Question: A classic sign may clinch the diagnosis in a desaturated patient

This Spot the Diagnosis article refers to ‘Answer: A classic sign may clinch the diagnosis in a desaturated patient’, by D.P. Raja et al., https://doi.org/10.1093/ehjacc/zuad160.

Case

A 65-year-old lady with no prior comorbidities had undergone vaginal hysterectomy for uterine prolapse. On post-operative Day 3, she developed acute onset breathlessness. On examination, she had tachycardia, tachypnoea, 90% oxygen saturation in room air, elevated jugular venous pressure, right ventricular S3, and soft pan systolic murmur at the left lower sternal border. The chest X-ray was not conspicuously abnormal. Electrocardiogram showed a heart rate of 100/min and S1Q3T3 pattern with minimal fragmentation of QRS complex in V1 with strain pattern (Figure 1A). Echocardiogram revealed right ventricular dysfunction, tricuspid annular plane systolic excursion (TAPSE) of 12 mm, mild tricuspid regurgitation, pulmonary artery systolic pressure of 50 mmHg, pulmonary acceleration time of 36 ms, and regional wall motion abnormalities of the right ventricular free wall with apical sparing (Figure 1B and C, Supplementary material online, Video S1 and S2). Troponin T was minimally elevated with significant elevation of D-dimer.

Figure 1

(A) Twelve-lead electrocardiogram showing a heart rate of 100/min and S1Q3T3 pattern with minimal fragmentation of QRS complex in V1 with strain pattern, (B) 2D echocardiogram in apical four-chamber view in diastole showing dilated right ventricle (arrows—RV free wall), and (C) 2D echocardiogram in apical four-chamber view in systole showing dyskinesia of the mid-segment free wall of the right ventricle with a significant contractile movement of the apex inward causing a notch (arrowheads).

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What is the likely aetiology?

1. Takotsubo cardiomyopathy

2. Acute pulmonary thromboembolism

3. Acute myocardial infarction

4. Myocarditis

Supplementary material

Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.

Author contribution

D.P.R. [Conceptualization (equal), Formal analysis (equal), Writing—original draft (equal), Writing—review & editing (equal)], S.M. [Conceptualization (equal), Formal analysis (equal), Writing—original draft (equal), Writing—review & editing (equal)], and S.K.G. [Writing—review & editing (equal)].

Funding

None declared.

Data availability

The data underlying this article are available in the article and in its online Supplementary material.

Author notes