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“Reverse McConnell's Sign?”: A Unique Right Ventricular Feature of Takotsubo Cardiomyopathy

      Bedside echocardiography plays an important role in the first-line diagnosis of Takotsubo cardiomyopathy (TC). Several classic imaging features could aid in the differential diagnosis in patients who have manifestation similar to that of acute coronary syndrome and potentially help in the risk stratification and management, including the decision to use coronary angiography.
      • Hurst R.T.
      • Prasad A.
      • Askew III, J.W.
      • Sengupta P.P.
      • Tajik A.J.
      Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology.
      • Movahed M.R.
      Important echocardiographic features of Takotsubo or stress-induced cardiomyopathy that can aid early diagnosis.
      Right ventricular (RV) involvement in TC has been previously identified.
      • Mrdovic I.
      • Kostic J.
      • Perunicic J.
      • Asanin M.
      • Vasiljevic Z.
      • Ostojic M.
      Right ventricular Takotsubo cardiomyopathy.
      • Haghi D.
      • Athanasiadis A.
      • Papavassiliu T.
      • Suselbeck T.
      • Fluechter S.
      • Mahrholdt H.
      • Borggrefe M.
      • Sechtem U.
      Right ventricular involvement in Takotsubo cardiomyopathy.
      However, these abnormal imaging features have never been well characterized and analyzed. Since September 2009, we have studied consecutive cases of TC diagnosed at our institute, with a specific focus on the analysis of RV morphologic abnormalities and their correlation with the unique hemodynamic effects of TC. We present a distinct regional pattern of RV free wall motion that could add additional diagnostic value to the assessment of TC. In patients with TC, the motion of the basilar and middle segments of the RV free wall is often hyperkinetic (Figure 1 and Videos 1 to 3). However, the motion of the apical segment of the RV free wall is usually hypokinetic (Figure 1 and Video 1 to 3), in the same manner as the left ventricular (LV) apical motion (Figure 2). Interestingly, this distinct imaging feature is exactly opposite the classic echocardiographic appearance in patients with acute and massive pulmonary embolism, McConnell's sign, which is defined as hyperkinesis of the RV apex and hypokinesis of the remaining segments of the RV free wall (Figure 1, Video 4 to 6).
      Figure thumbnail gr1
      Figure 1(A) RV free wall motion in diastole (A1, A3, and A5) and systole (A2, A4, and A6) in a patient with TC. (B) RV free wall motion in diastole (B1, B3, and B5) and systole (B2, B4, and B6) in a patient with acute and massive pulmonary embolism (“McConnell's sign”). (A1, A2, B1, B2) Parasternal long axis window; (A3, A4, B3, B4) apical window; and (A5, A6, B5, B6) subcostal window.
      Figure thumbnail gr2
      Figure 2LV wall motion abnormality revealed by 2-dimensional strain echocardiography in a patient with TC (A1) and a patient with acute massive pulmonary embolism (B1). Doppler (A2, B2) and tissue Doppler (A3, B3) studies suggested low LV filling pressure in a patient with TC (A2, A3) and a patient with acute massive pulmonary embolism (B2, B3). Both E/A and E/E′ ratios were low in both patients, suggestive of low LV filling pressure.
      (see Park et al
      • Park S.M.
      • Prasad A.
      • Rihal C.
      • Bell M.R.
      • Oh J.K.
      Left ventricular systolic and diastolic function in patients with apical ballooning syndrome compared with patients with acute anterior ST-segment elevation myocardial infarction: a functional paradox.
      )
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      References

        • Hurst R.T.
        • Prasad A.
        • Askew III, J.W.
        • Sengupta P.P.
        • Tajik A.J.
        Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology.
        J Am Coll Cardiol Img. 2010; 3: 641-649
        • Movahed M.R.
        Important echocardiographic features of Takotsubo or stress-induced cardiomyopathy that can aid early diagnosis.
        JACC Cardio Img. 2010; 3: 1200-1201
        • Mrdovic I.
        • Kostic J.
        • Perunicic J.
        • Asanin M.
        • Vasiljevic Z.
        • Ostojic M.
        Right ventricular Takotsubo cardiomyopathy.
        J Am Coll Cardiol. 2010; 55: 1751
        • Haghi D.
        • Athanasiadis A.
        • Papavassiliu T.
        • Suselbeck T.
        • Fluechter S.
        • Mahrholdt H.
        • Borggrefe M.
        • Sechtem U.
        Right ventricular involvement in Takotsubo cardiomyopathy.
        Eur Heart J. 2006; 27: 2433-2439
        • Park S.M.
        • Prasad A.
        • Rihal C.
        • Bell M.R.
        • Oh J.K.
        Left ventricular systolic and diastolic function in patients with apical ballooning syndrome compared with patients with acute anterior ST-segment elevation myocardial infarction: a functional paradox.
        Mayo Clin Proc. 2009; 84: 514-521
      1. Boppana S, Bhatta L, Liu K. Reversible tricuspid regurgitation in acute and chronic cardiomyopathies: medical management vs. surgical intervention? J Am Coll Cardiol: Cardiovasc Imaging (in press).