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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    • "In particular, clinical echocardiographic studies (Jardin et al. 1997, Mansencal et al. 2003) report RV dilation, hypokinesis and paradoxical motion of the inter-ventricular septum as the signs of RV mechanical dysfunction caused by APE. McConnell et al. (1996) suggested a RV echocardiographic functional sign that was originally reported to have a specificity of 94% and sensitivity of 77%, although its diagnostic utility has been questioned (Casazza et al. 2005; Lopez-Candales et al. 2010b). However, these clinical echocardiography studies report fully developed mechanical RV abnormalities as a result of mostly severe RV pressure overload, whereas the functional impact of acute mild or moderate RV pressure overload has been addressed only in a few research studies (Cho et al. 2009; Groth et al. 2010). "
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    ABSTRACT: Acute pulmonary embolism (APE) is the third most common cause of death in the United States. Appearing as a sudden blockage in a major pulmonary artery, APE may cause mild, moderate or severe right ventricular (RV) overload. Although severe RV overload produces diagnostically obvious RV mechanical failure, little progress has been made in gaining a clinical and biophysical understanding of moderate and mild acute RV overload and its impact on RV functionality. In the research described here, we conducted a pilot study in pigs using echocardiography and observed the following abnormalities in RV functionality under acute mild or moderate RV overload: (i) occurrence of paradoxical septal motion with "waving" dynamics; (ii) decrease in local curvature of the septum (p < 0.01); (iii) lower positive correlation between movement of the RV free wall and movement of the septum (p < 0.05); (iv) slower rate of RV fractional area change (p < 0.05); and (v) decrease in movement stability, particularly in the middle of the septum (p < 0.05).
    Full-text · Article · Aug 2013 · Ultrasound in medicine & biology
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    • "Perhaps the most sensitive and specific indirect sign is the McConnell sign, or hypokinesis of the RV mid-free wall with preserved apical contractility as seen in the four-chamber view. Originally described as 77% sensitive and 94% specific, a much lower specificity of 33% was found in a recent study which included patients with RV infarction[4]. These reported sensitivities and specificity are based on formal comprehensive transthoracic echocardiography, and ED-performed sonography may be even less sensitive and would not be adequate to rule out PE. "
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    ABSTRACT: Optimal management of the critically ill patient in shock requires rapid identification of its etiology. We describe a successful application of an emergency physician performed bedside ultrasound in a patient presenting with shock and subsequent cardiac arrest. Pulmonary embolus was diagnosed using bedside echocardiogram and confirmed with CTA of the thorax. Further validation and real-time implementation of this low-cost modality could facilitate the decision to implement thrombolytics for unstable patients with massive pulmonary embolism who cannot undergo formal radiographic evaluation.
    Full-text · Article · May 2012
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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.
    Full-text · Article · Dec 2011 · Journal of cardiovascular ultrasound
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