https://orcid.org/0009-0000-1901-5665
This Spot the Diagnosis article refers to ‘Question: A classic sign may clinch the diagnosis in a desaturated patient’, by D.P. Raja et al., https://doi.org/10.1093/ehjacc/zuae002.
What is the likely aetiology?
Takostubo cardiomyopathy
Acute pulmonary thromboembolism
Acute myocardial infarction
Myocarditis
Discussion
The correct answer is (2). This is a case of acute pulmonary thromboembolism (PTE) with an echocardiogram revealing a classical McConnel sign which refers to akinesia or dyskinesia of the mid-ventricular free wall of the right ventricle with normal to hyperkinetic motion in right ventricular apex (Figure 1B and C, see Supplementary material online, videos S1 and S2).1 Computed tomogram pulmonary angiogram substantiated the diagnosis of submassive pulmonary thromboembolism involving segmental pulmonary arteries. She was improved with heparin infusion and subsequently put on Rivaroxaban. Procoagulant work-up was negative with no evidence of deep venous thrombosis.
(A) 12-Lead electrocardiogram showing a heart rate of 100 b.p.m., the S1Q3T3 pattern with minimal fragmentation of the QRS complex in V1 with the strain pattern; (B) 2D echocardiogram in apical four-chamber view in diastole showing dilated right ventricle (arrows—RV free wall); (C) 2D echocardiogram in apical four-chamber view in systole showing dyskinesia of the mid-segment free wall of the right ventricle with a significant contractile movement of the apex inward causing a notch (arrowheads).
Postoperative status with immobility is one of the major causes of acute PTE. Common electrocardiographic patterns are tachycardia, S1S2S3, S1Q3T3, right bundle branch block, and right ventricular strain patterns (precordial T-wave inversion).2 An echocardiogram usually reveals a dilated right ventricle with regional hypokinesia, flattened interventricular septum, distended inferior caval vein, accelerated pulmonary ejection (pulmonary acceleration time <60 ms) with mildly elevated peak systolic gradient at the tricuspid valve (<60 mmHg), decreased TAPSE (usually <16 mm) and tricuspid annular tissue Doppler velocity (lateral s′ < 9.5 cm/s). The regional differences in cardiac motion can be explained by tethering of the right ventricle by the left ventricular apex.1 Another proposed mechanism is a change of the right ventricular cavity to a spherical shape to equalize regional wall stress by the acute increase in afterload.3,4 Localized subendocardial ischaemia may contribute to the wall motion abnormalities. Although reported sensitivity and specificity were reported as 77 and 94%, respectively, subsequent metanalysis showed that this sign is only 22% sensitive maintaining its specificity as high as 97%.5
Supplementary material
Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.
Author contributions
D.P.R. and S.M. were involved in conceptualization; formal analysis; writing—original draft; writing—review and editing; S.K.G. was involved in writing—review and editing. All authors contributed equally to the study.
Funding
None declared.
Consent
The consent was obtained from the patient in line with COPE guidance.
Data availability
The data underlying this article are available in the article and in its online supplementary material.
References
Author notes
Conflict of interest: None declared.
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