Five days after an inferior myocardial infarction, a 68-year-old woman develops abrupt pulmonary oedema with a new loud holosystolic murmur at the apex radiating to the axilla. Echocardiography shows a ruptured posteromedial papillary muscle with severe mitral regurgitation and preserved left ventricular function. After stabilisation with afterload reduction and intra-aortic balloon pump, the definitive management is:
- A Emergency mitral valve repair or replacement ✓
- B Repeat fibrinolysis with alteplase
- C Long-term oral anticoagulation with a DOAC
- D Percutaneous edge-to-edge mitral clip repair scheduled electively at six weeks
Correct answer: A. Emergency mitral valve repair or replacement
Explanation
Papillary muscle rupture classically occurs three to seven days after myocardial infarction, more often the posteromedial muscle after inferior infarction, and causes fulminant acute severe mitral regurgitation with pulmonary oedema despite preserved ventricular function. Haemodynamic stabilisation with vasodilators, diuretics and intra-aortic balloon counterpulsation is temporary; survival requires emergency surgical repair or valve replacement. Delaying surgery or treating medically carries very high mortality.
Reference: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 12th ed.
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Written and medically reviewed by the StethoPrep medical team.