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Three-Dimensional Transesophageal Echocardiography

of Papillary Muscle Rupture
William C. Culp, Jr., MD,* and Wade L. Knight, MD

60-year-old man presented to the hospital complaining of severe dyspnea with signs of respiratory
distress, hypotension, and pulmonary edema consistent with cardiogenic shock. After tracheal intubation, emergent cardiac catheterization revealed 95% stenosis of the left
circumflex artery and complete occlusion of the right coronary artery. The circumflex vessel was deemed too small for
percutaneous intervention, and despite angioplasty of the
right coronary artery, the patient remained in extremis. Transthoracic echocardiogram suggested severe mitral regurgitation possibly secondary to papillary muscle rupture; however,
images were of insufficient quality to make the diagnosis
conclusively. After placing an intraaortic balloon pump, the
patient was transferred to the operating room for coronary
artery bypass grafting, possible mitral valve surgery, and
diagnostic 2- and 3-dimensional transesophageal echocardiography (2D, 3D TEE) (IE33; Philips Medical, Bothell, WA).
TEE confirmed severe mitral regurgitation due to flail A2 and A3
scallops accompanying a posteriorly directed jet. Additionally,
inferior and lateral wall hypokinesis and mild biventricular
systolic dysfunction were identified while excluding other causes
of cardiogenic shock (Figs. 1 and 2) (Video 1 [see Supplemental Digital Content 1,];
Video 2 [see Supplemental Digital Content 2,]; and Video 3 [see Supplemental Digital Content 3,]; see
Appendix for video captions). Coronary artery bypass grafting
and mitral valve replacement were subsequently performed
with improved ventricular function and wall motion patterns,
and after a 4-week recovery, the patient was discharged from the
Papillary muscle rupture complicates the course of 1% to
3% of patients with acute myocardial infarction and almost
always involves the posteromedial papillary muscle because
of its solitary blood supply from the posterior descending
artery.1 The mitral A1, P1, and P2 regions are typically
supported by chordae tendineae arising from the anterior
papillary muscle and are generally intact with posteromedial
papillary muscle rupture. Inferior wall motion abnormalities
are typically seen in this setting of posterior descending artery
From the Division of *Cardiothoracic Anesthesiology and Cardiothoracic
Surgery, Scott & White Hospital, The Texas A&M University College of
Medicine, Temple, Texas.
Accepted for publication March 12, 2010.
Supported by routine departmental sources.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (
The authors sought and received written permission from the patient to
report the case.
Address correspondence and reprint requests to William C. Culp, Jr., MD,
Division of Cardiothoracic Anesthesiology, Scott & White Hospital, The
Texas A&M University College of Medicine, 2401 South 31st St., Temple, TX
76508. Address e-mail to
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181e29c24


occlusion. Two- and three-dimensional echocardiography

may directly depict a ruptured papillary muscle, although the
first clue may be mitral regurgitation detected by color
Doppler imaging, as in our patients presentation. Whereas
transthoracic echocardiography may not detect all cases of
papillary muscle rupture,2 TEE is ideally suited for this task
because of its superior imaging of the mitral valve apparatus
and the ability to image the papillary muscles directly, particularly in the transgastric 2-chamber view. Here, the papillary muscles and chordae tendineae are perpendicular to the
ultrasound beam and offer good specular reflector characteristics. Often, the ruptured papillary muscle with attached
chordae tendineae will be seen as a large, mobile echogenic
mass undulating within the left atrium. Careful, directed
imaging of the normal location of the papillary muscles will
help to differentiate this mass from vegetation, thrombus, or
tumor.3 Certainly, other etiologies of cardiogenic shock
should be sought and excluded after myocardial infarction,
including left and right ventricular dysfunction, ventricular
septal defect, tamponade, pseudoaneurysm, and ventricular
rupture. Additionally, the left atrium enlarges over time in
response to severe mitral regurgitation, so normal or nearnormal left atrial size as in this case may imply an acute cause
of mitral regurgitation.4
Using real-time 3D TEE, the ruptured papillary muscle
was clearly demonstrated within the left atrium in our
patient. More than 3000 acoustic elements in the matrix
array probe allow for 3D imaging by generating a pyramidal ultrasound beam.5 In Figure 2 and Video 3
(; see Appendix for video
caption), this beam has been further zoomed to provide a
focused area of 3D imaging, centered on the mitral valve.
This imaging modality has the advantage of being truly
real-time; hence, arrhythmias, patient motion, and respiration all have minimal effects in comparison to gated
acquisitions occurring over several cardiac cycles or even
minutes. Three-dimensional zoom imaging is notably limited, however, by its temporal resolution, which in our case
was 9 Hz. Temporal resolution is increased as the size of
the 3D zoom sector is decreased, so careful attention to
these variables will facilitate faster refresh rates.
Two-dimensional TEE, through a stepwise progression of
analyzing multiple 2D image planes, allows for a reasonably
high level of accuracy in correctly identifying mitral pathology, and enabled us to establish the diagnosis in this patient.
However, 3D TEE more completely and accurately depicts the
mitral valve and precisely localizes pathology compared with
2D imaging.6 This is likely because of the complex 3D
morphology of the mitral valve apparatus, and the limitations
with viewing such a structure in only 2 dimensions. Additionally, 3D echocardiography offers the advantage of any-plane
imaging, whereby the echocardiographer can manipulate a 3D
dataset to allow viewing of the heart from any perspective.
This allows the virtual atriotomy view to be quickly obtained
and the mitral pathology to be precisely described. Exact
August 2010 Volume 111 Number 2

3D TEE Papillary Muscle Rupture

Figure 1. Two-dimensional transesophageal echocardiographic midesophageal

4-chamber view without and with superimposed color Doppler. In this figure, the flail
anterior mitral valve leaflet can be seen
with a large posteriorly directed color jet,
representing severe mitral regurgitation.
Precise localization of involved leaflet scallops from a single 2-dimensional image,
however, is difficult.

Figure 2. Real-time 3-dimensional transesophageal

echocardiogram in a virtual atriotomy view. Using
any-plane imaging, the mitral valve is viewed from
within the left atrium, looking toward the ventricular
apex. The ruptured posteromedial papillary muscle
and attached chordae tendineae are clearly seen,
along with the resultant flail of the A2 and A3
portions of the anterior mitral valve leaflet.

anatomic diagnosis guides the surgeons decision to repair or

replace a mitral valve, or as in this case, the mitral valve and
papillary muscle.

affected scallops is possible with this single imaging plane, confirming and refining the diagnosis.


Video 1. A 2-dimensional (2D) transesophageal echocardiogram at the midesophageal level demonstrates a flail mitral
valve leaflet. Close examination reveals a mobile mass undulating
within the left atrium, attached to the mitral leaflet by a thin, linear
structure, consistent with a ruptured papillary muscle and associated chordae tendineae.
Video 2. Color Doppler superimposed on this 2-dimensional
midesophageal view of the mitral valve clearly depicts the posteriorly
directed regurgitant jet due to the flail anterior leaflet.
Video 3. In this real-time 3-dimensional (3D) transesophageal
echocardiographic (TEE) image, the mitral valve is viewed from the
perspective of the left atrium looking toward the apex of the heart.
This allows simultaneous visualization of each of the mitral valve
scallops. The temporal resolution is slightly limited at 9 Hz, and
causes the somewhat stuttered appearance during playback (which
has been reduced to half speed for easier viewing). However,
because this is a real-time image, spatial resolution is not adversely
affected by patient motion, respiration, or arrhythmias in contrast to
gated sequential 3D image acquisition that may take seconds or
minutes to acquire. The ruptured papillary muscle can be seen
bouncing within the left atrium, tethered to the flail anterior mitral
valve leaflet by the chordae tendineae. Precise localization of the

August 2010 Volume 111 Number 2

WCC helped in conduct of study, data/image analysis, and

manuscript preparation. WLK helped in conduct of study,
data/image analysis, and manuscript editing.

WCC received a single honorarium from Philips Medical for a

lecture presentation in 2007. WLK is a member of the hospital
Board of Trustees.
1. Russo A, Suri RM, Grigioni F, Roger VL, OH JK, Mahoney DW,
Schaff HV, Enriquez-Sarano M. Clinical outcome after surgical
correction of mitral regurgitation due to papillary muscle rupture. Circulation 2008;118:1528 34
2. Iwasaki K, Matsuo N, Hina K, Murakami T, Murakami M,
Matano S, Yamaji H, Hamamoto H, Ueeda M, Kusachi S.
Transesophageal echocardiography for detection of mitral regurgitation due to papillary muscle rupture or dysfunction
associated with acute myocardial infarction: a report of five
cases. Can J Cardiol 2000;16:12737
3. Madu EC, DCruz IA. The vital role of papillary muscles in
mitral and ventricular function: echocardiographic insights.
Clin Cardiol 1997;20:93 8



4. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet 2009;373:138294

5. Salcedo EE, Quiafe RA, Seres T, Carroll JD. A framework for
systematic characterization of the mitral valve by real-time
three-dimensional transesophageal echocardiography. J Am Soc
Echocardiogr 2009;22:108799

Clinicians Key Teaching Points

6. Macnab A, Jenkins NP, Bridgewater BJM, Hooper TL, Greenhalgh DL, Patrick MR, Ray SG. Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the
assessment of regurgitant mitral valve morphology. Eur J
Echocardiogr 2004;5:21222

By Kent H. Rehfeldt, MD, Nikolaos J. Skubas, MD,

and Martin J. London, MD

Papillary muscle rupture may occur within 1 day to 1 month after myocardial infarction. It almost always involves the
posteromedial papillary muscle due to its single-vessel perfusion from the posterior descending coronary artery. The
mitral scallops tethered to it (A2, A3, and P3) prolapse into the left atrium during ventricular systole causing severe
mitral regurgitation.
In the midesophageal 4-chamber or midesophageal long-axis view, the mitral regurgitant jet will be seen directed away
from the prolapsing scallops. Associated inferior or lateral wall motion abnormalities, along with a supporting clinical
history, should differentiate a ruptured papillary muscle head (along with its chordal attachments) from other mobile
pedunculated masses such as vegetation, tumor, or thrombus. The transgastric 2-chamber and long-axis views are
particularly useful because of the perpendicular orientation of the ultrasound beam with the papillary muscles,
facilitating visualization of the tissue defect and the to-and-fro motion of the ruptured muscle and chordae.
In this case, 3-dimensional real-time transesophageal echocardiography (TEE) was used to generate an en face view
of the mitral valve (looking down, from the left atrium perspective) and confirm the presence of a ruptured posterior
papillary muscle and the associated flail A2 and A3 scallops.
The anatomic and physiologic presentation of papillary muscle rupture should be apparent with a comprehensive
examination of the mitral apparatus using standard, 2-dimensional TEE imaging. Three-dimensional real-time TEE
generates multiple imaging planes of the mitral valve from different perspectives, further assisting in diagnosing the
etiology of mitral regurgitation. However, lower video frame rates and increased expense remain substantial