Rupture of the Posteromedial Papillary Muscle Leading to Partial Flail of the Anterior Mitral Leaflet

An 86-year-old woman with a history of hypertension presented with acute onset of chest pain and evidence of shock (hypotension and tachycardia). For the preceding 2 weeks, she had been experiencing intermittent nausea and vomiting; proton pump inhibitors did not improve her symptoms. The ECG showed ST elevations in the inferior leads and ST depressions in leads V1 and V2, with reciprocal ST depressions in leads I and aVL, suggesting an acute inferoposterior infarction (Figure 1). Physical examination also revealed a new 2/6 holosystolic murmur at the apex and significant bilateral rales. She was taken emergently to the cardiac catheterization laboratory, where 100% thrombotic occlusion of the middle right coronary artery was revealed (Figure 2A). A left ventriculogram revealed severe (4+) mitral regurgitation with a normal-sized left …