Biederman, Robert W

Cheema, Tariq

Doyle, Mark

Ivanova, Valentyna

Rayarao, Geetha

Shah, Moneal

Williams, Ronald B

Yamrozik, June

Journal of Cardiovascular Magnetic Resonance

English

PubMed

Valentyna Ivanova

Mark Doyle

June Yamrozik

Ronald B Williams

Geetha Rayarao

Moneal Shah

Tariq Cheema

Robert W Biederman

Crossref

McConnell’s sign unveiled

Springer - Publisher Connector

POSTER PRESENTATION Open Access
McConnell’s sign unveiled
Valentyna Ivanova*, Mark Doyle, June Yamrozik, Ronald B Williams, Geetha Rayarao, Moneal Shah, Tariq Cheema,
Robert W Biederman
From 15th Annual SCMR Scientific Sessions
Orlando, FL, USA. 2-5 February 2012
Summary
McConnell’s sign is well described in echocardiography
as a harbinger of severe RV failure and more extensive
arterial thrombus burden but its mechanical basis has
never been satifactorily defined despite multiple current
theories. CMR RF tissue-tagging now unveils the
mechanism.
Background
Evidence of echocardiographic RV ‘strain’ in the setting
of a large, clinically important, often devasting pulmon-
ary embolism (PE) is defined by the presence of para-
doxical, often hyperdynamic RV apical contraction in
the setting of severely dysfunctional RV function; so
denoted ‘McConnell’s sign’. Despite its original observa-
tion by its namesake in 1996, it has neither been
observed via CMR nor more importantly, while many
theories exist, mechanistically explained.
Hypothesis
We hypothesize that McConnell’s sign (MS) is observa-
ble utilizing CMR and can be explained via CMR defor-
mational analysis.
Methods
Modestly stable patients who had CT confirmed large
(>one pulmonary branch obstruction and/or saddle PE)
were evaluated via echocardiography and CMR. CMR
radio-frequency tissue tagging was performed to deter-
mine midwall intramyocardial deformation patterns with
superimposition of quiver plot technique to define direc-
tion and amplitude of myocardial displacements assum-
ing homogenous tissue strain (%S).
Results
Eleven patients (3 male; 59±9 years) were identified
from CT of which 7 had echocardiograms performed of
which 5 were MS+. Four patients had body habitus per-
mitting CMR examination (GE Excite1.5T, Milwaukee,
WI)within 36-96 hours of echocardiogram. The LV was
hyperdynamic,small and under-filled in all (LVEF=72-
81%; LVEDV <2SD below LLN). As expected, the RV
was severely dysfunctional and dilated in all (RVEF=23-
32%; RVEDV>2SD above ULN). MS+ was present in 2
patients but absent in 2 patients (imaged >72 hours
after CT/echo). All 4 patients underwent RF tagging in
multiple projections with %S and were compared to his-
toric controls. Circumferential (%SC), radial (%SR) and
meridional(%SL) were interrogated. In MS+, septal%SL
was markedly augmented (87%) as compared to MS-
(42%) and historic controls (15-18%) and less than the
moderately augmented lateral wall (58%) in MS+. RV
apical %SL was negligible(<1%). A distinct base-apex gra-
dient in %SL was present,highest at the LV apex adja-
cent tethered RV insertion point fibers (p<0.05 for all
vs. historic controls). %SC and %SR, while augmented,
did not demonstrate a directional component consistent
with observed MS+.
Conclusions
Standard CMR permits detection of McConnell’s sign in
patients with large, relevant pulmonary embolisms.
CMR appears for the first time to sufficiently explain
the mechanism behind the long-observed mechanism
McConnell’s sign: in the setting of substantial preload
reduction and reflex hyperadrenergic up-regulation, RF
tissue tagging demonstrates markedly augmented LV
septal intramyocardial deformations, such that tethered
RV insertion point fibers are acted upon via the hyper-
dynamic LV apex permitting translation with pro-
nounced but paradoxical RV apical passive deformation.
Allegheny General Hospital, Pittsburgh, PA, USA
Ivanova et al. Journal of Cardiovascular Magnetic Resonance 2012, 14(Suppl 1):P88
http://www.jcmr-online.com/content/14/S1/P88
© 2012 Ivanova et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Funding
Internal.
Published: 1 February 2012
doi:10.1186/1532-429X-14-S1-P88
Cite this article as: Ivanova et al.: McConnell’s sign unveiled. Journal of
Cardiovascular Magnetic Resonance 2012 14(Suppl 1):P88.
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Ivanova et al. Journal of Cardiovascular Magnetic Resonance 2012, 14(Suppl 1):P88
http://www.jcmr-online.com/content/14/S1/P88
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McConnell’s sign unveiled

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