Spontaneous Anterolateral Papillary Muscle Rupture Complicated by Acute Torrential Mitral Regurgitation and Cardiogenic Shock: A Case Report

Spontaneous papillary muscle rupture is a rare and life-threatening event. We present the case of a 70-year-old male who presented with shortness of breath and cough, with imaging findings consistent with flash bilateral pulmonary edema. Due to progressive respiratory failure and cardiogenic shock, he required emergent intubation and initiation of inotropic and vasopressor support. Transthoracic echocardiogram was concerning for a flail anterior mitral leaflet and showed normal left ventricular systolic function. As there was concern for acute mitral regurgitation, an emergent transesophageal echocardiography was performed and showed severe mitral regurgitation with a flail anterior mitral leaflet secondary to a ruptured anterolateral papillary muscle. The patient underwent emergent intra-aortic balloon pump placement and coronary angiography, which revealed 80% stenosis of the proximal left anterior descending artery. Subsequently, the patient underwent mitral valve replacement and single-vessel coronary artery bypass grafting (CABG) with the initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Post-surgery, a repeat transthoracic echocardiography (TTE) revealed severe biventricular systolic dysfunction. His hospital course was further complicated by the development of a large left atrial thrombus, necessitating removal of VA-ECMO and subsequently placement of an Impella (Abiomed, Danvers, MA) and right ventricular assist device (RVAD). After a prolonged hospital stay, the patient's condition stabilized, and he was discharged home with follow-up echocardiography demonstrating a recovered ejection fraction.