PMC8714394_01
Electrocardiogram, chest radiograph, and computed tomography of the chest on admission. (a) The electrocardiogram on admission showing sinus tachycardia with ST elevation in the leads II, III, and aVF. (b) The chest radiograph on admission showing marked pulmonary congestion. (c) Computed tomography of the chest showing consolidation and ground ground-glass opacity.
CRICC2021-1396194.001.jpg
PMC8714394_01_CRICC2021-1396194.001.jpg
fig1
Electrocardiography (ECG) showed sinus rhythm with ST-elevation on leads II, III, and aVF (Figure 1(a)). Chest radiography revealed a butterfly pattern (Figure 1(b)). CK-MB, 9 IU/L; blood urea nitrogen, 18.3 mg/dL; creatinine, 1.71 mg/dL; C-reactive protein (CRP), 9.28 mg/dL; troponin-T, 0.68 mg/dL; D-dimer, 7.8 mug/mL. Computed tomography of the lung revealed consolidation and ground-glass opacity (Figure 1(c)).
Coronary angiogram. (a) The right coronary artery (RCA) showing a total occlusion of the posterior descending branch (white arrow). (b) Revascularization achieved (white arrow) by performing balloon angioplasty to treat the distal RCA lesion.
CRICC2021-1396194.002.jpg
PMC8714394_01_CRICC2021-1396194.002.jpg
fig2
Emergency coronary angiography showed no significant stenosis in the major coronary arteries, except the total occlusion in the posterior descending branch of the right artery (Figure 2(a)). Balloon angioplasty was performed to restore patency (Figure 2(b)), but the patient remained in shock and oxygenation worsened.
Transthoracic and transesophageal echocardiogram on day 5. (a) A fluttering mass in the left ventricle (LV), suggestive of papillary muscle rupture (white arrow) on apical two-chamber view. (b) Systolic-phase view with color doppler showing systolic jet towards the probe, indicative of mitral regurgitation. (c, d) Systolic- and diastolic-phase images of the completely ruptured posterior papillary muscle moving between the LV and left atrium (white arrow).
CRICC2021-1396194.003.jpg
PMC8714394_01_CRICC2021-1396194.003.jpg
fig3
TTE was performed in the left lateral position (this was the only possible position) and showed a LV mass, suggestive of PMR (Figure 3(a)). TEE was performed, and a definitive diagnosis of acute MR and posterior PMR was confirmed (Figures 3(b)-3(d) ).