Wretched Excess: Stool-softener Abuse and Cardiogenic Shock

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Wretched Excess: Stool-softener Abuse and Cardiogenic Shock Tiberio M. Frisoli, MD, Daniel G. Swistel, MD, Harikrishna Makani, MD, Mark V. Sherrid, MD The American Journal of Medicine Volume 126, Issue 9, Pages 773-775 (September 2013) DOI: 10.1016/j.amjmed.2013.04.013 Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 1 Top panel, This late diastolic apical 3-chamber view shows asymmetric septal hypertrophy (thick arrow), the mitral valve anterior leaflet (arrowhead), and the large anteriorly-displaced papillary muscle in the left ventricular outflow tract that inserted into the middle of the anterior mitral leaflet without intervening chordae (thin arrows). This anomalous papillary muscle caused dynamic left ventricular outflow obstruction both because of direct systolic contact with the septum and because it prepositioned the mitral valve anteriorly in the outflow tract, inducing mitral systolic anterior motion. Bottom panel, Continuous wave Doppler echocardiography through the left ventricular outflow tract displays a systolic left ventricular outflow tract gradient of 160 mm Hg. Ao= aorta, LA= left atrium, LV= left ventricle. The American Journal of Medicine 2013 126, 773-775DOI: (10.1016/j.amjmed.2013.04.013) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 2 Relative to the normal papillary muscle, the anomalous accessory papillary muscle (arrow) was located medially. In this picture; the normal muscle can be seen to the right of the anomalous muscle. Attached to the A1 segment of the anterior mitral leaflet, the anomalous muscle was removed during surgery. The American Journal of Medicine 2013 126, 773-775DOI: (10.1016/j.amjmed.2013.04.013) Copyright © 2013 Elsevier Inc. Terms and Conditions