Acute pulmonary embolus with visible right heart thrombus in transit.

1 of 2 DESCRIPTION A 29-year-old woman presented to our emergency department with syncope, acute chest pain and circulatory collapse. She had a tachycardia of 135 bpm, blood pressure of 77/55 mm Hg and a profound metabolic acidosis (pH 7.07, lactate 10, base excess-20). A 12-lead ECG ( fi gure 1 ) showed sinus tachycardia with right axis deviation, large p waves and poor R wave progression across the chest leads, suggestive of acute right heart strain. A D-dimer was elevated at 15984 μg/l (reference range 0–200 μg/l); a plain anteroposterior chest radiograph was unremarkable. Bedside transthoracic echocardiography showed a dilated, poorly functioning right ventricle with visible thrombus prolapsing across the tricuspid valve as demonstrated in fi gure 2 and video 1 . These fi ndings confi rmed the clinical suspicion of acute massive pulmonary embolus causing circulatory collapse and intravenous thrombolysis was successfully administered. Once haemodynamic stability had been restored, CT pulmonary angiography confi rmed massive bilateral pulmonary emboli. Acute pulmonary embolus with visible right-heart thrombi is a rare phenomenon 1 associated with a poor prognosis. 2 Bedside transthoracic echocardiography is important in the visualisation of the right ventricle in the setting of circulatory collapse and can be used to identify thrombus in-transit. 3