D sign: Here we see the parasternal short axis view of the focused echo, the inter-ventricular septum is flat, instead of circular, indicating increased right ventricular pressures. The increased pressures force the septum toward the left ventricle. This creates the appearance a left ventricle that looks like the letter “D” in cross section.
A middle aged patient presents with shortness of breath. They’re hypoxic, with clear lung sounds bilaterally. PE is high on differential.
POCUS Cardiac: The parasternal short axis here shows septal wall flattening (D sign). CT scan and inpatient ultrasound read confirms septal wall flattening but no RV dilatation.
Sono Pearl: There are 3 ultrasonographic findings that define “Right ventricular (RV) strain”. RV dilatation, Septal wall flattening, and RV systolic dysfunction (ie: tapse). The first two require visualization as opposed to measurements. This case illustrates the importance of observing multiple views and not just looking for RV dilation but also septal wall flattening in PE.