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60-year-old man presented to the hospital complaining of severe dyspnea with signs of respiratory
distress, hypotension, and pulmonary edema consistent with cardiogenic shock. After tracheal intubation, emergent cardiac catheterization revealed 95% stenosis of the left
circumflex artery and complete occlusion of the right coronary artery. The circumflex vessel was deemed too small for
percutaneous intervention, and despite angioplasty of the
right coronary artery, the patient remained in extremis. Transthoracic echocardiogram suggested severe mitral regurgitation possibly secondary to papillary muscle rupture; however,
images were of insufficient quality to make the diagnosis
conclusively. After placing an intraaortic balloon pump, the
patient was transferred to the operating room for coronary
artery bypass grafting, possible mitral valve surgery, and
diagnostic 2- and 3-dimensional transesophageal echocardiography (2D, 3D TEE) (IE33; Philips Medical, Bothell, WA).
TEE confirmed severe mitral regurgitation due to flail A2 and A3
scallops accompanying a posteriorly directed jet. Additionally,
inferior and lateral wall hypokinesis and mild biventricular
systolic dysfunction were identified while excluding other causes
of cardiogenic shock (Figs. 1 and 2) (Video 1 [see Supplemental Digital Content 1, http://links.lww.com/AA/A151];
Video 2 [see Supplemental Digital Content 2,
http://links.lww.com/AA/A152]; and Video 3 [see Supplemental Digital Content 3, http://links.lww.com/AA/A153]; see
Appendix for video captions). Coronary artery bypass grafting
and mitral valve replacement were subsequently performed
with improved ventricular function and wall motion patterns,
and after a 4-week recovery, the patient was discharged from the
hospital.
Papillary muscle rupture complicates the course of 1% to
3% of patients with acute myocardial infarction and almost
always involves the posteromedial papillary muscle because
of its solitary blood supply from the posterior descending
artery.1 The mitral A1, P1, and P2 regions are typically
supported by chordae tendineae arising from the anterior
papillary muscle and are generally intact with posteromedial
papillary muscle rupture. Inferior wall motion abnormalities
are typically seen in this setting of posterior descending artery
From the Division of *Cardiothoracic Anesthesiology and Cardiothoracic
Surgery, Scott & White Hospital, The Texas A&M University College of
Medicine, Temple, Texas.
Accepted for publication March 12, 2010.
Supported by routine departmental sources.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.anesthesia-analgesia.org).
The authors sought and received written permission from the patient to
report the case.
Address correspondence and reprint requests to William C. Culp, Jr., MD,
Division of Cardiothoracic Anesthesiology, Scott & White Hospital, The
Texas A&M University College of Medicine, 2401 South 31st St., Temple, TX
76508. Address e-mail to wculp@swmail.sw.org.
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181e29c24
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affected scallops is possible with this single imaging plane, confirming and refining the diagnosis.
AUTHOR CONTRIBUTIONS
www.anesthesia-analgesia.org
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ECHO ROUNDS
6. Macnab A, Jenkins NP, Bridgewater BJM, Hooper TL, Greenhalgh DL, Patrick MR, Ray SG. Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the
assessment of regurgitant mitral valve morphology. Eur J
Echocardiogr 2004;5:21222
Papillary muscle rupture may occur within 1 day to 1 month after myocardial infarction. It almost always involves the
posteromedial papillary muscle due to its single-vessel perfusion from the posterior descending coronary artery. The
mitral scallops tethered to it (A2, A3, and P3) prolapse into the left atrium during ventricular systole causing severe
mitral regurgitation.
In the midesophageal 4-chamber or midesophageal long-axis view, the mitral regurgitant jet will be seen directed away
from the prolapsing scallops. Associated inferior or lateral wall motion abnormalities, along with a supporting clinical
history, should differentiate a ruptured papillary muscle head (along with its chordal attachments) from other mobile
pedunculated masses such as vegetation, tumor, or thrombus. The transgastric 2-chamber and long-axis views are
particularly useful because of the perpendicular orientation of the ultrasound beam with the papillary muscles,
facilitating visualization of the tissue defect and the to-and-fro motion of the ruptured muscle and chordae.
In this case, 3-dimensional real-time transesophageal echocardiography (TEE) was used to generate an en face view
of the mitral valve (looking down, from the left atrium perspective) and confirm the presence of a ruptured posterior
papillary muscle and the associated flail A2 and A3 scallops.
The anatomic and physiologic presentation of papillary muscle rupture should be apparent with a comprehensive
examination of the mitral apparatus using standard, 2-dimensional TEE imaging. Three-dimensional real-time TEE
generates multiple imaging planes of the mitral valve from different perspectives, further assisting in diagnosing the
etiology of mitral regurgitation. However, lower video frame rates and increased expense remain substantial
limitations.
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