A 70-year-old man develops mechanical mitral regurgitation 5 days after a large inferior STEMI. He is in cardiogenic shock with a new holosystolic murmur loudest at the apex. Echocardiogram shows posterior papillary muscle rupture with flail leaflet. What is the definitive management?

• A Emergency surgical repair or mitral valve replacement with concomitant CABG if needed ✓
• B Intra-aortic balloon pump insertion and MitraClip placement
• C Percutaneous edge-to-edge repair (TEER) with MitraClip
• D IV nitroprusside and furosemide to reduce afterload and stabilise

Explanation

Acute papillary muscle rupture causing severe mitral regurgitation is a mechanical complication of MI with extremely high in-hospital mortality without surgical intervention. The posterior papillary muscle is supplied by the PDA (RCA territory) and is more commonly affected. Emergency surgical mitral valve repair or replacement (with CABG if feasible) is the definitive treatment. MitraClip (TEER) has been used as a bridge in extreme surgical risk patients but is not standard of care for acute papillary muscle rupture. Intra-aortic balloon pump reduces afterload and can temporise but is not definitive. Nitroprusside reduces afterload and can help haemodynamically but surgery cannot be avoided.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.