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“Ripples in Water” Effect Detected by Ultrasound During Internal Jugular Catheterization

  • Don J Palamattam
    Correspondence
    Address correspondence to Don Jose Palamattam, MD, DM, Department of Cardiothoracic and Vascular Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum Kerala-695011, India.
    Affiliations
    Department of Cardiothoracic and Vascular Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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      To the Editor:
      Herein, I describe an interesting “ripples in water” effect in the right internal jugular vein using ultrasound guidance before its catheterization. A 54-year-old male with severe mitral stenosis, tricuspid regurgitation, pulmonary artery hypertension, and atrial fibrillation, was scheduled for mitral valve replacement. After the induction of anesthesia, the patient was positioned and prepared for a right internal jugular vein catheterization under ultrasound guidance. An ultrasound assessment revealed stasis of blood in the vessel and a “ripples in water” effect in a cross-sectional view (Fig 1; Video 1). Interrogation in a longitudinal view revealed the presence of a valve with thrombus, located more caudad (Fig 2; Video 2). This valve appeared to be fluttering because of the backward flow of blood into the vein from the right atrium due to elevation of the right ventricle end-diastolic pressure and a severe tricuspid regurgitant jet.
      • Marcus JT
      • Westerhof BE
      • Groeneveldt JA
      • et al.
      Vena cava backflow and right ventricular stiffness in pulmonary arterial hypertension.
      Fig 1
      Fig 1Ultrasound in a cross-sectional view showing venous stasis in the right internal jugular vein. CA, carotid artery; IJV, internal jugular vein.
      Fig 2
      Fig 2Ultrasound in a longitudinal view showing a valve with thrombus (*) in the right internal jugular vein. IJV, internal jugular vein.

      Conflict of Interest

      None.

      Appendix. Supplementary materials

      Reference

        • Marcus JT
        • Westerhof BE
        • Groeneveldt JA
        • et al.
        Vena cava backflow and right ventricular stiffness in pulmonary arterial hypertension.
        Eur Respir J. 2019; 541900625