about 90 y old patient mit cyanosis, dyspnoea, tachycardia. In TTE we could see a distinct RV-dysfunction with high elevated pulmonary hypertension (PAPsystolic about 90 mmHg, RAP-approach in respect to dilatated VCI with no inspiratory collaps about 20 mmHg > RVSP about 100-110 mmHg). systolic and also diastolic septal shift as a sign of RV-pressure and volume-overload; you can also see the variation of transtricupidal flow dependend on in-and exspiration (inspiratory increase of transtricuspial flow > 45%).
In my opinion there is a acute pulmonary embolism with the underlaying disease of chronic cor pulmonale (RV-Hypertrophie!). With ultrasound we found a thrombosis in lower legs. No CT-scan because of GFR of about 20 ml/min!
Lysis wasn´t needed till up to now. We started anticoagulation with UFH (aPTT 60-80 sec).
In my opinion you can see the classical McConnel sign (Hyperkinetic RV-Apex with hypo-akinetic lateral RV-wall).