THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[15-08-2025 12.50] PPM 1: An independence day gift from our CBBLE team working onsite offline on a holiday! @PPM3👇
Microbubbles are commonly observed in patients with mechanical mitral prostheses but are rare in those with tissue valve prostheses. Two main mechanisms, cavitation and degassing, are thought to underlie their formation. Cavitation occurs during valve closure due to high transient pressure drops, generating bubbles that collapse quickly. Degassing, linked to CO 2 release, produces longer-lasting bubbles. Microbubbles can be visualized using two-dimensional, transoesophageal echocardiography, and advanced three-dimensional echocardiography, which can help pinpoint their origin, often from the valve closure interface. These bubbles are typically benign and do not indicate valve dysfunction but may lead to misdiagnosis as thrombus or vegetation.
[15-08-2025 13:56] PPM 5: Yes sir
We do see microbubbles in post mechanical prosthetic valve patients. They are more common in mitral prosthetic valve than aortic
High pressure gradient and closure force in mitral valve - as aortic valve closes during ventricular diastole when the gradients across are lower and mitral valve closes during systole when there are high gradients
The mitral valve orifice is larger and has slower blood flow velocities compared to the aortic valve.
Slower flow through the mitral position might predispose to bubble formation due to longer residence time of blood in low-pressure zones during closure.
[15-08-2025 13:57] PPM 5: So yes we do see these microbubbles in prosthetic valve patients. More often in mitral mechanical prosthesis
[15-08-2025 14:02] PM 5: Some other interesting features on how to differentiate a mechanical and bioprothesis valves on echo are the acoustic shadowing and reverberations which are seen in mechanical prosthesis
[15-08-2025 14:05] PPM 5: And also the prosthetic valve clicks on Doppler seen in mechanical valves.
[17-08-2025 09:59] PPM 1: Was just seeing this: https://youtu.be/wobauWEIEWU?feature=shared
[17-08-2025 09:59] PPM 7: It’s good 👌
[18-08-2025 14.23] PPM 4: Based on the discussion in the NKP CBBLE group regarding microbubbles in prosthetic heart valves, here's a concise synthesis of key insights and clinical implications:
### Key Points from the Discussion:
1. *Microbubble Phenomenon*:
- Primarily observed in *mechanical mitral valves* (rare in tissue valves).
- *Mechanisms*:
- Cavitation: Transient pressure drops during valve closure create short-lived bubbles.
- Degassing: CO₂ release forms longer-lasting bubbles.
- More common in mitral vs. aortic prostheses due to:
- Higher pressure gradients during systole (mitral closure).
- Larger orifice size and slower flow velocity, increasing bubble residence time.
2. *Echocardiographic Features*:
- *Detection: Best visualized via **transoesophageal echocardiography (TEE)*, especially with 3D imaging to pinpoint origin (e.g., valve closure interface).
- *Differentiation from Pathology*:
- Benign microbubbles vs. thrombus/vegetation: Microbubbles are typically transient, lack associated valve dysfunction, and don't cause clinical symptoms.
- Mechanical valves also show *acoustic shadowing, **reverberations, and characteristic **Doppler clicks* (absent in bioprostheses).
3. *Clinical Significance*:
- *Misdiagnosis Risk*: Microbubbles may mimic thrombus or infection, potentially leading to unnecessary interventions (e.g., anticoagulation escalation or reoperation).
- *Reassurance*: When classic microbubble features are present (e.g., brief appearance post-closure, no flow obstruction), they can be considered normal.
### Supporting Evidence:
- The shared [ResearchGate article](https://www.researchgate.net/publication/393061154_Illuminating_spontaneous_microbubbles_in_prosthetic_heart_valves_with_echocardiography_A_case_report_and_literature_review) corroborates these mechanisms and emphasizes cavitation/degassing as key drivers.
- The YouTube video likely demonstrates real-time microbubble dynamics in a prosthetic mitral valve (unreviewed due to link constraints).
### Recommendations:
- *For Imaging Specialists*: Use advanced TEE/3D echo to trace bubble origin and rule out pathology.
- *Clinical Workup*: If microbubbles are seen:
- Assess valve function (gradients, regurgitation).
- Correlate with symptoms—isolated microbubbles require no action.
- Differentiate from abnormal findings (e.g., thrombus shows persistent mass, abnormal motion).
- *Education*: Include microbubbles in echo training to avoid overdiagnosis.
This aligns with literature (e.g., [Khand et al.](https://www.researchgate.net/publication/393061154)) and reinforces that microbubbles are usually incidental. Kudos to the NKP team for the illustrative case! 🩺✨
(Note: YouTube video not accessed; summary based on text descriptions.)
[19-08-2025 21:07] PPM 1: @PPM6 do share your telephonic history and insights around this patient
[19-08-2025 22:44] Rakesh Biswas Sir: EMR summary
Age/Gender: 40 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 14/08/2025 04:07 PM
Name of Treating Faculty
(AP)
Diagnosis
K/C/O CRHD S/P MVR 6 YEARS AGO
Case History and Clinical Findings
CHIEF COMPLAINTS: BREATHLESSNESS SINCE 4 DAYS
HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS
AGO THEN HE DEVELOPED BREATHLESSNESS INSIDIOUS IN ONSET, GRADE 2 MMRC,
ASSOCIATED WITH COUGH WITH WHITISH MUCOID SPUTUM, NON FOUL SMELLING, NON
BLOOD TINGED, THESE COMPLAINTS AGGREVATED ON EATING SPICY FOOD AND
CONSUMPTION OF ALCOHOL.
PAST HISTORY: K/C/O CRHD S/P MVR 6 YEARS AGO ON TAB ACITROM 2MG AND 3MG
ALTERNATE DAYS
N/K/C/O CVA, CAD, EPILEPSY, HTN, DM, THYROID DISORDERS, TB.
PERSONAL HISTORY: MARRIED, FARMER BY OCCUPATION, LOST APPETITE, MIXED DIET,
REGULAR BOWEL AND BLADDER MOVEMENTS, ADEQUATE SLEEP, NO KNOWN ALLERGIES,
CONSUMES ALCOHOL OCCASIONALLY, OCCASIONALLY SMOKER STOPPED 6 YRS BACK
GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, GENERALIZED LYMPHADEONPATHY OR
PEDAL EDEMA
TEMP-98.4, PR- 76BPM, RR-24CPM, BP-120/80MMHG, SPO2-98%, GRBS- 120MG% JVP-NOT
RAISED
SYSTEMIC EXAMINATION:
P/A, CNS- NORMAL
CVS- S1, S2 HEARD, NO MURMURS, METALLIC CLICK HEARD
RS- BAE PRESENT, DIFFUSE RHONCHI PRESENT
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KIMS HOSPITALS
COURSE IN HOSPITAL:
A 40 YEAR OLD PATIENT K/C/O CRHD S/P MVR PRESENTED WITH THE COMPLAINTS OF
COUGH AND SOB SINCE 5 DAYS. ON FURTHER HISTORY AND EXAMINATIONS DIAGNOSED
AS ACID PEPTIC DISEASE. INVESTIGATIONS REVELIED COAGULATION PROFILE WAS IN
SUBTHERAPUTIC RANGE, CARDIOLOGY OPINION WAS TAKEN AND TITRATED DOSES OF
ANTICOAGULANTS ACCORDINGLY. PATIENT WAS MANAGED WITH OTHER SUPPORTIVE
TREATMENT AS PATIENT VITALS WERE STABLE PATIENT IN BEING DISCHARGED IN
HAEMODYNAMICALLY STABLE CONDITION
Investigation
SEROLOGY-(HIV,HCV.HBSAG)-NEGATIVE
CBP:HB-16.5,PCV-43.4,TLC-7600, RBC-5.51,PLATELET-2.64
RBS-110MG%
RFT: UREA-26, S. CREATININE-1.3, S. SODIUM-135 ,S. POTTASIUM-3.6, S. CHLORIDE-98
LFT: TOTAL BILIRUBIN-O.71 ,DIRECT BILIRUBIN-0.16 ,SGPT-29, SGOT-20, ALK. PHOSPHATE-
175, TOTAL PROTEINS-7.1, ALBUMIN-4.4, A/G RATIO-1.60
PT-16 ,INR-1.11, APTT-31
15/8/25 - PT-18, INR -1.3, APTT-3.5
16/8/25-PT- INR- APTTCHEST
X RAY SHOWED HYPERINFLATED LUNGS
ECG -NORMAL SINUS RHYTHM, RSr' in v1, v2
2D ECHO DONE ON 16/8/25:
MITRAL VALVE- POST MVR (PROSTHETIC VALVE INSITU), AORTIC VALVE-SCLEROTIC
TRICUSPID VALVE, PULMONARY VALVE, RIGHT ATRIUM, RIGHT VENTRICLE- NORMAL
LEFT ATRIUM-3.2cm LEFT VENTRICLE- NO RWMA
EF-62% IVC- 0.9cm COLLAPSING
MITRAL VALVCE -VMAX:1.18m/s ,PPG:5.53 mmHg ,MPG-2.47 mmHg
AORTIC FLOW-1.42 ,PULMONARY FLOW-0.9 ,TRICUSPID FLOW: RVSP-35mmHg
MILD MR+, TRIVIAL TR NO PAH NO AR/NO PR NO RWMA, NO AS/MS
GOOD LV SYSTOLIC FUNCTION ,NO PE, NO LV CLOT
Treatment Given(Enter only Generic Name)
INJ CLEXANE 60 MG SC/BD GIVEN FOR 2 DAYS
TAB. ACITROM 3MG PO/OD
TAB. ECOSPRIN AV 75/10 PO/HS
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KIMS HOSPITALS
TAB. PAN 40mg PO/OD
TAB. NEUROBION FORTE PO/OD
SYP. SUCRAL O GEL 10ml PO/TID
Advice at Discharge
INJ CLEXANE 60MG SC/BD FOR 1 DAY
TAB. ACITROM 3MG PO/OD TO BE CONTINUED
TAB. PAN 40mg PO/OD FOR 5 DAYS
TAB. ECOSPRIN AV 75/10 PO/HS TO BE CONTINUED
TAB PULMOCLEAR PO/BD FOR 5 DAYS
TAB. NEUROBION FORTE PO/OD FOR 15 DAYS
SYP. SUCRAL O GEL 10ml PO/TID FOR 3 DAYS [20MINS BEFORE FOOD ]
Follow Up
REVIEW AT CARDIOLOGY OPD
REVIEW TO GM OPD AFTER 1 WEEK/SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:16/08/2025
Ward: AMC
Unit: IV
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