Cardiogenic shock as a complication of acute mitral valve regurgitation following posteromedial papillary muscle infarction in the absence of coronary artery disease

0.4%–5% of patients with acute myocardial infarction die from sudden and severe mitral regurgitation due to a complete rupture of a papillary muscle [1]. Most commonly, the posteromedial papillary muscle is involved, but in 20% of cases, the anterolateral papillary muscle is involved. The muscle rupture may represent a rare mechanical complication of a blunt chest trauma, or may be due to sepsis [2].Spontaneous rupture of the papillary muscle, secondary to isolated papillary muscle infarction, in the absence of coronary artery disease, is incommon or rare.We describe a case of a spontaneous acute papillary muscle rupture in the absence of a history of ischemic cardiopathy or blunt chest trauma or sepsis.A 48 year old man was transferred to the intensive care unit in June 2008 with signs and symptoms of cardiogenic shock after extreme exercise. He was a farmer and had been lifting a bale of corn. He collapsed immediately after exercise. Past medical history was positive for heavy smoking, severe arterial hypertension and hypercholesterolemia. There was no previous history of chest pain, heart murmurs or drug abuses. Up until the even the patient had appeared to be in good health and had not been on medication. There was no history of trauma to the chest.Physical examination revealed congestive heart failure and a loud pan-systolic apical murmur, radiating posteriorly. The ECG showed sinus tachycardia. Chest X-ray showed pulmonary venous congestion and was suspicion of an infiltrate in the right lower lobe which could be consistent with the patient's pyrexia. An urgent echocardiogram showed normal systolic function, severe left ventricular hypertrophy (14 mm septum wall), an increased end-diastolic diameter of the left ventricle (58 mm) and posterior and anterior mitral valve prolapse with severe mitral valve regurgitation. Coronary angiography and a left ventricular angiogram showed normal coronary arteries and a good left ventricular function with massive mitral reg