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A 26-year-old man with an unremarkable medical history sensed a momentary retrosternal ‘pop’ followed by overwhelming dyspnoea, without reporting any prodromal symptoms. At the emergency department, he had a significant tachycardia (170 bpm) and an extreme low diastolic blood pressure (<30 mm Hg). A loud, harsh and continuous murmur could be maximally auscultated at the right lower sternal border. ECG revealed global ST depression with ST elevation in lead aVR. Transthoracic echocardiography revealed severe aortic insufficiency and a high index of suspicion for a congenital cardiac anomaly; however, findings remained inconclusive. Transoesophageal echocardiography (figure 1A,B, online supplementary videos 1 and 2), cardiac CT (online supplementary figure 1A) and cardiac catheterisation (online supplementary figure 1B, supplementary video 3) were performed for diagnostic confirmation.
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C-WH and T-WL contributed equally.
Contributors All authors have substantial contribution to the manuscript.
Funding The study was funded by the National Cheng Kung University Hospital (10.13039/501100004844), grant number NCKUH-10603019.
Competing interests None declared.
Patient consent Obtained.
Ethics approval The study was approved by the Institutional Review Board (IRB) of National Cheng Kung University Hospital A-EC-107001.
Provenance and peer review Not commissioned; externally peer reviewed.
Correction notice Since this image challenge was first added online the IRB approval ID has been added in the footnotes.