doi: 10.1161/CIRCULATIONAHA.107.746602
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(Circulation. 2008;118:e517-e518.)
© 2008 American Heart Association, Inc.
Images in Cardiovascular Medicine |
McConnell’s Sign
From the University of Kansas Hospital, Kansas City (R.P.S., K.G.); and Kansas City VA Medical Center (K.G.).
Correspondence to Kamal Gupta, MD, Division of Cardiovascular Diseases, University of Kansas Hospital, 3901 Rainbow Blvd, MS 4023, Kansas City, KS 66160. E-mail kgupta{at}mac.md
A 46-year-old man with a history of neurosarcoidosis presented to the emergency room with nonradiating, midsternal chest pressure with associated dyspnea lasting for 10 minutes that occurred 1 day before presentation. He was found to be hypotensive; in sinus tachycardia; with a new right bundle-branch block on the ECG, a mildly elevated troponin (1.47 ng/mL), and significantly elevated hepatic transaminases indicative of shock liver; and in acute renal failure. He required large doses of vasopressors and became acutely bradycardic and pulseless. He was resuscitated after 8 minutes of advanced cardiac life support.
A stat transthoracic echocardiogram revealed normal left ventricular function (ejection fraction, 60%) and a moderately to severely enlarged right atrium. The right ventricle was moderately to severely enlarged with severely impaired systolic function that spared the right ventricular apex (see Movies I and II in the online Data Supplement). There was mild tricuspid regurgitation and a systolic pulmonary artery pressure of 60 mm Hg.
He emergently received alteplase through the right internal jugular central venous catheter for presumed massive pulmonary embolism (PE). Within a few hours, his clinical and hemodynamic picture improved dramatically. He was weaned off all vasopressors, and his right bundle-branch block resolved in a few hours. Duplex scan showed lower-extremity deep venous thrombosis in the right popliteal vein and bilateral tibioperoneal veins (Figures 1 through 3
). Repeat echocardiogram revealed a decrease in right ventricular and right atrial size with improved right ventricular function and a pulmonary artery pressure of 28 mm Hg.
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McConnell’s sign is a distinct echocardiographic finding described in patients with acute PE. There is a distinct regional pattern of right ventricular dysfunction, with akinesia of the mid free wall (centerline excursion, –0.2±0.8 mm; P=0.0001 versus normal) but normal motion at the apex (centerline excursion, 5.7±0.8 mm; P=NS versus normal).1 Three mechanisms have been proposed that may explain these findings. First, in acute PE, the tethering of the right ventricular apex to a contracting and often hyperdynamic left ventricle may account for the preserved wall motion at the apex.1 Second, the right ventricle may be assuming a more spherical shape to equalize regional wall stress when subjected to an abrupt increase in afterload.2,3 Third, there may be localized ischemia of the right ventricular free wall as a result of increased wall stress.1 Overall, echocardiography has a low sensitivity for diagnosing PE; however, the accuracy is much higher in the diagnosis of massive PE.4 Echocardiography may be useful in cases of massive PE in which a rapid presumptive diagnosis is required to justify the use of thrombolytic therapy.5 Regional wall motion abnormalities sparing the right ventricular apex (McConnell’s sign) are particularly suggestive of PE.2
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Disclosures |
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 Top Disclosures References |
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None.
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Footnotes |
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The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/15/e517/DC1.
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References |
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TopDisclosuresReferences |
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1. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996; 78: 469–473.[CrossRef][Medline] [Order article via Infotrieve]
2. Calvin JE. Pressure segment length analysis of right ventricular function: influence of loading conditions. Am J Physiol. 1991; 260: H1087–H1097.[Medline] [Order article via Infotrieve]
3. Janz RF, Kubert BR, Pate EF, Moriarty TF. Effect of shape on pressure volume relationships of ellipsoidal shells. Am J Physiol. 1980; 238: H917–H926.[Medline] [Order article via Infotrieve]
4. Grifoni S, Olivotto I, Cecchini P, Pieralli F, Camaiti A, Santoro G, Conti A, Agnelli G, Berni G. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000; 101: 2817–2822.
5. Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002; 136: 691–700.
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