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Mark Gabot: Subcostal 4-Chamber View – PE with McConnell Sign

Mark Gabot/LinkedIn

Nov 1, 2026, 13:08

Mark Gabot: Subcostal 4-Chamber View – PE with McConnell Sign

Mark Gabot, Limited Partner at Nurse Capital, shared a post on LinkedIn:

“Subcostal 4-Chamber View: Pulmonary Embolism (PE) with McConnell Sign

Echocardiographic Findings:

Right ventricular (RV) dilation: Enlarged RV, potentially approaching or exceeding LV size (RV/LV ratio at least 1), suggesting acute RV pressure overload.

McConnell Sign: Regional RV dysfunction characterized by akinesis or severe hypokinesis of the RV mid-free wall with relative preservation of apical contractility.

Reduced RV systolic function: Impaired RV free-wall contraction secondary to increased pulmonary vascular resistance.

Interventricular septal flattening: Leftward septal displacement from RV pressure overload, potentially producing a D-shaped LV (best appreciated in the parasternal short-axis view).

Dilated inferior vena cava (IVC): Reduced respiratory collapsibility, suggesting elevated right atrial pressure.

Clinical significance

Acute PE – Increased pulmonary vascular resistance – RV pressure overload – RV dilation and dysfunction – Reduced LV preload – Potential obstructive shock.

Key teaching point:

McConnell sign is suggestive of acute PE in the appropriate clinical context but is NOT pathognomonic. It can also occur with RV myocardial infarction and other causes of RV dysfunction.

POCUS Pearl: The subcostal 4-chamber view is particularly useful during resuscitation when parasternal and apical windows are difficult to obtain. Assess RV size, free-wall motion, septal position, and overall biventricular function.

Important: Echocardiography identifies RV strain rather than directly confirming PE. A normal RV does not exclude PE, and McConnell sign alone is insufficient for diagnosis.”

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