Acute Mitral Valve Regurgitation due to Complete Rupture of Anterior Papillary Muscle Mimicking Mitral Valve Vegetation

Abstract

We report the successful treatment of a 77-year-old man after a difficult diagnosis of mitral valve regurgitation resulting from complete rupture of the anterior papillary muscle. The patient with cardiogenic shock was an emergency admission. An electrocardiogram showed acute lateral wall myocardial infarction. He had complications of leukocytosis and a highgrade fever. Transesophageal echocardiography seemed to show the appearance of a large area of vegetation attached to the anterior mitral valve leaflet and aortic non-coronary cusp, resulting in severe mitral regurgitation. We performed coronary angiography, which showed complete obstruction of the circumflex coronary artery. We determined that the condition was caused by infective endocarditis. Emergency surgery showed the complete rupture of the anterior papillary muscle, but there was no vegetation. The mitral valve was replaced with a bioprosthetic valve and the circumflex coronary artery was bypassed with a saphenous vein graft. Pathological examination revealed mitral valve to be non-mycotic, and the postoperative course was uneventful.

Postpartum Rupture of the Posteromedial Papillary Muscle

“…Although the standard treatment for acute papillary muscle rupture is emergent mitral valve replacement, preoperative stabilization of such patients that are in florid cardiogenic shock may be challenging. Intra‐aortic counterpulsation balloon pump (IABP) support can be initiated quickly while diagnosis and stabilization are being accomplished, and may be a useful adjunct in such a scenario, as reported in similar cases 1,9 . An IABP was placed in our patient after she was already in severe cardiogenic shock.…”

“…Transesophageal echocardiography is more sensitive than TTE in diagnosing mitral valvular pathology. However, with tachycardia, clear discrimination of mitral leaflet vegetation from a torn papillary muscle head can be impossible, even with TEE, as recently reported 9 …”

Acute mitral valve regurgitation after acute coronary syndrome

“…All three are theorized to be consequences of lost tissue integrity from infarcted myocardium and carry a mortality of about 80% if not treated within the fi rst 24 hours. 1 Fortunately, advances in technology, operating technique, and early revascularization protocols mean that papillary muscle rupture after surgical revascularization occurs in just 2.3% of patients with acute MI. 2 Because papillary muscle rupture is diffi cult to recognize, suspect it in acutely decompensating patients presenting in heart failure.…”

“…The posteromedial papillary muscle has limited blood supply from the posterior descending artery, making it 6 to 12 times more prone to ischemia and rupture. 1 Clinicians should monitor patients closely in the days after MI because of the increased risk of mechanical abnormalities resulting from the structural deterioration of ischemic cardiac tissue. JAAPA…”

The role of echocardiography in acute myocardial infarction

“…3 Another ominous complication rapidly detectable by echocardiography is acute mitral regurgitation secondary to papillary muscle rupture. 4 Acute dynamic left ventricular outflow tract obstruction is another entity which can be uncovered by echocardiography. 5 …”