Bubble Echo Research Articles

Yield of Cardiac Investigations in Patients Presenting with Acute Ischaemic Stroke: A single tertiary centre experience.

Strokes are a major cause of morbidity and mortality. This study aimed to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischaemic strokes. This retrospective study involved patients who presented with a stroke to the Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019. A total of 183 patients (mean age = 66.2 ± 13.5 years), the majority of which were male (n = 109, 59.6%), were included. The common risk factors included hypertension (74.9%), diabetes (61.7%) and hyperlipidaemia (54.6%). The middle cerebral artery was the most common artery affected, in 44 patients (24.0%). On admission, 14 (7.6%) patients were in atrial fibrillation (AF), while the rest were in sinus rhythm. The 24-hour electrocardiogram (ECG) Holter monitoring revealed no abnormalities in 135 patients. AF was observed in 15 (8.1%) patients (inclusive of the 14 who had AF on resting ECG). Furthermore, 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia, and nine (4.9%) had non-sustained ventricular tachycardia. Frequent supraventricular ectopics (>30/hour) was noted on 30 patients (16.3%), while five (2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients; however, 10 out of 132 (7.5%) patients presented a positive bubble echo. Enlarged left atria were found in 24 (13.1%) patients. The overall diagnostic yield of the abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with cryptogenic stroke, as suggested by newer guidelines, is recommended.

O21 A case of thromboembolic ischaemic cardiomyopathy and intracardiac thrombus in a patient with antiphospholipid syndrome

Abstract Case report - Introduction Commonly found in association with lupus, antiphospholipid syndrome (APLS) is a potentially life-threatening disease of which an understanding is essential for rheumatologists. In addition to well-recognised sequelae such as pulmonary embolism and obstetric complications, APLS can provoke thrombi ranging from microscopic to massive in size in a wide range of arterial and venous territories. We present the case of a young woman with APLS who suffered significant morbidity as a result of intracardiac and coronary thromboembolism shortly after becoming pregnant and switching anticoagulant therapy, highlighting the importance of vigilance and investigation for rarer thromboses in APLS patients. Case report - Case description A 34-year-old woman with known APLS and 5 weeks pregnant was admitted to hospital with a history of headache, nausea/vomiting and mild photophobia followed by fever, shortness of breath, confusion, pleuritic chest pain and lower limb swelling. She had commenced enoxaparin in place of warfarin on becoming pregnant. Examination was suggestive of cardiac failure. Troponin and NTproBNP were markedly elevated, without ischaemic ECG changes. A brain CT venogram was reported as normal, but echocardiogram revealed a dilated LV with reduced ejection fraction (39%), inferior and lateral wall hypokinesia and possible LV thrombus. She was treated initially for myocarditis (presumed viral or autoimmune) and received antibiotics given her raised WCC and CRP. Treatment dose enoxaparin was continued. Bloods revealed anaemia, thrombocytopenia, and positive immunology: cardiolipin IgG 123U/ml, IgM 612, anti-B2GP1 IgG 19/IgM 607, ANA (1/320) and RNP 70. C3 was normal (0.8) and C4 low (0.03). A livedoid rash consistent with APLS was present on the trunk, but there were no other clinical manifestations of connective tissue disease. Repeat CT venogram performed after the patient reported worsening headaches revealed a small tentorial subdural haematoma, resulting in the reversal of enoxaparin with protamine. Later review of these images suggested a stable 5mm haematoma that was present on the earlier scan, and enoxaparin was recommenced. Cardiac MRI revealed extensive infarct with contained LV wall rupture. Coronary angiography showed normal vessels. LVEF on repeat echocardiogram fell to 28%. Surgical pregnancy termination was performed in accordance with patient wishes, with subsequent reversion to warfarin anticoagulation. Repeat MRI showed thinned anterior/lateral LV walls, evidence of transmural myocardial fibrosis and residual laminar thrombus, and bubble echo demonstrated no PFO. The patient was ultimately managed for presumed microembolic myocardial infarction with resulting heart failure, and has been referred to a cardiac transplant centre. Case report - Discussion This case highlights the potential risk associated with a relatively common scenario: anticoagulant switching in females with APLS at the start (or in anticipation) of pregnancy. In this case our patient started enoxaparin 80mg BD 48 hours after discontinuing warfarin, developing symptoms consistent with intracerebral thrombosis shortly afterwards, followed by those of heart failure. The possible diagnoses on the basis of the patient’s initial presentation were numerous, and she was appropriately investigated in the first instance for a possible cerebral thrombotic event with cranial CT and venogram. On development of cardiorespiratory symptoms, there was a delay in requesting investigations (troponin, BNP) that may have pointed towards myocardial pathology, and once these investigations were noted to be abnormal the patient was managed as a probable myocarditis in keeping with most other patients of her age without a significant past medical history. Perhaps insufficient diagnostic weight was given to her known thrombophilia and recent medication change, which may have prompted closer review of her brain imaging leading to earlier detection of the subdural haematoma. It may also have led to more rapid investigation for possible thrombus elsewhere via earlier echo, CTPA or cardiac MRI. The latter investigation was ultimately crucial in definitively showing myocardial injury to be the result of infarction rather than inflammation, where prior ECGs had not suggested ischaemia. The subsequent unremarkable coronary angiogram added weight to the likely thromboembolic nature of the infarction, potentially via multiple microemboli being thrown off the LV thrombus. The precise timing of the presumed embolisation to our patient’s coronary circulation is unclear, and the absence of overt ischaemic cardiac symptoms suggests this may have been a relatively prolonged, subacute process. Earlier recognition of the thrombotic nature of this event may have prevented myocardial injury if embolic showers continued into her inpatient stay. Case report - Key learning points

Pengaruh algoritma filter bubble dan echo chamber terhadap perilaku penggunaan internet

Introduction. This study aims to explore effects of bubble filter and echo chamber on information searching behaviour on the internet, how it affects the scope of the internet ecosystem and users, and what we can see from the behaviour.
 Data Collection Method. The paper used a mixed-methods approach with surveys, online discussions, and literature research. Twenty respondents between 19-21 years old participated in this exploratory study.
 Analysis Data. Data was obtained and calculations have automatically accumulated through Google Form. The user data analysis and discussion were conducted manually by considering aspects of rationality concerning the literature and previous research.
 Results and Discussions. The analysis results obtained were bubble filter and echo chambers were proven to affect internet users both in positive and negative ways.
 Conclusions. Bubble filter and echo chamber may have both positive and negative effects simultaneously, however, it depends on the user because the system has provided control features to reduce both features. Using internet wisely is also parts of the important aspect. 

A case of decompression illness not responding to hyperbaric oxygen

BackgroundThe case reinforces the importance of stepping back and looking at every possibility along with multiple co-existing pathologies. It takes into account the thought process of multiple systems and a multidisciplinary team approach. Learning points to take are that decompression illness can present atypically, but one must exclude other causes.Case presentationWe present the case of a 42-year-old male from the West Midlands, UK, who attended the emergency department post-scuba diving with confusion, light-headedness, left arm weakness, and bilateral paraesthesia of the hands. Post-diving, he displayed typical symptoms of decompression illness. He attended the hyperbaric decompression chamber before attending the emergency department but to no resolve. A computed tomography of the head showed no signs of intracranial pathology. He had another session in the hyperbaric oxygen chamber but to no success. Upon admission, his blood showed polycythaemia. His saturation had dropped to 91% on room air, and a computed tomography pulmonary angiogram revealed no obvious cause. A magnetic resonance imaging of his head revealed some deep periventricular ischaemic changes, old and new, however no signs of gas embolism or poor flow. A bubble echo confirmed a patent foramen ovale. A leptospirosis and a vasculitis screen were both negative. Symptoms had slowly improved but he was left with a left arm motor weakness, and the team was left puzzled as to what could have caused his signs and symptoms. Through a diagnosis of exclusion, decompression sickness was the conclusive diagnosis. The patient made a full recovery.ConclusionsDecompression illness results as a sudden decrease in pressures during underwater ascent; it is caused by nitrogen bubbles forming in tissue. Additionally, a patent foramen ovale allows arterial gas emboli to cause further harm. Type 2 decompression sickness is the more severe form and includes neurological, respiratory, and cardiovascular symptoms.

STARRY NIGHTS: COMA DUE TO CEREBRAL FAT EMBOLISM SYNDROME

Cerebral fat embolism can complicate long bone fractures and orthopaedic surgery. We present two patients with this syndrome who developed coma following long bone fracture or hip replacement surgery.Patient 1...

An Unusual Case of Cirrhosis

Purpose: A 49-year-old white female with history of sarcoidosis was referred to GI when her liver was noted to be nodular during laparoscopy for an ovarian cyst. She denied fatigue, hematemesis, abdominal distension and pain, ankle swelling, itching, yellow discoloration of skin and eyes and episodes of confusion or sleepiness. She denied alcohol abuse. Physical examination revealed normal VS and no icterus, spider nevi, clubbing, ascites, hepatosplenomegaly or edema. LFTs revealed mild elevation in alkaline phosphatase and PT was slightly prolonged. CBC showed mild thrombocytopenia. Hepatitis serologies, ANA, AMA, ASMA, Ferritin, Ceruloplasmin, and α1-AT level were unremarkable. A liver biopsy confi rmed cirrhosis. Biopsy did not show any granulomas, but showed sinusoidal dilatation, which prompted a referral to cardiology. ECHO showed enlarged IVC and was otherwise unremarkable. A left and right heart catheterization was done. LHC showed normal coronaries, and RHC showed RAP 12 mm Hg, PAP 32/15 (mean 21) mm Hg, PAWP 18 mm Hg, LVEDP 18 mm Hg and CO 5.2 l/min. She developed worsening shortness of breath and was referred to pulmonology here. PFTs showed mild restriction, but CXR was unrevealing. CTPA ruled out PE and showed scattered pericardial calcification. Bubble ECHO did not show a right to left shunt. She developed SVT and was hospitalized here. She underwent a repeat left and right heart catheterization: RAP was 25 mm Hg, PAP 52/25 (mean 37) mm Hg, PAWP 32 mm Hg, LVEDP 36 mm Hg, and CO 4.12 l/min. Simultaneous measurement of left and right sided pressures confirmed constrictive pericarditis. In retrospect, the cirrhosis is “cardiac” cirrhosis and the result of long-standing elevated right sided heart pressures. Similarly, her dyspnea on exertion can be explained by constrictive pericarditis. We believe that constrictive pericarditis resulted from Sarcoidosis. She is now being evaluated for pericardiectomy. Clinical pearls: 1.) A cardiac etiology should be considered in the work-up of cirrhosis especially when the most common causes are not found. 2.) Pericardial calcification should suggest the possibility of constrictive pericarditis. 3.) Simultaneous measurement of left and right sided pressures should be performed when there is suspicion of constrictive pericarditis. 4.) Sarcoidosis is a rare but well known cause of pericardial disease.Figure

The prevalence of hereditary hemorrhagic telangiectasia in Juvenile Polyposis syndrome patients with SMAD4 mutations

Background Juvenile Polyposis Syndrome (JPS) is defined by the presence of ≥ 5 colorectal juvenile polyps or any number of juvenile polyps in an individual with a family history of JPS. Genetic alterations including either point mutations or large rearrangements in BMPR1A or SMAD4 are found in 50% of affected individuals. Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disease diagnosed upon the presence of epistaxis, visceral arteriovenous malformations (AVM) or mucutaneous telangiectasias. HHT is diagnosed when there are ≥ 3 manifestations and is suspected when there are at least 2 manifestations. Most HHT cases are caused by a germline mutation in ALK1 or ENG ,m embers of the TGFb signaling pathway. Approximately 22% of patients with Juvenile Polyposis Syndrome (JPS) due to a SMAD4 mutation have been reported to also have HHT [1]. Most prior publications have few patients and no systematic approach to screening, so the true incidence of the combined JPS/HHT syndrome is not known. Our aim was to determine the prevalence of HHT in our patients with JPS with a SMAD4 mutation including those who underwent systematic screening for AVM’s. Methods JPS patients were identified from a comprehensive polyposis database using Cologene© software. Families carrying a germline SMAD4 mutation were studied by screening affected patients for cutaneous telangiectases and with cardiac bubble ECHO, CAT scan chest, or MRI of brain for other AVMs. Results

P40 A comparison of the value of oxygen shunt studies and cardiac bubble echo as screening tools for pulmonary arteriovenous malformations in patients with suspected hereditary haemorrhagic telangiectasia

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder associated with recurrent spontaneous epistaxis, mucocutaneous telangiectasia and visceral arteriovenous malformations (AVMs). Up to 30% of patients with HHT have...

Right-to-Left Anatomic Shunt Associated With a Persistent Left Superior Vena Cava: The Importance of Injection Site in Demonstrating the Shunt

Anatomic right-to-left shunt causes hypoxemia that can pose a diagnostic challenge to clinicians. Among the many possible causes of right-to-left shunt, persistent left-sided superior vena cava (PLSVC) with an “unroofed” coronary sinus represents an uncommon congenital anomaly in which detection by saline-contrast echocardiogram (bubble echo) or contrast-enhanced CT scan requires injection of contrast in the left arm. We present the case of an elderly man with hypoxemia on the basis of a right-to-left shunt accompanying a PLSVC with unroofed coronary sinus in whom the shunt escaped initial detection following a bubble echo with contrast injected into the right arm. This case reminds pulmonary clinicians, who are frequently called on to assess the cause of hypoxemia, that specifying a contrast injection into the left arm is required in the pursuit of this specific shunt-producing anomaly. Anatomic right-to-left shunt causes hypoxemia that can pose a diagnostic challenge to clinicians. Among the many possible causes of right-to-left shunt, persistent left-sided superior vena cava (PLSVC) with an “unroofed” coronary sinus represents an uncommon congenital anomaly in which detection by saline-contrast echocardiogram (bubble echo) or contrast-enhanced CT scan requires injection of contrast in the left arm. We present the case of an elderly man with hypoxemia on the basis of a right-to-left shunt accompanying a PLSVC with unroofed coronary sinus in whom the shunt escaped initial detection following a bubble echo with contrast injected into the right arm. This case reminds pulmonary clinicians, who are frequently called on to assess the cause of hypoxemia, that specifying a contrast injection into the left arm is required in the pursuit of this specific shunt-producing anomaly.

The effect of the phase of transmission on contrast agent echoes

Ultrasound contrast agents consist of a gas bubble, encapsulated by a shell for stabilization. The shell dampens the fluctuations in the bubble radius when insonified. The detection of contrast microbubbles during a medical examination can indicate whether a region is perfused with blood. Here, the authors consider the effect of the phase of sonification signal on the backscatter by the bubble echo. By transmitting two short pulses of ultrasound with opposite phases, the authors demonstrate that a unique pair of echoes can be generated by a single microbubble, and that the properties of these echoes may be useful in the discrimination of bubble and tissue echoes. Specifically, the significant echo amplitude begins coincident with each transmitted rarefactional half-cycle, and the mean frequency of this echo depends on the transmitted phase. When rarefaction is transmitted first for a 2.25 MHz signal, the mean frequency is 0.8 MHz higher for an albumin-shelled bubble and 0.9 MHz higher for a lipid-shelled bubble. The experimental results agree with the predictions of the Gilmore-Akulichev equation.

Fluid pressure measurement using bubbles insonified by two frequencies

The double frequency method, where bubbles rising through a fluid are illuminated simultaneously with a ‘pump’ frequency swept through the resonance frequency range and a megahertz imaging frequency, is used to measure pressure changes in fluids non-invasively. The bubble echo spectrum is centred at the imaging frequency with side bands at separations equal to the pump frequency. If the ambient pressure is changed, the bubbles undergo changes in their sizes. This would alter the resonant frequency of the bubble and hence the peak of the echo at the sum (or difference) frequency. By observing shifts in the frequency of the peak amplitude of the side bands it is shown that fluid pressure changes can be measured accurately.