788 Reverse McConnell’s sign in biventricular Takotsubo cardiomyopathy: how echo can guide the diagnosis
Authors: Molisana Michela , Procopio Antonio , Cicchitti Vincenzo , Caputo Marcello , Pierdomenico Sante D. 
Published: December 2021

Abstract
An 89-years-old woman presented at Emergency Department with a 10-h history of vertigo, headache, nausea, fatigue, and general discomfort. No chest pain or shortness of breath were reported. She had a history of hypertension, chronic kidney disease, paroxysmal atrial fibrillation (AF), osteoporosis, and hypoacusia. The patient suffered of chronic anxiety and the caregiver referred for a recent and acute emotional distress. At the admission, the patient didn’t show clinical signs of peripheral hypoperfusion. Fine crackles at lungs bases were objectivable with coherent ultra-sound lung comets and mild bilateral pleural effusion. Her usual therapy included nebivolol, apixaban, torsemide, candesartan, and D-vitamin. The EKG showed AF with a heart rate of about 110 b.p.m., no ST-segment deviation and normal QTc. The echo findings showed a slight increase in left ventricle volume with a severe reduction of the ejection fraction due to the akinesia of all apical segments with the typical aspect of the ‘apical ballooning’ and concomitant hyperkinesia of the basal segments. Despite normal dimensions, also the right ventricle showed a peculiar contractile pattern, with hyperkinetic basal movement and akinesia of the apex with the hinge point located in the free wall portion in continuity with the LV septal wall. No significant valvular disease was documented except for moderate tricuspid regurgitation. High-sensitive I troponin peaked up to 1500 pg/ml. The clinical appearance was very suggestive of TTS but INTERTAK score of 61 was not diagnostic and, according to the most recent consensus document, a coronary angiography was performed, without documentation of coronary artery disease. During the hospitalization serial electrocardiographic monitoring showed significant and transient QTc prolongation and dynamic T wave changes resulting in progressive INTERTAK score increase. No ventricular arrhythmic events occurred. The patient was treated with careful fluid support and with beta-blockers for AF rate control. Multiple echocardiographic evaluations documented a progressive recovery of systolic function up to complete normalization of biventricular global and regional systolic function. Clinical data, instrumental evidences and dynamic evolution oriented the diagnosis towards TTS with unusual and uneven impairment of right and left ventricular function. The described case focuses the attention on the reverse McConnell’s sign, an echocardiographic finding not often described in the literature, consisting of akinetic right ventricle apical segment and hyperkinetic basal and mid free wall. This discordant motion is exactly opposite to the classic echocardiographic RV aspect detected in acute significative pulmonary embolism described as McConnell’s sign, hence the name. It has been suggested that this functional variation might be a self-protection system of the heart through a mechanism of hibernation that is similar to that occurring during chronic hypoxia, consisting in a decrease in the ATP utilization and O2 consumption, as suggested by the activation of intracellular β2-induced signalling patterns documented in TTS. Recognizing this finding it’s important not only because it has been associated with a higher risk of developing haemodynamic instability but also to orient working diagnosis of TTS when initial clinical assessment through the INTERTAK score is inconclusive.