Ultrasound Case of the Month

Case of the month from October, 2016


A 36 year old female with no significant past medical history comes in with sudden onset chest pain. Bedside ultrasound for this patient is below:

This patient had a saddle pulmonary embolism, with right heart strain as evidenced by D sign and McConnell's sign, with a positive troponin!

Image 1:

This is an apical 4-chamber (A4C) view, which is obtained by imaging underneath and lateral to the nipple (in the breast crease for women) and pointing your ultrasound beam like a spear to the patient’s right scapula. You may need to roll the patient onto their left side to bring the heart closer to the chest wall and optimize the image. 

In the A4C you are able to evaluate for equality which is to compare the left and right ventricle.  The RV: LV ratio should be about 0.6:1.  If you don’t want to remember that ratio, no worries! Instead you can just remember that the RV should be equal or slightly smaller in size when compared to the LV and that the apex of the LV is usually higher on the screen than the apex of the RV (left apex dominant).  In this image we see evidence of what we call McConnell’s sign which is when there is RV strain and akinesis of the RV.  However, we often see apical sparing in this scenario.  So the RV apex is still moving, but the lateral wall is hypokinetic or akinetic, from RV strain.

Image 2:

This is a parasternal short view (PSS), which is acquired with the probe placed on the chest wall along the short axis of the heart (marker to the right hip). The LV should look round, like a donut, and the RV has a crescent shape. This image is an example of a “D-sign” which represents septal flattening.  The pressure in the RV is so high that it is exerting pressure on the interventricular septum and causing it to flatten. As a result the LV looks more like a “D” than an “O”.

For more information on right heart strain: 5 Minute Sono

Resident Reviewer: Dr. Chana Rich
Faculty Reviewer: Dr. Kristin Dwyer