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Clin. Cardiol. 23, 625 (2000)
This section edited by Edward A. Geiser, M.D.
Michael Campsey, M.D. and Christopher Kramer, M.D., F.A.C.C.
Division of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
A 70-year-old female with a past medical history of hypertension developed abrupt onset dyspnea and chest pain and presented to the emergency department hypotensive, hypoxemic, and in severe respiratory distress. She required emergent intubation and hemodynamic support with multiple vasopressors. Physical examination was significant for tachycardia, diffuse bilateral rales, and mottling of her skin. Chest radiograph (Fig. 1) revealed a diffuse right lung infiltrate. An electrocardiogram was characterized by sinus tachycardia with occasional premature ventricular contractions and ST-T wave changes in the lateral and inferior leads consistent with ischemia. Initial creatinine kinase was 222 IU/l with an MB fraction of 11.6 ng/ml. Emergency transthoracic echocardiography was performed and was suspicious for a flail mitral leaflet. An intra-aortic balloon pump was placed and the patient underwent emergent left and right heart catheterization. The results were as follows: 20% distal left main trunk lesion, 20% diffuse disease of the mid left anterior descending artery, 40% proximal left circumflex lesion, 40% proximal right coronary artery lesion, and a mean pulmonary capillary wedge pressure of 48 mmHg with a peak V wave of 60 mmHg. Prior to surgical intervention transesophageal echocardiography was performed to better define the structural defect. The patient had severe mitral regurgitation as a result of rupture of both heads of the anterolateral papillary muscle from their root (Fig. 2). Consequently, both mitral leaflets were flail and the regurgitant jet (Fig. 3) was directed into the right pulmonary veins. The eccentric jet was thought to be the etiology of the unilateral pulmonary edema. The patient died of refractory cardiogenic shock before surgical intervention could be attempted.
Fig. 1 Radiograph of the chest characterized by a unilateral, diffuse infiltrative process of the right lung.
Fig. 2 Transesophageal long-axis view of the left ventricle and left atrium (LA) during systole. The two heads of the anterolateral papillary muscle are seen in the LA attached to the anterior and posterior mitral leaflets, which are flail.
Fig. 3 Transesophageal long-axis view of the left ventricle and left atrium during systole. Color-flow Doppler reveals a wide eccentric jet indicating severe mitral regurgitation.
Unilateral pulmonary edema represents a unique presentation of acute onset mitral regurgitation secondary to papillary muscle rupture. This case illustrates the utility of transesophageal echocardiography in defining the etiology of the eccentric mitral regurgitation jet.