A 62-year-old man develops acute pulmonary edema five days after an inferior wall myocardial infarction. Examination shows a new harsh apical pansystolic murmur radiating to the axilla. Echocardiography shows a flail posterior mitral leaflet with a completely ruptured posteromedial papillary muscle; LVEF is 50%. What is the definitive next step?

• A Continue medical therapy with diuretics, nitrates and afterload reduction
• B Emergency surgical mitral valve repair or replacement ✓
• C Insert an intra-aortic balloon pump and defer intervention for six weeks
• D Percutaneous coronary intervention of the culprit vessel alone

Explanation

Complete papillary muscle rupture produces sudden massive mitral regurgitation into a non-compliant left atrium, causing refractory pulmonary edema with a preserved ejection fraction. Mortality exceeds 90% with medical therapy alone in the first weeks. Emergency surgical correction, usually combined with coronary bypass, is the definitive treatment. An intra-aortic balloon pump is only a temporizing bridge to surgery, and revascularization alone leaves the mechanical lesion uncorrected.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.