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McConnell's sign: Echocardiography in the management of acute pulmonary embolism.

ABSTRACT: Management of acute pulmonary embolism depends immensely on rapid diagnosis and early intervention. Transthoracic echocardiography has gained favorability in scenarios where diagnostic computed tomography angiography is not feasible. McConnell's sign, an echocardiographic finding of segmental right ventricular wall-motion abnormality with apical sparing, is highly specific and may guide therapeutic intervention. We present the case of a 59-year-old man who was found to have acute pulmonary embolism with obstructive shock, managed successfully with thrombolytic therapy after identification of McConnell's sign. We review current literature and develop a framework for the integration of echocardiography into the multimodal approach to management.

SUBMITTER: Patel VI

PROVIDER: S-EPMC8552222 | biostudies-literature | 2021 Oct

REPOSITORIES: biostudies-literature

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McConnell's sign: Echocardiography in the management of acute pulmonary embolism.

Patel Vishal I VI Miles Michelle M Shahangian Sharareh S Javien John J

Clinical case reports 20211028 10

Management of acute pulmonary embolism depends immensely on rapid diagnosis and early intervention. Transthoracic echocardiography has gained favorability in scenarios where diagnostic computed tomography angiography is not feasible. McConnell's sign, an echocardiographic finding of segmental right ventricular wall-motion abnormality with apical sparing, is highly specific and may guide therapeutic intervention. We present the case of a 59-year-old man who was found to have acute pulmonary embol ...[more]

PMID: 34745617

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Project description:Pulmonary embolism (PE) is a devastating diagnosis which carries a high mortality risk. Echocardiography is often performed to risk stratify patients diagnosed with PE, and guide management strategies. Trends in the performance of echocardiography among patients with PE and its role in influencing outcomes is unknown.We analyzed the 2005 to 2014 National Inpatient Sample Database to identify patients with primary diagnosis of PE or secondary diagnosis of PE and ≥1 of the following diagnoses: syncope, thrombolysis, acute deep vein thrombosis, acute cardiorespiratory failure, and secondary pulmonary hypertension. Trends in the performance of echocardiography and in-hospital mortality were analyzed. The admissions were divided into 2 groups with echocardiography, and without echocardiography, and 1:2 propensity score matching (PSM) was performed for comparison. The primary end-point was in-hospital mortality. The secondary endpoints were length of stay and total hospitalization costs. Odd ratios (OR) with confidence intervals (CI) were reported.A total of 299,536 unweighted PE cases were studied. Performance of echocardiography among patients with PE patients increased from 3.5% to 5.6%, whereas in-hospital mortality decreased from 4.2% to 3.7% between years 2005 and 2014. Before matching, patients who received an echocardiogram were more likely to be younger, African American, admitted to a large, urban teaching institute, and had higher rates of concurrent acute deep vein thrombosis, and acute respiratory failure. Post-PSM, patients who received echocardiography during hospitalization had lower in-hospital mortality (odds ratio 0.75, 95% confidence intervals (CI) 0.68-0.83; P < 0.001), longer length of stay (median 6 days vs 5 days; P < .001) and higher mean hospitalization costs ($34,379 vs $27,803; P < .001) compared to those without echocardiography.Performance of echocardiography among patients with a PE is increasing and is associated with lower in-hospital mortality.

Project description:BackgroundWe determine the predictive value of transthoracic echocardiographic (TTE) metrics for clinical deterioration within 5 days in adults with intermediate-risk pulmonary embolism (PE).MethodsThis was a prospective observational study of intermediate-risk PE patients. To determine associations of TTE and clinical predictors with clinical deterioration, we used univariable analysis, Youden's index for optimal thresholds, and multivariable analyses to report odds ratios (ORs) or area under the curve (AUC).ResultsOf 306 intermediate-risk PE patients, 115 (37.6%) experienced clinical deterioration. PE patients who had clinical deterioration within 5 days had greater baseline right ventricle (RV) dilatation and worse systolic function than the group without clinical deterioration as indicated by the following: RV basal diameter 4.46 ± 0.77 versus 4.20 ± 0.77 cm; RV/LV basal width ratio 1.14 ± 0.29 versus 1.02 ± 0.24; tricuspid annular plane systolic excursion (TAPSE) 1.56 ± 0.55 versus 1.80 ± 0.52 cm; and RV systolic excursion velocity 10.40 ± 3.58 versus 12.1 ± 12.5 cm/s, respectively. Optimal thresholds for predicting clinical deterioration were: RV basal width 3.9 cm (OR 2.85 [1.64, 4.97]), RV-to-left ventricle (RV/LV) ratio 1.08 (OR 3.32 [2.07, 5.33]), TAPSE 1.98 cm (OR 3.3 [2.06, 5.3]), systolic excursion velocity 10.10 cm/s (OR 2.85 [1.75, 4.63]), and natriuretic peptide 190 pg/mL (OR 2.89 [1.81, 4.62]). Significant independent predictors were: transient hypotension 6.1 (2.2, 18.9), highest heart rate 1.02 (1.00, 1.03), highest respiratory rate 1.02 (1.00, 1.04), and RV/LV ratio 1.29 (1.14, 1.47). By logistic regression and random forest analyses, AUCs were 0.80 (0.73, 0.87) and 0.78 (0.70, 0.85), respectively.ConclusionsBasal RV, RV/LV ratio, and RV systolic function measurements were significantly different between intermediate-risk PE patients grouped by subsequent clinical deterioration.

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McConnell's sign: Echocardiography in the management of acute pulmonary embolism.

Publications

McConnell's sign: Echocardiography in the management of acute pulmonary embolism.

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