic cardiac myxoma and should be considered in the differential diagnosis of atrial tumors.

Baseline subendocardial viability ratio influences left ventricular systolic improvement with cardiac rehabilitation.

OBJECTIVE: Subendocardial viability ratio (SEVR), defined as diastolic to systolic pressure-time integral ratio, is a useful tool reflecting the balance between coronary perfusion and arterial load. Suboptimal SEVR creating a supply-demand imbalance may limit favorable cardiac response to cardiac rehabilitation (CR). To explore this hypothesis, we designed a study to analyze the relationship between baseline SEVR and response to CR in patients with coronary artery disease (CAD). METHODS: In this prospectively study, after baseline arterial tonometry, echocardiography, and cardiopulmonary exercise tests (CPETs), patients undergone 20 sessions of CR. Post-CR echocardiographic and CPET measurements were obtained for comparison. RESULTS: Final study population was comprised of fifty subjects. Study population was divided into two subgroups by median SEVR value (1.45, interquartile range 0.38). Although both groups showed significant improvements in peak VO2, significant improvements in oxygen pulse (πO2) (from 16.1±3.4 to 19.1±4.8 mL O2.kg-1.beat-1; p<0.001) and stroke volume index (from 31±5 to 35±6 mL; p=0.008) were observed in only the patients in the above-median subgroup. The change in πO2 was also significantly higher in the above-median SEVR subgroup (2.9±3.3 vs. 0.5±2.4; p=0.007). CONCLUSION: Our study shows that baseline supply-demand imbalance may limit systolic improvement response to CR in patients with CAD.

Value of Baseline Cardiovascular Mechanics in Predicting Exercise Training Success.

PURPOSE: Despite being repeatedly shown that exercise training (ET) increases exercise capacity and decreases mortality in many cardiac conditions, not all patients enjoy the benefits of ET programs. We hypothesized that baseline cardiovascular mechanic properties, including cardiac systolic and diastolic functions, arterial mechanics and ventriculoarterial interaction, may have a role in predicting response to ET. METHODS: Full left ventricular pressure-volume loops were constructed and arterial mechanics were evaluated using echocardiographic and tonometric measurements. A cardiopulmonary exercise (CPX) test was performed before and after the ET program. RESULTS: Sixty of the 75 patients with coronary artery disease or heart failure diagnoses completed the study. All of the CPX parameters showed a significant improvement with ET. The change in oxygen uptake correlated only with arterial parameters, such as compliance (r = 0.399, P = .002), end-systolic arterial elastance (r = -0.293, P = .02), aortic pulse pressure (r = -0.302, P = .02), and brachial pulse pressure (r = -0.312, P = .01). Receiver-operating characteristics analysis demonstrated that baseline arterial compliance and brachial pulse pressure predicted a significantly positive ET result with reasonable sensitivity and specificity. CONCLUSIONS: Patients with a more compliant arterial system improved their exercise capacity more with ET. Evaluation of baseline arterial compliance may facilitate proper patient selection and may define patients who need optimizing measures for the arterial system before commencing ET. Even a simple blood pressure measurement may give clues in this regard.

Association between baseline cardiovascular mechanics and exercise capacity in patients with coronary artery disease.

OBJECTIVE: Functional capacity is one of the cardinal determinants of morbidity and mortality in patients with coronary artery disease (CAD). We hypothesized that baseline cardiovascular mechanics, including cardiac systolic and diastolic functions, arterial mechanics, and ventriculoarterial interaction, may play a role in predicting exercise capacity in patients with CAD. METHODS: Fifty consecutive patients with CAD who were referred to cardiac rehabilitation were prospectively included in the study. Patients with non-sinus rhythms or severe valvular disease were excluded. Full left ventricular pressure-volume loops were constructed and arterial mechanics was evaluated using echocardiographic and tonometric measurements. Cardiopulmonary exercise tests were performed to measure exercise capacity. RESULTS: Fifty patients were enrolled in the study. Ventriculo-arterial coupling showed a moderate correlation with peak oxygen consumption (VO2) (r=0.410, p=0.04) in patients with reduced left ventricular ejection fraction (LVEF). Only left ventricular volume at 15 mm Hg (r=0.514, p<0.01) in diastolic parameters (stiffness constant, p=0.75; ventricular compliance, p=0.17) and arterial compliance (r=0.467, p=0.01) in arterial parameters [arterial elastance, p=0.27; systemic vascular resistance, p=0.45; augmentation pressure, p=0.85; augmentation index (AIx), p=0.63; heart rate-corrected AIx, p=0.68] emerged as significant factors correlated with peak VO2 in patients with normal LVEF. CONCLUSION: Comprehensive evaluation of resting cardiovascular mechanics can give clues about exercise-recruited reserves of the cardiovascular system. Optimization of ventriculo-arterial coupling in patients with reduced LVEF and arterial compliance in patients with normal LVEF should be the main target in patients with CAD and limited functional capacity.

Effects of Cardiopulmonary Exercise Rehabilitation on Left Ventricular Mechanical Efficiency and Ventricular-Arterial Coupling in Patients With Systolic Heart Failure.

BACKGROUND: Success of cardiac rehabilitation (CR) is generally assessed by the objective improvement in peak volume of inhaled oxygen (VO2) measured by cardiopulmonary exercise test (CPX). However, cardiac mechanical efficiency and ventricular-arterial coupling (VAC) are the other important dimensions of the heart failure pathophysiology, which are not included in CPX-derived data. The effect of cardiac rehabilitation on left ventricular (LV) efficiency or VAC in unselected heart failure patients has not been studied thus far. METHODS AND RESULTS: Thirty patients with an ejection fraction of ≤45% were recruited for 20 sessions of exercise-based CR. Noninvasive LV pressure-volume loops were constructed and VAC was calculated with the help of applanation tonometry and echocardiography before and after CR. VAC showed an improved mechanical efficiency profile and increased significantly from 0.56±0.18 to 0.67±0.21 (P=0.02). LV mechanical efficiency improved from 43.9±9.1% to 48.8±9.1% (P=0.01). The change in peak VO2 was not in a significant correlation with the change in VAC (r=-0.18; P=0.31), mechanical efficiency (r=-0.16, P=0.39), or the change in ejection fraction (r=-0.07; P=0.68). CONCLUSIONS: CR is associated with an improvement in VAC and LV mechanical efficiency in heart failure patients. Further studies are needed to determine the incremental value of VAC and mechanical efficiency over CPX-derived data in predicting clinical outcomes.

Effects of exercise on postexercise ventricular-arterial coupling and pulsatile efficiency in patients with systolic dysfunction.

BACKGROUND: A suboptimal ventricular-arterial (VA) interaction may have a prolonged depressing effect on the failing heart after functional reserves forced to their limits under stress conditions such as exercise. The continuation of excessive load in the postexercise period may be more important than the load during exercise, because the sum of postexercise periods generally exceeds exercise time itself. We sought that exercise-induced changes in postexercise VA coupling and pulsatile efficiency in patients with heart failure (HF). METHODS: Thirty consecutive HF with reduced ejection fraction (EF) and thirty age-, sex- and peak VO2 -matched subjects with preserved EF were enrolled. Pre- and postexercise echocardiographic and tonometric measurements were taken to calculate left ventricular and arterial elastances, arterial compliance and wave reflections, and steady and pulsatile power. RESULTS: VA coupling significantly deteriorated in HF group (from 1·50 ± 0·47 to 2·00 ± 0·75 mmHg/mL, P < 0·01), but control group maintained basal favourable coupling status after exercise (from 1·04 ± 0·29 to 1·03 ± 0·24 mmHg/mL, P = 0·77). Pulsatile percentage of total power significantly increased with exercise in HF group, whereas it showed a significant decrease in control group. The change in pulsatile power fraction was correlated with the change in augmentation pressure (r = 0·41, ß = 3·00, P < 0·01) and inversely correlated with the change in total arterial compliance (r = -0·29, ß = -8·52, P = 0·02). CONCLUSION: Our data indicate that exercise-induced VA decoupling and pulsatile inefficiency extend into postexercise phase in patients with systolic dysfunction. The exact duration of these derangements requires further studies.