Papillary Muscle Rupture After Delayed Inferior ST-Segment Elevation Myocardial Infarction: Rapid Diagnosis and Impella-Assisted Surgical Rescue

Document Type

Conference Proceeding

Publication Date

5-2026

Publication Title

American Journal of Respiratory and Critical Care Medcine

Abstract

Papillary muscle rupture (PMR) is a rare but catastrophic mechanical complication of myocardial infarction (MI), occurring in fewer than 1% of cases. It typically presents with cardiogenic shock and pulmonary edema within days of infarction. Despite advances in reperfusion therapy, delayed presentation continues to pose diagnostic and management challenges, and survival depends on rapid diagnosis and timely surgical intervention. A 68-year-old man with prior thoracic aortic aneurysm repair and daily tobacco use presented with one week of intermittent chest pain that acutely worsened on the day of admission. He was diaphoretic, tachycardic, and hypoxic, with a new systolic murmur. Electrocardiography (ECG) showed inferior ST-segment elevation and a troponin level of 3,377 ng/L. Given his prior aneurysm repair and tearing chest pain, computed tomography angiography (CTA) ruled out aortic dissection. Coronary angiography revealed multivessel disease with 99% mid-right coronary artery (RCA) stenosis. During the procedure, he developed hypotension requiring hemodynamic support. Transesophageal echocardiography (TEE) demonstrated a flail posterior mitral leaflet with severe regurgitation due to posteromedial PMR. An Impella CP device stabilized the patient before emergent surgery. He underwent mitral valve replacement and double-vessel coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and a saphenous vein graft (SVG) to the RCA, with Impella removal. Intraoperatively, the papillary muscle was completely ruptured at its base, with preserved left ventricular systolic function and inferior wall hypokinesia. Postoperatively, he was supported with inotropes and weaned over 48 hours. Repeat echocardiography confirmed normal biventricular function. This case underscores the importance of recognizing PMR in late or atypical ST-segment elevation myocardial infarction (STEMI). Prompt use of multimodal imaging (CTA, coronary angiography, and TEE) was key to diagnosis. Temporary mechanical support allowed stabilization and safe surgery through rapid coordination among interventional, surgical, and critical care teams, a multidisciplinary approach that can significantly reduce mortality in this otherwise fatal complication.

Volume

212

Issue

S1

First Page

S1056

Comments

American Thoracic Society International Conference, May 15-20, 2026, Orlando, FL

Last Page

S1056

DOI

10.1093/ajrccm/aamag162.1403

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