PMC10077804_01
(a-d). (a and b) Echocardiographic image (four-chamber apical view of TTE) (a) during ventricular end systole and (b) during the ventricular proto-systole. TTE revealed a dilated right atrium and ventricle, an apparent hypokinetic mid-right ventricular free wall with a hypercontractile right ventricular apex (McConnell's signs, no dynamic image available), a hyperkinetic left ventricular myocardium, and a remarkable extremely high ejection left ventricle fraction. Right/left ventricular area ratio >> 0.7. The lack of motion of the right ventricle lateral free wall is remarkable compared to the right ventricular apex when comparing (a) and (b). (c and d) Computed tomographic pulmonary angiography confirming the diagnosis. (c) Axial image and (d) coronal image at the level of the pulmonary arteries, showing extensive phenomena of bilateral pulmonary embolism. The presence of a discrete pleural effusion bilaterally
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F1
Herein, a transthoracic echocardiographic image (four-chamber view) [Figure 1a and b] from a hip fracture surgery patient aged >90 years old is presented, without significant previous medical history. At the bedside, a point-of-care transthoracic echocardiography (TTE) (Acuson P300, Siemens, Germany) was undertaken by an anesthesiologist, revealing signs of massive pulmonary thromboembolism: inferior vena cava dilation/flattening, right cardiac chamber dilation, and McConnell signs (right ventricular apex hyperkinesia and lateral wall hypokinesia); the ventricular septal wall was shifting to the left side, and the left ventricular chamber collapsed at the end systole, indicating a high ejection fraction in the context of obstructive shock [Figure 1a and b]. The transthoracic echographic signs of thromboembolism were life-saving in this patient (the computed tomographic pulmonary angiography confirming the diagnosis [Figure 1c and d] was only performed after patient stabilization in the intensive care unit) as 5000 units of non-fractioned heparin (NFH) (BBraun, Germany) bolus IV and (off-label) alteptase (Actilyse, Boehringer Ingelheim Intenation GmbH, Germany) 100 mg IV were immediately initiated.