Worm in My Heart

Physical examination revealed a heart rate of 110 beats/min, respiratory rate of 24 breaths/min, hypoxemia with oxygen saturation of 86% on room air, and bilateral expiratory wheezing with a prolonged expiratory phase. Commonly used metrics of RV function include RV size, RV to left ventricle (LV) end-diastolic area ratio, tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, RV fractional area change; and the LV eccentricity index. Additional findings in our patient included RV dilatation (basal RV diameter of 4.8 cm and mid RV diameter of 3.9 cm on the apical four-chamber view; Figure 1); a McConnell sign (Video 3); D-shaped LV in systole in the parasternal short-axis view, consistent with RV pressure overload (Figure 2); RA enlargement and bowing of the interatrial septum toward the LA due to higher RA pressure (Figure 3); moderate tricuspid regurgitation with an estimated right ventricular systolic pressure of 40 to 50 mm Hg (Figure 4); reduced tricuspid annular plane systolic excursion (14 mm); reduced tricuspid annular peak systolic velocity (8 cm/s; Figure 5); reduced RV fractional area change (26.9%); and inferior vena cava dilation with lack of inspiratory collapse (Figure 6). Follow-Up Computed tomography pulmonary angiogram (Figure 7) revealed acute pulmonary emboli in the right and left main pulmonary arteries extending to the lobar arteries, and bilateral lower extremity runoff angiography showed acute right femoral and popliteal deep venous thrombosis.