Image 1: Apical 4 chamber of POCUS echo significant for tricuspid valve vegetation.
A 30-something year old female with a history of intravenous drug use presented to the emergency department with dyspnea. She reported fevers, bloody sputum production, and pleuritic chest pain. She appeared cachectic with track marks on both arms. Vital signs: heart rate 110 beats/min, blood pressure 90/60 mmHg, respiratory rate 20 breaths/min, and temperature 37.9C (100.2F).
POCUS cardiac revealed a large tricuspid valve vegetation clinching the diagnosis of infective endocarditis (Image 1 above). The patient was eventually placed on veno-venous extracorporeal membrane oxygenation support to undergo intravascular debulking of the tricuspid vegetation under transesophageal echocardiogram guidance, extracting an 11cm vegetation (Image 2 below).
POCUS pearl: Troubleshooting apical 4 chamber image acquisition. 1) If the septal wall is at an angle, try swinging your hand/transducer out laterally so that the septum is straight up and down, and 2) If you see two ventricles, but not the atria, try dropping your angle to open up the atria such that you can now see 4 chambers.
Image 2: 11 cm tricuspid valve vegetation