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Acute dyspnoea two days after chest pain
  1. J Eckstein,
  2. F Rueter,
  3. A Linka

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A 78 year old woman presented to a local hospital 10 hours after onset of typical angina. Based on symptoms of acute chest pain, ST elevation in anterior leads, and elevated creatine phosphokinase (maximum value 450 U/l), the diagnosis of an acute anterior myocardial infarction (AMI) was made. Because of the circumstances a conservative management was pursued. Twenty four hours later, after initial recovery, the patient presented with acute dyspnoea caused by pulmonary oedema and had to be intubated. For further diagnostics and treatment she was transferred to our institution. Transthoracic and transoesophageal ultrasound showed a ruptured posterior papillary muscle (panel A). Coronary angiography revealed a mild three vessel disease with a relevant stenosis of the left anterior descending artery (LAD). Due to low output an intra-aortic balloon pump was inserted. Emergency mitral valve replacement (MVR) combined with revascularisation of the LAD was performed (panel B). The surgical procedure was well tolerated. Further recovery was complicated by progressive respiratory distress syndrome with pneumonia leading to death of the patient 10 days later.

This case illustrates the typical occurrence of a mechanical complication after a relatively small AMI. Mechanical complications following AMI occurs relatively rarely (2–3%), but need to be diagnosed and treated as quickly as possible. Mechanical complications should be considered in any patient deteriorating acutely after a preceding ischaemic myocardial event and initial stabilisation. Once the diagnosis of an ischaemic papillary muscle rupture is made, immediate surgical intervention should be considered and undertaken.

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Panel A: Transoesophageal long axis view. Ruptured papillary muscle (arrow from the left). Panel B: Surgically resected mitral valve with necrotic ruptured papillary muscle.