McConnell's Sign Is Not Specific for Pulmonary Embolism: Case Report and Review of the Literature



      McConnell's sign (right ventricular [RV] free wall hypokinesis with apical sparing on echocardiography) is often described as very specific for the diagnosis of pulmonary embolism (PE). We present the case of a patient who, despite manifesting a classic McConnell's sign, was not found to have a PE.

      Case Report

      A 58-year-old woman presented to the emergency department with a cough, dyspnea, and leg swelling. A bedside focused cardiac ultrasound revealed hypokinesis of the RV free wall, with apical sparing, in the apical four-chamber view. A computed tomography angiogram for PE was negative. Ultrasounds of both lower extremities were negative for deep venous thrombosis, and a D-dimer was only marginally elevated. The patient was ultimately diagnosed with pulmonary hypertension due to chronic obstructive pulmonary disease and systemic lupus erythematosus.

      Why Should an Emergency Physician Be Aware of This?

      Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.


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        • Labovitz A.J.
        • Noble V.E.
        • Bierig M.
        • et al.
        Focused Cardiac ultrasound in the emergent setting: A Consensus Statement of the American Society of Echocardiography and American College of Emergency Physicians.
        J Am Soc Echocardiogr. 2010; 23: 1225-1230
        • Via G.
        • Hussain A.
        • Wells M.
        • et al.
        International evidence-based recommendations for focused cardiac ultrasound.
        J Am Soc Echocardiogr. 2014; 27: 683.e1-683.e33
        • Taylor R.A.
        • Davis J.
        • Liu R.
        • Gupta V.
        • Dziura J.
        • Moore C.L.
        Point-of-care focused cardiac ultrasound for prediction of pulmonary embolism adverse outcomes.
        J Emerg Med. 2013; 45: 392-399
        • McConnell M.V.
        • Solomon S.D.
        • Rayan M.E.
        • Come P.C.
        • Goldhaber S.Z.
        • Lee R.T.
        Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism.
        Am J Cardiol. 1996; 78: 469-473
        • Lodato J.A.
        • Ward R.P.
        • Lang R.M.
        Echocardiographic predictors of pulmonary embolism in patients referred for helical CT.
        Echocardiography. 2008; 25: 584-590
        • Dresden S.
        • Mitchell P.
        • Rahimi L.
        • et al.
        Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism.
        Ann Emerg Med. 2014; 63: 16-24
        • Aguilar D.
        • Bulwer B.
        Echocardiography in pulmonary embolism and secondary pulmonary hypertension.
        in: Solomon S.D. Essential echocardiography: a practical handbook with DVD. Humana Press, New York2007: 333-347
        • Carmody K.
        • Moore C.
        • Feller-Kopman D.
        Handbook of critical care and emergency ultrasound.
        McGraw-Hill Professional, New York2011
        • Casazza F.
        • Bongarzoni A.
        • Capozi A.
        • Agostoni O.
        Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction.
        Eur J Echocardiogr. 2005; 6: 11-14
        • López-Candales A.
        • Edelman K.
        • Candales M.D.
        Right ventricular apical contractility in acute pulmonary embolism: the McConnell sign revisited.
        Echocardiography. 2010; 27: 614-620
        • Vaid U.
        • Singer E.
        • Marhefka G.D.
        • Kraft W.K.
        • Baram M.
        Poor positive predictive value of McConnell’s sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism.
        Hosp Pract 1995. 2013; 41: 23-27
        • Inohara T.
        • Kohsaka S.
        • Fukuda K.
        • Menon V.
        The challenges in the management of right ventricular infarction.
        Eur Heart J Acute Cardiovasc Care. 2013; 2: 226-234
        • Arcasoy S.M.
        • Christie J.D.
        • Ferrari V.A.
        • et al.
        Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease.
        Am J Respir Crit Care Med. 2003; 167: 735-740
        • Gupta N.K.
        • Agrawal R.K.
        • Srivastav A.B.
        • Ved M.L.
        Echocardiographic evaluation of heart in chronic obstructive pulmonary disease patient and its co-relation with the severity of disease.
        Lung India Off Organ Indian Chest Soc. 2011; 28: 105-109
        • Chung S.-M.
        • Lee C.-K.
        • Lee E.Y.
        • Yoo B.
        • Lee S.-D.
        • Moon H.-B.
        Clinical aspects of pulmonary hypertension in patients with systemic lupus erythematosus and in patients with idiopathic pulmonary arterial hypertension.
        Clin Rheumatol. 2006; 25: 866-872
        • Kolb T.M.
        • Hassoun P.M.
        Right ventricular dysfunction in chronic lung disease.
        Cardiol Clin. 2012; 30: 243-256
        • Weitzenblum E.
        • Apprill M.
        • Oswald M.
        • Chaouat A.
        • Imbs J.L.
        Pulmonary hemodynamics in patients with chronic obstructive pulmonary disease before and during an episode of peripheral edema.
        Chest J. 1994; 105: 1377-1382
        • Liao M.M.
        • Theoret J.
        • Dannemiller E.M.
        • Erickson C.
        • Sanz G.E.
        • Kendall J.L.
        Emergency bedside ultrasound diagnosis of sub-massive acute pulmonary embolism: a case of the McConnell sign.
        Crit Ultrasound J. 2010; 2: 25-27
        • Haller E.P.
        • Nestler D.M.
        • Campbell R.L.
        • Bellamkonda V.R.
        Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in emergency medicine.
        J Emerg Med. 2014; 47: e19-e21
        • Ünlüer E.E.
        • GÖ Senturk
        • Karagöz A.
        • Uyar Y.
        • Bayata S.
        Red flag in bedside echocardiography for acute pulmonary embolism: remembering McConnell’s sign.
        Am J Emerg Med. 2013; 31: 719-721