Severe "silent" mitral regurgitation after myocardial infarction: a clinical conundrum.

Transesophageal Echocardiography as an Important Tool in the Diagnosis of Postinfarction Papillary Muscle Rupture

“…This is likely to be due to a combination of poor patient positioning in the critical care setting with additional problems from mechanical ventilation limiting adequate acoustic windows. Several recent reports on the limita tions of transthoracic echocardiography in papillary mus cle rupture have shown that our experience is not unique [9][10][11][12], Importantly, the absence of severe mitral incom petence by color flow mapping may be particularly mis leading, due to eccentricity of the regurgitant jet [8], Con versely, the proximity of the transesophageal probe to the heart allows unimpeded views to be obtained. As shown in our 3 cases, unambiguous information may be readily obtained by this procedure, including adequate visualiza tion of the regurgitant jet of mitral incompetence.…”

Diagnostic Pitfalls in Papillary Muscle Rupture-Associated Acute Mitral Regurgitation after Acute Myocardial Infarction

“…It has been reported that murmurs are inaudible in almost 50% of cases of moderate to-severe acute MR, particularly those with acute ischemic MR [ 4 ]. The absence of a murmur is attributable to the rapid equalization of left atrial and ventricular pressures with decreased regurgitant volume through the mitral valve [ 1 , 4 , 5 ]. Therefore, the absence of murmur does not rule out acute severe MR.…”

Papillary Muscle Rupture Complicating Acute Myocardial Infarction

“…In the context of PMR with “wide open” MR, the absence of a murmur may belie equalization of pressures between the left atrium and left ventricle, with decreased regurgitant volume through the valve in the setting of cardiogenic shock. This has been termed “silent MR” ( 5 , 6 ) and highlights the importance of maintaining a high index of suspicion and understanding various physiologic presentations of PMR.…”