Right Ventricular Dysfunction

45-year-old male presented to the ED with sudden onset shortness of breath. His medical history was notable for a gastric sleeve procedure performed less than two weeks prior. On arrival, he was hypoxic with oxygen saturations in the 80s on room air, and his oxygen requirements progressively increased over a 10-minute period while IV access was obtained. Bedside cardiac ultrasound revealed a large, mobile, serpiginous clot in transit within the right atrium and right ventricle (RV). The thrombus was not adherent to the chamber walls and was visualized in both the RV inflow and long axis views. A parasternal short axis view demonstrated a positive D-sign, consistent with right ventricular overload and strain, further supporting the diagnosis of massive pulmonary embolism. Immediately following completion of the ultrasound, the patient experienced a PEA arrest. Tenecteplase was administered during resuscitation, resulting in return of spontaneous circulation.

Contributed by Dr. Thomas O'Mara, DO; Dr. Irving Chung, DO; Dr. Nicole Yuzuk, DO

St. Joseph’s University Medical Center, Paterson, NJ

45-year-old male presented to the ED with sudden onset shortness of breath. His medical history was notable for a gastric sleeve procedure performed less than two weeks prior. On arrival, he was hypoxic with oxygen saturations in the 80s on room air, and his oxygen requirements progressively increased over a 10-minute period while IV access was obtained. Bedside cardiac ultrasound revealed a large, mobile, serpiginous clot in transit within the right atrium and right ventricle (RV). The thrombus was not adherent to the chamber walls and was visualized in both the RV inflow and long axis views. A parasternal short axis view demonstrated a positive D-sign, consistent with right ventricular overload and strain, further supporting the diagnosis of massive pulmonary embolism. Immediately following completion of the ultrasound, the patient experienced a PEA arrest. Tenecteplase was administered during resuscitation, resulting in return of spontaneous circulation.

Contributed by Dr. Thomas O'Mara, DO; Dr. Irving Chung, DO; Dr. Nicole Yuzuk, DO

St. Joseph’s University Medical Center, Paterson, NJ

A 74-year-old male patient with Chronic Obstructive Pulmonary Disease (COPD) (not on home oxygen) presented to the ED with acute worsening dyspnea with persistent hypoxia despite supplemental oxygen, tachypnea, and increased work of breathing. There was no infectious or environmental exposure to explain the patient’s presentation. The patient’s differential diagnosis included acute pulmonary embolism (PE) and COPD exacerbation/progression. Parasternal long-axis (PSLA) and short-axis (PSSA) views showed RV dilatation with RV strain. The RV strain was demonstrated by flattening of the interventricular septum, creating a D-shaped LV during systole (D-sign). Also, it shows hyperdynamic LV from tachycardia with near obliteration of the LV cavity in systole. CT angiography scan showed no evidence of PE. The patient was admitted and diagnosed with a progression of severe COPD with pulmonary hypertension and right ventricular remodeling.

Contributed by: Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, @HassanAlshaqaq

A 70-year-old patient with Chronic Obstructive Pulmonary Disease (COPD) (not on home oxygen) presented to the ED with acute worsening dyspnea with persistent hypoxia despite supplemental oxygen, tachypnea, and increased work of breathing. There was no infectious or environmental exposure to explain the patient’s presentation. The patient’s differential diagnosis included acute pulmonary embolism (PE) and COPD exacerbation/progression. Parasternal long-axis (PSLA) and short-axis (PSSA) views showed RV dilatation with RV strain. The RV strain was demonstrated by flattening of the interventricular septum,. Also, it shows hyperdynamic LV from tachycardia with near obliteration of the LV cavity in systole. CT angiography scan showed no evidence of PE. The patient was admitted and diagnosed with a progression of severe COPD with pulmonary hypertension and right ventricular remodeling.

Contributed by: Hassan Alshaqaq, MBBS, Emergency Medicine Resident at King Saud University Medical City, @HassanAlshaqaq

100 year old patient presented with dyspnea. CXR showed "atelectasis vs. pneumonia." No leukocytosis or fever seen. She began to have episodes of hypotension. Before giving fluids, an echo was performed......

She had chronic RV failure with an acute exacerbation. Notice severe RV enlargement seen in this PSLA view.

John Bowling, DO, Cleveland Clinic Akron General, @BModeBowling

An elderly female presented with 3 days of shortness of breath. PSLA view identified severe RV dilation on bedside ultrasound prior to CT confirming saddle PE.

Contributed by: Max Goder-Reiser, MD

Parasternal short axis view with interventricular flattening showing a ‘D-sign’ consistent with right heart strain in this patient with an acute pulmonary embolism

Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate)

An elderly female presented with 3 days of shortness of breath. Apical 4 chamber view identified clot in transit, severe RV dilation, and McConnell’s sign on bedside ultrasound prior to CT confirming saddle PE

Contributed by: Max Goder-Reiser, MD

Right ventricular enlargement in parasternal long view. Using the normal 1:1:1 ratio of LV:LVOT:RV you can see that RV in this clip is larger than the LV and LVOT.

Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate)

Clip showing McConnell Sign and right side heart enlargement consistent with acute RV strain. While this can be seen in acute pulmonary embolism, it can also be seen in other conditions that cause acute RV dysfunction such as MI or pHTN.

Dimitri Livshits DO, Ultrasound Fellow; Jane Belyavskaya MD, Ultrasound Fellow; Chris Hanuscin MD, Ultrasound Division Director (Kings County/SUNY Downstate)

An elderly patient presented with shortness of breath and generalized weakness found to have an NSTEMI and high degree AV block. Bedside focused cardiac ultrasound with 4 chamber apical view revealed: McConnell’s Sign.

Chest CTA neg for PE. Patient underwent cardiac catherization with culprit lesion being mid RCA.

Not all McConnell’s sign is related to acute PE. In this case RV infarct secondary to NSTEMI with mid RCA occlusion s/p DES PCI with complete resolution of AV block.

Dat Lu MD, Internal Medicine Clerkship Site Director Kaiser Roseville

RV dilation violating the rule of thirds. McConnell’s sign is also demonstrated in this view with RV apical hyperkinesis and lateral wall hypo/akinesis. Patient was found to have a submassive pulmonary embolism.

Moudi Hubeishy

@hubeishy_MD

An 50-year-old presented with shortness of breath and suffered witnessed PEA arrest subsequent to having obtained this POCUS image (subcostal view) notable for a hyperechoic, mobile structure within the RA). ACLS was administered in addition to TPA and ROSC was achieved. Subsequent formal ultrasound, following thrombolytic administration, revealed absence of thrombus.

Ryan Shelby PGY-3 EM Resident; @RyanShelby18
Central Michigan University

PSSX View. Septal Flattening is being demonstrated (D-sign) at the level of the papillary muscles and chordae tendinae visible in both the left ventricle and right ventricle. The right ventricle is demonstrating significant dilation in the setting of increased pressures secondary to a saddle embolus.

Moudi Hubeishy
@moudihubeishy

A female in her mid-30’s presented to the ED with chest pain and shortness of breath. POCUS at the apical window revealed right ventricular free wall akinesis with sparing of the apex, indicative of McConnell’s sign of a pulmonary embolism. A clot can also be seen within the right atrium.

Image courtesy of Robert Jones DO, FACEP @RJonesSonoEM

Director, Emergency Ultrasound; MetroHealth Medical Center; Professor, Case Western Reserve Medical School, Cleveland, OH

View his original post here

Shown here is an image acquired while performing a RUSH exam on a 40-year-old female who presented in shock. HPI notable for SOB and worsening abdominal distention x5 days; PMH of decompensated etoh cirrhosis. Vitals included BP 80/40; HR 110; RR 30; O2 sat 90% RA.

Seen here is the image obtained while performing subcostal sweep from base to apex. It is most notable for a dilated, hypokinetic RV with paradoxical septal motion and an underfilled, hyperdynamic LV. There is also intraperitoneal free fluid appreciated. Subsequent CT chest confirmed presence of large, bilateral pulmonary emboli as etiology of patient’s shock.

David Carroll

A 39-year-old female with known metastatic lung cancer complicated by multiple pulmonary emboli on apixaban presented with worsening dyspnea and productive cough over one week duration. POCUS identified a large circumferential pericardial effusion in multiple cardiac views in addition to signs of RV strain as demonstrated by flattening of her interventricular septum and ventricular interdependence (shown here on parasternal short axis view). The findings of RV strain are likely chronic and secondary to chronic thromboembolic disease complicated by pulmonary hypertension.

Shahad Al Chalaby, MD. PGY3 Internal Medicine.Highland Hospital. Alameda Health System Residency Program. Oakland, CA, USA. @shahad_Chalaby

Adam Mortimer, DO. PGY1 Internal Medicine. Highland Hospital. Alameda Health System Residency Program. Oakland, CA USA.

A 56-year-old female with history of metastatic breast cancer presented with acute shortness of breath. Physical examination was notable for hypotension, sinus tachycardia, raised JVP, and mild respiratory distress. There was no evidence of lower extremity edema and chest xray was unremarkable.

POCUS showed no B lines on lung views. Cardiac views (seen here) were notable for a hypokinetic and dilated RV with flattening of the interventricular septum creating a D shaped LV during systole. These findings are consistent with high right ventricle and pulmonary artery pressures in the absence of pulmonary artery stenosis. Specifically, a D-shaped LV during diastole reflects RV volume overload; a D-shaped LV during systole reflects RV pressure overload. RV pressure overload can be seen in massive and submassive pulmonary embolism (PE) and this patient was diagnosed with a submassive PE; findings confirmed by CT angiography. In this instance, POCUS enabled prompt diagnosis and early initiation of therapeutic anticoagulation.

Shahad Al Chalaby, MD. Highland Hospital. Alameda Health System Internal Medicine Residency Program. California, USA. shahad_Chalaby
Katherine Farley, OMS4. Touro University. California, USA.

38 yo previously-healthy male 8 days s/p ligamentous repair of the knee, presented with dyspnea and chest pain. Physical exam on room air notable for tachypnea (RR 35), hypoxia (O2 sat 89%), and lungs that were clear to auscultation. POCUS revealed intracardiac thrombus with D-sign and McConnell's Sign. Pt received full-dose anticoagulation prior to CTA-PE confirming the suspected diagnosis of PE. He subsequently underwent successful thrombectomy.

Stacey Frisch, MD
Chief Resident, Emergency Medicine
Kings County Hospital/SUNY Downstate
@emergenStacey

A 70 year old female patient presented with complaints of acute dyspnea. Oxygen saturation was 86% on room-air improved with O2-supplementation. She had poor hemodynamics with SBP ~ 100 mmHg. POCUS showed obvious right heart strain with a D-sign and thrombus intermittently visualized in the right ventricle. Correct therapy (thrombolytics) were given almost straight away after presentation in the ED because POCUS was available. Once stabilized, the patient was taken for a CTA chest which demonstrated a saddle embolism.

Dr. Van Roosmalen

An elderly female presented with complete AV heart block. Apical 4-chamber view was performed and was notable for regional RV dysfunction (aka McConnell’s Sign). Though this finding is commonly associated with acute PE, our patient was found to have right coronary artery occlusion as the etiology of all findings.

Renato Melo, Emergency Physician at HC de Marília-SP, Brazil. PocusJedi co-founder.
@Renato_Melo_

This apical 4-chamber view on M-mode was obtained from a patient with acute pulmonary embolism with right ventricular strain.

We measured tricuspid annular plane systolic excursion (TAPSE) as a validated parameter of global RV function. Specifically, TAPSE describes apex-to-base shortening and correlates closely with right ventricular ejection fraction.

TAPSE is measured on echo by placing a cursor at the tricuspid lateral annulus and measuring the distance to systolic annular RV excursion. Any distance of <17mm is suggestive of RV strain. Our patient’s TAPSE was 11.5mm.

Though there are multiple strategies to assess for right heart strain, TAPSE has the highest interrater reliability and best predicts 30-day mortality.

DaMarcus Ingram (MS4), Drexel University College of Medicine
Arthur Strzepka (MS4, Nova Southeastern University College of Osteopathic Medicine
Dr. Max Cooper, Director of Emergency Ultrasound at Crozer Chester Medical Center

60 year-old smoker presents with dyspnea and chest pain. Apical 4 chamber view is notable for a thrombus within the RV and associated evidence of RV strain including increased RV size and impaired systolic function with sparing of the apex (known as McConnell’s sign).

Renato Tambelli, @R_Tambelli
Emergency Physician Hospital das Clínicas de Marília, Sao Paulo/Brazil

This image is from a patient presenting after a high speed MVC. The patient had a past medical history of atrial fibrillation and was anti-coagulated. On arrival to ED, the patient was agitated, clammy, and noting shortness of breath. The initial eFAST was negative. The patient was intubated with propofol for CT imaging. 15 min post-intubation the patient became hemodynamically unstable and bradycardic followed by cardiac arrest. An apical four chamber view was obtained during pulse check showing dense clot in RV/RA with minimal cardiac activity.

Nishant Cherian

Emergency Medicine Registrar

This clip demonstrates severe right ventricular enlargement seen on a parasternal long axis view. The patient had developed cor pulmonale from longstanding COPD.

Pooja Belligund

[SonoClipShare Submission]: PLA demonstrating a small LV, an enlarged RV, and a hyperechoic lesion moving back and forth (later views confirming moving between RA and RV). 1st of 4 views to be submitted on the same case. This was an unfortunate 40ish y/o 6 months s/p CVA 2/2 ruptured aneurysm and IDDM presenting with 4 days of "feeling weak". Found to have a HR of 120 to 130, a BP around 90-100/60-70 and pulse ox of 90 - 92%. POCUS lungs were normal. Started on heparin, CTA confirmed PE and went to IR for catheter-directed tPA lysis with normalization of BP, HR and good clinical outcome.

Image courtesy of John Hipskind MD

88 y/o F presenting with chest pain and syncope. Shortly after arrival patient went into brief period of cardiac arrest with ROSC. POCUS shows massive thrombus floating back and forth across the tricuspid valve with a dilated right ventricle, D-sign, and global right heart hypokinesis. Patient was given TPA bolus. Approximately 1 hour after pushing TPA, repeat POCUS with resolution of thrombus on RV, but patient continued RV hypokinesis. Patient vitals stabilized enough for a CTA which showed left main pulmonary artery extending into both left upper lobe and left lower lobe branches with evidence for right heart strain.

Dr. Roderick Alfonso, Maan Al Dubayan, Andrew Sweeny - Kings County Emergency Medicine

88 y/o F presenting with chest pain and syncope. Shortly after arrival patient went into brief period of cardiac arrest with ROSC. POCUS shows massive thrombus floating back and forth across the tricuspid valve with a dilated right ventricle, D-sign, and global right heart hypokinesis. Patient was given TPA bolus. Approximately 1 hour after pushing TPA, repeat POCUS with resolution of thrombus on RV, but patient continued RV hypokinesis. Patient vitals stabilized enough for a CTA which showed left main pulmonary artery extending into both left upper lobe and left lower lobe branches with evidence for right heart strain.

Dr. Roderick Alfonso, Maan Al Dubayan, Andrew Sweeny - Kings County Emergency Medicine

Elderly patient with chest pain, sob, and HR in 120’s. During ER stay became hypotensive with systolic in 80’s. POCUS demonstrated RV enlargement and McConnell’s Sign - systolic akinesia of the RV free wall with preserved functioning of the apex. This is concerning for acute PE. Patient became progressively hypotensive and TPA was pushed.

Dr. Kelly Maurelus, Matthew Riscinti - Kings County Emergency Medicine

Young woman with a history of Idiopathic Pulmonary Arterial Hypertension w/ resultant R heart failure who came in short of breath.

Greg Powell, MD

Young woman with a history of Idiopathic Pulmonary Arterial Hypertension with resultant R heart failure who came in short of breath.

Greg Powell, MD

34 y/o female no PMH with chest pain and rapid onset dyspnea on exertion noticed over 1 day. Patient became increasingly tachycardic and ultimately hypotensive so RUSH exam was performed showing D - Sign. CTA was subsequently performed and found to have saddle emboli. Echo was done pre and post TPA showing partial resolution of the D-sign.

Dr. Joshua Schechter - Kings County Emergency Medicine

Young woman with a history of Idiopathic Pulmonary Arterial Hypertension with resultant R heart failure who came in short of breath.

Greg Powell, MD

Young male from Latin America with findings of right HF.  Focused cardiac ultrasound shows massive RA, moderate pericardial effusion, relatively normal RV and LV. Significant TR ruled out. Findings consistent with Endomyocardial Fibrosis, found in tropical countries. Need cardiac MRI to confirm. Similar to eosinophilic myocardial fibrosis found in temperate climates.

Dr. Gordon Johnson MD
Internist
Portland Oregon & Uganda
SonoPortlandia.com

A patient presenting with acute onset undifferentiated shortness of breath. POCUS was used to narrow the differential. Parasternal short axis demonstrated flattening of the interventricular septum which pushes the left ventricle into the shape of the letter D. Known as the sonographic D-sign, it is correlated with significant right ventricular overload. This sign is not highly sensitive for PE, but can be 80-90% specific when found and associated with other signs of right ventricular strain. Also note on this study: moderate pericardial effusion, right ventricular dilation.

Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy, Kelly Maurelus, Kings County/SUNY Downstate Emergency Medicine

A patient presenting with acute onset undifferentiated shortness of breath. POCUS was used to narrow the differential. Parasternal short axis demonstrated flattening of the interventricular septum which pushes the left ventricle into the shape of the letter D. Known as the sonographic D-sign, it is correlated with significant right ventricular overload. This sign is not highly sensitive for PE, but can be 80-90% specific when found and associated with other signs of right ventricular strain. Also note on this study: moderate pericardial effusion, right ventricular dilation.

Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy - Emergency Medicine Residents
Dr. Kelly Maurelus, Ultrasound Education Director

Kings County/SUNY Downstate Emergency Medicine

This is a parasternal short axis view in a patient with extensive pulmonary emboli on CT angiogram of the chest. The troponin was mildly elevated and patient hemodynamically stable. A bedside echo revealed evidence of RV strain (note the “D” shaped left ventricle). 

Therese Mead, DO

Emergency Physician

Middle age F presented initially to ED after a mechanical fall complaining of hip pain. Patient became tachypnic and altered during ER stay. POCUS done, and RA thrombus was noted with D sign and enlarged R ventricle. 

R heart thrombus (thrombus in transit) is highly mobile differentiating it from a mural thrombus, which forms in situ.  A meta-analysis of 1113 patients from the International Cooperative Pulmonary Embolism Registry showed mortality was 2x as high for pts with right heart thrombus and PE compared to those without right heart thrombus. The difference in mortality was more pronounced in the heparin alone treatment group (vs. lytics or embolectomy).

Another study by Rose et al (2002) showed patients with PE and a right heart thrombus had a mortality of 27%. They found these patients did better when treated more aggressively (i.e. thrombolysis or embolectomy).

Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002;121(3):806-14. (PMID: 11888964)

Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-51. (PMID: 12821255)

Submitted by Bobak Zonnoor, MD

Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. S Fares)

Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al. (Dr. S Fares)

Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.

Significant right ventricular dysfunction with moderate tricuspid regurgitation 

Sukh Singh, MD

34 y/o female no pmh with chest pain and rapid onset dyspnea on exertion noticed over 1 day. Patient became increasingly tachycardic and ultimately hypotensive so RUSH exam was performed showing D - Sign. CTA was subsequently performed and found to have saddle emboli. Echo was done pre and post TPA showing partial resolution of the D-sign.

Dr. Joshua Schechter - Kings County Emergency Medicine

This is a middle-aged male who developed dyspnea suddenly while ambulating. Several weeks prior, he had a laparoscopic procedure with a prolonged post-operative course spanning several weeks in the hospital. He denied chest pain or fever. He was tachypneic with otherwise normal vital signs. Lung sounds were clear, although he had obviously increased work of breathing and appeared diaphoretic. Bedside echocardiography revealed a dilated right ventricle with a positive McConnell sign. There was also a large, lobulated, and mobile hyperechoeic mass within the right atrium suspicious for thrombus. CTA of the chest showed bilateral pulmonary emboli. BNP and troponin were moderately elevated, consistent with submassive pulmonary embolism. 

Andrew Goodrich, MS, DO, PGY-3 
Chief Resident, Central Michigan University Emergency Medicine Residency 

Therese Mead, DO, RDMS, FACEP
Associate Program Director and Ultrasound Director, Central Michigan University Emergency Medicine Residency

A 70 year old female patient with complaints of acute dyspnea. Oxygen saturation 86% with room-air improved with O2-suppletion. Poor hemodynamics with systolic presure around 100 mmHg. POCUS shows obvious right heart strain with apical sparing (McConnel's sign) and trombus drifting around in right atrium and even hitting the right ventricle. Correct therapy (trombolytics) was started almost straight away after presentation at the ED because POCUS was available.

Dr. Van Roosmalen

46 year old man, intraoperative cardiac arrest after massive pulmonary embolism. Apical four chamber view obtained after resuscitation showed McConnell's sign. We found other signs of acute cor pulmonale : the 60/60 sign and RV dilatation.

Dr. Devigne

A 73 year old male presented with several day history of moderate dyspnea as well as right LE discomfort. POCUS identified both a right intracavitary thrombus as well as right femoral phlebitis. He was treated with heparin for both.

Pierre Bernatas, @pb2316
Emergency Physician. Limousin, France.

Elderly female with hypotension and shortness of breath and back pain presenting in extremis. Treated with TPA for a RA thrombus and saddle pulmonary embolism.

Dr. William Scheels

50s M with PMH COPD presented with dyspnea and increasing oxygen requirement. POCUS is shown here, demonstrating significant RV dilation, reduced RV function, and bowing of the septum concerning for pulmonary hypertension. Additional workup ultimately ruled out ACS and DVT/PE, and the patient was admitted for COPD exacerbation, and formal TTE confirmed a new diagnosis of pulmonary hypertension.

Dr. Cailin Frank, Ultrasound Fellow, Denver Health Ultrasound Fellowship

Dr. Anna Engeln, Denver Health Medical Center

30s F with PMH IVDU and prior endocarditis s/p tricuspid valve repair presented with fever, hypotension, and dyspnea. On RUSH evaluation, this cardiac image was acquired, showing significant RV dilation with bowing of the septum into the LV. The prosthetic tricuspid valve is shown here, but without color doppler, evaluation of the valve patency is limited. Formal TTE showed a patent tricuspid valve however with moderate to severe tricuspid regurgitation, likely explaining the severe RV overload.

Dr. Michael Duerson, PGY4

Denver Health Residency in Emergency Medicine