rss
BMJ Case Reports 2013; doi:10.1136/bcr-2013-009623

McConnell sign and S1Q3T3 pattern in pulmonary embolism: revisited

  1. M Chadi Alraies4
  1. 1Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2American University of Beirut Medical Center, Beirut, Beirut, Lebanon
  3. 3Department of Pulmonary Diseases, Critical Care, & Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
  4. 4Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr M Chadi Alraies, alraies{at}hotmail.com

Description

A 67-year-old man with a known history of venous thromboembolism was admitted with a 2 week history of dyspnoea. He denied chest pain, leg swelling or recent travelling. Clinical examination revealed blood pressure of 124/68 mm Hg, regular pulse of 54 bpm and respiratory rate of 27/min. Jugular veins were distended at 7 cm, and cardiopulmonary examination revealed no findings. ECG showed sinus bradycardia, S wave in lead I, Q wave in lead III with T-wave inversion (S1Q3T3) (figure 1A). Troponin T was negative and NT proBNP was elevated at 937 pg/ml. CT pulmonary angiography showed bilateral pulmonary embolism (figure 1B). Transthoracic echocardiogram revealed a moderately dilated right ventricle (RV) with moderate dysfunction. The RV apex was hyperkinetic and the free wall segment was akinetic, a finding consistent with McConnell sign (figure 1C). Anticoagulation was started, and the patient was discharged home in a stable condition. A repeat echocardiogram 2 months later showed disappearance of McConnell sign (figure 1D).1 ,2

Figure 1

(A) 12-lead ECG showing sinus bradycardia, S wave in lead I, Q wave in lead III with T-wave inversion (S1Q3T3); (B) CT pulmonary angiogram showing large clots in right and left main pulmonary arteries (arrows); (C) apical-four-chamber view on transthoracic echocardiogram showing normokinesia of the right ventricular apical segment (thin arrow) and akinesia of the midfree wall (thick arrow). LV, left ventricle; RV, right ventricle; (D) apical-four-chamber view on transthoracic echocardiogram postanticoagulation showing resolution of right ventricular wall motion abnormalities. LV, left ventricle; RV, right ventricle.

Learning points

  • The role of transthoracic echocardiography in patients with pulmonary embolism is to evaluate haemodynamic stability, pulmonary hypertension and right ventricular (RV) strain.

  • The McConnell sign, identified as RV-free wall hypokinesia with hyperkinetic apex, is sensitive and specific in pulmonary embolism, and is associated with worse outcomes.

Footnotes

  • Contributors All authors have been involved in drafting the article and revising it critically for important intellectual content, and read and approved the final version of the manuscript.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog

Navigate This Article