a 52-year - old previously healthy male patient visited the emergency department of a local clinic due to dyspnea with the recent onset of chest pain . an emergency coronary angiogram ( cag ) , which was prompted by a 12 lead ekg study suggesting precordial lead st segment elevation myocardial infarction revealed a totally occluded distal left circumflex coronary artery . although percutaneous stenting of the culprit vessel was successfully performed , the symptoms of dyspnea had persisted . a subsequent trans - thoracic echocardiogram showed severe mitral regurgitation ( mr ) caused by a ruptured papillary muscle head . the patient was , therefore , subsequently transferred to our hospital for urgent surgery of the mitral valve . a preoperative echocardiogram showed severe prolapsing mitral regurgitation ( a proximal isovelocity surface area radius of 14 mm at an aliasing velocity of 40 cm / sec ) due to rupture of the posteromedial papillary muscle and a decreased left ventricular ejection fraction of 48% . mild to moderate pulmonary hypertension with a tricuspid regurgitation ( tr ) velocity of 3.3 m / sec was also noted . at surgery moderate hypothermic cardiopulmonary bypass at 27 esophageal temperature was performed through selective cannulation of the aorta , superior vena cava , and inferior vena cava . maintenance of cardioplegia was achieved by continuous retrograde coronary sinus infusion of cold blood cardioplegia . the mitral valve was exposed by transseptal incision extended to the left atrial roof , as exposure would otherwise have been extremely difficult through sondergaard 's groove in the relatively small - sized normal left atrium of this patient . when viewed directly , it became clear that the anterior mitral valve a3 prolapse was caused by the disruption of a subpapillary muscle head of the posteromedial papillary muscle . after careful examination to rule out any additional structural valvular pathology that could have complicated the planned simple repair , the disrupted papillary muscle tip was reattached to the papillary muscle base with three interrupted mattress sutures of 5 - 0 polytetrafluoroethylene buttressed by a pledget . the approximating sutures were passed through healthy tissue adjacent to the endocardial surface at the base , thereby avoiding suturing the friable , necrotic tissue of the detached margins . finally , a 26 mm cosgrove - edwards annuloplasty band ( edwards lifesciences , irvine , california , usa ) was used to perform the undersized mitral annuloplasty ( fig . two interrupted stitches of 5 - 0 polypropylene sutures were placed to approximate the lateral commissural portions of the anterior and posterior mitral leaflets to correct the residual trivial mr on saline testing . after an uneventful weaning of the cardiopulmonary bypass ( cpb ) , the proceeding trans - esophageal echocardiography showed no residual mitral stenosis or regurgitation . follow up echocardiography on the fifth postoperative day showed no mitral regurgitation but persistent mild left ventricular dysfunction with an ejection fraction of 42% . the patient remained in excellent clinical condition on the 4 postoperative month , which was the last follow up . severe mr occurs in about 3% of patients presenting with an acute myocardial infarction , and is associated with an in - hospital mortality of up to 70% . although progress in surgical management has led to improved outcomes over the decades , operative mortality remains high . the papillary muscle is a contiguous structure of the adjacent left ventricular wall that serves to preserve the contractile function and acts as an anchor for the chordae tendinae . while the anterolateral papillary muscle receives dual blood supply from the left anterior descending and circumflex coronary arteries , the posteromedial papillary muscle usually receives a single blood supply from either the right or left circumflex coronary artery . as a result , the posteromedial papillary muscle is relatively more vulnerable to rupture than the anterolateral papillary muscle , with a nearly three- to six - fold higher reported rate of disruption after acute myocardial infarction . repair is usually recommended over replacement for the treatment of functional ischemic mr , as it is generally conducive to superior survival outcomes . however , in acute postinfarction papillary muscle rupture , experience is limited and most surgeons prefer to replace rather than repair the mitral valve . this is mainly due to their uncertainty regarding the durability of a repair that inevitably requires suturing onto friable and infarcted myocardial tissue . in addition , the potential for a longer aortic cross clamping time , greater technical difficulties in achieving a successful repair , and the likelihood of ventricular remodeling progression with consequent recurrence of mitral regurgitation have also led to a greater preference for valve replacement in this subset of patients . in the present case , one of two papillary projections of the posteromedial papillary muscle was disrupted . the basal portion of the main posteromedial papillary muscle appeared to be non - necrotic . therefore , from the perspective of the papillary muscle mass involvement , the posteromedial papillary muscle was partially infarcted and thus considered to be amenable to repair by re - attaching the detached papillary muscle head to normal tissue . reported a modified papillary muscle re - implantation technique involving reattaching the ruptured papillary muscle tip to a healthy area of the papillary muscle and reinforcing the repair with additional sandwiched pericardial pledgetted ptfe sutures . we avoided approximating necrotic tissue directly with necrotic tissue by placing the sutures through healthier - appearing tissue that was closer to the ventricular endocardium at the papillary muscle base . a search of the literature published in korea revealed surgery for acute post infarction papillary muscle rupture performed in nine patients . of note , in all of them , therefore , to the best of our knowledge , this is the first reported case of a post infarction papillary muscle rupture that was treated with reimplantation of the papillary muscle in korea . although the repair was successfully performed , further studies are warranted to substantiate and validate the durability of this method .
a 53-year - old man presenting with dyspnea and chest pain was diagnosed with acute myocardial infarction secondary to occlusion of the left circumflex coronary artery . urgent revascularization by percutaneous stenting was successfully performed . 
 however , the post - echocardiography revealed a ruptured papillary muscle that was causing severe mitral regurgitation and aggravation of congestive heart failure . 
 the patient subsequently underwent mitral valve repair with papillary muscle re - implantation . 
 postoperative echocardiography showed a competent mitral valve without residual stenosis or regurgitation . 
 the patient was discharged from the hospital with an uneventful recovery and has been doing well on outpatient follow up .