Bedside Transthoracic Echocardiography Research Articles

Delayed presentation of right and left ventricle perforation due to suicidal nail gun injury

We describe a case of delayed presentation of attempted suicide with a nail gun that penetrated both the right and left ventricle. Nearly invisible entry point of the nail did not reflect the gravity of the injury. A prompt and accurate history along with chest X-ray and bedside transthoracic echocardiography facilitated localization of the nails and helped assess the damage. Despite cardiac arrest after induction of general anesthesia, the patient had a successful outcome. Issues related to the injury site, modalities of investigation and management strategies in a patient with cardiac tamponade are discussed.

Massive pulmonary embolism immediately diagnosed by transthoracic echocardiography and treated with tenecteplase fibrinolysis

We report the case of a 75-year-old woman with new onset dyspnoea, hypotension, and right bundle branch block. Transthoracic echocardiography (TTE) showed a thrombus in the right pulmonary artery and acute pulmonary embolism was diagnosed. The patient immediately underwent fibrinolysis with tenecteplase, with prompt recovery of clinical conditions and ECG anomalies. Bedside TTE might be helpful for immediate diagnosis of massive PE needing rapid treatment by fibrinolysis.

The Right Atrial Thrombus: The Sword of Damocles With Real Risk of Massive Pulmonary Embolism

Cases of 6 patients admitted at the intensive care unit for massive pulmonary embolism are reported. All patients presented with dyspnea, tachypnea, and tachycardia, and 4 were hypotensive and had syncope. Lung ventilation/ perfusion scans revealed perfusion defects in 4 patients. Transthoracic echocardiography (TTE) demonstrated acute cor pulmonale. It also revealed mobile right atrial thrombi in 5 patients, adherent thrombus in the right atrium in 1 patient and patent foramen ovale in 4 patients. Thrombolytic therapy was initiated in 4 patients, and 2 patients received heparin infusion only. Effects of thrombolysis were monitored using bedside TTE during the first 24 hours and in follow-up. The outcome of 4 patients who received thrombolytic therapy was good whereas other 2 patients, who received only heparin, died. Thrombotic mass disappeared 8 to 12 hours after initiation of therapy, and 10 weeks after discharge TTE showed normalized right ventricle dimensions and function in all 4 patients.

Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients

Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population. Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients. Investigators were faculty, fellows, or residents from an academic emergency medicine department. Five standard cardiac views were performed: parasternal long axis (PSLA), parasternal short axis (PSSA), subxiphoid 4-chamber, subxiphoid short axis, and apical 4-chamber (AFC). LVEF was determined using at least 1 cardiac view. Investigators rated their preference for each cardiac view on a 5-point Likert scale. A total of 70 studies were performed on 70 patients during a 6-month period. Users rated the PSLA as the most useful view for estimation of LVEF (mean 4.23; 95% confidence interval, 3.95-4.51). Pairwise comparisons of cardiac ultrasound views revealed PSLA was preferred over all other views (P < .05) except PSSA (P = .23). Complete 5 view examinations were not achieved in all patients (PSLA in 98%, PSSA in 96%, apical 4-chamber in 74%, subxiphoid 4-chamber in 35%, and subxiphoid short axis in 18%). Interobserver correlation of LVEF estimation was good (r = 0.86, r2 = 0.74, P < .0001). Parasternal long axis and PSSA are the preferred echocardiographic windows for EP estimation of LVEF using focused bedside TTE in critical care patients. This may be an important consideration in patients who often have physical barriers to optimal echocardiographic evaluation, are relatively immobile, and have unstable conditions requiring rapid assessment and intervention.

Intraoperative Myocardial Rupture Heralded by Contrast Echocardiography

This case report shows the use of bedside transthoracic contrast echocardiography in the diagnosis of subacute myocardial rupture after acute myocardial infarction and indication of urgent surgery. Usefulness of intraoperative transesophageal echocardiography for detection of sudden complete myocardial rupture leading to pericardial tamponade during anesthetic induction, and prompt lifesaving surgical procedure are also presented.

Transthoracic Echocardiographic Detection, Differential Diagnosis, and Follow-Up of Esophageal Hematoma

Esophageal hematoma is a rare form of esophageal injury. It may occur spontaneously, or in association with direct esophageal damage or a bleeding diathesis. Endoscopy and computed tomography are generally necessary for the establishment of a diagnosis. In this report, we present a case of esophageal hematoma that was discovered via a bedside transthoracic echocardiography. The echocardiography was conducted to evaluate an unexplained shock in a critically ill-patient. After conservative treatment, complete resolution of the esophageal hematoma was documented by a 7-day short-term follow-up of bedside transthoracic echocardiography. To the best of our knowledge, this is the first case report regarding transthoracic echocardiographic detection, differential diagnosis, and follow-up for esophageal hematoma. (Korean Circ J 2007;37:666-670)

Acute Pulmonary Embolism

Case presentation : A 66-year-old man with a history of deep venous thrombosis (DVT) presented with acute dyspnea. He was normotensive, with a resting tachycardia of 110 beats per minute and an oxygen saturation of 76% on room air. The only electrocardiographic abnormality was sinus tachycardia. His brain-type natriuretic peptide (BNP) and cardiac troponin levels were elevated. Chest computed tomography (CT) with contrast demonstrated a large saddle pulmonary embolus and increased diameter of the right ventricle (RV) compared with the left ventricle (LV). The patient received intravenous bolus followed by continuous infusion unfractionated heparin. Within several hours, the patient became progressively more hypotensive and hypoxemic. Bedside transthoracic echocardiography (TTE) showed RV dilatation and hypokinesis. He then received intravenous fibrinolysis, with rapid improvement in hemodynamics and oxygenation. What were the clues that he was likely to suffer from progressive hypotension and hypoxemia? Pulmonary embolism (PE) represents a spectrum of syndromes ranging from small peripheral emboli causing pleuritic pain to massive PE resulting in cardiogenic shock or cardiac arrest. Most patients with PE present with normal blood pressure. However, some may rapidly deteriorate and manifest systemic hypotension, cardiogenic shock, and sudden death despite therapeutic levels of anticoagulation. Risk stratification to identify such patients has emerged as a critical component of care. The history and physical examination provide the starting point for risk stratification. The International Cooperative Pulmonary Embolism Registry (ICOPER) identified age >70 years, cancer, congestive heart failure, chronic obstructive pulmonary disease, and systolic blood pressure less than 90 mm Hg as significant predictors of increased mortality.1 Elevated cardiac biomarkers correlate with the presence of RV dysfunction, a powerful independent predictor of early mortality.2 Whereas cardiac troponins are released as a result of microinfarction due to RV pressure overload, BNP is secreted from cardiac myocytes in response to RV shear …

Echocardiographic Diagnosis of Air Embolism Associated with Central Venous Catheter Placement: Case Report and Review of the Literature

Transthoracic echocardiography (TTE) is a valuable tool in the evaluation of patients with suspected air embolism. This report describes the presentation and evaluation of a critically ill woman with spontaneous air embolism occurring during a central venous catheter replacement. Bedside TTE established the diagnosis of air embolism, allowing prompt initiation of appropriate therapy. This case report highlights this uncommon but potentially life-threatening complication of central line placement and the utility of echocardiography in its evaluation.

CLINICAL IMPACT OF EARLY GOAL-DIRECTED ECHOCARDIOGRAPHY IN SHOCK PATIENTS PERFORMED BY NON-CARDIOLOGIST INTENSIVISTS

PURPOSE: Circulatory shock is life-threatening requiring immediate therapeutic intervention. Real time assessment of cardiac function and volume provides information to guide fluid and vasopressor therapy. Early bedside transthoracic or transesophageal echocardiography performed by non-cardiologist intensivists has the potential to improve the management of patients with acute hemodynamic instability. The purpose of this study is to determine the clinical impact of limited, goal-directed bedside echocardiography performed by non-cardiologist intensivists in ICU patients in shock.

Echocardiographic visualization of acute pulmonary embolus and thrombolysis in the ED

Echocardiography has been used to diagnose acute right-sided dysfunction arising from pulmonary embolism (PE). Rarely, it can visualize the embolic material in the right heart cavities. We report a case of acute PE that was seen in the right ventricle and right pulmonary artery using bedside transthoracic echocardiography in the ED. As a result of the prompt diagnosis of a massive embolus and associated right ventricular dysfunction, the patient was treated with thrombolytics. Serial echocardiographs confirmed the response to therapy and the dissolution of thrombi. In this report, echocardiographic findings of acute PE and indications of thrombolytics in PE are also reviewed from the literature. Based on available evidence, those patients who present with cardiogenic shock from PE, and young patients with acute PE leading to right ventricular dysfunction benefit the most from early thrombolytic therapy.

“Thrombus in transit” – the role of echocardiography in the diagnosis of massive pulmonary embolism and a review of the literature

The diagnosis of acute pulmonary embolus is often difficult.We present a case history where bedside transthoracic echocardiography provided a rapid and convenient aid to diagnosis by demonstrating a venous “thrombosis in transit” as a spiral shaped mass in the right atrium prolapsing into the right ventricle.We also review the management and outcome in recent, similar cases. Overall mortality is 33% for pulmonary embolus and associated thrombus in transit.Transthoracic echocardiography may be a useful tool in the diagnosis of pulmonary embolus. The presence of thrombus in the right heart is a rare finding. The outcome in these patients is determined by the clinical presentation rather than by the identification of thrombus.