COTW: December 14th: A middle-aged male with a few days of worsening SOB...

A 44 year-old male comes in with 4 days of worsening shortness of breath and peripheral edema for 4 days. He has no significant Past Medical History but does admit to chronic methamphetamine use. Initial vitals show a stable hemodynamic status with hypoxemia satting at 90% with NC @ 4L/min, so you put some gel on the chest:

A4CH shows a large RV as compare to the LV size. Further inspection shows the RV free wall is hypodynamic, whereas the RV apex appears hyperdynamic (RV apical wink). This is also known as McConnell’s sign, a sign of pulmonary hypertension.

PLAX: The LV function appears normal, but notice how the interventricular septum bulges away from the RV, also consistent with elevated RV pressures.

Now focus on the RV free wall thickness, which is approximately 1cm. The normal upper limit of RV wall thickness is 5mm. This finding should not be present in acute pulmonary hypertension, as the RV needs enough time to remodel and show evidence of hypertrophy.

After obtaining further medical records that weren’t initially available, the patient had recently been diagnosed with chronic pulmonary hypertension, most likely due to chronic methamphetamine use.

POCUS Pearl:

While McConnell’s sign has been frequently described in the literature as highly specific for PE, most studies exclude patients with chronic pulmonary HTN, a population in which this is not an uncommon finding. Therefore, always integrate your pre-test probability and assess for evidence of chronic pulmonary hypertension by measuring RV free wall thickness.