Two dimensional echocardiographic diagnosis of partial papillary muscle rupture.

SUMMARY Two dimensional echocardiography showed partial rupture of the trunk of the posteromedial papillary muscle after acute inferior myocardial infarction. The findings in this case suggest that partial rupture may be a harbinger of complete rupture. By virtue of its ability to visualise noninvasively detailed anatomy of cardiac structures in real-time format, two dimensional echocardiography is ideally suited to diagnose mechanical (structural) complications of acute myocardial infarction. Structural disruptions after acute myocardial infarction are uncommon but are potentially correctable with timely diagnosis and treatment.1 2 We describe a patient with acute partial papillary muscle rupture, complicating acute myocardial infarction, diagnosed by two dimensional echocardiography. Case report A 67 year old white man was transferred to the Mayo Clinic f6r evaluation of cardiogenic shock. He had a history of stable angina but no hypertension or previous myocardial infarction. Two weeks before transfer, the patient sustained an acute inferior myo-cardial infarction, was admitted to hospital, and was found to be in shock, with pulmonary oedema. Despite initial improvement with medical treatment, he subsequently became hypotensive again and was transferred for further evaluation. On physical examination, the patient was in respiratory distress. The blood pressure was 100/60 mmHg and the pulse 100/min. The jugular venous pressure was raised. Bibasilar riles were noted. The left ventricular impulse, located in the anterior axillary line, was widened and hyperdynamic. No thrill was palpable. A grade 4/6 pansystolic apical murmur and a third sound were present. The remainder of the physical examination was normal. An electrocardiogram showed sinus rhythm and changes consistent with a recent inferior wall myo-cardial infarction. The chest x-ray film showed cardiac enlargement with pulmonary venous congestion. Bedside assessment of the haemodynamic data (Swan-Ganz catheter) is shown in the Table. Two dimensional echocardiography showed that the left ventricle was moderately dilated with depressed function. There was extensive and severe inferior wall hypokinesis, with involvement of the inferior septum and lateral walls as well, consistent with a large infero-lateral wall infarction. The anterior ventricular septum was hyperdynamic. A partial rupture of the trunk of the posteromedial papillary muscle was seen (Fig), with normal coaptation of the mitral leaflets. Using afterload reduction treatment and positive inotropic agents, the patient's condition remained stable. On the seventh hospital day, the patient suddenly became hypotensive and dyspnoeic, with an increase in the size of the "V" wave on the wedge tracing. This rapid deterioration was thought to be the …