A 46-year-old woman with a past medical history of protein S deficiency and multiple pulmonary emboli was referred for evaluation of worsening dyspnea. An echpcardiogram showed normal left ventricular systolic function with left ventricular ejection fraction greater than 55, right ventricular systolic pressure 38 mmHg, normal valves and diastolic function. A microcavitation study was performed with normal saline injected through the right brachial vein. Bubbles appeared on the left side of the heart within five cardiac cycles with no bubbles appearing on the right side of the heart. Very late appearance of few bubbles in the right side was seen after 13 cardiac cycles (Figure A and B).
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