A Case of Reverse McConnell’s Sign Associated With Acute Respiratory Distress Syndrome and Septic Shock

Abstract

We present a case of reverse McConnell’s sign, a rare echocardiographic finding of right ventricular apical hypokinesis and basal hyperkinesis, in a patient with acute respiratory distress syndrome and septic shock. Although multiple etiologies were hypothesized, providers attributed this cardiomyopathy to increased right heart afterload from hypoxic pulmonary vasoconstriction. Cardiac function normalized as the patient's respiratory failure and sepsis resolved. This study highlights the value of early echocardiography to help guide management in critical illness. In our case, this finding helped initiate diuresis and establish a baseline for monitoring cardiac function as this patient's critical illness resolved. Literature has most commonly associated reverse McConnell’s sign with massive pulmonary embolism and, more rarely, takotsubo cardiomyopathy. Given the absence of PE, takotsubo, or other identifiable cause, this case suggests that reverse McConnell’s sign may more generally indicate acutely increased right ventricular afterload rather than a specific diagnosis. When reverse McConnell’s sign is detected, treatment should focus on reversible causes of elevated right heart pressure (e.g., volume overload, PE) and increased pulmonary resistance.