Case 1

A 35-year-old man presents to the emergency department (ED) by ambulance after a syncopal episode at a bookmakers. He reports a 6 month history of progressive dyspnoea with intermittent palpitations. Over the last 36 hours he has become dyspnoeic at rest. He is a recent immigrant and has no general practitioner. He has no known past medical history. He is not on any medications.

On examination his pulse is 120 per minute, his respiratory rate is 30 per minute, O2 saturations 93% on air, BP 90/70. He is centrally cyanosed with digital clubbing. His jugular venous pressure is elevated. On cardiac auscultation, the pulmonary component of the second heart sound is found to be loud and a diastolic murmur is audible along the left sternal border. He has a palpable right ventricular heave. On lung auscultation, he has widespread crackles in both lung fields. His abdomen was distended with shifting dullness. He has bilateral lower extremity oedema.

The 12-lead electrocardiogram shows right axis deviation, right ventricular hypertrophy and atrial flutter. His chest X-ray shows an enlarged main pulmonary artery, grossly dilated right pulmonary artery, narrowing of the distal portion of the segmental pulmonary arteries and marked cardiomegaly.

What is the diagnosis?

Chose the four most appropriate immediate investigations/interventions from the following list.