Acute Mitral Regurgitation Presenting as Unilateral Pulmonary Edema

Acute mitral regurgitation caused by papillary muscle rupture is a rare and life-threatening complication of myocardial infarction. This devastating complication can present as unilateral cardiogenic pulmonary edema which can be easily mistaken for other cardiopulmonary pathology, resulting in delay of care. Proper evaluation and diagnosis is key for obtaining timely surgical evaluation. Here we present a case of an 87-year-old male with a past medical history of coronary artery disease status post percutaneous intervention with one stent, cerebrovascular accident status post left carotid stenting, and Alzheimer’s dementia that presented to the emergency department with a chief complaint of exertional dyspnea for three days. In the emergency department, he required 5L O2 by nasal cannula to maintain an oxygen saturation of 93%. He never required supplemental oxygen previously. Physical exam was significant for rales in the right lower lobe. No murmur, jugular venous distention, or pitting edema were noted. Chest imaging revealed right-sided infiltrate versus edema with a small right lower lobe effusion. The left lung was grossly normal on imaging. The patient was admitted to the medicine service and treated with IV antibiotics. Echocardiogram was later performed which showed an LV ejection fraction of 55-60% with new onset severe mitral regurgitation. The patient was urgently taken for cardiac catheterization and found to have critical coronary artery disease. An intra-aortic balloon pump was placed, and surgical evaluation was planned for possible CABG/MVR. However, patient was deemed to not be an appropriate surgical candidate and was subsequently transferred for placement of ventricular assist device and eventual Mitra Clip. Ultimately, the patient decompensated, and was transitioned to hospice care before passing away 22 days after initial presentation.