Diagnostic approaches of mitral valve papillary muscle rupture in a case of posterior STEMI

Introduction: The mechanical complications of acute myocardial infarction are rare in today’s reperfusion era but can have serious consequences. Papillary muscle rupture follows a myocardial infarction or occurs secondary to infective endocarditis. Acute rupture frequently results in severe mitral valve regurgitation, acute life-threatening cardiogenic shock, and pulmonary edema. In this case report, we aimed to present the diagnostic management of acute chordae rupture after myocardial infarction. Case: A 59-year-old woman with hypertension and diabetes mellitus comorbidities was admitted to the Emergency Department with chest pain for a week. Dyspnea and respiratory distress were noted. Vital values were blood pressure 90/60, saturation 85%, pulse 110/min. Posterior and lateral segment ST elevation was observed on ECG (Figure 1). Echocardiography revealed severe mitral regurgitation and hypokinesia in the posterior and lateral walls. (Figure 2) The patient with acute pulmonary oedema was intubated. Sedated. Under hypotension and critical clinical condition, urgent angiography was performed. Coronary angiography revealed that Circumflex artery was totally occluded. Then Through the lesion was crossed using a 0.014 floppy guidewire. The lesion was predilated with a 2.5x 15 MM PTCA compliant balloon. A 3.5x19 mm drug eluting stent was implanted in the residual lesion. TIMI 3 flow was achieved. Ventriculography confirmed severe mitral regurgitation. (Figure 3) An emergency mitral valve operation was performed by the cardiothoracic surgeons. A 27 mm mechanical mitral valve was replaced, and the ruptured posterolateral papillary muscle was resected (Figure 4). In the intensive care unit monitoring, mitral valve was functional, and EF was 45%. The patient was followed up with aspirin, clopidogrel and warfarin. The patient died on the 6th day of intensive care follow-up due to pulmonary capillary hemorrhage and respiratory failure. Conclusions: The critical importance of diagnosis and intervention in acute papillary muscle rupture following myocardial infarction, as early detection and treatment can be crucial in preventing fatal outcomes. Also, the severity and potential fatality of mechanical complications following myocardial infarction, even with prompt intervention.