Herceptin (Trastuzumab) is a widely used and effective drug for the treatment of Her2+ breast cancer but its cardiotoxic side effects require regular monitoring by echocardiography. A 10% reduction in left ventricular ejection fraction can lead to suspension of treatment and therefore has significant implications for patient prognosis in terms of cardiac and cancer outcomes. Assessment of LV function by conventional 2D biplane method of discs (2DEF) has limitations in accuracy and reproducibility. Global longitudinal strain (GLS) is becoming more widely available and user friendly. It has been shown to demonstrate myocardial damage earlier in treatment than 2DEF, allowing the option of pharmacological intervention at a pre-clinical stage and preventing the interruption of Herceptin. This study compares the reproducibility of GLS with that of 2DEF in a routine clinical environment. Fifty echocardiograms performed on female patients undergoing Herceptin treatment were used to measure both 2DEF and GLS within the recommended standard appointment time of 40 min. The data were re-measured (blind) by the same operator a minimum of 14 days later to determine intra-operator variation. These data were also measured by a second operator (blind), to assess inter-operator variation. Analysis by direct comparison, intra-class correlation (ICC), coefficient of variation (CV) and Bland–Altman plots demonstrated that GLS is a more reproducible measurement than 2DEF. This is important to prevent clinical decisions being erroneously based on variation in operator measurement. The investigation also shows that with advances in machine software this is a practical addition to routine assessment rather than merely a research tool.

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A 41-year-old male with insulin-dependent diabetes mellitus was admitted for an elective arthroscopic release of adhesive capsulitis of his left shoulder. At the end of the surgical procedure, he appeared to regain consciousness but then became unresponsive at the time of tracheal extubation after a violent bout of coughing, developing bilateral up-going plantar responses, decorticate posturing and abnormal pupillary reflexes. He was transferred to the intensive care unit. The following day, the patient made a full neurological recovery. Contrast echocardiography, performed using agitated saline delivered through a femoral venous line, revealed a large patent foramen ovale with evidence of right to left shunting. In the absence of risk factors for air embolism, the clinical diagnosis was one of paradoxical embolism of venous thrombus resulting in brain stem ischaemia. The patient was commenced on life-long aspirin to minimise future embolic risk. A patent foramen ovale is necessary in the fetal circulation to sustain intrauterine life. In utero, placental oxygenated blood enters the right atrium via the inferior vena cava and is directed towards the flap valve of the foramen ovale by the eustachian valve, thus enabling blood to enter the systemic circulation. At birth, the decrease in right-sided cardiac pressures and pulmonary vascular resistance reverses the right to left atrial pressure gradient and causes the flap of the foramen ovale to close against the atrial septum. Fusion is normally complete by the age of 2 years. In cases of incomplete fusion, the foramen ovale is kept sealed by the left atrial to right atrial pressure gradient but may be pushed open if right atrial pressure increases and exceeds that of the left atrium [1,2]. A patent foramen ovale is thus a potential route for emboli arising from the venous system to enter the systemic arterial circulation, resulting in the syndrome of 'paradoxical embolism'. We describe the case of a patient who experienced a paradoxical embolism induced by coughing during tracheal extubation. Case ReportA 41-year-old male with known microvascular complications secondary to insulin-dependent diabetes mellitus was admitted for an elective arthroscopic release of adhesive capsulitis of his left shoulder that had failed to respond to extensive physiotherapy. His past medical history included treated hypertension, micro-albuminuria, bilateral proliferative diabetic retinopathy and left exudative maculopathy with previous extensive panretinal photocoagulation. He had dyslipidaemia, drank alcohol occasionally and was a life-long non-smoker. Overall glycaemic control was good, but he had had several hospital admissions with symptomatic hypoglycaemia. Current medication included insulin, ramipril and over-the-counter analgesics.Six months previously, he had successfully undergone an elective arthroscopic release of his right shoulder with an excellent functional result. On this occasion, the general anaesthetic technique included fentanyl, propofol, atracurium and morphine...

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