Papillary Muscle Rupture in the Setting of Endocarditis

Papillary muscle rupture is commonly linked to ischemic events, occurring typically postmyocardial infarction. However, iatrogenic and nonischemic etiologies can play a role in papillary muscle rupture, including infective endocarditis. The case presented herein is an 85-year-old female with a history of heart failure with preserved ejection fraction (HFpEF), who presented with progressive dyspnea despite furosemide therapy, and was discovered to have a flail posterior mitral valve leaflet secondary to papillary muscle rupture associated with Streptococcus lutetiensis endocarditis. Transthoracic echocardiography revealed flail posterior mitral valve leaflet with newly appreciated severe wide-open mitral regurgitation. Emergent mitral valve repair was performed with a successful MitraClip placement. Patient had an atypical presentation without ischemic symptomology or electrocardiogram (EKG) changes indicative of ischemia. Despite transesophageal echocardiography, not revealing vegetations, infective endocarditis was presumed due to presence of Streptococcus lutetiensis bacteremia, osteomyelitis, elevated inflammatory markers, and clinical presentation. Papillary muscle rupture results in severe mitral regurgitation that is a medical emergency that requires prompt diagnosis and management from a multidisciplinary team. Therefore, it is imperative to ensure clinical insight into the multiple etiologies of papillary muscle rupture to provide timely treatment.