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+We present the case of a 66-year-old female patient with no significant past medical history presenting with chest pain that was treated with antacids by her primary care physician.
+The next day she presented to the emergency room, where an electrocardiogram revealed posterolateral ST elevation myocardial infarction.
+The patient was immediately taken to the catheterization lab.
+A successful percutaneous intervention was performed on an acutely occluded large ramus intermedius vessel that was supplying a large portion of the lateral wall (Figure 1).
+The patient did well initially, but several hours later she suddenly went into cardiogenic shock.
+An intra-aortic balloon pump was placed, and an echocardiogram demonstrated that she had severe mitral regurgitation from a ruptured papillary muscle (Figure 2).
+The patient, on maximal support, deteriorated rapidly with progressive acidosis, oliguria, and florid pulmonary edema.
+In spite of the very high risk, we decided to intervene surgically.
+Once in the operating room, transesophageal echocardiography confirmed severe mitral regurgitation with a ruptured anterolateral papillary muscle and a small left atrium.
+Shortly after the patient was put on cardiopulmonary bypass, the acidosis resolved and she began to make urine.
+Excellent visualization of the mitral valve was obtained using a vertical transseptal approach through the right atrium.
+The valve was carefully inspected and the necrotic ruptured anterolateral papillary muscle was seen (Figure 3).
+There was a large chunk of muscle attached to the A1 chordal apparatus.
+The anterior leaflet of the mitral valve was excised while keeping the posterior leaflet intact.
+A 27-mm St Jude Epic bioprosthesis was inserted (Figure 4).
+She was placed on extracorporeal membrane oxygenation that was successfully weaned 3 days later.
+Following this, she made a remarkable early recovery.
+One month later, just prior to discharge, she expired after developing pneumonia that progressed to sepsis with multiorgan failure.