Saddle pulmonary embolism detected by transthoracic echocardiography-a case report

Pulmonary embolism (PE) is a potentially life-threatening condition with variable presentation. Transthoracic echocardiography (TTE) is commonly used to identify indirect signs of right ventricular (RV) pressure overload, such as RV dilation, septal flattening, or regional dysfunction. Direct visualization of pulmonary artery thrombi is rare and not routinely assessed.

A 78-year-old white woman presented with sudden-onset dyspnea at rest. She was hemodynamically stable, in sinus rhythm, and showed no evidence of RV pressure overload on electrocardiography or standard TTE views. In a parasternal short axis-pulmonary artery view, a hyperechoic intraluminal structure was identified at the pulmonary artery bifurcation, consistent with a saddle thrombus. Anticoagulation with low molecular weight heparin was promptly initiated. Computed tomography pulmonary angiography (CTPA) confirmed central PE. Cardiac biomarkers were mildly elevated and the pulmonary embolism severity index classified the patient as intermediate-low risk.

Catheter-guided treatment was considered but deferred due to hemodynamic stability. The patient was monitored, transitioned to oral anticoagulation with apixaban and discharged after 3 days. Follow-up echocardiography showed no RV dysfunction.

This case demonstrates that targeted bedside TTE can directly visualize central pulmonary thrombi, even in the absence of signs of RV pressure overload. Incorporating a parasternal short-axis view of the pulmonary arteries as a complimentary approach can accelerate the diagnosis, guide early anticoagulation, refine risk assessment and support urgent decision-making in selected patients, particularly when CTPA is delayed or inconclusive. Although operator-dependent and limited by acoustic windows, this approach complements rather than replaces standard European Society of Cardiology (ESC)-recommended pathways, potentially enhancing clinical confidence and time to treatment in selected emergency cases.