Right ventricle dilatation: the big five

A 38-year-old man, previously well, presents after being mauled by a Cape buffalo, while on Safari in South Africa. He recovered well but visited a cardiologist for infrequent palpitations lasting less than 10 min. A chest radiograph demonstrated increased cardiothoracic ratio raising the concern of possible traumatic mediastinal injury. His clinical examination was unremarkable. ECG demonstrated sinus rhythm with incomplete right bundle branch block. Echocardiography revealed a dilated, hyperdynamic right ventricle (RV) and dilated coronary sinus (CS). The left ventricle (LV) and aorta were normal with no evidence of aneurysm or dissection. An agitated saline bubble study was performed via the left antecubital fossa. Interestingly, all bubbles entered the right atrium (RA) via the superior vena cava (SVC) with no bubbles entering via the CS and no bubbles shunting to the left …