Cystic tumour of the atrioventricular node: treatment dilemma.

An asymptomatic 18-year-old black woman was found to have an incidental finding of third-degree atrioventricular (AV) block on a routine ECG. 2-Dimensional transthoracic echocardiography showed a heterogeneous mass in the region of the peri-membranous septum in the AV node area. A cardiac MRI showed a well-defined cystic mass arising from the right side of the interatrial septal wall. An MRI compatible permanent pacemaker was implanted with plans to monitor the tumour with non-invasive imaging. Cystic tumour of the AV node is a rare primary cardiac tumour. It is known as the smallest and most common primary cardiac tumour that can cause sudden death. All previous six cases of living patients with cystic tumour of the AV node reported in the literature were females and symptomatic. We present a rare case of a patient with cystic tumour of the AV node, and we highlight the treatment dilemmas for this condition.

Hypertonic saline with furosemide for the treatment of acute congestive heart failure: a systematic review and meta-analysis.

BACKGROUND: Advanced congestive heart failure (CHF) therapies include intravenous inotropic agents, change in class of diuretics, and venous ultrafiltration or hemodialysis. These modalities have not been associated with improved prognosis and are limited by availability and cost. Compared to high-dose furosemide alone, concomitant hypertonic saline solution (HSS) administration has demonstrated improved clinical outcomes with good safety profile. METHODS: A literature search was conducted for randomized controlled trials that investigated the use of HSS in patients admitted to hospital with acute CHF. RESULTS: 1032 patients treated with HSS and 1032 controls, demonstrated decreased all-cause mortality in patients treat with HSS with RR of 0.56 (95% CI 0.41-0.76,p=0.0003). 1012 patients treated with HSS and 1020 controls, demonstrated decreased heart failure hospital readmission with RR of 0.50 (95% CI 0.33-0.76,p=0.001). Patients treated with HSS also demonstrated decreased hospital length of stay (p=0.0002), greater weight loss (p<0.00001), and preservation of renal function (p<0.00001). CONCLUSION: The results of this meta-analysis demonstrate that in patients with advanced CHF concomitant hypertonic saline administration improved weight loss, preserved renal function, and decreased length of hospitalization, mortality and heart failure rehospitalization. A future adequately powered, multi-centre, placebo controlled, randomized, double dummy, blinded trial is needed to assess the benefit of hypertonic saline in patients with renal dysfunction, in diverse patient populations, as well using a patient population on optimal current heart failure treatment. Pending further validation, there is promise for hypertonic saline as an advanced therapy for the management of acute advanced CHF.

Can parathyroid hormone be used as a biomarker for heart failure?

Secondary hyperparathyroidism in heart failure is a consequence of renin-angiotensin-aldosterone activation, chronic hyperaldosteronism, and loop diuretic usage, resulting in calcium excretion. The result is an inflammatory state with adverse effects on myocardial remodeling and systemic complications. Recent literature has suggested that elevated parathyroid hormone predicts adverse outcomes in patients with heart failure independent of serum calcium and phosphate, vitamin D deficiency, and renal insufficiency. Parathyroid hormone has been correlated with elevated brain natriuretic peptide levels, an established biomarker of heart failure severity. There are several limitations to the utilization of parathyroid hormone as a biomarker for heart failure, and further prospective studies need to be conducted to assess the value of multiple parathyroid hormone measurements over time and elucidate the role of parathyroid hormone in diastolic dysfunction. Pending further validation, there is promise for parathyroid hormone as a complementary biomarker in heart failure.