Pulmonary emboli with right heart strain

Case contributed by Dr Julian Maingard


84yo female with metastatic adrenocortical carcinoma. New onset atrial fibrillation.

Patient Data

Age: 84
Gender: Female



There are extensive multiple filling defects within segmental pulmonary arterial branches of all lobes of the lung. The main, left, and right pulmonary arteries appear enlarged. Furthermore, there is contrast reflux back into the hepatic veins as well as reflux of contrast into collateral veins around the scapula.

No enlarged hilar, mediastinal or axillary lymphadenopathy. Cardiomegaly. No pericardial effusion.

Retrosternal goiter with multiple hypodensities predominantly within the left lobe of the thyroid, one of which demonstrates peripheral coarse calcification. 


Conclusion: Extensive bilateral pulmonary emboli with secondary signs of acute right heart strain.


Case Discussion

The above case demonstrates multiple bilateral pulmonary emboli with secondary signs of right heart strain. Right heart strain refers to right ventricular dysfunction in the setting of pulmonary hypertension. Computed tomography secondary signs of acute right heart strain include flattening or displacement of the interventricular septum toward the left ventricle, enlargement of the pulmonary arteries, and reflux of contrast material into the inferior vena cava1.

Echocardiography can be a useful follow up modality in this setting, to directly evaluate potential right heart dysfunction.

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