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Question:

A 52 year-old man underwent thromboIytic therapy for an inferior STEMI. Two days later he suddenly develops severe SOB and hypotension and is found to be in acute pulmonary edema. On exam, he is sitting bolt upright in acute respiratory distress with rales in the lung fields but no murmur is audible. BP is 80/50 and HR 110. A TTE shows hyperdynamic LV function without pericardial effusion but is of poor quality.

What is the best management approach?

  1. TEE with surgical standby
  2. Right and left heart catheterization with saturations
  3. Place SG catheter with nitroprusside and dobutamine.
  4. Proceed directly to surgery

Answer Rationale:

Patients with acute onset of pulmonary edema and hypotension after MI should be evaluated for mechanical complications of MI. Acute papillary muscle rupture is seen with an inferior MI due to the single blood supply to the postero-medial papillary muscle. This is frequently missed by TTE but should be suspected on the basis of the clinical scenerio and hyperdynamic LV function. A TEE is required for diagnosis and then urgent surgery is indicated.

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1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.

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