Extract

An 82-year-old male presented with acute increasing fatigue. A chest X-ray revealed diffuse congestion. Transthoracic echocardiography showed a hyperkinetic left ventricle, but mitral regurgitation (MR) was not clearly visualized. After examination, the patient suddenly went into shock.

Transoesophageal echocardiography (TEE) was performed and showed flail of the mitral leaflet, a mobile mass, and severe MR. A volume rendering image of three-dimensional (3D) TEE demonstrated prolapsed A2, A1, and P1 scallops and a mobile mass attached to the leaflet, which went to the left atrium (Panels A and C, and see Supplementary data online, Video S1 and Supplementary Data). A multiplanar reconstruction image revealed that the anterior papillary muscle (APM) prolapsed to the left atrium during systole (Panel D and see Supplementary data online, Video SSupplementary Data). We made a diagnosis of complete rupture of the APM. The patient was referred for emergent surgery.

On surgical inspection, total complete rupture of the tip of APM was found (Panel B). Mitral valve replacement was performed successfully. No significant stenosis was detected by coronary computed tomography after surgery. Pathological examination showed no findings of endocarditis of the mitral leaflet (Panel E), but showed the neutrophil infiltration in the papillary muscle suggesting acute suppurative myocarditis (Panel F). The patient was uneventfully discharged.

You do not currently have access to this article.