MioAtlas
G1: Left-sided valves

Acute mitral regurgitation from papillary muscle rupture

Catastrophic acute mitral regurgitation secondary to necrosis and complete or partial mechanical rupture of a papillary muscle (typically the posteromedial papillary muscle in the setting of an acute inferior or inferolateral myocardial infarction).

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Definition

Catastrophic acute mitral regurgitation secondary to necrosis and complete or partial mechanical rupture of a papillary muscle (typically the posteromedial papillary muscle in the setting of an acute inferior or inferolateral myocardial infarction), causing sudden loss of valvular coaptation, massive regurgitation into a non-compliant left atrium, cardiogenic shock, and acute pulmonary edema [V1] [V3] [C9].

Severity criteria

  • Single grade (Severe / Emergency, G / Ú):
    • Effective regurgitant orifice area (EROA) ≥ 0.40 cm²; Regurgitant volume (RV) ≥ 60 mL/beat; Regurgitant fraction (RF) ≥ 50 %; vena contracta (VC) ≥ 0.7 cm [V1] [V3].
    • Mean pulmonary capillary wedge pressure > 25–35 mmHg with giant transmitted 'v' wave > 40–60 mmHg in the left atrial / pulmonary capillary pressure curve [C9] [V1].
    • Severe arterial hypotension (systolic blood pressure < 90 mmHg) and low cardiac index (< 2.0 L/min/m²) [C9].
    • Echocardiographic visualization of severed head or trunk of the ruptured papillary muscle with hypermobile chaotic motion in the LV/LA (massive flail leaflet) [V1] [V3] [C9].

Findings by layer

Hemodynamics

  • Massive acute volume overload on left atrium and left ventricle with normal or only slightly enlarged chamber sizes [V1] [V3].
  • Giant regurgitant 'v' wave in left atrium approaching left ventricular systolic pressure [C9].
  • Cardiogenic shock with severely diminished forward cardiac output [C9].

Rhythm

  • Obligatory sinus tachycardia as an adrenergic compensatory mechanism [C9] [V1].

ECG

  • Signs of transmural or evolving acute myocardial infarction: ST elevation or pathological Q waves of necrosis in inferior leads (DII, DIII, aVF) or inferolateral leads (due to compromise of right coronary artery or circumflex branch supplying the posteromedial muscle) [E1] [C9].

Heart sounds and murmurs

  • Systolic murmur: Early decrescendo holosystolic or mid-systolic murmur (often soft, grade 2–3/6, or muffled due to early equilibration of LV-LA systolic pressures) auscultated at the apex [V1] [G1-14].
  • Murmur radiation: In posteromedial papillary rupture (most common), the regurgitant jet is directed toward the anterior LA wall and aortic root, radiating toward the cardiac base and carotid arteries (mimicking aortic stenosis) [V3] [C9] [G1-06] [G1-14].
  • First heart sound (S1): Decreased or muffled due to coaptation incompetence [G1-10].
  • Added sounds: Persistent third heart sound (S3) [G1-12] [C9]; frequent fourth heart sound (S4) if sinus rhythm is present [G1-13] [C9].
  • Second heart sound (S2): Loud P2 due to acute pulmonary arterial and venocapillary hypertension [G1-11] [C9].

Arterial pulse

  • Thready, rapid pulse with greatly reduced volume (pulsus parvus et celer / tachycardic) characteristic of cardiogenic shock [B4] [C9].

Jugular venous pulse

  • Marked jugular venous distention with acute systemic venous hypertension [B3] [C9].

Maneuvers

  • The patient is in extreme hemodynamic instability (physical provocative stress maneuvers are contraindicated) [C9].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Sinus Tachycardia

Also known as: Papillary muscle rupture · Acute ischemic mitral regurgitation · Acute mitral regurgitation · Papillary rupture

Other pathologies in this group

Related clinical comparisons

Sources

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [C9] Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association . Circulation (2021) . DOI: 10.1161/CIR.0000000000000985 PubMed: 34126755
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [G1-06] The mitral apparatus. Functional anatomy of mitral regurgitation . Circulation (1972) . DOI: 10.1161/01.cir.46.2.227 PubMed: 5046018
  6. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  7. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  8. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  9. [G1-13] The Fourth Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250185
  10. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  11. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  12. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623