Diagnosis: massive pulmonary embolism
This echocardiogram demonstrates a dilated, hypokenetic RV. There is right ventricular free wall hypokinesis in the presence of normal right ventricular apical contractility, this is known as McConnell Sign. The RV is larger than the hyperkenetic LV. Lastly, it is evident on the parasternal short axis view that the septal wall is bowing into the LV due to high right sided pressures, deforming the LV into “D” shape.
This patient had no historical features that suggested PE, which was low on the differential list. After the echo was performed, a CTA of the chest confirmed massive PE. It is extremely unlikely that the diagnosis would have been made without the information obtained from this echocardiogram. This patient was given full dose thrombolytics due to persistent hypotension in the setting of massive PE.
Take home points:
- Every patient with undifferentiated hypotension needs a bedside echo, better yet, a RUSH Exam.
- A lateral RV wall measurement of < 0.5 cm suggests acute pulmonary hypertension (PH), > 0.5 cm suggests chronic PH. This measurement should be made from the subcostal view at end diastole.1
- A significant tricuspid regurgitation jet suggests more profound PH.
- It is imperative that the physician is certain that the probe marker is appropriately oriented to differentiate RV from LV failure (cardiogenic shock patients need levophed, not thrombolytics).
- Mcconnell Sign is not specific for PE, it can be seen in acute RV infarct. Both massive/submassive PE and RV infarct patients will have elevated cardiac markers.2
1. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. [PDF]
2. 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(1):11-4. [PDF]