An 82 year -old male presented with two days of progressive abdominal pain and worsening dyspnea. His systolic blood pressure was 85 mmHg. EKG Showed deep precordial ST depression with Q waves in inferior leads.

Cardiac Catheterization:

He underwent an emergent cardiac catheterization which showed two vessel coronary artery disease [distal right coronary artery (RCA)thrombotic total occlusion, mid left anterior descending (LAD) artery thrombotic subtotal occlusion]. Left circumflex artery did not present with any significant obstruction. Left ventricular function was severely depressed with an ejection fraction of 25 %.
The patient underwent successful percutaneous intervention of RCA and LAD with stent placement. An intraaortic balloon pump was inserted for hemodynamic support.
Five days following the coronary intervention, while recovering in the hospital, the patient became hemodynamically unstable and developed respiratory distress requiring emergent intubation. At auscultation, a loud systolic murmur of mitral regurgitation was audible at the apex.
Echocardiography:

Transesophageal echocardiography showed Type II mitral valve dysfunction due to papillary muscle rupture. The prolapse of the anterior leaflet was clearly visible as shown here. On Doppler echocardiography the jet was posteriorly directed. The ruptured segment of the muscle could be directly viewed as a mobile ventricular mass. There was severe mitral valve regurgitation. The overall left ventricular systolic function was preserved.

Operative Procedure:
The patient was taken emergently to the operating room for mitral valve surgery. Following the exposure of the mitral valve, a detailed mitral valve analysis was performed and showed a prolapse of theA3 segment and the postero-medial commissure. The inspection of the left ventricle showed an extensive subendocardial hemorrhagic plaque involving the posterolateral wall. The examination of subvalvular apparatus showed a postero-medial papillary muscle with two heads. There was a complete rupture of the head which was supporting the anterior leaflet. The muscle was hemorrhagic, necrotic and very friable. The posterior head with chordae attachment to the posterior leaflet was intact. These anatomic findings were in accordance with echocardiographic findings of anterior leaflet prolapse.
The patient underwent a biologic mitral valve replacement with the preservation of the posterior leaflet. Postbypass transesophageal echocardiography showed a well-functioning bioprosthetic valve in the mitral position. Left ventricular function was mildly depressed.

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