Performance of an automated ultrasound device in identifying and tracing the heart in porcine cardiac arrest

Background While intra-arrest echocardiography can be used to guide and monitor chest compression quality, it is not currently feasible on the scene of out-of-hospital cardiac arrests. Rapid and automated sonographic localization of the heart may provide first-responders guidance to an optimal area of compression without requiring them to interpret ultrasound images. In this proof-of-concept porcine study, we sought to describe the performance of an automated ultrasound device in correctly identifying and tracing the borders of the heart in three distinct states: pre-arrest, arrest, and late arrest. Methods An automated ultrasound device (bladder scanner) was placed on the chests of 7 swine, along the left sternal border (4th–8th intercostal spaces). Scanner-generated images were recorded for each space during pre-arrest, arrest, and finally late arrest. 828 images of the LV and LV outflow tract were randomized and 150 (50/state) selected for analysis. Scanner tracings of the heart were then digitally obscured to facilitate tracing by expert reviewers who were blinded to the physiologic state. Reviewer tracings were compared to bladder scanner tracings; with concordance between these images determined via Sørensen–Dice index (SDI). Results When compared to human reviewers, the bladder scanner was able to identify and trace the borders during cardiac arrest. The bladder scanner performed best at the time of arrest (SDI 0.900 ± 0.059). As resuscitation efforts continued and time from initial arrest increased, the scanner’s performance decreased dramatically (SDI 0.597 ± 0.241 in late arrest). Conclusion An automated ultrasound device (bladder scanner) reliably traced porcine hearts during cardiac arrest. It is possible a device could be developed to indicate where compressions should be performed without requiring the operator to interpret ultrasound images. Further investigation into rapid, automated, sonographic localization of the heart to identify the area of compression in out-of-hospital cardiac arrest is warranted.

Spectral Doppler Tracing of Locomotor Brachii sign in Severe Aortic Insufficiency

A 37-year-old gentleman with no significant past medical history presented to the emergency department with a two-week history of progressively worsening shortness of breath. Vital signs were stable on arrival and initial physical exam was remarkable for a high pitched early diastolic decrescendo murmur at the left lower sternal border. Further physical examination revealed bounding carotid pulses (consistent with Corrigan’s sign), and a systolic contraction and diastolic dilation of pupil (consistent with Landolfi’s sign). Brachial artery was noted to be tortuous and prominently pulsatile with a bruit audible on auscultation, consistent with locomotor brachii (panel A). Upon further evaluation using point of care ultrasound, diastolic flow reversal and double bruit (both systolic and diastolic) on compression, were noted on spectral Doppler tracing (panel B). Transthoracic echocardiography showed bicuspid aortic valve with flail leaflet and severe eccentric aortic insufficiency; thereby confirming the diagnosis of aortic regurgitation. The patient eventually underwent a surgical aortic valve replacement with mechanical valve.

Pulsation of catheter during coronary angiography: Is it a sign of severe aortic regurgitation?

A 48-year-old male patient was admitted to our outpatient clinic with complaints of shortness of breath. He also had a holo-diastolic murmur at the right sternal border and an apical impulse being displaced laterally and inferiorly. Transthoracic echocardiography showed a severe aortic regurgitation without aortic valve stenosis and a mildly dilated left ventricle accompanied by an ejection fraction of 55%. The aortic regurgitation jet was eccentric and there were significant holodiastolic flow reversals in the descending thoracic aorta. Surgical management was advised for this patient because of symptomatic severe aortic regurgitation. Then, the patient underwent preoperative coronary angiography through the right femoral artery route. The left coronary ostium could be engaged with a 6 Fr Judkins left diagnostic catheter; however, the catheter jumped through the ascending aorta. Afterwards, the catheter was engaged and again jumped through the ascending aorta. Engagement and jumping cycles observed between successive systole to diastole. In our opinion, this catheter movement is explained by wide pulse pressure, like the severe characteristic physical findings of severe aortic regurgitation. Further studies are needed to understand whether this catheter movement is angiographically evidence of severe aortic regurgitation.

A case report showing unusual atrial communication with severe regurgitation of multiple valves and pulmonary aneurysm: double atrial septum with persistent interatrial space

Background We discuss an unusual association: double atrial septum, pulmonary artery aneurysm, and severe regurgitation of multiple valves. Case summary A 70-year-old man was admitted into the hospital because of progressive dyspnoea. Physical examination showed a blood pressure of 132/70 mmHg, a systolic murmur on the right upper sternal border, another systolic murmur at the apex, and a diastolic murmur at the lower left sternal border. Electrocardiogram revealed atrial fibrillation and complete left bundle branch block. Transthoracic echocardiography showed mitral prolapse, severe mitral, aortic, and pulmonary regurgitation, a 60 mm diameter pulmonary artery aneurysm, mild to moderate tricuspid regurgitation, and moderate pulmonary hypertension. Transoesophageal echocardiography also showed an unusual atrial communication consisting of a double atrial septum with a mid-line chamber between both atria. A cardiac magnetic resonance scan was performed and confirmed echocardiography findings and QP:QS ratio = 1.3. Discussion In our knowledge, this is the first case report with this association. We present the main clinical features of the double atrial septum with persistent interatrial space, its echocardiography anatomy, differential diagnosis, and embryology.

Successful treatment of aortic valve endocarditis caused by Enterococcus casseliflavus: a case report

Background Enterococcus casseliflavus is rarely isolated from human specimens. To the best of our knowledge, there are no reports on its detailed treatment course and prognosis. Here, we present the first known case of E. casseliflavus endocarditis with a detailed treatment course. Case presentation An 86-year-old Japanese woman was transferred to the emergency department with dyspnoea, wheezing, and lumbago. Her medical history included hypertension, chronic kidney disease, idiopathic interstitial pneumonia, and rectal carcinoma. Physical examination revealed expiratory wheezes and a diastolic murmur (Levine 2/6) at the 4th right sternal border. Chest radiography revealed bilateral interstitial opacities and slight cardiac dilatation. Transthoracic echocardiography demonstrated the presence of mobile vegetation with perforation, prolapse, and regurgitation of the aortic valve. With a suspicion of infective endocarditis, we started administering intravenous ampicillin/sulbactam. Thereafter, blood cultures identified E. casseliflavus through matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The antimicrobial treatment was then switched to ampicillin plus gentamicin. The patient underwent aortic valve replacement on the thirteenth hospital day. She was administered intravenous ampicillin and gentamicin for 6 weeks. The patient was discharged 8 weeks after admission. Conclusions Our case demonstrated that E. casseliflavus could cause infective endocarditis, which can be successfully treated with a 6-week regimen of ampicillin and gentamicin in combination with proper surgical treatment.

Atypical presentation of right-sided native valve infective endocarditis

A previously healthy 55-year-old man presented to hospital with 10 days of progressive dyspnea with fever, night sweats, and a productive cough and no history of recreational drug use or occupational or animal exposures. His wife had developed similar symptoms 2 weeks earlier but had since recovered. Physical exam revealed a new systolic murmur best heard at the left lower sternal border. Transesophageal echocardiogram demonstrated severe tricuspid regurgitation with a small vegetation. Blood cultures were positive for non-typeable Haemophilus influenzae. This case illustrates the necessity of both timely and proficient diagnosis of H. influenzae infection and the unique challenges associated with detecting H. influenzae–related pathology. Clinicians should be aware of the variable presentations of Haemophilus infection, including respiratory infection, neurological infection, and infective endocarditis. Given the fastidious nature of H. influenzae and variability between subtype pathogenicity, microbiology laboratories require tools to culture and differentiate Haemophilus species.

Missed case of fever of unknown origin during COVID-19 pandemic: patent ductus arteriosus endarteritis

A 40-year-old woman presented with fever of unknown origin (FUO) for 2 months. Without a definitive diagnosis and having received multiple empirical antibiotics from outside without relief, she was referred to our centre. Cardiac auscultation was remarkable for a grade 3/6 continuous murmur in the upper left sternal border. Echocardiogram revealed a patent ductus arteriosus (PDA) and a 5×7 mm mobile vegetation at the pulmonary artery bifurcation. Blood culture grew Streptococcus mutans. Embolisation of the vegetation to the pulmonary circulation occurred after the start of intravenous antibiotics resulting in fever relapse. Antibiotics were continued for 6 weeks and the fever settled. She underwent device closure of PDA after 12 weeks and is currently doing fine. Infective endocarditis/endarteritis is an important differential in a patient of FUO. A thorough clinical examination is important in every case of FUO, gives an important lead into diagnosis and guides appropriate investigations to confirm it.

Pulmonary Hypertension and Hypocholesterolemia Secondary to Thyrotoxicosis

Background. Thyroid disorders commonly affect the cardiovascular system. Thyrotoxicosis leading to pulmonary hypertension has been increasingly reported during recent years. Thyroid dysfunction affects the lipid metabolism, and thyrotoxicosis can be associated with low lipid levels. Thyrotoxicosis presenting with right ventricular dysfunction is rare, and only few cases had been reported. Case Presentation. A 53-year-old woman presented with progressive shortness of breath and swelling of body for four months. Examination showed generalized oedema and a systolic murmur over the left sternal border. Transthoracic echocardiography confirmed pulmonary hypertension with tricuspid regurgitation. Investigations revealed thyrotoxicosis and very low cholesterol levels. Diagnosis of Graves’ disease was confirmed with detection of thyrotropin receptor antibodies. Pulmonary pressure was normalized six months after antithyroid therapy. Conclusion. Thyrotoxicosis is a recognized cause of reversible pulmonary hypertension and acquired hypocholesterolemia. However, most clinicians are not aware of these associations. This case illustrates the importance of assessing thyroid function in patients presenting with pulmonary hypertension.

Comparison of the second and third intercostal spaces regarding the use of internal mammary vessels as recipient vessels in DIEP flap breast reconstruction: An anatomical and clinical study

Background The purpose of this study was to compare the anatomical features of the internal mammary vessels (IMVs) at the second and third intercostal spaces (ICSs) with regard to their use as recipient vessels in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction.Methods A total of 38 consecutive DIEP breast reconstructions in 36 patients were performed using IMVs as recipient vessels between March 2017 and August 2018. The intraoperative findings and postoperative complications were analyzed. Anatomical analyses were performed using intraoperative measurements and computed tomography (CT) angiographic images.Results CT angiographic analysis revealed the mean diameter of the deep inferior epigastric artery to be 2.42±0.27 mm, while that of the deep inferior epigastric vein was 2.91±0.30 mm. A larger mean vessel diameter was observed at the second than at the third ICS for both the internal mammary artery (2.26±0.32 mm vs. 1.99±0.33 mm, respectively; P=0.001) and the internal mammary vein (IMv) (2.52±0.46 mm vs. 2.05±0.42 mm, respectively; P<0.001). Similarly, the second ICS was wider than the third (18.08±3.72 mm vs. 12.32±2.96 mm, respectively; P<0.001) and the distance from the medial sternal border to the medial IMv was greater (9.49±2.28 mm vs. 7.18±2.13 mm, respectively; P<0.001). Bifurcations of the IMv were found in 18.4% of cases at the second ICS and in 63.2% of cases at the third ICS.Conclusions The IMVs at the second ICS had more favorable anatomic features for use as recipient vessels in DIEP flap breast reconstruction than those at the third ICS.

Traumatic pneumothorax mapping using computed tomography to assess optimal area to scan with POCUS

ABSTRACTIntroductionIt is traditionally taught that the location to place an ultrasound probe to detect a pneumothorax with point-of-care ultrasound (POCUS) is the anterior chest, given the theory that air will collect at the least dependent area in the supine patient. There is a wide variety of scanning protocols with varying accuracy and completeness. We sought to assess the optimal area to scan for diagnosing pneumothorax by mapping the location of traumatic pneumothorax on computed tomography (CT).MethodsPatients were selected after a retrospective cohort of adult patients who presented to a regional trauma center with a pneumothorax diagnosed on CT. Data were extracted using a standardized data collection tool, and 20% of charts were reviewed by two reviewers. Predefined zones were used to map the areas of pneumothoraces. Theoretical sensitivity and 95% confidence intervals (CIs) are reported.ResultsA total of 203 traumatic pneumothoraces were reviewed from 2006 to 2016. The majority of the pneumothoraces were found in an area defined by the para-sternal border and the mid-clavicular line from the inferior aspect of the clavicle to the physiologic lung point (liver on the right, heart on the left). The theoretical sensitivity for pneumothorax of scanning this area was 91.6% (95% CI, 86.9–95%).ConclusionThis study suggests any POCUS scanning protocol for traumatic pneumothorax should include an area from the inferior border of the clavicle at the parasternal border down to the liver or cardiac lung points and then the mid clavicular line down to the liver or cardiac lung points.