Three-Dimensional Imaging in Rupture of Papillary Muscle After Acute Myocardial Infarction
A 62-year-old male was referred to our hospital for cardiogenic shock. Two weeks before, he complained of transient epigastric pain; 1 hour before admission, he underwent advanced life support maneuvers because of the onset of severe dyspnea and a syncopal attack with 2 episodes of asystole that occurred during transportation to our coronary care unit. A 12-lead ECG tracing and cardiac enzyme levels were consistent with a diagnosis of myocardial infarction.
At admission, he underwent a routine 2D echocardiographic examination (Figure 1; Movie I), which showed akinetic inferior and inferolateral left ventricular walls, complete rupture of the inferomedial papillary muscle of the left ventricle, and mitral regurgitation of a severe degree. Although a severe prolapse of the mitral leaflets was found, no images of the systolic eversion of the papillary muscle in the left atrium were recorded because of the presence of residual chordae binding the ruptured muscle to the ventricular free wall (Figure 1B). A 3D echocardiographic examination was performed with a Sonos 7500 (Phillips) with the 3D live mode (Figure 2; Movies II and III). Thus, the exact shape and movement of the ruptured papillary muscle and its ruptured base were imaged. The volume data-set analysis showed binding of the papillary muscle to the left ventricular wall as the cause of the absence of its systolic eversion in the left atrium. Eventually, the patient underwent successful prosthetic mitral valve implantation and single CABG implantation with complete restoration of neurological integrity and no extension of the left ventricular asynergic area. The ruptured papillary muscle and excised mitral valve are shown in Figure 3.
We thank Claudio Bellini and Barbara Hildebrand for their assistance in the preparation of the artwork and the manuscript, respectively.
Movies I, II, and III may be found in the online-only Data Supplement at http://circ.ahajournals.org/cgi/content/full/111/23/e385/DC1.