P1748 Left atrial diastolic and systolic functions modulate the response to the standardised Valsalva maneuver in normal subjects

Background

Although the Valsalva maneuver (VM) is being advocated by current guidelines to identify with echocardiography patients with increased left ventricular (LV) filling pressures using a decrease in mitral E/A velocity > 0.5 as cutoff, there are limited published data for both patients and the normal response to the maneuver in healthy subjects.

Purpose

To assess LV and left atrial (LA) physiology during a standardized VM (VMs) in normal subjects.

Methods

The VMs was performed in 50 healthy subjects (M:F 38:12; age 40 ± 12 y.; HR 70 ± 11 bpm; BSA 1.81 ± 11 m2), instructed to forcefully exhale for 20 seconds without an initial deep breath into a tube connected to a sphygmomanometer, maintaining a 25-35 mmHg pressure. The VM was repeated 2 times at 5 minute intervals to record sequentially in the apical 4-chamber view: 1. LV and LA volumes; 2. Transmitral flow velocities. LA diastolic reservoir function (LAres) was calculated as: (maximum – minimum volume) / minimum volume x 100. Results. During the VMs, in all subjects LV indexed end-diastolic (-14 ± 7 ml/m2, -31 ± 15 %) and end-systolic (-6 ± 4 ml/m2, -31 ± 18 %) volumes, and stroke volume index (-9 ± 5 ml/m2, -30 ± 15 %) decreased similarly with unchanged LV ejection fraction %, and LA maximum and minimum volume indices both decreased (respectively -8 ± 6 ml/m2, -3 ± 3 ml/m2;-32 ± 25 %) with high variability. Mitral peak E velocity also decreased (-22 ± 13 cm/s, -27 ± 14 %) in all subjects, whereas peak A velocity change varied, such that a "pseudo-abnormal" decrease of E/A > 0.5 was seen in 18 subjects (37 %). At baseline, this subgroup had lower heart rate (66 ± 11 vs 73 ± 10 bpm, p= .026), higher LAres (193 ± 67 vs 145 ± 47 %, p= .006), lower peak A velocity (50 ± 12 vs 58 ± 12 cm/s, p= .04) and higher E/A (1.8±.6 vs 1.4±.3, p= .004). During VMs, LV and LA volumes decreased similarly in all subjects, but increase in heart rate was higher (12 ± 8 vs 6 ± 5 bpm, p= .023), and peak A wave increased instead of decreasing (20 ± 20 % vs -8 ± 18 %, p< .001) in the subjects with "pseudo-abnormal" decrease of E/A. During VMs, decrease in E/A was mainly determined (regression analysis, r: .76, p= .029) by baseline LAres (B= -.71) and change in LAres during VMs (B= -.47), whereas an increase in peak A velocity (r: .46, p= .031) was mainly determined by degree of HR increase (B= .41) and baseline LV EF (B= .3).

Conclusions

During VMs, a "pseudo-abnormal" decrease of the E/A velocity ratio is present in almost 40 % of normal subjects, and is determined by the interplay of the baseline diastolic compliance and the increase in systolic function of the LA during VM. These results may influence the accuracy of the VMs in the detection of increased LV filling pressures in patients.

Plasmacytoma of the larynx diagnosed by fine-needle aspiration cytology: a case report

Extramedullary plasmacytoma is a rare lesion. The use of fine-needle aspiration for diagnosis of plasmacytoma has been described in a few sporadic reports. To the best of our knowledge, none of these reports described the cytologic findings from plasmacytoma of the larynx. We report on a case of laryngeal plasmacytoma in a 79-yr-old man diagnosed by fine-needle aspiration cytology. The patient had a history of a plasmacytoma involving the sixth thoracic vertebra diagnosed in 1996, which progressed to multiple myeloma in 1997. He received treatment in the form of local radiation to the skeletal vertebrae and chemotherapy. Two years later, the patient presented with a large neck mass. Computed tomography (CT) was done at an outside facility, and the radiologic impression was of a large right glottic carcinoma with invasion into the right thyroid cartilage. Because of the history of multiple myeloma, a fine-needle aspiration (FNA) biopsy was performed of the laryngeal mass. Cytologic examination demonstrated atypical plasma cells arranged in a dissociative fashion, consistent with a plasmacytoma. Although there are previous surgical pathology reports of laryngeal plasmacytoma, to the best of our knowledge, this is the first report of plasmacytoma of the larynx diagnosed by FNA cytology.