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[Early papillary muscle rupture in myocardial infarction, diagnosis with transesophageal echography]
F Casazza1, D Malaspina, C Montaperto
1Divisione di Cardiologia, Ospedale S Carlo Borromeo, Milano.
Abstract:
We describe the case of posterior papillary muscle (PPM) rupture with severe mitral regurgitation at the very beginning of an inferior myocardial infarction (MI) in a 79-year-old woman. The diagnosis was made by transesophageal echocardiography (TEE) and confirmed at autopsy. This case confirms the value of TEE in diagnosing PPM rupture and the association of PPM rupture with small posterior myocardial infarction. Moreover the case presents some unusual aspects: the rupture occurred very early; at transthoracic approach, a systolic convergence flow zone was the only sign of mitral regurgitation by color flow mapping; at TEE flail mitral leaflets were absent; in systole, the trunked papillary muscle did not prolapse into the left atrial cavity, but crushed into the atrial side of posterior mitral leaflet, remaining at the atrioventricular level; at autopsy, there was a split PPM with a completely ruptured medial branch. On the atrial side of the posterior mitral leaflet there was an ecchimothic zone, due to the crushing of the PPM.
Insights
Posterior papillary muscle rupture causing severe mitral regurgitation can occur early in myocardial infarction. Transesophageal echocardiography is crucial for diagnosing this rare but serious complication.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pathology
Background:
- Posterior papillary muscle (PPM) rupture is a rare but often fatal mechanical complication of myocardial infarction (MI).
- Early diagnosis and intervention are critical for improving patient outcomes.
Observation:
- A case of early-onset PPM rupture with severe mitral regurgitation during an inferior MI in a 79-year-old woman.
- Diagnosis was established using transesophageal echocardiography (TEE) and confirmed by autopsy.
- Unusual findings included early rupture, subtle transthoracic echocardiogram signs, absence of flail mitral leaflets on TEE, and unique papillary muscle behavior during systole.
Findings:
- TEE proved valuable in diagnosing PPM rupture, highlighting its association with small posterior MIs.
- Autopsy revealed a split PPM with a ruptured medial branch and an ecchymotic zone on the posterior mitral leaflet due to muscle crushing.
- The ruptured papillary muscle segment crushed into the posterior mitral leaflet rather than prolapsing into the left atrium.
Implications:
- This case underscores the diagnostic utility of TEE in identifying PPM rupture, even with atypical presentations.
- It emphasizes the importance of considering PPM rupture in patients with acute MI and new-onset severe mitral regurgitation.
- Understanding the specific mechanisms of PPM rupture can refine diagnostic and therapeutic strategies for this critical cardiac emergency.