Spontaneous Rupture of a Papillary Muscle

An 86-year-old woman without any history of heart disease or trauma to the chest experienced an acute onset of dyspnea associated with a productive cough for 2 hours. Her medical history revealed that she was hypertensive for the past 20 years. Her blood pressure was 90 mmHg in systole and 50 mmHg in diastole. Immediately after admission, mechanical ventilation was initiated because there was progressive respiratory depression. A chest x-ray showed marked pulmonary congestion (Figure 1A). On physical examination, a grade III systolic murmur was noted at the apex, and a coarse breathing sound was detected within the whole lung field. ECG showed sinus tachycardia without any evidence of myocardial infarction (Figure 1B). Creatine kinase and its MB isoenzyme were not elevated, but high-sensitivity troponin T was 0.035 ng/mL (normal, 0–0.014 ng/mL). Transthoracic echocardiography revealed left ventricular hypertrophy without regional wall motion abnormalities. The left ventricular ejection fraction was >70%, and E/E′ was 34, suggesting …