Emergency Department Echocardiogram of Right Ventricle Thrombus and McConnell’s Sign in a Patient with Dyspnea
Article first published online: 10 APR 2009
© 2009 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Volume 16, Issue 5, page 474, May 2009
How to Cite
Scott Bomann, J. and Moore, C. (2009), Emergency Department Echocardiogram of Right Ventricle Thrombus and McConnell’s Sign in a Patient with Dyspnea . Academic Emergency Medicine, 16: 474. doi: 10.1111/j.1553-2712.2009.00406.x
- Issue published online: 27 APR 2009
- Article first published online: 10 APR 2009
A 55-year-old male with a history of hypertension, Type 2 diabetes, and hypercholesterolemia presented to the emergency department with dyspnea that began abruptly 24 hours prior to arrival. He denied chest pain, cough, fever, hemoptysis, or leg pain or swelling. His vital signs were as follows: blood pressure 100/70 mm Hg, pulse 87 beats/min, respirations 23 breaths/min, O2 saturation (room air) 93%, temperature 98.8°F. He had recently been treated with azithromycin for a presumed upper respiratory infection. No significant risk factors for thrombosis were elicited.
Physical exam was remarkable only for mild tachypnea. His breath sounds were normal and he had no lower extremity tenderness or edema. His electrocardiogram showed new, deeply inverted T waves in the precordial leads. His chest x-ray was unremarkable. His troponin was 0.39 ng/ml, and his B-type natriuretic peptide (BNP) was 836 pg/ml.
A bedside echocardiogram was performed by an emergency physician (Video Clip S1, available as supporting information in the online version of this paper). Views of the right heart showed a severely dilated right ventricle with McConnell’s sign (right ventricular hypokinesis with apical sparing). There was a free-floating density within the right ventricle consistent with a thrombus (Figure 1, Video Clip S2). These findings made the diagnosis of pulmonary embolus highly likely. A subsequent computed tomography (CT) pulmonary angiogram showed a right mainstem thrombus as well as thrombi in multiple left lobar and segmental arteries (Figure 2). While the initial blood pressure was borderline for “massive” pulmonary embolism, the presence of right ventricular thrombus is an indication for more aggressive management, including thrombolysis or thrombectomy. The elevated troponin and BNP, low oxygen saturation, and CT findings also suggest a large clot burden that may not respond well to heparin alone. The patient underwent an emergency thrombectomy and was later discharged from the hospital.
Video Clip S1. McConnell’s sign.
Video Clip S2. Dilated right ventricle with free-floating thrombus.
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