Images in Clinical Medicine

Rupture of Papillary Muscle during Acute Myocardial Infarction

Rajiv Verma, M.D., and Israel Freeman, M.D.

N Engl J Med 1999; 341:247July 22, 1999

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Figure 1 Examination of a 48-year-old man with a two-hour history of chest pain and dyspnea revealed him to be acutely ill, with tachypnea, a blood pressure of 100/60 mm Hg, a pulse rate of 117 beats per minute, and severe pulmonary edema, necessitating intubation and mechanical ventilation. The electrocardiogram (Panel A) revealed sinus tachycardia, left atrial and ventricular enlargement, and ST-segment depression in leads I, II, III, aVF, V₃, V₄, V₅, and V₆. Transthoracic echocardiography showed complete rupture of the anterolateral papillary muscle (arrow in Panel B), prolapse of the muscle into the left atrium (arrow in Panel C), and severe mitral regurgitation (Panel D). Cardiogenic shock developed despite treatment with dobutamine, nitroprusside, and an intraaortic balloon pump. The patient died on the way to the operating room.

Rajiv Verma, M.D.
Israel Freeman, M.D.
Nassau County Medical Center, East Meadow, NY 11554