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Open Access 02-02-2023 | Image Puzzle – Question

The spells of iatrogeny

Auteurs: A. F. Cardoso, G. Dias, B. Faria, F. Almeida, A. Lourenço

Gepubliceerd in: Netherlands Heart Journal | Uitgave 5/2023


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Video 1 Transthoracic echocardiogram, apical 4‑chamber view

Video online

The online version of this article contains one video. The article and the video are online available (https://​doi.​org/​10.​1007/​s12471-023-01761-8). The video can be found in the article back matter as “Electronic Supplementary Material”.
A 50-year-old female presented to the emergency department with complaints of tiredness, atypical chest pain, nausea and headache for the last 3 days. She had a 2-year history of arterial hypertension. On admission, her blood pressure was 120/70 mm Hg, her heart rate was 100 bpm and she was apyretic. Physical examination was unremarkable. The electrocardiogram (ECG) showed a sinus rhythm with poor R wave progression and biphasic T waves in the precordial leads. Blood tests revealed elevated levels of high-sensitivity troponin I (745 ng/l; reference value < 45) and N‑terminal-prohormone brain natriuretic peptide (5000 pg/ml; reference value < 125). Transthoracic echocardiography showed moderate left ventricular dysfunction with akinesis of mid and apical segments.
She was admitted with the diagnosis of probable Takotsubo cardiomyopathy. ECG evolved with deep inverted T waves on precordial leads. She was started on beta-blocker therapy (carvedilol 6.25 mg), and intravenous metoclopramide was administered for nausea control. Soon thereafter, we observed significant clinical worsening. The patient evolved with pallor, diaphoresis, worsening headache and palpitations. ECG and invasive blood pressure monitoring are represented in Fig. 1a. Echocardiography showed superimposed left ventricular alterations. In subcostal view, a heterogeneous mass with well-defined borders, measuring approximately 48 × 61 mm, was visible under the liver (Fig. 1b and see Video 1 in Electronic Supplementary Material).
What is the most likely diagnosis?


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No funding was required for this manuscript.

Conflict of interest

A.F. Cardoso, G. Dias, B. Faria, F. Almeida and A. Lourenço declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.

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Supplementary Information

Video 1 Transthoracic echocardiogram, apical 4‑chamber view
The spells of iatrogeny
A. F. Cardoso
G. Dias
B. Faria
F. Almeida
A. Lourenço
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 5/2023
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250

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