Abstract 16856: The Upside Down: A Case of Reverse McConnell’s Sign in Mixed Shock and ARDS

Abstract

Introduction: We present a case of reverse McConnell’s sign in shock and respiratory failure. Hospital Course: A 48-year-old woman with cirrhosis presented to the emergency department with hypoxia, hypotension, and tachycardia. She endorsed lower extremity edema and orthopnea. Labs noted elevated BNP, procalcitonin, troponin, and lactate. Urinalysis showed signs of infection. EKG did not reveal ischemic changes. CT pulmonary embolism (PE) protocol was negative for PE but showed pulmonary edema. Parasternal short axis views on bedside ultrasound revealed interventricular septal flattening during systole consistent with right ventricular pressure overload ("D sign"). She received broad-spectrum antibiotics for E. coli bacteremia. Trans-thoracic echocardiogram showed a hyperdynamic LV and decreased RV function with a "reverse McConnell sign (rMS)" (figure 1). Providers initiated diuresis once her vasopressor requirement stabilized. She was soon extubated and her oxygen requirement continued to improve with diuresis. Vasopressors weaned in several days. Prior to discharge, trans-thoracic echocardiogram echo showed recovery of RV function. Discussion: This case of respiratory failure and shock highlights the value of prompt echocardiography. Her rMS was likely caused by increased pulmonary arterial pressure from hypoxic vasoconstriction and V/Q mismatch from ARDS. Other heart failure processes seem unlikely. rMS refers to right apical hypokinesis and basal hyperkinesis, inverted compared to its counterpart. Cases are associated with PE and Takotsubo cardiomyopathy, but rMS likely more generally indicates right heart strain. Evidence suggests that rMS may be associated with higher rates of comorbidities and adverse events. Finally, it may represent the RV’s protective mechanism for abruptly increased afterload. Conclusion: Providers should consider rMS as a sign of RV strain to assist diagnosis and management of undifferentiated shock.