Acute posteromedial papillary muscle rupture secondary to aortic valve endocarditis: a case report

Background Acute papillary muscle (PM) rupture due to infective involvement has been recognized as a complication of infective endocarditis. However, there is very limited literature describing the rupture of the posteromedial PM in primary aortic valve endocarditis without aortic root abscess. This report highlights the aetiology of the PM rupture in the setting of primary aortic valve endocarditis and the importance of a multidisciplinary approach. Case summary An 81-year-old man without any heart failure symptoms presented with fever and loss of vision in his left eye. Initial echocardiography revealed moderate aortic valve regurgitation due to a perforated right coronary cusp without aortic root abscess, and his blood cultures were positive for Group G Streptococci. During adequate antibiotic therapy, he developed acute severe mitral regurgitation secondary to posteromedial PM rupture. Following emergent aortic and mitral valve replacement using bioprosthetic valves, he made excellent progress on a 6-week course of intravenous antibiotics. Discussion The echocardiography and the histological findings suggested that the main cause of PM rupture was most likely a metastatic focus of infection from the aortic valve via a regurgitant jet. Successful treatment of this fatal complication includes early diagnosis and prompt surgical intervention by a multidisciplinary approach.