Portentous pinball.

A 76-year-old woman presented with a six-day history of pleuritic pain, dyspnea and a swollen, tender left calf. She was dyspneic, tachypneic and tachycardic (heart rate 109 beats/min), with decreased oxygen saturation (83%) and a partial pressure of oxygen of 9 kPa. Her blood pressure was 119/79 mmHg, and she had elevated jugular venous pressure (11 mmHg). A computed tomographic pulmonary angiogram revealed extensive bilateral pulmonary artery thrombi and an ultrasound confirmed a lower limb thrombus. Echocardiography demonstrated a dilated right ventricle with pulmonary artery hypertension (75 mmHg) and a free-floating thrombus of 1.5 cm x 4 cm, which ricocheted across the right ventricular outflow tract from the tricuspid to the pulmonary valve. The left ventricle was underfilled and hyperdynamic. Following thrombolysis, the patient's clinical status improved. Echocardiography revealed improved biventricular function, no residual right ventricular thrombus, and pulmonary artery pressure normalization. The present case demonstrates the usefulness of echocardiography in submassive pulmonary embolus risk stratification and management.