From the Guidelines
A ruptured mitral valve leaflet can indeed appear as a mass or vegetation on echocardiography, and the most recent and highest quality study recommends urgent surgical intervention for papillary muscle rupture, with mitral valve replacement being the procedure of choice 1. When the mitral valve leaflet ruptures, typically due to myxomatous degeneration, infective endocarditis, or trauma, the torn portion of the leaflet can flail into the left atrium during systole, creating a mobile, echo-dense structure that may be mistaken for a vegetation or mass. The key distinguishing features include:
- The timing of the abnormal motion (systolic)
- Its attachment to the mitral valve apparatus
- Associated severe mitral regurgitation on color Doppler To differentiate a ruptured mitral valve leaflet from true vegetation, clinicians should:
- Look for clinical signs of endocarditis
- Assess the motion pattern (ruptured leaflets typically have a more organized to-and-fro motion)
- Evaluate the integrity of the chordae tendineae Transesophageal echocardiography (TEE) provides better resolution than transthoracic echo and is often necessary for definitive diagnosis, as noted in earlier studies 1. The presence of a ruptured mitral valve leaflet typically requires surgical intervention, as it usually causes significant mitral regurgitation that can lead to heart failure if left untreated, with a relatively high mortality rate associated with emergency mitral valve replacement, but improved survival and ventricular function with surgery compared to medical therapy alone 1.
From the Research
Echocardiographic Appearance of Ruptured Mitral PMVL
- A ruptured mitral papillary muscle can appear as a mass or vegetation on echocardiography (ECHO) 2
- Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in detecting papillary muscle rupture, but misdiagnosis can still occur 2
- Comprehensive echocardiographic examination is crucial in identifying the ruptured papillary muscle segment, visualizing flail mitral valve segments, evaluating mitral regurgitation severity, and assessing left ventricular systolic function 3
Differentiation from Other Conditions
- Echocardiography can help differentiate valvular causes from myocardial causes of regurgitation 4
- Two-dimensional echocardiography is superior to M-mode echocardiography in diagnosing a flail leaflet, papillary muscle dysfunction, and cleft mitral valve 4
- Papillary muscle rupture can be distinguished from mitral valve vegetation, although the echocardiographic appearance may be similar 2
Diagnostic Insights
- Two-dimensional echocardiography is 96% sensitive in detecting rupture of chordae tendineae, a common cause of acute mitral regurgitation 4
- Echocardiography can provide valuable insights into papillary muscle function and mitral valve competence, including the detection of papillary muscle calcification and hypertrophy 5
- The role of papillary muscle dysfunction in causing mitral regurgitation post-infarction is controversial, but echocardiography can help assess the extent of papillary muscle and adjacent left ventricular wall ischemia or infarction 5