Bedside Transthoracic Echocardiography Research Articles

An atypical case of pulmonary embolism from a jugular vein

SummaryNeck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

A 3-Dimensional Printed Ultrasound Probe Visuospatial Trainer.

Training adult learners to use ultrasound in clinical practice relies on the ability of the learner to apply visuospatial concepts to the anatomy of the human body. We describe a visuospatial trainer that replicates the housing of an ultrasound transducer, through which a linear laser projects light in the same plane and orientation as the ultrasonic sound waves. We use this trainer in combination with a porcine heart dissection laboratory to teach bedside cardiac ultrasound and transthoracic echocardiography (TTE). Off-the-shelf components, including an on/off switch, a laser, and 2 ampere batteries are connected in series and placed inside the 3-dimensional (3D)-printed housing. The trainer's laser emission projects a red line that visually represents the ultrasound's field. Learners project the laser against a porcine or human heart in the orientation of the TTE window they wish to obtain and then dissect the heart in that plane, allowing for visualization of how grayscale images are obtained from 3D structures. Previous research has demonstrated that visuospatial aptitude is correlated with ultrasound procedural performance. We present this trainer and educational method as a specific training intervention that could enhance the visuospatial ability of the ultrasound learner. This visuospatial trainer and educational method present a novel process for enhancing learner understanding of 2-dimensional ultrasound images as they relate to 3D structures. Having a clear understanding of how images are generated in cross section may translate into more proficient adaptation of cardiac ultrasound and TTE.

The use of point-of-care ultrasound to diagnose patent foramen ovale in elective hip and knee arthroplasty patients and its association with postoperative delirium.

Hip and knee arthroplasty surgeries are associated with embolism of materials such as air, cement, and fat. Patent foramen ovale (PFO) is a common congenital cardiac condition that has been reported to lead to paradoxical embolism. This observational study aimed to investigate if the presence of a PFO was associated with an increased risk of postoperative delirium in patients undergoing primary elective hip or knee arthroplasties. This was a prospective cohort study at a tertiary teaching hospital. We enrolled patients undergoing primary elective hip or knee arthroplasty who did not have any risk factors for embolism or delirium. Bedside transthoracic echocardiography (TTE) with a bubble study was performed on all patients to detect the presence of PFO. The primary outcome was postoperative delirium as assessed by the standardized Confusion Assessment Method. Secondary outcomes included the ease of performing a TTE bubble study in the perioperative setting, the quality of the TTE images, length of stay, major cardiovascular and neurologic complications, and effects of anesthetic or analgesic management techniques on delirium. Two hundred two patients completed the study. The median [interquartile range] duration of stay was 2 [2-3] days. Only 16 patients (8%) had a positive bubble study. Postoperative delirium was observed in only one patient. Major adverse events were not seen. The inter-rater reliability for the TTE image quality scores was fair (kappa statistic = 0.22). Given the very low incidence of PFO and postoperative delirium in this study, we could not form any conclusions regarding the impact of a PFO on important outcomes including delirium or other major adverse events. No recommendation can be made regarding screening for PFO in patients scheduled for lower extremity arthroplasty surgery. ClinicalTrials.gov (NCT02400892). Registered 27 March 2015.

Clinics in diagnostic imaging (182)

A 77-year-old man presented with acute-onset severe chest pain radiating to the back and elevated blood pressure. Multiphasic computed tomography of the aorta revealed an intimal tear in the descending thoracic aorta which extended both retrograde to the aortic root and antegrade to the infra-renal abdominal aorta. The initial impression, that the images showed a Stanford type B aortic dissection, was because the portion of the false lumen that extended beyond the aortic arch remained unopacified even on delayed phases, making it challenging to assess the extent of the dissection flap. Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. This case highlights the need for early and accurate imaging assessment of acute aortic dissection, including accurate identification of the site of intimal tear and the extent of the dissection flap.

An echocardiographic clue for ostial left main coronary artery stenosis

Calcified nodules in human coronary arteries are usually focally distributed. Non-invasive imaging of coronary arteries by bedside emergency transthoracic echocardiography in adults is possible and may become a useful adjunct to other methods of coronary artery examination. Coronary artery stenosis can be identified as localized color aliasing and accelerated flow velocities. Complete visualization of individual ostial coronary segments might ease the demonstration of coronary stenosis by bedside transthoracic echocardiography. The left main coronary artery stenosis requires prompt emergency evaluation and treatment because emergency conditions have higher mortality rates. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life-threatening condition.

An aberrantly positioned central venous catheter: A presage of an underlying anatomical anomaly

Sir, The left subclavian vein was cannulated uneventfully using bony landmark technique in a 52-year-old male for hyperalimentation and administration of inotropes and intravascular fluids in Intensive Care Unit (ICU). He was a postoperative case of cancer of the sigmoid colon and had undergone a hemicolectomy. He was admitted in view of massive intraoperative blood loss leading to hemodynamic instability and long duration of surgery. His stay was further complicated by development of septic shock. Postinsertion chest radiograph revealed the position of the catheter in the left para mediastinal location [Figure 1]. This raised suspicion of a left-sided superior vena cava (SVC). Cross-sectional imaging with computed tomography (CT), magnetic resonance, or a saline contrast echocardiography was the options available to confirm the diagnosis. A bedside CT (contrast-enhanced) of the thorax is not available in our ICU and decision to shift the patient to radiology was deferred in view of hemodynamic instability of the patient and requirement of high dose of inotropes. Bedside transthoracic echocardiography was performed which showed a structurally normal heart with a dilated coronary sinus. The tip of the central venous catheter, however, could not be observed with confidence. Agitated saline was infused via the central venous catheter and this was followed by opacification of the coronary sinus and the right atrium. Persistent left-sided SVC (PLSVC) draining to right atrium via coronary sinus was confirmed. Malpositioning into tributaries of left brachiocephalic vein (left internal thoracic vein, left superior intercostal vein) and left pericardiophrenic vein was unlikely as the pressure tracing was consistent with central venous placement (a, c, x, v, y waves could be identified). Placement in left subclavian artery and descending thoracic aorta was ruled out as pressures ranged from 5-8cm of H20 and results of blood gas analysis were consistent with venous placement. Figure 1 Chest X-ray suggestive of persistent left-sided superior vena cava; widening of the aortic shadow, a paramedian bulge along the left heart border. An electrocardiography lead and a surgical drain can also be visualized The incidence of PLSVC is 0.3–0.5% in healthy individuals and 1.3–4.5% in patients with coexisting cardiac defects.[1,2] About 82% of PLSVC coexist with a right SVC and so this anomaly is often missed when central venous catheters are inserted on the right side. Venous drainage of PLSVC is into right atrium in majority of cases but could be in the left atrium also [Table 1]. Table 1 Venous drainage of persistent left-sided superior vena cava Left-sided jugular venous distention and an abnormal and exaggerated jugular venous waveform on left-sided catheterizations due to direct transmission of left atrial pressures raise suspicion of this anomaly. Anesthetist and intensivist need to be aware of this anomaly as it may cause the following complications:[3,4,5] Difficulty in insertion of left-sided pulmonary artery catheters or pacing wire Systemic embolization of air or thrombus in patients with PLSVC draining into the left atria Right-to-left shunting and unexplained cyanosis and clubbing in the patient (PLSVC draining into left atria) Arrythmias, cardiac arrest, and coronary sinus thrombosis Causes distention of the right heart during cardiac surgeries if not ligated or separately cannulated. It is a contraindication to retrograde cardioplegia. Left para mediastinal location of central venous catheter led to diagnostic dilemma in our patient, but a methodological assessment of all the differential diagnosis using simple bedside tests enabled us to make a diagnosis of PLSVC draining into right atria. It is the most common congenital venous anomaly in the chest and it is thus important for the clinicians to be aware of this. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Endpoints in resuscitation.

Shock occurs because of a failure to deliver adequate oxygen to meet the metabolic demands of the body resulting in metabolic acidosis, inflammation, and coagulopathy. Resuscitation is the process of treating shock in an attempt to restore normal physiology. Various hemodynamic, metabolic, and regional endpoints have been described to evaluate the degree of shock and guide resuscitation efforts. We will briefly describe these endpoints, and propose damage control resuscitation as an additional endpoint. Serum lactate, base deficit, and pH are well established endpoints of resuscitation that provide valuable information when trended over time; however, a single value is inadequate to determine adequacy of resuscitation. Rapid normalization of central venous oxygen concentration has been associated with improved survival, and bedside transthoracic echocardiography can be a reliable assessment of volume status. In hypovolemic/hemorrhagic shock, early hypotensive, or controlled resuscitation strategies have been associated with improved survival, and hemostatic strategies guided by thrombelastography using a balanced transfusion approach result in improved hemostasis. Numerous endpoints are available; however, no single endpoint is universally applicable. Damage control resuscitation strategies have demonstrated improved survival, hemostasis, and less early death from exsanguination, suggesting that hemorrhage control should be an additional endpoint in resuscitation.

Thrombus flottant dans les cavités droites

Free-floating thrombi in the right heart chambers is a rare phenomenon. Nearly 99% of detected cases are associated with the presence of proven pulmonary embolism. Its presence is associated with a poor outcome with a mortality between 27 to 44% according to studies. Despite the emergency of treatment, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 84-year-old man hospitalised for acute decompensated heart failure. After an initial favourable evolution, a degradation of respiratory occurred with dyspnea and desaturation. A bedside transthoracic echocardiography showed a mobile serpiginous thrombus, 7cm size, moving to and across the tricuspid valve. A computed tomography of the chest demonstrated massive bilateral pulmonary embolism. After persistence of the thrombus and seven days of heparinotherapy, thrombolysis therapy was initiated. The thrombus disappeared 24h after thrombolysis. Without contra-indication, thrombolysis is a faster, readily available treatment for the management of floating thrombus in the right heart chambers associated with pulmonary embolism.

Ischaemic perforation of the free left ventricular wall covered by pericardial adhesion as an incidental finding in a patient presenting with acute cerebral ischaemia

A 48-year-old male without known cardiac history presented with transient hemiplegia and paraesthesia of the left arm to our neurologic department. Cranial computed tomography confirmed ischaemia of the left temporoparietal region. Bedside transthoracic echocardiography due to atypical chest pain 1 week ago demonstrated dyskinesia of the entire apex together with filiform free-floating structures …

56. Echocardiography in PICU; the heart sees what is invisible to the eye

Objective Echocardiography has become an indispensible bedside diagnostic tool in the realm of pediatric intensive care units (PICU). It has proven to be an influential factor in the formula of clinical decision making. The intent of this study is to delineate the impact of echocardiography on the management of critically ill pediatric patients in our PICU. Design Retrospective case series. Setting Tertiary five- bed PICU in Sultan Qaboos University Hospital, Oman. Patients We reviewed all patients admitted to our PICU from January 2011 to December 2012. Intervention Bedside transthoracic echocardiography (echo) during the period of stay in the PICU. Results Over a-24-month period, 424 patients were admitted in our PICU. One hundred and one clinically indicated transthoracic echoes were performed. 82% of these echoes had new findings ( N : 82) that significantly impacted the clinical decision of patient management namely altered drug therapy and procedure, whereas no difference in the management was yielded in the remaining 18% of the studied cases. Conclusions Echocardiography had a significant impact on the management of PICU patients. Such salutary effect was consequently reflected on the outcome. Pediatric intensivists are encouraged to acquire such bed side skill.

30-OR

Objectives Cathepsin D has been implicated in the development of preeclampsia and peripartum cardiomyopathy. We sought to examine the association of cathepsin D with cardiac dysfunction on echocardiography in women with preeclampsia. Methods Preeclamptic women aged 18–43 were recruited for this IRB approved study. Demographics, clinical data, and outcomes were recorded throughout the antepartum and postpartum course. Serum for cathepsin D activity and placental growth factor (PlGF) was drawn at the time of clinical labs. PlGF (pg/ml) was determined using ELISA. Cathepsin D activity (μM) was determined using a fluorimetric Sensolyte® 520 Immunoassay. Bedside transthoracic echocardiography was performed antepartum and postpartum for determination of standard myocardial function parameters as well as myocardial strain with speckle tracking. Statistical analyses included t-test, ANOVA, and pairwise correlations. Results We enrolled 23 women with mild (n = 10) and severe (n = 13) preeclampsia. Echocardiography was available antepartum on 21 women (strain imaging on 8) and postpartum on 17 women (strain imaging on 11). Mean age was 28.7 ± 5.6 years. Most women were Caucasian (n = 21) and primigravida (n = 14). Average gestational age at enrollment was 32.0 ± 4.8 weeks. Increasing ratio of cathepsin D activity to PlGF was associated with worsening longitudinal strain antepartum (p = 0.02). Postpartum, increasing ratio of cathepsin D to PlGF was associated with decreasing fractional shortening (p = 0.02). Conclusions Ratio of cathepsin D activity to PlGF is associated with subclinical cardiac dysfunction as determined by speckle tracking for cardiac strain as well as fractional shortening on echocardiography. A ratio of cathepsin D activity to PlGF as a marker of anti-angiogenic factors to pro-angiogenic balance better indicates this association than cathepsin D activity alone. Disclosures C.F. Pearce: None. G.S. Dhaliwal: None. M. Keihanian: None. S. Mast: None. R.I. Pollack: None. J.M. O’Brien: None. W.F. Hansen: None. T.E. Curry: None. A.L. Bailey: None.

Acute stroke with concomitant acute myocardial infarction: will you thrombolyse?

Acute stroke with concomitant acute myocardial infarction: will you thrombolyse?

Free Floating Right Heart Thrombus Associated with Acute Pulmonary Embolism: An Unsettled Therapeutic Difficulty.

Free floating right heart thrombus is a rare phenomenon in the context of acute pulmonary embolism and it is associated with a poor outcome. The increased use of echocardiography has led to an increased detection of right heart thrombi. However, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 74-year-old woman who presented to the emergency department with acute onset dyspnea on minimal exertion which had developed over a period of 1 day. A computed tomography of the chest demonstrated massive bilateral proximal pulmonary embolism. A bedside transthoracic echocardiography performed showed a moderately dilated, poorly functioning right ventricle with visible highly mobile serpiginous thrombus moving to and fro across the tricuspid valve. Thrombolytic therapy was immediately initiated with tenecteplase which resulted in excellent results. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.

Cardiac vignette: Isolated case of right ventricular non-compaction

A 33-year-old female experienced a witnessed cardiac arrest in the emergency department. No significant prior medical history. Initial presenting complaint of progressive dyspnoea with ECG findings of sinus tachycardia. Subsequent development of sinus bradycardia on monitoring followed by cardiac arrest requiring cardiopulmonary resuscitation. Urgent bedside transthoracic echocardiography upon successful resuscitation showed severely dilated and dysfunctional right ventricle (RV). Emergent thrombolysis performed with subsequent CTPA showing evidence of extensive filling defects involving the right pulmonary arterial vasculature consistent with acute pulmonary embolism. Formal transthoracic and transoesophageal echocardiography (Images 1 and 2, respectively) were performed showing significant RV dilatation and prominent trabeculations within the RV apex, in keeping with RV non-compaction (RVNC). Cardiac MRI was subsequently performed (Image 3 and 4), confirming diagnosis of RV non-compaction with RV dilatation as well as prominent left ventricular trabeculations. No significant intra-cardiac luminal thrombus was seen. Patient underwent RV endomyocardial biopsy which revealed mild interstitial fibrosis along with significant fat infiltration (30-40% of the biopsy specimen was infiltrated and replaced by fat). No significant myocyte hypertrophy or myofibre disarray was noted. No significant inflammation, granulomas, iron deposits and amyloid deposits were seen. The clinical case illustrates the difficulty faced in diagnosis of RVNC. Along with RV dilatation (found in pulmonary embolism), histopathological findings point to the diagnosis of RV dysplasia. Imaging findings however raise the likelihood of RVNC. Though well described in literature, the histological features of RVNC is yet to be clearly elucidated and hence radiological and clinical correlation is suggested for accurate diagnosis.

Ventilator Liberation for High-Risk-for-Failure Patients: Improving Value of the Spontaneous Breathing Trial.

Several patient populations have been identified as high risk for extubation failure despite successful completion of a spontaneous breathing trial (SBT). Extubation failure and subsequent need for emergent re-intubation have been associated with increased morbidity and mortality. In this review, we discuss ways to optimize the value and performance of the SBT in a subgroup of high-risk patients (elderly, cardiac, and/or respiratory failure) to reduce the rate of extubation failure. We recommend the use of T-piece mode, longer duration SBT, and measurement of the rapid shallow breathing index (breathing frequency/tidal volume in L) off ventilatory support to increase the predictive value of the SBT. In addition, measurement of changes in central venous oxygen saturation and serum brain natriuretic peptide, and measurements of mitral inflow and annular velocity using bedside transthoracic echocardiography with tissue Doppler imaging may help guide the clinician in determining who and when to extubate and thus minimize the rate of extubation failure. Arterial blood gas analysis performed at the end of the SBT may help determine who will benefit from prophylactic use of noninvasive ventilatory support postextubation.

Epicardial Coronary Artery Compression Secondary to Pericardial Adhesions Demonstrated by Multi-Modality Imaging, and Treated by Coronary Stenting

A 42-year-old female presented with sudden onset severe left-sided chest pain radiating to the left arm while watching a movie at home. She was rushed to the hospital within 10 minutes. She was found having ST elevation myocardial infarction on ECG and ventricular fibrillation arrest 2 times requiring cardiac resuscitation and defibrillation. Retrospectively, the patient recalled some ill-defined episodes of chest pain with exercise in the past few months before the admission. Her past surgical history 20 years previous was significant for video-assisted thoracoscopic surgery and pericardial window for removal of large, nonhemorrhagic pericardial effusion of 1.2 L, which occurred ≈1 week after her chest wall injury from basketball. Bedside transthoracic echocardiography revealed mildly decreased left ventricular systolic ejection fraction of 40% to 45%, and pericardial thickening with small pericardial effusion. The patient underwent emergent cardiac catheterization and coronary …

An Unusual Cause of Electrocardiographic ST Elevation- Can the Japanese Fishing Industry Help Us?

A 76-year-old previously well woman presented after an unwitnessed collapse. She had no coronary disease risk factors. Physical examination result was unremarkable and she appeared well. Her ECG showed ST-segment elevation (V2-6/II/III and aVF) (Figure 1), and her troponin T level was 2.87 μg/L (normal limit 0.04 μg/L). Bedside transthoracic echocardiography showed akinesia of all mid and apical left ventricular segments (Figure 2). Invasive coronary angiography demonstrated no disease but apical ballooning on left-sided ventriculography (Figure 3).

Cardiac Hemangioma of RVOT in a Patient with Atypical Chest Pain.

A 40-year-old man presented with atypical chest pain and fatigue from 15 days ago a suspicious mass in the right ventricle based on a bed side transthoracic echocardiography. Preoperative diagnosis of a cardiac hemangioma comes to mind in a minority of cases. In our case, a cardiac tumor was diagnosed and the vascular nature of the tumor was suggested by vascular blush on the coronary angiography. In addition, right ventriculotomy was the approach of choice in our case because of its inaccessibility and its particular location.

Persistent left superior vena cava: diagnosed by bedside echocardiography in a liver transplant patient: a case report.

In most cases, persistent left superior vena cava (PLSVC) is asymptomatic and discovered accidentally. This case involves a 43-year-old male who underwent an emergency cadaveric liver transplantation. Postoperatively, the left internal jugular vein was cannulated using a sono-guided Seldinger technique in the intensive care unit. But the chest X-ray showed that the catheter followed the left paramediastinal course instead of crossing midline to the right to enter the superior vena cava. In consideration of the patient's status, an intra-arterial or extra-vascular placement could be excluded. For a diagnosis, we performed a bed-side transthoracic echocardiography with an agitated saline micro-bubble test. When agitated saline was injected through the catheter, the coronary sinus was initially opacified, and then the right atrium followed. In conclusion, we were able to make a diagnosis of PLSVC by a bedside test without radiation exposure.

Introduction of an Echocardiography Service to a General Intensive Care Unit

Studies have suggested that significant undiagnosed pathology exists in the intensive care unit (ICU) population, and that bedside transthoracic echocardiography (TTE) can aid prompt diagnosis with potential outcome benefits. This study assesses the introduction of a bedside echocardiography service on patient care in a tertiary university intensive care unit (ICU). Data were collected from 101 TTEs, of which 58 were full studies and 43 were screening TTEs with a limited dataset. Seventy-five scans (74%) revealed previously undiagnosed pathology, which was considered serious in 30 (30%) cases. The most commonly diagnosed pathologies were: severe ventricular dysfunction (n=19), severe valvular dysfunction (n=9) and severe pulmonary hypertension (n=4). Full studies were more likely than screening studies to reveal previously undiagnosed pathology (47/58 vs 28/43 studies, p=0.035). However, the number of patients whose management was changed as a result of TTE was not significantly different between the two groups. Overall, patient management was altered as a result of the TTE in 51 cases (50%), and 11 patients (11%) were subsequently referred for cardiology consultation. In keeping with previous work, we have found that TTE uncovered a high percentage of unsuspected cardiac abnormalities, which impacted management in half of the patients who were scanned.