Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr 6:11-14

Division of Cardiology, San Carlo Borromeo Hospital, via Pio 2, n 3, 20153 Milan, Italy.
European Heart Journal – Cardiovascular Imaging (Impact Factor: 4.11). 02/2005; 6(1):11-4. DOI: 10.1016/j.euje.2004.06.002
Source: PubMed


A normally contracting right ventricular apex associated to a severe hypokinesia of the mid-free wall ('McConnell sign') has been considered a distinct echocardiographic pattern of acute pulmonary embolism.
To evaluate the clinical utility of the 'McConnell sign' in the bedside diagnostic work-up of patients presenting to the Emergency Department with an acute right ventricular dysfunction due to pulmonary embolism or right ventricular infarction.
Among 201 patients, consecutively selected from our clinical database and diagnosed as having massive or submassive pulmonary embolism or right ventricular infarction, 161 were suitable for an echocardiographic review of regional right ventricular contraction and were included in the study. There were 107 cases with pulmonary embolism (group 1) and 54 cases with right ventricular infarction (group 2). All echocardiographic studies were randomly examined by two experienced and independent echocardiographers, blinded to the patient diagnosis and without Doppler informations.
The McConnell sign was detected in 75 of 107 patients in group 1 (70%) and in 36 of 54 patients in group 2 (67%); the finding was absent in 32 cases in group 1 and in 18 cases in group 2 (P=0.657). The sensitivity, specificity, positive and negative predictive values of the McConnell sign for the diagnosis of pulmonary embolism were respectively 70, 33, 67 and 36%.
In a clinical setting of patients with acute right ventricular dysfunction the McConnell sign cannot be considered a specific marker of pulmonary embolism.

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    • "Echocardiography is frequently performed in PE patients, because it permits reliable, qualitative, hemodynamic assessment of RV size, RV systolic function, and pulmonary arterial pressure.6)7) Prognostic information can be obtained with the help of echocardiography.8)9) Furthermore, in a critically ill patient with worsening symptoms who cannot undergo CTPA without delay, bedside echocardiography contributes to early diagnosis and treatment of PE. "
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    ABSTRACT: We describe a 42-year-old man presenting to the emergency department with cardiogenic shock. He had a prior history of acute pulmonary embolism (PE), and had been on anticoagulation for 2 years. Although computed tomographic pulmonary angiography performed at the emergency department showed no change in the extent of PE and did not support a role of surgical treatment, pulmonary embolectomy was recommended by attending physician based on clinical and echocardiographic hemodynamic findings like unstable vital sign and markedly enlarged right ventricle with severely depressed systolic function. Surgery confirmed the presence of fresh thrombi. After surgery, hemodynamic status was progressively improved, but the patient died due to pneumonia and pulmonary hemorrhage.
    Journal of cardiovascular ultrasound 12/2011; 19(4):224-7. DOI:10.4250/jcu.2011.19.4.224
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    • "However, recently, Casazza et al. demonstrated that McConnell sign can also be seen in cases of right ventricular infarction and thus cannot be considered as a specific marker for the diagnosis of acute pulmonary embolism [3] "
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    ABSTRACT: A 48-year-old female was admitted after experiencing a brief syncopal episode. Three weeks ago the patient sustained a right arm humerus bone fracture in a motor vehicle accident. Since the accident, her mobility has been limited. CT angiogram of the chest revealed massive bilateral pulmonary emboli. A 2D echocardiogram was performed, which demonstrated McConnell sign and severe right ventricle dysfunction. Considering potential of hemodynamic instability, the patient received fibrinolytic therapy with Alteplase. A subsequent 2D echocardiogram showed complete resolution of McConnell sign and right ventricle dysfunction.
    07/2011; 2011. DOI:10.1155/2011/201097
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    • "Casazza and co., however, showed that this sign is not useful in the differential diagnosis of these two conditions. [38] "
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    ABSTRACT: It is frequently recognized in medical literature as well as in daily clinical practice that right ventricular myocardial infarction and pulmonary embolism are two of the most challenging clinical pictures to differentiate in cardiology and the treatment, often chosen upon a mixture of clinical suspicion criteria subsequently confirmed by other diagnostic methods, can lead to therapeutic success. Differential diagnosis is often difficult due to similar clinical picture, unspecific electrocardiographic changes and unspecific biological markers. It is very important to know the risk factors and the associated comorbidities for these two clinical entities in order to be able to interpret them contextually. In most cases the diagnosis key is the clinical suspicion. Usually in evaluating these cases we are in the position of choosing more complex diagnostic procedures, most likely not available in Emergency Department. In conclusion it is expected from the clinician to use the available methods with a thorough approach to details but in the same time considering the whole clinical picture.
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