Fatal Cardiogenic Shock Following Papillary Muscle Rupture in a Patient with STEMI: A Case Report

Fatal Cardiogenic Shock Following Papillary Muscle Rupture in a Patient with STEMI: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Fatal Cardiogenic Shock Following Papillary Muscle Rupture in a Patient with STEMI: A Case Report HAMDANI Z, HATIM H, ROCHD EM, ETTACHFINI T, BOUZIANE M, HABOUB M, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6541554/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report the case of a 55-year-old hypertensive and asthmatic patient who presented with an ST-segment elevation myocardial infarction in the high lateral wall. The patient was thrombolysed 4 hours after symptom onset but subsequently developed cardiogenic shock due to acute mitral insufficiency secondary to rupture of the anterolateral papillary muscle. Despite aggressive management, including thrombolysis, inotropic support, and oro-tracheal intubation, the outcome was fatal due to refractory bradycardia and asystole. Cardiac & Cardiovascular Systems Acute Myocardial Infarction Cardiogenic Shock Papillary Muscle Rupture Mitral Regurgitation STEMI Thrombolysis Cardiovascular Complications Emergency Medicine Echocardiography Inotropic Support Acute Pulmonary Edema Emergency Surgery Cardiac Arrest Prognosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Acute mitral regurgitation caused by papillary muscle rupture is a rare but life-threatening complication of myocardial infarction, occurring in approximately 1–2% of cases [1, 2]. PMR often leads to acute pulmonary edema and cardiogenic shock, as the acute mitral insufficiency overwhelms the heart's ability to maintain adequate systemic perfusion [3, 4]. This case highlights the rapid progression of clinical deterioration in a patient with high lateral STEMI complicated by cardiogenic shock due to papillary muscle rupture. Case Presentation A 55-year-old hypertensive and asthmatic patient presented to the emergency department 4 hours after the onset of retrosternal chest pain. The patient was conscious and alert with a Glasgow Coma Scale of 15/15. He reported symptoms of rest angina and resting dyspnea. Upon examination, his vital signs showed a blood pressure of 70/50 mmHg, with cold extremities and mottling at the knees. His heart rate was 100 bpm, and his oxygen saturation was 87% on room air, which improved to 97% with a non-rebreather mask. Pulmonary auscultation revealed bilateral wheezes. The initial electrocardiogram showed ST-segment elevation in the high lateral wall, consistent with a STEMI. The patient was treated with thrombolysis using Metalyse® in the resuscitation unit after exclusion of contraindications and obtaining informed consent. He was also started on a Dobutamine infusion (5 µg/kg/min) to address the cardiogenic shock. Following thrombolysis, auscultation revealed crackles at the lung apices and a systolic murmur at the mitral area. Echocardiography showed a non-dilated, non-hypertrophied, hyperkinetic left ventricle with an ejection fraction of 75%. Severe mitral regurgitation was present due to prolapse of the posterior mitral leaflet caused by rupture of the anterolateral papillary muscle. The inferior vena cava measured 18 mm, which was consistent with elevated filling pressures. Approximately 1.5 hours after thrombolysis, the patient developed signs of respiratory distress, confusion, and agitation, which required immediate oro-tracheal intubation. Aspiration revealed abundant frothy hematic secretions. Subsequently, the patient developed severe bradycardia, which progressed to asystole despite resuscitative efforts. Discussion Papillary muscle rupture is a catastrophic mechanical complication of myocardial infarction, occurring in 1-2% of cases, more frequently in the context of delayed reperfusion or transmural infarction [2, 4]. The rupture often results in acute severe mitral regurgitation (MR), which leads to rapid hemodynamic decompensation, pulmonary edema, and cardiogenic shock [3, 5]. Early diagnosis, typically via echocardiography, is crucial for the successful management of this condition. In our case, the rupture of the anterolateral papillary muscle caused acute MR, complicated by refractory cardiogenic shock and respiratory failure. Although thrombolysis and inotropic support were initiated promptly, the patient’s clinical deterioration was too rapid to allow for surgical intervention, underscoring the aggressive nature of Papillary muscle rupture . The management of papillary muscle rupture requires both medical stabilization and definitive surgical intervention. In terms of medical stabilization, inotropes such as dobutamine are used to enhance myocardial contractility and cardiac output, which is crucial in cases of cardiogenic shock [6]. Intravenous diuretics are essential for managing acute pulmonary congestion and optimizing preload, as seen in our patient [1]. Mechanical ventilation plays a significant role in reducing the work of breathing and improving oxygenation, particularly in patients with pulmonary edema. Additionally, an intra-aortic balloon pump can be employed to improve coronary perfusion and reduce afterload as a bridge to surgery [7]. For definitive surgical intervention, emergency mitral valve repair or replacement remains the cornerstone of treatment for acute severe mitral regurgitation caused by papillary muscle rupture. Delayed surgical intervention is associated with a very high mortality rate, often exceeding 80% in untreated cases [2, 5]. Early diagnosis through echocardiography and rapid transfer to a surgical center are critical for improving survival outcomes [3, 4]. Challenges in Our Case Despite thrombolysis, IV diuretics, and inotropic support, the patient's rapid clinical deterioration precluded definitive surgical intervention. This highlights the aggressive nature of acute mitral regurgitation secondary to papillary muscle rupture, particularly when presentation is delayed. Conclusion This case underscores the importance of early recognition and aggressive management of mechanical complications of myocardial infarction, such as papillary muscle rupture. While medical stabilization with thrombolysis, inotropes, and diuretics is essential, emergency surgical intervention remains the definitive treatment. Unfortunately, in our patient, the delayed presentation and rapid progression to cardiogenic shock led to a fatal outcome before surgery could be performed. This case highlights the need for vigilance in diagnosing post-infarction complications and the importance of timely reperfusion to prevent such catastrophic events. Declarations Informed consent for publication was obtained from the patient’s next of kin. References Yasuda S., Fukui K., Tada H., et al. (2018). Papillary muscle rupture complicating acute myocardial infarction. J Am Coll Cardiol . 72(8):940-949. doi:10.1016/j.jacc.2018.04.063 Sica DA, Lamberti G, et al. (2017). Surgical management of acute mitral regurgitation due to papillary muscle rupture. J Thorac Cardiovasc Surg . 153(5): 1351-1356. doi:10.1016/j.jtcvs.2016.12.046 Khattar R. S., Murtuza B., et al. (2019). Management of papillary muscle rupture in myocardial infarction. Int J Cardiol . 10(1): 101-105. doi:10.1016/j.ijcard.2018.08.054 Cimino L., Jäger B., et al. (2017). Acute mitral regurgitation due to papillary muscle rupture after myocardial infarction: Prognostic value of echocardiography. Heart . 103(1): 89-95. doi:10.1136/heartjnl-2016-309555 Cheng H. L., Koo C. Y., et al. (2016). Inotropic support in patients with acute heart failure due to papillary muscle rupture. J Card Fail . 22(11): 819-825. doi:10.1016/j.cardfail.2016.05.004 Boccalandro F., Cincotti F., et al. (2020). Use of intra-aortic balloon pump in cardiogenic shock complicating acute myocardial infarction. Heart Lung . 49(3): 396-400. doi:10.1016/j.hrtlng.2019.12.011 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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electrocardiogram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6541554/v1/8d2ba0e0f0de1a85e02731c4.png"},{"id":81966819,"identity":"cc6f9b37-37e4-4e5f-84d5-3d884c82035f","added_by":"auto","created_at":"2025-05-05 11:38:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":200751,"visible":true,"origin":"","legend":"\u003cp\u003eTransthoracic echocardiography (A4C view) showing a ruptured mitral papillary muscle\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6541554/v1/d69ea413b5176b4af5416bb9.png"},{"id":81967979,"identity":"dac5ae78-2a57-4495-a120-c919e5c583eb","added_by":"auto","created_at":"2025-05-05 11:46:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":254555,"visible":true,"origin":"","legend":"\u003cp\u003eTransthoracic echocardiography demonstrating a flail mitral leaflet\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6541554/v1/dbcbb95354ba952169b7de15.png"},{"id":81966820,"identity":"7a93a54e-00c6-4efb-940f-8b6c0c45d58a","added_by":"auto","created_at":"2025-05-05 11:38:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":354964,"visible":true,"origin":"","legend":"\u003cp\u003eContinuous-wave Doppler echocardiography demonstrating a dense, holosystolic regurgitant jet across the mitral valve, consistent with severe mitral regurgitation secondary to papillary muscle rupture.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6541554/v1/6137765286a46e23c472660f.png"},{"id":81968763,"identity":"2b23a30f-63fa-495f-a582-b3c88710acdd","added_by":"auto","created_at":"2025-05-05 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PMR often leads to acute pulmonary edema and cardiogenic shock, as the acute mitral insufficiency overwhelms the heart's ability to maintain adequate systemic perfusion [3, 4]. This case highlights the rapid progression of clinical deterioration in a patient with high lateral STEMI complicated by cardiogenic shock due to papillary muscle rupture.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 55-year-old hypertensive and asthmatic patient presented to the emergency department 4 hours after the onset of retrosternal chest pain.\u003c/p\u003e \u003cp\u003eThe patient was conscious and alert with a Glasgow Coma Scale of 15/15.\u003c/p\u003e \u003cp\u003eHe reported symptoms of rest angina and resting dyspnea.\u003c/p\u003e \u003cp\u003eUpon examination, his vital signs showed a blood pressure of 70/50 mmHg, with cold extremities and mottling at the knees. His heart rate was 100 bpm, and his oxygen saturation was 87% on room air, which improved to 97% with a non-rebreather mask. Pulmonary auscultation revealed bilateral wheezes.\u003c/p\u003e \u003cp\u003eThe initial electrocardiogram showed ST-segment elevation in the high lateral wall, consistent with a STEMI.\u003c/p\u003e \u003cp\u003eThe patient was treated with thrombolysis using Metalyse\u0026reg; in the resuscitation unit after exclusion of contraindications and obtaining informed consent. He was also started on a Dobutamine infusion (5 \u0026micro;g/kg/min) to address the cardiogenic shock.\u003c/p\u003e \u003cp\u003eFollowing thrombolysis, auscultation revealed crackles at the lung apices and a systolic murmur at the mitral area. Echocardiography showed a non-dilated, non-hypertrophied, hyperkinetic left ventricle with an ejection fraction of 75%. Severe mitral regurgitation was present due to prolapse of the posterior mitral leaflet caused by rupture of the anterolateral papillary muscle. The inferior vena cava measured 18 mm, which was consistent with elevated filling pressures.\u003c/p\u003e \u003cp\u003eApproximately 1.5 hours after thrombolysis, the patient developed signs of respiratory distress, confusion, and agitation, which required immediate oro-tracheal intubation. Aspiration revealed abundant frothy hematic secretions. Subsequently, the patient developed severe bradycardia, which progressed to asystole despite resuscitative efforts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePapillary muscle rupture is a catastrophic mechanical complication of myocardial infarction, occurring in 1-2% of cases, more frequently in the context of delayed reperfusion or transmural infarction [2, 4]. The rupture often results in acute severe mitral regurgitation (MR), which leads to rapid hemodynamic decompensation, pulmonary edema, and cardiogenic shock [3, 5]. Early diagnosis, typically via echocardiography, is crucial for the successful management of this condition.\u003c/p\u003e\n\u003cp\u003eIn our case, the rupture of the anterolateral papillary muscle caused acute MR, complicated by refractory cardiogenic shock and respiratory failure. Although thrombolysis and inotropic support were initiated promptly, the patient\u0026rsquo;s clinical deterioration was too rapid to allow for surgical intervention, underscoring the aggressive nature of Papillary muscle rupture .\u003c/p\u003e\n\u003cp\u003eThe management of papillary muscle rupture requires both medical stabilization and definitive surgical intervention. In terms of medical stabilization, inotropes such as dobutamine are used to enhance myocardial contractility and cardiac output, which is crucial in cases of cardiogenic shock [6]. Intravenous diuretics \u0026nbsp;are essential for managing acute pulmonary congestion and optimizing preload, as seen in our patient [1]. Mechanical ventilation plays a significant role in reducing the work of breathing and improving oxygenation, particularly in patients with pulmonary edema. Additionally, an intra-aortic balloon pump can be employed to improve coronary perfusion and reduce afterload as a bridge to surgery [7].\u003c/p\u003e\n\u003cp\u003eFor definitive surgical intervention, emergency mitral valve repair or replacement remains the cornerstone of treatment for acute severe mitral regurgitation caused by papillary muscle rupture. Delayed surgical intervention is associated with a very high mortality rate, often exceeding 80% in untreated cases [2, 5].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEarly diagnosis through echocardiography and rapid transfer to a surgical center are critical for improving survival outcomes [3, 4].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges in Our Case\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite thrombolysis, IV diuretics, and inotropic support, the patient\u0026apos;s rapid clinical deterioration precluded definitive surgical intervention. This highlights the aggressive nature of acute mitral regurgitation secondary to papillary muscle rupture, particularly when presentation is delayed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores the importance of early recognition and aggressive management of mechanical complications of myocardial infarction, such as papillary muscle rupture. While medical stabilization with thrombolysis, inotropes, and diuretics is essential, emergency surgical intervention remains the definitive treatment. Unfortunately, in our patient, the delayed presentation and rapid progression to cardiogenic shock led to a fatal outcome before surgery could be performed. This case highlights the need for vigilance in diagnosing post-infarction complications and the importance of timely reperfusion to prevent such catastrophic events.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eInformed consent for publication was obtained from the patient\u0026rsquo;s next of kin.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYasuda S., Fukui K., Tada H., et al. (2018). Papillary muscle rupture complicating acute myocardial infarction. \u003cem\u003eJ Am Coll Cardiol\u003c/em\u003e. 72(8):940-949. doi:10.1016/j.jacc.2018.04.063\u003c/li\u003e\n\u003cli\u003eSica DA, Lamberti G, et al. (2017). Surgical management of acute mitral regurgitation due to papillary muscle rupture. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 153(5): 1351-1356. doi:10.1016/j.jtcvs.2016.12.046\u003c/li\u003e\n\u003cli\u003eKhattar R. S., Murtuza B., et al. (2019). Management of papillary muscle rupture in myocardial infarction. \u003cem\u003eInt J Cardiol\u003c/em\u003e. 10(1): 101-105. doi:10.1016/j.ijcard.2018.08.054\u003c/li\u003e\n\u003cli\u003eCimino L., J\u0026auml;ger B., et al. (2017). Acute mitral regurgitation due to papillary muscle rupture after myocardial infarction: Prognostic value of echocardiography. \u003cem\u003eHeart\u003c/em\u003e. 103(1): 89-95. doi:10.1136/heartjnl-2016-309555\u003c/li\u003e\n\u003cli\u003eCheng H. L., Koo C. Y., et al. (2016). Inotropic support in patients with acute heart failure due to papillary muscle rupture. \u003cem\u003eJ Card Fail\u003c/em\u003e. 22(11): 819-825. doi:10.1016/j.cardfail.2016.05.004\u003c/li\u003e\n\u003cli\u003eBoccalandro F., Cincotti F., et al. (2020). Use of intra-aortic balloon pump in cardiogenic shock complicating acute myocardial infarction. \u003cem\u003eHeart Lung\u003c/em\u003e. 49(3): 396-400. doi:10.1016/j.hrtlng.2019.12.011\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Centre Hospitalier Universitaire Ibn Rochd","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute Myocardial Infarction, Cardiogenic Shock, Papillary Muscle Rupture, Mitral Regurgitation, STEMI, Thrombolysis, Cardiovascular Complications, Emergency Medicine, Echocardiography, Inotropic Support, Acute Pulmonary Edema, Emergency Surgery, Cardiac Arrest, Prognosis","lastPublishedDoi":"10.21203/rs.3.rs-6541554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6541554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report the case of a 55-year-old hypertensive and asthmatic patient who presented with an ST-segment elevation myocardial infarction in the high lateral wall.\u003c/p\u003e \u003cp\u003eThe patient was thrombolysed 4 hours after symptom onset but subsequently developed cardiogenic shock due to acute mitral insufficiency secondary to rupture of the anterolateral papillary muscle.\u003c/p\u003e \u003cp\u003eDespite aggressive management, including thrombolysis, inotropic support, and oro-tracheal intubation, the outcome was fatal due to refractory bradycardia and asystole.\u003c/p\u003e","manuscriptTitle":"Fatal Cardiogenic Shock Following Papillary Muscle Rupture in a Patient with STEMI: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 11:38:05","doi":"10.21203/rs.3.rs-6541554/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f796f49d-f59d-404a-a504-725e257b7ac1","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":47744039,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-05-05T11:38:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 11:38:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6541554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6541554","identity":"rs-6541554","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}